While much remains to be delineated, especially regarding the extent to which precautions are needed, exercise has been one of the best-studied areas of cancer rehabilitation in recent years. In addition to benefits relating to physical conditioning, improvements have been found in quality of life, psychological factors, and fatigue, even duration of neutropenia and of hospital stay (11, 12, 13, 14, 15). Beneficial effects have been seen in populations ranging from inpatients in the midst of intensive antineoplastic treatment, to outpatients recovering from breast cancer treatment (16), to long-term survivors (17). The goals of exercise vary with the stage of disease and the patient’s place in the treatment trajectory. For example, for an acutely ill hospitalized patient, the main goal of exercise might be to slow down the loss of strength, whereas posttreatment the goals will be genuinely restorative. Exercise can be conceptualized both in terms of maximizing general fitness (strength, cardiopulmonary conditioning), as well as targeting specific issues that the individual with cancer might need to address (such as lymphedema, amputation, hemiparesis, contracture). While formal conditioning programs do not
generally have a role in end-stage cachexia, rehabilitation therapies such as physical or occupational therapies may still be of benefit to help address the patient’s functional needs and overall independence level (18, 19). On the other end of the spectrum, for obese individuals, exercise is an important component of meeting weight loss goals, and shows promise in preventing weight gain in patients with breast cancer receiving chemotherapy (20). Special considerations regarding obesity in the cancer population are its association with reduced survival (and increased risk of malignancy in the first place) for at least some tumor types (21), and its association with lymphedema (22). A number of studies have shown benefits of exercise in cancer-related immune parameters (23). Physical activity has been associated with reduced overall and site-specific (breast, colon) cancer risk (24).

Many exercise precautions have been cited for individuals with cancer, on a commonsense basis, but the evidence basis is very limited (Table 69.3). Factors to consider include blood counts (especially platelet count), bony integrity, and cardiovascular status. Generally, exercise can be unlimited with platelet count greater than 30–50 K, should be limited to low-impact, nonresistive activities when the platelets are under that level, and totally restricted (except perhaps brief walking) when platelets are under 10–20 K. The concern is that bleeding will result from the physical impact or from blood pressure response to activity. If there is a concern of bony stability, orthopaedic assessment is indicated for possible surgical fixation, bracing, or use of an assistive device before initiating the exercise program (25). Cardiovascular problems are common in the general population, and given the demographics of cancer they must be considered. A cancer-specific concern is cardiotoxicity of anthracycline chemotherapy. In this setting, warm-up and cool-down phases are essential, and the patient might not mount a predictable heart rate response to activity (26). Improved physical performance results from exercise, but is considered to be due to peripheral adaptation rather than intrinsic cardiac factors (27). Weight-lifting restrictions have sometimes been recommended for individuals with lymphedema, but, in the authors’ opinion, there is no one-size-fits-all cut-off as to how much may be lifted. Rather, patients should be counseled to build their activity gradually, avoiding sudden exposure to heavy weights.

A perennial difficulty with exercise programs, as with many therapies, is long-term compliance, and, of course, quality of life is always a consideration. Therefore, to the extent possible the patient’s enjoyment of the activity and
access concerns, must be considered and incorporated into the exercise recommendations. Courneya has outlined exercise programs for early stage patients and long-term healthy survivors (28).

Generally, when cardiovascular conditioning is desired, an aerobic program is favored. Data is lacking as to when the exercise program needs to be supervised versus self-directed (16). Ideally, there should be a method of monitoring exercise intensity, to assure that a training effect is being reached. Over time, the individual will be able to increase his or her exercise intensity, with progressively greater physical work being performed before the anaerobic threshold is reached. Possible parameters include target heart rate based on exercise stress test data (the ideal, especially in the setting of known cardiac problems, but not always feasible) or calculated values (220 less age in years as a rough gauge of maximum heart rate in a healthy individual). Target exercise heart rate is typically 60–85% of maximum, with those in poor physical condition aiming for the lower end of this spectrum. Alternatively, for the frail individual, one might aim empirically for an approximately 20 beats per minute increase from resting heart rate, or use the Borg Rating of Perceived Exertion, a self-administered rating scale which has been shown to correlate with heart rate and other physiologic training effect parameters (26). While adjunctive pharmacologic strategies, such as use of stimulants, anabolic steroids, or red blood cell promoting agents, have been considered to improve exercise tolerance and/or muscle mass in the patient with cancer, data as to effectiveness and specific indications is pending. One study of weight losing cancer patients did exhibit improved exercise tolerance with erythropoietin (29).

Strengthening is initially best tolerated with isotonic (nonresistive, high-repetition) activities, gradually incorporating more intensity into the program. However, when one desires to minimize forces across a joint (e.g., in the presence of bony invasion, pain, or arthritis), isometric exercise may be best tolerated. Isometric exercise consists of muscle contraction in the absence of joint excursion. Isometric strength is important for some aspects of functional activity, such as transfers, and maintaining a wheelchair push-up.

Flexibility on the part of the therapist is needed, and tolerance may be limited by medical complications and fatigue. Even if, while acutely ill, the level of participation is minimal, the patient benefits from the “habit” and trust that is built with the therapist, which may translate into quicker transition to physical activity when the patient is ready (30, 31).

For individuals with focal weakness, the activity program will include strengthening of the affected parts, and compensatory strategies. The prognosis for improvement will vary with the etiology and severity of the lesion (see section Mobility and Gait Training). For those with contracture, a stretching program is important (see section Deconditioning). Stretches are also an important preventative strategy, especially for patients who have received radiation therapy across a joint, amputation (contractures will impede prosthetic use), or with a weakness pattern resulting in imbalance in the strength of agonist/antagonist muscles surrounding a joint.

Exercise is an important part of complex decongestive therapy (CDT) for lymphedema (see section Lymphedema), although it has not been well studied as an isolated modality for this condition.

Mobility refers to the ability to move and explore one’s environment. It includes the ability to move in bed (bed mobility) including changing positions from supine to sitting, rolling on one’s side, sitting on the side of the bed, and transferring from one surface to another. It may be at the wheelchair or ambulatory level. Impaired mobility may be caused by a number of conditions (see section Spectrum of Functional Impairment). Cognitive and visual perception factors imposed by central nervous system lesions may also limit mobility and pose additional challenges in rehabilitation.

For the severely impaired person having difficulty moving in bed, poor sitting tolerance, and inability to transfer, physical therapy is needed. Physical therapy may also be indicated to attain a higher functional level (reconditioning), or to help the patient regain deficient skills. The therapy may begin at the bedside to promote independent mobility in bed, balance and sitting tolerance, and transfers out of bed to a standing position or to another chair. The use of a tilt table may allow the person with autonomic dysfunction to gradually tolerate changes in position from supine to sitting and eventually to standing. Locomotion may be achieved with a wheelchair, or
walking with an assistive device such as a walker or cane. The prescription of an orthosis or prosthesis may be necessary to promote functional independence. Additional physical therapy goals may include strengthening affected muscles, stretching contractures, reducing spasticity, improving proprioception and balance, and helping develop compensatory strategies for those with visual–spatial deficits or communication disorders.

Gait disturbances due to weakness, spasticity, proprioceptive deficits, and leg-length discrepancies may be corrected with a combination of orthoses, specially adapted assistive devices and gait training. Physical therapists also provide gait training to those who have had lower limb amputations. This may include teaching them to ambulate using assistive devises such as crutches or a walker, as well as providing prosthesis (artificial limb) training. Gait abnormalities associated with poorly fitting or incorrectly fitted prostheses can also be identified and corrected by a team including the physical therapist, physiatrist, and prosthetist (Figure 69.1).

Functional abnormalities due to spasticity including ambulation and gait may be addressed with a combination of physical therapy, medications, and other interventions if necessary. Pharmacologic management of spasticity may be initiated if the conventional therapeutic techniques of stretching and bracing are not effective and if the condition limits ambulation, activities of daily living (ADL), and hygiene and/or causes pain. These agents include baclofen, tizanidine, and dantrolene. Interventional techniques such as botulinum toxin injections, neurolysis with phenol and intrathecal baclofen pumps are additional strategies that physiatrists may use to reduce the complications of spasticity that often limit ambulation, as well as other ADL.

Functional ADL include activities of self-care including bathing, grooming, personal hygiene, toileting, eating, and dressing. Additional instrumental ADL include meal preparation, shopping, paying bills, and household duties. The inability to perform ADL may be due to the same factors that limit mobility including cognitive and visual perception deficits.

Occupational therapists are trained to help people regain their ability to perform their ADL. They help the patient develop compensatory strategies to perform self-care activities including functional transfers to the commode and bath or shower, based on the individual’s impairments. Assistive devices such as a reacher or shoehorn may help a person regain the ability to dress. Modified eating utensils and upper extremity orthoses may assist in self-feeding. Additional devices including a raised toilet seat and tub or shower chair may help compensate for orthopaedic or neurologic impairments and allow a person to perform toileting and bathing activities.

Occupational therapists are also trained to provide focused therapies to improve generalized upper extremity weakness and range of motion, and implement techniques such as constraint-induced therapy for those with long-standing upper extremity hemiparesis. They, along with physical therapists, are trained to provide education and training to patients and their families, as well as, teach safety techniques and energy conservation strategies (such as pacing, prioritization, planning, and attention to posture with activities) and perform a home checkout. Home therapies may be effective in establishing independence and compensatory strategies in the home environment, as well as in developing home modifications to improve safety and accommodate specific limitations and equipment (Figure 69.2).