**4. Exercise prescription**

**8.** To improve the physiologic and psychological ability to withstand any current or future

With the right program, remaining physically active during and after cancer treatment will have a favorable effect on symptom management and quality of life. As such, we wish to present a step-by-step guide intended to assist an exercise trainer when working with a client who has been diagnosed with cancer. This guide will begin with pre-participation paperwork and will cover all pertinent information through exercise program development. Presented are guidelines for both facility-based settings and a home-based setting. These techniques have been employed by Maple Tree Cancer Alliance, a non-profit organization in southwest Ohio whose mission is to improve the physical and spiritual well-being of individuals battling

It is important to mention, however, that "cancer" is a broad term. No two cancer diagnoses are alike. Similarly, no two patients are alike. With so many different forms of cancer existing, each with its own treatment regimen, it is vital for the exercise trainer to remain in communi‐ cation with the patient's physician. Equally important, is the need to personalize each exercise program to the ever-changing needs of the patient. Therefore, the guidelines described in this book are just that – guidelines. Adjustments can and should be made accordingly, where

Obtaining information about the patient is vital to ensuring a safe and effective exercise program. Before any exercise is conducted, the exercise trainer must learn all they can about the patient's medical and cancer history, treatment regimen, psychological well-being, exercise history, as well as any pertinent negative side effects related to cancer treatment. The exercise trainer will also want to have the patient's physician sign a release form, and the patient sign

After all necessary paperwork is complete and the physician's clearance has been signed and returned, the exercise trainer may begin the exercise program development process. The first step in this process a comprehensive fitness assessment. The purpose of the fitness assessment is to determine the patient's current level of fitness. This will assist in goal setting and exercise program development. It is important to note, however, that cancer-specific norm charts have yet to be developed. Thus, any score received on the fitness assessment will be compared to a norm chart representative of a healthy population. Therefore, it would be wise to set goals that are relatively modest, particularly when working with a patient who is currently in treatment. At Maple Tree Cancer Alliance, we recommend conducting one test for each component of fitness. To measure VO2, we utilize the Bruce Treadmill Protocol, and have each patient

cancer treatments.

120 Updates on Cancer Treatment

cancer.

appropriate.

**2. Pre-participation paperwork**

a waiver prior to beginning any exercise program.

**3. Fitness assessment procedures**

Once the fitness assessment has been completed and reviewed, the cancer exercise trainer designs an individualized exercise prescription for the patient, where recommendations pertaining to the frequency, intensity, duration, mode, and progression of exercise are addressed. Ideally, for an individual undergoing cancer treatment, the prescription will include a whole-body workout that targets all the major muscle groups. The overall goal of the exercise program should be to minimize the general de-conditioning that often results from cancer treatment so that the cancer treatments are better tolerated. In general, the exercise prescription should include a slow progression and demonstrate adaptability to changes in the patient's health status, which frequently will change from day-to-day during treatment.

At present, the optimal frequency, duration, and time course of adaptation to aerobic and resistance exercise training in cancer patients are not known, although research indicates that individuals undergoing cancer therapy benefit from low-to-moderate intensity aerobic and resistance exercise [13]. Based on available data, Table 1 presents some general guidelines a fitness professional may follow when designing an exercise program (Schmitz et al., 2010; Physical Activities Guidelines Advisory Committee, 2008; Haskell et al., 2007; Schneider & Carter, 2003).


**Table 1.** Guidelines for Designing an Exercise Prescription for Individuals Undergoing Cancer Treatment.

Initially, intensity will depend on the patient's functional status and exercise history prior to cancer diagnosis. Typically, previously active cancer patients may continue their exercise regimen, although intensity may need to be decreased during treatment. Progression should consist of increases in frequency and duration rather than in intensity (Physical Activities Guidelines Committee, 2008; Schneider & Carter, 2003).

## **5. Exercise program**

#### **5.1. Pre-exercise guidelines**

Prior to each exercise session, the cancer exercise trainer must assess the patient's readiness to exercise. Resting heart rate and blood pressure should be measured, and general information regarding the patient's overall health status should be obtained. Contraindications to exercise are listed in Table 2. Depending on the information attained from the patient, the exercise intervention may need to be adjusted for that day.


**Table 2.** Contraindications to exercise in cancer patients.

#### **5.2. Supervised exercise training session**


dizziness, nausea, or chest pain occurs, all exercise should be stopped. Frequent short breaks are sometimes encouraged to accommodate therapy-related fatigue.



**Figure 1.** The Borg Scale Rating Perception of Effort (RPE).

#### **6. Follow up**

regimen, although intensity may need to be decreased during treatment. Progression should consist of increases in frequency and duration rather than in intensity (Physical Activities

Prior to each exercise session, the cancer exercise trainer must assess the patient's readiness to exercise. Resting heart rate and blood pressure should be measured, and general information regarding the patient's overall health status should be obtained. Contraindications to exercise are listed in Table 2. Depending on the information attained from the patient, the exercise

**• Warm up:** Each session should begin with a 5- to 10-minute warm-up that stimulates blood flow to the working muscles. The warm-up should involve some mild stretching and light

**• Aerobic Component:** During the aerobic component of exercise, it is important to frequently monitor blood pressure and heart rate. If the patient is on a medication that affects heart rate, the Borg Scale of Exertion (Borg, 1973) (Figure 1) may be used to monitor intensity. Based on this scale, a light-to-moderate intensity (RPE of 11 to 14) should be encouraged. If

Guidelines Committee, 2008; Schneider & Carter, 2003).

intervention may need to be adjusted for that day.

Decreased heart rate and blood pressure with increased workload

**5. Exercise program**

122 Updates on Cancer Treatment

**5.1. Pre-exercise guidelines**

Onset of nausea following exercise initiation

Chemotherapy treatment within the last 24-hours

**Table 2.** Contraindications to exercise in cancer patients.

**5.2. Supervised exercise training session**

Vomiting within the last 24 hours

Difficult or shallow breathing Unusual muscle weakness Numbness in the extremities

Irregular pulse during exertion Disorientation and confusion

aerobic activity.

Leg pain

Chest pain

Dizziness

To assist in progression, patients should be reassessed approximately every 6 months (Schneid‐ er & Carter, 2003). In addition, it is advisable to maintain communication with the patient's primary oncologist. The following form, used by Maple Tree Cancer Alliance, is sent to the physician every 3-6 months, and is a simple way to keep the doctor abreast of the patient's progress.
