Historically, patients diagnosed with cancer have been instructed to minimize physical activity, conserve energy, and ask for assistance with activities of daily living due to the fatigue associated with cancer and its treatment side effects. 1,2 This “prescribed” immobility has physiologic consequences including a decrease in cardio-vascular/pulmonary capacity, lean body mass, bone density, muscle strength, ability to fight infections, and memory, and an increase in pain and adipose tissue- leading to a synergistic effect on fatigue.2,3
Fatigue, when not reversed by treating conditions such as anemia, hypothyroidism, and depression or not relieved by rest or sleep, has been identified as Cancer Related Fatigue (CRF).2,4,5 The National Comprehensive Cancer Network (NCCN) has defined CRF as “a persistent subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and that it significantly interferes with usual functioning”.4 It is reported that CRF:
- affects 50-100% of the 12 million cancer survivors
- occurs anywhere from diagnosis through the years post-treatment
- debilitates patients more than nausea and/or pain
- leads to decreased quality of life, and
- improves with exercise and physical activity.
Exercise and physical activity are known to increase aerobic capacity, muscular function, and mood- all combating fatigue, enhancing physical functioning, and improving quality of life.3 What remains unknown for patients actively receiving/after completion of treatment is the ideal exercise prescription. That is to say what type, dose/length, intensity, frequency, and mode of exercise would be best.1,2,3 Evidence demonstrates aerobic activity and resistance training are effective means of decreasing CRF. 2,3,5 Randomized controlled trials study the effects of exercise intervention compared to control groups; results being statistically significant decreases in fatigue of patients participating in home exercise programs or supervised outpatient settings.2,3,5 Outcomes measuring fatigue include the Functional Assessment of Cancer Therapy Fatigue Scale (FACT-F), the Brief Fatigue Inventory (BFI), and the Visual Analog Scale (VAS).2,4 Studies produced guidelines for exercise and physical activity: aerobic activity at moderate intensity (55-75% heart rate maximum/40-60% VO2max) for 150 minutes per week, resistance training (60-80% 1 repetition maximum) 2 to 3 days per week, and flexibility exercises on alternate days.1,2,3 Interestingly, resistance training proved more efficacious than aerobic activity in alleviating CRF in breast and prostate cancer survivors, and there was a greater decrease in fatigue in patients 65 years or older compared to younger participants.1
Although there is no defined prescription of which exercises offer a greater benefit than another, evidence based practice exists for health care providers to educate patients on the importance of exercise in survivorship.4 The aforementioned guidelines are a starting point, but the following needs to be considered for each patient when beginning exercise and physical activity: pre-morbid activities, co-morbidities, and treatment response.2 Exercise and physical activity are safe for most cancer survivors undergoing and/or after treatment, and further research demonstrating improvements in physical and emotional function may lead to a case for third party payers to assist with coverage for cancer rehabilitation programs, similar to phase II cardiac rehabilitation programs.1,3
Related Article: Exercise in Cancer: Progressing Towards Integration
1. Brown JC, Huedo-Medina TB, Pescatello LS, Pescatello SM, Ferrer RA, Johnson BT. Efficacy of Exercise Interventions in Modulating Cancer-Related Fatigue among Adult Cancer Survivors: A Meta-Analysis. Cancer Epidemiol Biomarkers Prev; 2011; 20 (10); 123-33.
2. Cramp F, Daniel J. Exercise for the Management of Cancer-Related Fatigue in Adults (Review). Cochrane Database Systematic Review; 2010; (11); CD006145.
3. Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors. Med Sci Sports Exerc. 2010; 42; 1409-26.
4. Campos MPO, Hassan BJ, Riechelmann R, Del Giglio A. Cancer-Related Fatigue: A Practical Review. Annals of Oncology. 2011; 22 (6); 1273-79.
5. Mustian KM, Morrow GR, Carroll JK, Figueroa-Moseley CD, Jean-Pierre JP, Williams GC. Integrative Nonpharmacologic Behavioral Interventions for the Management of Cancer-Related Fatigue. The Oncologist. 2007; 12 (suppl 1); 52-67.
Cynthia Barbe, MS, PT, DPT is the Team Coordinator for PT, OT, and SLP services in the Oncology Center at the Johns Hopkins Hospital in the Department of Physical Medicine and Rehabilitation. Her primary caseload consists of medical and surgical oncology patients in the acute care setting. Cynthia’s sessions range from evaluation in the ICU for early mobility, to treatment of floor patients post- BMT and/or chemotherapy and radiation for higher level balance and independence with mobility. Cynthia coordinates therapy services to promote quality of care from a multi-disciplinary approach in order for patients to reach their highest functional ability.
Cynthia and her team, working in conjunction with physicians and social workers, strive to refer patients to the appropriate setting for continued therapy services across the survivorship continuum. Her goal is for all patients to achieve their full potential and not accept a new normal due to cancer diagnoses and the effects of their respective treatment regimens. Cynthia will be presenting a poster at the APTA Combined Sections Meeting in February 2012, on the topic of Comprehensive Cancer Rehabilitation Across the Continuum of Care- Bridging the Gap from Acute Care to Outpatient Care. Cynthia has presented evidence based practice lectures in university settings to graduate students and to PM&R physicians. She is a STAR certified clinician who provides continuing education on STAR principles and mentors new staff in this specialty.