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Clinical exercise programming for cancer rehabilitation

This is an excerpt from Clinical Exercise Physiology 6th Edition by Jonathan K Ehrman,Paul Gordon,Paul S. Visich,Steven J. Keteyian.

By Jonathan K. Ehrman, PhD

Programs for patients diagnosed with cancer may begin at any stage of the continuum of cancer care, which includes prior to, during, and after cancer treatments. The rationale for beginning exercise training during the treatment phase of cancer care relates to the mitigation of side effects associated with the various treatments. Common side effects include pain, fatigue, reductions in physical function, and cognitive changes.³⁵ However, data show that less than half of cancer survivors meet physical activity guidelines and that up to one-third of patients are completely inactive. One barrier is the lack of recommendation from an oncology clinician, with less than 25% of patients with cancer receiving referrals to exercise programs.⁴⁸ Other barriers to participation include financial constraints due to self-pay (cancer rehabilitation is not insurance reimbursable), transportation issues and distance to the exercise location, and ongoing cancer and cancer treatment side effects.

The overall benefits of exercise in those with various types of cancers can be found in chapter 25. The changes in functional ability during the phases of cancer diagnosis, treatment, and recovery are provided in figure 8.6. Radiation tends to result in fewer functional side effects, while combination therapies (drugs [including chemo- and immune-therapies] and drugs + radiation) have a greater impact on physical function. Implementing exercise and regular physical activity can often result in higher levels of physical functioning than prior to the diagnosis.

Program Effectiveness

The primary complaints after cancer treatment are often fatigue and weakness, likely due to reduced physical activity, loss of muscle mass, or the development of anemia. Some patients experience cancer- or treatment-related pain as a result of surgery or possibly metastases, among other potential reasons. Wonders reported a reduction in emergency room visits, hospital admissions at 30 d after treatment, and length of hospital stay in those who exercised during treatment versus those who remained sedentary.⁵⁴ This study and others also reported reductions in health care costs associated with office visits, emergency room visits, and hospital readmissions in the exercise group.^{54, 55, 56}

Program Structure and Processes

There are generally two types of structured exercise programs for patients during cancer care or in recovery. The latter includes programs usually found in commercial fitness centers that work with lower-risk patients following treatment. Less common are stand-alone cancer rehabilitation programs. For instance, Henry Ford Hospital in Detroit has a dedicated exercise facility on the first floor of its cancer hospital for patients treated for cancer at Henry Ford. A more common setting is the maintenance (phase 3) programs of cardiac rehabilitation, deemed ideal because of the staffing expertise (i.e., clinical exercise physiologists) and existing facilities and equipment. Since cancer rehabilitation is not yet insurance reimbursable, all patients must self-pay for services. The CR maintenance program setting is likely to be less expensive than a stand-alone program because of shared space, equipment, and staffing. Lower-risk patients or those with a previous exercise history may do well with general exercise counseling and performing their exercise either at home or in another nonclinical location. However, facility-based exercise settings offer the benefits of both improved physical functioning and increased long-term adherence, which may be related to the socialization that occurs in the group setting of a CR program.^{24, 51} Another option for cancer exercise therapy is virtual synchronous audio and visual supervision by clinical exercise physiologists.³¹

The structure of the clinical setting for those with cancer does not differ much from a CR program setting. There is a focus on both aerobic and resistance exercise. Some patients may require specific training for deficits acquired through disease progression (weight loss, balance issues, loss of strength, loss of endurance) or treatment (e.g., reduced shoulder range of motion or lymphedema after breast cancer surgery). Exercise in groups or classes can make it easier for staffing to handle larger numbers of patients and also increases the socialization aspect of a program.

Program Policies

Although the qualifications of exercise professionals vary, many programs require staff to have a minimum of a bachelor’s degree and certification as a clinical exercise professional (see chapter 1). There are also several cancer-specific certifications from both professional exercise associations and university settings.³⁹ Program referral should be made by a patient’s treating or primary care physician. Staff can either develop a medical screening process to determine safety to begin exercise or rely on information provided by the referring physician. Since some patients may be in an immunocompromised state, each exercise setting should implement processes (e.g., cleaning equipment) to lower patient risk of acquiring a communicable disease.

More Excerpts From Clinical Exercise Physiology 6th Edition

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