What types of exercise are best for cancer bone metastasis? Should you walk, swim or do your aerobic classes? What should a cancer patient do if she has never exercised? What about yoga for bone cancer patients?
Mary-Ann recently retired as the clinical director of the Rehabilitation and Exercise Oncology Program (REOP) at the Segal Cancer Center in Montreal. She taught Cancer Rehabilitation (2003-2011) at the School of Physical and Occupational Therapy at McGill University and was co-founder and Associate Director of the McGill Cancer Nutrition-Rehabilitation Program from 2002 to 2006.
If you are located in the United States and want to locate a Physical Therapist who specializes in cancer/oncology, please visit the online directory at the APTA. If you are in Canada, please use Google to track down a therapist in your area.
I have also included a discussion, after my interview with Mary-Ann on cancer bone metastasis, on osteoporosis and cancer later in this blog.
Cancer Bone Metastasis and Exercise Choice
My name is Mary-Ann Dalzell. I’m a physiotherapist and past Clinical Director of the Rehabilitation and Exercise Oncology program, Hope and Cope Segal Cancer Center in Montreal.
I want to address the following topic: What type of exercise can you engage in if you know that your bones are at risk, either because of your cancer or because you have developed osteoporosis related to your cancer.
Yoga for Bone Cancer Patients
Yoga for bone cancer patients is highly recommended. As we all know, yoga is very popular and has substantial health benefits.
Quite a number of studies have been done on yoga for bone cancer patients. The research has found is that, without question, yoga practice leads to improvements in the following areas:
- Quality of life.
- Breathing capacity.
- Lung capacity.
- Cardiovascular capacity.
However, when you have bone health issues (such as osteoporosis) or if you have bone metastasis, there are quite a number of positions within the realm of yoga that you should be very cautious with or avoid altogether.
Yoga for Bone Cancer Patients Recommendations
The types of movement within yoga that are not recommended, if you have bone issues, are those in which your spine, for example, is being put into extensive extension or flexion. Too much extreme of movement of the spine, in itself, is not recommended if you have either osteoporosis or bone cancer.
In addition, many times yoga movements involves rotation and loading — specifically, opposite loading. Instead of loading your feet and your legs as you normally would, you’re putting yourself upside down purposefully. When you perform yoga poses that lead to rotation and loading of the spine, you have to be more cautious about your bones. Here are my specific recommendations regarding yoga for bone cancer patients:
- It is extremely important that you maintain a stable pose without twists, flexion or rotation.
- You should avoid extremes of motion of either flexion, extension, or any rotation.
- You should focus on your breathing.
- Practice simple postures within the realm of yoga.
- Do not go to any extremes by any means of rotation, stretching, headstands, neck stands would be absolutely need to be avoided if you have any bone health issues.
Finally, if you want to learn more about safe yoga for people with osteoporosis, check out Yoga for Better Bones.
Exercise and Cancer Bone Metastasis
Many of our patients come to us with these questions on:
- Can I do my aerobics classes if I have cancer?
- What about yoga for bone cancer patients?
- Can I do hip-hop?
- Can I do various dance classes?
- Can I still do the tango?
- Can I swim?
- Can I walk?
- Can I jog?
Not All Exercises Are the Same
I think it’s extremely important for you to understand that every one of these types of exercises and exercise classes put different stresses and strains on your body. They’re not all equivalent. Walking, as a form of exercise, is not equivalent to running or swimming or cycling.
Exercising in the gym for 30 minutes, 45 minutes on your treadmill, riding your bicycle or weight training is not equivalent to walking or to other types of exercise.
Not all exercises are equal. This needs to be understood.
Where You Start is Important
If you happen to be someone who’s very sedentary, someone who rarely did any exercise in your life, who feels more comfortable sitting, listening to music, or reading, and lives a relatively sedentary life, then you need to be careful when you choose your exercise program. You might want to consult with a Physiotherapist.
However, when you do start to exercise, you need is what we call deliberate exercise or deliberate physical activity. It’s not just gardening, or perhaps the few stairs that you might be doing in your home or walking the dog when the dog is primarily walking you.
I think it’s important to define that if you’re going to use walking or even something that’s very low level of activity, that it be deliberate, that it be done at a certain pace and at a certain frequency, so that it can actually be categorized as exercise.
Exercise in oncology or for patients with cancer requires deliberate bouts of exercise that you can count in your week. You can say, “I have expended this amount of energy this week,” and it is actually related to survivorship in cancer.
Safe Exercises for Cancer Bone Metastasis
There are a tremendous number of studies that have been done on the benefits of exercise to survivorship in many different types of cancer. You can do yourself the best good by doing any type of exercise. However, when you have bone health issues, start looking at, “All right, what of those categories of exercises are safe for me to do?” So let’s backtrack once again.
Simple walking, swimming and exercises that are done in the pool are, generally speaking, very healthy for your bone and it’s rare that they would impose excess of stress and strain on your bones.
Any type of walking program, not jogging program, walking programs, even at a greater pace, or swimming or aerobics within a pool setting are generally highly recommended for patients, any patients, even those with bone metastasis.
Aerobics and Cancer Bone Metastasis
There are many types of aerobics classes. The problem with some of the aerobic classes, as there is with generally prescribed gym programs, is that these programs are prescribed for people who are healthy, who don’t have specific bone or joint problems. In the case of either of these, you need additional guidance in order to participate in either of those activities.
If you are taking an aerobics class, you need for the instructor to know that you have bone health issues so that she can determine which of the movements within that class you should avoid and you just simply remove yourself for that poor component of the class. It doesn’t mean that you shouldn’t participate, but you need to know where you might be at risk and your instructor needs to know if you will be at risk.
Ideally you have an instructor who’s experienced in management of patients who have cancer. There are many centers across Canada. We know particularly in Montreal, we have many centers that have now become specialized in exercise classes for patients who have had cancer.
Weight Training and Cancer Bone Metastasis
The other type of exercise is the gym exercise where you’re doing weight training and cardiovascular. Once again, your trainer or the prescriber of your program or if you are self-prescribed insofar as the type of nature of the exercises you’re doing, you need to be very cautious of the type of stress and strain and impact that you’re putting on your bones.
You can’t just be focused on your muscles. You need to remember that those same muscles are attached to bones that are extremely important to your health and well-being.
There are different types of exercise, different classes, there are dance classes, there are many types of exercise available to you if you have had cancer and all of which have shown to be beneficial. There is no question that exercise is beneficial to you whether you have early or advanced disease. You should, at some level, do deliberate physical activity of your choice.
That is the other great important thing. I will not force anyone to go into gymnasium. The studies haven’t necessarily been done in that realm.
You need to choose something that you would do consistently and that would give you pleasure and that will improve and enhance your well-being without putting stress and strain on your bones. The greater the guidance you can get, the better.
How to Build Bone After Breast Cancer
Many women (and even some Health Professionals) believe that bone lost from breast cancer treatment cannot be recovered. However, a recent study should (hopefully) change that belief.
The study found that women who participated in an exercise program one year after their radiation treatment demonstrated considerably better bone health than women who did not.
Exercise is prescribed during cancer treatment because it has been shown to be effective in reducing nausea, fatigue, pain, anxiety, as well as depression. (1)
For the past decade, the exercise prescription for cancer survivors has been aerobic and strength training. Research has demonstrated the following benefits accrue from an exercise program:
- The aerobic training reduces fatigue, improves quality of life and increases aerobic capacity.
- Strength training has a positive affect on fatigue and quality of life but has the added benefit of improving strength. (2,3)
- Exercise has also been linked to increased survivorship. For certain cancers, such as breast and colorectal, exercise was shown to improve survival rates by as much as 60%! (2)
Affect of Exercise on Bone Health of Women with Breast Cancer
Recently, a number of researchers hypothesized that an exercise program for individuals recovering from breast cancer treatment could reduce risk factors for fracture and obesity-related diseases. Until now, few studies actually looked at the benefit of exercise specifically related to bone loss from the treatment of cancer.
A new study, recently released ahead of print, shows that there are benefits to moderate-intensity resistance and impact (jump) exercises on preventing bone loss usually associated with cancer treatment. (4)
The study involved the following:
- Postmenopausal women who were at least one-year post radiation and/or chemotherapy.
- The women in the study were 50 years of age or older and free of medication for bone loss.
- The women had never been on a resistance or impact-training program prior to the study.
- Participants took part in a progressive resistance and impact training three times per week for one year.
Not only did the women involved in the study have an increase in lean body mass but their DXA scores and biomarkers of bone turnover showed significant improvement compared to the group who participated in a stretching program (the control group).
Exercise for Secondary Prevention of Breast Cancer
The evidence that exercise is beneficial for breast cancer prevention is continuing to build. Another study (5) published this month in Cancer Prevention Research on exercise for secondary prevention of breast cancer concludes:
Burgeoning observational evidence indicates that prescribing aerobic exercise of 3 hours or more per week could have meaningful mortality and morbidity benefits for breast cancer survivors.
The author of the study goes on to emphasize the important role of a trained Health Professional:
Adherence to this exercise prescription, however, will require an infrastructure to guide survivors and to address the common clinical treatment sequelae that might interfere with survivors’ ability to regularly perform this level of activity.
In other words, look for trained Health Professionals able to prescribe and manage an exercise program. Working with a qualified and trained Health Professional improves your chance of adhering to your exercise program and succeeding.
I encourage Health Professionals to acquire exercise prescription skills that clients value and need through study and practical application.
This study demonstrates that women who have completed their breast cancer treatment and are free of medication can improve bone health with an exercise program. However, the exercise program must include resistance and impact training.
If you have had breast cancer, have completed your treatment and are free of medication, you should start an osteoporosis exercise program that includes the key elements of bone building and fracture risk reduction.
If you are a Health Professional you should look to include a well designed, effective and safe osteoporosis exercise program for your clients. If you have not had specific training in exercise and the prevention and treatment of osteoporosis, you should consider the online MelioGuide Building Better Bones course.
Osteoporosis and Bone Cancer
This is the second of a two part series on bones, osteoporosis, exercise and cancer. In this second part, I discuss osteoporosis and bone cancer. I cover specific exercise considerations during cancer care, precautions for people who have cancer, and provide specific exercise guidelines if you have cancer. In part 1, I provided a deep overview of bone health.
If you had missed Section 1, this section is understandable. Without it, maybe you’ll certainly get more information in regards to bones, bone physiology, and how we build bone. All of that is covered in Section 1.
Just a quick word here.
Most of you who’ve been following my blogs know that I am very passionate about osteoporosis and exercise and equally as passionate about the loss of bone due to cancer.
However, I am less comfortable with this topic area. So, if I make any errors, those of you who may be listening and know the topic better than myself, I apologize in advance. But the information here is as accurate as I could get and is based mainly on an article that you’ll see referenced, and that’s a very recent 2017 article.
So, today’s agenda covers Section 2, is the considerations for exercise in cancer care, contraindications and precautions, getting started in exercise, and, lastly, exercise guidelines.
So, what are some of the exercise considerations when it comes to cancer care? So, we will be covering these areas, and that is surgery, lymphedema following surgery, radiotherapy-induced heart disease, chemotherapy-induced pathology, cancer-related fatigue, cancer-induced peripheral neuropathy, and metabolic disturbances.
Surgery and Cancer
So, let’s cover each one. Surgical treatments may be indicated at the time of the initial diagnosis, such as biopsy. Surgical intervention may be very small or can involve a very invasive procedure. Depending, obviously, on the surgery, there may be a period of acute rehabilitation, followed by an extended period of body reconditioning, and so that’s where so far as surgery the consideration does come in.
There is the post-surgical lymphedema that has to be taken into consideration.
That involves alternating someone’s body image, reducing arm function or leg function, increasing risk to secondary infections. Also, can be an outcome of lymphedema, and so far as upper arm swelling, shoulder mobility will be affected.
And we know that studies (6) have shown that stretching and resistance training assist with reducing the lymphedema and reducing the risk of obtaining frozen shoulder, so a very important consideration.
Radiotherapy Induced Heart Disease
When it comes to radiotherapy, it is very commonly known that it affects the heart, and so there’s a condition called radiotherapy-induced heart disease, and these are severe abnormalities of the coronary vessels, the blood vessels that feed the heart, as well as abnormalities of the pericardium valves. Radiotherapy-induced heart disease can also be measured by the index in the conduction of the heart and fibrosis of the heart, so the heart is less elastic, which increases the risk for arrhythmias or irregular heartbeats.
Now, with radiotherapy-induced heart disease, an important factor to keep in mind here is the latency period. So, someone may have recovered from their cancer. They may be on with their life. They maybe get cancer in their younger years, and 10 to 15 years later, they’re following a really active lifestyle, and the radiotherapy-induced heart disease does not appear until 10 to 15 years post-radiotherapy treatment.
Another consideration is chemotherapy, and chemotherapy-induced pathology involves several things. One is reduction in the ejection fraction of the left ventricle, so that is the second to last chamber, but a powerful chamber to get the blood going through the body. And so when that is reduced, that will certainly affect your cardiovascular function. Something as extreme as heart failure, thromboembolism, severe increase in blood pressure, and lethal, or deadly, arrhythmias are all part of this pathology.
So, needless to say, the earlier, the better, but early cardiac function testing is very important. And exercise should be considered as an effective cardiac protector since it has less side effects than many medications that otherwise could be used as a cardiac protector. Resistance exercises have been shown to reduce the dosage and the delays of chemotherapy treatments in women with breast cancer.
So, the real benefit being that, you know, you have that reduction in dosage and less delays, so a real plus there for resistant exercises.
Cancer Related Fatigue
When it comes to cancer-related fatigue, this affects up to 80% to 90% of persons with cancer. It is more severe than what we refer to as general fatigue when people sort of say, “I’m tired,” but it’s not the same. It’s often not helped by rest or sleep. It can result in depression and lower the quality of life now that it’s due in part to altered metabolism from decreased circulation in the limbs and an increase in inflammation in the body.
For cancer-related fatigue, other causes are numerous and should be excluded before just, you know, ruling out the fact that, you know, somebody is just experiencing cancer-related fatigue. So, other causes are tumor-related electrolyte abnormalities, dehydration, loss of appetite or aversion to food, thrombosis or pulmonary embolism, renal and liver failure, adrenal fatigue and exhaustion, and neurological deficits. So, all these should be ruled out as possible causes of fatigue.
We know that studies have shown that multi-modal exercise programs…so when you’re mixing up a variety of approaches to exercise, walking, restorative approaches have been shown to benefit both the fatigue and the depression that is associated with fatigue.
Cancer-induced Peripheral Neuropathy
When it comes to cancer-induced peripheral neuropathy, so peripheral being the ends of your limbs, peripheral being fingers and toes, hands and feet that individuals receiving chemotherapy up to 30 to 40 percent of them will potentially experience this cancer-induced peripheral neuropathy. So, the symptoms of axonal degeneration, so where the axons of the nerves degenerate, include pain, tingling, numbness, temperature sensitivity.
Also, other symptoms are impairment or loss of voluntary movement, pain from a touch that’s not normally painful, muscle weakness, as well as worsening of balance, which increases the risk of falling, which is a big concern. Now, as well with cancer-induced peripheral neuropathy, it has been shown that exercise has a positive effect in reducing pain and improving physical function. There’s new evidence suggesting that exercise and muscle stimulation may actually decrease the rate of degeneration of the axons. And that exercise should be targeting not only at the overall physical activity but should also be limb-specific or region-specific. So, if you’re getting that numbness and tingling in the arms, walking, they will not be sufficient and will want to do some upper body exercise. And in persons who have symptoms of the cancer-induced peripheral neuropathy, physical activity should incorporate exercises that increase strength. And, for reasons we’ve mentioned above, to reduce slip or fall, these exercises should also target improving that.
And, lastly, in cancer care considerations is metabolic disturbances. So, initially, the concern is that the tumor metabolism may increase caloric needs, and we need to address those caloric needs to offset muscle wasting, because the tumor will actually get its calories wherever it needs to, and sometimes that is through taking the calories that the muscles consume. So, possible destruction of mitochondria, which are the energy-producing cells within the muscle, as well as loss of blood flow in the extremities will affect the metabolism.
The impact will really be seen in cardiovascular fitness and aerobic capacity. Here, the article that is mentioned here at the bottom by Laura Stefani, “The Clinical Implementation of Exercise Guidelines for Cancer Patients.” I do have a link in the blog post to that article and specifically for this section on contraindications and precautions for exercise prescription.
I highly recommend that you obtain that through the article if you’re able to access this article for free online. There’s a great chart and certainly a great list based on not just the topics that we’ve covered already, the factors related to cancer treatment, but hematological issues, musculoskeletal issues. And, as an example, since this isn’t the area that I’m most comfortable talking about on musculoskeletal, are, for instance, the contraindications to exercise, testing, and training here would be extreme fatigue or muscle weakness, bone, back, or neck pain.
Things that might be precautions or requiring modification and/or a physician’s approval might be pain or cracking, things that need to be investigated before green light is given for exercise. Somebody may already have osteopenia or osteoporosis, so avoiding high impact to decrease the risk of fractures. So, those are the types of things that there’s this, you know, long list under each category, goes down through all of the areas, systemic, gastrointestinal, cardiovascular, pulmonary, neurologic. And, certainly, if I have a diagnosis of cancer and was considering exercise in my life or more exercise in my life, then I could be walking around with this chart and checking off all of the hospital contraindications and precautions before proceeding. And, certainly, if you are a healthcare professional working with cancer survivors, I encourage you to access this article as well.
So, in part four, getting started.
So, during cancer treatment, prescriptive exercises are ideally initiated by your oncologist, but post-cancer treatment, you often will not see your oncologist, you know, on a regular basis.
And so you may be getting started through the guidance of your GP or sports medicine doctor. But because of the precautions that we talked about earlier, a standard echocardiography and stress echocardiogram should be part of the protocol to ensure that your heart is safe to start to exercise, and blood pressure monitoring to allow the healthcare provider that you’re working with to identify an appropriate exercise level, intensity level, for you to get started at is very important.
So, what are some of the things that you should be expecting in a pre-exercise medical assessment? So, one of the things may include body composition, whether it’s done through the DEXA.
One way that they are now using DEXA testing is to assess very accurate body composition.
Other components of the assessment should include strength, flexibility, balance, and then specific physical therapy assessments that would be based on your surgical interventions or on previous musculoskeletal problems that you might have experienced prior to or during your time with cancer.
And, part five, here are exercise guidelines.
So, these guidelines were established by the American College of Sports Medicine in about 2011. And so the reason for exercise guidelines were that exercise we know slows down the rate of physical decline and improves day-to-day function for individuals with cancer. That is a very positive impact on quality of life.
So, although there is no current validated guidelines during cancer treatment, exercise is still encouraged, but the cautionary note here is to proceed with caution.
There is a direct relationship between cardiovascular fitness and mortality, and cancer survivors of all cancer types and all stages of cancer have been shown to increase aerobic capacity when given the appropriate workload, and that’s a really important part, given the appropriate workload. So, that’s where the testing comes in.
Aerobic Exercise Guidelines
What are the guidelines specifically for aerobic exercise?
Well, the starting point is dependent on current level of fitness. Aerobic activity in blocks of at least 10 minutes preferably spread throughout the week.
The recommended time for cardiovascular fitness is 150 minutes a week of moderate intensity exercise aerobic activity or 75 minutes of vigorous intensity exercise, and individuals are encouraged to increase to 300 minutes a week of moderate intensity exercise or to be as physically active as one can.
Anaerobic or Resistance Training
When it comes to anaerobic or resistance training, the recommendations are moderate to high intensity strength training that involves all major muscle groups. That, as I mentioned earlier in Section 1, should be progressive and tailored to the individual.
The resistance training ideally is two or more days per week. It can be gym or home-based. A well-rounded program should incorporate posture, mobility, isolated stability, and whole body stability, as well as balance and agility training.
The strength gains that one gets through resistance training will carry over into day-to-day activities and things like gardening and picking up, you know, your groceries from the store. Those kind of things will be made easier. A note to keep in mind here is that fibrosis from radiation and surgical complications need to be considered when the resistance training program is being established.
And lastly for flexibility, flexibility should be incorporated into a resistance training warmup or at any time, but it’s nice to incorporate into a warmup and allows you to emphasize more dynamic movement. Static stretching should be saved for the end of your workout. And, along with cardiovascular exercise and strength training, flexibility will allow you to stand tall and move well.
And if you’re looking for a safe program and if you have not purchased “Exercise for Better Bones,” I encourage you to look at and go through “Exercise for Better Bones” as a great foundation for an exercise program.
As well, as I’m speaking now, in June 2017, and I will shortly be producing a DVD that would be also an excellent add-on to anybody’s program that incorporates all of the components that I spoke about.
So, with that, I want to thank you for tuning in and wish you healthy bones and a happy life. I’m Margaret from MelioGuide. Keep well.
- Visovsky, C., Exercise and Cancer Recovery, Online J Issues Nurs. 2005;10(2)
- Newton RU, Galvao DA Exercise in Prevention and Management of Cancer. Curr Treat Options Oncol. 2008 Aug 13
- Rajarajeswaran, P and Vishnupriya, R Exercise in Cancer Indian J med Paediatr Oncol. 2009 30(2): 61-70
- Winters-Stone, KM et al. Strength training stops bone loss and builds muscle in postmenopausal breast cancer survivors: a randomized, controlled trial. Breast Cancer Res Treat. 2011 Mar 19. [Epub ahead of print]
- Schmiz, KH. Exercise for Secondary Prevention of Breast Cancer: Moving from Evidence to Changing Clinical Practice. Cancer Prevention Research (Phila). 2011 Apr: 4(4): 476-80.
- Laura Stefani, “The Clinical Implementation of Exercise Guidelines for Cancer Patients.”
For more information, check out my Osteoporosis Guidelines.