Designing Exercise Programs for People With Cancer

Goals

Specific, well-designed goals of an exercise program should drive the interventions, because specific interventions will likely produce specific outcomes. The most common types of exercise are aerobic, strength training, and flexibility exercises. However, given the heterogeneity of cancer types, a one-size-fits-all approach to exercise and cancer is unlikely to be effective. For example, for patients in whom cardiac output may have been compromised, a carefully planned exercise program with the goal of improving cardiorespiratory fitness may be in order; however, another group of patients may need strength training to combat the effects of muscle wasting and inactivity.

Goals for this population should be clearly defined.

  • Alleviate symptoms?
  • Improved functional capacity?
  • Restore muscle function?

Exercise Prescriptions

The goals for the target population will define the exercise prescription, which has five components (Whaley, Brubacker, & Otto, 2006).

  • Mode: What type of exercise will be performed?
  • Intensity: How strenuously will the patient be asked to perform the exercise?
  • Duration: How long will the exercise sessions last, or how many repetitions of a certain exercise are required?
  • Frequency: How many days per week will the patient exercise?
  • Progression: What is the point at which optimal benefit is achieved at one level of exercise, requiring increased weights, repetitions, or intensity to achieve further results?

Other factors to consider in an exercise prescription:

  • Will the patient be supervised or unsupervised while exercising?

Although many published guidelines recommend exercise programs for healthy people (such as the Centers for Disease Control and Prevention's guidelines), adapting guidelines for people with cancer may pose some challenges. For example, patients who are at risk for infection, such as those with neutropenia, should not share equipment or may not be well enough to attend a public exercise class; patients with nontunneled vascular access devices may not be able to participate in water exercise activities.

Exercise Testing

Testing patients for their level of exercise tolerance prior to initiating an exercise program will increase the likelihood of success. Testing may consist of health questionnaires, lab tests, physical examinations, aerobic capacity and muscular strength. The goal of the program will greatly determine the direction of the testing; for example, if the goal is to improve muscle strength and stability, then the cardiorespiratory testing may not be as vigorous as it might be for programs with alternate goals. Testing should be modified for patients for whom metastatic disease, symptomatology, or other cancer-related conditions may prevent an accurate result. The American College of Sports Medicine's guideline for exercise testing is one resource that may be used to develop testing plans (Whaley et al., 2006).

Adherence to the Program

A beautifully planned exercise program will not be effective if a patient is unable or unwilling to adhere to it. Even for healthy people, adhering to an exercise regimen can be a challenge; the addition of the multifaceted challenges of a cancer diagnosis makes adherence all the more challenging. Adherence may be influenced by symptoms such as nausea or fatigue. Other factors that may influence adherence may not be related to cancer, such as time to perform the activities, transportation to and from a supervised program, or simply lack of interest.

Monitoring patient adherence is a particularly challenging task. Because a simple record of time spent in the exercise session does not necessarily represent adequate performance of the exercise prescription, not surprisingly, many studies do not report adherence rates, or data is confounding. Because so many factors can affect adherence, it is important to provide as many reinforcers as possible to encourage patient participation. Ideas include (Adkins, 2009; Hacker, 2009)

  • Encouraging partners to exercise together
  • Ensuring that goals are realistic and achievable
  • Varying the exercise routine to prevent boredom
  • Identifying an exercise plan that is enjoyable to the patient
  • Encouraging journal entries of exercise completed to be able to see efforts and improvements
  • Maintaining weekly contact with the patient (if the program is home-based)
  • Helping patients identify and overcome barriers to exercising
  • Indentifying opportunities for incorporating exercise into daily activities

Evaluation

Evaluation of improvement in an exercise prescription is again closely related to the exercise goals. Some potential evaluation endpoints include (Hacker, 2009)

  • Biologic endpoints
    - Oxygen capacity
    - Body fat
    - Heart rate
    - Blood pressure
    - Body composition
  • Functional status
    - Distance walked, or steps climbed
    - Strength in legs, arms, hands
    - Aerobic capacity
    - Time needed to perform activities of daily living (ADLs)
  • Symptoms: presence and/or severity of
    - Depression
    - Fatigue
    - Anxiety
    - Sleep disturbances
    - Distress
  • Quality of Life: perceptions of
    - Life satisfaction
    - Role performance
    - Cognitive functioning
    - Social functioning
    - Satisfaction with overall health

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