|Perched by Susan Karlen Mayer||Page 01|
|Personalized Exercise||Page 03|
|I Don't Wanna||Page 04|
|Pick and Choose||Page 06|
|Journal Plans||Page 07|
|Exercise Can Hurt||Page 09|
|Water Bottle||Page 11|
|Connection: Cancer and Exercise||Page 12|
|Cancer Fatigue||Page 13|
|Counting Cells||Page 14|
|Eating Well||Page 15|
|Cancer Pain is Very Frightening||Page 16|
|Exercise = Energy||Page 18|
by Susan Karlen Mayer breast cancer survivor diagnosed June 30, 1997
I was perched on the seat of my exercycle pedaling to beat my best — when suddenly I realized my right hand was cradling my left breast. There was a lump; it was cancer I’d found. My world no longer had solid ground. I looked mortality in the eyes, and it mattered not — the state of my thighs.
What I needed now was just to live. I wore comfy clothes with plenty of give. My body spent lots of its time in bed though the real exhaustion was up in my head.
It took a long time, but the cancer has gone. I believe now my life can go on, and on. I try to do things to take care of myself but my workout clothes remain on the shelf.
Still, a thought was nagging at me to remember something that used to be: On that exercise bike I’d been using each day better feeling, some peace, was coming my way.
It wasn’t just getting thinner and strong, my times of depression weren’t lasting as long. I was sleeping better, and waking up clear my dreams were less muddled, not so full of fear.
Sure my life wasn’t perfect, some days were just hell but new coping skills were serving me well. I found myself calmer, less likely to rage when the world and myself weren’t on the same page.
So I sit with this thought going round in my brain: should I get up and get moving again? If I don’t like it, if it’s too big a pain, I can simply stop and lie down again.
It’s time to regain control of my fate and while this may be a shock — I’m ending this poem and getting my shoes for a walk around the block.
Hopefully you are feeling better if you are actually thinking about exercising to improve your health. Cancer and cancer treatments impact one’s physical, emotional, and spiritual well-being. Regular exercise at all levels of disease can combat these effects. Celebrate the fact that you are well enough to even think about exercising! Before beginning any exercise program, be sure to talk to your doctor.
Personalize your own definition of exercise. Everyone approaches exercise with different expectations and anticipations. It might be helpful to expand your definition of exercise to include the activities you enjoy. Depending on your level of fitness, exercise can include meeting a friend for coffee, baking cookies, going for a walk, dancing in your living room, snapping photos, scattering crumbs for the birds, going to the beach, flying a kite, shooting baskets, riding a bike, skipping around the yard, and taking the scenic route. You might want to save all your strength for one major event, like sitting in the park and watching your grandchildren, going to a baseball game, or joining a friend for dinner.
If you have never exercised or have low physical endurance because of advancing disease, your fitness goals may be different from one who is more physically active. You also may share the common goals of improving your sense of well-being, changing your sleep patterns and appetite, decreasing discomfort from joint stiffness and muscle tension, and increasing your strength, endurance, and flexibility. You may know the general benefits of exercise but need direction in your exercise regimen.
I Don't Wanna
Reasons not to exercise are numerous. Some feel that their body has been through so much that it can’t stand the impact of working out. Others feel tired and question whether or not they have the energy to exercise. Still others state they just don’t have the time. An understanding of the benefits of exercise is helpful. Strong muscles protect bone and might even limit the risk of fracture. Good circulation might reduce the risk of blood clots. Exercise encourages the flow of lymphatic fluids, hopefully improving the immune system by eliminating toxins. Exercise produces adrenaline, which acts as a natural decongestant that can help clear sinuses and bronchial airways.
Books on fitness and exercise often state that “all” one needs to do to be physically fit is to work out for 20 minutes 4 times a week. For many of you, that goal might seem impossible. For some of you, it took years to get out of shape and it’s going to take a while to get into good physical condition.
Begin your activity slowly. If you have been very ill or have not been exercising on a regular basis, walking five minutes, turning around and walking back might be a realistic goal. Then try to do it twice a day. Start exercising slowly and build up gradually. If you are able to build up endurance without problems, increase the time you exercise by not more than 10 percent each week. In other words, if you walk for 15 minutes three times a week — a total of 45 minutes — don’t walk more than a total of 50 minutes next week. Remember that there is a fine balance between too much and not enough exercise. If you were active before your diagnosis, you might consider cutting back on your exercise by at least 50 percent until you feel you can add distance and intensity. During weight training, reduce by half the number of sets you complete and limit your effort to about 50 percent of your previous output. Increase or decrease your repetitions and weights, based on how you feel.
Women who exercise beyond the American College of Sports Medicine (ACSM) guidelines do not rank higher on measures of cardiovascular fitness or fat loss than women who follow their guidelines. More is not necessarily better. ACSM recommends 3 to 5 days a week for 20 to 60 minutes of continuous or intermittent aerobic activity.
While it is important to exercise regularly, don’t feel you can’t take a day or two off. Your body needs time to adjust to the physiological changes occurring in your body. Muscle takes time to repair and rebuild. Rest also aids in the removal of metabolic waste products, such as lactic acid, the chemical responsible for muscle soreness and fatigue. You need rest to perform your best.
If you work too hard and get your heart rate up too high, you will fatigue rapidly and be unable to keep up your activity. On days when you are tired or stressed, you may notice that your resting heart rate is higher than usual. This is a normal response and is your body’s signal to proceed more slowly.
Pick and Choose
Choose your activity. What form of exercise do you enjoy? What would personally interest you? Start with the expectation that you want to enjoy and complete the activity. After the activity, ask yourself how much fun you had. On a scale of one to ten, how would you rank the activity? Log this number in the Daily Exercise Plan located at the end of this guide.
Many people applaud exercise as a means of increasing their strength, making them feel happier, and instilling hope. People who are fit often have a more positive outlook on life, experience less fatigue, and face problems in a more relaxed manner. A fit person has greater cardiovascular endurance and muscular strength.
Many have stated that it helps to get a buddy to exercise with them. People who exercise together build friendships and develop an appreciation for the uniqueness of others. Support from your family and friends help make the experience more enjoyable. Some like consistency in their routine; others like to vary the types of exercise they do and where they do it. Go ahead…pick and choose!
Journal your goals and set daily plans. It may be helpful to establish goals you hope to accomplish in a short period of time and those that might require a longer commitment. Long-term goals may be an extension of a shorter-term goal. In six months, you might want to feel that exercise is a more vibrant part of your life. Whatever your goals, write them down, keep a log. An exercise journal is provided at the end of this pamphlet.These goals are yours; they must be individualized to what you hope to accomplish, not what others wish for you or for themselves.
Daily plans are different from your goals, as they may change, based on how you feel at the moment. Write your daily plan in pencil with an eraser. Don’t feel depressed if you can’t complete your goals. If you feel ill the day you plan to exercise, modify your plan for the day. Still exercise, but on a lesser level. If your daily plans are obtainable, the possibility of reaching monthly goals is more realistic.
When you finish exercising, write down your accomplishments in the Daily Exercise Plan located at the end of this pamphlet. Five weeks of logs are included at the end of this pamphlet. Photocopy additional copies as you continue to exercise. A completed sample is shown on page 26. Note the easiest part of the workout for comparison. Was it easier at the beginning or at the end? How does today compare with previous days? If it is harder today, think about why. Was your diet a contributor? Did you recently have a cancer treatment? Did something happen to make you sad? Log these comments in the comment section of the journal. What did you enjoy most? Did you exercise with a friend, was the weather especially nice, or did you just generally feel well. You might also want to journal your thoughts and observations.
Beginning an exercise program involves taking a reasonable risk. It involves change. Change may be positive, but it can also cause anxiety. Don’t pass judgment on your activities. Accept your blunders. Mistakes are a natural part of the learning process. Give yourself enough time and practice to adapt.Your body will take note of the demands of a new activity, including energy expenditure, speed, timing, and direction of the movements. With proper instruction and practice, your body will eventually develop a blueprint of skills needed for the activity.
Exercise Can Hurt
If not done safely, exercise can be detrimental. All people currently receiving treatment for cancer should talk with their physician before beginning an exercise program. If increased pain is noted during or following your exercise, contact your cancer care specialist. Practice good home safety to reduce your risk of falling. A fracture would seriously interrupt your exercise regimen. A couple of home safety tips include:
- Rugs are often called “throw rugs.” They should be thrown away, as they could easily contribute to a fall. Keep walking areas free from objects that could trip you.
- Have adequate lighting, with light switches within easy reach.
- Keep electrical cords out of the way of walking traffic.
- Try to avoid walking in stocking feet, loose slippers, or bare feet. Keep your shoes tied securely so you don’t trip on your shoe laces. Consider using Velcro on your tennis shoes, instead of laces.
- Use rubber strips and hand rails in your bathtub and shower.
- Be cautious on walkways that are wet or have uneven ground.
- Always wear a helmet when bicycling.
Don’t begin your exercise program alone or in isolated areas. If you exercise outside your home, never walk the same course each time. Vary your route. Always carry identification, change for a telephone, and money for a taxi. Ideally carry a cell phone. Have a back-up plan for getting home if you become tired. Phone a friend for a ride home or take a taxi.
Walking is inexpensive. It requires no fancy equipment, except comfortable walking clothes and good shoes. In cold weather, it is wise to layer your clothing. Wear fabrics that wick the sweat away from your skin and help keep you dry. If you are walking in the early morning or evening, wear clothing that makes you visible in traffic. Watch for seasonal injuries. Obviously, the leading cause of winter injuries is slipping on ice. Try to breathe through your nose to warm and moisturize incoming air. On cold days you might want to wear a scarf or surgical mask.
Carry a water bottle. Adequate hydration is very important. Do not wait until you are thirsty to drink. By the time you actually feel thirsty, you have waited too long and may be on your way to becoming dehydrated. Always drink more than thirst demands. Symptoms of dehydration include feelings of listlessness, general fatigue, muscle fatigue, heat intolerance, light-headed-ness, headache, and low volumes of dark yellow urine.
Connection: Cancer and Exercise
Scientists continue to research the connection between exercise and one’s cancer risk. People who choose on their own to exercise are very different from those who do not choose to exercise. Several studies have shown that those who exercise have other good health habits. They tend to drink less alcohol, eat healthier diets, smoke less if at all, take more vitamin supplements, and take better overall care of their health. As a result, it’s difficult to be sure that the exercise by itself is having the effect. (Breast Fitness, p. 62)
A widely publicized report from the Harvard School of Public Health in 1997 estimated that 65 percent of cancer deaths are caused by unhealthy lifestyles. The authors of the Harvard study cited smoking cessation, proper diet, and daily exercise as the best means of reducing the risk of developing a number of types of cancer. If physical activity can play a role in preventing cancer, couldn’t it also affect a person’s recovery from treatment? Growing scientific evidence suggests that physically fit cancer patients can fight the disease better, improve their quality of life, and maybe even live longer. (The Force Program — The Proven Way to Fight Cancer Through Physical Activity and Exercise, pp. 2-5)
Physical activity may boost the immune system’s ability to suppress cancer cells. When one exercises, weight and body fat can be reduced, which could produce a lower estrogen level. Exercise speeds the passage of food through the digestive system, possibly leaving less time for carcinogenic substances to damage the intestines and colon. How much exercise is necessary to impact one’s risk for cancer continues to be unknown.
The actual incidence of cancer fatigue varies, with reports ranging from 60 to over 90 percent. Fatigue may be a sign of the cancer itself or a side effect from cancer therapy. Besides tiredness, symptoms of fatigue can include nausea, stress, depression, anxiety, change in activity level or rest patterns, loss of appetite, and weight changes. Many cancer patients are more concerned about fatigue than they are about cancer pain. Exercise has helped many combat their fatigue. The following questions might help you evaluate your fatigue and plan a way to minimize it.
- How long have you felt this way?
- Does rest help?
- Does exercise help?
- When does it most often occur?
- What activities does it stop you from doing?
- When do you feel the best?
- How physically active are you?
- Have you spoken with your physician about your fatigue?
- Have you experienced a significant change in weight — either gain or loss?
- Could the fatigue be a complication of medications?
- Is the fatigue due to the disease process? Worry? Memory problems? Sleep deprivation?
- What have you tried that has been effective?
- How long was it effective or has it been effective?
- What has happened to make it no longer effective?
If you are experiencing fatigue, talk with your physician to determinewhether or not medications may help your symptoms. The following tips may be helpful:
- Avoid lying in bed at night when alert, tossing and turning.
- When you can’t sleep, get out of bed and maybe even go to a different room. Don’t read or watch television in bed.
- Sometimes it is helpful to take a shower or hot bath in the middle of the night. When you return to bed, you may sleep better.
- Consider playing music or listening to tapes that put you to sleep.
- Avoid eating sugar, especially chocolate, prior to bedtime.
Instead of counting sheep, you might want to list three beautiful things you have seen that day. Once you have identified those, add three sounds you remember hearing, three feelings you are experiencing at the present moment, and three things for which you are thankful. If you are still awake, list five beautiful things you have seen that day, five sounds you remember hearing, five feelings you are experiencing, and five things for which you are thankful. Listing these items often helps you direct your thoughts from worries to gratitude, and results in a peaceful sleep. Write down worries that keep you from sleeping. Identify those beyond your control. When you can’t sleep, get out of bed, read your list, acknowledge those that you cannot alter. For the items where you can make a difference, think about what you can do. Think also about what you don’t want to do, that maybe you could do, but choose not to. Log your levels of fatigue. On a scale of one to ten, how tired are you? Write your level of fatigue on the Daily Exercise Plan located at the end of this pamphlet. Monitor your changes. Hopefully this log will show your improvements over time, indicating that your exercise has helped.
Another concern is your added risk of infection. White blood cells (neutrophils) help to protect your body from infection and disease. When white blood cell counts drop below a normal range, it is called neutropenia. With this condition, your body has less ability to fight infection. If your absolute neutrophil count is less than 1,000, your immune system is temporarily compromised and you should exercise at home. Do not work out aggressively if you have an infection or a fever. Some sports should be avoided, such as swimming and using community exercise equipment.
Platelets are important for blood clotting. Alter your workout if your platelet count drops below 50,000. Intense exercise could cause bruising or bleeding. When platelet counts fall below normal range, it is called thrombocytomenia.
Keep careful records of your workout and share them with the clinicians planning your healthcare. In addition, you might also want to consult a physical therapist or an exercise physiologist to assist you in establishing your exercise regimen.
Eating well is especially important. The American Institute for Cancer Research has suggested that we reduce the intake of total dietary fat from the current average of approximately 37 percent to a level of 30 percent or less of our total caloric intake. In particular, we should reduce our intake of saturated fat to less than 10 percent of our total calories. We should increase the amount of fruits, vegetables, and whole grains that we eat. Salt-cured, salt-pickled, and smoked foods should be consumed only in moderation. Alcohol should be consumed only in moderation, if at all. Eat fresh or frozen foods, rather than canned or packaged ones. Read labels carefully for fat, sugar, and sodium content.
Increase fiber. Eat less red meat and more fish and skinless poultry. Eat breakfast every day. Consult a nutritionist for your special needs.
Many cancer patients take herbal supplements. Consult your cancer care specialist before taking a supplement, as they could have side effects with the medications you are taking.
Weight gain occurs in 70 percent of women undergoing treatment for breast cancer. People often think that those on chemotherapy loose weight due to nausea and decreased appetite; this is generally not the case. Women who gain weight after diagnosis have poorer survival rates compared to women whose weight remains stable. Exercise can help guard against weight gain as a result of cancer treatment.
Cancer Pain is Very Frightening
Many people with cancer pain are frightened. They choose not to talk about their pain for fear that it is an indication of advanced disease. Increased mobility can sometimes reduce pain. Physical therapists can provide exercise programs to restore strength, increase range of motion, and improve endurance. Other physical exercises, such as walking programs and programs provided in fitness centers, have also been shown to be beneficial. Weights, upper and lower extremity fitness equipment, TENS units, pool therapy, myofacial release, therapeutic touch, ultra sound, treadmills, exercise bikes and universal gyms — all could be appropriate in treating patients with cancer pain, as long as the program is individualized for you. Talk to your doctor about the possibility of a physical therapy consult.
Log your level of pain, again according to a ten-point scale. Does exercise help relieve or worsen that pain? Record your pain level in the Daily Exercise Plan provided at the end of this pamphlet. You might want to share these numbers with your healthcare provider.
|No Pain||Medium Pain||Worst Pain Imaginable|
Ready Set Go!
You are now able to begin your workout. Start with a warm-up. This might be as simple as walking in place or moving your arms up and down. This simple activity prepares your body for exercise by increasing blood flow to the working muscles and connective tissue. The duration of the warm-up will depend on the intensity of your workout as well as your own fitness level.
After the aerobic warm-up activity, incorporate flexibility or stretching exercises. Stretching muscles after warming them up with low-intensity aerobic activity will produce a better stretch since the rise in muscle temperature and circulation increases muscle elasticity, making them more pliable.
Stretching increases flexibility and may prevent muscle strain. Never bounce or force a stretch. Hold for about 15 to 20 seconds — to mild discomfort, not pain, to enhance flexibility. Stretching should be relaxing, not painful. Stretching, yoga, tai chi, qui gong, and Pilates exercises can improve balance and flexibility.
One aim of exercise is to increase your body’s capacity to breathe oxygen in, and to increase the capability of your heart and circulatory system to supply blood and oxygen to all organs and tissues. Monitor your heart rate by checking your pulse or by using a heart rate monitor. This is a good way to tell if you are staying at appropriate exercise intensity levels. To determine your target heart rate, simply subtract your age from 220. For example, if you are forty, your age-predicted maximum heart rate is 180.
Some researchers suggest that when cancer patients exercise above 65 percent of their maximum heart rate, fatigue levels may increase. After treatment, above 65 percent is encouraged (60-80 percent). Exercising above 80 percent of your maximum heart rate is not recommended for three to six months following treatment.
Resistance training, especially lifting weights, improves muscle strength. It is important to complement cardiovascular training with stretching and resistance training. Strength training uses either the body’s own weight or the resistance provided by weights or bands, to apply stress to the bones by way of the muscles. Muscle strengthening increases your muscle mass, which boosts your body’s resting metabolic rate and helps you burn calories more efficiently and keep your blood sugar in check. Weight training can increase strength, muscle, and bone mass more rapidly than walking can.
Before initiating a weight program, become familiar with the equipment. Attend a training session or get help from an instructor or weight trainer. Warm-up your arms and legs before you lift weights. Only you can determine how much weight you can lift. Start with two or three sets of eight slow repetitions, and gradually add more repetitions as your strength increases. Do not advance beyond four sets and/or 20 repetitions. Rest between sets, and try to breathe naturally during the exercise. Lift and lower slowly and smoothly. Exhale as you lift, inhale as you lower the weight. Stop if you feel any pain. Sore joints mean you have overdone it. Stretch after your workout to increase flexibility.
Water or pool exercises may restore mobility, build strength, and increase endurance. The buoyancy of water reduces the stress on weight bearing joints, bones, and muscles. For this reason, it is unlikely that a water workout will result in an injury or leave you with sore muscles. Water exercise can encompass all of the components of fitness: cardiovascular fitness, muscular strength and endurance, and flexibility. Many classes are suitable for non-swimmers and are offered at indoor and outdoor sites.
Exercise vs. Energy
If you have exercised at the proper intensity, you should feel energized, not exhausted afterwards. Some muscle soreness is natural with a new activity. If you experience soreness that persists longer than 72 hours, listen to your body. Identify what hurts. Is there pain or swelling in your joints? Did you exercise too much? Does your form need to be corrected? Are you performing an activity that may be harmful to you? Perhaps the activity needs to be modified to suit your needs.
Five signs that you are working hard enough:
- You feel energized and a little hungry after your workout.
- You’re sweating.
- Your heart rate and breathing are noticeably faster than usual.
- You can feel your mood lift.
- You want to keep on going because you are not bored or stressed.
Four signs that you worked too hard:
Log your level of exertion, again using a ten-point scale.
|No Exertion||Moderate Exertion||Maximum Exertion|
Your target pace should be between four and six. If you are working at more than a level of seven, you are working too hard and may experience increased fatigue.
Continuing an exercise program is more difficult than initiating an exercise routine. People discontinue exercising for numerous reasons. Some don’t notice significant benefits from the program; others experience injury. Activities other than exercising may take priority. The exercise program might not have been enjoyable. It might have been too challenging or too easy. Somehow it didn’t fit into the person’s lifestyle and provide sufficient rewards. If your personal plan of exercise doesn’t work, keep revising it until it does. You might need to change the type of activity, the time, or the intensity until you find a plan that works for you.
Congratulate yourself on your efforts! Applaud yourself and pat yourself on the back for a job well done.
Connie Carson, Ph. D. Healthcare Consultant Denver, CO
Susan Lasker-Hertz, RN, MSN, AOCN Oncology Network Director, HealthONE Denver, CO
Pat Stanfill-Edens, RN, MS, MBA, CHE Assistant V. P., Quality Department Intn’l Oncology Service Line Director HCA, Inc., Nashville, TN
With technical assistance from:
Michelle Lefevre, BS, ACSM Certified Director of Business Development/Sports Medicine Program HealthONE Clinic Services Denver, Colorado
Libby Matern, MSPT Director of Orthopedic Program and the Institute for Limb Preservation HealthONE, Presbyterian/St.Luke’s Hospital Denver, Colorado
Gail Keeley breast cancer survivor, member of Rocky Mountain Team Survivor and tri-athlete
Alois Jay Nagle Exercise Physiologist
HealthONE Aurora, Colorado Completed Cancer Exercise Specialist training at the Rocky Mountain Cancer Rehabilitation Institute, University of Northern Colorado, Greeley, Colorado.
Susan Blue, PT HealthONE, Presbyterian/St.Luke’s Rehabilitation and Sports Medicine Center Denver, Colorado Completed Cancer Exercise Specialist training at the Rocky Mountain Cancer Rehabilitation Institute, University of Northern Colorado, Greeley, Colorado.
Copyright © 2002 HCA Cancer Care, All Rights Reserved.
All content, including the artwork, is the property of HCA Cancer Care, an affiliate of HCA. Inc. Permission to copy any portions of this work should be obtained from HCA Cancer Care.
All references to “HCA,” “HCA Cancer Care” or the “Company” in this document refer to HCA Inc., and/or its affiliates, as applicable.
Breast Fitness, An Optimal Exercise and Health Plan for Reducing your Risk of Breast Cancer Anne McTiernan, M.D., Ph.D.; Julie Gralow, M.D.; and Lisa Talbott, M.P.H. St. Martin’s Griffin, New York, October 2001
The Force Program: The Proven Way to Fight Cancer Through Physical Activity and Exercise Jeff Berman; Fran Fleegler, M.D.; and John Hanc Ballantine Books, New York, October 2001
The Strength for Living Book: Planner and Guide Ortho Biotech Inc., 2000
Personal Options for Wellness, Exercise and Rehabilitation offers individualized assessment, goal setting and exercise plans monitored by cancer exercise specialists. For more information, contact Michelle LeFevre, BS, ACSM Certified, Director of Business Development/Sports Medicine Program, HealthONE Clinic Services, Denver, Colorado at 303-584-8000.
Team Survivor USA offers a variety of free exercise programs for women cancer survivors in all stages of treatment and recovery. Programs are designed for any fitness level and include strength training, walking, cycling, hiking, swimming, and yoga. Programs may vary in each city. For more information, go to www.teamsurvivor.org or call 310-829-7849.
In the Denver metro area, Rocky Mountain Team Survivor information is available at www.rockymtn-teamsurvivor.org or call Connie Carson at 303-798-7614.
The Susan G. Komen Breast Cancer Foundation 5005 LBJ Freeway, Suite 250 Dallas, Texas 75244 800 I'MAWARE ® (800.462.9273) www.komen.org The Susan G.Komen Breast Cancer Foundation, working through a network of U.S. and interna-tional Affiliates and Komen Race for the Cure ® 5K fitness runs/walks, is fighting to eradicate breast cancer as a life-threatening disease by supporting research, education, screening and treatment projects around the world.
YWCA Encore Program, started in the 1970s, focuses on water exercise for breast cancer survivors who want to restore strength in the upper body and regain range of motion. Classes offered are suitable for non-swimmers and are conducted at YWCAs throughout the U.S.
Casting For Recovery PMB-257 946 Great Plain Avenue Needham, MA 02492-3030 888-553-3500 www.castingforrecovery.org. Casting For Recovery offers FREE fly-fishing retreats for women recovering from breast cancer.