About 25-30 percent of women treated for breast cancer develop lymphedema, an accumulation of excess lymphatic fluid that causes arm swelling. Lymphedema can develop at any time – soon after surgery or radiation or many months to years later. Doctors do not fully understand why some patients are more likely to have problems with lymphedema than others.
Exercise training is emerging as a complementary treatment for breast cancer, as recent research suggests that exercise is feasible and can help manage negative psychological and physiological side effects associated with cancer diagnosis and treatment.
The American College of Sports Medicine (ACSM) guidelines for exercise prescription can be followed with a few modifications:
- Frequency:3-7 days/week (depending on intensity and duration)
- Intensity:40-80% aerobic capacity or heart rate reserve
- Duration:20-40 minutes of aerobic activity
For this population, a variety of modalities for aerobic activity are appropriate, such as walking, biking, rowing, swimming and stationary cardiovascular equipment. Intensity and duration depend on the woman’s current health status and exercise capacity. If the participant has been inactive for a long time, she should be encouraged to start slowly at 40-50 percent of aerobic capacity for 10 to 20 minutes and gradually work up to 75-80 percent of aerobic capacity for 30-40 minutes as tolerated.
Benefits of Exercise
Exercise training during and following cancer treatment is associated with many benefits including:
- Enhanced functional capacity
- Greater muscle strength
- Increased flexibility
- Increased range of motion of the affected shoulder
- Attenuation of weight gain associated with chemotherapy
- Decreased fatigue associated with chemotherapy and radiation therapy
- Less incidence of nausea during chemotherapy
- Improved sleep patterns
- Enhanced psychological well-being
- Improved quality of life
Who Should Exercise? Women with breast cancer should discuss their participation in an exercise program with their physician and be screened to ensure safety and provide appropriate exercise prescriptions. In screening, a common mistake is to focus exclusively on the cancer while overlooking other health concerns that can affect exercise programming. Post-menopausal breast cancer patients can have other comorbid conditions such as heart disease, chronic obstructive pulmonary disease, diabetes, hypertension and arthritis. Thus, screening for cardiovascular risk, injury history, arthritis and other underlying medical conditions is important to develop the safest exercise program.
Most women with breast cancer can start exercising once they have recovered from surgery. Typical goals for women undergoing treatment are to maintain strength, endurance and functional ability and to minimize side effects. For women who have finished their treatment, goals may shift to improving functional ability and fitness.
Resistance and flexibility exercises also are very important for this population. Both should include exercises for the major muscle groups with some additional exercises for the shoulder area. General guidelines for flexibility and resistance training are appropriate
- Frequency: at least 2-3 days per week
- Intensity: to a position of mild discomfort
- Duration: 10 to 30 seconds for static stretches
- Frequency: 2-3 days per week
- Intensity: 12-15 repetitions (see precautions for shoulder area)
- Duration: 1-3 depending on goals
Fitness Assessment and Exercise Prescription
Women with breast cancer can perform the same fitness assessments and exercise programs as other health/fitness clients with few modifications. To help develop an appropriate exercise prescription, fitness assessments should include measurements of resting heart rate and blood pressure, body composition, strength, flexibility and aerobic capacity. Assessment of shoulder range of motion and strength may determine if the breast cancer survivor has any deficits of the affected side and thereby would need specific exercises or a referral to physical therapy.
Aerobic, flexibility and resistance activities should be incorporated into the exercise program. Exercise can be performed at home or in a fitness facility. Many women with breast cancer enjoy exercising with a group of other breast cancer survivors.
The shoulder area may have some limitations in range of motion and strength as a result of surgery. Consequently, additional stretching exercises for flexion, abduction and internal and external rotation may be indicated.
The major concern with resistance training of the affected arm and shoulder is its possible role in triggering lymphedema. Consequently, breast cancer patients are instructed to limit the amount of weight lifted in upper body exercises-however, this recommendation is based on conventional wisdom rather than scientific evidence.
Some experts believe that gradual progression of flexibility and resistance exercises can help women regain their normal range of shoulder and arm movement and may help to prevent lymphedema by pumping lymph fluid out of the arm through the undamaged lymph vessels.
Women should follow a systematic and progressive plan. Progression of exercises should be gradual, depending on tolerance, from the use of no resistance to limb/body weight for resistance, easy resistance bands, challenging resistance bands, free weights, and possibly the use of strength training machines. If a woman cannot complete at least 10 repetitions, the resistance should be decreased. Once she can do 15-18 repetitions, either add another set or increase the load.
The fitness professional should monitor each step in the progression to ensure that the affected arm and shoulder are ready and capable of the next level of resistance. The participant may have different abilities on the affected side compared to the unaffected side. In this case, the use of different resistance in each arm is appropriate.
Women who exercise while undergoing treatment may have to vary their workouts on a day-to-day basis as fatigue and other side effects affect their ability to workout. It is important for fitness professionals to take stock of their client’s overall condition prior to each workout and make modifications – or even suggest skipping a workout – if necessary.
October is Breast Cancer Awareness month and all across North America thousands of teams are racing and fund raising to advance public awareness, contribute to research efforts and assist survivors. For Kathy Levy of Hamilton, every month is Breast Cancer Awareness Month.
Since being diagnosed with Lupus at age 11 and then Breast Cancer, Kathy has stubbornly refused to give up being active. Shortly after the Breast Cancer diagnosis, Kathy found Dr. Don MacKenzie, a British Columbia exercise physiologist who has organized Dragon Boat Racing teams for Breast Cancer survivors. Dragon Boating, a very physically demanding upper body activity for the average, usually young individual, is now attracting 40-70 year olds who have had major, invasive upper body surgery. It was just what Kathy was looking for.
Kathy founded the “Knot a Breast” paddling team now consisting of over 80 members who are out training rain or shine. They wear black and white as compared to the traditional pink in recognition that men also suffer from Breast Cancer. When asked recently where she gets her inspiration, she replied from her team members and their dedication to overcoming their own hardships. One woman recently came up to her after a race, and told her that she was not supposed to have been here this year…but was now looking forward to next year. This is where I get my strength, says Kathy.
Kathy was forced to stop paddling recently. Instead of retiring from Dragon Boating, she started coaching and continues to work hard at her “floating” support group. Life is really worth fighting for says Kathy Levy.
Fitness professionals should be aware that each type of breast cancer treatment requires special consideration when the patient is exercising.
Chemotherapy: Women should not exercise immediately prior to chemotherapy or 24-48 hours afterwards.
- Women are at increased risk of dehydration and should be encouraged to drink plenty of fluids before, during and after exercise.
- Women who are nauseated or lose their appetite should be encouraged to eat a few hours before exercising.
- Women who have a port implanted should allow the incision to heal before exercising in a pool.
- Women experiencing fatigue should decrease intensity and or duration.
Radiation therapy: Women experiencing fatigue should decrease intensity and or duration.
- If burns to local tissue areas are present, discontinue pool use until burns have healed and modify other exercises to avoid irritating burn areas, e.g., modify or discontinue arm motion.
Hormonal therapy: Few modifications are necessary. If joint pain occurs, water activity may be a good option.
Participants with lymphedema should be referred to their health care providers, and the fitness professional should follow up to determine if exercise prescriptions must be altered. For mild symptoms, gentle stretching and decreased resistance exercise on the affected side are the first adjustments. For severe symptoms, discontinue upper-body exercise until symptoms resolve or the client has been cleared to exercise by her health care provider or physical therapist.
Specific adjustments on cardiovascular equipment for patients with lymphedema include not gripping the side railings on treadmills and stepping machines, allowing the affected arm to “ride along” (not actively pushing or pulling) on equipment such as total-body cross-trainers and limiting or discontinuing use of rowing machines. Pool activity provides an excellent alternative.
Women with breast cancer often have several unique concerns that are mainly focused on a new body awareness during treatment and recovery. These issues may become obstacles for women considering exercising in a health/fitness facility. For some women, body image is an issue when changing in public areas such as locker rooms. Others may have to address what to wear on their heads while exercising (wig, scarf or nothing) or how to handle a prosthetic breast or radiation burns.
Fitness professionals can play an instrumental role in developing a comfortable environment where women feel free to participate and get the assistance they may need. Some tips for dealing with these specific issues are listed below:
Environment: Provide private changing areas.
- Encourage a clientele mix that includes other clinical populations who may make some participants feel more comfortable.
Headwear: For women who lose their hair: Wigs are hot and do not allow for proper heat dissipation during exercise. Wearing scarves and light hats are options that work well in air-conditioned environments, keeping the head warm while allowing for heat dissipation.
Prosthetic breast: Can be uncomfortable when exercising because it does not always move with the body when exercising. Encourage women to exercise without it if it becomes uncomfortable.
- Can be buoyant in the pool. Swimsuits are available that can secure the prosthesis in place.
Exercise training is safe and effective for women with breast cancer. This population can show tremendous progression when participating in a consistent, well-designed exercise program. Ultimately, working with clients with breast cancer can be very rewarding for fitness professionals.
Ann Ward, Ph.D., FACSM, is an Associate Faculty Associate in the Department of Kinesiology at the University of Wisconsin-Madison. Jackie Kuta Bangsberg, M.S., Clinical Exercise Physiologist, Cathy Burt, B.S., Exercise Specialist, and Lisa Sanborn, B.S., Exercise Specialist, are at UW Health Sports Medicine Center, a clinic of the University of Wisconsin Hospital and Clinics. Sponsored by Life Fitness.