Cancer survivor rehabilitation (FS-26)

Focused symposium
Monday 13 May 2019, 15:45-17:15
Room W+X

Drouin J1Morris GS2, Newstead AH3Speksnijder CM4 
1Oakland University, Physical Therapy, Rochester, United States, 2Wingate University, Physical Therapy, Wingate, United States, 3 Audie Murphy Veterans Administration Hospital, San Antonio, TX (WOC) and AHNew Physical Therapy (Private Practice), Helotes, TX, San Antonio, TX, United States, 4The Netherlands University University Medical Center; University of Utrecht, Physical Therapy, Utrecht, Netherlands

Learning objective 1: Administer safe, effective physiological (aerobic capacity and strength) and functional capacity assessments.
Learning objective 2: Develop/implement safe, efficacious exercise prescriptions from assessment findings.
Learning objective 3: Recognize/respond to indications, precautions, and contraindications to exercise testing and training.
Description: Introduction: Cancer survivors can be poorly conditioned from their disease, its treatment and lifestyle behaviors. Deconditioning increases the symptom burden and risk for frailty, disability and chronic disease, thus influencing life expectancy. Minimizing deconditioning through exercise testing, prescription and training are vital oncology pre-/rehabilitation components. However, exercise testing responses and training adaptations among cancer survivors may not be similar to healthy individuals. Therefore, this symposium will provide evidence-based methods for exercise testing, prescription and training protocols in this population. The American College of Sports Medicine's 2018 update for exercise testing, prescription and training for people with cancer will be summarised and explained.1,2 
Aerobic exercise capacity assessment: Exercise assessments are selected based on an individual's goals.2 To promote maintenance and prevent deconditioning, functional assessments (ADLs) or short walking tests are used with vital signs monitoring. To promote health and wellness or higher performance, assessments include standardized exercise tests and/or exercise safety questionnaires. The validity and reliability of standardized exercise tests for individuals with a cancer diagnosis are not established and may over or underestimate fitness levels.2,3 Therefore, test outcomes are best used as a guideline for training and patients require monitoring during initial training sessions to adapt exercise prescriptions.2,3 For sedentary individuals or those with cardiovascular risks, standardized instrumented exercise protocols are preferred for determining the safety, efficacy and intensity for training. Since cardiovascular disease risks increase following cancer treatment, screening for heart disease is essential and abnormal exercise responses require referral to a physician. Precautions and contraindications to exercise include shortness of breath, pallor, extreme fatigue, nausea, vomiting, dehydration, ataxia, bruising or bleeding, sudden weight loss, disorientation and unexplained pain.2,4-6 Pain symptoms associated with cancer treatment may impact upon an individual's adherence to treatment or their ability to undertake exercise as part of cancer rehabilitation. Exercise may prevent such pain.4-6
Aerobic Training and Considerations: For deconditioned individuals, exercise prescriptions begin with bed or chair activities and light resistance, advancing to well-tolerated standing or ambulation activities.2, 3 The exercise prescription duration is 3-5 minutes several times per day to build stamina, the frequency is daily, and the intensity is guided by vital signs monitoring.3 Resistance training is recommended at least two days per week and tailored to an individual's needs. Patient education for self-advocacy includes normal and abnormal responses to training and when to seek professional care. For apparently healthy individuals with normal vital signs and no risk factors, exercise prescriptions follow recommended guidelines for frequency, intensity and duration.3 
Exercise training adaptations may be diminished among cancer survivors as tumors and chemotherapy impair heart and skeletal muscle function. Heart rate variability and maximal heart rates are reduced; lowering exercise tolerance.7 Cardiorespiratory fitness improvements may be lower at 6-8% compared to 15-20% in healthy sedentary individuals. Cardiovascular efficiency demonstrated by reductions in resting heart rate and blood pressure may not be observed following training.2,8 Cancer survivors may report lower ratings of perceived exertion by 1-2 categories compared to what is expected for measured exercise intensities.9 Disease and treatment comorbidities including fatigue, peripheral neuropathies, balance deficits, muscle loss, pain and osteoporosis may affect test and training outcomes and require safety adaptations.4,5 Factors such as client choice to continue working concurrently with cancer treatments as well as psychosocial variables may affect exercise prescriptions.4,5 Weight and BMI do not consistently improve with aerobic training, and muscle mass may not consistently increase; therefore, resistance training is essential in comprehensive exercise programs. For clinical practice applicability, future research must include minimal detectable differences and minimal clinically important differences in training outcomes.
Advanced Head and Neck Cancer (HNC) with Chemo-radiotherapy (CRT) negatively impacts physical functioning, body composition, fatigue and health related quality of life (HRQoL). Unintentional weight loss, particularly lean body mass, often occurs despite nutritional support making physical exercise vital for maintaining and rebuilding muscle mass.10 Evidence suggests exercise interventions during chemotherapy positively affect physical functioning, fatigue and HRQoL. HNC patients may also benefit from exercise during CRT.10 Exercise programs require tailoring to HNC patients' preferences and abilities during CRT.
Implications / Conclusions: Appropriate exercise levels are vital to optimise recovery and reduce symptom burden and risks related to deconditioning from cancer and its treatment. Evidence-based exercise assessment, prescription, and training expectations provide safe, efficient and effective pre-/rehabilitation experiences and outcomes for individuals in cancer survivorship. 
Key-words: 1. Oncology Rehabilitation 2. Exercise 3. Cancer
Funding acknowledgements: 
Relevance to physical therapy globally: Regardless of their geographic location, cancer survivors are typically deconditioned, increasing their symptom burden and risk for developing physical and psychosocial impairments and disabilities. Participation in reconditioning programs is paramount, however the medical complexity of many survivors makes successful participation in such programs challenging. This symposium will introduce clinicians to evidence-based interventions for implementing safe and efficacious reconditioning programs to improve quality of life in cancer survivorship.
Target audience: Physical Therapists, Physical Therapist Assistants, Exercise Physiologists, other Exercise Professionals, Rehabilitation Nurses, Oncologists, and Physiatrists