Jim received a referral for a client with bladder cancer. He’s a PT assistant and has been a Cancer Exercise Specialist for three years, but this is his first client with bladder cancer. He asked if he could hire me to help him with and teach him how to put together Jen’s exercise program. He completed her initial assessment and health history and shared the following information with me:
- Jen is 67 years old and not in the best shape prior to her cancer diagnosis
- Jen is 5’2 and currently 168 lbs. She has 35% bodyfat
- Jen has osteoarthritis and has been swimming at the local YMCA for the past 5 years. Prior to her cancer diagnosis she did two water weights classes per week and swam laps for 1/2 hour three times per week. She also has osteoporosis in her lumbar spine.
- She was diagnosed with stage three bladder cancer in June 2018.
- She completed chemotherapy in December 2018, but has yet to feel like herself again. She is tired all the time and has a hard time getting out of bed in the morning.
- Following chemotherapy to shrink her tumor, she underwent a radical cystectomy in March 2019. Since she was already menopausal, the fact that she had her ovaries, uterus, and part of her vagina removed was not that traumatic for her. She has a vertical incision from her naval to her pubic bone. She can not stand completely erect and the forward hip flexion is putting added stress on her lower back. She had 15 inguinal lymph nodes removed. She is able to urinate normally following her neobladder reconstruction in May 2019.
- Jen has Stage II lymphedema in her right groin and upper thigh area. She receives complete decongestive therapy (CDT) once a week and wears a compression stocking at all times except when showering.
- She is on Fosomax for her osteoporosis. Jim reminds her that she must remain in a upright position for 30 minutes after taking it. She is struggling with joint pain throughout her body. She has occasional nausea and diarrhea.
- Her BP is 140/85 and her RHR is 78. She just started taking Atenolol (Beta Blocker).
- She has not done any exercise since her diagnosis because she is afraid of being in more pain or hurting herself. Her doctor recommended that she see a CES to begin a safe exercise program.
Postural Assessment:
- Severe upper-crossed syndrome
- Forward flexed at the hips
- Both knees medially rotated
- Medial knee rotation on squat test
- Arms fall forward and bend on squat test
- She has moderate winged scapula on both sides
- She meets the 90% requirement in all planes of motion so there is no reason she can’t begin upper-body weight training.
- She has neuropathy in both feet and struggles with her balance from that and the lymphedema.
- Since she has been prescribed a compression stocking, she must wear it to exercise. Jim lets Jen know up front that if she does not wear it to training that he will have to cancel their session. Jen’s doctor did give her permission to exercise in the pool because her blood counts are back to normal. She may remove her stocking in the water only.
Jim is overwhelmed with the combination of her health history, comorbidities, and physical assessment. He is not sure where to begin.
I started by compiling my own notes and breaking everything down for Jim one step at a time.
- Because Jen has lymphedema in her right groin and upper thigh, Jim will begin every session with a five-minute upper body ergometer workout. This will allow Jen to effectively warm-up her body in preparation for exercise without putting any more stress on her lower body. He will make sure that she stays hydrated, exercises in a cool environment, doesn’t wear restrictive clothing on her lower body, and doesn’t overheat. Following her warm-up Jim will have her lie in supine position and perform the series of lower body lymph drainage exercises. Jen will only begin with 1/2 hour sessions. Jim will need to make sure that Jen feels more energy (Rather than being exhausted) following each workout. He will allow time in between exercises and ask her how she is feeling every few minutes. If she appears to be struggling, he will have her perform deep breathing exercises and do some assisted stretching. He will need to monitor her swelling to make sure that it does not get worse. If there is an increase in swelling it may mean that they are doing too much too fast. Therefore, they will progress very slowly to see what her lymphatic system can handle. She may begin performing strength training for her upper body with special attention being paid to her muscle imbalances.
- Because she has neuropathy in her feet, Jim will need to choose lower body exercises that don’t increase her pain or put her at risk for falling. He also needs to make sure to start and progress slowly with both cardio and lower-body exercises to make sure there is not an increase in swelling.
- Because Jen underwent chemotherapy, she is at a higher risk for diabetes, future cancers, and damage to the heart and lungs. Her weight is a big concern for many reasons – heart disease, future cancers, diabetes, etc… Jim refers Jen to a registered dietician who works with cancer patients at the local hospital. The combination of a proper diet, cardio, and increasing lean muscle mass through strength training should help to improve her body composition and minimize the risk of additional comorbidities.
- On days that Jen has diarrhea, she will need to avoid exercise for 24-36 hours and make sure that she re-hydrates and replenishes electrolytes. If he has spells of nausea, Jim will have her stop exercising, sit down, and drink water. If the feeling does not pass, he will suggest that she go home.
- Jim will incorporate upper-body strength training to help increase her bone density, and cardio to help strengthen her heart and lungs.
- Because of the upper-crossed syndrome, Jen needs to stretch both her pecs and lats. She should avoid isometrics due to her high BP and Jim will teach her how to use the Borg scale of perceived exertion since taking her heart rate will not provide an accurate account due to her medications. She should focus on shoulder retraction and depression to stabilize her shoulder girdle. That will also help with the winged scapula, but Jim is going to have her do ceiling punches in a supine position to help strengthen her serratus muscles. He will start by having Jen lie supine and reach her arms and legs in opposite directions to stretch her abdomen. If she can do that with no pain, he will progress her to the top of a BOSU(R) Balance Trainer. To strengthen the opposing low back muscles, he will start with pelvic tilts. He has to be careful to not have her do too much weight-bearing on her legs because of the lymphedema He might start her with one or two reps of “bird dog.” Because of the osteoporosis in her lower back Jim would normally have her do stair climbing, jumping, jump rope and other high impact activities. This, however, would be ill-advised with her lymphedema and nueropathy. He will work with her to teach her the fundamentals of functional exercises that she will need on a daily basis. Proper squatting in order to bend or pick something up will be critical. He is going to introduce her to a yoga therapist at his gym who specializes in working with mature adults. She will teach Jen some safe yoga moves that if done consistently, may help to improve her bone density as well. She must not flex or bend her spine forward. Backward bending or leaning back however reduces stress on the front of the spine.
- After Jim completed the Modified Thomas Test on Jen, he was able to determine that her left & right adductors are tight. Therefore, he would need to focus on hip abduction and avoid hip adduction-type exercises. He will need to avoid using exercise bands or having her perform any type of exercise that applies too much pressure to the affected leg. They will begin with body-weight exercises like squats. Because she does not have good balance, he will have her hold on to a stable bar or counter top to begin with. As she improves and feels more confident, she can begin to perform them without holding on. Jim should always be right there to spot her.
- Jim wants to get Jen in a swimming pool ASAP. He knows that the warm water will be great for her arthritis and that the hydrostatic pressure of the water will be great for her lymphedema. She will also start to hopefully feel like her old self and be energized by the comraderie of the group class.
Once I gathered my thoughts, I was able to come up with the following workout routine for Jim to facilitate with Jen for her initial 6-8 weeks.
DAILY lower extremity lymph drainage exercises. These should be done before and after exercise sessions (can be done more often if desired). She can NOT do crunches because of her osteoporosis. She can do a few more pelvic tilts instead. Jen will use the upper body ergometer for 5 minutes a day, working up to 10-15 minutes each day as tolerated. If her energy is really low, she can break this into 5-minute increments (or whatever she can do without becoming more fatigued). Done properly, Jen should feel energized. Each cardio session should end with lower body lymph drainage exercises. If there is no additional swelling, Jen may increase either intensity or duration – in very small increments. She should not wear tight fitting clothing on her lower body or exercise in very hot/humid temperatures. She should also stay well-hydrated. If at any point there is an increase in swelling, Jim will instruct Jen to return to the level of intensity and duration that she was at prior to the increase in swelling. Jim also wants her to incorporate water jogging as an alternative to her lap swimming days. Balance exercises will be critical. She must make sure that she has something stable to hold on to, or always has a spotter.
2 x PER WEEK Lower-body strength training – starting with functional training. Jim will place his hands gently on the lateral side of Jen’s knees and instruct her to do squats while gently pushing laterally against his hands. They will aim for 3-5, but stop if Jen gets too fatigued. Jim will have her do clams on each side. He will place a pillow under her head and make sure her spine is in alignment they will aim for 3-5 reps. on each side. Fatigue will be the determining factor for both reps and resistance as they progress. Jeff needs to make sure that whatever they do gives Jen more energy rather than causing her to be more fatigued as well as making sure there is no additional swelling in her groin/leg.
On two of the non-leg days Jen will do exercises to stretch the chest and lats, head retractions (forward head), and adductor stretches. She will begin with reverse flys using a yellow figure eight band and sitting in an upright bench. Jim will teach her how to stabilize her shoulder girdle and engage her core while performing 5-6 reps to begin with. He will have her lie supine with her knees bent and start her with 2 lb. weights for chest flys. They will start with 5-6 reps and work on her form. They will add reps and resistance as her energy level and strength increases.
She will do one private yoga class at her discretion each week.
Jim will re-assess Jen in 8 weeks and either continue with this routine, or progress to longer duration of cardio, more repetitions, and the addition of more strength training exercises.
If you are in need of assistance with a special-needs or physically-challenged client, you can get Andrea Leonard’s help in with custom exercise programming