Khiarica received a referral for a client with melanoma. She has been a Cancer Exercise Specialist for two years, and this is her first client with melanoma. She asked if she could hire me to help her with Mort’s exercise program and teach her how to put the program together. She completed his initial assessment and health history and shared the following information with me:
- Mort is 78 years old and not in the best shape prior to his cancer diagnosis. He has COPD and Type II Diabetes.
- Mort is 5’11 and currently 210 lbs. He has 24% bodyfat
- Other than slow walks with his dog, Mort did not exercise regularly prior to his diagnosis
- He was diagnosed with stage II melanoma following an incisional biopsy and sentinel node biopsy on his left shoulder in July 2019. He had 6 positive lymph nodes.
- He is currently undergoing chemotherapy. He is tired all the time and has a hard time getting out of bed in the morning because he often has nausea and vomiting.
- He takes Metformin for his diabetes and Albuterol because he struggles with breathlessness upon exertion from his COPD.
- His BP is 135/85 and his RHR is 88. It has become elevated from Albuterol. The Albuterol also causes some shakiness.
- He has not done any exercise since his diagnosis
- Severe upper-crossed syndrome
- Moderate anterior pelvic tilt
- Struggles with balance particularly on left leg
- Left knee laterally rotated (had ACL reconstruction 20 years ago)
- Lateral knee rotation (L) on squat test
- Arms fall forward and bend on squat test
- He has limited flexion, abduction, and external rotation in his left arm/shoulder
- She has slight in both hands and struggles with fine motor skills.
- Since he is at risk for lymphedema in his left arm, Khiarica takes his initial baseline measurements, teaches him about pitting edema, and gives him a printout of ways to prevent lymphedema.
Khiarica is a bit overwhelmed with the combination of his health history, comorbidities, and physical assessment. She is not sure where to begin.
I started by compiling my own notes and breaking everything down for her one step at a time.
- Because Mort is at risk for lymphedema in his left arm/shoulder and upper thigh, Khiarica will begin every session with a five-minute warm-up on the recumbent bike. This will allow Mort to effectively warm-up his body in preparation for exercise. She will make sure that he stays hydrated, exercises in a cool environment, and doesn’t overheat. Following his warm-up Khiarica will have him perform the series of upper body lymph drainage exercises. Mort will begin with 1/2 hour sessions. Khiarica will need to make sure that Mort feels more energy (rather than being exhausted) following each workout. She will allow time in between exercises and ask him how he is feeling every few minutes. If he appears to be struggling, she will have him perform deep breathing exercises and do some assisted stretching. She will need to monitor him for swelling to make sure that things remain the same. If there is any swelling, she will tell Mort to see his doctor right away for evaluation and require a medical clearance form when her returns. Then they will progress very slowly to see what his lymphatic system can handle. He may begin performing strength training for his lower body with no lymphedema-based limitations.
- Because he has neuropathy in his hands, Khiarica will need to chose upper body exercises that don’t put him at risk for dropping the weights or letting go of the bands. She will focus on machines for his upper-body workout. She also needs to make sure to start and progress slowly with both cardio and upper-body exercises to make sure there is not an increase in his baseline measurements.
- Because Mort is undergoing chemotherapy, he is at a higher risk for diabetes, future cancers, and damage to the heart and lungs. His weight is a big concern for many reasons; heart disease, future cancers, diabetes, etc… Khiarica refers Mort 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 his body composition and minimize the risk of additional comorbidities.
- On days that Mort has vomiting, he will need to avoid exercise for 24-36 hours and make sure that he re-hydrates and replenishes electrolytes. If he has spells of nausea, Khairaica will have him stop exercising, sit down, and drink water. If the feeling does not pass, she will suggest that he go home.
- Khiarica will also incorporate lower-body ‘functional’ exercises, particularly squats to help increase his bone density and perform activities of daily living. She will have him squeeze a ball between his legs while performing squats to help strengthen the adductors and correct his lateral knee rotation. She will also work with him to stretch his left ITB on the foam roller. Cardio will help to strengthen his heart and lungs.
- Because of the upper-crossed syndrome, Mort needs to stretch both his pecs and lats. He should focus on shoulder retraction and depression to stabilize his shoulder girdle. To strengthen the opposing upper/middle back muscles he will start with rows and reverse flys at a very low weight and just a few repetitions. She has to be careful to not have him lift too much weight with his upper body because of the risk of lymphedema. Becuase his range of motion is not limited in extension, she feels comfortable with this plan. She wants to add external rotation, but must get him to 90% of normal range of motion prior to adding a load; this will apply to any exercises in flexion or abduction as well.
- He will need to avoid using exercise bands or having him perform any type of exercise that applies too much pressure to the affected arm/shoulder.
- After Khiarica completed the Modified Thomas Test on Mort she was able to determine that his left abductors/ITB are tight. Therefore, he would need to focus on hip adduction and avoid hip abduction-type exercises.
- Khiarica wants to get Mort in a swimming pool ASAP. She knows that the hydrostatic pressure of the water will be great for preventing lymphedema and that movement in the warm water will help him to regain range of motion in his affected shoulder. She must wait until Mort’s blood counts are in normal range again. It will probably be several months after he completes chemotherapy. In the meantime she will have him perform side and front walks for flexion and abduction as well as exercise to improve external rotation. Once I gathered my thoughts, I was able to come up with the following workout routine for Khiarica to facilitate with Mort for his initial 6-8 weeks.
DAILY upper extremity lymph drainage exercises. These should be done before and after exercise sessions (can be done more often if desired). He should do alternative crunches because of his severe forward head. Mort will use the recumbent bike for 5 minutes a day, working up to 10-15 minutes each day as tolerated. If his energy is really low, he can break this into 5 minute increments (or whatever he can do without becoming more fatigued). Done properly, Mort should feel energized. Each cardio session should end with upper-body lymph drainage exercises. If there is no swelling, Mort may increase either intensity or duration – in very small increments. He should not exercise in very hot/humid temperatures and should stay well-hydrated. If at any point there is an increase in his original girth measurements on his affected arm, Khiarica will instruct Mort to return to the level of intensity and duration that he was at prior to the increase in swelling. Balance exercises and core exercises will be critical for fall and injuryt prevention. She must make sure that he has something stable to hold on to, or has a spotter until he feels more confident in his abilities.
2 x PER WEEK Lower-body strength training – starting with functional training. Khiarica will place a ball or pillow in between the medial side of Mort’s knees and instruct him to do squats while gently squeezing against the ball or pillow. They will aim for 5-6, but stop if Mort gets too fatigued. Khiarica will also have him do side-lying adduction/leg raises. She will place a pillow under his head and make sure his spine is in alignment. They will aim for 8-10 reps on each side. Fatigue will be the determining factor for the number of reps as they progress. Khiarica needs to make sure that whatever they do gives Mort more energy rather than causing him to be more fatigued.
On two of the non-leg days Mort will do exercises to stretch the chest and lats, head retractions (forward head), and abductor/ITB foam rolling. He will begin with isometric reverse flys while sitting in an upright bench. Khiarica will teach him how to stabilize his shoulder girdle and engage his core while performing 5-6 reps to begin with. She will have him perform Cybex rows using the lowest weight and just a few repetitions to begin with while working on his form and kinesthetic awareness. They will add reps and resistance as his energy level and strength increases and in the absense of swelling i the affected arm/shoulder.
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.