Will received a referral for a client with pancreatic cancer. He’s been a Cancer Exercise Specialist for three years, but this is his first client with pancreatic cancer. Although it was caught earlier than most, Will is unsure if he can handle the emotional component that goes along with a pancreatic cancer diagnosis, not to mention the actual exercise programming. He asked if he could hire me to help him with and teach him how to put together Jane’s exercise program. He completed her initial assessment and health history and shared the following information with me:
- Jane is 51 years old, smokes a pack of cigarettes per day and typically has 2-3 alcoholic beverages per night. She has had Type II Diabetes for the last five years and is on Metformin/Rosiglitazone.
- Jane is 5’5 and currently 178 lbs. She has 35% bodyfat
- Since her Diabetes diagnosis in 2014, she had begun walking 3 miles per day 6-7 days a week. She also had been going to a water-aerobics class twice a week.
- She was diagnosed with pancreatic cancer in July 2019 and has been suffering with severe depression. While her prognosis is better than most, she has a 45% chance of surviving 5+ years. She is on Sertraline for her depression and is seeing a psychiatrist weekly.
- She underwent a Whipple Procedure 8/1/2019 and has suffered with early dumping syndrome since then. She is also having a more difficult time managing her blood – glucose levels.
- She is currently undergoing chemotherapy and will have her last treatment in December.
- Her BP is 130/85 and her RHR is 80.
- Moderate upper-crossed syndrome and winged scapula
- Flexed forward at the hips due in part to the large vertical incision extending from her sternum to her pubic bone.
- Both feet supinate
- Lateral knee rotation on left leg (ACL reconstruction in 2010)
- Arms fall forward on squat test
- She has some difficulty with balance due to peripheral neuropathy in her feet and struggles with fine motor skills do to peripheral neuropathy in her hands.
- She has Stage 1 lymphedema in her left leg. She has been prescribed a compression stocking and must wear it to exercise. Will lets Jane know up front that if she does not wear it to training that he will have to cancel their session.
Will was concerned about making the lymphedema worse and working with someone with early dumping syndrome.
I started by compiling my own notes and breaking everything down for Will one step at a time.
- Because Jane has a large vertical incision in her abdomen, she is unable to stand erect due to a combination of fear and scar tissue that has built up.
- Because she has mild lymphedema on her left leg, Will needs to incorporate lower extremity lymph drainage exercises before and after each exercise session. Her upper body exercises will work towards correcting postural deviations, but will not impact her lymphedema. On the other hand, he will need to start and progress slowly with lower body exercises and make sure that there is no increase in swelling. With proper exercise programming, Jane may even see a reduction in the swelling.
- Because Jane is undergoing chemotherapy, she will be at a greater risk for osteoporosis and damage to her heart and lungs.
- Will will incorporate strength training to help prevent osteoporosis, cardio to help strengthen her heart and lungs, both cardio and strength training will help to increase lean muscle mass and decrease her body fat percentage. This is critical in the prevention of heart disease, controlling her diabetes, and possibly future cancers.
- Because of the peripheral neuropathy in her feet, Will has to make sure that cardio is done with little to no impact. He must also make sure to minimize her risk of falling due to her poor balance. He will probably begin with a recumbent bike. Another option would be an upper body ergometer if one is available; minimizing the risk of increasing the swelling in her lower extremities. Normally he would suggest for her to continue with her water aerobics, but her immune system is compromised and that is contraindicated. Riding the recumbent bike will minimize her risk of falling and will eliminate the potential pain and discomfort of weight-bearing.
- Because of the upper-crossed syndrome, Jane needs to stretch both her pecs and lats while strengthening the scapular stabilizers to help correct round shoulder syndrome and the winged scapula. She should avoid pushing exercises like push-ups and chest press and focus on shoulder retraction/depression, rowing, and maybe reverse flys. She should do shoulder protraction exercises like ceiling punches or wall push-ups for his winged scapula. He must take into consideration that she could have difficulty holding weights or bands and that could be dangerous for both of them. He will begin with isometrics and teaching kinesthetic awareness and gradually move on to manual resistance and machines as tolerated. Until she can stand erect, she should not do any “crunch-type” exercises as they will only exacerbate her flexed-forward stance. In the interim, she should be stretching through her torso while strengthening the opposing lower back muscles. She can also be working on her core through balance exercises seated or supine on the exercise ball and foam roller. Standing balance exercises can be incorporated based on her discomfort/pain from neuropathy and should be progressed/regressed accordingly.
- Will is recommending that Jane be fitted for walking shoes that will cater to her over-supination. He will also include exercises that will include stretches for the calves, shins, ankles, and achilles tendons. He will also incorporate glute and hip strengthening exercises that will bring greater stability to her ankles and feet.
- After Will completed the Modified Thomas Test on Jane he was able to determine her left abductors are tight. Therefore, she would need to focus on hip adduction and avoid hip abduction-type exercises. He will avoid bands, or weighted pressure on her legs to avoid restricting lymphatic flow.
- Because Jane has early dumping syndrome, Will has instructed her to eat two hours prior to working out in order to avoid side-effects rapid heart rate and low blood pressure.
- Because lactic acidosis is a potential side-effect of her Diabetes meds, he tells her that he she has any of the following side effects she needs to get emergency medical help;muscle pain or weakness, numb or cold feeling in your arms and legs, trouble breathing, stomach pain, nausea with vomiting, slow or irregular heart rate, dizziness, or feeling very weak or tired. If she has vomiting or diarrhea (from her depression or Diabetes meds), she will need to avoid exercise for 24-36 hours, re-hydrate, rest, and replenish electrolytes.
- Because she is currently undergoing chemotherapy, they will need to figure out the best schedule for Jane based on her “good days and bad days.” Will will take all precautions for working with a client who is immunocompromized.
- He will also encourage her to stop drinking as it is a contraindication for both of her medications as well as chemotherapy, and may help with regulating her blood sugar and weight loss as well.
Once I gathered my thoughts, I was able to come up with the following workout routine for Will to facilitate with Jane 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 do these alternative crunches that will be better for her neck and not require full flexion like a sit-up or even a crunch. Following the lymph drainage exercises Jane can do a variety of core exercises that Will instructs her to do safely and effectively. I suggested that they begin with marching in place on an exercise ball (he can place one of his hands on her left medical knee and instruct her to gently press inward to correct over-abduction and lateral rotation of the knee) and lying supine on a foam roller – marching in place. Will has included door stretches (chest), head retractions (forward head), end-to-end stretch for abdominals, calf, shin, ankle, adductor, and achilles stretches.
2 x PER WEEK Upper-body strength training – starting very basic. Jane can do chest flys while lying supine on a foam roller (starting with isometrics only), focusing on broad range of motion and opening up the chest. She should avoid any type of “pushing” exercise until her posture is ‘corrected.’ Will incorporated some rowing and reverse flys (using machines) to avoid injuries due to the neuropathy in her hands. There is no risk of lymphedema with her upper body so Will can gradually increase reps, resistance, and sets as Jane’s energy level and muscle soreness dictate.
Lower-body strength training – squats are critical for activities of daily living. Will works with Jane on form and correcting lateral knee rotation and tight abductors on the left leg. Because of the lymphedema, she will need to begin with just a few body-weight squats and make sure that there is no additional swelling. Will places his hands on the inside of Jane’s left knee and instructs her to gently push inward while doing squats. This will help to strengthen the adductor muscles. His initial instinct was to use a circular band around her legs, but that is contraindicated because of the lymphedema. Will has Jane perform “clams” (no band) lying on her side. He will start with a few repetitions on each side and make sure that there is not an increase in swelling following the workouts. They will start with only one or two repetitions of each and gradually add more as tolerated. Will plans on re-assessing Jane 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.
Will teaches Jane how to use the BORG Perceived Exertion scale to help determine exercise intensity since some of her medications and treatment may affect her heart rate.
ALTERNATING DAYS (or as tolerated) –
Jane has purchased a recumbent bike for cardio. Will has instructed her to take notice of any additional swelling in her legs and end each session with her lymphatic drainage exercises. Each walk should end with lower body lymph drainage exercises. If there is no additional swelling, Jane 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, Will has instructed Jane to return to the level of intensity and duration that she was at prior to the increase in swelling. Will also wants her to get back to water aerobics after she has completed chemotherapy and her blood counts are normal. The hydrostatic pressure of the water may help to manage her lymphedema and will also be a relief to her feet (non weight-bearing). Will is also suggesting that Jane work with a registered dietitian, or nutritionist who specializes in working with cancer patients, that can put together a healthy plan for Jane to gain lean muscle and lose the extra body fat. This is out of Will’s scope of practice as a personal trainer and Cancer Exercise Specialist.
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.