Customized Exercise Programming – Cervical Cancer

Sharon received a referral for a client with invasive cervical cancer. She’s a physical therapist but has worked mostly with orthopedic patients. She recently became a Cancer Exercise Specialist and asked if she could hire me to help her with and teach her how to put together Melinda’s exercise program. She completed her initial assessment and health history and shared the following information with me:

Melinda is 37 years old and a triathlete prior to her cancer diagnosis
Melinda is 5’7 and currently 128 lbs. She has 10% bodyfat
Melinda has competed in 10 full and two half triathlons in the past 10 years. Prior to her cancer diagnosis she ran at least ten miles per day and did light weights once or twice a week.
She was diagnosed with stage one cervical cancer in June 2019.
She underwent a total abdominal hysterectomy and had 15 pelvic lymph nodes removed. She also had a radical trachelectomy on July 6, 2019 and began walking (per her doctor’s instructions) one week after surgery. She has worked up to three miles a day but struggles with fatigue and bone and muscle pain. She wants to begin core exercises but is afraid to do anything that will cause her any more pain.
She is undergoing immunotherapy with monoclonal antibodies and radioactive molecules (Zevalin)
Her BP is 110/65 and her RHR is 48
Her doctor recommended physical therapy for pelvic floor strengthening.

Postural Assessment:

Mild upper-crossed syndrome
Forward flexed at the hips (large vertical incision in abdomen)
Left knee medially rotated
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. This is a new concern for her.

I started by compiling my own notes and breaking everything down for Sharon one step at a time.

Because Melinda is at risk for lymphedema in her pelvis and either leg, Sharon will begin every session with a five-minute upper body ergometer workout. This will allow Melinda to effectively warm-up her body in preparation for exercise without putting any more stress on her lower body. It is also safer for her until they figure out why she has neuropathy and get it under control. She will make sure that Melinda stays hydrated, exercises in a cool environment, doesn’t wear restrictive clothing on her lower body, and doesn’t overheat. Following her warm-up Sharon will have her lie in supine position and perform the series of lower body lymph drainage exercises. Melinda will only begin with 1/2 hour sessions. Sharon will need to make sure that Melinda feels more energy (rather than being exhausted) following each workout. She will allow time in between exercises and ask Melinda how she is feeling every few minutes. If she appears to be struggling, she will have her perform deep breathing exercises and do some assisted stretching. If there is an increase in girth measurements in her lower body, 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. Since she is beyond the 6-week mark, there is no longer a 10 lb. weight restriction.
Melinda has been struggling with vomiting and diarrhea from her treatment. On days that she has either, Sharon has instructed her to cancel her sessions and avoid exercise for 24-36 hours while resting, rehydrating, and replenishing her electrolytes. If she is running a fever, she needs to notify her doctor right away.
Because she has neuropathy in her feet, Sharon suggests that she get tested for diabetes. In the meantime, she will need to choose lower body exercises that don’t increase her pain or put her at risk for falling. She 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.
Sharon will incorporate upper-body strength training to help increase her bone density; she is at a higher risk for osteoporosis since she is now menopausal.
Because of the upper-crossed syndrome, Melinda needs to stretch both her pecs and lats. She should focus on shoulder retraction and depression to stabilize her shoulder girdle. That will also help with the winged scapula, but Sharon is going to have her do ceiling punches in a supine position to help strengthen her serratus muscles. She will start by having Melinda lie supine and reach her arms and legs in opposite directions to stretch her abdomen. If she can do that with no pain, she will progress her to the top of a BOSU(R) Balance Trainer. To strengthen her opposing low back muscles and pelvic floor muscles, she will start with pelvic tilts and bridges. Sharon has to be careful to not have her do too much weight-bearing on her legs because of the risk of lymphedema. She might start her with one or two reps of “bird dog.” Over time, Sharon will have her do stair climbing, jumping, jump rope and other high impact activities to strengthen her bones. The goal is to get her back to triathlon training by the beginning of 2020. Right now, this would be ill-advised with her risk of lymphedema and neuropathy in her feet. Sharon will teach Melinda some safe yoga moves that if done consistently, may help to improve her bone density as well.
After Sharon completed the Modified Thomas Test on Melinda, she was able to determine that her left adductors are tight. Therefore, she would need to focus on hip abduction and avoid hip adduction-type exercises on the left leg. She will need to avoid using exercise bands or having her perform any type of exercise that applies too much pressure to the legs because she does not want to interfere with circulations that could ultimately lead to lymphedema. They will begin with body-weight exercises like squats and lunges; starting with just a few repetitions and seeing what she can tolerate.
Sharon wants to get Melinda in a swimming pool ASAP. She knows that the hydrostatic pressure of the water will be great for her lymphedema and she can get her jogging in the water (making her feel like she’s working toward her goal of running again) and beginning to do laps as well.

Once I gathered my thoughts, I was able to come up with the following workout routine for Sharon to facilitate with Melinda 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 crunches once she can stand erect without forward hip flexion. She can do a few more pelvic tilts for now. Melinda will either walk or use the upper body ergometer for 5 minutes a day, working up to 20-30 minutes each day as tolerated. If her energy is really low, she can break this into 5-10 minute increments (or whatever she can do without becoming more fatigued). Done properly, Melinda should feel energized. Each cardio session should end with lower body lymph drainage exercises. If there is no swelling, Melinda 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 girth measurements, Sharon will instruct Melinda to return to the level of intensity and duration that she was at prior to the increase in swelling. Sharon also wants her to incorporate balance exercises while she struggles with neuropathy.

2 x PER WEEK Lower-body strength training – starting with functional training. Sharon will place her hand gently on the lateral side of Melinda’s left knee and instruct her to do squats while gently pushing laterally against her hand. They will aim for 3-5 but stop if Melinda gets too fatigued. Sharon will have her do clams on each side. She 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. Sharon needs to make sure that whatever they do gives Melinda more energy rather than causing her to be more fatigued as well as making sure there is no swelling in her groin/leg.

On two of the non-leg days Melinda 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 band and sitting in an upright bench. Sharon will teach her how to stabilize her shoulder girdle and engage her core while performing 5-6 reps with her palms facing the ceiling (this will help with scapular stabilization and strengthening) to begin with. She will have her lie supine with her knees bent and start her with 2 lb.

weights for chest flys. She will start with 5-6 reps and work on her form. They will add reps and resistance as Melinda’s energy level and strength increases.

She will do one private yoga class at her discretion each week.

Sharon will re-assess Melinda 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

Customized Exercise Programming – Cervical Cancer