Customized Exercise Programming – Pancreatic Cancer

Blog, Patients, Professionals, Uncategorized

Customized Exercise Programming - Pancreatic Cancer

Customized Exercise Programming – Pancreatic Cancer

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.

John is 64 years old, smokes a pack of cigarettes daily, and typically has 2-3 alcoholic beverages per night. He has had Type II Diabetes for the last five years and is on Metformin/Rosiglitazone.

  • John is 5’10 and currently 198 lbs. He has 35% body fat
  • Since his Diabetes diagnosis in 2018, he had begun walking 3 miles daily, 6-7 days a week. He also had been going to a yoga class twice a week.
  • He was diagnosed with pancreatic cancer in July 2022 and suffers from severe depression. While his prognosis is better than most, he has a relatively low chance of surviving 5+ years. He is on Sertraline for his depression and is seeing a psychiatrist weekly.
  • He underwent a Whipple Procedure 8/1/2022 and has suffered from early dumping syndrome since then. He is also having a more difficult time managing his blood-glucose levels.
  • He is currently undergoing chemotherapy and will have his last treatment in December.
  • His BP is 130/85, and his RHR is 80.

Postural Assessment:

  • 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 the left leg (ACL reconstruction in 2010)
  • Arms fall forward on the squat test
  • He has some difficulty with balance due to peripheral neuropathy in her feet and struggles with fine motor skills due to peripheral neuropathy in her hands.
  • He has Stage 1 lymphedema in his left leg. He has been prescribed a compression stocking and must wear it to exercise. Will let John know up front that if he 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 notes and breaking everything down for Will one step at a time.

  1. Because John has a large vertical incision in his abdomen, he cannot stand erect due to a combination of fear and scar tissue that has built up.
  2. Because he has mild lymphedema on his left leg, Will must incorporate lower extremity lymph drainage exercises before and after each exercise session. His upper body exercises will work towards correcting postural deviations but will not impact his 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, John may even see a reduction in the swelling.
  3. Because John is undergoing chemotherapy, he will be at a greater risk for osteoporosis and damage to his heart and lungs.
  4. Will will incorporate strength training to help prevent osteoporosis and cardio to help strengthen her heart and lungs; both cardio and strength training will help to increase lean muscle mass and decrease his body fat percentage. This is critical in preventing heart disease, controlling his diabetes, and possibly future cancers.
  5. Because of the peripheral neuropathy in his feet, Will has to ensure that cardio is done with little to no impact. He must also make sure to minimize his risk of falling due to his 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 his lower extremities. Riding the recumbent bike will minimize his risk of falling and will eliminate the potential pain and discomfort of weight-bearing. 
  6. Because of the upper-crossed syndrome, John needs to stretch both his pecs and lats while strengthening the scapular stabilizers. He should avoid pushing exercises like push-ups and chest presses and focus on shoulder retraction/depression, rowing, and maybe reverse flys.  He should do shoulder protraction exercises like ceiling punches or wall push-ups for his winged scapula. He must take into consideration that he could have difficulty holding weights or bands, and that could be dangerous for both of them. Will begins with isometrics and teaching kinesthetic awareness and gradually moves on to manual resistance and machines as tolerated. Until he can stand erect, he should not do any “crunch-type” exercises as they will only exacerbate his flexed-forward stance. In the interim, he should stretch his torso while strengthening the opposing lower back muscles. He can also work on his core through balance exercises seated or supine on the exercise ball and foam roller. Standing balance exercises can be incorporated based on his discomfort/pain from neuropathy and should be progressed/regressed accordingly.
  7. Will is recommending that John be fitted for walking shoes that will cater to his 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 to stabilize his ankles and feet.
  8. After Will completed the Modified Thomas Test on John, he determined that his left abductors are tight. Therefore, he would need to focus on hip adduction and avoid hip abduction-type exercises. He will avoid bands or weighted pressure on his legs to avoid restricting lymphatic flow.
  9. Because John has early dumping syndrome, Will has instructed him to eat two hours before working out to avoid side effects such as rapid heart rate and low blood pressure.
  10. Because lactic acidosis is a potential side-effect of his Diabetes meds, Will tells John that if he has any of the following side effects, he needs to get emergency medical help: muscle pain or weakness, numb or cold feeling in his arms and legs, trouble breathing, stomach pain, nausea with vomiting, slow or irregular heart rate, dizziness, or feeling very weak or tired. If he has vomiting or diarrhea (from his depression or diabetes meds), he will need to avoid exercise for 24-36 hours, rehydrate, rest, and replenish electrolytes.
  11. Because he is currently undergoing chemotherapy, they will need to figure out the best schedule for John based on his “good days and bad days.” Will takes all precautions for working with a client who is immunocompromized.
  12. He will also encourage John to stop drinking alcoholic beverages as it is a contraindication for both of his medications as well as chemotherapy, and may help with regulating his 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 John for his 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). He can do these alternative crunches that will be better for his neck and not require full flexion like a sit-up or even a crunch. Following the lymph drainage exercises John can do various core exercises that Will instructs him to do safely and effectively. I suggested that they begin with marching in place on an exercise ball (Will can place one of his hands on John’s left medial knee and instruct him 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. John can do chest flys while lying supine on a foam roller (starting with isometrics only), focusing on a broad range of motion and opening up the chest. He should avoid any type of “pushing” exercise until his posture is ‘corrected.’  Will incorporates some rowing and reverse flys (using machines) to avoid injuries due to the neuropathy in his hands. There is no risk of lymphedema with his upper body, so Will gradually increase reps, resistance, and sets as John’s energy level and muscle soreness dictate.

Lower-body strength training – squats are critical for activities of daily living. Will works with John on form and correcting lateral knee rotation and tight abductors on the left leg.  Because of the lymphedema, he 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 John’s left knee and instructs him 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 John’s legs, which is contraindicated because of the lymphedema. Will has John perform “clams” (no band) lying on his 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 John in 8 weeks and either continue with this routine or progress to a longer duration of cardio, more repetitions and the addition of more strength training exercises.

Will teaches John how to use the BORG Perceived Exertion scale to help determine exercise intensity since some of his medications and treatment may affect his heart rate.

 

ALTERNATING DAYS (or as tolerated) –

Johnhas purchased a recumbent bike for cardio. Will has instructed him to take notice of any additional leg swelling and end each session with his lymphatic drainage exercises. Each walk should end with lower body lymph drainage exercises. If there is no additional swelling, John may increase either intensity or duration – in tiny increments.  He should not wear tight-fitting clothing on his lower body or exercise in very hot/humid temperatures. He should also stay well-hydrated. If at any point there is an increase in swelling, Will has instructed John to return to the level of intensity and duration that he was at before the increase in swelling. Will is also suggesting that John works with a registered dietitian or nutritionist who specializes in working with cancer patients, that can put together a healthy plan for John to gain lean muscle and lose the extra body fat. This is outside Will’s scope of practice as a personal trainer and Cancer Exercise Specialist.

If you need assistance with a special-needs or physically-challenged client, you can get Andrea Leonard’s help in with custom exercise programming.