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Scott Webb (Host): Focused on getting you on the road to recovery, Franciscan Health Outpatient Rehabilitation, provides an assortment of therapies for patients with various diagnoses and work-related injuries, including outpatient, physical, occupational, and speech therapies. And joining me today to discuss Oncology Rehab and the role that physical therapists play in developing an exercise prescription and working with cancer patients well past recovery, is Paula Stout. She's a Board Certified Specialist in Oncologic Physical Therapy. This is the Franciscan Health Doc Pod. I'm Scott Webb. So, Paula, it's so great to have you on today. We're talking about exercise and cancer treatment and Oncology Rehab. So, lots to get through today. Want to start off by asking you, how does regular exercise help patients that are going through cancer treatment?

Paula Stout, PT, DPT, CLT-LANA (Guest): In talking about why exercise is important and how it helps cancer patients, I really want to start out with saying that we know that the number one side effects, the most common side effect of cancer and cancer treatments is cancer related to fatigue. And it's really not specific to any cancer diagnosis, but it impacts up to 96% of survivors.

And I honestly would say that I feel like it affects everybody who's affected by a cancer diagnosis. But it's really a distressing, persistent, subjective sense of physical and emotional and cognitive tiredness. And one of the most important considerations, and often even in helping to assist in the diagnosis is the fact that cancer related fatigue is not relieved by rest. A lot of times it doesn't make sense. Why am I still tired? And as I alluded to, we know that there's significant evidence that exercise is the number one treatment for cancer related fatigue. So, even if we just want to narrow it down to that specific side effect, we know that exercise helps and there are a lot of other side effects that I think we'll probably talk about as we move along here.

Host: That's very interesting that it's really this sort of overall, you know, mental, physical fatigue. And at least we have a sense now as we get rolling here, how exercise can help with that. Before we get too far along here, should exercises vary by diagnosis? And if so, maybe you can explain.

Paula: That's a really good question. The important thing to note is that it's really important for all cancer survivors, no matter where you are along the cancer care continuum, from diagnosis throughout survival, because we know that when someone starts treatment for cancer, that there will be sequelae that will happen. Okay. There might be chemo induced peripheral neuropathy. Well, then that starts to affect balance and things like that. There might be like I said, weakness or fatigue because certain chemotherapeutic drugs cause that, and actually affect the muscles on a cellular level.

So, we know there's going to be some weakness. What I think is important to answer this question is that this is the point where most of the time the individual needs to be seen by a physical therapist, someone who's trained in Oncology Rehab, because that's really what we do is we provide exercise prescription. So, a lot of times people hear exercise and it's like, oh, that's scary. That, or it sounds awful. You know? I don't feel good. I don't feel like getting off the couch. I mean, I'm sick from chemo and you're telling me I should exercise, but exercise is not just exercise. So, I think it's important that we prescribe the right exercise.

Host: I love the way you put that. It's an exercise prescription. That's such a great way to put that because we all know understand what an exercise is and a prescription, and it may vary by diagnosis. And as you say, you know, people just because of what they're going through, they may just not want to get off the couch, but it's important that they do. And along those lines, what happens when a patient doesn't get enough exercise?

Paula: Well, again, the fatigue is a huge thing, and even knowing that if you look at the statistics for the age of persons who are diagnosed with cancer, you know, there may already be comorbidities. There may already be some balance issues and some weakness and things like that. And so balance is a huge thing because the treatments often cause some balance deficits because of the neuropathy, but also just with those comorbidities. But another thing to note is that, think about it, if your muscles are weak, everything you do takes more effort, right? So, some of these weaknesses that ensue it's not that the person did anything wrong, it's just the effects of the treatments on their body. And, you know, the paradox that exists with cancer sometimes, is that oftentimes when a person is diagnosed with cancer, they feel pretty healthy. They feel pretty good. They're going about their day, doing their normal things. And that this is not always the case, but oftentimes it is.

And all of a sudden, now I have this diagnosis and now I start treatment. And the very treatment that's meant to save their lives is making them sick. And so this is where exercise comes in. And again, you know, you asked specific exercises, there are specific exercises for specific times throughout. I always tell my patients that the cancer treatment continuum is very dynamic. So, how you feel today might not be how you feel next week after you just had a chemo treatment. But then in a few days it's going to be different. So, that's where we really vary what we're doing along that continuum to make sure we're doing what we need to do, at the right time. But the important thing is the initial exercises that we might start with anyone going through treatment, there are things you can do, even when you don't feel good, again, even when you don't feel like getting off the couch. And I would like to talk some more about just general exercise guidelines too, as we go along.

Host: Yeah, let's do that. What are the most effective exercises? How long should a patient exercise every day? How many days per week? Let's go through this.

Paula: Perfect. That's really good. And so we know that it's important to engage in moderate intensity aerobic exercise. And I'll talk about that just a little more in a minute, and also some resistance exercises. And a really neat thing about that is also that the American College of Sports Medicine convened an international multidisciplinary round table to really look at the evidence and decide, okay, how does exercise really affect not just how you go through treatment, but survival. And so we had really good evidence in 2010 that came out, but even just in 2018, they looked at that evidence again. And we know that there's strong evidence for the protective effect of physical activity against certain cancers.

So, colon, breast, endometrial, kidney, bladder, esophageal, stomach cancer. And we know that there's moderate evidence that prediagnosis physical activity may reduce the risk of dying from cancer, especially in breast and colon cancer. So, it's important for everyone to think about the importance of maintaining physical activity. But there's also really good evidence that higher levels of physical activity post-diagnosis, are associated with lower risk of dying from certain cancers. So not just do we feel better, but we can help to reduce the risk of recurrence. And from this, looking at all the evidence and what they showed in 2018, is that moderate intensity, aerobic and resistance exercise three times a week for 30 minutes for at least eight to 12 weeks can really consistently improve treatment related symptoms and side effects and also help improve survival. So, if we look at our general guidelines for activity, we'd really like everyone to do 300 minutes of moderate intensity exercise a week.

So, instead of going to those things where you say, okay, you need to do 30 minutes a day. If we can kind of divide that up. But this shows that the 150 minutes a week is effective and that then even 90 minutes a week, when you're first going through treatment is effective. So, what's moderate intensity aerobic activity? Well, most people can walk. Okay. So, that's an aerobic type activity, unless there are other joint issues or reasons that we can't walk. And the important thing I always tell people is we have to start where we are, right? So, if we're sedentary and walking five minutes wears us out, you know what, that's where you start and you walk five minutes, two or three times a day, right. Or you just get up and down and you walk to your kitchen and back. So, I want to go back to 150 minutes a week of moderate intensity aerobic exercise, or if you like biking, if you like swimming and moderate intensity means I can carry on a conversation and get a little bit out of breath like I am right now because I'm talking so fast, but I can still carry on a conversation, right? I'm not working so hard that I can't breathe like this. And so that is how we configure moderate intensity. And then two days a week of resistance exercise. Again, when we talk about resistance, that might be biceps curls with a little three pound dumbbell. So, we're not thinking we have to go all out, we have to start. We have to meet the patient where they are.

Host: That's so great that patient centered approach. And as you say, we can be creative about this. Maybe you don't start with the dumbbells. Maybe you start with cans of soup or something in the pantry, you know, anything. Anything just to get going. And you mentioned in there about cancer survivors, and I'm assuming that it's important that the exercise plan regimen that have immediately following diagnosis and treatment that they keep that up. Right?

Paula: Absolutely. It's so important to continue and I always talk about too, that not only can we help to get survivors back to their previous level of activity, but often more, because this is a health wake up call, if you will, you know, saying, okay, if I do this, I'm going to feel better. I'm going to help reduce my risk of recurrence and continue to survive throughout survival.

Host: So. Yeah. And of course, all of us staying mentally and physically well, whether you're a cancer survivor or not, exercise plays a factor in there, certainly helps with fatigue and a multitude of other things other comorbidities as you've discussed. What are some of the precautions for cancer survivors that want to continue the exercise or anything they need to be aware of as they begin to maybe get stronger and feel more powerful and want to continue and build on the original exercise prescription? Anything they need to be on the lookout for?

Paula: I think just really paying attention to how they feel. Because again, that is a very broad question when we think about all the different diagnoses and the different pathways, you know, that happen. But if we really think about the fact that balance may become an issue, then they need to be aware that if I start to feel like, you know what, I'm not so steady on my feet, then they probably need to get back in with a physical therapist. Another big precaution would be those individuals who might have bone metastasis. And again, the great thing about this is that exercise can continue to help through even in these situations where there are metastases. But we have to be really careful that they're doing the right types of exercise and not to keep going back to this fact, but to keep going back to this fact, that it's such a dynamic process, that we really talk a lot about perspective surveillance, meaning we continue to see individuals at regular follow-ups. Just like your other doctors where you go for your regular follow-ups, with your oncologist and with your radiation oncologist and with your primary care provider and your surgeon. We tend to at least every three months, and again that's individualized, but we need to continue to see these individuals back in the clinic to say, okay, what else is going on? Also, for them to know that if you start to see problems with your balance, if you start to feel like, oh, I'm not getting around as well as I used to, I can't get in and out of the car or in and out of bed. Those types of things probably need to give us a call and get back in to be given maybe a little modification in the exercise prescription.

Host: Yeah, and it really seems like a cancer diagnosis is the beginning of a new journey for people. And it's really great to hear that physical therapists are there for cancer patients, cancer survivors, along this journey it doesn't just end when they maybe are cancer-free right? So, great to know. And as we wrap up here today, Paula, anything else you want people to know about Oncology Rehab and the role that you and other physical therapists play in helping people to recover and then continue to live their lives cancer-free hopefully?

Paula: I really think that the main takeaway point I would like to make is that Oncology Rehab should be involved from the time of diagnosis throughout the cancer care continuum, even in those individuals where we're talking about end of life, even in those diagnoses that we're not really looking for cure now, we're looking for quality of life as they continue to live the life that they have. And Oncology Rehab should be part of that. And I love that you used the word journey because for years, this is something that I say and I feel is that I'm, so I'm very honored to be a part of the journey with cancer patients in helping them to do better and feel better as they go throughout that continuum of care.

Host: That's well said, you know, do better, feel better and you are so compassionate and knowledgeable. Thank you so much for your time today. You stay well.

Paula: Thank you and you too.

Host: For more information, visit Franciscan health.org and search physical therapy and rehabilitation.

And if you found this podcast helpful, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.