Aerobic Component

The aerobic component is a vital element of one's rehabilitation. In general, you should try to include a 20 to 30 minute aerobic activity into your daily activities. If to0 difficult, break a walk, for example, into two 10 minute phases, one in the morning and one at night. In addition to a stand alone aerobic component, an aerobic activity serves as a warmup to a more complete exercise session including strength and flexibility. In this context, the aerobic phase serves three functions: as a warmup, cardiorespiratory fitness and weight management. (Note that for some, losing weight may not be advisable but rather maintenance of, or gain weight may be advised.) The type of exercise chosen depends on your fitness level and the one you like to do. One of my favorite sayings is. "The best exercise is the one you'll do." Implicit in that is doing it consistently. Therefore, if you like to walk, that is the best one, if you like to swim, that is the one. Others include biking and a variety of aerobic machines such as rowing machine or an elliptical trainer. An advantage of using whole body machines such as an elliptical trainer or rowing machine is that in addition to elevating your heart rate, you are also warming up many major muscle groups in both the upper and lower body.

Warmup

The warmup prepares the body for the exercise that follows and is composed of both general and specific components. The general warmup incorporates a 1o-15 minute cardiorespiratory activity such as treadmill, cycling, elliptical trainer, followed by general stretching of major muscle groups of the body, particularly those of the shoulder, back and abdominal areas. The is followed by a warmup that is more activity specific and involves stretching of the specifc muscle groups that you will be using and followed by light sets of the first exercise of the activity you'll perform. This will help you practice the movement to follow thereby increasing your efficiency with heavier weights.

Exercise Prescription: Introduction

The following exercise prescription is a menu of options specific to the needs of breast cancer. The exercises will be broken down into three general phases: the aerobic phase, flexibility, strength building or maintenance. These will be followed by a cool down. Exercise at your own level of tolerance. That means the length of time, how hard you do it and the number of times per week. That said, remember that while you don't want to overdo it, you must not underdo it. Gains are only made by stressing your system or systems,  albeit incrementally. 

Precautions

Neutropenia
Neutrophils are the most common type of white blood cell (WBC) and plays an important role in the defense against bacterial infections. (There are several kinds of white blood cells, including monocytes, lymphocytes, neutrophils, eosinophils, and basophils.) Neutropenia is a decrease in neutrophil cell counts in the blood and is a common side effect of chemotherapy for many forms of cancer, including breast cancer, lung cancer, lymphomas and leukemias. Neutropenia and a susceptibility to infection is a primary reason patients cannot adhere to their chemotherapy regimen. Neupogen and Neulasta are medications that stimulate the production of blood forming protein CSF thereby elevating WBC and have proved effective against it. In cases of neutropenia it may be wise to avoid public areas including an exercise center during the flu season and use anti-bacterial soap after using exercise equipment. Mild to moderate joint pain is a common side affect and one that may preclude weight bearing exercise.

Precautions

With physician approval regarding an adequate recovery from surgery, possible complications from any metastasis and your blood counts there are few precautions to take when exercising. However, the following may be helpful to those who may be concerned about the possibility of lymphedema and to those who have had breast reconstruction.

Lymphedema
Lymphedema is a swelling of the affected arm due to lymph channels becoming blocked often as a result of surgery, axillary lymph node dissection and radiation. While many women are justifiably concerned about lymphedema, high level vigorous and repetitive activity of the upper-extremity have been shown not lead to lymphedema (Physician and Sport Medicine, August, 2002). However, if the lymphatic channels are impaired due to treatment, caution may need to be taken with heavy weights as it may lead to inflammation with the lymphatic fluid backing up in the arm. (Sander T, PT, personal correspondence, December 9, 1999). The wearing of a compression sleeve during exercise is suggested. Similarly, if swelling occurs in the hands and wrist, try wearing spandex biking gloves. Also, when working in the garden hands and arms should be protected from infection with gloves and long sleeves.

Breast Reconstruction
For those with breast implants and living tissue reconstruction strength training can usually be resumed within 12 to 16 weeks. It is, however, particularly important that you check with your surgeon before beginning your program. To those who have had the TRAM flap procedure moderate abdominal exercises should only be performed. Heavy lifting such as small children, or heavy laundry should also be restricted for about three to four months. Swimming is particularly recommended. Remember to “walk tall” with your shoulders back.

Exercise Goals for Breast Cancer cont.

3. Correct Postural Imbalance
Just as many favor one arm to the detriment of the affected arm, many patients carry one's shoulder forward or carry the involved arm close to the body resulting in postural imbalance. This, in turn, further limits shoulder flexibility. Similarly the loss of a breast without reconstruction or prosthesis often results postural imbalance.

4. Weight Management
Weight gain frequently occurs as a result of hormonal therapy such as the use of tamoxifen, and inactivity and has been associated with the likelihood of recurrence and lymphedema.

5. Manage Hypercalcemia
Certain types of cancer, particularly lung and breast cancer, as well as some cancers of the blood, such as multiple myeloma, stimulate the release of calcium from bones into your blood. This is known as hypercalcemia Spread of cancer to the bones also increases the risk of hypercalcemia. Moderate weight bearing exercises like walking and moderate closed chain exercises such as free weights to maintain bone density is suggested.

Exercise Goals for Breast Cancer

In general, primary exercise goals for breast cancer rehabilitation include maintaining one's range of motion or flexibility in the shoulder area, maintaining or regaining one's strength and weight management.

1. Flexibility
A primary goal is to maintain or increase the range of motion around the shoulder joint. Tumor removal, axillary dissection and radiation often result in skin tightness, scarring and the all of which can affect range of motion in the shoulder area. Surgery such as a mastectomy and radiation can also result in frozen shoulder which is a tightening of the capsule around the shoulder due to shortening of the tendons and ligaments. This, in turn, can limit movement for extended periods which often compounds the problem.

2. Strength
A related goal is the maintenance of strength of strength around the shoulder joint and the arm. Unless, it is a radical mastectomy, loss of strength is generally due to lack of use resulting in the weakening of shoulder muscles and the shortening of connective tissue. Many women will, unfortunately, limit the use of the affected arm due to a fear of lymphedema (to be discussed in a later posting). The foregoing reduces the ability to perform many daily activities again resulting in decreased strength.

Breast Cancer

Breast cancer is the leading cancer for women but one with a high survival rate. It is also the cancer type that lends itself most directly to therapeutic exercise. Depending upon the diagnosis, treatment may involve a lumpectomy, a simple or modified radical mastectomy or on occasion a radical mastectomy. In these later cases many younger women may opt for breast reconstruction. During initial surgery, lymph nodes in the axilla or underarm area are often removed for staging purposes. The recent use of sentinal node biopsies reduce the need for the the removal of many lymph nodes thereby limiting scarring. Breast cancer may spread by seeding to adjacent areas or metastasize to adjacent areas to through the blood vessels and/or lymph vessels. The most common sites of distant metastasis for breast cancer are the bones, lungs, liver and occasionally the brain. Treatments commonly include radiation therapy, chemotherapy and hormone therapy such as tamoxifen with two or more methods often being used in combination.