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The Healing Powe
of Movement
 Also by Lisa Hoffman
Better Than Ever: The Four-Week Workout Program for Women Over 40
the healing Pow
of Movemen
How to Benefit from
Physical Activity During
Your Cancer Treatment

Lisa Hoffman, M.A.,

with Alison Freeland

PERSEUS P U B L I S H I N G
Cambridge, Massachusetts
Many of the designations used by manufacturers and sellers to distinguish their products are claimed
as trademarks. Where those designations appear in this book, and where Perseus Publishing was
aware of a trademark claim, those designations have been printed with initial capital letters,

Copyright © 2002 by Lisa Hoffman and Alison Freeland

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or other-
wise, without the prior written permission of the Publisher, Printed in the United States of America.

Cataloging-in-Publication Data is available from the Library of Congress

ISBN 0-7382-0540-0

Perseus Publishing is a member of the Perseus Books Group.

Visit us on the World Wide Web at http://www.perseuspublishing.com,
Perseus Publishing books are available at special discounts for bulk purchases in the United States by
corporations, institutions, and other organizations. For more information, please contact the Special
Markets Department at the Perseus Books Group, 11 Cambridge Center, Cambridge, MA 02142, or
call (800) 255-1514 or (617) 252-5298, or e-mail [email protected].

Text design by Reggie Thompson

Illustrations by Meryl Henderson
Set in 11 -point Berling Roman by Perseus Publishing Services

First printing, January 2002

1 2 3 4 5 6 7 8 9 10—040302
 In memory of those
who have included movement
to heal and gave dignity to their battle.
This page intentionally left blank
Vitality shows not only the ability to persist
but the ability to start over.
—F. Scott Fitzgerald
This page intentionally left blank
 A Note To The Reader

The ideas, exercises, and suggestions contained in this book are not intended as a
substitute for consulting with your physician or as medical advice. All matters re-
garding your health require medical supervision. All readers should consult with a
physician before proceeding with these exercises or suggestions. Any undertaking
of the exercises or suggestions in this book is at the reader's discretion and sole risk.

/x
This page intentionally left blank
 Contents

Foreword by Dr. Barrie Cassileth xiii

A Note from Dr. Stephen Nimer xv
Preface xvii

Introduction 1
1 How to Use This Book 7
2 Exercise and Cancer Therapy 9
3 How Much Should I Exercise? 13
4 From Your Diagnosis Forward 17
5 Bed Exercises: Feeling Lousy 23
6 Chair Exercises: Beginning to Move 39
7 Standing Exercises: Walking, Balance, Building Endurance 53
8 Stretching 67
9 Physical Activity Chart 75
10 Perspective 81

Bibliography 85
Acknowledgments 91

xi
This page intentionally left blank
 l-oreword

Decades ago, rehabilitation and quality of life were not the integral aspects of can-
cer care that they are today. We were unable to focus on living well with and after
cancer because too few patients survived the diagnosis. Today we have that luxury.
Close to 60 percent of Americans with cancer are cured. Literally millions of peo-
ple in the United States right now are under cancer treatment, in rehabilitation, or
working to prevent recurrence of their disease.
This book is about improving their strength and enhancing their quality of life. It
is a guide for those who have been diagnosed with cancer, who receive or have
completed treatment, and who are working their way back to normal, active lives.
It offers encouragement and guidance, showing patients that a level of beneficial
exercise can be accomplished no matter where they are in the battle against this
difficult complex of diseases.
Lisa Hoffman has developed creative exercises for every person facing cancer.
Described in words as well as easy-to-follow illustrations, her book is based on sub-
stantial experience and shows great sensitivity to the difficulties, motivation, and
restrictions experienced by cancer patients. These exercise regimens can be accom-
plished at every level, from diagnosis through treatment and recovery.
This book is also a testament to the fact that patients have active, important
roles to play in their own recovery. Exercise is an important component. Exercis-
ing to rebuild strength, flexibility, and coordination provides us with a powerful

xiii
xiv FOREWORD

means of control. We can contribute importantly to our own recovery. Exercise

also releases endorphins and makes us feel better—it enhances quality of life in
several dimensions.
A professional treatment regimen should be part of every patient's recovery pro-
gram. The value of this book lies in its careful, creative presentation of a program
that can fit the needs and capabilities of every cancer patient, regardless of stage of
treatment or rehabilitation. It is a great way to begin and an excellent guide all
along the road to recovery.
—Barrie R. Cassikth, Ph.D.
Chief, Integrative Medicine Program
Memorial Sloan-Kettering Cancer Center, New York
 A Note from Dr. Stephen Nimer

Recently at the hospital we held what we call a survivors' party for patients who
have undergone cancer treatment with us. Five hundred people attended, and what
a joyful occasion it was. Instead of focusing on their illness, they were focusing on
getting back to normal living. For many of them, the issues of how they are dealing
with their self-image, their sex drive, and their family relationships are paramount.
For many, the topic of the evening was the role of exercise in their life.
There's no question that the medical world's attitude toward illness and exercise
has changed in the last decade. For one thing, recuperation time after most surg-
eries has shortened. Our procedures have improved, and with that, the time it
takes for someone to get out of bed and moving has shortened as well.
Additionally, the prevailing mindset used to be "stay in bed and rest as long as
possible." Now it's "get up and get around, and it will actually speed your recovery."
We encourage patients to get up and move around, even if it's just a walk down the
hall, for many reasons, Moving around helps prevent pneumonia that can come
with too much bed rest. It helps digestion and stimulates a few endorphins that
give a sense of well-being. I can't state unequivocally that activity improves the im-
mune system, but I know it helps fight depression and the feeling that you've lost
all control over your life.
When I recommend activity for someone in cancer therapy, I'm not talking about
pushing as hard as Lance Armstrong did. Athletes push beyond their endurance as a

XK
xv A NOTE FROM DR. STEPHEN NIMER

matter of course, I'm talking about helping yourself maintain a level of fitness. I'm
not even looking for you to improve your fitness level, just to maintain it.
Now and then a cancer patient may fear that by being active, they may cause the
cancer to actually spread through the body. There is no truth to that fear whatso-
ever, and pushing the body, not to the point of pain, but to the point of tiredness, is
completely safe.
Of course, there are conditions that could preclude you from exercising. If
your blood count or platelets are very low, there could be severe bleeding if you
were to fall. If your bone density were seriously compromised by illness, you
wouldn't want to risk fracturing a bone. However, if bone disease is not an issue,
improving your muscle tone will actually increase your chances of not hurting
your bones. I wouldn't always recommend weight lifting, but lifting your own
body weight is helpful.
Overall, my goal for patients is to see them resume a normal life. For many of
them it means being able to play tennis, ski, or run five miles. For many others it
means having the strength to run for a bus, climb to the second floor of the house,
or pick up a grandchild. There is no reason not to start some kind of activity as soon
as you can during and after cancer treatment, and the exercises in this book are a
marvelous way to begin.
—Dr. Stephen Nimer
Head, Division of Hematologic Oncology
ChieC Hematology Services
Memorial Sloan-Kettering Cancer Center, New York
 Preface

Since 1990,1 have trained hundreds of men and women with varied health condi-
tions, fitness goals, and motivations. But nothing in my training prepared me for the
physical and emotional complexity of working with people fighting for their lives
because of cancer.
Special health conditions weren't foreign to me. For over a decade I have trained
people to cope with and modify activities for certain health situations. Mostly the
modifications were for osteoporosis, rheumatoid arthritis, hip replacements, or even
tennis elbow. Cancer, however, brought a whole new meaning to the term "training."
As an exercise physiologist and modern dancer, I have always been interested in
how movement can fulfill and enhance physical health, mental well-being, body
awareness, and even creative expression. Basically, I worked with people who had a
similar interest—people who can't imagine even two days going by without setting
off some endorphins while they exercised. They may take classes in a gym, walk,
run, or practice tai chi.
When working with people who have cancer, however, I've also discovered oth-
ers who have no history of wanting to exercise. As a so-called motivator of move-
ment, how do I begin to teach and encourage people with a diagnosis of cancer to
regularly participate in physical activity during this time no matter which category
they fit in? And so the challenge begins not only for the clients, but for their physi-
cians too. It may be new for the oncologists as well to encourage their patients to be

AV//
jcviii PREFACE

as active as possible during treatment. It may not seem so foreign for avid exercisers
to continue to move through their treatment, but for those who have never been
interested, how, in fact, can it start now?
What is the appropriate exercise program during treatment, especially when fa-
tigue and nausea can be overwhelming side effects? The program itself has to
match one's current energy level, mood, strength, and skill. While I was researching
for this book, I came across over forty-three studies that had substantiated the fact
that physical activity during cancer treatment is beneficial to one's overall physical
function and well-being. This opinion conies from evidence-based research.
This brings me to my next point. Medication is discovered and proven through
research. Exercise programs are tried out and proven or disproved as a viable
quality-of-life intervention through clinical studies. This is how we benefit and
plan our medication treatment protocol or exercise program. Advances in medicine
and science are results of new ideas and approaches developed through research.
New cancer treatments must prove to be safe and effective in scientific studies
with a certain number of patients before they can be made widely available. Then
they must withstand critical review by other scientists (known as peer review) in
order to be published results in peer-reviewed medical and scientific journals. They
are designed to demonstrate that a particular new surgical procedure, radiation or
chemotherapeutic treatment, dietary change, or exercise approach has a significant
advantage over customary care.
The gold standard of research is the randomized, double-blind clinical trial. In this
trial, people are randomly assigned either to a group receiving the experimental treat-
ment, or to a control group, which receives the conventional treatment, a placebo, or
nothing. In the case of a double-blind research study design, neither the participants
nor the researcher knows which subjects are in the experimental group and which
subjects are in the control group. This is to minimize any bias that may happen on ei-
ther end. By comparing the effects of treatment on both groups, scientists can deter-
mine whether the experimental treatment is better than the conventional treatment.
If you or your family member already has cancer, then enrolling in a study may
be of interest. Consider asking your physician if there is a study right for you,
Maybe there is an exercise physiologist in your cancer center doing a study on qual-
 PREFACE x/x

ity of life and activity while you are there. Or your physician may be interested in
new treatments that have had positive results in the past and will ask you if you
would like to partake in a study. With the emergence of new treatments, screening
techniques, and decoding of the human genome, questions are beginning to be an-
swered at a rapid pace. Perhaps a clinical trial is right for you.
Cancer is nothing short of a life-threatening illness with an uncertain prognosis
with often devastating treatments. It's a shake-up for the patient and his or her
family, friends, and coworkers. From diagnosis forward, a new person has evolved—
someone living with cancer. Learning to live now with a certain level of ambiguity
and vulnerability is part of your life. Let movement be a means of coping, strength-
ening, and progressing to the vital person you will be again.
I hope this book helps you get moving even when you're in bed most of the day.
I hope it helps you regain strength and function when you're feeling better, and
helps to motivate you, knowing that physical activity will make you feel better in
the short and long term. And, most of all, I hope it helps you heal.
This page intentionally left blank
 Introduction

whard
EN PEOPLE THINK OF PERSONAL TRAINERS, they envision a world of
bodies and calorie counting, of spandex outfits and mirrors in the
gym. Although there is a place for that in our society, the kind of personal training
I've been involved with for the last ten years is another world entirely. For many
years, I've been an exercise physiologist for a special group of clients whose motiva-
tion is not vanity but survival. The clients who make up my business may not be
able to do even one push-up, and their victories are measured in inches instead of
miles. They are all ages and from all professions, but they have one thing in com-
mon—cancer stole a part of their life, and they want it back.
In 1999, Lance Armstrong won a stunning victory in the Tour de France after un-
dergoing surgery and chemotherapy for testicular cancer. After his even more im-
pressive second victory a year later and more to follow, the world at large began to
acknowledge what many of us in the health industry have suspected for a long
time: Exercise rather than rest may be the best thing for someone undergoing can-
cer therapy. Soon after Armstrong's first victory, the Associated Press carried the
message of new research in the field. According to Colleen Doyle, director of nutri-
tion and physical activity for the American Cancer Society, the new research is
promising enough that the society is revising its exercise recommendations.
At the advent of this new approach to cancer therapy, I already have a decade of
working with people who have proven that such an approach works. The Healing

1
2 THE HEALING POWER Of MOVEMENT

Power of Movement is based on my experience with people who have made moder-
ate exercise a part of their cancer therapy—the quietly brave souls who sometimes
count the walk to the gym the sum total of what they can do that day. Their words
and their discoveries have fueled this book.
In addition, because of my interaction with doctors at Memorial Sloan-Kettering
Cancer Center in New York City and other hospitals, I've been able to incorporate
medical research and precautions into the exercise regimens I design for our clients.
Their words are also a part of this book.

Inspirations for This Book

Elaine is a typical client of Solo Fitness, my personal training company based in
New York City. I think of Elaine as a New York type, but I know there are Elaines
all across the country. In her early fifties, she is a no-nonsense partner in an invest-
ment firm and a no-nonsense fitness client as well. She had already worked with an-
other personal trainer when I met her and was consistent, demanding, and well
versed concerning her physical training. Her business self spilled over into the gym,
and I was impressed by how she would set goals for herself, get clear on how to
achieve them, and then get to work.
Sessions with Elaine usually had a no-dilly-dally, let's-get-going tempo. If she
worked on her legs and felt the left side didn't get as much work as her right, she'd
do it over again. "Let's do more," she'd say to me. "I didn't feel it yet." Elaine was
into strenuous workouts, and when I was with her we pushed hard.
By Christmas of our first year working together, Elaine experienced a persistent
sore throat, and over the next few months it just seemed to worsen. By spring she
was diagnosed with leukemia. I went to see her in the hospital when she started her
chemotherapy treatments, and I brought a funny book for her. She was still Elaine,
conducting so many business calls from her bed that I eventually had to leave with-
out getting to talk to her.
It was many months before I saw Elaine again, and I have to admit I gasped when
she walked into the room. It wasn't just the weight loss or the fact that she was
bald that made her so different. It was her movements. This strong, decisive woman
 Intr04ncti0n 3

had become cautious. Finally I noticed her bright blue eyes and said to myself, "Oh,
thank heavens. She's still in there."
Elaine began to describe her limitations to me. She had undergone a stem cell
transplant procedure and felt frequent dizziness and nausea. Like many people in
cancer therapy, she had mind-numbing fatigue. When she got out of bed, she was
afraid of going down stairs because her legs might buckle and she'd lose her bal-
ance. Her nails were coming off, so she had to be careful what she grabbed. Sitting
down and getting up were difficult, and she couldn't take baths because she
couldn't get in and out of the tub. She had been embarrassed by not being able to
get out of the backseat of a taxi. Her clothes were double-hung on two levels in her
clothes closet and she had trouble reaching the top rack.
"I have to get on a step stool to reach my jackets," she moaned. "And I don't want
to lose my balance." I looked in the closet and assured her that if she fell, she'd only
land in a pile of clothes. For a moment she almost laughed, and I knew we had be-
gun to work together again.
Before I did anything with Elaine, I spoke with her doctor about what we were
planning to do. The word exercise seems to scare everyone. I knew the doctor sus-
pected I would get Elaine on a trampoline or make her run a mile, and so I talked
about activity instead. "I mean we're going to work on getting out of a chair," I ex-
plained. "My goal is for Elaine to be able to pick up a towel if she drops it on the
bathroom floor, to turn around if someone calls her name, to hoist her purse on her
shoulder. That's my goal."
When I worked with Elaine, I had already learned a great deal about fitness for
people who have been debilitated by disease. A major portion of our clientele with
Solo Fitness have osteoporosis or a fracture or are at risk of this bone-thinning disease.
I was used to fine-tuning a program to suit a person's limitations. I began to focus on
lower body strength with Elaine so she could stand up and sit down easily. We worked
with low ankle weights, building up the muscles that had atrophied in the hospital. I
helped her regain range of motion in her ankle joints and flexibility in her torso. The
hardest part for her was her frustration at her own condition. Knowing where she'd
been before, she was devastated that she couldn't even lift a small weight.
The way Elaine and I got through those first sessions was by laughing and talking
together and by my refusal to focus on what she'd lost. She would bend her arms
4 THE HEALING POWER Of MOVEMENT

several times in a row and I'd say, "Look, Elaine, you're moving again." Instead of
hating how weak she was, she would just try to do it again. If she couldn't lie on her
side because she was sensitive from having bone marrow extracted, we did exer-
cises from her knees or from a sitting position.
A year later much of the old Elaine was back again. Her hair grew in and she re-
gained muscle tone. When she bent her arms to do bicep curls, she again held eight-
pound weights, and when she went for a walk in the park, she did it without fear
that fatigue would overwhelm her and keep her from making it back home. Re-
cently she stood up and sat down twenty times for rne without using her hands for
help, and one night she called to tell me she had taken her first bath,
Elaine is one of many individuals who keep teaching me how to work with peo-
ple recovering from cancer. Another one of our clients has multiple myeloma. She
opened the door the first time I met her, and I was struck by how fragile she was, as
if she might break either physically or mentally. She reminded me of a tree in the
middle of winter, bare of leaves and spindly. We began our first session by standing
near the wall and placing our palms flat against the surface. She was tentative about
even doing that much. Then we pressed a little bit. A while later I put her on a sta-
tionary bicycle. She never pedaled, and I never turned it on. I just held her there.
Many fitness trainers track their clients' progress by the energy exerted, the
weight lost, or the obvious improvement in someone's ability to lift weights or
work on a treadmill. Working with a client with cancer, I track progress in different
increments. Did the client laugh today? That's a big deal. Were they able to carry
their own towel and hand weight to the gym? That's progress. Did they feel safe
and stable on their feet? That's a great day. Did they leave our time together feeling
uplifted? That's victory.
When I work with people who have been through chemotherapy, radiation
treatment, stem cell or bone marrow transplants, hormone therapy, and surgery, I
throw out all the benchmarks I used to hold for our other clients. When a person is
at their weakest, sometimes we just press palms together and call it a day. Today
I'm gratified if the person makes it through a session without having to be sick or
lean against the wall or cry. I know that any amount of activity is beneficial both
physically and mentally and helps contribute to a feeling of control.
 Intr04ncti0n 5

We can thank Lance Armstrong for making people conscious of a new way of
dealing with cancer therapy and exercise. For years the medical profession felt the
human body was working hard enough just fighting cancer. The only activity they
recommended was relaxation techniques or gentle stretching.
One of our clients, Matthew, was completely frustrated when his doctor told
him not to run anymore when he was diagnosed with cancer. Running was how
Matthew relaxed and how he worked out issues. To be forbidden to run when he
still felt well was a blow. Matthew inspired my original research into physical activ-
ity during cancer treatment. As far as I could find, there was no need to stop all ac-
tivity when undergoing therapy. After reviewing the literature with me, he made
the decision to stay as active as possible and to take each day as it came. Matthew
was able to run on the treadmill for the majority of his treatment. Even though his
five-mile run turned into a one-mile run and a two-mile walk, he continued to do
what made him comfortable and happy.
Then the world watched in 1999 as Lance Armstrong won the Tour de France
cycling race and wore the winner's yellow jersey. Three years earlier, Lance had
been diagnosed with testicular cancer and had surgery to remove a diseased testi-
cle. His nightmare intensified when they found that the cancer had spread to his vi-
tal organs. He went through chemotherapy.
The remarkable aspect to Lance's story is that while coming back from
chemotherapy treatments, he began training again. He rode at least fifty miles a
day. He was fortunate and trained well enough to race in the Tour de France,
and then he won. To come back not just to riding again, but to race in the most
demanding competition, and then to win, was visible evidence that not only
would exercise not hurt someone recovering from cancer—it might help them
regain their normal life.
Lance Armstrong became a vivid example of what health professionals had al-
ready started to realize—keeping active during and after cancer treatment at worst
causes no harm, and at best can improve quality of life and perhaps speed recov-
ery. Obviously, there are considerations depending on a person's age, type of ill-
ness, and factors such as blood counts and level of physical fitness to begin with.
Few people would think of cycling fifty miles a day even when they were totally
6 THE HEALING POWER Of MOVEMENT

healthy. Nevertheless, there is an emerging sense that maintaining some kind of ac-
tivity during and after cancer treatment is important. The question is, how to go
about it?
The how of staying active through your treatment is where this book comes in.
The activity suggestions and philosophy in this book come from my experience as
an exercise physiologist. The information is a combination of what was learned
from my own research, our clients' experiences, and doctors' suggestions.
It's now been over ten years since the first time I worked with someone who
had cancer. This book came about because of all the Elaines and Matthews, and
the countless other brave and funny souls I've worked with during this time,
who have taught me that sometimes just putting one foot in front of the other is
a major victory.
 /

How to Use This Book

tHE HEALING POWER OF MOVEMENT is a step-by-step guide to help a person

undergoing cancer treatment begin to move again and to find a level of activ-
ity that helps them energize. I think of it as the book a cancer patient will want to
keep close at hand for motivation and direction. The chapters address people who
can barely move from their beds, all the way through to those who are walking and
jogging and resuming a normal life.
When someone walks out the hospital door after each cancer treatment, he or
she also walks away from the medical staff that is there to help and answer ques-
tions. The patient goes back to a home and life, often with depleted energy, fright-
ening side effects from drugs, and specific limitations to movement. The Healing
Power of Movement is like having a personal trainer in the house with suggestions on
how to approach a reasonable exercise regimen, someone who can relate to the in-
cremental steps of progress common to those being treated for cancer.
This book includes specific exercises for different stages of cancer treatments
and for different types of cancers, clearly illustrated. The book includes input from
cancer specialists as well as input from the fitness trainers in my company who
have been working with cancer patients to formulate personal routines and ways
around their unique limitations.
Not everyone can hire a personal trainer to come in and work with them during
an illness. Therefore, I've included in this book activities for you to do on your own

7
8 THE HEALING POWER Of MOVEMENT

and with a partner. There are suggestions for the bedridden and for those who can
move about the room. I've marked activities for special conditions such as dizziness
or when one part of the body is specifically affected by surgery. In each section I've
included warnings about conditions that might make the activity dangerous.
The Healing Power of Movement includes the voices of many of the people who
have helped me develop these programs. The cancer specialists at Memorial Sloan-
Kettering Cancer Center in New York City have contributed their understanding of
what is appropriate activity for cancer patients. The Solo Fitness trainers con-
tributed their collective knowledge of what it is to work with people whose physi-
cal bodies have been impaired.
All readers will want to review the chapters "Exercise and Cancer Therapy" and
"How Much Should I Exercise?" Then, depending on the stage of your cancer ther-
apy, choose the chapter of activities that best reflects how much you're able to move.
Recently I became involved with an organization in New York City called Mira-
cle House. As in many other areas near large hospitals, Miracle House offers out-of-
town patients who have an extended treatment at the hospital a place to live.
When I first made my services available at Miracle House, I met a man named
Jimmy who came from Florida to have specialized cancer therapy in New York.
Jimmy was used to working outdoors, and the closeness of Manhattan's buildings
coupled with the fatigue from the drugs he was taking was giving him the added
problem of depression.
Again, it was one of my clients who taught me some important lessons. When I
began working with Jimmy, his wife sat to one side watching. This was a couple
who had been together for many years, and having her as an observer seemed dis-
tant and awkward to all of us. Soon Jimmy's wife was involved with our activity,
and I learned about the importance of inviting a partner to help with these exer-
cises. It was also with Jimmy that I added music to the regimen. After a session in-
volving all three of us moving to music in a small New York bedroom, Jimmy was
able to laugh and admit that he felt more like himself.
I encourage you to follow our example. If there is a partner or caretaker in your
life who can help you follow an exercise routine, it will make it all the easier to ac-
complish. And music is an essential ingredient. Choose the most upbeat music you
can find, and see if it doesn't help lift you from the bed.
 2

k^ercise and Cancer Therapy

iNiCAL STUDIES FROM THE LAST DECADE are starting to show what I've
c seen on a small scale for a long time; moderate physical activity is a progressive
new method for rehabilitating cancer patients. It has been shown in numerous studies
that structured physical activity helps a cancer patient be able to do activities of
daily living with less effort, to cope with fatigue, to increase aerobic capacity, and to
counter the effects of inactivity and help fight depression, still feeling in control of
one's body. As more cancer practitioners encourage their patients to become active,
the benefits are becoming clearer.
More and more people are cancer survivors owing to early detection, more effec-
tive screening, and improved quality of treatment. Whatever can contribute to
quality of life for you during treatment and recovery is essential. People are looking
for ways to combat the side effects of treatment and help maintain some sort of
normalcy during this very erratic and intrusive time of life. Both researchers and
physicians are looking into the importance of staying active and functional through
cancer treatment.
Moderate physical activity such as walking on a treadmill, cycling (continuous or
intermittent), light weights, relaxation techniques, and stretching can all help main-
tain physical function, combat fatigue, and decrease nausea and neuropathy in the
short term. In the long term, it can diminish consequences of cancer treatment such
as early menopause because of cancer therapy or the increased risk of osteoporosis.

9
10 THE HEALING POWER Of MOVEMENT

Maybe most important, light exercise enables one to be proactive during cancer
treatment.
As suggested by prominent sports medicine researcher Dr. Fernando Dimeo, be-
ing physical during this difficult, scary, and unnerving time may not be possible
throughout your recovery. For instance, you need to watch for times when your
platelet count is too low or you are just too nauseous from your medication or if it
is too difficult to eat and drink sufficiently to maintain energy. The overall aim is
not to give you a hard body or to help you train for a marathon, but simply to get
you up and functioning during your therapy rather than delaying movement until
your therapy is completed.
You may have heard of possible dangers to physical exercise during cancer treat-
ment, or you may have thought up some all on your own. Until recently, doctors
looked at the fatigue experienced by many cancer patients and told them to rest as
much as possible, trying to help them conserve precious energy for only the most
necessary activities. Research data indicates, however, that the absence of activity
may generate its own effects of impairment and that the only way to begin over-
coming fatigue is to start moving.
A fear some patients have is that physical exertion will somehow cause their can-
cer to spread around the body, a worry that doctors say is medically groundless. A
concern doctors have had, however, is that physical activity might depress the body's
natural killer cells (NKCs) and thus damage the body's natural cancer-fighting de-
fenses. NKCs are important in combating viral infections and cancer. Data suggest
that both cancer history and stress may be associated with reductions in NKC activ-
ity. However, continuous long-term moderate exercise has been shown to enhance
the immune system; only extreme exercise can have an ill effect on the NKCs.
We all know that many people with cancer have as hard a fight with the disease
mentally as they do physically. The shock of hearing the diagnosis, combined with
fear and the foreignness of the hospital environment, makes for a real life-changer
for anyone in the situation. It's almost certain you'll experience depression over
both the illness and the treatment as well as some sense of losing control over your
life. Add to that the bone-deep fatigue and possible loss of movement because of
surgery, and you may feel that you barely know yourself anymore.
 txercise and Cancer Therapy 11

Nevertheless, even moderate activity can begin to reverse the most debilitating
mental effects of the disease. First of all, being able to perform a routine exercise
gives you one place in your life where you begin to regain control. Instead of being
a passive recipient of all kinds of drug and surgical therapies, you can begin to be an
active participant in your recovery. Second, and ironically, moderate activity tends
to give you energy instead of depleting it. After exercising, you will feel more like
getting up and doing something than if you had lain in bed for the same amount of
time. Additionally, exercise fights off the bad effects of inactivity such as muscle
weakness, loss of energy, and stiffness. Last, one effect of exercise seems to be an in-
creased ability to control your moods. This is where the hard-to-define term "qual-
ity of life" comes in. If exercise helps reduce anxiety even a little bit, it becomes an
essential component of your life every day.
Recent medical studies have taken patients with different types of cancer and
had some of them do moderate exercising during their treatment. In most cases the
exercise consisted of aerobic activity such as stationary bicycling or walking on a
treadmill, increased over time. The control group didn't exercise. In each case1 (the
studies are listed below), the people who exercised showed better results than the
control group, especially in the quality-of-life arena. Even moderate exercise
helped people function at a higher level in their daily life. This could mean any-
thing from an increased ability to make it up the stairs after a meal to being able to
carry out simple chores like bringing in the mail or taking the dog for a walk.
Exercise enhances recovery and doesn't hinder the immune system or other bod-
ily systems such as cardiac or respiratory functions. The results of the clinical stud-
ies, in brief, show that exercise is not dangerous, but in fact improves your overall
health and well-being.
In this book, I want to help you find the motivation and the method to begin
some kind of physical activity during your cancer treatment. The critical issue is
to figure out the optimal level of activity that you can perform with the lowest
risk. Exercise guidelines are given for specific cancers and their considerations.

'Studies cited for exercise during cancer treatment: MacVicar, 1989; Dimeo, 1996; Mock, 1994;
Brennan, 1998; Pedersen, 1995; Nieman, 1995.
12 THE HEALING POWER Of MOVEMENT

For example, if a side effect of your surgery is lyrnphedema in one of your arms,
there are ways to address that problem and concentrate on the other arm. Per-
haps you are dealing with bone cancer and have pain associated with weight-
bearing activities; then I suggest other ways to exercise that you can do while ly-
ing down or sitting in a chair. Individual programs are explained to make the
most out of your physical activity. There is no medical reason to wait until after
your treatment to start moving again. Starting sooner rather than later will offset
the bad effects of inactivity, help you regain confidence and control, and most
likely help elevate your mood and your outlook on life. With that as the goal,
there's no time like the present to start.
 J

H0u/ Muck Should I b^ercise?

t HERE is NOT ONE ULTIMATE EXERCISE prescription for cancer patients at

various stages of the disease. Right now there are not even explicit standards
for the type, frequency, duration, intensity, or progression of exercise for people in
cancer treatment. However, we can make confident recommendations drawn from
the growing body of research studies of the last ten years. Above all, studies con-
clude that exercise is safe, feasible, and beneficial to anyone's quality of life at al-
most any stage of cancer therapy. Of course, there are considerations if you have a
severe physical impairment, a condition such as anemia, or a particular part of your
body that is limited because of surgery, but they are just that—considerations—not
reasons to avoid activity.
Although the focus of The Healing Power of Movement is to promote physical ac-
tivity, there may be mitigating factors that make exercise unwise or dangerous for a
few individuals. Some patients may benefit from a supervised exercise program,
and close medical supervision may be required for others.
There may be times during your treatment that you don't feel like exercising.
These down days are different for each person and may vary from cycle to cycle.
The key is to listen to your body and modify the frequency, intensity, or duration of
any exercise. As you go through treatment, you will get used to hearing a lot of
numbers associated with your condition. You will have your blood counts and heart
function checked regularly in addition to receiving nutritional guidance. As for the

13
14 THE HEALING POWER OF MOVEMENT

Contraindications and Restrictions to Exercise

Red blood cells s 10 mg/Hb (normal count is 12-14 mg/Hb)
Platelets s 50,000 cells per microliter
Neutrophik s \ ,000 cells per microliter
White blood cells -s, 3,000 cells per microliter (normal count is in 5,000-10,000 range)
Fever > 100° F
Muscle weakness
Numbness in the extremities
Extreme fatigue
Pain
Nausea
Dizziness
Dehydration
Day of surgery/treatment

numbers above, they should be used only as a guideline and should not be substi-
tuted for a physician's supervision.
The American College of Sports Medicine (ACSM) has set guidelines for the
general population, and people in cancer treatment may closely follow the same
suggestions. The guidelines call for exercising three to five days a week, twenty to
thirty minutes per session.

What Kind of "Exercise?

Mountain climbing, running, playing tennis? The most important point is that the
exercise feels right to you. You have to use your instinct as to which activities you
want to perform. While you're in cancer therapy you probably won't take up a
sport you've never attempted before, and any activity you attempt has to be modi-
fied for the treatment effects of surgery, chemotherapy, or radiation.
Let me start by saying that walking and cycling are the two activities recom-
mended most often because they are safe and tolerable for the majority of people.
Doctors who have studied cancer treatment and exercise have concentrated on
 How Much Sfieuld I Exercise? 15

exercises for the large muscle groups, and concentrated on exercises that are easily
measured. Walking is a natural choice because it relates to all of the activities of
daily living that anyone recovering from a disease looks forward to doing.
Most of the medical studies concerning cycling were done in a hospital setting,
and cycling proves to be a good choice for most recovering patients. Some studies
were even done while the patients were bedridden and only able to move their
legs. Swimming has proven to be another safe aerobic activity that promotes car-
diovascular and overall fitness. However, if your cancer therapy includes catheters
or nephrostomy tubes, swimming may not be appropriate for you. Good sense
would tell you that if you are recovering from primary or metastatic bone cancer,
high-impact or contact sports are out of the question.

Can I t)(ercise Too Much?

There is some evidence that repeated, high-intensity exercise could lower your im-
mune system and therefore be unsafe if you are recovering from surgery or
chemotherapy. Dr. Fernando Dimeo suggests you will want to keep your heart rate
under 75 percent of maximum (subtract your age from 220 to get your maximum
heart rate). On the other hand, unless you have been a professional athlete, it is un-
likely that you will want to push yourself to this extreme during cancer treatment.
Once you've rebounded from treatment, however, and returned to your normal
workload and lifestyle, there is no evidence that high-intensity exercise isn't appro-
priate.

Can / Vary the t^ercises?

Many researchers in this field recommend intermittent or interval training. This
means short bouts of exercise coupled with rest. If you are in the first stages of re-
covery from chemotherapy or bone marrow transplants, this intermittent exercise
throughout the day is a good way to accumulate your thirty minutes.
16 THE HEALING POWER Of MOVEMENT

As for weight training, studies on the efficacy of this type of exercise are only be-
ginning to come to light. It is likely that the optimal exercise regime for most can-
cer patients will combine aerobic activity and weight training. The exercises I've
recommended in this book offer that combination.
The key to The Healing Power of Movement is not just to focus on walking or cy-
cling, but to add specific muscle conditioning to help you maintain the optimal
level of function at any given time during your treatment. From my years of experi-
ence working with all different kinds of patients and survivors, I've seen that walk-
ing alone simply doesn't cut it. Just as for healthy adults who aren't fighting cancer,
you will need to combine aerobic activity with muscle conditioning and strength-
ening, and add stretching as well.
The clinical studies suggest that the sooner you begin to exercise, no matter how
feeble the attempt, the sooner you will regain your normal level of functioning. If
you allow yourself only rest, you will contribute to further decline of your agility,
your energy level, and ultimately to your quality of life. Your question really isn't
"can I exercise too much?" but "how can I exercise enough?"
 4

t-rom Your Diagnosis For ward

s VERAL YEARS AGO, ONE OF MY CLIENTS, Gini, was getting ready for a much-
needed break at the beach during the last weeks of August. I had worked
with Gini twice weekly for three years, mostly doing weight training for specific
parts of her body and helping her build endurance on a stationary bike. Gini was
in her early fifties and had recovered from surgery for breast cancer that occurred
before I knew her. A lawyer by profession, she spent most of her day sitting in a
chair. For her, getting up and doing some exercise during the day was wel-
comed. Standing face-to-face with me, she had a good eight inches on my five-
foot-one body. She was always a dynamic presence, authoritative, domineering,
and what I call a very styling woman. With short spiky brown hair and clothes
that seemed to fall perfectly over her body, she tastefully camouflaged her not-
so-perfect waist and arms. Always, Gini was polished and meticulous down to
her socks and shoes.
I knew that Gini had undergone a lumpectomy and had a few lymph nodes re-
moved. She had a tendency for lymphedema when she would carry luggage or a
heavy package. She was also on medication for both high blood pressure and high
cholesterol. At the time of our meeting, she was premenopausal and not thinking of
taking hormone replacement therapy for various reasons. This also prompted her to
be consistent in her exercise routine to help decrease her risk of heart disease, os-
teoporosis, and to help her maintain a proper weight, but mostly just to feel good.

17
18 THE HEALING POWER OF MOVEMENT

That summer, I arrived for our usual workout on a Monday. As far as I knew,
Gini and I were winding down before the summer break and putting together a
program for her to follow at the beach. I walked into her living room and sat down
to check her blood pressure as I always did. She looked at me hesitantly and said,
"Lisa, I have cancer again."
As her exercise physiologist, I thought, "What do I say? How do I react? What is
the professional response to this?" In the end I only managed to say one word:
"Oh," as I realized that from that moment on, our workout schedule, our goals, and
our routines would change dramatically.
It takes time to figure out a strategy for fighting cancer, and days go by as you try
to cope, cry a little, investigate your options, research, talk, and plan for life with
unknown limitations. My job was to provide Gini with a variety of exercises, move-
ments, and stretches that she could handle at the time of each session. For a few
weeks, the only perceptible change we dealt with was the diagnosis. Gini didn't feel
sick or tired; she couldn't feel cancer. She did, however, feel anxious and confused,
and she knew she was facing an ordeal that could take over her life for more than
the next few months. My goal became to help her maintain her physicality
throughout her treatment.
I continued Gini's basic routine, but I added some walks outside in the park
where we would stop to watch schoolchildren play and dogs chase each other in
the sunshine. Not only was it enjoyable to get outside during the summer, but
walking is also a weight-bearing activity that helps to maintain bone health. We
also used these walks as a time to talk about what was to come and to plan for the
physical challenges ahead.
Gini's strategy for her breast cancer this time was a mastectomy, and for her
breast reconstruction, a TRAM-flap at the same time as her mastectomy. A TRAM-
flap procedure stands for transverse rectus abdominus myocutaneous flap. Basically
the surgeon takes an area of skin around and below the belly button and transfers it
to the place where the breast has been removed. Most commonly the skin and fat
remains attached to one or both of the rectus abdorninus muscles that provide a
blood supply. The abdomen is closed, leaving a scar from hip to hip. The missing
muscle is often replaced with a surgical mesh material to reduce the risk of a hernia
 f-r0m Y0ur Diagnosis l-0rwar4 19

or bulging of the abdomen. Another part of Gini's treatment strategy would be a

regimen of the drug Tamoxifen for five years and having a nipple reconstruction
one year after surgery.
In the few weeks between her diagnosis and surgery I added more light stretches
to Gini's routine and moments of relaxation at the end of each session. We contin-
ued working on her upper body strength because we knew she would have to rely
on her arms and legs to get out of bed instead of her abdominal muscles. We also
focused on lower back exercises and posture alignment, since after surgery it would
probably be difficult to stand upright and walk straight for the first few weeks,
which in turn might aggravate her back. We continued her program with stationary-
bicycling and full-body strength training and stretching. Gini was still able to do
just about everything, from bicep curls with five-pound weights to sit-ups and
outer thigh lifts. Since she had a history of lymphedema, we did not do any heavy
lifting with the affected arm (blood pressure was always taken on the nonaffected
arm). We continued to do some upper back work with exercise bands in a sitting
position to maintain upper body strength and posture. We began playing classical
music in the background while we worked out. Exercising to the sounds of Mozart
or Beethoven gave us both an hour of freedom of movement when cancer was a
distant thought.
I didn't see Gini again until four weeks after her surgery. She walked tentatively
to greet me, and I noticed she was wearing a loose dress that hung over her midsec-
tion so it wouldn't irritate her scar. Underneath, she told me, she was wrapped with
bandages and her skin was black and blue. Her range of motion around the affected
arm was limited, and she talked about being sore all over. She was also having
sleepless nights due to night sweats from her Tamoxifen, and because of the inci-
sion in her abdominal area, it was hard to get into a comfortable position to sleep.
Needless to say, during the first few weeks when we began working together again,
she was feeling pretty fatigued and sore. I had already spoken with her doctor and
nurses, and after a big hello and a gentle hug, we started a plan of helping Gini stay
active through her treatment.
Since part of her abdominal muscle was no longer there but was replaced by
strong mesh during her reconstruction surgery, there was a loss of strength and sen-
20 HE HEALING POWER Of MOVEMENT

sation around her midsection. Most movements that one wouldn't think twice
about, such as standing up, getting out of bed, or putting on a shirt, became tedious
and painful chores. Our exercises focused on everyday life activities, and I sensed
that Gini was already becoming an active participant in her own recovery. We be-
gan with exercises to restore her shoulder function, then moved on to resolving the
back pain that sneaked in at times from her strained posture.
As time went on, the exercise routine gradually changed. From doing light
stretches in her chair to prevent scar tissue and maintain an upright position, Gini
improved to doing standing exercises, using the wall for support. I could see her
strength and confidence return. I began to focus on improving the range of motion
of her shoulder joint with exercises we call wall climbs. I learned to help her keep
her arm elevated when appropriate and pump her hand to facilitate fluid drainage
because of her sensitivity for lymphedema. She continued to strengthen her torso
and abdominal area and to do basic leg exercises to support her lower body, as
shown in the exercise sections of this book. I made sure Gini stayed away from any
heavy lifting for her upper body and any activity that caused pain in her abdominal
area. She even included some light exercises while lying in bed, since this was easier
for her than lying on the floor.
A few months after surgery, Gini could lie down on a mat and do a series of
pelvic tilts and bridges. Her body needed to compensate for the weakness in her ab-
dominal area when transitioning from standing to sitting to lying on the floor and
back up again. So it took a bit longer to get down on the floor, using her arms for
stability, but once she made it there, I made sure it was worth it. She was able to lie
on her stomach with pillow support to perform some basic back exercises. Six
months after surgery she performed twisting, or oblique, exercises, and with a se-
lect choice of sit-ups (lifting the upper body off the floor by only a few inches) to
slowly bring back some abdominal strength without risking any bulging or a hernia.
By this time we were taking walks together again and she was confident she could
walk away from home and not find herself too fatigued to get back.
It's now been three years since Gini's surgery, and we're still working together.
Even though our program has become routine, I am constantly aware of not asking
her to do an activity that would aggravate the sites of her surgeries. She can even do
 f-r0m Y0ur Diagnosis l-0rwar4 21

sit-ups, in moderation, without any discomfort. There are times here and there that
lymphedema occurs, usually after she has been traveling and carrying her luggage.
At that point, we shift our exercise focus to more range of motion and stretching
exercises and leave the hand weights for another day. She has even started to take a
yoga class. She's not able to perform every posture, but her instructor has shown
her variations that work for her. And I can certainly see the difference, especially in
her alignment, balance, and strength.
I know whenever Gini is facing another check-up at the oncologist's office or an-
other outpatient procedure, because I see the anxiety building in her expressions
and in her eyes. We usually use the few days before a doctor's appointment to do
simple stretching and relaxation sessions to help her calm her mind. We have both
seen that maintaining her exercise routine, no matter what her physical condition,
has given her a sense of calm during emotionally trying times, and more important,
a sense of control during chaos.
Everyone reacts differently to the diagnosis of cancer, but Gini's example
touches on the issues everyone shares in common. Keeping physical activity a part
of your life, no matter how bleak the conditions, gives you a tangible way to partic-
ipate in your treatment and keeps you fit enough to restart your life with a mini-
mum of discomfort.
This page intentionally left blank
 5

Bed t^ercises: f-eeliw^ Lousy

Goal: To prepare your body for movement

t tivity
HE AIM OF BED EXERCISES IS TO HELP YOU avoid the effects of physical inac-
and to improve your physical functioning during cancer therapy rather
than delay it until afterward. There's no reason to wait to move until you are done
with your treatment. These activities will prepare your body for being active once
you're on your feet, even if you're only preparing to walk to the mailbox or to
climb some stairs. These exercises also help maintain lean body mass and weight.
You can perform the following exercises in your bed at home or in the hospital
when appropriate. This section is for those of you who feel generally lousy, mostly
exhausted, and defeated by even the smallest activity. The thought of getting out of
bed even to get a glass of water seems like climbing Mount Everest. Perhaps this is a
day or two after your chemotherapy, a few days after surgery, or a week after your
stem cell or bone marrow transplant. You have spent the majority of the day resting
in bed. You may have the added indignity of side effects such as mouth sores, dry
skin, or tingling in the feet. Often nausea or dizziness makes standing up impossible.
I've learned a little about what goes through a person's mind at a time like this. I
look at someone in your situation and know that you don't think you have the en-
ergy to move. What I do know, however, is that movement will actually give you

23
24 THE HEALING POWER Of MOVEMENT

energy. You might remember that it's possible to lift your arm, but it's hard for you
to picture it actually happening. You can recall walking across the room to answer
the phone or bending down to pick up a piece of paper that has fallen from the
table, yet now those simple actions seem to belong to another world,
When you are in this situation, the first challenge to overcome is a mental chal-
lenge. You need to find the motivation to attempt movement. It's likely the motiva-
tion will come from someone else, and that's why it helps to have a caregiver or a
friend or family member who will stand by your bed and encourage you to give it a
try. The movement won't hurt you. Continuing to lie motionless will.
Being sedentary has multiple bad effects on the body. Lying down for several weeks
can decrease your muscle mass, insulin sensitivity and bone density. You will tend to
retain more fluid, and your lung capacity will diminish. (In turn, these put you at in-
creased risk for other health issues.) Psychologically you begin to feel helpless.
The reason I want to get you moving is that activity, no matter how small, will
actually give you energy. You'll see, a few days after you start, you'll be able to do
more and more and eventually will go on to the next section of this book. The ef-
fects of training will take place. Movement stimulates your blood flow and gets
more oxygen into your cells. It facilitates glucose metabolism and can help you feel
less stiff and lethargic. Movement will do something for your mind as well. It will
give you a bit of hope that better times are to come. Remember, small movements,
even getting dressed, will help. As one client wrote to us, "Even if we only press
hands together, it will be something." Moving helps more than your muscles and
joints, it simply makes you feel better. The following activities are for your darkest
hours and may be done with the help of a caregiver or loved one.

Plan Y0nr Physical Activity Program

Your doctors have administered the medical treatment, and now it's your turn to par-
ticipate in your recovery by administering the movement treatment. First of all, ask
your physician if there are limitations to an exercise program for you. In addition,
get advice on the kind of nutrition you might need to maintain your energy when
adding or reintroducing exercise to your daily routine. Begin when you are ready,
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