The Physician and Sportsmedicine

ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://tandfonline.com/loi/ipsm20

Exercise for Cancer Patients: Guidelines and

Precautions

Maryl L. Winningham PhD, Mary G. MacVicar RN, PhD & Carol A. Burke BS

To cite this article: Maryl L. Winningham PhD, Mary G. MacVicar RN, PhD & Carol A. Burke
BS (1986) Exercise for Cancer Patients: Guidelines and Precautions, The Physician and
Sportsmedicine, 14:10, 125-134, DOI: 10.1080/00913847.1986.11709201

To link to this article: http://dx.doi.org/10.1080/00913847.1986.11709201

Published online: 11 Jul 2016.

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Exercise for Cancer Patients:
Guidelines and Precautions

Maryl L. Winningham, PhD

Mary G. MacVicar, RN, PhD
Carol A. Burke, BS
Pt"*>S: ShOOowlght © 1986
In brief: With more cancer patients recover-
ing or surviving for long periods, techniques
are needed to help them overcome the dis-
abling effects of the disease, the therapies,
and prolonged immobilization. Previous re-
search and clinical observations indicate that
exercise is a promising restorative technique
for cancer patients, but it is a fairly new con-
cept; no guidelines exist for objectively mea-
suring the functional capacity of such pa-
tients or designing safe programs for them.
Medical teams that devise such exercise pro-
grams should consider the fitness, age, and
current medical and psychological status of
the patient, the type and stage of cancer, the
possibility of coronary artery disease, side
effects of therapy, and the timing of blood
tests and chemotherapy.

xercise as a restorative technique for

E cancer patients is a relatively novel

concept. Forty years ago, people were
amazed by the idea of cardiac patients
exercising, but rehabilitation programs for car-
diac patients now are commonplace. Fear of
cancer has prevented widespread understanding
of the potential for the recovery, long-term sur-
vival, and rehabilitation of cancer patients. It is
time to develop concepts of exercise for those
suffering from cancer, which is second only to
heart disease as a cause of death. 1
Advances in treatment methods have led to
increased survival and cure rates for individuals
with a variety of malignant neoplasms. Expec-
Dr Winningham is an exercise physiologist and director of
the Health Promotion and Restorative Training Laboratory,
College of Nursing, Ohio State University; Dr MacVicar is
an associate professor In the College of Nursing and the
Comprehensive Cancer Center, Ohio State University; and
Ms Burke is a student in the College of Medicine, Ohio
State University. Dr Winningham and Dr MacVicar are
members of the American College of Sports Medicine.
Patients exercise under the supervision of an Interdisciplinary team at the Ohio
State University Comprehensive Cancer Center.
tation of increased survival rates has focused at-
tention on the need for rehabilitative techniques
to mitigate the disabling consequences of dis-
ease and therapy. Progressive loss of function is
commonly reported in cancer patients; how-
ever, it is unclear whether this deterioration is
due to cancer and its therapy or to the debilitat-
ing effects of inactivity and bed rest. The im-
mobilization syndrome in itself can lead to life-
threatening conditions. 2.3 Decreased muscle
strength and endurance, negative nitrogen bal-
ance, phlebothromboses, pneumonitis, renal
calculi, increased diuresis, orthostatic hypoten-
sion, and skin breakdown are but a few of the
continued

TKI PMYIICIAN AND IPORTIMIDICINI e Vo114 • No. 10 • October 86 125

 cancer continued
In one study conducted by the authors, cancer patients reported reduced
feelings of nausea within a few minutes after starting to exercise.
well-documented consequences of prolonged
inactivity. Many of these complications can be
preveqted by moderate activity. Despite an ac-
cumulation of data showing that activity is ben-
eficial for clinical populations, well-meaning
health professionals continue to recommend
rest and inactivity to their patients. When treat-
ment, disease, and hypokinetic conditions com-
bine, there is dramatic loss of functional ability
that can compound the emotional distress of
cancer patients. Until this decade, rehabilitation
of cancer patients was more a philosophical
commitment than a practical objective. Now re-
habilitation is being viewed as an essential part
of comprehensive care. Regardless of prognosis,
efforts are being made to develop techniques
that promote functional independence.
Over the past several years, an interdisciplin-
ary team affiliated with the Ohio State Univer-
sity Comprehensive Cancer Center has been
studying the physical and psychological effects
of exercise on cancer patients. The recommen-
dations and precautions suggested in this article
are a result of their experience and are being of-
fered to help researchers and clinicians evaluate Guidelines Needed
cancer patients and prescribe safe exercise pro-
grams for them.
Literature Review
Only two empirical studies of exercising can- and fare better for longer periods. Moderate ex-
cer patients are recorded in the literature, but ercise thus shows promise as a way to delay or re-
126
both showed encouraging results. Buettner and
Gavron 4 reported on two groups of men and
women who had a history of cancer. An exercis-
ing group and a sedentary control group were
compared on estimated Vol max, grip strength,
reduction in resting heart rate, weight, skinfold
thickness, and several psychological variables.
The exercising subjects showed improvement on
all measures after an eight-week aerobic training
program; however, only two of the subjects were
undergoing treatment for cancer at the time.
The other study, by Winningham and Mac-
Vicar, 5 was a comparison of three groups of un-
trained women (n = 16). Stage II breast cancer
patients on chemotherapy were randomized to
an exercise and a nonexercise (control) group. A
third group consisting ofexercising, age-matched
healthy women was used for comparison. The
exercise treatment consisted of ten weeks of tri-
weekly aerobic interval training on a cycle
ergometer. The exercise group showed marked
improvement in fitness level on the graded ex-
ercise test when compared with the nonexercis-
ing cancer patients (a 20.7% increase vs a 1.8%
decrease in Vo2 peak). Further, the exercising
cancer patients on chemotherapy demonstrated
an increase in Vol peak (functional capacity)
similar to that ofthe healthy women (17.4%).
The researchers were surprised by patient re-
ports of decreased feelings of nausea within
minutes of beginning an exercise session.
Mac Vicar and Winningham 6 obtained addi-
tional data on cancer patients' exercise experi-
ences by conducting a survey of 254 cancer pa-
tients (ages 10 to 77) identified as regular
exercisers. Forty-four percent reported prob-
lems maintaining an exercise program; half of
these stated that easy fatigability was the biggest
problem. Two thirds of the participants reported
that they were able to maintain some sort of ex-
ercise regimen throughout their period of treat-
ment even though they had no guidance in this
regard. Furthermore, 85% of the respondents
listed exercise counseling as a significant unmet
need for cancer patients.
In addition to the aforementioned findings,
we and some other clinicians have observed that
cancer patients who stay physically active seem
to have fewer emotional and physical problems
continued
Vo114 • No. 10 • October 86 e THI PHYIICIAN AND IPORTIMIDICINI:
 cancer continued
Patients who were sedentary before their Illness may
wrongly Interpret fatigue or weakness as evidence of a
need to rest.
verse a patient's decline in functional ability. But
no guidelines exist for objective evaluation of
functional capacity or for restorative exercise
programs specifically for cancer patients.
Guidelines and recommendations should ad-
dress the needs oftwo types of patients: those ac-
customed to exercise and those who have been
sedentary. Patients who are used to vigorous ac-
tivity often want to continue exercising during
and after treatment to maintain their life-style
and feelings of well-being. Such patients are of-
ten unaware of the effects of disease or side ef-
fects oftreatment that may make vigorous activ-
ity hazardous; they may need counseling about
the appropriate timing, type, and intensity of ex-
ercise. In some cases, exercise may be contrain-
dicated for a time depending on the type of can-
cer and possible side effects of treatment. By
contrast, patients who have been sedentary may
128
interpret fatigue and/or weakness as evidence of
their need to rest or "take it easy." These symp-
toms may be viewed as inevitable consequences
of illness and treatment and thus become an in-
centive for further reductions in activity. This
group needs encouragement to stay active and
may profit from individualized instruction and
motivational programs. Both kinds ofcancer pa-
tients, like cardiac or pulmonary patients, need
supervised exercise programs to ensure that they
receive optimal benefits with minimal risk.
General Concerns
In designing an exercise program for cancer
patients, one must deal with a long list of vari-
ables and potential problems.
First, of course, are the well-documented
pathological effects of malignancy. Fever, an-
orexia, weight loss, and fatigue are common. 7·8
Hematologic changes can include polycythemia,
anemia, leukocytosis, leukopenia, thrombocy-
tosis, thrombocytopenia, and a variety of coag-
ulation abnormalities. Metabolic alterations
may include hypercalcemia and lactic acidosis,
as well as corticosteroid-induced hypergly-
cemia.7·9
In addition, it is important to recognize that
cancer patients who are receiving chemotherapy
or irradiation therapy may not respond nor-
mally to training. Antineoplastic agents, in par-
ticular, tend to inhibit protein anabolism and
could conceivably block the biochemical pro-
cesses that are responsible for training effects.
There have been few studies of the metabolic in-
teraction between antineoplastic drugs and ex-
ercise training. Side effects of therapies can im-
pair a cancer patient's ability to maintain a
training program. Symptoms such as nausea,
vomiting, diarrhea, and decreased appetite can
contribute to electrolyte disturbances and nutri-
tional deficiencies. In addition, myelosuppres-
sion resulting in reduced WBC, platelet, and
RBC counts increases the risk ofbleeding, infec-
tion, and anemia.
Furthermore, one must be aware that individ-
ual responses to a treatment modality differ con-
siderably. One patient may be extremely sensi-
tive to the side effects of a particular treatment
and be incapacitated for a time, while another
may suffer little and be able to carry on normal
activities. For this reason, exercise must be con-
tinually monitored and re-evaluated with re-
spect to treatment response and potential side
continued
Vol14 • No. 10 • October 86 e THI PKYIICIAN AND IPORTIMEDICINI
 Slow-K®
potassium chloride USP
Slow-Release Tablets cancer continued

INDICAnONS AND USAGE "Table 1. Common Side Effects of

BECAUSE Of REPORTS Of INTtSnNAL AND GASTRIC ULCERAnON AND BUEDINO Wrrti SLOW·REilASE
POTASSIUM CHLORIDE PREPARAnONS, THESE DRUGS SHOULD BE RESERVED FOR THOSE PATIENTS WHO Antineoplastic Thempy
CANNOT TOLfftATE Oft REfUSE TO TAKE LIOUID OR EFFERVESCENT POTASSIUM PREPARATIONS OR FOR
PAnENTS IN WHOM THERE IS APROBilM OF COMPLIANCE WITH THESE PREPARATIONS.
1. For lherapeubc use mpatienls w11tl hypokalemia w11h or WilhoUI melabolic alkalos,s; mdiQIIalis inloXIcalion Bleeding
and 1n pa11en1s Wllti hypokalemiC tam111~ penod1c para~1s.
2. for prev.nlion of potassium deplel1on when !he d~elary inlake of polasslum IS madequate 1n !he follow1ng Infection
condili<lns: pa11en1s reteiVIng digllaiiS and d1urebcs lor congesbve heart failure; hepabc CirrhOSis w1!h asCites;
slales of aldosterone excess w11h normal renal tunc11on; potiSSIUm·IOSing nephropalhy; and certa~n diarrheal Cardiac dysrhythmias
sbles.
3. The use of pot1ss1um salts in ~tienls receivlni d1uretics for uncomplicaled essenlial h:rtension is ohen Electrolyte imbalance
~~~~~~~e~h:~ s~~h ~~~~~Iaa~~r~~~:ia~~~fe~!~t.t~~u:,~o~~~;~~~h:~~'"'"~ro~~ ~:~~ Dehydration
adaquale 10 conlrol mil:/.r cases. In more sovere cases supplemenlallon wilh polassiUm sails may be 1nd•caled Nausea and vomiting
CONTlWNDtCAnONS
Po1aSS1um supplemenls are con!ra1ndica!ed in patienls wilh hyperl<alemia, smce a further increase in serum Diarrhea
~~~~~gm:~:';;n~r~n~'";~t~'\~~~r~~~s%~~ ~~~~~s a~ec~ ~Y~a::~c"';~,~~s~o~~;:a~:~;Jr~~~~~~ Muscular weakness
extenSive. bssue breakdown as in sovere burns, adrenalinsulliC.IellC)', or !he adrnims1ra11on of apolasSium-spar·
11",1 d1Urel1c (e g., Spironolaclone, lnamterene) (see OVERDOSAGE).
Fatigability
Anemia
a:e;t~~~~.~~~~ge7~:~~~~~g~uf~~~:rr~~~:,~:~;~~~.~~~~;r;:~X~~~~;:~~~~~ut~e~~~sP~~.~:~~
bon should be wilh aliqu~ prepara11on. Wax·malnx potasSium chlonde prepara11ons have produced esophageal
ulceralion in certa1n cardiac pa110nls w11t1 esophage.JI compresSion duelo an en1a1ged loll alnum.
WARNINGS
Hyptrbftmft(Soe OVERDOSAGE )
In pa~enls wilh Impaired mechamsms for excretmg po!assium, me admmtrat1on of polassium sails can
produce hyperblem'a and cardiac arrest. This occurs mosl common~ In pal~nls gwen polasSium Dy !he
Intravenous route bUI may ~so occur 1n panenls given pobsSium orally. Polen11ally !alai hyperkalemia can
dl6velop rapidly and De asymploma11c.
Thble 2. Contmindications to Exercise for
TIIO use ot potlssium sails In pa11en1s with chronic renal disease, or any other cond111on wh~h impairs
po1ass1um excrenon, reqUires particularly caretul mollilonng of the serum polasSium concen1ra11on and appro·
Cancer Patients
pna1e dosage adjustment.
lnltractton With Pallufum-Spa~IIQ Dlurttlct
Hypokalemia Should not be treated by the concom1t1nt admmlstralion ol pctlssium sails and apolassium·spar· Unusual fatigability
11\Q diurellc (e.g., s~ronolaclone or tr~mlerene). Since the Simultaneous adm,mslralion of lhese agenls can Unusual muscular weakness
produce severe hyperkalemia.
Oulnllnttltlnaf llllotla Development of irregular pulse
Polasmum chlonde tlblels have produced stenolic andtor ulcerai1Veles10ns olltle small bowol and deams These
les1ons are caused by ahigh local~ed concenlralion of potass1um 10n 1n !he reg1on ol arapidly diSsOlving !able!, Leg pain or cramps
which 1n1ur8S !he llowef wall and !hereby produces oDslrue11on. hemorrhage, or pertoranon. Slow·K. IS a
wax·malriX tlblet formulated to provide aconnoll<ld. rate of release of po1ass1um chlonde and lhus to m101mlle Chest pain
!he posSibility of ahiQh lo~ concenlralion of polas11um 10n near lhellowel w~l. Wh1lelhe reported frequency ol Acute onset of nausea during exercise
~l·llowelleslons IS much less wilh wax·malnx laDiels (~531tlan one per 100,000 palienl·yea") tt11n Wilh
enleric-coaled polaSSium chlondelab~IS (40·50 per 100,000 pal~nt-~ea") cases asSOC!aled w11h wax·ma!riX Vomiting within pra.tious 24-36 hours
::~~~P~n~~~~:~~;~~~~~~~~:desre~a~ p~~~~ln ~~~io~:~.~~~;,P~~!':~~~~~~1
0
Sa.tere diarrhea within previous 24-36 hours
upper gasuomF.snn~ Dleed1ng assoCiated wiltlltlese produels. The lolai number ol gasUOinleslinalleSions
remams approximately one per 100.000 palienl·yea". Slow·K should be d1scon11nued 1mmedia!oly and the Disorientation/confusion
poss1b1h~ of bowel obstruction or per1orauon conslllered 11 severe vomrtlnQ, abdommal pa1n. distentiOn, or
gastro1n1es11~ bleedmg occurs. Dizziness/blurred vision/faintness
Mtllbollc Atldolfa
ltypokalllmia 1n palients w11tl mmbol~ acidOSis should be lre.Jied wilh an alkillinllmg polasSium san such as
Pallor/cyanosis
polasSium b1cartlonate, polaSSium Cllrale, or pot1ss1um acetlle. Sudden-onset dyspnea
PRECAUTIONS
Gtlltral: Decreased heart rate andjor blood pressure with
The diagnosis ol pot1ss1um depleUon 11 ord1nanty made Dy demons1ra11ng hypokalemia 1n apalienl w1th ac1101cal increased 'NOrkload
~~~~ ~f~~~solho; ~~~~~~r:s~~~~.d~~e~~~~~n~~~~~~~~~~t~~c';~,~ :1;',:~n ~ fa~~:~
1

potls~um, while acute acidosis fl61 se can 1ncre.1se !he serum polasSium concenlra11on 1010 !he irormal range
IV chemotherapy within pra.~ious 24 hours
even 1n !tie presence of areduced totat body pctasswm.
lntonnltlon lor PaUtflll
Pnv~1oons should conSider rem10ding the paUent of ltlelollowing:
To tlkB each dose w11hout cruShing, Chewif\Q. or suck1ng !he tlbl•ts.
To tlke t~s med1one only IS directed. Th1s is espec11lly important 11 !he palient is also laking Dolh diure11cs and
dl~~~~~~~~~~ physlclan il there is lrou~e swallowing lablels or d !he tiDiels seem lo snck m!he lhroal.
5

To check w11h the dOclor at once 11 tlrry stools or other eVIdence of gas1ro10tesonal bleed10g IS nollced
LlboratoryTnll
Regular serum potasSium delerm10a11ons are recommended. In addllion, dunng !he trealment of polasSium effects. Developments such as an irregular
deplenon, careful anennon should be pa1d Ill aCid· base balance. olher serum eleclro~e ~vels !he eleclrocar·
~J~:· and !he d101cal slalus of !he pa11001, part~ularty 1n !he presence of card1ac 1sease, renal d1sease, or pulse, joint pain, shortness of breath, or exces-
0111f lrearull0111 sive fatigability should be reported to the refer-
PolasSium·spanng diurelics: see WARNINGS.
Cln:f~ntsll, MUIIDtiAtlfl, lmplfnntnt of Ftr1Utty ring physician immediately. Table 1 lists prob-
Long·term carcmogemcily s1ud1es '" an1~s have no! been pertormed
lems commonly related to antineoplastic
=:r~~J~~ ~IIJdiel have not been condUded Wllh Slow·K. Ills also not known whelher Slow-K can
cause folal harm when admmiSiered loa pregnanl woman or can allecl reproducbon capaCily Slow·K should be
gMn Ill apr6Qnanl woman only 11 cle.Jrly needed.
therapy, while table 2 lists some contraindica-
NulllnQMotllen
The nonn~ poliiSSium 1on conlenl ol human milk 15 aboUI13 mEQII.. II IS no! known il Slow·K has an ellecl on
tions to exercise in cancer patients. During pe-
1!\IS conlent. Caulion should be exerdsed when Slow·K IS adm1mstered 10 anu,.lng woman.
PtdfllriCUit
riods when activity is reduced because of treat-
Safely and eflectNeness 10 children have not been established. ment, range-of-motion and mild resistance
AllYERU REACTIONS
One olltle most stvere adverse ellec!S IS hyperl<alemia (see CONTlWNDICAnONS. WARNINGS. and OVER·
DOSAGE). There also have been repons ot upper and lower gasiiOinleslinal cond11iono Including obslrucliOn.
activities can still help minimize the harmful ef-
Dleed1ng, ulceranon. and pertorallon (see CONTlWNDtCAnONS and WARNINGS); olher taelors known lobe
assoc~led Wllh &uch condmons were present in many of lhese paflents.
fects of hypokinesia and maintain the strength
The most common adverse reac11ons to oral polassium sans are nausea. vom111ng. aDdomrnal diScomfort.
and diarrflea. T~ symploms are due Ill lrrit4110n ol !he gastr01nteshna1 tract and are Dest managed Dy lakmg
necessary for activities of daily living.
lhf dose wll!l meals or reducing ltla dose.
Skln rash has been reported rarely. In view of the many potential problems, and
Do not store above 66"1' (30·C). Prolecllrom m0i•1ure. Protecl from light
0iS{Jt!IS4 in /JQhl, lighl·flisisiJnl conlilintr (USP)
because few individuals are trained in both the
C6S·39(Rev 7166) principles of exercise and the problems of clini-
cal oncology, teamwork is necessary to establish
safe, individualized exercise guidelines for can-
cer patients. A team that devises such guidelines
continued
Dfll.trr.
tiiA f'lllnnutU1icll ComplfiY
blvllton Ill CIIIA·GlfGY CDrporaUon
hll1lllf1. "",.,..., 000 128·7866-A C I ll A Vol U o No. 10 o October 86 e THI PHYSICIAN AND IPORTIMIDICINI
 In non-Insulin-dependent diabetes

Tolinase
(tolazamide)
11blcts
!00, 250, & 500 mg
cancer continued
should have prior training and practice in exer-
cise programs for cardiac patients as well as
One tablet ... one day's therapy other chronic disease patients (pulmonary, re-
CONTRAINDICATION$ nal, and diabetic). The team also should have ex-
TOLINASE laotets are contra>nd!Cated mpat1ents w>th
1 Known hypersenSitiVIty or allerqy to the drug perience with inpatient and outpatient oncology
2. D1abet1C ketoacidOSIS, With or Without coma. Th1s conditiOn should be treated W1th msulm.
3 Type I diabetes mellitus. as sole therapy problems and treatment practices. Such a team
SPECIAL WARNING ON INCREASED RISK Of CARDIOVASCULAR MORTALITY
The admlnlslrallon ol oral hwpoalwcemlc drugs hll beta reported lo be usoclated with could consist of an exercise physiologist, a clini-
Increased cardlovucular mortality 11 compared to treatment with diet alooe or diet plus
Insulin. This warolng Is based on the sludr conducted br the University Group Diabetes cal nurse specialist in oncology, a physical ther-
Program (UGDPJ, along-term praspocllu clinical trial designed Ia evaluate tho ellecllwtnen
olgluctse-lowerlng drugs In prevenllng Dr delaying vascular ctmpllcatlons In patients with
•••·lnsulln·depondtnl dlabetn. Thestudwtnvolvod 123 pallootswha were randomlynslgned
apist, and a dietician. In addition, the team
to ont of lour treatmentgroups(Diabeles, 11 (Suppl2):741-130, 1970). should include physician-consultants such as a
(1.5 grams per ••rl
UGDP reported that pallutstreated lor 5to &run with dltl plus all11d dOll of tolbutamide
had a rate ol cardltvucutar mortallt[ appro11matetw 2\i limes that Dl cardiologist and an oncologist/radiologist. A
r::~::~s:m::~t~!~:~·~:!o:~·c~::r:!~:·bn:~:~r::~~!n,~~r~:s:r~~~~~~::::~~~:·~~~~i~~;. team of this kind should be able to address the
thusllmlllngtht apportunllw hr tht studrto show u Increase In overall morlalllr. Despite
controversy regardlnC the lnttrprttallon ol thou results, the llndlngs ol the UGDP studr activity needs ofa variety ofcancer patients with
~~~~·:~~:::.~~1::~~ or;~L~=~~~~:/:r~fir~~W:::O~',!ho~~~~~=~:.'"med otthe potential
Although only one drug In the sullonrluru ctou (tolbutamide) wu Included In this study, It Is
a wide range of functional abilities.
crudenl from I 111111 lllftdpelnl IO COOSider thai lhls warnln~ may apply IO Olhtr 0111
c~=~,~it':.'~c~~~=~ In this class, In view ol their cloll slmllarlt 11 In mode ol action and
PR£CAUTIONS-Gtnoral Screening and Monitoring
Hypoglycemia.· All sulfonylureas are capable of producmg severe hypoglycemia. P10per palienl
5 Screening should always precede exercise test-
~:~~~~~~~=~~~~~~~~~ftr~~edn~ y~ ~jdc~;f~ d!~~~~~~~~~r~~n~~~n~~~;~h~~P~S r~~~~~~n~:~~~:~~~t~~~~~~~~
0 1 1

p1tu>tary 1nsufi•C16ncy, are part>cular(y susceptible to hypoglycem>a Hypoglycemia may be d•fliCult to ing or the start ofan exercise program, according
recogniZe 1n the elderly and •n people tak>ng beta·adrenergic block>ng d1ugs. Hypoglycemia 1s more
l1kely to occur when calonc mlake IS dellc>ent. after severe or prolonged exerciSe, when alcohol IS
1ngostM. or when more t11an one glucose·lowenng drug 1s used.
to the American College of Sports Medicine. 10
Loss of Control of Blood Glucose· ThiS may occur in d>abehc pat>ents exposed to stress such as fever. For a cancer patient the first consideration in
trauma. mfoct10n. or surgery. It rnay then be m:cossary to drscontmue TOLINASE and admrmster msulln.
Adequate adtustment of dose and adherence to dl61 should be assessed before clasSIIymg apatient as a pre-exercise screening is the possibility of exist-
secondaryfallure
Information lor Patlents--Pat,.nts should be mformed of the potont>al nsks and advantages of ing coronary artery disease. Patients also should
TOLINASE and olalternat>ve modes of therapy. They also should be mformed about the importance of
adherence to d>etary •nstruct1ons. ol a regular exerciSe program, and ol regular lestmg ol unne and/or
blood glucose. The nsks of hypoglycem>a.>ts symptoms and treatment. and cond>t>ons that prediSpose
be screened for orthopedic problems, especially
to 1ts development should be expla>ned to patients and respons1ble lam>ly members Pnmary and
secondary larlure should also be explarned.
those resulting from prior injuries. For older in-
LaboraiDrl Tills-Response to TOLINASE Tablets should be monllored by frequent unne glucose
tests and penorl>C blood glucose tests. Measurement ol glycosylated hemoglob>n levels may be helpful
dividuals, particularly, evaluation by a physical
msome pat rents therapist or orthopedist may be indicated.
Drug Interactions-The hypoglycemiC actmn of sullonylureas may be potent•aled by certam drugs
mcludtnQ nonster01ddl arlll·mflammatory agents and other drugs that are hrghly protem bound,
salrcylates. surfonamrdes. chlorarnphemcol, probenecrd, coumanns. monoamme oxrdase mhrbrtors. and
Pre-exercise screening should be followed up
beta adronergrc blor.ktng agents.
Certa>n druys tend to produce hyperglycemia and may lead to loss of control. These drugs Include the
with periodic reevaluations during a patient's
thrazrdes and other diUrehcs, cortrcosterords. phenothrazmes, thyrOid products. estrogens, oral
contraceptrves, phenytmn, nrcotmrc acrd. sympaltlomrmctrcs, calcrum channel blockmo drugs, and
exercise program, particularly if he or she begins
l!i01lt8lld
Preglancw-TOLINASE should be used dunng pregnancy only 11 clearly needed lnsulm should be used
to show signs of decreased exercise tolerance. In
dunng pregndncy to ma~nta>n blood glucose as close to normal as posSible Prolonged severe
hypoglycom.a (4 to 10 days) has been reported 1n neonates born to mothers who were rece~v>ng a
addition to those already mentioned, the follow-
sulfonylurea drug at the lime of del>very TOLINASE should be d>scon!lnued at least two weeks before
the expected delivery date. ing special concerns should be considered in
Nur&lftg Mothtrs -Some sulfonylurea drugs are known to be excreted mhuman nulk.lnsulm therapy
should be cons>dered
pre-exercise screening and ongoing monitoring:
Pediatric UU·-Salety and effectiveness mchildren have not bean establiShed
ADVlRSE RUCTIONS
1. Fitness Level and Age. Cancer is most com-
HypO()Iycenua See Precaullans and Overdosage secttans. Gastromtestmal ReaCtions· Cholastatrc
taund•ce m;y occur rarely; TOliNASE Tablets should be diScontinued 1f th>S occurs Gastromtest>nal
mon among aging individuals, many of whom
~~~~~~~~~ncT~e: ~itn~ar;e~e ~~:~~~~~~uJI~~~sma~vd J~:~~~~~ !~~~h~o~~~~ ~~r:~ie~~ab~~~~~~;;9~: are already deconditioned when they first seek
Reactwns: Allerg1c skm react1ons, e u.. fruntus. erythema, urttcana. and morblll1formor maculopapular treatment. These patients may deny increasing
erup!IOns occurred m0 4% ol patients. hese may be trans10nt and mayd>sappear despite continued use
ol TOliNASE. 1f skm reactions persiSt. t11e drug should be d>sconlinued. Porphyna cutanea tarda and
phOtosenSIIIVIIV reac11ons have been reporled w1th su!fonylureas. Hematologic ReactiOns: leukopema. weakness until it interferes with their daily activ-
1 1
~~~~~~~~~~~~~s~~it~~~~r~~~V~~~a~~i~~~~~~~~~~:~~~~!tt~P~~;~ ~y~~ ~~·d~~~~~:a"~YI~~~~~~~~~~~ ~~~~ ities. Although the clinician occasionally en-
befm reported With sulfonylureas, hOwever, d1sulftram·l1ke react1ons have been reported very rarely
MIScelldneoos · Weakness, fatigue, dtzzmess, verttgo, malatse. and headache have tnfrequent!y been
reported
counters young, fit patients, aging, decondi-
OVERDOSAGE
0
tioned patients are more common. It is
~~~~~~a~~a~n~~~~n~~,:~~P~cc:~t",~! ~~~:~E :~g~j~s·~:" ~~~~u~e rha~go/~fr~~~~O~~~~~eg~~6~m~1 important that the exercise be designed to stim-
concentrated (50%J glucose soluMn Th1s should be followed &v a continuous mlus1on of a more d1lute
(10%) glucose solut1on at a rate wh1cll w111 mamtam the blood glucose at a level above 100 mg/dl
Patients should be closely mondored tor a mm1mum of 24to 48 hours. smce hypoglycemia may recur
ulate the patient without promoting fatigue or
after apparent clinical recovery
HOW SUPPLIED
soreness. The patient's functional capacity (fit-
TOUNASE Tablets are ava1lable m the lollowmg strengths and package Sites:
1DO mg (scored. round, while/ U1111 ·of Use boltles of tOO NOC 0009·0070·02 ness level) is best assessed with a symptom-lim-
250 mg (scored. round. while) Boltles of 200 NOC 0009·0t 14·04
Bottles of 1000 NOC 0009 0 t 1H2 ited, graded exercise test. In our experience, it is
Umt·of·UsebottlesoltOO NOC 0009·0t 14·05
Umt·Oose package of 100 NOC 0009·0114·06 rare to obtain a true maximal heart rate or ox-
500 mg (scored. round. while) Umt·Of·Use bottleso1100 . NDC 0009 047].06
C•utlo•: Federal law prohltllls dtspensmg wrttlout pre.scnptwn. Store at controlled room temperature ygen uptake in cancer patients. However, the
15'·30" C(59" 86' f). D>spcnsed 1n well closed con Iamers w>th safely closures. Keep con tamer lightly
closed 'peak heart rate or oxygen uptake ('\'o2 peak)
For adrJitJOnaJ product mlvrmat10n see your UpJofm 1eprcsentat1Ve
B·lt S
IJlmml ACentury on a symptom-limited exercise test is adequate
0 )J
{ j(rl\\ of Caring to evaluate functional capacity and develop an
J6559 June. t986 ~ 1886·1986
exercise prescription. Exercise recommenda-

132 Vol14• No.10•0ctober86 • THIPHYIICIANANDIPORTIMEDICINI

 tions for healthy persons typically suggest that
the exercise heart rate be within 65% to 90% of
maximum for best results. Our experience has
shown that many patients could benefit from
lower intensities (20% to 60% of maximal heart
rate) that may not be as threatening or fatiguing.
It is important to remember that cancer patients
are often deconditioned because of surgery and
prolonged medical therapy and consequently
may develop a rapid heart rate in response to ap-
parently mild exertion.
2. Diagnosis. Consideration of the type, site,
and stage ofcancer is critical in planning for safe
exercise, as the term "cancer" includes more
than 200 pathologies. These neoplasms can be
divided into two general groups: solid tumors
and tumors of hematopoietic origin. The type,
together with the location and size or extent of
neoplastic involvement, can indicate possible
problems or complications that could occur with
exercise. A lung cancer patient obviously will
suffer from pulmonary restrictions, and the
same is true of the breast cancer patient whose
irradiation resulted in some pulmonary fibrosis.
Less obvious is the case ofthe individual with
multiple myeloma, for whom, because ofthe risk
of fractures, jogging and even walking may be
contraindicated. Metastatic sites, whether actual
or potential, are also important considerations.
3. Side Effects of Therapy. Harmful second-
ary effects ofcancer therapy (table 1) that can in-
terfere with exercise fall into three classes: long-
term effects, nutrition problems, and hemato-
logic/immunologic effects.
Certain side effects may become apparent
only after several months of treatment or after
treatment has stopped. 1Hrp4 1•82•127 ).12· 13 Individu-
als who have been treated with hydrocortisone
or prednisone for extended periods can develop
osteoporosis as well as type II diabetes. Drugs
such as doxorubicin hydrochloride (Adriamy-
cin) and bleomycin sulfate (Blenoxane) have po-
tentially toxic side effects on the heart and lungs,
respectively. Vincristine sulfate (Oncovin) bas
well-documented neurotoxic effects. Irradia-
tion-induced pneumonitis can result in some
degree of pulmonary fibrosis, and pericarditis
and clinical manifestations of coronary artery
disease are other possible complications of ra-
diation therapy. 1HPPI0 1- 145> Clearance for exercise
should include evaluation of these problems.
Concerning nutrition problems, various anti-
THI PHYSICIAN AND IPORTIMEDICINE e Vol14 • No. 10 • October 66
neoplastic agents directly cause nutritional and Clinical
electrolyte imbalances, aggravating imbalances manifestations
that may be induced secondarily by anorexia, of coronary
nausea, vomiting, and diarrhea. Methotrexate, artery disease
for example, is a folic acid antagonist Cisplatin arc possible
enhances urinary excretion of divalent cations side effects of
such as magnesium, and 5-fluorouracil causes radiation therapy.
thiamine deficiency. The action of nearly all cy-
totoxic agents has similar nutritional implica-
tions. Bleomycin, doxorubicin, hydroxyurea,
and methotrexate cause mucositis, and numer-
ous cytotoxic drugs cause intestinal ulceration
leading to decreased nutrient absorption. 8•14 It is
not known, in most cases, whether replacement
of these micronutrients by supplements would
modify the therapeutic efficacy of these cyto-
toxic agents. 1~
In the hematologic/immunologic area, tem-
porary restrictions on a patient's activity or test-
ing may be necessary because of fever, opportu-
See related article
onpage170.
mstlc infection, or myelosuppression (ie,
depression in platelet and WBC count or hemo-
globin). Since individuals undergoing irradia-
tion and chemotherapy may be more susceptible
to infection during times of leukopenia, they
should beware ofcrowded exercise facilities such
as health spas and swimming pools. When test-
ing these individuals in the laboratory, particu-
larly when oxygen uptake is being measured,
equipment (mouthpiece and respiratory tubing)
must be sterile. Since many patients present with
stomatitis, which makes the mouth sensitive, we
prefer using facemasks to mouthpieces for col-
lection of respiratory gases. Anemia can contrib-
ute to feelings of weakness and fatigue. Further,
platelet counts of 50,000 or lower should dictate
caution regarding activity.
4. Psychological Status. It is common knowl-
edge that depressed individuals are less sponta-
neously active. For this reason, it is important to
determine whether inactivity is related primar-
ily to emotional stress or to physiological limi-
tations imposed by age, fitness level, disease, or
treatment. Although graded exercise testing has
rarely been used with cancer patients, it has great
potential for establishing objective measures of
functional capacity. Patients often worry about
their functional status, and family members fre-
continued
133
cancer continued
quently reinforce their fears about "doing too
much" or "hurting themselves." Feelings offa-
tigue and weakness are taken as signs ofthe need
for rest and become catalysts for further inactiv-
ity and decreased functional status. It is impor-
tant to assure family and friends as well as pa-
tients that carefully planned, moderate activity
can be beneficial. Further, it is necessary to be-
gin the activity slowly and cautiously to reassure
the patient that exercise need not cause undue fa-
tigue or discomfort.
5. Timing of Tests and Chemotherapy. It has
been our practice to discourage vigorous activity
on days when blood tests or other laboratory
tests are done. Vigorous activity can cause
marked leukocytosis, which reflects temporary
changes in compartmentalization rather than
absolute changes. Because treatment is often al-
tered according to WBC count, it is best not to
risk obtaining this misleading result. 16 Similarly,
serum enzymes occasionally are measured for
monitoring purposes; the nonspecific SGOT
may be elevated as a result of heavy activity (as
well as in some malignancies and liver dis-
eases), 17 causing a misleading measurement. In
addition, we generally advise against activity the
same day the patient receives intravenous che-
References
I. Dietz JH: Rehabilitation Oncology. New York City,
John Wiley and Sons, 1981
2. Corcoran PJ: Disability consequences of bed rest, in
Stolov WC, Clowers MR (eds): Handbook of Severe
Disability. US DepartmentofEducation, Rehabilitation
Services Administration stock No 017-090-00054-2,
Government Printing Office, 1981, p 55
3. Vallbona C: Bodily responses to immobilization, in
Kottke FJ, Stillwell GK, Lehmann JF (eds): Krusen's
Handbook of Physical Medicine and Rehabilitation, ed
3. Philadelphia, WB Saunders, 1982, p 966
4. Buettner LL, Gavron SJ: Personality changes and phys-
iological effects of a personalized fitness enrichment
program for cancer patients. Read at the Third Inter-
national Symposium on Adapted Physical Activity,
New Orleans, Nov 23-25, 1981
5. Winningham ML, Mac Vicar MG: Response of cancer
patients on chemothempy to a supervised exercise pro-
gram, abstmcted. Med Sci Sports Exerc 1985; 17(April):
292
6. Mac Vicar MG. Winningham ML: Promoting the func-
tional capacity of cancer patients. Cancer Dul 1986;
38(November-Dccember), to be published
7. Feldman BF, Ruehl WW: Labomtory aspects ofcancer.
Mod Vet Pmct 1984;65(0ctober):771-773
8. Shils ME: Nutrition and neoplasia, in Goodhart RS,
Shils ME (cds): Modern Nutrition in Health and Dis-
case, ed 6. Philadelphia, Lea and Febigcr, 1980, pp
1173-1176, 1185-1186
9. Meuret G: Haematologische komplikationen und ger-
134
motherapy. This precaution is based on a study
by Unverferth et al, 18 who discovered a signifi-
cant increase in cardiac dysrhythmias on Holter
monitor recordings in the first two to six hours
following the administration of chemotherapy.
Conclusion
Many of the concepts that have proved so suc-
cessful in cardiac rehabilitation can be applied
to rehabilitation oncology if modifications spe-
cific to the disease and treatment are incorpo-
rated. With more and more cancer patients sur-
viving longer, oncology rehabilitation programs
arc an idea whose time has come.
Acknowledgments
The authors thank cardiologist Donald V. Unverferth.
MD, hematologist Jane A. Leiby, MD, and Bill Castle
for their assistance. This work »us partially supported by
Public 1/ea/th Service research grants P 30 C4 16058 12
and 2 R25 CA/8016-0BA/, awarded by the National
Cancer Institute, DJIJIS, and by grant 5 ROJNU1078-
02, awarded by the Nursing Division, Dlll/S.
Address correspondence to Mary! L. Winningham, PhD,
Ohio State University, College of Nursing, 1585 Neil Ave-
nue, Columbus 43210.
innungs-problcme bei tumorkranken. Die Mcdizin-
ischeWclt 1984;35:1204-1208
10. American College of Sports Medicine: Guidelines for
Exercise Testing and Prescription, ed 3. Philadelphia,
Lea and f'Cbiger, 1986, p I
II. Ali MK, Ewer MS: Cancer and the cardiopulmonary
system. New York City, Raven Press, 1984
12. Tokaz LK, Von HoffDD: The cardiotoxicity of anti-
cancer agents, in Perry MC, Yarbro JW (eds): Toxicity
of Chemotherapy. Orlando, FL, Grune & Stratton Inc,
. I984, pp 199-226
13. Ginsberg SJ, Com is RL: The pulmonary toxicity of an-
tineoplastic agents, in Perry MC, Yarbro JW (cds): Tox-
icity of Chemotherapy. Orlando, FL. Grunc & Stratton,
Inc, 1984, pp 227-268
14. Cancer: Dietary Modifications in Disease. Columbus,
011, Ross Laboratories, 1983, p 10
15. Hoffman r-A: Micronutrient requirements of cancer pa-
tients. Cancer 1985;55(January suppl):295-300
16. Robertson AJ, Ramesar KC, Potts RC, et al: The effect
of strenuous physical exercise on circulating blood lym-
phocytes and serum cortisol levels. J Clin Lab Immu-
noll981;5(January):53-57
17. Wallach J (ed): Interpretation of Diagnostic Tests, A
Handbook Synopsis of Laboratory Medicine, ed 3.
Boston, Little Brown & Co, 1978, pp 57-58
18. Unvcrferth DV, Balcerzak SP, Neidhart JA: Ventricular
arrhythmias following intravenous cancer chemother-
apy, abstracted. Clin Res !983;31(4):742A
Va114 • No. 10 • October 86 • THtr: PHYSICIAN AND IPORTIMIEDICINI!