Rehabilitación (Madr).

2013;47(3):170---178

www.elsevier.es/rh

REVIEW

Exercise prescription in oncology patients: General principles

M.J. Azevedo a,∗ , S. Viamonte b , A. Castro a

a
Physical and Rehabilitation Medicine Department, Alto Ave Hospital Centre, Guimarães, Portugal
b
Physical and Rehabilitation Medicine Department, Porto Hospital Centre, Porto, Portugal

Received 5 November 2012; accepted 9 April 2013

Available online 24 June 2013

KEYWORDS Abstract
Cancer; Objective: The incidence of oncological diseases as well as the survival rates of cancer patients
Exercise; has risen in recent years. Cancer-related research has also increased, particularly with respect
Oncology; to the role of exercise. We performed a review of the literature on exercise prescription in
Physical activity oncology patients.
Materials and methods: A search was conducted in reference textbooks and electronic
databases.
Results: Exercise bestows benefits to oncology patients with respect to fatigue, functional and
physical performance. In addition, exercise exhibits promising effects in the maintenance of the
body composition, metabolism, immune and psychological functioning. International Societies
recommend 30 min of moderate aerobic physical activity at least five times per week, strength
training three times per week, and flexibility exercises. Exercise must be prescribed on an
individual basis, taking age, previous activity level, tolerance to exertion, diagnosis, disease
stage, therapeutic approach, and the patients’ comorbidities into account.
Conclusions: Exercise plays an important role as an adjuvant of oncological treatment.
© 2012 Elsevier España, S.L. and SERMEF. All rights reserved.

PALABRAS CLAVE Prescripción de ejercicio en pacientes de oncología: principios generales

Cáncer;
Ejercicio; Resumen
Oncología; Objetivo: La incidencia de las enfermedades oncológicas, así como las tasas de supervivencia
Actividad física de los pacientes con cáncer han aumentado en los últimos años. La investigación sobre el cáncer
también ha aumentado, particularmente, con respecto a la función del ejercicio. Se realiza una
revisión de la literatura sobre la prescripción de ejercicio en los pacientes oncológicos.
Materiales y métodos: Se realiza una búsqueda en los libros de referencia y bases de datos
electrónicas.
Resultados: El ejercicio otorga beneficios a los pacientes oncológicos con respecto a la fatiga y
desempeño funcional y físico. Además, el ejercicio muestra efectos prometedores en el manten-
imiento de la composición corporal, el metabolismo, el funcionamiento inmune, y el psicológico.

∗ Corresponding author.
E-mail address: mjazevedo@net.sapo.pt (M.J. Azevedo).

0048-7120/$ – see front matter © 2012 Elsevier España, S.L. and SERMEF. All rights reserved.
http://dx.doi.org/10.1016/j.rh.2013.04.002
Exercise prescription in oncology patients: General principles 171

Las sociedades internacionales recomiendan 30 min de actividad física aeróbica moderada, por
lo menos 5 veces a la semana, entrenamiento de fuerza 3 veces por semana, y ejercicios
de flexibilidad. El ejercicio debe ser prescrito en una base individual, teniendo en cuenta la
edad, el nivel de actividad anterior, la tolerancia al esfuerzo, el diagnóstico, el estadio de la
enfermedad, el enfoque terapéutico, y las comorbilidades de los pacientes.
Conclusiones: El ejercicio juega un papel importante como adyuvante del tratamiento
oncológico.
© 2012 Elsevier España, S.L. y SERMEF. Todos los derechos reservados.

Introduction prescription’’, ‘‘oncologic exercise’’, and ‘‘physical activity

Cancer is an important cause of both morbidity and
mortality,1,2 but together with recent medical advances
in early diagnosis and treatment, the life expectancy of
patients diagnosed with cancer has increased and the 5-year
overall survival is greater than 65%.1---4 However, the cure
rate of cancer remains quite low and oncological disease is
viewed as a chronic and dynamic process.3
The cell destruction underlying some cancer treatments
also damages healthy tissues, and cancer patients are
thus often exposed to side effects that limits not only
physical performance but also their functional and cogni-
tive capacity,1,2,4---6 compromising health-related quality of
life.5---7
Furthermore among cancer survivors there is evidence
that while some health-related behaviour (e.g. diet, smok-
ing) improve after cancer diagnosis, physical activity levels
reduce significantly.8
Nowadays physicians must be prepared not only to
diagnose cancer, but also to provide appropriate lifestyle
advices, to manage the consequences of cancer diagnosis
and therapy.1
Historically clinicians advised cancer patients to rest
and to avoid activity.5 However, current empirical evi-
dence suggests that exercise is relatively safe and should
improve physiologic and psychological outcomes for most
patients1,2,5,6,9---11 and it can be considered a therapeutic
intervention.9
Exercise is a type of physical activity defined by planned,
structured, and repetitive body movements done to improve
or maintain one or more components of physical fitness.4
The authors performed a review of the literature in order
to establish some general principles of exercise prescription
in these patients, its effects, indications and contraindica-
tions.
Materials and methods
cancer prescription’’.
A total of 28 articles were selected and included sys-
tematic review articles and meta-analysis of randomised
controlled trials. Were also selected some single studies for
themes not covered by systematic reviews, with outcomes
adequate to the purposes of the present article (effects,
pre-exercise assessment, recommendations, period of inter-
vention, adherence and contraindications of exercise).
Effects of exercise on oncological patients
The potential of exercise to improve the lives of individuals
with oncological diseases is a current focus of interest and
research. There are many decades of evidence for the posi-
tive effects of exercise on psychological well-being, quality
of life, and fatigue, however, the importance of exercise on
physical performance, body weight and composition, mus-
cle strength and resistance, and immune function has only
recently been reported.1,2,5,6,9,10
Physical performance and cardiorespiratory
function
The psychological fatigue and physical symptoms related to
cancer and its treatment contribute to immobility, muscle
weakness, atrophy, and reduced functional and cardiorespi-
ratory performance.12
Several studies with breast cancer patients observed
significant functional improvement, including in cardiorespi-
ratory function, associated with exercise programmes during
and after treatment.12 Similarly, an increase in aerobic func-
tion was observed among lung cancer patients; however,
there was no significant improvement in the pulmonary
function parameters (vital capacity and forced expiratory
volume in 1 second (FEV1 )).13

Data were collected from the Guidelines for oncologic exer-
cise prescription of the ACSM (American College of Sports
Medicine) and the ACS (American Cancer Society) and from
reference textbooks: Delisa’s Physical Medicine & Rehabili-
tation.
In addition, the electronic databases PubMed, Science
Direct, EMBASE and Scopus were searched to identify
mainly review articles using the terms ‘‘cancer exercise
Fatigue
Cancer-related fatigue is a complex, multifactorial, and
poorly understood phenomenon. Nevertheless, there is
strong evidence that exercise reduces fatigue in patients
with oncological diseases, including patients subjected to
intensive treatment or with advanced disease. This exercise
effect is consistent whether the exercise is supervised or
172
not, whether aerobic or resistance training, and whether it
occurs during or after oncological treatment.14---16
Insulin regulation
Exercise makes a crucial contribution to reductions in the
levels of insulin and glucose.2 High levels of insulin, glucose
and insulin-like growth factor (IGF), and IGF binding protein
3 are associated with an increased risk for breast, prostate
and colorectal cancer.12 Therefore, exercise plays an impor-
tant role in primary and secondary cancer prevention.
Body weight and composition
Although weight loss is typically associated with oncologi-
cal patients, weight gain and sarcopenia have also been
documented, especially in individuals subjected to adju-
vant systemic treatment. Similarly, the reduction in physical
activity associated with a diagnosis of cancer leads to weight
gain and alterations of body composition.
Exercise is crucial to maintaining and preventing weight
and fat mass gain, which in turn is essential to reduce the risk
of co-morbid illnesses (hypertension, diabetes, and heart
disease), and may also be factors in reducing recurrence
and improving survival.2,17
The amount and intensity of exercise needed to induce
weight maintenance or loss are not yet well established
because in these individuals, the hormonal and treatment
factors that may influence metabolism are not yet fully
understood.12
Immune function
Several studies in animal and human models have demon-
strated that endurance training bestows protection against
cancer by increasing the activity of macrophages and Natural
killer cells.12
The hypothesis that exercise might induce immunity in
oncological patients has been the target of countless stud-
ies, however, the results are controversial.
Bone mineral density
Reductions in bone mineral density have been documented
in breast and prostate cancer survivors. The benefits of load-
bearing exercise in the maintenance and improvement of
the bone mass of non-oncological individuals has been well
established. However, studies with cancer populations are
few, and their results are contradictory. Further research in
this area is needed.12
Upper limbs function
Oncological treatments that include axillary dissection and
irradiation of the upper limbs predispose patients to impair-
ment of upper limb function and lymphedema. Traditionally,
such patients are oriented to avoid hard labour and intense
exercise involving the affected limb due to a putative risk of
increasing lymphedema. However, the evidence supporting
this practice is limited.
M.J. Azevedo et al.
Several studies demonstrate that exercise helps main-
taining the flexibility and mobility of the shoulders and
upper limbs18---20 and did not observe a significant difference
in the triggering or exacerbation of lymphedema.5
Period of intervention
Courneya and Friedenreich21 were the first to study the ben-
efits of exercise in oncological patients and described the
interval between the end of the initial oncological treat-
ment and relapse or death as the period of survival. The
latter is sub-classified into a period of rehabilitation (3---6
months after the end of treatment) and a period of disease
prevention/health promotion (long-term survival).
Courneya and Friedenreich believe that although the
implementation of programmes of exercise and other types
of physical activity is important in both the rehabilitation
period and long-term survival, it is more valuable in the
former, due to the following reasons6,22 :
- During treatment, patients’ level of physical activity
declines remarkably, and a large number of side effects
associated with cytotoxic therapy can manifest. These
side effects are potentially modifiable by exercise pro-
grammes.
- A cancer diagnosis is considered a key-event that triggers
lifestyle changes and can represent a motivational factor
promoting the onset of physical activity.
- The maintenance of surveillance after treatment permits
a less abrupt transition from the high levels of surveillance
they receive during oncological treatment.
Pre-exercise assessment
Exercise is usually a safe and well-tolerated activity
for oncology patients both during and after adjuvant
treatment.1,23
Cancer patients are generally elderly, exhibit a large
number of comorbidities, and are subjected to a large
number of loco-regional and systemic cytotoxic treatments
that can increase the risk of complications associated with
exercise.23
A careful clinical history and physical examination seek-
ing cardiac, respiratory, neurological (including screening
of peripheral neuropathies), and musculoskeletal assess-
ment as well as laboratory tests comprising complete blood
count, lipid profile, and pulmonary function tests ensure
the safety of the exercise practise or point out the need
to perform a more thorough investigation.4,9 For individuals
who received hormone therapy, evaluation of fracture risk
is recommended.9
Most of the haematological parameters of exercise
are empirical. Thrombocytopenia are associated with the
increase in blood pressure that occurs during isometric exer-
cise, which can result in intracranial haemorrhage, and with
the risk of intra-articular haemorrhage inherent to high-
impact activities.3 Therefore, exercise can be performed
without any restriction if the patient has a platelet count
above 50,000/␮L, and aerobic (but not resistance) train-
ing might be performed with counts above 10,000/␮L. Any
Exercise prescription in oncology patients: General principles
modality of active exercise is contraindicated with platelet
counts below 10,000/␮L.3,5,9
Patients subjected to chemotherapy with cardiotoxic
agents, namely anthracyclines can develop permanent heart
alterations that affect their physical performance. In such
patients, assessment of cardiovascular function, including
stress tests, is of paramount importance to define their exer-
cise programmes.3
Additional tumour site-specific assessment is also rec-
ommended: breast cancer survivors should have arm
and shoulder mobility assessed; prostate cancer survivors
require detailed evaluation of muscle strength and wasting;
colon cancer survivors who have an ostomy need practices
for management of infection risk; obese survivors (spe-
cially pertinent for the endometrial cancer population) may
require additional clearance and supervision.9
Stress test performance
Stress tests are not indicated in all patients, but they are
especially important in those patients treated with car-
diotoxic agents or who have underlying heart disease. In such
cases, it is useful to establish the training HR.
In spite of the lack of consensus on the safety of the stress
test and training in oncological patients, a set of guidelines
for this population based on current evidence and clinical
experience has been established.4
Such guidelines are explicitly conservative and do not
necessarily apply to all cancer patients given their wide indi-
vidual variability. However, these guidelines have paramount
importance for healthcare professionals with respect to the
stress test performance and exercise prescription.4,9
The stress test protocols applied to the overall population
(generally the Bruce protocol) are as a whole also appro-
priate for the oncological population. Some modifications
may be required as a function of comorbidities, symptoms
specifically related with the disease, or the side effects of
treatment.4,9
In the case of elderly patients or patients with advanced
disease, in whom the main aim of exercise is to increase or
to maintain their ability to perform everyday activities, less
demanding protocol (Naughton or Balke-Ware protocols) or
submaximal tests may be more appropriate.4
The test modality must take into account the specifici-
ties of disease and the limitations imposed by treatment
(e.g. patients subjected to rectal or prostatic surgery
or radiation, treadmills are more appropriate than cycle
ergometers).4
Recommendations for the practise of exercise
Many conditions require precautions, as with tissue
expanders, peripherally inserted central catheter lines,
intraperitoneal catheters and postsurgical limitations.5,9 A
patient’s arterial blood pressure, HR rate, and other vital
signs must be monitored before, during, and after exercise.
Training must be interrupted whenever abnormal symptoms
appear, such as chest pain, nausea, or dizziness.4
The current recommendations by ACSM4,5 are similar to
the general principles for exercise prescription, and include
173
aerobic, resistance, and flexibility training according to the
FITT principle (Frequency, Intensity, Type, and Time).
Such recommendations, which are listed in Table 1, agree
with the ones by ACS24 as well as with those by Courneya
et al.25 for patients in the initial stages of cancer without
other comorbidities.
There is no sufficient evidence supporting precise guide-
lines for exercise prescription for each different type of
cancer. However, ACSM gives some recommendations for
patients with breast (supervised resistance exercise pro-
gramme and progress slowly), colon (lower resistance and
slower progression), gynecologic (additional supervision)
and hematologic cancer (aerobic exercise is recommend
starting with lighter intensity and slower progression).5,9
The frequency of exercise corresponds to the num-
ber of times it is practised per week. Aerobic exercise is
recommended4,25 three to five times per week, and its pro-
gression must be adjusted to the side effects of treatment
(e.g. daily and shorter sessions). Resistance training is rec-
ommended two to three times per week on non-consecutive
days, and flexibility training is recommended 2---7 days per
week, ideally before and after the other modalities of exer-
cise.
The intensity of exercise can be easily explained to the
patients using the talk test, whereby moderate exercise
does not interfere with conversation, whereas vigorous exer-
cise impedes conversation.
The methods used to establish the intensity of exercise
include HR monitoring, subjective perception of exertion
as reported by the patients, maximal oxygen consump-
tion (VO2 max), oxygen consumption at rest, and metabolic
equivalents (METs).4 It is worth observing that the first are
more easily applied.
The calculation of the training HR can be performed using
the formulas described in Fig. 1, or they can be based on per-
centages of the maximal HR (HRmax), which is estimated
using the formula for age-predicted maximal heart rate
(APMHR) (Fig. 1) or based on the stress test.4 The heart rate
reserve (HRR) is calculated using Karvonen formula (Fig. 1).4
The most widely used method to assess the subjective
perception of exertion is the Borg scale, whose score must
vary between 11 and 14 (light to somewhat hard).25
Exercise is rated light when it uses less than 3 METs, mod-
erate when between 3 and 6 METs, and vigorous when more
than 6 METs.4
The ACSM recommends oncology patients exercise at an
intensity between 40 and 60% of their HRR and VO2 reserve
(VO2 R), whereas Courneya et al.25 advocate a percentage
Age-predicted maximum heart rate (APMHR)
HRmax = 220 - age
Karvonen formula
% HRR = ([HRmax – RHR] x % intensity) + RHR
Figure 1 Formulas used to calculate the intensity of aero-
bic exercise. Abbreviations: HRmax, maximal heart rate; HRR,
heart rate reserve; RHR, resting heart rate.
174 M.J. Azevedo et al.

Table 1 Exercise prescription for oncological patients. Adapted from the ACSM and ACS guidelines4,5 and Courneya et al.25
Frequency Intensity Time Type
ACS
Aerobic training 5 or more days/wk Moderate-to-vigorous At least 30′ (45′ to 60′ Daily usual activities
physical activity of intentional using the major
physical activity are muscle groups
preferable)
Courneya et al.
Aerobic training 3---5 days/wk • 50---75% HRR/VO2 R At least 20′ to 30′ Long-lasting and
• 60---80% HRmax continuously/session rhythmic, using the
• Borg 11---14 major muscle groups
(walking, bicycle,
swimming)
ACSM
Aerobic training 3---5 days/wk • 40 to <60% 20′ to 60′ /session Long-lasting and
VO2 max/HRR (interrupted rhythmic, using the
whenever needed) major muscle groups
(walking, bicycle,
swimming)
Resistance training 2---3 days/wk (with 40---60% 1RM 1---3 sets of 8---12 Elastic bands,
48-h recovery) repetitions per weights, resistance
exercise to a machines, weight
maximum of 15 lifting in functional
repetitions in tasks, major muscle
deconditioned groups
individuals or with
fatigue.
Flexibility training 2---7 days/wk Slow and static 4 repetitions of 10′′ to Elongation of all the
stretching 30′′ per elongation major muscle groups
with attention to
areas with limitations
due to treatment
Abbreviations: wk, week; HRR, heart rate reserve; VO2 R, maximum oxygen consumption reserve; VO2 max, maximum oxygen consump-
tion; HRmax, maximal heart rate; MR, maximal repetition.

of HRR and VO2 max rates corresponding to 50---75% and of
HRmax between 60% and 80%.4,26 Several studies defend
that high intensity exercise tended to increase DNA dam-
age, so data suggest that exercise in cancer survivors might
warrant a focus on moderate-intensity, rather than vigorous
activities.2
Walking is the type of exercise preferred by most peo-
ple. However, the static bicycle might be more appropriate
for individuals with gait or coordination disorders.24 Aquatic
exercise might be an excellent solution in such cases, but
it should be avoided by patients with nephrostomy tubes,
central venous access devices, or urinary catheters. Sim-
ilarly, aquatic exercise must also be avoided by patients
with white blood cells counts below 0.5 × 109 /L due to risk
of bacterial infection.25 Survivors subjected to radiotherapy
must avoid exposing irradiated skin to chlorine.25 The static
bicycle should not be prescribed after prostate or rectal
surgery and patients with bone metastases or osteoporosis
risk should avoid high impact or contact activities.4
The duration of aerobic exercise should be between 20
and 60 min per session. The duration can be modified over
the progression of the exercise programme or as a function
of the treatment side effects (e.g. several exercise periods
separated by resting intervals). Resistance training must last
less than 60 min, and flexibility training must include muscle
elongations for 10---30 s repeated 2---4 times.4 The majority
of studies emphasised long term (>6 months) interventions
to produce benefits.2
Progression is defined as the rate of increase of the fre-
quency, intensity and duration of exercise from the initial
to the maintenance stages. Progression varies according to
numerous factors, including the aims of exercise, tolerance
to exertion, and age. Patients undergoing oncological treat-
ment recover in a poorly predictable and often non-linear
manner. The progression of such patients can vary accord-
ing to multiple factors, including the treatment protocol,
oscillating cell counts, and abnormal symptoms. Therefore,
the prescribed exercise may not always be tolerated and
may even be contraindicated on some days. There are no
recommendations for the progression of exercise in onco-
logical patients. Nevertheless, Courneya et al.25 describe
some principles for patients during the initial stage of dis-
ease. They suggest that the frequency and length goals must
be met first and only then should intensity be increased.
Those authors further advocate that progression must be
slower and more gradual in patients without physical condi-
tioning and in patients exhibiting important treatment side
effects.
Exercise prescription in oncology patients: General principles 175

Resistance training is essential to increase muscle mass
and avoid strength impairment in all cancer patients.
Cachectic patients or those in whom aerobic exercise is con-
traindicated must give preference to resistance training.23
The decision of when to start this modality depends on indi-
vidual needs.
Resistance training might initially comprise resistance
exercises using elastic bands, free weights (0.5---2 Kg), or
medicine balls. Patients who are physically able to per-
form more resistance training must be subjected to muscle
strength assessment. The most widely used method for
assessing muscle strength is one-repetition maximum (1RM),
which corresponds to the maximal amount of weight that
can be lifted at one time. Alternatively, gradually increasing
repetitions can be used to establish the training intensity.4
Resistance training must be performed rhythmically, at a
slow to moderate speed, extending across the entire avail-
able joint amplitude, while maintaining breathing control.
The major muscle groups must be trained first, and exer-
cises involving the upper and the lower limbs should be
alternated.4
The key to the prescription of effective and safe exer-
cise is the individualisation of programmes to the particular
needs of each patient. Such prescription poses a challenge
when the variability of individuals, pathophysiology, ther-
apeutic approaches, and prognoses within the context of
oncological disease is taken into account.
The basis for individualised prescriptions relies on the
current performance of each individual. The patients fol-
lowing ACSM guidelines (Table 1) must be encouraged to
keep them. However, such guidelines represent the min-
imum effort needed to produce benefits, which will be
greater as the minimum goals are surpassed. Such benefits
can be achieved by means of variations in the intensity, fre-
quency, duration, and type of exercise every 2---3 weeks23
(Fig. 2).
Patients who do not follow the ACSM guidelines (Table 1)
must start the exercise programme following an initial indi-
vidualised prescription. When they exhibit tolerance to the
initial prescription, the frequency and duration might be
increased 2---3 weeks later. Resistance training and exercise
variation can be started at least 12 weeks later23 (Fig. 2).
Recommendations for advanced disease
Although some patients are cured or their disease is steadily
controlled, other patients live with advanced disease.
In such patients, physical activity is important to estab-
lish or maintain an overall feeling of well-being and quality
of life,24 but there are few studies exploring these benefits.
Thus, the available evidence does not suffice to make rec-
ommendations, which are consequently based on individual
abilities and needs.24
Neuromuscular electrical stimulation
Patients too weak to perform any type of physical activity
might start transcutaneous neuromuscular electrical stim-
ulation (NMES), which is easy to perform also in bedridden
patients. NMES may also be useful in patients with conditions
that transiently contraindicate intense exercise.26
After several weeks of use, this method can mimic
the effects of regular training---muscle hypertrophy and

Variation: Strength training:

Follows F: ≥5/wk F: 2/wk
ACSM I: moderate-vigorous I: 12-15 rep; 2sets
guidelines Tp: several modalities Tp: UL and LL poly-
(Table 1) Tm: 20-60’/session articular
Tm: 20’/session

Present or
previous
physical
performance *
* **
**
(last month)

Initial Progression:
Does not prescription: F: 5/wk
follow ACSM *2-3 wk
F: 3/wk I: moderate
guidelines I: moderate Tp: fast walking
(Table 1) Tp: fast walking Tm: 30’/session
Tm: 20’/session
**

Figure 2 Overall approach to individualised exercise prescription. Adapted from Jones et al.23 Abbreviations: F, frequency; I,
intensity; Tp, type; Tm, time; ACSM, American College of Sports Medicine; *tolerance of prescription; **non-tolerance of prescrip-
tion.
176 M.J. Azevedo et al.

increased capillarisation and type I and II fibres. Such results
have been observed in patients with chronic obstructive pul-
monary disease (COPD) and chronic heart failure, in whom
studies demonstrate increases in functional capacity when
NMES was applied to the femoral quadriceps muscle for 6---8
weeks.26
There are no specific NMES protocols for oncologi-
cal patients. However, studies performed in patients with
COPD suggest electrical stimulation of the major muscles
individually or in groups (quadriceps, ischiotibial, gastroc-
nemius, and glutei) using a biphasic current, a frequency
of stimulation between 10 and 50 Hz (high frequencies
(>50 Hz) to induce muscle strength gain, and high and low
(<50 Hz) frequencies to increase the oxidative capacity),
pulse durations between 300 and 400 ␮s, and cycles varying
between 1:1 and 1:5. However, the ideal levels to achieve

Table 2 Contraindications and precautions for exercise and stress tests in cancer patients.
Factors Contraindications Precautions requiring modifications
Related to oncological treatment • On the day of or up to 24 h • Under treatment with pulmonary or cardiac
after IV ChT; effects: requires medical supervision
• Before blood harvesting; • Aphthous stomatitis: avoid mouthpieces in
• Severe tissue reaction to maximal tests; wear facemask
radiotherapy
Haematological • Platelets <50,000/␮L; • Platelets 50,000---150,000/␮L: avoid tests
• Leukocytes <3000/␮L; with haemorrhage risk
• Haemoglobin <10 g/dL • Leukocytes 3000---4000/␮L: ensure proper
sterilisation of equipment
• Haemoglobin >10 ---11.5/13.5: care with
maximal tests
Musculoskeletal • Recent bone or spinal pain; • If pain or cramp: investigate
• Uncommon muscle weakness; • Osteopenia: avoid high-risk exercise if risk of
• Extreme cachexia; fracture exists
• Uncommon/extreme fatigue; • Corticoid-induced myopathy
• Poor functional state: avoid • Cachexia: multidisciplinary assessment
stress test if Karnofsky scale • Slight to moderate fatigue: monitor response
(Table 3) ≤60% to exercise
Systemic • Acute infections; • Recent systemic disease or infection: avoid
• Fever >38 ◦ C; exercise until symptoms-free >48 h
• Overall ill feeling
Gastrointestinal • Severe nausea • Altered water or food intake:
• Vomiting or diarrhoea for multidisciplinary assessment/assessment by
24---36 h nutritionist
• Dehydration
• Malnutrition: inappropriate
water/food intake
Cardiovascular • Chest pain; • Attention to risk of cardiovascular disease:
• RHR >100 bpm or <50 bpm; medical supervision of tests and training is
• SAP rest >145 mmHg and/or recommended
DAP rest >95 mmHg; • Undertreatment with anti-hypertensive drugs
• SAP rest <85 bpm; that affect the HR: training HR might not be
• Arrhythmia; achieved
Oedema of LL • Lymphedema: wear compression sleeves in
the affected limb during exercise
Pulmonary • Severe dyspnoea; • Slight to moderate dyspnoea: avoid maximal
• Cough, wheezing; tests
• Chest pain increases with
deep breathing
Neurological • Significant impairment of • Mild cognitive disorders: ensure the patients
cognitive functions; is able to understand and obey commands
• Dizziness/vertigo; • Equilibrium disorders/peripheral sensitive
• Disorientation; neuropathy: employ more stable postures
• Blurred vision; during exercise
• Ataxia
Adapted from ACSM.4,29
Abbreviations: ChT, chemotherapy; IV, intravenous; Karnofsky index (Table 3); RHR, resting heart rate; HR, heart rate; SAP, systolic
arterial pressure; DAP, diastolic arterial pressure; LL, lower limbs.
Exercise prescription in oncology patients: General principles
Table 3 Karnofsky performance scale.3
Able to carry on normal activity and work; no
special care needed
Normal; no complaints; no evidence of disease 100%
Able to carry on normal activity; minor signs or 90%
symptoms of disease
Normal activity with effort; some signs or 80%
symptoms of disease
Unable to work; able to live at home and care for
most personal needs; varying amount of
assistance needed
Cares for self; unable to carry on normal activity 70%
but able to care for most personal needs
Requires occasional assistance but able to care 60%
for most personal needs
Requires considerable assistance and frequent 50%
medical care
Unable to care for oneself; requires equivalent of
institutional or hospital care; disease may be
progressing rapidly
Disabled; requires special care and assistance 40%
Severely disabled; hospital admission is 30%
indicated although death not imminent
Very sick; hospital admission necessary; active 20%
supportive treatment necessary
Moribund; fatal processes progressing rapidly 10%
Dead 0%
greater effectiveness while avoiding excessive fatigue are
not known. The intensity of stimulation must be increased
until a strong muscle contraction is observed or until the
patients’ tolerance threshold is reached.27
Contraindications of exercise and precautions
Although there is no evidence supporting specific absolute
or relative contraindications to exercise in adults with can-
cer, an informed evaluation of potential contraindications
should be performed, based on the best available knowl-
edge and clinical experience.1 The contraindications to and
the precautions needed in the practise of exercise are listed
in Table 2.
Adherence to exercise programmes
Adherence to exercise is critical for maintenance of
benefit.6 Mc Tiernan28 identified the risk factors that influ-
ence the performance of exercise by cancer survivors,
including the following: reduced cardiac reserve or other
heart complications related to treatment, physical decondi-
tioning and reduction of muscle mass, neuropathy, increased
intracranial pressure, high risk of infection, lymphedema,
pain, amputations, and bone metastases (Table 3).
Although some patients were able to begin and maintain
an individually adequate exercise programme, they exhib-
ited specific problems requiring supervision and monitoring
by Physical and Rehabilitation Medicine.6
177
Conclusions
It is generally agreed that exercise improves fatigue, func-
tional ability, and physical performance in oncological
patients. In addition, exercise has other promising effects
on the maintenance of the body weight and composition,
metabolism, and immune function.
Exercise is considered a safe and well-tolerated adjuvant
treatment when it is appropriately performed and moni-
tored, and exercise represents an efficacious intervention
for the regression or prevention of the negative effects of
oncological treatment.
Patients should be warned that exercise ought to be
performed within their tolerance limits, under appropriate
medical supervision, and when there are no contraindica-
tions.
The ACS and ACSM recommend performing 30---60 min of
moderate aerobic physical activity three to five times per
week and resistance training three times per week, with
elongation before and after exercise.
Exercise must be prescribed on an individual basis after
taking into account the patient’s age, previous activity level,
tolerance to exertion, diagnosis, disease stage, medical
treatment and comorbidities.
Most studies consent that more evidence and largest
quality studies are needed to establish precise recommen-
dations for the prescription of exercise.1,2,6,9,10
Although a comprehensive literature search was per-
formed, some databases and eligible studies were possibly
missed, which is a limitation of this review.
Ethical disclosures
Protection of human and animal subjects. The authors
declare that no experiments were performed on humans or
animals for this investigation.
Confidentiality of data. The authors declare that no patient
data appear in this article.
Right to privacy and informed consent. The authors
declare that no patient data appears in this article.
Conflict of interest
The authors declare no conflict of interest.
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