CANCER MANAGEMENT PROTOCOL:

 The most common side effect from the use of chemotherapy is chemotherapy -induced
peripheral neuropathy (CIPN), which impacts both on a patient's Physiological and Psychological
health.

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CIPN can lead to a change in their Quality of Life (QoL) due to influences in their neuromuscular system.
Patients with CIPN experience

 pain,
 Muscle weakness,
 Decrease balance control,
 Gait unsteadiness
 Reduced or absent reflexes.
 Common to have altered sensation such as numbness, burning, and tingling, along with
dysaesthesias and paraesthesias that follow a stocking and glove pattern in the lower and upper
extremities.

These symptoms may improve to a certain extent but complete re solution is rare.

 Motor deficits such as balance impairment, decreased gait speed, and lower limb strength can
persist, with increases in fall rates.
 The clinically meaningful physical impairments of CIPN can lead to a vicious circle, impacting a
patient's ability to independently complete Activities Daily Life (ADLs).
 In contrast, promoting a healthy, active lifestyle could increase physical function and postural
control, which can decrease fall risks and increase QoL.

Benefits of Balance Training-

The most significant improvements to postural control were combined exercise protocols which involved
endurance, Strength and sensory-motor training. As well, exercise sessions led to an increase in patient
QoL and independence.
 Static Balance Control:

Significant improvements in static balance have been found to occur when programs include three
major components in each exercise session;

1. Sensory-motor training and postural exercises, such as tasks that required stabilization
2. Closed kinematic chain exercises
3. Stability training focused on engaging the core during balance exercises

Clinical recommendations for improving static balance control:

Sensory-motor training:

It focuses on postural control using Balance board, foam pads and elastic bands to challenge balance. It
progressively challenges proprioception to regain normal motor patterns. An example of an exercise
program found to be effective at improving static balance is to progress through four different postural
exercises, three sets of each. Hold each position for 20 seconds, rest of 20 seconds, and 1 minute
between exercises to prevent fatigue. In fact, sensory-motor training has the potential to improve
neuromuscular mechanisms that affect balance for various patient populations.
Interestingly, Diabetic patients who have diabetic peripheral neuropathy (DPN), a type of nerve damage
similar to CIPN, demonstrate an increase in balance control and trunk Proprioception following a
program of balance exercises.

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Table 1: Sample Cancer Rehab for CIPN Routine

Exercise Instructions

(1) Open chain active Draw alphabet in the air by moving the ankle.
ankle range of motion
exercises
(including warm up)

(2) Bipedal toe raises Try to do this as quickly as possible, with support if needed.
and heel raises Start with one set of 10, and increase by one set every 5 exercise sessions. The goal is 3 sets.
Progress depending on their tolerance.

(3) Bipedal inversion This challenges the participant to control their center of mass, as they will tend to shift
and eversion laterally using their ankle invertors and evertors.
Start without support from upper extremities. The goal is to do it independently. The key is to
move toes in and out. Begin with 10 reps in both directions. Increase by adding another set
after 5 sessions, or progress depending on their tolerance.

(4) Unipedal toe raises Try to do this as quickly as possible, with support if needed.
and heel raises Lift the non-weight bearing limb, with the knee bent at about 45°. Start with five repetitions in
each direction, and increase to 10 repetitions each set. Then increase to two sets after 10
exercise sessions, or progress depending on their tolerance.
(5) Unipedal inversion Try to do this as quickly as possible, with support if needed.
and eversion Lift the non-weight bearing limb, with the knee bent at about 45°. Start with five repetitions in
each direction, and increase to 10 repetitions each set. Then increase to two sets after 10
exercise sessions, or progress depending on their tolerance.

(6) Wall slides Lie facing ceiling, with both legs up against a wall. Slide heels along wall to a maximum of
where the knee bends to 45°
Do 3 sets of 10 repetitions. Progress depending on their tolerance.

(7) Uni-pedal balance Stand on one leg and try to maintain balance without losing control over posture for as long as
for time they can. Try with eyes open, then eyes closed. Choose a time target appropriate to
participants’ level. Progress depending on their tolerance.

Closed kinematic chain exercises

Completing these CKC exercises at least 15 times over 3 weeks can increase a participant's subjective
understanding of the severity of CIPN as well as his/her static and dynamic balance . Thus, these
exercises can improve postural control over a short amount of time and are tolerated well by
participants.

The improvement in balance may be due to increasing the challenge of the exercises . The exercises were
first completed with support, then after a few sessions, the subjects were tasked with using minimal
support, working their way up to performing the exercises without any support. Furthermore, there was
an increase in proprioception and strength of muscles around the ankle joint which may have led to an
increase in their balance and decreased incidents of falls.

Stability training

Static balance can be measured using a single-leg balance test. After 12 weeks of exercise training
consisting of Aerobic, Resistance, Core stability and Balance exercise sessions led to improvements
which were maintained by a follow-up assessment after 24 weeks.

Dynamic Balance Control:

Exercise training for cancer survivors can improve dynamic balance or postural control during
movement.

Clinical recommendations for improving static balance control:

 Using obstacle courses (interactive game-based balance training) Obstacle courses that involved
repetitive weight shifting and crossing-over obstacles led to significant (43-74%) improvements
of dynamic balance. After the exercises, the sway of the hip, ankle and center of mass had
significantly decreased while standing in feet-closed position with eyes open among older
cancer patients with CIPN. Significant increases in postural balance may be due to the nature of
 obstacle courses so that the participant has many opportunities to continuously weight shift.
The most significant improvements to dynamic balance were observed in the monopedal (single
leg) stance. Individuals without access to game-based balance exercises can include obstacle
courses in balance training programs so they can still utilize dynamic control repetitively for
prolonged periods of time.
 Gait training: Furthermore, dynamic control for people with CIPN can be improved by using gait
training. Those with CIPN can exhibit gait patterns similar to diabetic patients with DPN who
have prolonged time in stance phase, slower speeds, and reduced step length as a strategy to
maintain stability in walking. Walking tasks (e.g. tandem walk, or different types of gait
patterns), functional exercises (sit to stands from a chair, climbing stairs, walking up and down
an incline, or small hops) and walking with progressive task complexity (e.g. concurrent head
rotations or verbal tasks like counting by 10’s) have been shown to be effective for patients
with DPN.
 Mechanical perturbations: An effective way to challenge the participant’s dynamic balance
when they have gained back more postural control is to add in mechanical perturbations.
Mechanical perturbations involve tasks that suddenly change the partici pant’s center of mass
so she learns to adjust her balance according to unexpected changes. For example, with a
patient standing on one leg, an exercise band can be tied around the stance knee and then
pulled in different directions at random intervals by a physiotherapist or friend/family member,
thus challenging the patient to regain postural control after each external force

Quality of Life and Physical Function

Although a balance rehab program with a combination o f aerobic, strength, and sensory-motor training
did not significantly improve the fear of falling, the lack of change may be due to the short -term, 4-week
intervention period of the program. In fact, balance programs that lasted from 10 to 36 weeks improved
quality of life, and the benefits remained at the follow-up period. Thus, longer balance rehab programs
may be more effective at QoL and long-term changes for people with CIPN.

Interestingly, balance rehab programs help patients with the adverse effects of chemotherapy by
introducing breathing techniques and stretches. Thus, alternatives to exercise-based balance rehab
programs, such as yoga, which focus on breathing techniques and stretches may be beneficial to
improve aspects of QoL for patients with CIPN.

In addition, exercise-based balance rehab programs improve upper and lower body strength and lower
body functional abilities over a long-period of time, which can then lead the adoption of a healthy,
active lifestyle. Exercise helps to prevent the effects of physical inactivity durin g chemotherapy, such as
muscle atrophy, Osteopenia, decreased cardio respiratory fitness, decreased insulin sensitivity,
decreased immune function and increased risk of chronic illness.

Balance Training and Impact on Sensation: Balance and exercise training can help people with sensory
neuropathy which is common to CIPN. After 15 sessions of CKC exercise, patients state they have a
decrease in tingling sensation and pain and return to having normal sensation for a pinprick and
vibration in the lower limbs.