Thriving, Not Just Surviving, after Transplant through Exercise and Fatigue Management

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Thriving, Not Just Surviving, after Transplant through Exercise and Fatigue Management

Sunday, May 1, 2022

Presenters: Karthik Jayaraman PT, DPT, and Bonnie Lucio PT, CLT, Baylor Scott & White Institute for Rehabilitation, Dallas, Texas

Presentation is 12 minutes long with 15 minutes of video-recorded exercises.

Summary: Fatigue is the most common symptom associated with cancer treatment and it is caused by many factors. This presentation discusses factors that contribute to fatigue, and how an individualized exercise program can be an effective strategy to fight fatigue.

Highlights:

• Transplant recipients sometimes assume they must just live with fatigue. It’s important to communicate symptoms of fatigue to your medical team because there are therapies that can help manage the problem.
• An effective exercise program should involve flexibility training and resistance training performed on two to three non-consecutive days per week.
• Energy conservation can help minimize fatigue.  Plan your activities around periods when you have the greatest energy and break tasks into smaller, less fatiguing steps.

Key Points:

(01:22): Fatigue can be rated on scale from 1 to 10 like the pain scale and tracked over time to better manage symptoms.

(02:42): The vast majority of cancer patients who receive chemotherapy experience fatigue.

(03:13): Adequate nutrition and hydration are essential to combat fatigue.

(05:03): Pain and medications can contribute to fatigue but pain can be managed and medications can be adjusted. 

(06:08): Anemia or too few red blood cells make fatigue worse.

(06:58): Poor sleep is a major contributor to fatigue.

(08:25): Physical or occupational therapists can help combat fatigue.

(09:49): Starting an exercise program slowly and building up is the best way to integrate exercise into one’s care.

(11:03): People should work closely with their health care providers to maximize the benefits of exercise.

(12:07): At this point, the presentation involves a video demonstration of various exercises that are described in subsequent narrations.

Transcript of Presentation:

(00:01) [Bonnie Lucio] Introduction of Speakers. Hi, my name is Bonnie Lucio. I'm a physical therapist at Baylor Scott & White Institute for Rehabilitation in Dallas, Texas, where I work with stem cell transplant recipients. With me is Karthik Jayaraman, center manager for outpatient rehabilitation at the Institute who also works with stem cell transplant recipients. We're going to talk with you about ways to minimize fatigue after transplant and demonstrate some exercises that can build stamina and strength.

(00:30): Overview of Talk. At the conclusion of the workshop, attendees should have a clear understanding of the following: How an exercise program can increase stamina and strength; how a physical therapist can tailor an exercise program to address an individual's needs; specific exercises recovering patients can perform at home to increase stamina and strength; and the role of other factors such as nutrition and energy conservation in managing fatigue.

(00:58): Fatigue is the most common side effect of cancer treatment. The National Comprehensive Cancer Network defines fatigue as a distressing, persistent, subjective sense of tiredness or exhaustion related to cancer, or cancer treatment, which is not proportional to recent activity and interferes with usual functioning. Fatigue is by far the most common, and for many, the most distressing symptom.

(01:22): Fatigue can be rated on scale from 1 to 10 like the pain scale and tracked over time to better manage symptoms. People describe fatigue in many different ways. It can affect us both mentally and physically. They describe it as weakness, exhaustion, lack of energy or no energy. They feel drained and they have difficulty concentrating. You can also rate your fatigue. Fatigue can be rated on a zero to 10 scale, similar to the pain scale with one to three being mild fatigue, four to six being moderate fatigue, which many people have at least moderate fatigue during and soon after treatment. Seven to 10 is extreme fatigue and 10 is the worst fatigue.

(02:03): It can be helpful for the healthcare team to keep a diary and track your fatigue and report these symptoms so that they can better help manage them.

(02:14): Many factors can cause fatigue. There are many causes of fatigue. Treatment and medication side effects. Some medications make it hard to stay awake and some make people wired and they have trouble going to sleep. So timing can make a big difference. Nutrition problems and dehydration, stress, pain, anemia, sleep changes, and underlying medical issues can also cause problems. Karthik can go into more details in this area.

(02:42): The vast majority of cancer patients who receive chemotherapy experience fatigue. Cancer related fatigue is experienced by 70 to 100% of cancer patients while receiving chemotherapy. It may continue to be disruptive in healing for months or even years after the treatment ends. It can often take twice as long to get your strength back as it does to lose it. So be patient with yourself.

(03:03): Fatigue can also cause a patient not to continue with treatment. When people's bodies get too weak, they can't tolerate medications as well.

(03:13): Adequate nutrition and hydration are essential to combat fatigue. Adequate nutrition also plays an essential role in fighting cancer and its recovery. This can be affected by mouth sores, nausea, vomiting, or foods just not taste like they used to. Patients who adequately nourish, generally tolerate treatment better and recover faster. Ask your healthcare team for a consult with a registered dietitian to develop an individualized plan that meets your needs and your body needs fuel in order to perform properly.

(03:49): The average adult, dehydration is also an issue. The average adult needs 10 ounces of liquid for every 50 pounds of body weight. Most of us should drink between two and three quarts of water per day. It's especially important to increase water intake during active treatment to avoid fatigue. Drink, drink, drink that water. Keep water available and hydrate during the day and throughout exercise.

(04:17): Psychological stress contributes to fatigue. Mental and emotional stress can also cause a problem. A treatment for cancer can be an emotional roller coaster. Hormonal changes, mood swings and disruption of sleep can all contribute to fatigue. Relaxation techniques and physical activity may help balance these things out. Some suggestions: supportive and expressive therapies like support groups, counseling, journaling, and diaries. And there' are a lot of complementary techniques that can be very helpful as well like breath control, progressive muscle relaxation, guided imagery, massage, yoga and Tai Chi. These things are going to be discussed at a later presentation in more detail.

(05:03): [Karthik Jayaraman] Pain and medications can contribute to fatigue but pain can be managed and medications can be adjusted.  Another common cause of fatigue is pain. And this is something pretty much all of our patients deal with at some point along their cancer continuum. When you have increased fatigue, it can cause changes in your hormonal levels and lower your threshold for pain perception. So it's really important to communicate with your healthcare provider if you're noticing changes in your pain levels. And some of these suggestions below are things that can really help to track your pain and then manage it effectively.

(05:31): Another common cause of fatigue is the medications that you'll be receiving as part of your treatment. Almost all of these medications will contribute to the feelings of fatigue that you experience, and a lot of the drugs that combat nausea, that you'll be feeling during your treatment, can also cause sleepiness.

(05:48): So it's really important to discuss with your healthcare team and your doctors if you have any questions about adjusting your medications, just to ensure that you are not making changes on your own. So please communicate with your team as much as you can as your timing and your dosage can really make an effect on your side effects.

(06:08): Anemia or too few red blood cells makes fatigue worse. Another common cause of fatigue is anemia. Anemia is basically when your body has too few red blood cells. So when that happens, it has to work a lot harder to supply oxygen to your muscles. So simple activities like climbing stairs can feel like climbing a mountain. So the importance of muscular conditioning is vital here.

(06:30): A fit muscle uses less energy and oxygen to get the job done. So we can really come in and help as healthcare providers and therapists because we can work with you, based off of your individual lab values, to create a safe exercise program. So we often ask our patients to provide us with their current lab values, if they're available, during their treatment and even after transplant to make sure that we are exercising at a safe level.

(06:58): Poor sleep is a major contributor to fatigue. Another common cause of fatigue is poor sleep. This is pretty straightforward, but four out of five patients have trouble sleeping. And I would say pretty much every patient that I've treated along their cancer continuum is dealing with sleep disturbance to some degree. So it's really important to be managing this on a daily basis and trying to talk with your healthcare providers about different strategies to help manage this effectively. So some of these suggestions below, especially in our day and age with reducing screen time and using phones, laptops, tablets before bed, and just reducing stimulation can be really effective in this.

(07:40): Energy conservation is a good way to counter fatigue. Another important thing to combat fatigue is energy conservation. So I often recommend patients to keep a journal or a log of their daily fatigue especially during active treatment, as this might help them plan their activities around when they're feeling more energized.

(07:58): The other thing that's important is to just break your tasks into parts. So if you're doing something, like laundry, work on moving things into the washer first, take a break before you then move things from the dryer and participate in meaningful activities when you have that energy or you're feeling more energized. This can be really helpful. And of course allowing those around you to help and provide support when they're able to.

(08:25): Physical or occupational therapists can help combat fatigue. Another area where we can combat fatigue is working with a physical or occupational therapist. So this is where we can really come in. We can play a role in evaluating your specific needs in determining a plan that helps you throughout your survivorship. So please remember that wherever you are in your cancer continuum, whether it's active treatment or post-treatment, we can play a role in helping to manage that fatigue and then maximize your function.

(08:52): So these are some of the areas that we consider when we're evaluating our patients. And there's a lot more that goes into this, but the main takeaway here is that a lot of patients, after transplant, may think that they have to live with some of the symptoms that they're dealing with, whereas we can really manage these and reduce some of the deficits that you're dealing with.

(09:14): An individualized exercise plan is vital to combat fatigue. Along those same lines, exercise is another way to combat fatigue. And although it might be counterintuitive, exercise can really help fight fatigue, especially during active treatment. So we want to be able to, again, create a plan that's fits your specific needs and allows you to be as active as possible in a safe manner. So we would really prefer you all to meet with a skilled therapist to help manage this appropriately and create a program that fits your specific situation.

(09:49): Starting slow and building up is the best way to integrate exercise into one’s care. In terms of how much exercise or how often you should be exercising, the general recommendations from the American College of Sports Medicine are the same for cancer survivors as they are for healthy individuals. And that consists of 150 minutes of moderate intensity aerobic activity or 75 minutes of vigorous intensity aerobic activity.

(10:12): Now, this is something that we would want to work up to. That may not be something that you're able to do at this moment. But hopefully, working along with a therapist, you could eventually get to that point.

(10:24): Resistance training and flexibility training are important components of an exercise program. The other portion of that would be two to three non-consecutive days per week of resistance training and flexibility training. The flexibility portion will be very important for our bone marrow transplant recipients, especially in light of graft versus host disease. So we'll really make sure we incorporate some of those exercises into your individualized program.

(10:47): And then some of the suggestions below are general recommendations that we recommend for most people, but it's very important to include a warmup or cool down and basically as much activity as possible that we can get out of you as you're going through your treatment and even after.

(11:03): People should work closely with their health care providers to maximize the benefits of exercise. Overall, I think the main takeaway is that we want you to be communicating with your healthcare team whenever you're noticing changes in how you're feeling as you're going through your treatment or even after your treatment because we can really help to develop an individualized plan that can help maximize your function. We want you to be pacing yourself and listening to your body so you can set appropriate limits and priorities.

(11:32): An exercise program will often have a number of different stretches and resistance training. And this overall outline is just an exercise recommendation for our patients. It has these components that you see here. And overall the big thing that I've mentioned many times is whenever starting a new exercise program, you want to be consulting your healthcare providers, because we need to develop a program that is specific to what you have currently going on. We will be demonstrating some of these components and you can follow along with the handouts that we've provided.

VIDEO Demonstration of Exercises – download slides for photos of each

(12:07): [Bonnie Lucio] This stretch is a Standing Quad Stretch. So Karthik is going to put his leg up on a chair or a table behind, and he needs, very important, to stand up nice and straight because you're stretching your quadricep muscle right in the front of your leg. And again, you're going to hold this stretch for 15 to 30 seconds. One thing that people have a tendency to do is have their leg kind of out to the side a little bit and not drop down. And then they're not getting a good stretch.

(12:37): You can also, if you can tolerate it, you can grab the back of your leg and get a really good stretch like this. And again, he corrected himself and he dropped right back down like this. So let's go ahead and stretch the other side. Same thing. Stand up nice and tall because that quadricep muscle attaches on your pelvis. So if you stand up tall, you're going to get a better stretch. Very good. Thank you.

(13:04): This exercise is the seated hamstring stretch. The picture shows doing it on a physio ball, but you can also sit in a chair like Karthik is here. So what you want to do is put your leg straight forward. You want hands at your hips and you want to bring your chest toward your knee. And you want to hold the stretch for 15 to 30 seconds. A tendency that people have is to round their shoulders like this, but you're not getting a good stretch on your hamstring. So you want to sit up nice and straight and hinge at your hips. And you want to also make sure that you stretch on both sides. So sit up nice and straight and lean forward. Hold it, and then relax.

(13:56): The next stretch is the Runner Stretch or Gastroc Stretch. You're going to have either a chair or a wall or something in front of you. And you're going to put your one of your legs straight back. Make sure that your heel is touching the ground and that your foot is pointing straight forward. You want to stand up tall and you want to lean into the stretch. Keep your back leg straight. And again, hold it for 15 to 30 seconds. Okay. Let's do the other side now. Stand up tall, heel touching and lean in. Good job.

(14:36): The next exercise is Lower Trunk Rotation. So you're going to lie down with your knees bent. And I like to have people have their arms out to the side at a 90-degree angle because it gets a good stretch all the way along your side. What you're going to do is bring your knees over to the right, just like Karthik is doing. You're going to get a good stretch all along the side here and in your low back. And you're going to hold it for 15 to 30 seconds and then you're going to come and go the other direction. Notice how he's keeping the top part of his body flat against the table.

(15:16): The next stretch is the Butterfly Stretch. You're going to be sitting on a firm surface with your feet together like Karthik has. If you can bring them a little bit closer, you can see that Karthik is a little tight here. So you want to make sure that you're sitting up nice and straight and that your shoulders are not rounded. And if you can, you want to hinge at your hips and come forward and get a really good stretch. If you need a little bit of extra stretch, you can use your elbows and push in here and get a little bit more of a stretch. Again, 15 to 30 seconds. You'll feel that on the inner thigh area.

(15:58): The next stretch is a Unilateral Pec Stretch. So you're going to find a corner of a wall and you're going to put your hand up here. What you're going to do is you're going to stand up nice and straight and you're going to lean in. And if you can, you can bring your shoulder back a little bit and get a good stretch on that pec muscle on the left side there. 15 to 30 seconds. You'll want to make sure that you do both sides. And you can also it in a corner do both sides at the same time if you'd like. That's another variation. Okay. Be sure to do the other side as well. So go ahead and put your arm up and lean in. Stand up straight. Good posture is very important.

(16:51): The next stretch is the Triceps Stretch. So you're going to reach your hand back like you're scratching your back. You're going to take your other hand and you're going to pull it back so that you get a good stretch. It's very important on this exercise that you don't arch your back. If you need to, stand with your back to the wall to keep you from arching, because you want this stretch to be in this triceps muscle right here. Okay, let's go ahead and stretch the other side, and hold it for 15 to 30 seconds. He's doing a good job of standing up nice and straight and having good posture.

(17:31): This next exercise is a Transverse Abdominis Exercise. So you're going to lie down with your knees bent and I want you to go, and you can put your hands right over here and you're going to make sure that you can feel those abdominal muscles coming into your fingers. So what you're going to do is you're going to tighten your stomach and you're going to try to bring your belly button toward your spine and rotate your hip a little bit back toward the mat.

(17:59): You're going to hold it for about 15 seconds and then relax. You should be able to feel those muscles coming into your fingers there. These are muscles that we frequently don't use on a day-to-day basis, so we have to sometimes teach them how to respond. Good job. Okay.

(18:28): So this exercise, you're going to incorporate some marching with your abdominal tightening bracing exercise. So go ahead and tighten up your abdominal muscles, and you bring one knee up to about 90 degrees and then slowly bring it back down. Now, you're going to bring the other knee up and slowly bring it back down and then you're going to relax your contraction between each one. Okay? Tighten your abdominals. Knee up, down, the other knee up, down and relax. You can make this a little bit more challenging by tightening up your abdominal muscles, bringing your knee up, keeping it there, bringing the other knee up, bring one down the other one down and then relax.

(19:23): The next exercise is Bridging. So Karthik is going to tighten up his abdominal muscles and he's going to lift his bottom up, and then gradually slowly bring it back down and then relax. Okay? Tighten up your abdominals, lift up, back down, and relax. So you can also tighten your gluteal muscles at the same time while you're lifting your bottom up off the mat, and back down, and rest.

(19:57): [Karthik Jayaraman] This next exercise is a Standing Hip Abduction exercise. So we're going to be working the lateral muscles of the hip. Bonnie is going to be standing nice and tall with a chair next to her for balance support and she's slowly going to move that leg out to the side and in. We'll go ahead and do this on the other side too. Some important things to think about is we want to make sure she's not leaning to one side, as she's bringing the leg out, but she's staying nice and tall and slowly moving that leg out and slowly moving that leg back in. She's doing a good job of maintaining her posture while she moves here.

(20:36): This next exercise is a Standing Hamstring Curl. So we're going to be working this muscle right here in the posterior thigh. So what Bonnie is going to be doing is standing nice and tall with the chair in front of her with her toe pointed behind her, slowly bending her knee up and slowly bringing it back down to the ground. She's doing a good job of staying nice and tall with her posture and not leaning forward as she lifts the leg and lowers the leg. Okay, let's go ahead and switch sides.

(21:03): The other thing to think about when you're doing this exercise is you want to make sure that your thigh is not coming too far forward as you bend your knee up. That's a common substitution that we see here. So Bonnie is doing a good job of keeping her knees aligned together as she lifts and lower that knee.

(21:24): Good. The next exercise we're going to be doing is a Standing March with Support. So Bonnie is going to be standing nice and tall with a chair for balance and slowly lifting up one hip to about a 90-degree angle to her trunk and coming back down. We're working the front part of the hip flexor muscles with this exercise. And we're also getting some balance involved in this exercise. So the more support she uses through that chair or the less support, the more she could challenge her balance. And you see she's going nice and slow and controlled with her lifting and lowering of the leg. She's also staying up nice and tall with her posture.

(22:03): This next exercise is called a Sit to Stand exercise. It's a very functional activity that we all have to do throughout the day. So the first thing Bonnie is going to do is scoot forward in her chair. This will help her get her momentum, a little bit more forward. And what she's basically going to do is try and bring her body weight forward without using her hands to come to a standing position. And she's doing a good job of keeping nice tall posture with her back and slowly controlling on the way back down.

(22:32): If you're unable to do this without using your hands, you can always cross them out in front. Or if you need to push from the chair to give you a little bit more support, you may. But we often have to get up from low surfaces throughout the day whether it's a low toilet seat or a low soft couch. So this is an important exercise to practice to help those activities be a little bit easier during your day-to-day activities.

(22:57): This next exercise is a Step Up with support. So Bonnie is basically going to bring one foot up to the step and slowly step up to that step and slowly come back down. Now, she's got a chair right next to her for support, and if you can do this at home, if you've got stairs or steps with a railing that you can use that for support next to you. And so this is a really important exercise for the front of those thigh muscles, your quadriceps, your hamstring muscles and your glutes. And this is something we all have to do throughout the day often, being able to safely navigate stairs and steps.

(23:34): The next exercise we're going to be doing here is a Shoulder Flexion exercise focused on the front part of the shoulder muscle here, your deltoid muscle. And you can use dumbbells here or resistance bands that's shown in the handout. So what Bonnie going to do is start with one arm, raise it straight up forward to about shoulder height and slowly lower it back down. It's really important to try and keep your elbows straight when you're doing this exercise so that the front of that shoulder muscle, that deltoid muscle gets the majority of the work. A common error we see when people do this is they want to bend at that elbow or bend forward at their trunk. So you really want to think about staying up nice and tall, keeping your elbow straight and controlling that weight up and down as you move through this exercise.

(24:20): Good. The next exercise we're going to be doing is a Bent Over Row. So what Bonnie is going to do is slowly hinge forward at her hips, maintaining good back posture. She's going to start with those dumbbells out in front and she's slowly going to row those dumbbells up and squeeze her shoulder blade muscles together. So the purpose of this exercise is to target these muscles right here in the middle of her shoulder blade and in her back. And she's doing a nice job of maintaining good posture, keeping those shoulder blades squeezed as she lifts and lower. Perfect. Just like that.

(25:01): This next exercise is called Scaption and it's basically working some of the lateral shoulder muscles here. It's a very functional activity that we often have to do when we're reaching and grabbing things from cabinets in the kitchen or up overhead. So what Bonnie is going to do is stand tall with her arms by her side, slowly lift up almost making a V shape with her arms and slowly coming back down. Again, it's really important for her to try and keep those elbows straight as she's raising those dumbbells up and slowly coming back down, maintaining good tall posture as she moves as well. Perfect.

(25:39): This next exercise is called a Triceps Kickback. So we're going to be working this triceps muscle right here in the back of the arm. Bonnie is going to use a chair in front of her and slowly bend forward at the waist. She's going to start with that arm by her side and just move at the elbow to straighten that elbow back and slowly come forward, working this muscle right here. And you see she's doing a good job of not moving her whole arm, but just at the elbow to isolate that muscle.

(26:05): Good. And let's switch sides. Same thing here. She's coming back nice and slow keeping that elbow as the only piece moving and the shoulder nice and steady. Good.

(26:22): All right. The last exercise here is a Bicep Curl. So Bonnie is going to start with her arms by her side, palms opened up and she's slowly going to curl those weights up and slowly lower back down. The big substitution that we often see with this is people are wanting to really rock and use momentum to bring those weights up. So you really want to find a weight that allows you to maintain good posture with your back and slowly lift and lower as she's doing here. Perfect.

(26:57): [Karthik Jayaraman] Closing. We hope these demonstrations of these exercises were helpful for you all as you move along your cancer continuum. And just please remember that if you are looking to start an exercise program that you meet with your healthcare providers and try to get with a physical or occupational therapist to help design an exercise program that meets all of your needs.