Living Well: Exercises /Strategies for Improving Endurance and Strength

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Living Well:  Exercise/Strategies for Improving Stamina and Strength

May 4, 2023

Presenter: Noel Espiritu, PT, DPT, with Kristen Eggers, PT, DPT, Ester Kerzner, PT, DPT, and Julia Warrack, PT, DPT, CSCS,  Mount Sinai Hospital, New York

Presentation is 42 minutes long; followed by 14 minutes of Q&A

Summary:   This presentation explains how exercise can improve stamina and strength; how a physical therapist can tailor an exercise program to meet your needs; and how energy conservation plays a role in managing fatigue. It also provide a demonstration of some exercises that transplant recipients can perform at home.

Highlights:

• Fatigue is common among people getting chemotherapy, radiotherapy, or a bone marrow/stem cell transplant. Fatigue affects about 65% of people with cancer, of which more than two thirds will have severe fatigue for at least six months.
• Exercise is one of the most promising treatments available to relieve transplant-related fatigue.
• Before embarking on an exercise program, transplant recipients should check with their healthcare provider to confirm that it is safe to begin exercising.

Key Points:

(03:54): There are different factors that contribute to fatigue, like having pain, experiencing emotional problems, being anemic, suffering from sleep problems, having nutritional issues, your activity level, or a side effect of certain medications.

(06:21): According to the exercise guidelines for cancer survivors published by the American College of Sports Medicine (ACSM), there is evidence that exercise lowers the risk of developing some cancers like colon, breast, endometrial, kidney, bladder, esophageal, and stomach cancers.

(07:39): There is a difference between physical activity and exercise.

(08:52): Aerobic exercise, also called endurance or cardio, is the type of exercise that can help reduce transplant-related fatigue.

(09:41): An exercise program must have three components: Frequency, how often you exercise; intensity, how hard you work to do the exercise, and time, how long you exercise.

(13:09): You don't need to go to a gym or buy expensive equipment to do strength exercise. There are ways to do strength exercises at home.

(15:15): The recommendation is that you do aerobic exercise at a moderate intensity level for at least 30 minutes at least three times a week, and you do that for eight to 12 weeks.

(17:57): Even limited physical activity is better than nothing.

(18:42): Understand the risk that a particular exercise or activity brings to you, and then try to eliminate or minimize those risks.

(26:36): Video Demonstration of Exercises

Transcript of Presentation

(00:01): [Marsha Seligman]:  Hello everyone. Welcome to the workshop, Living Well: Exercise/Strategies for Improving Endurance and Strength. My name is Marsha Seligman, and I will be your moderator for this workshop.

(00:12): Introduction of Speakers. It is my pleasure to introduce today's speaker, Noel Espiritu. Mr. Espiritu is a physical therapist, master clinician, currently working at Mount Sinai Hospital in New York, where he evaluates and treats oncology patients and others in the acute care setting. He also teaches physical therapy at the City University of New York. Mr. Espiritu has devoted most of his career as a physical therapist to working with people with cancer and has co-developed a general exercise regime for people undergoing bone marrow transplant.

(00:45): Mr. Espiritu and his team have created a video for you demonstrating exercises to help you build endurance and strength. He will show this following some introductory remarks. Please note these exercises are for demonstration purposes only. Consult with your doctor before beginning any exercise program.

(01:05): I'd also like to introduce the physical therapists from Mount Sinai Hospital who will be demonstrating the exercises today; Kristen Eggers, Ester Kerzner, and Julia Warrack. Please join me in welcoming Noel Espiritu and his team.

 (01:22): [Noel Espiritu]:  Thank you for inviting me to this conference to talk about how exercise can increase endurance and strength after a bone marrow transplant.

(01:43): We have four learning objectives for this presentation. Number one is to understand how an exercise program can increase stamina or endurance and strength. Number two is to learn how a physical therapist tailors an exercise program to address an individual's needs. Number three is to identify exercises that people recovering from stem cell transplants can perform at home to increase endurance and strength. And number four is to know the role of energy conservation in the managing of fatigue. As always, before starting any exercise program, please consult your physician or your healthcare provider first.

(02:32): The National Comprehensive Cancer Care Network describes cancer-related fatigue as distressing, persistent, subjective, sense of physical, emotional, and or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with useful functioning. Yesterday, Dr. Grigory Syrkin did an excellent presentation about fatigue. I just want to reinforce a few things from that presentation. The tiredness from fatigue is multidimensional. It's not just physical, it's also emotional and it affects your thinking process. This fatigue is not relieved by resting or sleeping; it is persistent and it limits your ability to do your daily activities.

(03:23): Fatigue is common among people getting chemotherapy, radiotherapy, or a bone marrow transplant. Fatigue affects about 65% of people with cancer, of which more than two thirds will have severe fatigue for at least six months. In about one third of all cases, fatigue will continue years after cancer treatment is finished.

(03:54): There are different factors that contribute to fatigue, like having pain, experiencing emotional problems, being anemic, suffering from sleep problems, having nutritional issues, your activity level, or a side effect of certain medications. Fatigue doesn't show up by itself. Alcohol and substance abuse and other diseases are medical conditions or comorbidities.

(04:22): Fatigue is common, but it is underreported and therefore underdiagnosed. People underreport fatigue because they think that they're going to be seen as a complainer, or that they're going to be a bother to the " busy healthcare provider". They also delay reporting fatigue until it's already severe, when they can barely function. There's also the fear that reporting fatigue will impact their treatment in a negative way.

(04:51): Some people don't report their fatigue because they think nothing can be done about it. It's part of the disease and they say, 'I just need to learn to live with it'. The takeaway point is that it's important to tell your healthcare provider that you are experiencing fatigue. There is a way to screen for fatigue; it can be measured and there are treatments available for those conditions that are associated with fatigue.

(05:22): Exercise is one of the most promising treatments available for transplant-related fatigue. It's one of the first things that your healthcare provider will tell you to do when you tell them that you are experiencing transplant-related fatigue. Exercise is generally safe and can be tolerated well when you're doing it correctly. You can usually tolerate it before, during and after your transplant.

(05:50): Exercise can be inexpensive or even free to do. It makes you feel better about yourself. You can make it enjoyable. You can exercise with people you like; it’s much preferable to taking expensive medications than can have side effects. What exercise does is improve your cardio-respiratory fitness and your endurance. It increases your strength and improves your physical fitness and your quality of life.

(06:21): According to the exercise guidelines for cancer survivors published by the American College of Sports Medicine, the ACSM, there is evidence that exercise lowers the risk of developing some cancers like colon, breast, endometrial, kidney, bladder, esophageal and stomach cancers. Exercise also improves survival after diagnosis for people with breast, colon, and prostate cancers. Despite all these benefits available for people who exercise, only about 45% of cancer survivors report that they do any regular physical activity. Why is that? It's mainly because no one told them to exercise, so there is huge room for improvement for healthcare providers in terms of being proactive and telling people that they need to exercise.

(07:39): There is a difference between physical activity and exercise. I would like to point out the difference between physical activity and exercise before we start talking about exercise that you can do following a stem cell transplant. Sometimes these terms are used interchangeably; physical activity versus exercise. However, they are somewhat different. Physical activity means anything that involves moving your body, which in turn uses energy. When you clean your house, when you walk your dog, you are engaging in physical activities and they're all good and they have their own benefits.

(08:17): An exercise program has a structure. It is what you want to do when you have specific goals. Examples of these goals are to improve your endurance, to get stronger, you want better posture, be more flexible or improve your balance. An exercise program has all four of these components: frequency, intensity, the type of exercise and the time or repetitions and sets.

(08:52): Now we're going to discuss the types of exercise that you can do after your transplant. First, aerobic exercise. Aerobics, also called endurance or cardio, is the type of exercise that can help reduce transplant-related fatigue. This exercise involves moving the large muscles of your body. This could be your arms, your legs, your back; and is performed continuously and at a steady pace. The longer that you do that, the more effort you will need to breathe, and the more your heart rate will increase. Some examples of aerobic exercise include walking, jogging, riding your bicycle, dancing, swimming, and rowing.

(09:41): An exercise program must have these three components. First, there is frequency, which is the measure of how hard you work to do the exercise. For example, casual, leisurely walking for most people, that's usually considered a low intensity exercise. Brisk walking is moderately intense and jogging, that's considered vigorously intense for most people. The third component is time, which measures how long you do the exercise.

(10:20): One thing to keep in mind with regard to intensity when doing aerobic exercise, is that exercise intensity is subjective. How fit you are determines how you perceive intensity. Obviously, if you're fit or you have good conditioning, you'll find an exercise to be less intense than someone doing the same exercise who is not as fit.

(10:44): Within ourselves, how we perceive intensity can sometimes change if we compare certain time points in our lives versus another. An example of how our perception of intensity can change is this: before the stem cell transplant, a person used to run regularly, and running for 30 minutes was easy for this individual. After the stem cell transplant, the most this same person could do was brisk walking and even then, s/he could only do it for 15 minutes before getting tired. Our perception of intensity changes depending on how fit we are at a given moment in time.

(11:28): You can estimate the intensity of your exercise by doing two tests. The first one is by using a scale of zero to 10. Think of zero as the effort that you give when you're sitting and 10 as being the highest level of effort that you can exert. A moderately intense exercise should be around an effort of five or six, and the vigorous intense exercise would be around a seven or eight.

(11:59): There's another way you can measure exercise intensity, and that's by doing a talk test. The exercise is moderately intense when you can still talk but not sing while you're exercising. The exercise is vigorously intense when you have trouble talking and may be out of breath.

(12:20): Strength or resistance training or weightlifting exercise increases muscle strength, power, and size; it can also improve your endurance. When doing strength training, you make your muscles work against a relatively heavy force, usually provided by color-coded elastic bands of different strengths, or by lifting free weights.

(12:48): There are three parts of a strength training exercise program just like aerobic exercise. First, there's the intensity, which is the force or weight that you are working against, compared to how strong you are. Second is the frequency, how often you exercise. Third, are repetitions and sets, which is how many times you're doing a specific activity.

(13:09): You don't need to go to a gym or buy expensive equipment to do strength exercise. They're not a requirement. There are ways to do strength exercises at home. For example, you can use elastic bands, dumbbells, or kettlebells, or you can use your body weight as resistance, like you when you do pushups or pullups, or you do chair ‘sit-to-stand’ exercises.

(13:35): Some of the exercise that we discussed, like jogging, dancing, or lifting weights, can be considered as weight-bearing or weight-loading exercise, too. Weight-bearing exercise is good for promoting bone growth and strength. But be aware the weight-bearing exercise, especially the high impact types like kickboxing, may not be effective or safe for if you have certain orthopedic conditions like problems with your joints, your hips, your knees, or conditions that make your bones weak, like osteoporosis. These are all considered inconsistent as far as whether this type of exercise provides bone health benefits for cancer survivors. Check with your healthcare provider first to know if weight-bearing exercise is good for you to do.

(14:22): Flexibility or stretching exercise helps your joints move through the fullest range of motion. In the video portion of this presentation, we'll show you the best ways to stretch the different muscles of your body.

(14:37): The last type of exercise that we will talk about is multi-component exercise. For example, dancing, yoga, tai chi, or engaging in sports. This exercise combines muscle strengthening, aerobics, and some form of balance activities. Because there's many types of yoga and different types of sport, there's currently no standard recommendations about these types of exercises.

(15:15): What do you need to do to get some of the health benefits from exercise, like reducing fatigue? The recommendation is, at a minimum, that you do aerobic exercise at a moderate intensity level for at least 30 minutes at least three times a week, and you do that for eight to 12 weeks. Keep in mind that this is a general recommendation and that some people, after transplant, especially those who are dealing with other medical conditions, might find this hard to accomplish while others might find this doable after a few training sessions. There will be some, of course, who will find this to be too easy and might need a higher goal. As far as your personal exercise journey is concerned, the starting point, the midpoint, and the end point will be different for everyone.

(16:10): The key is in knowing where, exactly, you should be in your exercise journey and making sure that you try to advance to the safest and most appropriate level. If you're 65 years of age and above, and are dealing with other chronic medical conditions, even if you don't meet this recommended exercise guideline, engage in regular physical activity anyway. One of the benefits of staying physically active is that it can help reduce your risk of falling; if you do fall, you will be less likely to get seriously injured. The general rule is to do as much exercise as your medical condition will allow you to do safely, and that you return to doing your activities of daily living as soon as possible following the transplant, after surgery, or after any other medical treatment that you get. So don't sit throughout the day. Get up, move, and do some light intense activities instead.

(17:24): With regards to exercising safely and tolerating exercise after a stem cell transplant-- first, not everyone will be able to tolerate the recommended exercise guidelines for reducing fatigue, and that's okay. Second, your exercise program needs to be individualized to be effective. Third, everyone's exercise tolerance changes during and after transplant. When this happens, adjust your exercise program to your current fitness level.

(17:57): Remember, some physical activity is still better than nothing. If you are inactive and you're starting an exercise program, as a rule, you start low and you go slow. For example, start by walking slowly and walk for about five to 10 minutes a day. Once you find that this is not challenging anymore, you can slowly increase your speed and increase your time, say by another five to 10 minutes. Now you keep going until you reach a goal of 30 minutes per day. If you can, continue to build your intensity by walking faster and/or at an incline.

(18:42): Understand the risk that a particular exercise or activity brings to you, and then try to eliminate or minimize those risks; this is very important. There are valid reasons for fearing that exercise or physical therapy can hurt you or make your situation worse. For example, you may have a heart condition, osteoporosis, neuropathy or balance problems, that make you unsteady on your feet, or you may have pain that gets worse after you exercise. It's overwhelming sometimes. But do know that there are many different modes of exercises, and that most physical activity and exercise can be modified to make them safer for you. This is when a physical therapist can really help. They can help identify those risks, make you aware of them, and provide you with a safe and effective alternative exercise program.

(19:45): What other things can you do? Choose activities that are safe for you. For example, if you have problems with balance, use a stationary bike instead of the treadmill as there will be less risk of falling. Use the proper gear and sports equipment, like wearing a helmet when riding your bike. Choose a safe environment for doing your exercise. Give your immune system some time to fully recover after the transplant before returning to the gym. The timing of this is something that you should discuss with your healthcare provider.

(20:21): Finally, consult a healthcare practitioner before starting any exercise program. For those who have not yet seen a physical therapist, this is what we do to tailor an individualized exercise program for our clients. First, the physical therapist will perform an evaluation. We will look at your current medical condition and the treatments that you're getting, including the medications that you are taking. We'll assess your strength, your range of motion, your balance, the way you move, your functional status, and your overall level of fitness among other things. The physical therapist will then synthesize all this information to make a safe exercise plan for you to achieve your goals. We will then give you an exercise program to do in the rehab gym and at home. We will make sure that you're doing your exercises correctly, that you're using the right technique.

(21:30): As your condition improves, we will reassess, adjust your exercise program, and continue doing this until you eventually achieve your physical therapy goals. We will then discharge you from the physical therapy program with specific instructions on how to continue your exercise at home or in the community.

(21:52): Throughout this presentation we've been talking about exercise and how it can reduce fatigue and increase your strength. This time we're going to talk about energy conservation techniques. Energy conservation, unlike exercise, does not improve your stamina or endurance, nor will increase your strength, but it will help minimize fatigue for you when you have to do certain things. If your endurance is very limited or you have breathing problems, these techniques will be helpful for you.

(22:34): First you set priorities. For example, look at the things that you want to do during the day or week and find out which ones are important and need to be done, and which can be put off for another day. What you want to do is do the important ones first, those that need high energy first, so that if you run out of energy, you can leave the less important tasks for another day.

(23:01): Second is by pacing yourself. So don't rush. Go slowly and don't hold your breath. Instead, practice deep breathing and pursed lip breathing. And those two we will show you during the video presentation that comes next. If you become tired while doing something, stop and rest. And if you can't continue, finish whatever you're doing for another time or day when you're not as tired.

(23:30): Third is by delegating. I know, for some, this is hard to achieve, and we would rather just struggle. But if you have too many important or high energy things to do and you can't do them, don’t hesitate to delegate. Ask your family and friends for help.

(23:49): Fourth is by scheduling your activities. Plan to not do so many things in one day, spread them out evenly during the day or week.

(23:59): Fifth is by using labor-saving and assistive devices. For example, for dressing, you can use long-handed tools like a dressing stick, a shoehorn, or a sock aid for putting socks on.

(24:12): Finally, you can conserve your energy. Rest before and after you do something. If you can do your activity sitting down, that would be easier for you, just go ahead and do that.

(24:29): Some final words about how you can ensure success in your exercise journey. Number one is to advocate for yourself. If you are experiencing fatigue, even if it's not severe, let your healthcare provider know.

(24:43): Number two is to educate. Continue talking with other professionals who can give you exercise advice. Of course, BMT InfoNet is one major source of helpful information.

(24:56):  Number three is to have realistic goals. This is something that you get by having a conversation with your healthcare provider.

(25:04): Number four is to use a team approach. You are the most important person in this team, most definitely, but do make sure you're not alone in this process. Discuss with your doctor about the need to be referred to professionals such as physical therapists, occupational therapists, or dieticians.

(25:23): Number five is focusing on safety. Number six is using a holistic approach. There are many factors that contribute to fatigue. You must be screened by your healthcare provider for those factors and seek treatment. Fatigue is multi-dimensional, so do take care of your mental and emotional health as well.

(25:45): Number seven is to continuously find ways to increase your commitment to your exercise journey. You can do this by scheduling your exercise in your calendar, picking a time to exercise when you have the most energy to do the exercise, doing activities that are enjoyable for you to do and exercising with someone who can keep you accountable, what we call an exercise buddy.

(26:17): I hope you find the information in this presentation to be useful. I wish you success in your exercise journey. What comes next is a video about exercise that my colleagues at Mount Sinai Hospital prepared for you and I'll see you in a bit when we get to the question-and-answer portion of this program.

Video Demonstration of Exercises

(26:36): [Kristen Eggers] Hi, I'm Kristen Eggers.

 (26:37): [Ester Kerzner]: I'm Ester Kerzner.

 (26:38): [Julia Warrack]: And I'm Julia Warrack. We're all physical therapists at Mount Sinai Hospital in New York. Today we're going to walk you through an exercise program that you can incorporate into your daily activities.

(26:49): Before we get started on specific exercises, I wanted to bring up the importance of monitoring your heart rate and your oxygen. It's important to monitor these two things before, during and after exercise. To monitor your heart rate, you can do so by getting a pulse oximeter, another electronic device such as an Apple Watch or checking it manually. To check your heart rate manually, you're going to take two fingers at the base of your wrist, right below your thumb between the bone and the tendon. Once you feel a pulse, you're going to time the beat for 15 seconds and multiply that number by four.

(27:24): It's also important for you to know your maximum heart rate, and this could be calculated by subtracting your age from 220. So, for example, if you're 60 years old, you're going to subtract 60 from 220, which would give you a max heart rate of 160 beats per minute. While you exercise, your heart rate should be somewhere between your resting heart rate and your maximum heart rate. But please check with your physician for specifics that are safe for you. It's also important to monitor your oxygen before, during, and after exercise. This should be done using a pulse oximeter. This can be bought online or at your local pharmacy. The one that we have here, the heart rate is on the top and the oxygen is on the bottom, but please check the manual for your specific one. If you notice any significant drop in your oxygen, you should immediately report that to your doctor.

(28:10): A good way to increase your oxygen intake is by using an incentive spirometer. Kristen's going to demonstrate here. You're going to inhale through the nozzle, and you're going to focus on keeping the dial in between the two arrows. Remove the incentive spirometer and exhale normally. Again, big inhale through the nozzle, keeping the dial in between the two arrows and exhaling normally.

(28:34): Another good way to increase your oxygen intake is by focusing on pursed lip breathing and diaphragmatic breathing. Pursed lip breathing is simple. All you do is take a nice big deep breath in through your nose for two to three seconds, and exhale through pursed lips, as if you're blowing out candles. You can also add diaphragmatic breathing into this by placing one hand on your chest and one hand on your belly. This time, when you inhale, you're really going to focus on your belly expanding. The arm on your chest should barely be moving. If you get dizzy or lightheaded during any of these exercises, please stop immediately.

(29:28): I'm now going to walk you through a couple of exercises that will focus on muscles used in your posture. To perform a chin- tuck you're going to sit up nice and tall, and you're going to take two fingers right to your chin, and you're going to push your neck backwards and try to make a double chin, just like that. Hold it for about two to three seconds and relax. Focus on keeping your shoulders away from your ear. it should feel like a nice stretch.

(29:52): This next group of exercises can be performed sitting or standing and can be progressed to use dumbbells. Before doing them standing or with dumbbells, please consult with your physical therapist. For our demonstrations, we're going to do them sitting down. Kristen's going to demonstrate as we go.

(30:09): The first one is going to be ‘I's’, so you're going to bring your arms all the way up overhead, forming an I. Your elbows are going to be nice and straight. The next one is going to be ‘T’. You're going to go out to your side right to shoulder height and then back down. Elbow as straight as possible.

(30:36): The next one is going to be ‘Y’, so this is going to be in between the I and the T at about a 45-degree angle. Try to relax your shoulders as you go through all this. And then the last one is a ‘W’. Your elbows are going to go in towards your side and you're going to go up to shoulder height forming a W and back down. This one you can kind of squeeze your shoulder blades behind you as well.

(31:06): For this next exercise, you're going to have your elbows in towards your side making a fist. You're going to gently roll your elbows backwards, really stretching and squeezing your shoulder blades together, and then rowing forward. When you squeeze backwards, try to focus as if your shoulder blades are squeezing a pencil or a straw. Relaxing your shoulders as always, and gently row forward.

(31:40): This next exercise is a progression to the scapular retractions, and it does involve some balance. Please consult with your physical therapist before performing these on your own. Kristen's going to demonstrate here. You're going to be standing shoulder width a part. You're going to row your elbows backwards, squeezing your shoulder blades together, and then rowing back in front of you. Make sure your back is not too arched. You want it nice and flat.

(32:15): [Ester Kerzner]: Now I'm going to introduce strengthening exercises as well as resistance band exercises. These bands have different colors, depending on the level of resistance that they give. You should talk to your physical therapist before deciding which color/resistance works best for you. You should also talk to your physical therapist to ensure that these strengthening exercises are appropriate for you. They can make sure that you have the right form so that you can do these on your own.

(32:35): For this next exercise, you'll begin standing with a chair in front of you, feet, shoulder width apart. You'll begin by slowly raising your heels all the way up. Then down. Again, up, and down.

(32:53): For this next exercise, you will start sitting in a chair that is against a wall to ensure safety. You will scoot forward till your feet are flat on the ground. Then tuck your feet in a little bit so that they're shoulder width apart. You'll push off with your arms to come to standing, and then reach back with your arms to sit. Let's do that one more time. In order to progress this exercise, you can fold your arms over your chest, so now you're going to focus more on your legs to come to standing. You're going to lean forward again, really using your leg muscles, and then sit back down.

(33:31): For this next exercise, you'll begin lying on your mat, arms at your side. knees bent and feet flat on the mat. Squeeze your glutes and bring your hips up into the air in a bridge position. Hold for one to two seconds and come back down, making sure not to arch your back. Squeeze and come back down. For the next exercise, you'll begin laying on your side, knees bent and feet together. You'll bring one knee up towards the ceiling, and then come back down to the starting position. Make sure to keep your feet together, and don't let your hips rock forward or backward. To progress this exercise, you can add a resistance band right above your knees to make the exercise a little bit harder. But make sure to talk to your physical therapist about what color/resistance band you should use.

(34:37): These next few exercises are a bit more difficult than the ones we just went through. Make sure to talk to your physical therapist to make sure that these are appropriate for you.

(34:45): This exercise is called ‘sidestepping’. Standing upright, straight and tall; you will keep your feet shoulder width apart and come to a mini squat position. You can keep your hands at your side or in the middle. You will start by stepping to the side, keeping your toes facing forward. Don't let your knees collapse in towards in each other. Remember not to bend your back very much. Keep a nice upright posture. To progress this exercise, you can add a resistance band above your ankles or below your knees to help make it harder.

(35:18): The next exercise is ‘wall-sits’. You'll begin standing one step in front of a wall. You'll place your back against the wall and slide down until you're in a mini squat position. Imagine you are sitting in an invisible chair. You will hold this for about 15 to 20 seconds. Make sure to keep your toes pointing forward. Don't let your knees collapse in. Keep your back straight.

(35:41): This next exercise is ‘lunges’. You will begin standing next to a counter or chair, to ensure safety. You will have your feet shoulder width apart. and then with one leg, you will slowly come down to the floor into a lunge position. Carefully return to the starting position and then come out with the other leg. Make sure to keep your back straight. You can progress this exercise by adding dumbbells to make the exercise more difficult. Make sure to talk to your physical therapist before doing so.

(36:17): This next exercise is called ‘bird-dogs’. You'll come onto the mat on all fours. You will start by alternating and reaching one arm, straight out holding for one to three seconds. Alternate with the other hand. Make sure to keep your back straight and don't let your hips rock. To progress this exercise, you can reach out opposing arm and leg at the same time. Hold for a few seconds. Make sure to talk to your physical therapist to ensure that you have the correct balance and safety for this exercise.

(37:01): [Kristen Eggers]: I'm going to talk about different types of aerobic exercise. Make sure you talk to your physician about your own specific heart rate parameters before you start a new aerobic exercise program.

(37:11): I'm now going to show you how to safely use a treadmill. The first thing you do when you get on a treadmill is you find the safety clip or the safety bracelet. You're going to put that on first and then you can step up onto the treadmill and turn it on. You want to start by walking at a comfortable pace. Your first goal is to increase the length of your walks. You can then start adjusting the speed that you're walking as well as the incline of the treadmill. While you're exercising you want to keep track of your heart rate to make sure that you're within your parameters and to see how hard you're working.

(37:59): You can also monitor your intensity by doing something called the talk test. The talk test is you try talking on the treadmill. If you're able to talk but you're not able to sing because you're too out of breath, you know that you're working at a moderate level of intensity.

(38:16): You can also improve your aerobic endurance by walking outside. The same principles apply as on the treadmill. First, you can increase the distance that you walk. Then you can experiment with walking at different speeds and also walking in hillier areas. Again, remember to monitor your heart rate. There are a lot of different apps you can use to make sure that you're keeping track of your heart rate, your distance, and how fast you're walking.

(38:39): Now I'm going to show you how to use a stationary bike. This is an upright stationary bike. There's also one that's called a recumbent bike that has a seat back. For the upright bike, you want to first make sure that the seat height lines up with your hips. Then you want to get on carefully. You can swing one leg over, put your foot in the pedals, your other foot in the pedal. Then you can get started. You want to start by pedaling at a comfortable pace. Again, like with walking, you want to first increase the amount of time that you spend on the bike. Once you've done that, you can start experimenting with different resistances and also different speeds. You always want to bike at a speed that's comfortable for you. And again, you want to monitor your heart rate, and you can also monitor how hard you're working with a talk test.

(39:31): Now I'm going to go over different types of stretches. For all of these stretches, you want to feel a gentle pulling sensation and never pain. If you do feel pain, talk to your physician or your physical therapist before continuing the stretch. We're going to go through these stretches a little bit quickly, but you should hold all of them for 20 to 30 seconds and repeat them three times on each side.

(39:50): This stretch is for the side of your neck. You're going to start by tilting your head and bringing your ear towards your shoulder. Then you can use your hand and start pulling your head a little closer to that shoulder. You want to make sure that you keep the opposite shoulder down and you can hold onto the edge of the table to make sure that shoulder stays down. You should feel a gentle pulling alongside your neck, and you're going to hold for 20 to 30 seconds and then repeat on the other side.

(40:15): This next stretch is for your ‘pecs or your chest muscles’. What you're going to do is you're going to find a doorway or a corner of a wall like this. You're going to put your arm in an L position, lean it against the wall, then take a step forward and lunge forward. You'll feel a stretch along your chest. It may be in front of your armpit. You're going to hold that position and then switch sides.

(40:42): This next stretch is for your ‘quad muscle’, which is the big muscle at the front of your thigh. You're going to start by holding onto a steady surface. You're going to kick your foot back behind you and grab your ankle. In this position you'll feel the stretch going down the front, but if you want to deepen the stretch a little bit, you can pull your foot in closer towards you.

(40:57): Another way to deepen the stretch is to squeeze your glute muscles and push your pelvis forward. Hold this stretch and then repeat on the other side.

(41:06): This stretch is for your gastrocnemius (gastroc) muscle, which is the back of your calf. You're going to find a wall, be about arm distance away. Put your hands against the wall, and now take a big step backwards. You're going to feel the stretch in this back calf muscle. Now you can lean forward into a lunge position, and you'll feel a stretch along that back calf. If you need to adjust the position of the back foot to feel the stretch better, that's okay. You're going to hold the stretch and then switch sides.

(41:42): This next stretch is for your hamstring muscle, which is the back of your thigh. You're going to sit in a chair. You're going to sit at the edge and sit up nice and tall. Kick one leg out forward so that your heel's on the floor and bring your toes towards you. You might feel the stretch in this position, which is fine. If you don't, you can hinge forward at your hips. Don't worry about touching your toes. And you can repeat on the other side. Remember for all of these stretches, you want to hold them for 20 to 30 seconds and repeat them three times on each side.

(42:16): [Julia Warrack]: Thank you so much for tuning in. We hope that you found this educational.

Question-and-Answer Segment

(42:22): [Marsha Seligman]:  Thank you, Mr. Espiritu, and your team for this excellent presentation. We will now begin the question-and-answer session. Our first question is, I exercise, but I still get short of breath when I do things. Any suggestions?

(42:50): [Noel Espiritu]:  In this case, you would want to look at what you're doing in terms of doing your exercise. You might be exercising below your capacity, meaning you probably could do more in terms of doing your exercise, so your body is not getting challenged enough. In this case your endurance is not getting better because you're not challenging your systems. Either that or you might be doing too much, and your body systems can't keep up with the exercise and then you get tired for a day or two. You might want to look at those two things.

(43:36): The other thing I can think of is that you might want to see if anything has come up such as those contributing factors to fatigue that we talked about. Are you having problems eating? Are you not sleeping as well lately? Maybe you're getting anemic. Try to look at what's happening as far as that is concerned too. The answer is to be a bit more systematic. Try to ascertain what's happening in your case and why you're not improving and are still getting tired even when you exercise.

(44:15): [Marsha Seligman]: How do you suggest motivating someone to start to exercise?

(44:28): [Noel Espiritu]:  I can tell you to think of reasons why you should want to exercise. Do you want to stay healthy? Do you want to live longer or maybe have a better quality of life, or do you just want to keep up with your friends when you go hiking?  Think about whom you want to do the exercise for. Is it for yourself or for your loved ones? Sometimes we're more motivated if we do things that are more for other people instead of for us. Really, I think of motivation as a switch that you turn on internally. I can tell you reasons why it's good for you to exercise.  Ultimately you must find your own reasons why you want to exercise.

(45:32): You must look deep within yourself, to discover why you want to exercise, who you want to exercise for, and then convince yourself that it's worth it for you to do the exercise. Even if you hate exercising, try to convince yourself that what you're doing is worth it for those reasons that you identify. I prefer the word commitment. Just if you want to exercise, what will make it easier? You could just try to reference that. Making a schedule on your calendar so that you're committed to doing the exercise or doing exercise with your friends or having a workout buddy who can make you accountable. Try to find ways in which you can commit yourself to doing your exercise. Hopefully that turns your motivation switch on.

(47:05): [Marsha Seligman]:  Are there specialized exercise programs for older BMT survivors who have considerable osteoporosis and osteoarthritis; are these available online?

(47:17): [Noel Espiritu]:  If you have severe or considerable osteoporosis and osteoarthritis, I would not recommend that you rely on online sources for your exercise regimen. My recommendation is to have something more individualized for you. Online information is usually generalized and if you have osteoporosis or osteoarthritis that may affect different parts of your body, you may be able to modify exercises based on what body part is affected. I would recommend having your physical therapist suggest exercises individualized to suit your own body. If less bone loading is what you need, you can find out if you are permitted to swim. That's better for you if you have osteoporosis. Bottom- line; have your exercises individualized for your condition.

(48:26): [Marsha Seligman]:  Question: I am 10-year post allo stem cell transplant and I have never regained my full strength. I have exercised daily for over 40 years, but since the transplant, when I try to do anything more than the basics, I get injured or ‘pull something’, so I have to stop for weeks or months. I have been in physical therapy several times and just can't seem to get beyond the basics. Any suggestions?

(48:53): [Noel Espiritu]:  I would look more into why you're having those pains and aches and what’s happening when you say you're ‘pulling something’. I think you may need to step back a little bit, maybe scale down and have those issues taken care of. You may have other issues to investigate as to why you’re getting easily injured. This may be something that you need to speak with a healthcare provider about, and ease off exercising until you can cause the reason behind your dilemma.

(49:26): [Marsha Seligman]:  I am currently doing a “stay fit program” at my hospital's physical therapy center. I mostly do the treadmill for my cardio workouts. The few times I've done the recumbent bike, it hurts a lot when I get up. They think that may be putting pressure on the tailbone. Would the regular bike be better, or should I not do the bike for my cardio component?

(50:05): [Noel Espiritu]:  It might be the positioning of a recumbent bike, how that tilts your pelvis and then puts more pressure on one area versus another. If you're safe to use a stationary bike, try that and see if that is more comfortable for you. Maybe better padding will also help. I think most recumbent bikes have firmer seats than stationary bikes. Try that and see if that works. But it could be the tilting of the pelvis because in the recumbent bike, your pelvis is tilted a little bit more and not in a natural position.

(50:52): [Marsha Seligman]:  What are some exercises for the core? Sit-ups hurt or feel strange in my midsection, so I don't like doing them.

(51:03): [Noel Espiritu]:  I think Kristen or Julia or Ester managed to show some of those exercises, including doing ‘planks’. Some of those you can do and some of those you can modify. I would refer you back to the video presentations; they have an excellent demonstration of exercise for your core.

(51:32): [Marsha Seligman]:  What is the expected duration of fatigue for post CAR T patients?

(51:40): [Noel Espiritu]:  I don't have any studies to back me up on that. You may want to check with your healthcare provider.

(51:57): [Marsha Seligman]:  I had a cervical fusion in 2021 due to a tumor. Would you recommend or advise against unmodified dips and pull-ups? Also, how soon should I attempt running? I miss it, but I'm a little scared due to pounding and jolting on my neck.

(52:16): [Noel Espiritu]:  Again, this is one of those cases where an individualized exercise program is going to help you because you have a very particular issue here, and especially it involves your neck. I would recommend that you go to a physical therapist, because you need to be assessed before you can have a specialized individualized or a modified exercise program that you know is going to be safe for you. Sometimes it is better to go back to the healthcare provider because the recommendations that they give to you come from a thorough assessment and that gives you more confidence. It will make you more confident in that you're doing the right exercise and the most appropriate exercise for you, and that actually ensures success for you when you do the exercise.

(53:17): [Marsha Seligman]:  Our final question. I have stiffness in the back part of my leg or crease. I didn't see any exercises to address that part of my leg. Would this be an area that is something beyond exercise or might this be something to discuss with my primary care physician?

(53:41): [Noel Espiritu]:  Definitely discuss this with your primary care physician, but if you're saying that the back part of your leg is problematic, that sounds like something that you can stretch using one of the techniques that the video presenters showed you. That would be sitting on the chair, keeping your legs straight, pointing your toes towards you, and then leaning forward and holding it for 30 seconds. That should be able to address that issue. But I would suggest going to your primary care provider just in case there's other issues.

(54:25): [Marsha Seligman]:  On behalf of BMT InfoNet and our partners, I'd like to thank Mr. Espiritu and his team for a very helpful presentation. And thank you the audience for your excellent questions. Please contact BMT InfoNet if we can help you in any way. Enjoy the rest of the symposium.