Enhancing Survivorship with Exercise

Transcript of Presentation:  

(00:00): Jordan Sexton: Introduction. Good morning, and welcome to the workshop, Enhancing Survivorship with Exercise. My name is Jordan Sexton: Sexton and I'll be your moderator for this workshop.

(00:07): It's my pleasure to introduce you to today's speaker, Dr. Nathan Parker. Dr. Parker is an Assistant Member of the Department of Health Outcomes and Behavior at Moffitt Cancer Center in Tampa, Florida. His research focuses on designing and evaluating exercise interventions for cancer survivors to improve fitness and quality of life during and following cancer treatment. Please note that although Dr. Parker: will be discussing specific exercises, you should first consult with your doctor before beginning any exercise program. Please join me in welcoming Dr. Parker:.

(00:40): Dr. Nate Parker: Overview of  Talk. Thank you so much for the introduction, and good morning or afternoon, depending on the time zone of where you're located. I appreciate it, and I'm grateful for the opportunity to be with you all today and speak with you about enhancing your survivorship experience with exercise.

(00:57): Just to quickly highlight the objectives of this workshop--I hope you'll leave with a better understanding of how exercise can increase your stamina and strength in survivorship, and how exercise plans or programs can be tailored or individualized to meet your specific needs.

(01:20): You'll also learn examples of exercises and routines that you might be ready to start and sustain, and how other factors like nutrition and conserving energy can help you manage fatigue.

(01:38): I'm probably not telling anybody here anything new when I say that the effects of cancer and its treatments are profound. Many folks experience lots of fatigue. This, coupled with things like appetite loss, can lead to loss of healthy muscle tissue. This, in turn, can lead to reduced strength and fitness, as well as issues with physical functioning.

(02:01): Some treatments cause neuropathy or nerve damage that can be painful and make loss of physical functioning even worse.

(02:10): Dealing with diagnoses and treatments can be really taxing on the emotional or psychological  side, too, by increasing symptoms of depression and anxiety. This is tough. Obviously, it's really tough, and it would be really nice to have a pill that just treats all of this. That pill, unfortunately, doesn't exist. Perhaps the closest thing we've got is exercise.

(02:37): Exercise has benefits for fatigue, appetite, muscle mass, and physical functioning. Exercise can help reduce fatigue over time as the body adapts to handle the increased workload it's being put through. Exercise can also help increase appetite since our body needs more calories for fuel, and protein for its building blocks. This, of course, can help us maintain our muscle mass, improving both muscular and cardiovascular strength and fitness. It also helps to improve physical functioning or going about daily activities as easily as possible.

(03:09): Exercise can also reduce anxiety and depressive symptoms. If you've ever felt a rush of energy and good mood after exercising, you've experienced that boost of endorphins that comes with exercise. And beyond those short-term emotional benefits, exercise is something you can control and help improve your wellbeing at times when a lot of things probably feel really out of control and chaotic and hectic and challenging and stressful. Controlling exercise can help reduce anxiety and depressive symptoms over time. It's sort of a tool in your tool shed to help you get through cancer treatment, coast more smoothly in cancer survivorship, and have better quality of life.

(03:55): I really like this quote as a summary of those last two slides. Dr. Robert Butler, who is the founding director of the National Institute on Aging, said, "If exercise could be packaged in a pill, it would be the single most widely prescribed and beneficial medicine in the nation." This nicely captures what we're trying to do in the field of exercise oncology. We're trying to harness the benefits of exercise to help folks tolerate cancer treatments more easily and move through the continuum of cancer survivorship while maintaining the best quality of life possible.

(04:33) If you think about cancer survivorship as a continuum, there's an important role for exercise at every single stage. Before undergoing treatment such as the lead up to bone marrow transplant or cellular therapies, exercise can help people become stronger and more robust and help them handle and then recover from those treatments more easily. We call this sort of exercise in the lead up to a treatment, ‘exercise pre-habilitation’, but it doesn't stop there.

(05:04): During treatment, exercise can help reduce those side effects like fatigue and loss of healthy muscle tissue. The benefits and importance of exercise, of course, continue well into the recovery and post-treatment phases of cancer survivorship. Exercise helps people stay as strong as possible and maintain good quality of life.

(05:26): I'll focus a little bit more on the further right end of the continuum here today, and the recovery and post-treatment phases. I want to take a quick step back to describe what we mean when we say ‘be more physically active’ versus ‘engage in exercise or exercise training’.

(05:48) Physical activity, by definition, is basically anything that we do with our bodies that requires more effort from our muscles, and thus more energy expenditure than simply sitting or lying down. Underneath that umbrella of physical activity is more formal exercise training, which includes resistance training, aerobic training, and training for flexibility and balance.

(06:16): Physical activity is any movement or positioning of the body that uses energy. That can include chores, yard work, walking to get somewhere or walking for transportation, grocery shopping, even playing with kids or grandkids. Even simply standing is physical activity because it requires that we use muscles and expend some energy to hold ourselves up and remain stable.  

(06:39): Exercise is physical activity that is planned and repeated to improve fitness. If you think back to that last slide, exercise falls under this umbrella of physical activity, and it's physical activity that's planned, controlled, and usually repeated in a structured way, with the goal of maintaining or improving some aspect of fitness. Examples include walking for exercise, jogging, bicycling, swimming, doing strength or resistance training with weights or bands or your body weight, as well as activities that are designed to improve flexibility and balance like stretching.

(07:11):  I want to stress that both of these are important and contribute to optimal fitness and well-being. Most of my presentation focuses on exercise training, but I definitely want to encourage general physical activity as well as trying to avoid spending too much time being sedentary. Sort of move more, sit less.

(07:36): A well-rounded exercise program has five important components: resistance or strength training, aerobic training, balance training, flexibility training, and rest and recovery. I'm going to focus on the top two here, resistance or strength training and aerobic training, as they're the two that tend to involve the most planning and structure and will constitute the bulk of time spent exercising.

(08:01): In the next several slides, I'll address some common questions that cancer survivors have about exercise, such as when and how should you start exercising, how much should you do and how hard should it be, how do you progress exercise, move it forward so that you continue to improve aspects of your fitness, and what specific exercises or types of exercise should you do. I'll also discuss how you can make exercise more convenient and fun so that it's easier for you to stick to it. Finally, I'll outline some important safety tips to keep in mind and refer you to resources that may help you enhance your survivorship experience with exercise.

(08:47) Exercise is important immediately following treatment but you should have some supervision from an exercise professional.  Let’s start with when you should start an exercise program. The short answer here is that an appropriate and safe level of physical activity or exercise is super important, really immediately following treatment, as well as during treatment, be that transplant or cellular therapy. I know, for example, that individuals are encouraged to walk daily in many cancer centers when they're still inpatients following these procedures. But of course there are levels to exercise, and it's important to make sure it's safe to progress in intensity or quantity of exercise.

(09:23): If you have any hesitations, make sure you speak with your care team about what you're planning or considering, and ensure that you've checked off all the boxes to start exercising safely. You may need to get some medical clearance or set up a more formal exercise program with a qualified professional if you're dealing with health conditions like the ones I've listed here in the blue box. And by no means is this list intended to frighten you away from exercising, because, in fact, exercise is generally encouraged in most of these situations. But there's a higher likelihood that the exercise should be supervised by an exercise professional or potentially medically supervised to ensure that you are starting and progressing in your program as safely and effectively as possible.

(10:11): Platelet levels in the blood are a good guide to how much exercise is recommended over time. The next question is, how should you start an exercise program? In the context of bone marrow transplant and cellular therapies specifically, platelet counts provide really important information about the safety of different types of exercise, or different intensities of exercise. Your care team will help you monitor and understand your platelet levels in your blood, which are cell fragments that are produced in bone marrow that circulate in your blood and are responsible for clotting to prevent or stop bleeding. Having low platelets, which is called thrombocytopenia, can put you at risk of bleeding, particularly during resistance exercises.

(10:48)  It's important to make sure with your team that you've hit these thresholds before moving things forward and progressing in intensity. If platelets are below 10,000, you'll need to limit activity and only engage in physical activity recommended by a physical therapist. If platelets are in that 10,000 to 20,000 range, you'll generally be able to proceed with light aerobic exercise and normal activities, mainly just avoiding adding resistance or weight to your body for exercise.

(11:19): If platelets are between 20,000 and 50,000, it will generally be safe to walk more briskly and use light weights or resistance bands, or your own body weight to do some strength training. If platelets are between 50,000 and 80,000, you can generally engage in moderate intensity aerobic exercise and progressive resistance training starting at levels that are appropriate for your current fitness level. When platelets are above 80,000, you can engage in higher intensity aerobic exercise, up to the moderate to vigorous intensity level. Progressive resistance training is just making sure that you're exercising at intensities that are appropriate for your current physical condition. I'll note that the exercise training guidance I'll get into here shortly and in more detail focuses more on these higher levels of platelets-- at the 50,000 and above ranges.

(12:18): Next, I'll get into how much exercise you should do, starting with aerobic exercise. We have evidence-based guidelines with years and decades of data that we've collected across research studies in exercise oncology. These are compiled and put together from organizations like the American Cancer Society and the American College of Sports Medicine. They help us determine, based on research findings, how much exercise is safe and beneficial in different contexts.

(12:49): During treatment, or when still recovering from an acute previous treatment, the main guideline is to aim for at least 30 minutes of moderate intensity aerobic exercise on at least three separate days per week. As you become comfortable with that volume of aerobic exercise, you can work your way up to 150 minutes a week, so maybe five days a week for at least 30 minutes each day.

(13:12): Following treatment and acute recoveries from treatment, guidelines recommend working up to that same level of 150 minutes per week. I'll talk a little bit more about intensity of aerobic exercise shortly, but you can note that if you're able to push a little harder into what we call vigorous intensity aerobic exercise, you can tend to achieve the same benefits in less time--a little more bang for your buck.

(13:40): For resistance or strength training, the guidelines are less about time, and more about how frequently you work major muscle groups. Specifically, the guidelines recommend training or working out all of your major muscle groups at least two times per week, and it's a good idea to give each muscle group at least a day to rest and recover before training it again.

(14:03): So what does it mean to train a muscle group? That means doing at least two sets of 8 to 15 repetitions each time, with some rest in between sets so that those muscles can be ready to engage in the next set, the second set.

(14:16): For those who may not be familiar with the terms repetitions and sets, a repetition means doing an exercise one time with full range of motion. For example, doing one bicep curl. A set would be a group of repetitions, so a set would be the 8 to 15 repetitions of that biceps curl that you do all at once-- slowly and safely of course, but without stopping to rest before you put that weight down.

(14:47): The next important question is about the intensity of your exercise, or how hard you should be exercising. For aerobic exercise, it's important to try to aim for at least moderate intensity. That's where we know benefits stem from the time that you're putting into exercise.

(15:07): Moderate-intensity aerobic exercise increases our heart rate, makes us breathe deeper and faster, but it's not exhausting. It's an intensity that you could probably maintain for an hour or longer if you needed to, or wanted to, before you're getting super tired. You can work up a sweat at moderate intensity, especially if you're outdoors and it's warm out.

(15:24): A good way to guide moderate-intensity aerobic exercise is to use what we call a talk test. If you can maintain a conversation in short sentences, you're probably at moderate intensity. If you feel like you can belt out a full song, you can probably dial it up a little bit more. I mean to say, you're not quite pushing your cardiorespiratory system up to that moderate intensity if you can belt out a full song without stopping. But if you can barely get a word out and you're uncomfortable, you can probably dial it back and make yourself more comfortable while still benefiting from what you're doing in terms of the work that you're doing for your cardiorespiratory system.

(16:07): That vigorous intensity where it's more difficult to talk, where you might feel like you can only get a few words out  involves higher heart rates and deeper and faster breathing. It's an intensity that most people would have trouble maintaining for longer than 20 to 30 minutes.

(16:24): Because you're taxing your body more at that higher vigorous intensity, you can get more bang for your buck, and benefit with shorter durations of exercise. For example, walking briskly at a pace of about 2.5 to 3 miles per hour would generally be moderate intensity exercise for most individuals. Of course, all of this is relative based on somebody's physical functioning or fitness condition. If you were to pick that pace up to jogging at about five to six miles an hour, you're generally going to be pushing more into the vigorous exercise intensity for most individuals, so it's not a perfect calculation.

(17:03): You can generally count minutes you spend exercising at vigorous intensity as double those you spend exercising at moderate intensity. You can walk briskly for 10 minutes, and then jog for another 10 minutes, or do the same equivalent, say pedaling on a stationary bicycle, nice and easy for 10 minutes, and then pick up the pace for another 10 minutes. Even though you exercise for 20 minutes total, you can generally count that as 30 minutes towards your weekly goal because of that higher physiological demand you placed on your body when you are jogging or pedaling more quickly. For resistance or strength training, the recommendation is to make it moderate intensity.

(17:47): Resistance or strength training is about the amount of weight you’re using and how difficult it is to complete a set of movements. If you've engaged in resistance or strength training before, you know that it doesn't really have to do with the same breathing or heart rate guidance as aerobic exercise. It's more about the load or the amount of weight or resistance you're using, and how difficult it is for you to complete the sets that you intend to complete. Moderate intensity strength training means that, in general, your last few repetitions in a set should feel hard as your muscles are getting tired as you approach the end of that set, but you can still maintain proper form. You can also think of it based on how many repetitions you'd have "left in the tank" when you finish a set. When you finish a set of say 8 to 15 repetitions, you should feel like you could have performed just a few more repetitions if you had to, and that would be moderate intensity resistance training.

(18:39): Going back to the bicep curl example, if you were to finish a set of 15 bicep curls and feel like you could keep going with that weight all day, then you need a heavier weight to properly stimulate your muscles and to reach that moderate intensity. You shouldn't be able to keep going forever after 15 if you're at moderate intensity. But if you have to strain and contort your body to get the final few repetitions that you intend to complete, you can do fewer repetitions or use a lighter weight.

(19:06): You can think about how your body feels as you complete a set and use that guidance to help make sure that you're doing your resistance training at the proper intensity, or the intensity that's going to produce benefits and be safe for you.

(19:25): The next question is about how you can progress your exercise over time. One of the coolest things about exercise is that you'll see results when you're consistent. You can make progress and see how your body responds to get fitter and stronger. A 20-minute brisk walk might feel really challenging when you first start out, but it'll feel easier after doing it consistently for a few weeks.

(19:48): Similarly, a set of 12 repetitions for a 10- pound chest press or bicep curl might feel difficult the first time, but easier after you've included it in a few strength training workouts.

(20:01): As you improve your fitness, you want to up the ante or provide your muscles and your cardiorespiratory system with greater stimuli so that they can continue to respond. That's called exercise progression. It's kind of overloading these systems over time as they get stronger so that you're continuing to encourage them to improve their strength and fitness.

(20:21): For aerobic exercise, progression can look like increasing variables, such as how often you exercise, or the frequency; how long you exercise, or the duration each time you go out; or how hard you exercise, or the intensity of it. For resistance or strength training. You can add exercises to your routine to work muscle groups in different ways or target new muscles that you might not be hitting with the exercises you've been doing. You can also increase the amount of resistance or weight that you're using over time as it becomes easier for you to lift that weight in your intended sets.

(20:59): Another cool aspect of embarking on an exercise program is that you can be creative and mix it up. Aerobic exercise can include walking or jogging indoors or outdoors, on a treadmill, or on a safe sidewalk or trail. It can include stationary bicycling by yourself, in a group class, or riding safely outdoors.

(21:18): Swimming is another great form of aerobic exercise. It can also help strengthen muscle groups in your arms and back, even your legs that may not be as engaged in other types of aerobic exercise that your body's more accustomed to, like walking or jogging or cycling.

(21:33): Other forms of aerobic exercise are:  traditional aerobics or water aerobics, Zumba, any other forms of dance, boxing or kickboxing, and playing or practicing recreational sports. You can use your exercise program to help you find and develop new hobbies, or you can focus your exercise goals and your progress towards them on things you already know you enjoy and want to spend your time doing.

(22:02): Resistance training might be a little more intimidating for somebody who's getting into it for the first time because we tend to think about it involving loud gyms, bodybuilders with heavy weights and complicated machines, barbells loaded up. And while that environment and training format works for some people, it's important to know that there are many ways to build strength that may be less daunting or intimidating.

(22:24): Resistance training can use resistance tubes, dumbbells, kettle balls or even your own body weight. In studies in my lab at Moffitt, we really like working with resistance tubes for participants because they're super portable and they provide lots of options for setting up different exercises with different levels of resistance. You can find those relatively inexpensively and they are frequently available in gyms or fitness centers.

(22:42): There are relatively inexpensive sets of adjustable dumbbells or dumbbell sets that you can purchase to provide different levels of resistance for different exercises. And there are pieces of equipment you're more likely to find in gyms, like barbells and free weights, and pin and plate loaded machines with a stack of weights. You'll see those set up for resistance training circuits that you can work through.

(23:08): Kettlebells that are pictured here on the top left have nice big handles that are particularly good for building grip strength, which helps with day-to-day functioning.  And they help you train in a really functional way that makes you balance and find your center of gravity and maintain stability. That can be a type of functional training for a variety of exercises.

(23:29): And last but not least, you can use your own body weight for exercises like chair stands, body weight squats or lunges, different variations of push-ups, or the plank exercise that's pictured in the bottom right. Using your own body weight is also a great way to build strength, and is certainly effective,  simple, and obviously convenient.

(23:53): Resistance training can be very simple just using your own body weight or household objects. To highlight how simple resistance training can be, I've got a little routine to present here that you can do without any special equipment at all. These first three exercises on this slide use just your own body weight for resistance. We've got squats or chair stands that work large major muscle groups in your legs and your glutes. We've got push-ups against the wall, and those can progress to a countertop, or different varieties from the floor that work your chest and your arms. And then in the bottom right I've got seated knee raises with a pause at the top that can work your hips and abdominal muscles, your core, or your trunk muscles without having to get down on the floor and do a crunch or a sit-up or use a specialized machine.

(24:46): There are some additional and simple exercises that you can do with objects you'd likely have around the house like canned goods or jugs, really any object you can picture. Going clockwise from the top left, we have a shoulder press using canned goods. Then we have a bent-over row for back and arm muscles using a jug with water in it. There is a triceps extension for the muscles in the back of your arm and back using the canned good for that triceps extension, and then a bicep curl going back to the jug.

(25:19) So picture this jug or the canned good as alternatives to something like dumbbells or resistance bands. Instead of grabbing a heavier dumbbell or resistance band as you get stronger, you can simply add more water to the jug or make that a heavier canned good or object from your house, so that you're progressing these exercises and continuing to strengthen your muscles over time.

(25:45): When embarking on exercise, several safety steps should be kept in mind. Next, I'll highlight some important safety tips to keep in mind as you get comfortable starting and progressing your exercise program. It's really important, of course, to drink lots of water and stay hydrated, and also to maintain a healthy diet to provide your body with the fuel it needs for exercise. Also important is wearing proper clothing and footwear while you're exercising.

(26:08): Here are a few more safety tips. You want to aim for gradual progression of your program as you improve your fitness, not trying to do too much too quickly. Exercising with a partner or at least with trusted people nearby to help you in case of an emergency is also important and can be helpful if needed.

(26:25): Environmental variables play a key role in exercise safety. For example, exercising outdoors can be really motivating and rewarding, but it's important to avoid excess heat by trying to get out there in the mornings or evenings on hot days.  If you live in a colder climate, make sure that you're dressed warmly to make sure that your body stays warm enough while you're exercising.

(26:48): The final few safety tips to keep in mind are in the category of environmental variables. Wearing sunscreen and protective clothing can help prevent your skin from damage due to sun exposure. And if you're doing something like walking, jogging or bicycling outdoors, it's important to make sure the routes that you choose are safe from traffic, and that you're protected from traffic.

(27:11): During or following cancer treatment, it can be important to avoid crowded indoor exercise environments so you're not exposing what could be a compromised immune system to many other people who may pass along sicknesses. You can speak with your medical team about the safety of exercising in these types of indoor environments that might be crowded and involve heightened risk for germ exposure.

(27:34): And as always, you want to listen to your body. Building in adequate rest, recovery, and sleep helps your body adapt to progressive exercise programming more effectively. It gives your muscles and your cardiorespiratory system the time and the rest that it needs to adapt to that increasing stimulus that you're putting on it over time.

(27:53): If your exercise level feels like too much for your body, don’t hesitate to dial it back. Exercise can feel uncomfortable sometimes as it involves intentionally putting some stress on your body so that it adapts to be stronger and more fit. But if the amount of exercise or the intensity of what you're doing feels like too much for your body, or that it's worsening any underlying health issues you have, it's important that you dial it back, progress more slowly and gradually. Discuss your goals and the program that you've put together for yourself, or are planning for yourself, with your medical team to make sure it's safe.

(28:27): Exercise does not need to be something you dread. There are a lot of ways you can help make sure it's convenient and fun for you. If you find yourself in that dreading exercise camp, it's totally understandable and nothing to be ashamed of. But as you get consistent and make progress, you might be amazed at how your mindset flips and exercise becomes something you crave and look forward to--a part of your day that you're really looking forward to each day. This can be because of the sense of accomplishment you feel when you do something that's hard and make progress or because you end up enjoying the activities you choose, or because you get that boost of endorphins that brightens up your mood for the rest of your day.

(29:08): I like to say that the best form of exercise is the one you can stick to. It's a great opportunity for you to figure out what you like and not force yourself to do things that you don't enjoy. This can mean identifying activities that you enjoy and lining those activities up with a friend or family member who can provide companionship and accountability. It can also mean finding or exploring new places with exercise that are fun, interesting, or aesthetically pleasing, fun to look at and be in.

(29:37): An additional tip for making exercise convenient and fun is planning ahead and scheduling exercise into your routine. Even block it off in your personal calendar. If it makes sense to exercise during a break from work or on your way to or from work, make that decision easier by packing the shoes, the clothes, and the water bottle that you need to go do that exercise and get it in.

(30:00): Working with a certified personal trainer can be very helpful for guidance and accountability, as can group exercise classes and recreational sports.

(30:13): Using exercise apps and mixing up your exercise routine can keep it fun and engaging. Here are the last few tips for making exercise convenient and fun. As you progress in your program, it can be motivating to set and monitor your progress towards short- and long- term goals, and to make sure that you celebrate your progress along the way. There are many smartphone apps and devices, things like Fitbits and other smartwatches, that can help you set goals and plan an exercise program to help you achieve them. You can self-monitor your progress and even add in some friendly competition with family or friends for things like daily step counts or weekly minutes of physical activity.

(30:47): And last, but not least, if you get bored with a certain type of exercise, like I said before, mix it up. There are so many different ways to build exercise into your daily or weekly routines, and mixing it up can help you, one--work different muscle groups. Two--discover or develop new interests or hobbies. And three--potentially meet new friends and folks that you want to be around every day and look forward to exercising with.

(31:14):  Fatigue is one of the most common and significant challenges that cancer survivors face. And cancer-related fatigue can persist long after completing different cancer therapies. It really is a multifactorial problem. It can be different for everybody, but trying to be consistent by addressing it through a number of minor piecemeal strategies can really help.

(31:36): Managing fatigue can be an ongoing challenge but there are strategies for dealing with it. For example, if accomplishing a long to-do list feels overwhelming due to cancer-related fatigue, it can help to prioritize the most important tasks and try to accomplish them at times when you have enough energy. Discussing your concerns about fatigue with your care team might help identify some supportive care strategies available to you that can help you reduce and overcome your fatigue. It's also important to ask for help from friends and family so they're aware of what you're dealing with and can pitch in to help you get through those to-do lists.

(32:08): It's really important to strike a balance with staying active. Again, capitalizing on windows of time when you might have more energy, and balancing that with getting adequate rest, can be helpful. It can seem counterintuitive to think about being more physically active and exercising when you're feeling a lot of fatigue, but that sort of health-promoting tax that you put on your body and your mind by exercising when you can will help you build up an energy reserve over time. It's like you're buffering against that fatigue.

(32:38): Relaxation exercises like meditation and deep breathing can help reduce stress that otherwise exacerbates or worsens fatigue. And lastly, eating nutritious foods and staying well- hydrated can help your body's systems keep up with its day-to-day demands.

(32:57): We all experience barriers to starting or keeping up with an exercise routine. Of course, going through cancer and cancer therapy certainly adds to these challenges in a really significant way. It's totally understandable that there are barriers to face, particularly as you're just getting started, but they're also addressable. There are ways that you can overcome them. If you're hesitant to start engaging in an exercise program because it's been a long time since you've done so, it's important to make sure you progress gradually.

(33:26): All safe and effective exercise programming should be appropriate for your current capabilities and include gradually increasing quantity and/or intensity as you adapt and improve your fitness over time.

(33:37): Feeling like you don't have time is another common barrier. It's important to remember that with exercise, something is better than nothing. Start by building short exercise sessions into your day, even just 10 minutes at a time. And if there are more sedentary activities that you enjoy, like reading and watching TV, and you don't want to sacrifice those, you can find ways to exercise while you're doing them.

(34:00): Cost can also be a barrier. As I went over earlier, exercise doesn't have to mean going to a fancy gym, buying any new equipment, or hiring a personal trainer. Things you have around home and your body weight can be all you need to engage in effective resistance training. And your neighborhood or nearby parks and trails can provide safe and fun locations for aerobic exercise.

(34:21): We've even had participants on studies of mine wear out a track around their local Lowe's or Home Depot, walking around the inside, because it provides a nice long distance. It's cooler in hot weather, more fun to be inside and look at things. Maybe they'll even hook you up with a Home Depot or Lowe's vest over time so you can help answer questions for customers.

(34:43): Fatigue, of course, shows up as a barrier as well. And this goes back to the same advice from the previous slide, in that starting slowly and gradually building that energy reserve from exercise will help you deal with that fatigue over time.

(34:57): And last, but not least, is soreness. When muscles haven't been used in certain ways for a while, some soreness is normal, especially as you're just starting out. That preliminary or early soreness actually tells you that your muscles are rebuilding and repairing themselves to be stronger and more functional than they were before you did that exercise with them. Increasing blood flow to those sore muscle groups, such as by stretching and doing some light physical activity, will help them get everything they need to accelerate that repair process and reduce soreness over time.

(35:29): Soreness from starting something new or increasing your activity is totally normal, but it's still important to differentiate between that and injuries that require more rest and potentially medical attention. If soreness persists, or if you think exercise may have caused an injury, you should make sure you follow up with your care team and get the appropriate medical considerations that you need, and make sure that you're resting and recovering from the type of exercise that caused the injury.

(35:59): There are many resources available to start and maintain an exercise program. I want to direct you to some additional resources that can be really helpful to jumpstart your exercise program or find new ways to help you meet exercise guidelines and your personal goals. One is the LIVESTRONG program at the YMCA, ymca.org/what-we-do/healthy-living/fitness/livestrong, which includes a twelve-week small group exercise program designed specifically for cancer survivors, and it's completely free. You can look at websites for local YMCAs in your area or call around to find out about upcoming LIVESTRONG program sessions near you.

(36:29): I included a few additional online resources here as well. The Cancer Exercise Smartphone app at cancerexerciseapp.com is also totally free and can help you design an exercise program that's tailored specifically for you, as well as help you track your progress along the way.

(36:43): Maple Tree Cancer Alliance's website is mapletreecanceralliance.org. It's a national organization with exercise professionals who are trained in program delivery for cancer survivors. You can reach out to Maple Tree via their website to set up in-person or remote exercise consultations, depending on where you are. You can set up ongoing personal training, which is also offered either in-person or remotely, or subscribe to online programs and ongoing monthly challenges that can help guide you with exercise.

(37:12): And finally, the American College of Sports Medicine maintains this website called the Moving Through Cancer Exercise Program at exerciseismedicine.org/eim-in-action/moving-through-cancer-2/ where you can search for qualified professionals and programs in your area.

(37:28): To wrap up and summarize, I hope you're coming away with a new or increased understanding about the importance of being active and exercising for improving your health and well-being during and following treatment.

(37:40): To benefit most from exercise, you should incorporate aerobic and resistance exercise along with flexibility and balance. All the while, of course, listening to your body and making sure you get adequate rest and recovery.

(37:57): As you get started, it's always a good idea to consult with your medical team to ensure your plans are safe for you and remember to start off according to your body's current capabilities and make gradual progress over time. Thank you very much, and I'm more than happy to answer any questions.

Question and Answer Session.

(38:15): Jordan Sexton: Thank you very much, Dr. Parker:. That was an excellent presentation. We're going to take some questions from the audience now. And our first question is from someone who describes themselves as the type that doesn't like to specifically exercise.  They didn't do much in their first year post- transplant, and they're currently four years post- transplant. And after about two and a half to three years, joint mobility and flexibility issues are starting for them. They're wondering if they possibly set themselves up for this issue by lack of exercise or slacking off early on in their post-transplant journey.

(38:58): Dr. Nate Parker: I'm certainly not going to knock this individual personally by saying that they slacked off because this certainly is a challenging continuum and journey through transplant and recovering from it. So in no way should you knock yourself for the state that you find yourself in now, but it's never too late to get started.

So starting slow, you'll see gradual improvements in joint mobility and flexibility. But, of course, remember the guidance that you have to start at a level that's appropriate for where you currently are, and not try to do too much at once, or right off the bat, because that will lead to frustration, and can also be unsafe. Make sure you're starting where you need to be and making very gradual progression and you'll see progress over time.

(39:54): Jordan Sexton: Is hot yoga a safe form of exercise after a bone marrow transplant for AML, and is being very hot even on a summer day a concern?

(40:06): Dr. Nate Parker: So hot and cold, they're certainly hot topics right now. We see a lot of sauna therapy and cold plunges. Cold tubs are all the rage in fitness right now. And I know hot yoga has been around for a long time, it certainly can help with adding some additional stimulus. Your body is further taxed by the heat in that yoga studio. It can also help you... Since your muscles are warmer, you can have better flexibility. I have no reason to say that I don't think hot yoga would be safe, but I would also encourage you make sure you're staying very well hydrated.

I know those yoga studios get very sweaty, so make sure you replace those fluids and preempt those sessions with plenty of water and electrolytes, and make sure that you maintain adequate nutrition as well.  It's an additional sort of stimulus that you're adding into exercise by doing it in that hot environment. I have no reason to think that it would be unsafe outside of ensuring that your care team feels that it's safe for you to be in what can be more crowded environments with potential for germ exposure.

(41:23): Jordan Sexton: And can exercise help with chemo brain or cog fog? And if so, is there any type of exercise that's best?

(41:31): Dr. Nate Parker: This is a really good question. For one, I'll say we have some preliminary evidence and we're building more evidence in this field with cognitive function as an outcome of exercise interventions. We know that folks who stay more active tend to maintain better cognitive function, but I'd say the jury's still out in terms of randomized controlled trials with that as the primary outcome. There certainly is some evidence to suggest that this might be the case.  Staying more active, and the planning and structure that goes with exercise, the improvement in mood and reduction of depressive symptoms and anxiety, can certainly help on the cognitive functioning side of things as well.

Designing your resistance training program and keeping careful track of things like sets and repetitions can add some cognitive stimulus. And, interestingly, I don't know if we have any pickleball players on the line here, but there's some promising preliminary evidence that the scoring and the teamwork involved with a sport like pickleball, which is very popular, can add some cognitive tasks, along with the exercise.

(43:08): Jordan Sexton: This one is short and sweet. What is the best way to stay hydrated?

(43:19): Dr. Nate Parker: Water. Hydro comes from water. Water is certainly the best way to stay hydrated. There are ways, particularly if you're exercising a lot, of losing a lot of water to sweat. You're also using up the electrolytes. The salts that are in your blood are evaporating from your body as sweat, so it can also be helpful to replace those with electrolytes. There are calorie-free, sugar-free electrolyte powders that you can add to water.

A lot of electrolyte beverages can also include things like caffeine or high levels of sugar, and you want to make sure that you're careful about the additional things that might be in a beverage along with electrolytes. There are things like powders in a little packet that you can rip open and dissolve in water. Just make sure you're using brands that go along with your current dietary plans and recommendations as well.

(44:21): Jordan Sexton: Would you consider it safe to play pickleball if you're on a blood thinner?

(44:27): Dr. Nate Parker: If on a blood thinner, I would say for the most part yes, but I'm not a medical doctor and I would definitely encourage you to follow up with your medical team about that, just ask about your specific risks. But absent something like physical functioning limitations or fall risk that could make it more likely or increase your risk for an injury or fall during pickleball, in general, being on a blood thinner does not make it unsafe to engage in that level of moderate intensity exercise that you'd be engaging in pickleball.

The risk comes because you're potentially needing to move in different ways or new ways. You might want to make sure that you're not backpedaling. I know a lot of the injuries in pickleball come from that backpedaling that our bodies aren't used to. Keep it facing forward. Don't worry if somebody lobs the ball over your head, let that one go for their point. No big deal. Making sure that you're not having any fall risk, or extra fall risk, or playing the game in a way that increases your propensity or likelihood of falling would be the important things.

(45:45): Jordan Sexton: Are there any symptoms during or after exercise that should prompt someone to stop, or when should they call their clinic?

(45:54): Dr. Nate Parker: That's a good question. This can be challenging because the point of exercise is to stress our bodies in a way that makes them recover and rebound and be stronger than they were before that session of exercise. So that entails things like a higher heart rate and breathlessness.

What I would encourage you to do is to keep track of your heart rate. You can use stationary equipment that has sensors that you're gripping that can tell you your heart rate. Of course, on many of the smartwatches, there are chest straps that you can wear that will sync up with machines or sync up with your watch to help you keep careful guidance on heart rate.

If it seems like that the heart rate's accelerating far more quickly than the stimulus that you're putting on it should entail, that would be a sign to dial it back. Same with extreme dyspnea or breathlessness, essentially listen to your body.

And if anything feels like it's far more taxing than it should be based on your level of fitness, I would check in with your medical team, and also dial back the intensity of exercise. If a very low intensity exercise is causing these types of issues, such as just going out for a moderate intensity walk, if that's leading to super high heart rates or deeper faster breathing than you're comfortable with, you should check in with a care team and ensure that the exercise you're doing and planning is safe for you.

(47:30): Jordan Sexton: Are there any specialized exercise programs for older BMT survivors who may have considerable osteoporosis or osteoarthritis, and are any available online?

(47:43): Great question. The resources that I had on one of my last slides about things like the Maple Tree Cancer Alliance and LIVESTRONG at the YMCA and the American College of Sports Medicines, Moving Through Cancer Directory, can help refer you to programs where that exercise would be supervised. Not that having osteoarthritis or osteopenia are fun problems to have, by no means am I saying that. But the good thing about exercise is that it's probably the single most effective nonmedical treatment for those conditions. Weight-bearing exercise is known to increase bone density and strength.

Resistance training, really anything where you're on your feet and using the force of gravity to put some stress on your bones, would be good. Basically, anything that is on your feet-- walking, jogging, using an elliptical trainer--things like that would be effective ways to help strengthen your bones.

Of course, those aren't necessarily the easiest things to do with osteoarthritis. It's sort of a predicament. For osteoarthritis, things like water aerobics and stationary cycling are things that can take some of that impact from repetitive movements off of your joints and help reduce the side effects of exercise or prevent exacerbating any pain that you feel with osteoarthritis.

Of course, you want to speak with your care team about managing those conditions medically, and what you need to do on those fronts. But in general, you can design exercise programs in ways that are one, going to strengthen your bones and two, help you accommodate issues that you're having with osteoarthritis.

And I also didn't mention moving the joints and strengthening the muscles that surround the joints.  For example, somebody with knee pain can really benefit from strengthening their quadriceps muscles and their hamstrings--the things that move the knee.

Strengthening those muscles, making them bigger, stronger, more effective, can help take some of the stress off of those joints that you might feel with exercise, too. It could be more gradual, but you can certainly help treat those conditions with exercise.

(50:08): Jordan Sexton: Are there any limitations people should keep in mind based on medication, particularly if they're on steroids?

(50:17): Dr. Nate Parker: I'm hesitant to get into medical things too much since I'm not a medical doctor. I would definitely encourage you to consult with your care team about the potential for any medications you're taking to be something that would contraindicate exercise. But in general, moderate intensity exercise and moderate intensity aerobic and resistance training is typically recommendable, and advisable, even with most medications that somebody would be taking. Of course, I'd encourage you to follow up about your condition or medical routine specifically with your care team.

(51:00): Jordan Sexton:  Is there a best time to exercise, morning or night? And do you recommend eating before or after?

(51:07): Dr. Nate Parker: Good question. I go back to what I like to say about a lot of questions about exercise. The best thing that you can do is the thing that you're going to stick to. So if morning or night is more convenient for you, if it works better with your schedule, then that helps answer your question. Oftentimes folks will... Like me for example, I always feel like I can get a more effective workout in later in the day when my muscles have sort of woken up. If I'm going to pick up heavy things, sometimes my hands will feel not ready to lift the same weight in the morning as they are later in the afternoon or evening. So it could be very personal as to when your body feels best exercising or is able to accomplish what you want to do.

Sometimes people dislike exercising later in the evenings or at night because it kind of stimulates your nervous system, fires you up, revs up your engine, so to say.  It can be more difficult to relax and get ready to go to bed and go to sleep afterwards. Thinking about what works best for you personally with your schedule is really the crux of exercise timing. The key is to get it in when you can and learn what's sustainable for you.

As far as eating goes in relation to exercising, I'd say you do want to make sure that your body has adequate fuel for the exercise you're going to do. That doesn't mean pounding a bunch of food just before going out because your body's not going to have digested that yet and have the nutrients in it. The sugar and fuel from that food, the fat and the protein, it's not going to be digested yet. It's just going to be sitting in your belly, which can make it uncomfortable to exercise sometimes.

But there's also the idea that some moderate intensity exercise like going for a walk after a meal can help with digestion in some cases. Fuel is needed for exercise training, especially if it's more vigorous. You don't really want to do that on a full stomach, but you also don't want it to be a completely empty stomach either. You want to make sure you have that fuel, but also that you're not making it more difficult or uncomfortable to exercise with a full belly.

(53:22): Jordan Sexton:  How would you suggest motivating someone to start to exercise?

Dr. Nate Parker: (53:34) That's a really good question. If this is coming from a cancer survivor who's looking for motivation for themselves, I would think about and keep your mind focused on the long-term benefits of exercise. How today you might feel uncomfortable about it and not want to do it. But if you look down the road, say six months out, a few months out, even a few weeks out, you'll be feeling better than you do today by embarking on and sticking to an exercise program.

If this is from say, a caregiver, family, or friend, thinking about how to motivate a loved one who's a cancer survivor, I would suggest offering informational support or companionship support. It's often very personal. Some people would respond differently to different types of motivation, but I'd suggest being there as a resource for the person who can exercise along with them. Organize or plan ways to make exercise easier and more convenient. Those are certainly ways that you can help motivate somebody.

Either way, whether it's directly for a survivor or for a family or friend or caregiver, things like self-monitoring, using devices like Fitbits or apps, or even just keeping a log of what you're doing and how you feel while you're doing it can help you understand and see the progress.

And progress in and of itself can be really motivational over time.  Starting is the hard part, but I've never met somebody who didn't like that they started on and stuck to an exercise program. You feel good about it after doing it a little bit. So that can be motivational, getting in that positive head space.

(55:30): Jordan Sexton: Only have one question left. This person exercises but still gets short of breath when they do things. Do you have any suggestions?

(55:39): Dr. Nate Parker: Good question. Breathlessness or dyspnea can be one of two things. Of course, it can be a result of physical deconditioning, not being in tip-top shape. So that can be addressed by that gradual progress that I reflected on a lot during my presentation of starting slow. And that's a level that's comfortable for you right now.

But dyspnea or breathlessness can also indicate underlying medical issues and those would be the things that you'd want to make sure you talk with your care team about and address, either outside of your exercise plan or alongside your exercise plan, to make sure that what you're doing is safe for you, because you don't want to push into areas where you're totally out of breath while exercising all the time.

(56:29): Jordan Sexton: Closing. Awesome. Well, thank you very much. On behalf of BMT InfoNet and our partners, I'd like to thank you, Dr. Parker:, for your excellent presentation on exercise. And thank you to the audience for all your questions and for your time here. Please contact BMT InfoNet if we can help you in any way and have a great day.