Customized Exercise Programming – Colorectal Cancer

Ben received a referral for a client with colon cancer. He’s been a Cancer Exercise Specialist for two years, but this is his first client with colorectal cancer. He asked if he could hire me to help him with and teach him how to put together Amelia’s exercise program. He completed her initial assessment and health history and shared the following information with me:

• Amelia is 71 years old and in good health prior to her cancer diagnosis
• Amelia is 5’2 and currently 98 lbs. She has 25% bodyfat
• While she has slowed down over the last decade, Amelia has remained active playing golf twice a week, attending a water aerobic class 2-3 times per week, and walking her dog for 1/2 hour daily. She is not sure what she can do now that she has an ostomy bag
• She was diagnosed with colon cancer in September 2017
• She underwent an open right side colectomy and lymph node dissection in October 2017
• She completed chemotherapy in April of 2017
• She is taking Wellbutrin for depression and anxiety and Lopressor for high blood pressure
• Her BP is 120/80 (while on meds) and her RHR is 70.
• She has been walking her dog daily since surgery, but has not done any other exercise.

Postural Assessment:

• Upper-crossed syndrome
• Flexed forward at the hips
• Both feet pronate
• Medial knee rotation on both legs (noticed on squat test)
• Arms fall forward on squat test
• She has some difficulty with balance due to peripheral neuropathy in her feet
• She has Stage 1 lymphedema in her right upper thigh. She has been prescribed a compression stocking and must wear it to exercise. Ben lets Amelia know up front that if she does not wear it to training that he will have to cancel their session.

Ben was concerned about making the lymphedema worse and working with someone with an ostomy bag.

I started by compiling my own notes and breaking everything down for Ben one step at a time.

1. Because Amelia underwent an open colectomy on the right side, she has a large vertical incision in her abdomen. She is unable to stand erect due to a combination of fear and scar tissue that has built up.
2. Because she has mild lymphedema on her right leg, Ben will need to incorporate lower extremity lymph drainage exercises before and after each exercise session. Her upper body exercises will work towards correcting postural deviations, but will not impact her lymphedema. On the other hand, he will need to start and progress slowly with lower body exercises and make sure that there is no increase in swelling. With proper exercise programming, Amelia may even see a reduction in the swelling.
3. Because Amelia underwent chemotherapy, she will be at a greater risk for osteoporosis, diabetes, and damage to the heart and lungs.
4. Ben will incorporate strength training to help prevent osteoporosis, cardio to help strengthen her heart and lungs, both cardio and strength training will help to increase lean muscle mass and decrease her body fat percentage. This is critical in the prevention of heart disease, diabetes, and possibly future cancers.
5. Because of the peripheral neuropathy in her feet, Ben will have to make sure that cardio is done in a way that minimizes her risk of falling. He will probably begin with a recumbant bike.  Not only will this minimize her risk of falling, it will eliminate the potential pain and discomfort of weight-bearing. If this proves to be uncomfortable, he will use the upper body ergometer (UBE).
6. Because of the upper-crossed syndrome, Amelia needs to stretch both her pecs and lats while strengthening the scapular stabilizers to help correct round shoulder syndrome and the winged scapula. She should avoid pushing exercises like push-ups and chest press and focus on shoulder retraction/depression, rowing, and maybe reverse flys.  She should do shoulder protraction exercises like ceiling punches or wall push-ups for his winged scapula. Until she can stand erect, she should not do any “crunch-type” exercises as they will only exacerbate her flexed-forward stance. In the interim, she should be stretching through her torso while strengthening the opposing lower back muscles. She can also be working on her core through balance exercises seated or supine on the exercise ball and foam roller. Standing balance exercises can be incorporated based on her discomfort/pain from neuropathy.
7. Ben is recommending that Amelia be fitted for walking shoes that will cater to her over-pronation. He will also include exercises that will include stretches for the calves and achilles tendons. He will also incorporate exercises in which Amelia pushes her big toes toward the ground, thus raising the arch of her foot.
8. After Ben completed the Modified Thomas Test on Amelia he was able to determine  that both her left and right adductors are tight. Therefore, she would need to focus on hip abduction and avoid hip adduction-type exercises.
9. Because Amelia has an ostomy bag, she is self-conscious and worried about leaks in the swimming pool. Ben reassures her that the bag is fitted not to leak and that it would be a very rare circumstance for that to happen. He encourages swimming both for her mind and body. Swimming will be great for the lymphedema as well as the nuropathy.

Once I gathered my thoughts, I was able to come up with the following workout routine for Amelia to facilitate with Ben for her initial 6-8 weeks.

DAILY  Lower extremity lymph drainage exercises  these should be done before and after exercise sessions (can be done more often if desired). She can do these alternative crunches that will be better for her neck and not require full flexion like a sit-up or even a crunch. Following the lymph drainage exercises Amelia can do a variety of core exercises that Ben will instruct her to do safely and effectively. I suggested that they begin with marching in place on an exercise ball and lying supine on a foam roller – marching in place. Ben will also include door stretches (chest), head retractions (forward head), end-to-end stretch for abdominals, calf, adductor, and achilles stretches.

2 x PER WEEK Upper-body strength training – starting very basic. Amelia can do chest flys, focusing on broad range of motion and opening up the chest; beginning with very light weight and just focusing on ROM. She should avoid any time of “pushing” exercise until her posture is ‘corrected.’  Ben will incorporate some rowing and reverse flys (with a figure 8 band) while she is seated on exercise ball (incorporate some balance and core work) to strengthen the opposing back muscles. There is no risk of lymphedema with her upper body so Ben can start her with light weights, cables, or resistance bands and gradually increase them as his energy level and muscle soreness dictate.

Lower-body strength training – squats are critical for activities of daily living. Ben will work with Amelia on form and correcting medial knee rotation and tight adductors. Because of the lymphedema, she will need to begin with just a few body-weight squats and make sure that there is no additional swelling. Ben will place his hands on the outside of Amelias knees and instruct her to gently push outward while doing squats. This will help to strengthen the adductor muscles. His initial instinct was to use a circular band around her legs, but that is contraindicated because of the lymphedema. Ben will also have Amelia perform “clams” (no band) lying on her side. He will start with a few repetitions on each side and make sure that there is not an increase in swelling following the workouts. Start with only one or two repetitions of each and gradually add more as tolerated. Ben will re-assess Amelia in 8 weeks and either continue with this routine, or progress to longer duration of cardio, more repetitions, and the addition of  more strength training exercises.

*Ben will avoid exercises in prone position that may place excessive pressure on the ostomy bag and cause it to leak.

**Ben teaches Amelia how to use the Borg Scale of Perceived Exertion instead of hear rate (it will be inaccurate because of the Beta Blocker she is on)

ALTERNATING DAYS (or as tolerated) –

Amelia will continue walking daily with her dog. Each walk  should end with lower body lymph drainage exercises. If there is no additional swelling, Amelia may increase either intensity or duration – in very small increments.  She should not wear tight fitting clothing on her lower body or exercise in very hot/humid temperatures. She should also stay well-hydrated. If at any point there is an increase in swelling, Ben will instruct Amelia to return to the level of intensity and duration that she was at prior to the increase in swelling. Ben also wants her  to incorporate water jogging  as well as lap swimming. The buoyancy of the water may help to manage her lymphedema and will also be a relief to her feet (non weight-bearing). Ben is also suggesting that Amelia work with a registered dietitian, or nutritionist who specializes in working with cancer patients, that can put together a healthy plan for Amelia gain lean muscle and lose the extra body fat. This is out of Ben’s scope of practice as a personal trainer and Cancer Exercise Specialist.

If you are in need of assistance with a special-needs or physically-challenged client, you can get Andrea Leonard’s help in with custom exercise programming.