Adam received a referral for a woman with stage III lip and oral cavity cancer. He’s been a Cancer Exercise Specialist for three years, but has not had any experience working with someone that has had lip and oral cavity cancer. He asked if he could hire me to help her with custom exercise programming and teach him how to put together Jenny’s exercise program. He completed her initial assessment and health history and shared the following information with me:
- Jenny is 54 years old and has worked in an industrial/heavily polluted environment for 30 years
- Jenny is 5’5″ and 111 lbs. She has 22% bodyfat.
- She had been getting in about 12k steps a day prior to her diagnosis
- She had a hemi-glossectomy, maxillectomy, and cervical node biopsy in December 2020
- She was diagnosed with cancer of the tongue and hard palate in December 2020
- She underwent radiation treatment and completed it in January 2021
- She is currently undergoing chemotherapy and will finish at the end of April 2021
- She will undergo tongue reconstructive surgery with a lateral arm flap after her blood counts get back to normal following completion of chemotherapy. She currently has a prosthesis for her hard palate
- Her BP is 130/85 and her RHR is 78.
- She has cancer cachexia and has lost 41 pounds since she underwent treatment
Adam conducted a comprehensive assessment.
- Jenny has moderate to severe upper-crossed syndrome and extreme forward head
- Her left shoulder is slightly elevated
- She has limited shoulder flexion in her left arm
- She has a moderate to severe anterior pelvic tilt
- Her right knee is laterally rotated and per her Thomas test, she has tight right ITB and quad. She complains about knee pain when she walks. Her hip flexors are extremely tight on both sides.
- She has peripheral neuropathy in her hands and feet from the chemotherapy and is struggling with balance
Since her surgeries, Jenny’s self-esteem and self-confidence has plummeted. She has become an introvert and doesn’t like to leave her house. She has difficulty speaking and doesn’t like to try and talk. Adam believes that her self-image, in addition to her surgical procedures, have contributed to the compensations that have led to her poor upper body posture and limited ROM in the shoulder.
I started by compiling my own notes and breaking everything down for Adam one step at a time.
- Because she underwent a total maxillectomy and hemi-glossectomy she has a difficult time chewing and swallowing. She is not getting the nutrients she needs and that has led to cancer cachexia (anorexia). She should be referred to a registered dietician that specializes in oncology since she is currently undergoing treatment and there may be contraindications with certain foods and herbs. and She has severe fatigue form the radiation and chemotherapy and is having a difficult time with self-care and just getting to work.
- Because of her upper-crossed syndrome, Jenny needs to stretch both her pecs and lats while strengthening the scapular stabilizers. She should avoid pushing exercises like push-ups and chest press and focus on shoulder retraction/depression, rowing, and maybe reverse flys. Right now, her best bet will be gentle stretching and restorative yoga.
- Because her left shoulder is elevated, Adam recommends a variety of neck stretches to alleviate what appears as tension in the musculature.
- Because she had radiation and a few lymph nodes removed in her neck, Adam is including upper body lymph drainage exercises in her workouts and suggesting that she does them daily to prevent lymphedema. He also gives her a list of ways to prevent lymphedema and educated her on the subject (she had no idea what lymphedema was, let alone that she would be at risk for it).
- Adam is concerned about the lateral rotation of the knee and hip on the right side and how continuing with improper tracking can lead to future degeneration and injury.
- Jenny is immunocompromised so Adam suggests that they have ZOOM sessions for the time-being.
Once I wrapped my head around the aforementioned notes, I was able to come up with the following workout routine for Adam to facilitate with Jenny for her initial 6-8 weeks.
- Lymph drainage exercises for her upper body.
- Walking for 5-10 minutes a day – more if tolerated. He does not want to deplete her energy any more than it already is. The endorphins produced during cardio can give her much-needed energy, but they will have to find the perfect balance. The cardio may also help to improve her mood; especially if she can go for a walk outside in nature.
- Stretch pecs and lats. This can be done more often if desired and tolerated. Start with restorative yoga poses on bolster in supine position with arms out to the side/palms up as well as Child’s pose to stretch lats as well as improve shoulder flexion. Hold for 20-30 sec. or whatever she can tolerate PAIN FREE.
3 x PER WEEK
- Perform several repetitions of scapular stabilization exercises.
- Squats are critical for activities of daily living. Working with Jenny on form is important to her quality of life and ability to perform activities of daily living without the fear of injury from poor biomechanics. She will start with body weight and do a few repetitions with good form and, in the absence of pain. Adam will start to add repetitions, and then resistance, as Jenny tolerates it and in the absence of pain. Even without adding resistance, body-weight exercises will still stimulate protein synthesis and help Jenny begin to re-build her lean muscle mass.
- Adam includes a strength training component that begins with little to no weight for Jenny’s upper body. Because she is at risk for cervical lymphedema, they do not know what her body can tolerate. He will have her add repetitions and weight as her body tolerates it and in the absence of swelling. She has no limitations on her lower body as far as lymphedema goes, but the exercises need to focus on muscle balance and proper biomechanics.
o Stretch ITB/strengthen adductors – avoid abduction exercises as they may exacerbate the lateral hip rotation and tight ITB
o Daily quad stretches
o Focus on strengthening her hamstrings to balance out quad dominance
- To correct her anterior tilt, Adam feels that she needs to stretch her hip flexors several times per day and eventually will incorporate exercises that focus on hip extension and strengthening the glutes.
Because of Jenny’s neuropathy in her feet, she struggles with her balance. He has her begin with balancing on one foot/leg – trying to work up to 30-sec. She holds on to the countertop for balance. When she can do this with good stability, he will encourage her to let go of the countertop. If she is unstable when doing so, she will go back to holding on. Eventually he hopes to progress her to an Airex pad.
Adam will re-assess Jenny in 8 weeks and either continue with this routine, or progress to longer bouts of cardio, more repetitions, and additional weight and repetitions for strength training exercises.
When Jenny has her reconstruction, Adam will need another medical clearance form from Jenny’s doctor. On some level, they will need to start at square one and allow for the recovery in both her mouth and the area where the flap was taken from. He will need to re-assess her shoulder/arm mobility and focus on range of motion exercises if need be.
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.