Customized Exercise Programming – Esophageal Cancer

Hank received a referral for a woman with locally advanced esophageal cancer. Her family is very worried about both her mental and physical state and are hoping that a structured exercise program will help facilitate her recovery.

He’s been a Cancer Exercise Specialist for five years, but has not had any experience working with someone that has had esophageal cancer. He asked if he could hire me to help her with custom exercise programming and teach him how to put together an exercise program for Ellen. He completed her initial assessment and health history and shared the following information with me:

• Ellen is 64 years old and has smoked a pack of cigarettes a day for as long as she can remember
• She is 5’6″ and 141 lbs. She has 20% bodyfat. She has lost 40 lbs. since her surgery and has been diagnosed with cancer cachexia.
• She had been sedentary for the last 20 years
• She underwent a total esophagectomy in January 2021 along with a cervical lymph node sampling
• She completed chemotherapy at the and of March 2021 and began radiation therapy at the beginning of April 2021
• Her BP is 135/85 and her RHR is 82.

Hank conducted a comprehensive assessment.

• Ellen has moderate to severe upper-crossed syndrome
• Her head is rotated slightly toward her left shoulder 
• She has limited shoulder flexion, extension, and abduction, in her left arm
• She is moderately flexed forward at the hips
• Both knees are laterally rotated and per her Thomas test, she has tight ITB’s and quad’s. 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 surgery and treatment Ellen has been struggling with terrible fatigue and severe depression. Hank believes that her self-esteem and depression, in addition to multiple surgical incisions, have contributed to the compensations that have led to her poor posture and limited ROM in the left shoulder.

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

1. Because she underwent a total esophagectomy she has an incision on the left side of her neck, under her left breast, and between her sternum and naval. Particular attention will need to be paid to correcting muscle imbalances and avoiding discomfort in certain positions. They will begin with simple range of motion exercises to help restore normal shoulder function and help with her ADL’s and independence. Until she has normal range of motion, they will not be adding any resistance in these planes of motion.
2. She has early dumping syndrome and it is not uncommon for her to vomit shortly after eating. The combination of surgery and dumping syndrome have led to her cachexia (muscle wasting). 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. The R.D. will be able to make recommendations that will help her safely regain lean muscle mass and healthy weight.
3. Her exercise sessions should be scheduled several hours after eating to avoid the side effects of early dumping syndrome. He will make an exception to the ’24-36′ hour rule for vomiting because it may be a chronic condition and the benefits of exercise outweigh the risks. She must rehydrate, replenish electrolytes, and rest.
4. She has severe fatigue form the radiation and chemotherapy and is having a difficult time with self-care and motivating herself to get out of bed. Exercise should be kept to a very low intensity. No more than 20-30 minutes 3-4 times per week. This may be too large a goal for her right now. The 20-30 minutes may even need to be broken up into smaller, easier to achieve goals such as walking for 5 minutes several times per day.
5. Because of her upper-crossed syndrome, Ellen needs to stretch both her pecs and lats while strengthening the scapular stabilizers. She should focus on isometric shoulder retraction and depression. Her risk for osteoporosis is elevated due to chemotherapy, but because she is so deconditioned they must take baby steps. Right now, her best bet will be gentle stretching and restorative yoga.
6. Because her head is rotated toward the left (where one of her incisions is), Hank recommends a variety of neck stretches to alleviate what appears as tension in the musculature. He wants to make sure that she maintains range of motion and decreases the chance of scar tissue formation. These stretches can also serve as part of the lymphatic drainage routine.
7. Because she had radiation and a few lymph nodes removed in her neck, Hank 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). Her risk of lymphedema is compounded due to radiation as well as lymph node removal. If she has swelling, it will most likely be in the neck and facial area.
8. Hank is concerned about the lateral rotation of the both knees and hips and how continuing with improper tracking can lead to future degeneration and injury. She should avoid “abduction-type” exercises and focus on strengthening her hip adductors.
9. Ellen is immunocompromised so Hank 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 Hank to facilitate with Ellen for her initial 6-8 weeks.

DAILY 

• 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. Because of the potential heart/lung damage from chemotherapy, the goal will be to perform some type of cardiovascular exercise at moderate intensity for 150 minutes per week; but they are a long way from that!

• 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 forward arm slides on her desk or countertop to stretch the lats as well as improve shoulder flexion. Hold for 20-30 sec. or whatever she can tolerate PAIN FREE. Since she has multiple incisions, he wants to make sure that she is able to avoid further compensations that could lead to new or worsening muscle imbalances.

3 x PER WEEK

• Perform several repetitions of scapular stabilization exercises.
• Squats are critical for activities of daily living. Working with Ellen 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. Hank gives her a squishy ball to squeeze between her thighs during the squats. This will help to strengthen the adductor muscles and, through reciprocal inhibition, stretch the abductors. He will start to add repetitions as she tolerates each workout, Eventually he may consider adding resistance. Even without adding resistance, body-weight exercises will still stimulate protein synthesis and help Ellen begin to re-build her lean muscle mass.
• Hank includes a strength training component that begins with little to no weight for Ellen’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 forward hip flexion, Hank feels that she needs to gently stretch her abdominal area several times per day. She is complaining of moderate to severe low back pain. this may be due to a combination of tight hip flexors, over-compensating low back musculature, and ischemia where her abdominal incision is. He will start her off with some gentle “cat-cow” movements. If she is able to tolerate the movement he may have her perform a modified baby cobra with props so there is no pressure directly applied to the incision site. Because of Ellen’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.

Hank will re-assess Ellen 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.

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.