Question

Subjective

Cancer

Mr. CB is a 68 yr old Caucasian male with metastatic renal cell carcinoma. He is seen today (accompanied by his wife) following referral by his oncologist to the hospital’s oncology rehabilitation program. He states marked fatigue with exertion and his wife states observations of altered mood (increased anxiety) over the course of his illness. He was a millwright for the city water department but is now retired. He has a medical history of hypertension, dyslipidemia (June 2015: total cholesterol = 178 mg · dL–1, high-density lipoprotein cholesterol = 39 mg · dL–1, triglyceride = 274 mg · dL–1), and myocardial infarction in August 2003 (completed cardiac rehabilitation). He complains of rare but stable angina with exertion, which is being treated medically at present. He also has a history of atrial fibrillation.

In 2010 during a follow-up visit for impotency in the Department of Urology, urine tests detected microscopic hematuria. The following year, still having difficulties of impotency, the patient complained of gross hematuria and right flank discomfort. An intravenous pyelogram suggested a renal mass. Results of a computed tomography scan showed a right renal mass that invaded the right kidney and the inferior vena cava. He underwent a right radical nephrectomy in November 2011 for stage IIIA renal cell carcinoma. Pathology showed invasion of the renal capsule, as well as the renal vein and inferior vena cava.

A follow-up computed tomography scan in April 2013 showed metastases in the lower lobe of the left lung. These nodules were considered too small for biopsy. In May 2013 he complained of radiating pain from the right buttock to the knee. A bone scan identified widespread bone metastases. Magnetic resonance imaging showed a mass in the left posterior lateral aspect of the lumbar vertebrae. He underwent 14 d of radiotherapy in June 2013, during which his back discomfort improved. As part of a clinical trial, he also received two courses of interferon and chemotherapy.

In May 2014, Mr. CB underwent surgical decompression and excision of an L3 vertebrae tumor. He began immunotherapy with interferon alpha in July 2014. Repeat magnetic resonance imaging and bone scans through January 2015 showed the disease to be stable.

Objective

Mr. CB is an older appearing and slightly frail appearing white male. Body mass today was 68 kg (BMI = 24), his blood pressure was 110/70 mmHg, and his heart rate was 61 beats · min–1. Current medications are metoprolol, isosorbide dinitrate, Solu-cortef, fenofibrate, and aspirin.

Mr. CB’s most recent electrocardiogram showed normal sinus bradycardia with evidence of a previous inferior wall myocardial infarction. Resting heart rate was 53 beats · min–1. An exercise stress test completed earlier today is suggestive of ischemia, with a V̇O2peak of 17.6 mL · kg⁻¹ · min−1. Peak heart rate was 112 beats · min–1, and exercise was discontinued because of mild- to

moderate-grade angina (first noticed at heart rate of 108 beats · min–1). His cardiac status is now stable with Canadian Cardiovascular Society grade 2 angina.

Assessment and Plan

Cancer-related fatigue associated with increased anxiety. Enroll in oncology rehabilitation 2-3 times per week. Progressively increase duration of activity up to 30 continuous min, maintaining exercise heart rate and rating of perceived exertion at or below 98 beats · min–1 and between 11- 13, respectively. As tolerated and after 3 wk of training modalities to improve cardiorespiratory fitness, initiate a once or twice per week resistance training program focusing on trunk, hip, and upper and lower limb strength and endurance. Integrate and progress to a full home-based program as tolerated, within 12 wk if possible.

Exercise-induced angina (stable on current medication). Maintain exercise intensity during exercise as described above.

Anxiety disorder? Refer to behavioral services.

Frail? Advise patient and wife about in-home steps to be taken to prevent falls (remove floor rugs/cords, adequate lighting) and consider initiating functional and multi-plane balance exercises (tai chi?).

Case Study Discussion Questions

1. What effect does metoprolol have on heart rate response to exercise? Would you alter how you go about guiding exercise intensity for patients taking this drug?
2. Fatigue and mood disturbances are common complaints of patients with cancer, often attributable both to the disease itself and to the treatments used to manage the disorder. Explain whether exercise should be used or withheld in and around those times when a patient is undergoing chemotherapy or radiation therapy. And what clinical features and symptoms would lead you to consider (or not consider) exercise during this time?
3. How might you quantify whether, in fact, a patient is or is not responding to an exercise regimen?
4. Given this patient’s history, do you have any concerns with respect to starting resistance training? What cancer-related complaint should you periodically screen for to ensure ongoing resistance training is safe in patients with a history of bone cancer?

   Subjective

   Cancer

   Mr. CB is a 68 yr old Caucasian male with metastatic renal cell carcinoma. He is seen today (accompanied by his wife) following referral by his oncologist to the hospital’s oncology rehabilitation program. He states marked fatigue with exertion and his wife states observations of altered mood (increased anxiety) over the course of his illness. He was a millwright for the city water department but is now retired. He has a medical history of hypertension, dyslipidemia (June 2015: total cholesterol = 178 mg · dL–1, high-density lipoprotein cholesterol = 39 mg · dL–1, triglyceride = 274 mg · dL–1), and myocardial infarction in August 2003 (completed cardiac rehabilitation). He complains of rare but stable angina with exertion, which is being treated medically at present. He also has a history of atrial fibrillation.

   In 2010 during a follow-up visit for impotency in the Department of Urology, urine tests detected microscopic hematuria. The following year, still having difficulties of impotency, the patient complained of gross hematuria and right flank discomfort. An intravenous pyelogram suggested a renal mass. Results of a computed tomography scan showed a right renal mass that invaded the right kidney and the inferior vena cava. He underwent a right radical nephrectomy in November 2011 for stage IIIA renal cell carcinoma. Pathology showed invasion of the renal capsule, as well as the renal vein and inferior vena cava.

   A follow-up computed tomography scan in April 2013 showed metastases in the lower lobe of the left lung. These nodules were considered too small for biopsy. In May 2013 he complained of radiating pain from the right buttock to the knee. A bone scan identified widespread bone metastases. Magnetic resonance imaging showed a mass in the left posterior lateral aspect of the lumbar vertebrae. He underwent 14 d of radiotherapy in June 2013, during which his back discomfort improved. As part of a clinical trial, he also received two courses of interferon and chemotherapy.

   In May 2014, Mr. CB underwent surgical decompression and excision of an L3 vertebrae tumor. He began immunotherapy with interferon alpha in July 2014. Repeat magnetic resonance imaging and bone scans through January 2015 showed the disease to be stable.

   Objective

   Mr. CB is an older appearing and slightly frail appearing white male. Body mass today was 68 kg (BMI = 24), his blood pressure was 110/70 mmHg, and his heart rate was 61 beats · min–1. Current medications are metoprolol, isosorbide dinitrate, Solu-cortef, fenofibrate, and aspirin.

   Mr. CB’s most recent electrocardiogram showed normal sinus bradycardia with evidence of a previous inferior wall myocardial infarction. Resting heart rate was 53 beats · min–1. An exercise stress test completed earlier today is suggestive of ischemia, with a V̇O2peak of 17.6 mL · kg⁻¹ · min−1. Peak heart rate was 112 beats · min–1, and exercise was discontinued because of mild- to

   moderate-grade angina (first noticed at heart rate of 108 beats · min–1). His cardiac status is now stable with Canadian Cardiovascular Society grade 2 angina.

   Assessment and Plan

   Cancer-related fatigue associated with increased anxiety. Enroll in oncology rehabilitation 2-3 times per week. Progressively increase duration of activity up to 30 continuous min, maintaining exercise heart rate and rating of perceived exertion at or below 98 beats · min–1 and between 11- 13, respectively. As tolerated and after 3 wk of training modalities to improve cardiorespiratory fitness, initiate a once or twice per week resistance training program focusing on trunk, hip, and upper and lower limb strength and endurance. Integrate and progress to a full home-based program as tolerated, within 12 wk if possible.

   Exercise-induced angina (stable on current medication). Maintain exercise intensity during exercise as described above.

   Anxiety disorder? Refer to behavioral services.

   Frail? Advise patient and wife about in-home steps to be taken to prevent falls (remove floor rugs/cords, adequate lighting) and consider initiating functional and multi-plane balance exercises (tai chi?).

   Case Study Discussion Questions

5. What effect does metoprolol have on heart rate response to exercise? Would you alter how you go about guiding exercise intensity for patients taking this drug?
6. Fatigue and mood disturbances are common complaints of patients with cancer, often attributable both to the disease itself and to the treatments used to manage the disorder. Explain whether exercise should be used or withheld in and around those times when a patient is undergoing chemotherapy or radiation therapy. And what clinical features and symptoms would lead you to consider (or not consider) exercise during this time?
7. How might you quantify whether, in fact, a patient is or is not responding to an exercise regimen?
8. Given this patient’s history, do you have any concerns with respect to starting resistance training? What cancer-related complaint should you periodically screen for to ensure ongoing resistance training is safe in patients with a history of bone cancer?

Answer 1

5.. Betablockers prevent the binding of epinephrine, released during the physical activity, thus blunts the usual increase in HR and BP that corresponds to exercise intensities or workloads . As a result , both resting and exercise BP, HR values are decreased.

Modifications required in the exercise program

The therapeutic effect created by b-blockers alter physiological response to exercise. The traditional methods for establishing HR such as Peak HR method or HR reserve method are invalid . Therefore, the most important program for individuals taking beta blocker is to use an alternative setting target intensity. The ratings of Percevied Exertion scale is a better alternative option

6. cancer patients experience symptoms and adverse effects of treatment that may last even after the symptoms

• Exercise is a safe,non-pharmacological and cost-effective tharapy that can provide health benefits in cancer patient and survivors reducing cancer symptoms and treatment side-effects
• Exercise has a crucial impact on bone health and is life long

Preferred exercises

Impact and weight exercise training has to be preferred for bone health

Impact exercises

Running and jumping causes mechanical loads on bones stimulates bone formation and promotes structural modifications of bone tissue. High impact training combined with resistance activiites are effective in increasing bone mineral density at the hip and spine level

Weight training

It involves muscle pull and muscular insertion of skeletal sites of interest produce a delay in loss of bone-mineral density

Precautions to be taken before exercising includes the following

• Do not exercise if you have low RBC or Hb because this will cause fatigue and dizziness
• If the client is neutropenic ( Low WBC count), then they are at high risk of infection. During that period, stay away from public gyms and places to reduce the risk of infection
• If you are suffering from side effects of chemotherapy such as severe vomiting and diarrhea , then you might have sodium and potassium abnormalities Do not exercise at this time
• Do not execise above the moderate level of exertion. Always talk to your health care provider and determine your actiivity level
• If you feel excessive fatigue and do not want to exercise that day consider doing 10 minutes of light exercises
• Do not use heavy weights or exercises that cause severe stress on your bone . Stay away from uneven surfaces to reduce risk for fall

7.The execise specialist has to develop an exercise program based on client's age, gender, type of cancer, complications co-morbidities and fitness level

Guidelines to follow to prescribe exercise regimen based on Faigue level

Ask the patient to rate the fatigue level from 0-10. According to the ratings Cardiorespiratory Fitness (CRF) can be classified as follows

• Mild-1-3
• Moderate-4-6
• Severe 7-10

Recommendations of exercises for patients with mild fatigue

• They can perform progressive aerobic exercise program that includes
• 20-30 minutes/session,3-5 days per week at 60-80% of maximum HR

Resistance Exercises

8-10 exercises of major muscle groups of lower and upper extremities 2-3 days per week

Patients with moderate fatigue

They should be encouraged to increase exercises with repeated bouts of 5-10 minutes per session

Resistance training

Similar that of patients with mild fatigue but , they have to increase exercise frequency or duration before increasing intensity

Patient's with severe fatigue

They were encouraged to do low intensity execises such as walking/biking for 5-10 mts adequately spaced throughout the day