Explore concerns

Many people with health problems - and those without - have reasonable concerns about becoming more active

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“What concerns might you have about becoming more active, if you decided to?”

Saying “if you decided to” reminds them that they are the decision maker, not you. This helps keep the discussion open and active, focusing your role on providing support.

For example say ‘Yes, that is a common concern’  or a reflection such as ‘you’re concerned that being more active may make your pain worse’ (said as a statement, not a question)

Your role is to help them feel listened to and understood rather than to immediately jump in to dismiss their concern or to offer information, advice and reassurance.  Acknowledging their views will help them to feel supported and may help them to be more receptive to any new information you might want to share with them.

Allow some space for people to talk about and explore new information, asking ‘what do you think about what I’ve just said?’ rather than asking ‘do you understand?’ which can shut things down. Ask if they need anything clarifying and what concerns they might have about how the information applies to them.

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If they mention one of these common concerns, click on it to see a useful response.

I already feel so tired and you want me to do more….

Cancer related fatigue is very common. Tiredness affects everyone differently. Becoming more active is the most important treatment for persistent fatigue as it helps with body reconditioning and boosts energy levels. It can be a way for individuals to take back some control over their health.

Tips you may wish to share:

  • Encourage a slow start with a gradual build up to small bouts of activity (this just needs to be a few minutes). This can increase over time
  • Increase the number of activity sessions first, then increase the duration each activity, followed by the intensity of an activity

No one in my community does exercise, it is not in our culture…

A daily routine such as using the stairs or walking to the shops are physical activity opportunities that are shared across all communities. Other activities such as dancing might be culturally acceptable activity.

Tips you may wish to share:

  • Do enjoyable activities
  • Build activities into your daily routine

 

 

My gym said I need medical clearance before being active: am I OK to exercise?

For the vast majority of people, medical clearance is not required to safely undertake progressive, moderate intensity activity. Important exceptions to this are people experiencing active symptoms (see below) or previously inactive people who disregard advice to build up gradually. An additional list of contraindications is listed below [1,2].

Significant events are so rare that medical screening has the potential to be an unnecessary barrier to physical activity. Screening is most effective when focussed on active symptoms and co-morbidity [3].

It is fairly common for gyms to request a medical letter for people to use their facilities. Consider the option of providing a signed letter to overcome this barrier for individuals. Encouraging a slow start with gradual build up of activity (over 3 months or so) reduces the chances of poor outcomes.

This flow diagram will help you decide who might need referral for formal assessment before increasing their physical activity levels and may help address queries from gyms:

Notes

Signs and symptoms, at rest or during activity; includes pain, discomfort in the chest, neck, jaw, arms, or other areas that may result from ischemia; shortness of breath at rest or with mild exertion; dizziness or syncope; orthopnea or paroxysmal nocturnal dyspnea; ankle edema; palpitations or tachycardia; intermittent claudication; known heart murmur; or unusual fatigue or shortness of breath with usual activities

  1. An easy way to explain the intensity of exercise is the talk test:
  • Moderate intensity: breathing rate is increased but you can still talk
  • Vigorous intensity: breathing rate is further increased and it is not possible to talk in full sentences

 

  1. Patients with active symptoms or high risk necessitating medical screening will require formal investigations such as cardiac stress testing

Contraindications to physical activity include:

  • Unstable angina
  • Severe valvular stenosis or regurgitation
  • Active myocarditis or pericarditis
  • Ventricular tachycardia (uncontrolled)
  • Decompensated heart failure
  • Blood pressure >200/115 mmHg
  • Recent myocardial infarction (< six weeks)
  • Other clinical entities known to worsen during exercise
  • Acute Systemic infection

References

1) Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873-934.

2) Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;25 Suppl 3:1-72.

3) Thompson PD, Arena R, Riebe D, Pescatello LS, Medicine ACoS. ACSM’s new preparticipation health screening recommendations from ACSM’s guidelines for exercise testing and prescription, ninth edition. Curr Sports Med Rep. 2013;12(4):215-7.

How do I know when to stop being physically active?

It is normal for anyone who is not used to being physically active to experience some muscle soreness after doing a new activity and this pain will reduce as they become more accustomed to the activity.  Worsening symptoms may be due to increasing activity too quickly – reducing activity levels a little and then gradually increasing them again more slowly can help

Dizziness, sickness or excessive tiredness are signals to stop exercising and wait for symptoms to settle. Warning signs to seek urgent medical attention include blacking out, chest pain, or excessive shortness of breath.

Tips you may wish to share:

  • Encourage a slow, steady increase in activity to allow for adaptation to the new activity
  • During the first 2-3 months of increasing physical activity it is sensible to be physically active with other people

I’m worried my heart is affected by my cancer treatment

Some people are at higher risk from heart problems depending on their treatment, for example chemotherapy, immunotherapy, hormones, radiotherapy immunotherapy – these individuals should be directed to expert advice.

Tips you may wish to share:

  1. If you’re planning to take activity further but have had treatment that may have affected your heart, check with an exercise medicine or cardiology specialist first
  2. If starting physical activity for the first time build up very gradually over 3 months
  3. Avoid sudden unaccustomed vigorous physical activity Vigorous activity makes you increase your breathing to the level that it makes it hard to complete a sentence
  4. Being more active should improve your heart health in the long term

"I am already in pain..."

Cancer-related pain can impact wellbeing. Even gentle movement can help to strengthen muscles and help people to maintain strength, which  may help with pain. Being active can also help with better sleep, which can help with pain management

Some patients experience pain in their joints (arthralgia) associated with disease or treatment and exercise that keeps healthy muscle functioning can also help.

Tips you may wish to share:

  1. It is normal for anyone who is not used to being physically active to experience some muscle soreness after doing a new activity and this pain will reduce as they become more accustomed to the activity.  Worsening symptoms may be due to increasing activity too quickly – reducing activity levels a little and then gradually increasing them again more slowly can help.
  2. Ensure an adequate warm up and cool down of 5-10 minutes
  3. Exercise at the time of day when pain is usually least severe
  4. Review pain control  medications, working with your specialist or GP
  5. If you feel new pain in a bone or joint, see a specialist for advice
  6. Take extra care of muscles and joints when you’re on treatment

“Won't physical activity harm my joints?”

There is no evidence to suggest that regular, even intensive exercise will harm your joints.

Start slow and build up gradually

Tips you may wish to share:

  1. Physical activity does not damage joints but it does support them.
  2. If you’ve experienced new joint pain it might be related to treatment and specialist review can help
  3. Take extra care of muscles and joints when you’re on treatment

I have lympohedema

It is still important to exercise

Tips you may wish to share:

  1. Gently increasing use of your affected arm can help reduce swelling. This can improve pain and reduce risk of skin infection
  2. Wear a well-fitted compression sleeve to support your arm

My movement is restricted because I had surgery

It’s important to allow healing but then to get back a good range of movement. For example, patients who have had breast surgery or chest radiotherapy can find it helps to stretch upper-body muscles by reaching upwards.

My treatment has affected my bowel/bladder control and I'm not confident to do some physical activity

Seek advice from your specialist team. In many cases, your medical team can link to specialist physiotherapy to help build back up your pelvic floor and assess the type of exercise that will allow you to get the benefits without worrying.

More information can be found here:

https://www.macmillan.org.uk/_images/the-importance-physical-activity-for-people-living-with-and-beyond-cancer_tcm9-290123.pdf

I have altered feeling in my hands/feet. It's painful or affects my balance.

This can be caused by your disease and also by treatment. See your team to help with the symptoms, but physiotherapy can also assist you with improving balance.

Tips you may wish to share:

  1. Wear gloves if you are being active in cold weather
  2. Support stockings can help with dizziness and its important to try to keep your lower leg muscles strong too
  3. Make sure your shoes fit well
3
Ask

“Has that helped?”

Did you know?

Start gently and build up slowly

The risk of death from physical activity is extremely low. For Men it is 1 death per 23 million hours and Women it is 1 death per 36.5 million hours.

  1. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med. 2000;343(19):1355-1361.
  2. Whang W, Manson JE, Hu FB, et al. Physical exertion, exercise, and sudden cardiac death in women. JAMA. 2006;295(12):1399-1403.