Chapter 10: A Plan for Every Woman

Excerpted from The Breast Cancer Survivor’s Fitness Plan

By Carolyn M. Kaelin, M.D., M.P.H., Francesca Coltrera, Josie Gardiner, and Joy Prouty

Reprinted by permission of the McGraw-Hill Companies; © Copyright 2007 by President and Fellows of Harvard College. All Rights Reserved.

For more information or to purchase this book, follow this link.

The Right Mix

The right mix of exercises and the right timing for getting started are outlined in this chapter. Scales that will help you work out at a safe level of intensity are described here, too. You also will find sample exercise logs to copy and fill in as you launch your workouts. Although general principles remain the same for every woman, the exercises and timing chosen for the workout plans vary depending on the extent of your surgery and the speed of your recovery. Discuss this with your doctor.

Over the course of a week, a comprehensive exercise plan ­combines cardiovascular training with balance, stretching, and strength exercises. If the thought of all this exhausts you, take heart: you’ll start to build toward this slowly and add on as you feel ready to progress.

Slow progress is best because it allows your heart, lungs, muscles, skin, and other tissues to gradually adapt to challenges presented by the exercises. Even women starting this program many years after their treatment will find a gradual approach valuable, particularly if they have not been active.

Often, women feel exhausted at various times during treatment and recovery, especially in the weeks after surgery or during the course of chemotherapy or radiation therapy. If your energy fluctuates, try to take a walk or do other activities at times of day when you feel least tired. A little exercise is always better than none. Think of activity as a bank—add small amounts several times a day by taking a short walk or doing a group of balance exercises or stretches so that the final tally rises gradually. On days or at times when you feel better, try to do more; on difficult days, accept that you need to do less or sometimes even take the day off. Ultimately, the workouts we’ve selected will help energize you while easing aches and pains.

Cardiovascular Exercise

After surgery, the very first thing you can do for yourself is get out of bed and walk. Usually, it’s fine to do so by the second day. Make sure that someone walks alongside you to assist you as necessary. The first steps you take may simply be the short path from bed to bathroom. Next, try to walk to the nurses’ station, and then to the end of the hall. Rather than concentrating on speed, focus on traveling a little bit farther each time. It takes time, but by walking as often as you can, you will gradually attain goals that seem completely out of reach right now—whether that is a short walk without pain or a much longer walk at a pace you enjoy.

If you follow health news, you know that goalposts for cardiovascular exercise sometimes shift confusingly. Our guidelines—and thus, your goals—stem from careful analysis of numerous sources, including recent breast cancer research, the 2005 Dietary Guidelines for Americans, and recommendations made for cancer patients by the American College of Sports Medicine. Our simple walking program delivers significant benefits that vary depending on the time expended:

Breast cancer benefits. Walking at an average pace for three to five hours a week (about 30 minutes a day) cuts the risk for breast cancer recurrence by 40 percent, according to data from the Nurses’ Health Study published in 2005.

Additional health benefits. Walking for 30 minutes most days of the week offers health benefits, such as lowering your risk for heart disease, diabetes, osteoporosis, and many other ailments, according to the 2005 Dietary Guidelines for Americans.

Healthy weight benefits. Weight matters to good health, too, and may play a role in survival after breast cancer treatment, as explained in Chapter 2. Combined with a healthy diet, walking 30 to 60 minutes on most days of the week can help keep you from gaining weight. Raising the bar to 60 to 90 minutes most days of the week may be necessary if you’re struggling to lose weight or have lost a great deal and wish to keep those pounds from creeping back. Our bodies and our eating habits differ, so you’ll need to see what works best for you. See Chapters 1 and 2 for more information if you are trying to lose weight.

Setting Goals. Here are tips to help you set your goals for ­walking.

• Frequency. Start out walking at least three times a week. Work up to most days or daily if possible.
• Intensity. Start at 1 on the effort scale (see sidebar, “Measuring Intensity: Scales and Songs”). Move to 2 or 3 on the effort scale as you feel able to do so. Initially, adding days and time or steps is more important than boosting intensity.
• Progressing. First add days until you are walking as many days of the week as possible. Next, set new goals by adding time or steps to your baseline assessment in Chapter 9. Some days you won’t be able to reach your goal—you may even slip backward. Remember that any activity is better than none. On other days you will exceed your goal. Keep trying!
• Counting time? To progress, add at least 10 percent to your baseline to set a new goal. Thus, if your baseline is 10 minutes, add 1 minute so that your new goal is 11 minutes. Depending on how fast you feel able to move ahead, you could add 10 percent to your current goal daily, twice a week, or once a week. Each time you do this, you set a new goal for yourself. Ultimately, aim for 30 to 60 minutes of walking during the day, which can be divided into 10- or 15-minute segments.
• Tracking steps with a pedometer? Clip it onto your hip as soon as you get up in the morning. Each day, try to add 10 percent more steps than the previous day’s walk. Thus, if your baseline is 500 steps, you’ll add 50 steps (10 percent) to 500 steps for a total of 550 steps. The following day, try adding 55 steps plus 550 steps for a total of 605 steps and so on. As your walking program progresses, make your intermediate goals 3,000 steps, 6,000 steps, and 8,000 steps. Ultimately, aim for 10,000 steps a day.
• Having trouble? Are these goals too daunting? They may seem unattainable if you recently have had surgery, are undergoing chemotherapy or radiation, or simply haven’t been physically active before. If so, make walking 5 minutes every hour your first goal. At the end of eight hours, you’ll have walked 40 minutes. Gradually build up to longer walks. If a goal you set proves too hard, listen to your body and just do what you can on as many days of the week as possible.

Starting Off. A few tips before you start:

• Get ready. Go to the bathroom. For cool weather, dress for outdoor walks in layers of clothes to peel off as needed. Put on sunscreen and a broad-brimmed hat. Fill up your water bottle and plan to sip from it often to stay hydrated.
• Stay safe. Walk with a partner if possible, especially at first. Have a destination in mind, but listen to your body so that you rest or stop when you need to do so. Carry a cell phone, identification, and phone numbers. If you’re walking on a road, traffic should be coming toward you.
• Warm up. Walk slowly for five minutes. The swing of your arms dictates your pace. Once you’ve warmed up, move more quickly, if possible (see sidebar, “Measuring Intensity: Scales and Songs”).
• Practice good posture. Check your posture and alignment occasionally as you walk:
• Keep your chin parallel to the ground.
• Lift your chest and roll your shoulders back and down away from your ears, then relax them.
• Pull in your abdominal muscles.
• Swing your arms forward and backward in a relaxed fashion. (Do not swing your arms from side to side as if rocking a baby.)
• Stride comfortably and naturally, planting the heel, ball, and then toe of your foot.
• Breathe normally.
• Cool down. Walk slowly for five minutes.

Stretching Exercises

Gentle stretching exercises go hand in hand with the early weeks of your walking program. All of our stretch and balance workouts are tailored to the type of surgery you’ve undergone.

Why is stretching so essential? It counters stiffness and changes in posture that follow surgery and sometimes radiation. Otherwise, inactivity can permit muscles and tendons to shorten and tighten in less than ideal positions. After TRAM surgery, for example, it’s natural to bend forward at the waist and hip to avoid pain and tension at the broad abdominal incision where skin and muscle were taken from the belly and moved up to the chest. Over time, this can shorten the hip flexors that link legs to trunk, making it hard to straighten the legs and causing lower back pain. What’s more, such decreased flexibility prompts lasting problems with posture and balance and may interfere with daily tasks.

Stretching is the first step toward regaining flexibility—that is, the ability to move each joint through its range of motion with little resistance from surrounding muscles and tissues. Not only will our program make you more flexible—in fact, probably more so than you were before surgery—it improves posture and balance, enabling you to undertake daily tasks and activities with minimal effort and maximum effect.

Setting Goals. Here are tips to help you set your goals for practicing stretching exercises.

• Frequency. Repeat each stretch 2–4 times, once or twice a day.
• Intensity. Only stretch to the point of tightness.
• Time. Hold each stretch 5–20 seconds (or longer, if you like, since after 20 seconds you may feel the muscle relax ­further).
• Progressing. The more often you perform the stretches, the more quickly your body will regain a comfortable range of motion.

Our program is designed to enhance recovery from surgery, so it differs slightly from guidelines issued by the American College of Sports Medicine (ACSM) in 2006. We recommend performing stretches once or twice a day, while the ACSM recommends doing stretches at least two to three times a week (and ideally five to seven times). Because your body is recovering from surgery, we recommend holding stretches for 5–20 seconds, while the ACSM recommends 15–30 seconds. Hold each stretch at the point of tightness without discomfort other than that which you might normally feel after surgery.

Starting Off. A few tips before you start:

• Get the go-ahead. Find out from your surgeon whether you need to limit your range of motion or avoid certain stretches at first. A doctor may recommend not raising your arms above shoulder level for a number of weeks after surgery, especially if you had reconstructive surgery. Show your surgeon the stretches in your workout so that she or he can decide what is best for you.
• Warm up. Muscles are like bubble gum—when warm, they stretch farther and more easily and are less likely to tear or be injured. Before performing a stretching workout, warm your muscles for at least 5–10 minutes by walking, dancing to a few songs, engaging in exercise, or taking a warm bath or shower.
• Proceed slowly. Start slowly and build gradually, progressing at your own pace. Over time, making the effort to stretch correctly and consistently while focusing on problem areas will loosen your muscles, improve your flexibility, and make you feel better. As a quick illustration of these benefits, try this: Slowly turn your head to the point of tightness. Hold the position for 5–20 seconds, breathing normally. Slowly turn back to center. Repeat three times. Do you notice a difference in how far you can comfortably turn?
• Stay in control. Make smooth, controlled movements, stretching just to the point of tightness. When you feel comfortable, see if you can take the stretch a little bit farther. Don’t strain to hold any pose. Think of bending a finger back toward your wrist until you begin to feel a stretch. If you push farther, you’ll start to feel pain. Similarly, as you stretch other muscles in your body, you want to feel the stretch without feeling pain.
• Listen to your body. Muscle fibers stretched too far spark pain. In response, nerves tell your muscles to contract. This stretch reflex helps prevents injury. Some discomfort is realistic after surgery, but pushing a stretch too far or bouncing does more harm than good. Your muscles actually tighten to protect themselves rather than relaxing. Overstretching temporarily or permanently damages muscle fibers, prompting increased soreness and the formation of scar tissue that can further affect flexibility.
• Hold and relax. Usually, we recommend holding stretches for 5–20 seconds. If you wish to hold a stretch a bit longer, do so. After 20 seconds you may feel the muscle relax further, so holding for up to 30 seconds can pay more dividends.
• Breathe deeply. Breathe smoothly in through your nose and out through your mouth. Deep, fluid breathing relaxes you, thereby improving the effectiveness of each stretch.

Balance Exercises

As we go about our lives, many of us give little thought to balance—the ability to respond to challenges to our equilibrium while standing still (static balance) or moving (dynamic balance). Your center of gravity hovers over the center of your legs to maintain balance. That sounds easy, but it is really quite complex. Sensory systems—among them vision, hearing, and special receptor cells in skin, muscle, joints, tendons, and ligaments called proprioceptors—collect information about your body as you move. Your brain processes these signals and sends motor commands to the appropriate parts of your body. Staying balanced requires your body to constantly adjust itself and quickly adapt to changes.

As we grow older, sensory receptors become less sensitive, so that the brain receives less information about the body’s position in space. Deteriorating eyesight, depth perception, and muscle strength coupled with slower reflexes further diminish ­equilibrium.

Whether balance is thrown off by surgery or age, compensating by taking smaller steps or standing with feet apart actually makes it harder to negotiate obstacles safely. A fall, or merely being anxious about falling, may encourage you to withdraw from daily activities and thus prompts a steady decline in your quality of life.

Balance training, which strengthens legs and improves flexibility in the feet, is often left out of exercise programs. Yet everyone can benefit from it, and women who have had breast cancer surgery, which can easily affect posture and balance, truly need it. Being off balance is a serious problem. If the wheels of a finely tuned car are badly balanced, unevenly worn tires, a bumpy ride, extra fuel demands, and loss of control that may lead to accidents typically follow. It’s not all that different for humans. Spending just 5 to 10 minutes each day on balance training exercises can make a significant difference.

Setting Goals. Here are tips to help you set your goals for practicing balance training.

• Frequency. Repeat each balance exercise three to five times, once or twice a day.
• Intensity. Aim for 1 or 2 on the effort scale. These are gentle exercises.
• Progressing. The more often you do balance training, the better the results, so think about incorporating these easy exercises into your day—while standing at the sink, perhaps, talking on the phone, waiting at a store, or watching TV.

Starting Off. A few tips about balance and balance training before you start:

• Check medications. Some medications, such as sedatives, muscle relaxants, and blood pressure drugs, may cause weakness, dizziness, lightheadedness, or loss of balance. Certain chemotherapy drugs, such as paclitaxel (Taxol), can affect sensation in your feet and hands. Other medications taken during treatment can cause fatigue, diminish alertness, and impair judgment so that falls and other accidents occur. Particularly if you take four or more medications, some side effects, such as dizziness, are more likely to occur. Talk to your doctor about possible side effects from prescription and over-the-counter medications. Your doctor may be able to recommend substitute medications or a lower dose if you are experiencing problems, or can suggest other helpful precautions to take while exercising.
• Stay hydrated. Dizziness sometimes stems from dehydration, which may be hastened by drinking too little, heat, exercise, changes tied to aging, some medications like diuretics, and certain chemotherapy drugs. Make sure you take in enough fluids during the day. By the time you actually feel thirsty enough to crave a drink, you already may be somewhat dehydrated. Checking your urine (it should be straw-colored, not dark) usually is more helpful.
• Check sight and glasses. Poor vision may affect balance, so regular eye exams are a good idea. Regular eye exams are especially important for women taking tamoxifen (Nolva­dex), a drug that slightly raises the risk of cataracts, which can blur vision. Be aware that bifocals and reading glasses can impair depth perception. Be careful if you wear them while exercising.
• Prevent falls. Throughout the day and especially while exercising, wear shoes that grip and provide proper support. Wear outfits that won’t trip you by steering clear of clothes that are too big or too long. Clear away or avoid other household hazards, such as loose rugs or carpets, clutter, insufficient lighting, electrical cords, pets, spills, slippery floor surfaces, and the like.
• Steady yourself. Make it a habit to stabilize yourself before you move. Often people lose balance when they get up, change directions, or transfer their weight too quickly. Rising swiftly after sitting or lying down makes some people dizzy due to a sudden drop in blood pressure (orthostatic hypotension). If you’re lying down, slowly sit up and wait a few moments before standing; if you’re sitting, slowly get up.
• Gain support. When first starting to do balance exercises, stand next to a counter or a chair for support. Check your posture in the mirror before and during exercises. Square your shoulders and hips. Notice any imbalances. Becoming aware of strengths and weaknesses will help you to make improvements.

Strength Exercises

Strength training can benefit anyone, regardless of age, but is especially helpful for breast cancer survivors left with muscle imbalances and weaknesses after surgery. The muscles of your body can be likened to a rowing team. Pulling on the oars all together speeds the boat ahead. Uncoordinated actions by rowers slow the boat or simply do nothing to help advance it. If one rower is tired or drops off the team, the rest of the rowers must pick up the slack to reap the same results. Similarly, if you’ve had reconstructive surgery in which a muscle was relocated, you must recruit and strengthen surrounding muscles to compensate for the loss. If a muscle or muscle group has weakened due to surgery or inactivity, you must rebuild its strength gradually so that daily tasks and enjoyable activities become possible again.

One more among many reasons to begin strength training is findings from a study published in the journal Cancer in 2006. Eighty-six women who had been treated for breast cancer were randomly assigned to a group that performed weight training twice a week or a control group for six months. As upper body strength or muscle mass improved in the strength training group, so, too, did a variety of measures of psychosocial well-being. Physical challenges that disrupted daily activities eased, for example. Communication grew better in personal relationships and with medical team members.

• Walking, balance training, and stretching all have a place in the early weeks after surgery. Strength training does not. Before you begin strength training:
• Work on regaining upright posture and a comfortable or full range of motion in your joints, especially at the shoulder.
• Wait until surgical drains have been removed and tissues have healed. You should have no open wounds from surgery or radiation therapy.
• Ask your surgeon whether your surgery (and reconstruction, if you had this) has healed sufficiently for you to start our light-weight training program.
• If you had a mastectomy, traditional lymph node surgery, or reconstructive surgery, also see the information in the “Save Your Shoulder” sidebar in Chapter 9. It explains how to tailor your exercise program to regain shoulder mobility and protect and strengthen shoulder rotator cuff muscles.

Pushing ahead too quickly before these conditions are met may set you up for serious injuries. It can hamper healing and affect the cosmetic outcome of reconstructive surgery.

Setting Goals. Here are tips to help you set your goals for strength training.

• Frequency. Start with one set of strength exercises one or two times a week. Ultimately, aim for three times a week. Rest at least two days (48 hours) between sessions.
• Intensity. At first, aim for 1 on the effort scale. As you progress, work out at 2 or 3 on the scale. If lymphedema is a concern, ask your doctor about this before beginning our program.
• Choosing weight. Initially, do the exercises without any weights so you can focus on proper body alignment, a full or comfortable range of motion, and slow, steady, controlled movements. Next, choose a light weight of one to three pounds that makes you feel only mildly fatigued by the end of 10 repetitions. The amount of weight will vary depending on the exercise. A repetition, or rep, means going through the movement one time. In our program, 10 reps equals one set. You should be able to maintain good form, use a full, comfortable range of motion, and stay in control throughout all 10 reps. If not, decrease the weight.
• Progressing. When 10 reps become easy to do, you have some choices about how to progress. Change only one at
  a time:
• Increase weight by the smallest amount possible (for example, go from one-pound to two-pound weights).
• Or, increase sets (go from one set to two sets, or from two sets to three sets) by repeating the entire workout from start to finish.
• Or, increase days (go from one to two days a week, or from two to three days a week). Be sure to rest for two days between sessions.

American College of Sports Medicine (ACSM) guidelines recommend two or three weekly strength training sessions during which you perform one to three sets of 8 to 10 exercises that overload—that is, tire out—the major muscles of the body. Because you are rebuilding strength after surgery, the program we suggest is lighter. If you feel especially tired, take a day off or cut back on the amount of weight you lift or the number of repetitions you perform.

Starting Off. A few tips before you start:

• Check precautions. If you have had lymph nodes removed or radiation treatments to the underarm or collarbone area, review the lymphedema precautions for exercise in Chap­ter 9.
• Choose a workout. Review the “Save Your Shoulder” sidebar in Chapter 9 to see if you would benefit from a regimen designed to help you regain shoulder mobility and protect and strengthen your rotator cuff muscles. If so, start there first. If not, choose either of the strength workouts tailored to the type of surgery you had. A choice of two workouts can help keep you motivated.
• Pick up weights correctly. To prevent back problems, hinge from the hips and slightly bend your knees when picking up weights.
• Hold weights firmly. During exercises, hold weights or resistance bands firmly, but not too tightly.
• Check posture and positioning. Look in a mirror every now and then (see “Posture Check” in Chapter 9 and the following positioning tips) so that good form will become second nature.
• Keep your wrists firm (straight as a pipe) as you lift and lower weights.
• Keep knees and elbows soft rather than locking your joints.
• When you are performing a wall squat, your knees should bend only 30 to 45 degrees. Don’t allow your buttocks to go below knee height to avoid putting too much pressure on your knees.
• Breathe. Breathe normally throughout each exercise, exhaling as you exert yourself to lift, push, or pull against resistance. If you tend to hold your breath, try counting aloud to prevent this.
• Progress slowly. Muscles strengthen more quickly than connective ligaments and tendons, which need time to catch up to minimize the chance of injury. Slow progression is the key to success and injury prevention. If you cannot manage all 10 reps, do what you can and work on adding reps slowly.

Building Your Routine

The advice below comes from experts—women being treated for breast cancer, breast cancer survivors, and exercise professionals:

• Set small, achievable goals. Start with short walks on as many days of the week as you can manage and build up to longer walks. Likewise, start with one strength training session a week and add on when you can do so.
• Embrace wellness and commit to health. Just try the program and see how you feel. Routine helps, so try to exercise at the same time of day. Walk in the morning, for example, if this is when you have more energy. “I can’t believe what a difference exercise makes in your all-around attitude,” says Laurie Durgan, a busy 47-year-old mother, who credits Joy Prouty with teaching her a range of exercises to prepare for surgery and recover from it. “We are spiritual, emotional, mental, and physical beings. When one is out of whack, the rest get out of whack. Getting my physical body going has helped me in my mental and emotional states. It just makes me feel happier.”
• Connect with friends. Four mornings a week, Joan Lawhon, a board member of Latinas for a Cure in San Antonio, Texas, and a six-year survivor, walks three miles around a local track with a very close friend with whom she can discuss anything. “It’s not just good for our bodies, it’s good for our souls,” she says.
• Group up. Merry Murray Meade, a preschool teacher with children of her own, and Dara* had never met before they started rowing on the Charles River in Boston. While Dara had enjoyed small boats as a child, neither had crewed on a team before joining forces through WeCanRow, a program designed to enhance wellness and rehabilitation for breast cancer survivors, which Olympic rower Holly Metcalf launched as part of Row as One Institute (see Resources). Team members rarely skip sessions unless they’re really sick, says Dara. “We take it seriously because we love it and we love being together. We have fun.” Adds Meade, “Rowing has given me strength and endurance. It pushed me to know I can take on something new, which is kind of cool at my age.” (*Not her actual name)
• Problem solve. Karen Jackson is founder and CEO of ­Sisters Network, Inc., a national organization dedicated to promoting breast health education and supporting African American survivors and community. At 62, Ms. Jackson is very active physically, too—she rides a bike, walks, and swims. “All of these activities can be enjoyed alone if you are unable to find a partner,” she notes. “If you wait for somebody to join you, you may never, ever get around to exercising. Make your exercise program a top priority.” If you get derailed—whether because of exhaustion, a move, or a time crunch—try again.
• Enjoy good days, accept bad days. Any exercise is better than none, so it helps to do whatever you can. Terri Gray, a vibrant woman with metastatic breast cancer, slows down at times when anticancer drugs prove especially taxing. On days when her energy is in short supply she gives herself permission to do little, perhaps just joining her husband in taking their three Boston terriers for a walk. “Sometimes, my walk is barely a stroll,” she reports. “I’m holding onto my husband’s elbow and saying, ‘Pretend we’re 99—that’s what I feel like today!’” Otherwise, she’s a dynamo, walking full speed ahead and attending Jazzercise classes several days a week.
• Celebrate every victory. As Gloria Wade-Lessier recovered from the first of three bouts with breast cancer, her legs were so weak that a physical therapist had her do all of her exercises in a swimming pool at her Nevada home. “It took me a long time to get stronger, but I did,” she says. “I did exercises in the swimming pool. Then I could walk a little farther, a little longer.” Now she goes to the gym three times a week.
• Expand your activities. Once you’re feeling more like your old self, branch out. Yoga, Pilates, and tai chi are fine flexibility exercises; yoga and Pilates strengthen muscles, as well. Dancing, swimming, climbing stairs, running, and cycling offer cardiovascular benefits.
• Recapture joy. Sally Edwards, a professional athlete and author of Heart Zones Training, notes that the joy of motion often gets lost as girls who reveled in riding a bike, sinking a basketball, or hitting a softball grow up. “People need to do activities that they love,” she says. Sometimes exercise is a vehicle to get you to the point where you can do what you love. Other times, it’s an enjoyable end in itself. If you’re bored, try something new! (See Resources.)

The Right Timing

Ideally, you would begin this comprehensive program before you had surgery. That way, you’d have a better sense of your usual range of motion and strength before surgery, which would help you work toward regaining these afterward. You’d also be in better physical condition overall, which could ease your journey through treatment and speed your recovery.

Most likely, though, you are somewhere along the path of treatment or recovery. If you had surgery on one breast, try comparing the range of motion and strength on that side of your body to your other side. This will give you a sense of the changes brought about by surgery that your workouts will help you address. If you had surgery on both breasts, your workouts will help you aim for a full or comfortable range of motion and improvements in strength on both sides of your body.

Before starting our program, get advice and permission from your doctor.

	Click to enlarge		The Breast Cancer Survivor’s Fitness Plan When you are going through cancer treatments, the last thing you feel like doing is exercising — but it can be the key to your well-being and ultimate survival. In an encouraging, compassionate "I’ve been there" tone, Dr. Carolyn Kaelin offers a wealth of practical advice, proven techniques, and much-needed support. Read more