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Corrective Exercise for Cancer Survivors Imperative is Nothing New – Surgery the #1 Reason

Corrective Exercise for Cancer Survivors Imperative is Nothing New – Surgery the #1 Reason

Table of Contents

By Andrea Leonard

Why corrective exercise for cancer survivors is so important

Cancer surgery often causes muscle imbalances and range of motion limitations. Therefore, corrective exercise for cancer survivors is important.

Following any cancer surgery there is bound to be pain, scar tissue, and the possibility of adhesions. All of these can contribute to muscle imbalances and range of motion limitations and the need for corrective exercise.

Most muscle pain is the result of a muscle spasm and the resulting ischemia (inadequate circulation to a local area due to blockage of the blood vessels in the area) from the prolonged muscle contraction. When someone comes to you with chronic musculoskeletal pain it may suggest that the problem lies within the muscle, or group of muscles. It will usually not stem from the bones, joints, and ligaments.  

This pain within a muscle or a group of muscles will ultimately lead to fatigue and result in a decreased ability to meet normal postural and movement demands. In the acute phase of pain, the muscles may respond by altering movement patterns to compensate for the injured area. As time passes, the CNS will adapt this altered movement pattern.

Muscle imbalance may be the source of the pain or it may be the result of the pain

Our bodies have a protective adaptation to pain in which the flexor response is activated to protect the injured area. Not only will this affect movement patterns, it will also result in decreased range of motion. These altered movement patterns will ultimately lead to altered joint position which will cause more stress on the joints.

This can also be caused by altered reciprocal inhibition. This is the process by which a tight muscle causes decreased neural drive and, therefore, optimal recruitment of its functional antagonist is not achieved. Altered reciprocal inhibition may lead to synergistic dominance. This is the process in which a synergist compensates for a prime mover to maintain force production (the force generated by a muscle action).

To address these altered movement patterns is why corrective exercise for cancer survivors is so important after surgery.

Using the Janda approach for corrective exercise for cancer survivors

Upper-crossed syndrome

Vladamir Janda observed three distinct stereotypical patterns of muscle tightness/weakness that cross between the dorsal and ventral sides of the body. The first, and perhaps most common is upper-crossed syndrome. Tightness in the levator scapulae and upper trapezius on the dorsal side crosses with the tightness of the pectoralis major/minor. Weakness of the deep cervical flexors on the ventral side crosses with weakness of the middle and lower trapezius.

This pattern of muscle imbalance creates joint dysfunction that results in forward head, cervical lordosis, elevated and protracted (rounded) shoulders, winged scapulae, and thoracic kyphosis. This combination wreaks havoc on the glenohumeral joint by decreasing joint stability, which then leads to increased activation by the levator scapulae and upper trapezius, in an effort to maintain the integrity of the joint.

Individuals who present with upper-crossed syndrome typically exhibit rotator cuff impingement, shoulder instability, biceps tendinitis, thoracic outlet syndrome, and headaches.

Lower-crossed syndrome

Lower-crossed syndrome manifests when the tightness in the thoracolumbar extensors on the dorsal side crosses with the tightness of the iliopsoas and rectus femoris. Weakness of the deep abdominal muscles ventrally crosses with weakness of the gluteus maximus/medius. Look for increased lumbar lordosis, lateral lumbar shift and leg rotation, and knee hyperextension. There are two variations of LCS: anterior tilt and posterior tilt.

The client with an anterior pelvic tilt will usually present with slight hip and knee flexion and hyperlordosis of the lumbar spine and hyperkyphosis of the upper lumbar and lower thoracolumbar areas. Those with a posterior pelvic tilt present with locked out knees, hypolordosis (flat back), thoracic hyperkyphosis and head protraction.

More than likely they will also have tight hamstrings and dynamic movement patterns may be affected. Individuals who present with lower-crossed syndrome typically exhibit anterior knee and low back pain, posterior tibialis (shin-splints), and plantar fasciitis.

Layer syndrome

Layer syndrome is the combination of LCS and UCS where clients display impairment with motor skills and have a poorer prognosis because of the longer duration of their impairment. You are more likely to see this in older patients and the elderly.

Muscle imbalance after surgery creates the greatest need of corrective exercise for cancer survivors

There are several factors that can affect muscle balance:

  • Repetitive movement – can result in overuse or injury and can lead to a change in elasticity of the muscle. It may be as simple as bad posture and lack of regular daily activity. Muscle that is repeatedly placed in a shortened position (psoas complex during sitting, or pectorals following a mastectomy/radiation), will eventually adapt to that new position and it will become its new “norm.”
  • Acute injury – an individual may alter their movement patterns to avoid pain, or to perform an activity out of desire or necessity. Because of the newly established “norm,” an individual may need to re-train their body back to their more normal motor pattern. Injury can also result in tissue that becomes hypomobile (restricted) from splinting or self-immobilization due to pain.
  • Surgery – scar tissue can alter tissue alignment and pull on the fascia. This will alter muscle and joint function. It is critical to assess ROM and posture and to use corrective exercise for cancer survivors to return to a normal motor pattern and correct imbalances.

Postural analysis test protocol to determine muscle imbalances before corrective exercise for cancer survivors

Purpose: to determine muscle imbalances which may cause unnecessary stress on the bones, joints, ligaments, and muscles. This may prove to be the most critical component to determine corrective exercise for cancer survivors and create a proper exercise prescription.

Equipment: none

Procedures: a thorough postural analysis is essential to get a clear understanding of symmetry, contour, and tone of the muscles as they are observed in static posture. The postural analysis is done with the participant wearing minimal clothing, standing erect, naturally, with the arms hanging downward at their sides, and bare feet.

Have client march in place with their eyes closed for a few seconds, making sure that they are standing naturally. Have them stop marching, hold their position, and open their eyes. Ask them to stand as still as they can so that you can conduct the assessment. 

Begin by looking posteriorly at spinal curves; excessiveness, scoliosis, leg-length discrepancy, or other orthopedic deviations. From there you should evaluate the pelvis; as this is where most dysfunctions of the lumbar spine, SI joint, and lower limbs will originate. Not only can the pelvic tilt affect lumbar lordosis, it can also influence the orientation of the head and other parts of the body.

The position of the pelvis should be evaluated by locating the iliac crests and the anterior and posterior iliac spines to determine muscle imbalances before corrective exercise for cancer survivors

Locating the posterior/anterior superior iliac spine for corrective exercise for cancer survivors :

The ilium is the most superior part of the innominate bone and articulates the pelvis with the spinal column through the sacrum. At the most anterior and posterior aspects of the ilium are bony prominences known as the anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS). The ridge of bone that runs between the ASIS and PSIS, and is a major source of muscle attachments, is known as the crest of the ilium or iliac crest.

Place your hands on your clients’ hips and feel for the iliac crests. While you are doing so, follow the crest to its anterior and posterior ends and those will be the ASIS and PSIS.

After identifying the aforementioned structures, there are several things you will want to look for to determine muscle imbalances before applying corrective exercise for cancer survivors:        

  • Lateral tilt
  • Rotation
  • Anterior tilt
  • Posterior tilt
Postural analysis test protocal to determine muscle imbalances before corrective exercise for cancer survivors

Looking at the subject from the back to determine muscle imbalances before applying corrective exercise for cancer survivors:

  • Head should be erect and not tilted to either side
  • Shoulders should be level and one should not be higher than the other
  • Shoulder blades should not be “winged” and they should be at the same height
  • Curvatures of the spine are minimal (no scoliosis)
  • Hips should be at the same level; one should not be higher than the other
  • Legs are vertical
  • Arches of the feet should not be excessively flat or raised, but should appear normal
  • Heels should be equal distance apart
  • Body weight should appear to be evenly distributed on both feet

Looking at the subject from the front to determine muscle imbalances before applying corrective exercise for cancer survivors:

  • Head should be erect and should not be tilted to either side
  • Shoulders should be level and one should not be higher than the other
  • Arms and hands should face toward the body
  • If there is considerable round shoulderedness, it will cause the hands to rotate so that the palms face backward
  • Hips should be at the same level; one should not be higher than the other
  • Legs are vertical and kneecaps should face forward and be centered
  • Toes should be in a straight line
  • Feet should be turned out at about ten degrees
  • Arches of the feet should not be excessively flat, or raised, but should appear normal
  • Heels should be equal distance apart
  • Body weight should appear to be evenly distributed over the feet

Looking at the subject from the side to determine muscle imbalances before applying corrective exercise for cancer survivors:

  • Head should be erect and should not be pulled back or extended forward
  • Shoulders should be level and should not be rounded
  • Curvatures of the spine should be minimal
  • Arms and hands should face towards the body
  • Chest should be lifted and should not appear depressed or protruding
  • Abdominals should be flat
  • Knees should not be over flexed or hyperextended, but should appear straight
  • Toes should be in a straight line  

Common range of motion limitations that require corrective exercise for cancer survivors

Following breast surgery/reconstruction shoulder range of motion limitations (ROM) are not uncommon. This may also be the case with some head and neck cancer surgeries. It’s important to address these issues because they can lead to additional joint deterioration, and/or frozen shoulder, if not corrected. Conducting a ROM assessment with a goniometer will help determine which areas need attention to determine muscle imbalances before applying corrective exercise for cancer survivors.

Flexibility limitations always outweigh strength limitations when designing corretive eercise for cancer survivors

Flexibility or strength?

Before beginning a resistance training program, your client should have 90% or better of the lower end of the ROM norm. Remember that ROM measurements taken passively are typically a reflection of flexibility while measurements taken actively are typically a reflection of strength.

For example, if norms for flexion are 150-180, your client should be at no less than 135 degrees of passive ROM before they do any resistance training in flexion. If they are limited in passive ROM, it is likely that they will be limited in active ROM as well. It is a good idea to begin by taking the passive ROM measurements as the results will dictate the next step before applying corrective exercise for cancer survivors.

Flexibility limitations always outweigh strength limitations when considering corrective exercise for cancer survivors

If they are limited in passive ROM, there isn’t much need to take the active ROM measurement (other than for baseline purposes), as their focus will need to be on flexibility and ROM before they begin strength training. Flexibility limitations always outweigh strength limitations. You do not want a client to become stronger in a limited plane of motion.

Clients may begin resistance training in other planes of motion if they are 90% or better of the normal range in that plane. Therefore, your client who only has 125 degrees of shoulder ROM in flexion, should not do a pullover, or other “shoulder flexion” exercise, with any type of resistance.

They can, however, do exercises with resistance in the other planes of motion. It is important for you to consider which exercises take place in any given plane of motion. You can use this determination to make recommendations based on the need for improved flexibility or strength to determine the corrective exercise for cancer survivor specifics.

You can use any exercise you would like – with strength vs. flexibility in mind. They can be conventional strength training, yoga, Pilates, water-based, etc. Keep in mind that these corrective exercises apply to anyone in a corrective exercise for cancer survivors program (not just breast cancer clients) who has a specific ROM deficiency.

  Contraindications for corrective exercise for cancer survivors:

  • Only have your client stretch to the point of mild discomfort — NO PAIN!
  • If your client has expanders (breast reconstruction) — NO CHEST STRETCHES AT ALL
  • If your client has severely impaired ROM, recommend that they see a physical therapist or occupational therapist to focus on that particular area and then return to you for an overall corrective exercise for cancer survivors program.
  • Have client focus on stretches in the plane of motion that they are limited in. Make sure they stay in that plane throughout the movement. For example, if your client is working on shoulder flexion, make sure that their arm does not abduct during the movement.
  • If they have less than 90% of the norm in any plane of motion, DO NOT begin strength training in that plane of motion for a corrective exercise for cancer survivors program.

Using a goniometer to measure range of motion needs and improvements of corrective exercise for cancer survivors

A goniometer is a device that is typically used by physical and occupational therapists to measure the range of motion around a joint. The word goniometer is derived from the Greek terms gonia and metron, which mean angle and measure, respectively.  Goniometers can help the examiner to determine whether the restriction at a particular joint is primarily a function of strength (or lack of) or flexibility (or lack of – possibly from scar tissue).

Measurements may be taken actively (when the client or patient moves the selected joint(s) through full ROM without any assistance form the examiner), or passively (when the examiner moves the joint(s) through full ROM without any assistance from the client/patient). A goniometer is usually made of transparent plastic.

There are some goniometers that are made of metal. There are two “arms” of the goniometer: the stationary arm and the moveable arm. Each arm is positioned at specific points on the body and the center of the goniometer (axis of rotation) is aligned at the joint to be measured.

When first meeting with a client/patient, you should use a goniometer to obtain a baseline range of motion around a specific joint before starting a corrective exercise for cancer survivors program.  These measurements can be compared to normative ROM data for each joint, thus helping to determine what the goal(s) of a particular exercise will be.

Typically, measurements are taken again after 8-12 weeks to look for tangible signs of improvement from your corrective exercise for cancer survivors programming.

Using a goniometer to measure range of motion needs and improvements of corrective exercise for cancer survivors
Goniometer

The best way to improve flexibility in a corrective exercise for cancer survivors program is to perform exercises in the plane of motion in which they are limited

  1. Identify Flexibility vs. Strength before beginning a corrective exercise for cancer survivors program.
  2. Flexibility – for the purposes of our testing for a corrective exercise for cancer survivors program, this will refer to the amount of motion that is obtained while client is in supine position. This is not to say that these measurements are not affected at all by muscular strength, or lack thereof however, they are a fairly accurate reflection of the client’s limitations from scar tissue and adhesions vs. actual muscular strength.
  3. Strength – for the purposes of our testing for a corrective exercise for cancer survivors program, this will refer to the amount of motion that is obtained while client is in upright standing or sitting position (when unable to stand).
  4. Begin by taking supine measurements on both sides. Note the difference between the affected side (side with surgery or radiation) and the unaffected side.
  5. If ROM in the supine position is not 90% of the lowest end or the norms (i.e.,150˚ – 180˚ the client needs to have at least 135˚ before adding any resistance in that particular plane of motion). The focus will need to be on improving ROM through stretching and flexibility exercises before you even consider adding a load to any movement.
  6. To place an additional load on the muscles would strengthen them in that limited ROM and hinder their improvement. Therefore, if there are limitations in supine position, it is not necessary to take those measurements standing.
  7. If a client is able to achieve 90% of the lowest norm in supine, they have no limitations (other than existing orthopedic conditions) to which strength training exercises they may do from an exercise for cancer survivors program.

Measuring flexion, abduction, extension, external rotation, internal extension to create a corrective exercise for cancer survivors individualized program

A.  Flexion ROM norms: 150˚180˚ Measurements outside of the normal range will require an individualized corrective exercise for cancer survivors program

measuring flexion ROM for a corrective exercise for cancer survivors
Figure 1A
measuring flexion ROM for corrective exercise for cancer survivors
Figure 1B
  • Stationary arm – in line with body
  • Axis – at shoulder joint
  • Movement arm – in line with elbow/shaft of humerus

Have client in the supine position, with knees bent to flatten the lumbar spine. The arm should be extended at the side of the body (Figure 1A). This is the starting position. The arm is then raised forward and up overhead (Figure 1B). Palm will face in toward the body with thumb pointing upward and will end with palm still facing in, but thumb pointing down or backward.

Make sure to have client stabilize the scapula to prevent upward rotation and elevation of the scapula. If you notice excessive movement in their scapula, or see their lower back arch, have them back off a few degrees to the point where the compensation is no longer obvious.

Remember, measurements outside of the normal range will require you to create an individualized corrective exercise for cancer survivors program.

B.  Abduction ROM norms: 150˚180˚ Measurements outside of the normal range will require an individualized corrective exercise for cancer survivors program

measuring abduction ROM for corrective exercise for cancer survivors
Figure 2A
measuring abduction ROM for corrective exercise for cancer survivors
Figure 2B
  • Stationary arm – in line with body
  • Axis – at armpit 
  • Movement arm – in line with elbow/shaft of humerus

Have client in the supine position, with knees bent to flatten the lumbar spine. Arm should be extended at the side of the body with palm facing upward (Figure 2A). The arm is moved laterally away from the client’s trunk, moving toward the head (Figure 2B). The palm stays facing upward throughout the motion.

Make sure that the client does not rotate their arm (watch the elbow) and that their humerus does not come off of the table or floor when taking measurement. If either of those things are noted, have the client back off a few degrees to the point where the compensation is no longer obvious.

Remember, measurements outside of the normal range will require you to create an individualized corrective exercise for cancer survivors program.

C.  Extension ROM norms: 40˚60˚ Measurements outside of the normal range will require an individualized corrective exercise for cancer survivors program

measuring extension ROM for corrective exercise for cancer survivors
Figure 3A
measuring extension ROM for corrective exercise for cancer survivors
Figure 3B

Make sure to have the client stabilize the scapula to prevent upward rotation and elevation of the scapula. If you notice excessive movement in their scapula, or see their lower back arch, have them back off a few degrees to the point where the compensation is no longer obvious.

  • Stationary arm – in line with body
  • Axis – at shoulder joint
  • Movement arm – in line with elbow/shaft of humerus

Have the client lie on their side, making sure that their spine is in a straight line and their head is supported with a pillow (Figure 3A).  This may be a more comfortable option for someone who has recently undergone surgery or is otherwise uncomfortable in prone position. Keeping their arm level, and parallel to the table, have them extend it behind the midline of their body (Figure 3B). Make sure that their spine remains in a straight line.

Make sure to have the client stabilize the scapula to prevent anterior tilting of the lumbar spine and elevation of the trapezius. If you notice excessive movement in their trapezius, or see their back arch, have them back off a few degrees to the point where the compensation is no longer obvious.

Remember, measurements outside of the normal range will require you to create an individualized corrective exercise for cancer survivors program.

In addition, be sure to mark in your notes that this measurement was taken in side-lying position; as the results may differ from a prone or standing measurement.

D. External rotation ROM norms: 70˚ 90˚ Measurements outside of the normal range will require an individualized corrective exercise for cancer survivors program

measuring external rotation ROM for corrective exercise for cancer survivors
Figure 4A
measuring external rotation ROM for corrective exercise for cancer survivors
Figure 4B
  • Stationary arm – perpendicular to table or floor
  • Axis – elbow joint (if taken while lying on the floor, the bottom of the stationary arm will be resting on the floor and axis of rotation will be slightly above the elbow
  • Movement arm – along shaft of ulna (forearm)

Have the client in the supine position, with knees bent to flatten the lumbar spine.  Have them bend their elbow to 90 degrees (at the shoulder joint). Their forearm should be perpendicular to the table, with their palm facing away from them (towards feet) and their fingers pointing straight up to the ceiling (Figure 4A). It is helpful to place a very small rolled up towel under their elbow to keep the upper arm level and keep the elbow from dipping below the shoulder.

The humerus should be supported by the table, and the elbow will be unsupported (the elbow will be supported if taking the measurement on the floor).  Have them rotate their forearm backward toward floor (Figure 4B). At the beginning of the motion, stabilize the elbow joint in order to maintain 90˚.

Make sure to have the client stabilize the scapula to prevent upward rotation and elevation of the scapula. If you notice excessive movement in their scapula, or see their lower back arch, have them back off a few degrees to the point where the compensation is no longer obvious.

Remember, measurements outside of the normal range will require you to create an individualized corrective exercise for the cancer survivors program.

E. Internal rotation ROM norms: 40˚ 60˚ Measurements outside of the normal range will require an individualized corrective exercise for cancer survivors program   

measuring internal rotation ROM for corrective exercise for cancer survivors
Figure 5A
measuring internal rotation ROM for corrective exercise for cancer survivors
Figure 5B
  • Stationary arm – perpendicular to table or floor
  • Axis – elbow joint
  • Movement arm – along shaft of ulna (forearm)

Have the client in the supine position, with knees bent to flatten the lumbar spine. Have them bend their elbow to 90 degrees (at shoulder joint). Their forearm should be perpendicular to the table, with their palm facing away from them (towards the feet) and their fingers pointing straight up to the ceiling (Figure 5A). It is helpful to place a very small rolled up towel under their elbow to keep the upper arm level and keep the elbow from dipping below the shoulder. The humerus should be supported by the table, and the elbow will be unsupported (the elbow will be supported if taking the measurement on the floor). 

Have the client rotate their arm forward (Figure 5B). Towards the end of the motion, use your hand to stabilize the clavicle and acromiom processes to prevent anterior tilting and protraction of the shoulder (you should be gently placing your hand on the AC joint and stopping their movement as soon as you feel a contraction beneath your fingertips).

Make sure to have the client stabilize the scapula to prevent anterior tilting of the lumbar spine. If you notice excessive movement in their clavicle/acromiom process, or see their back arch, have them back off a few degrees to the point where the compensation is no longer obvious.

Remember, measurements outside of the normal range will require you to create an individualized corrective exercise for cancer survivors program.

Summary of Why Corrective Exercise for Cancer Survivors is so Important and What You Should Know as a Fitness Professional

Following any cancer surgery there is bound to be pain, scar tissue, and the possibility of adhesions. All of these can contribute to muscle imbalances and range of motion limitations and the need for corrective exercise. Muscle imbalance after surgery creates the greatest need of corrective exercise for cancer survivors

This pain within a muscle or a group of muscles will ultimately lead to fatigue and result in a decreased ability to meet normal postural and movement demands. In the acute phase of pain, the muscles may respond by altering movement patterns to compensate for the injured area. As time passes, the CNS will adapt this altered movement pattern. Muscle imbalance may be the source of the pain or it may be the result of the pain.

The Janda approach for corrective exercise for cancer survivors is important to understand. Vladamir Janda observed three distinct stereotypical patterns of muscle tightness/weakness that cross between the dorsal and ventral sides of the body.

The first, and perhaps most common is upper-crossed syndrome characterized by tightness in the levator scapulae and upper trapezius on the dorsal side crosses with the tightness of the pectoralis major/minor. Weakness of the deep cervical flexors on the ventral side crosses with weakness of the middle and lower trapezius.

Lower-crossed syndrome manifests when the tightness in the thoracolumbar extensors on the dorsal side crosses with the tightness of the iliopsoas and rectus femoris. Weakness of the deep abdominal muscles ventrally crosses with weakness of the gluteus maximus/medius.

Layer syndrome is the combination of LCS and UCS where clients display impairment with motor skills and have a poorer prognosis because of the longer duration of their impairment.

You should understand the postural analysis test protocol which is used to determine muscle imbalances which may cause unnecessary stress on the bones, joints, ligaments, and muscles. This test may prove to be the most critical component for proper corrective exercise for cancer survivors exercise prescription.

If a client is limited in passive ROM, their focus will need to be on flexibility and ROM before they begin strength training. Flexibility limitations always outweigh strength limitations. You do not want a client to become stronger in a limited plane of motion.

When first meeting with a client/patient, you should use a goniometer to obtain a baseline range of motion around a specific joint before starting a corrective exercise for cancer survivors program. It is important to measure flexion, abduction, extension, external rotation, internal extension, to gage the need for and to create a corrective exercise for cancer survivors individualized program.

These measurements are important because measurements outside of the normal range will require you to create an individualized program for that joint.

These measurements can be compared to normative ROM data for each joint, thus helping to determine what the goal(s) of a particular exercise will be. Typically, measurements are taken again after 8-12 weeks to look for tangible signs of improvement from your corrective exercise for cancer survivors programming.

The best way to improve flexibility in a corrective exercise for cancer survivors program is to perform exercises in the plane of motion in which they are limited.

Resources for working with cancer survivors

Cancer Exercise Certificate

This program is designed to give you a complete understanding of the entire cancer process from diagnosis and treatment to reconstruction and survivorship. With its unique and individualized programming, it will help to improve your patient’s ability to cope with the mental and physical stress following cancer diagnosis and treatment.

Exercise and Cancer Survivorship

The course offers the most current evidence-based information compiled by the American College of Sports Medicine (ACSM) for working with survivors of many types of cancers and is designed to assist health and fitness professionals in using exercise to help cancer survivors with recovery, rehabilitation and reducing the risk of recurrence.

Cancer and the Older Adult

This course provides advanced continuing education for health and fitness professionals who wish to work safely and effectively with mature adults who have experienced cancer or would like to specialize in training cancer survivors in general. It identifies cancer risk factors and provides cancer prevention strategies related to lifestyle.

SrFit: Mature Fitness Program

The SrFit™ Mature Fitness course provides advanced training for experienced, certified health and fitness professionals who wish to safely and effectively work with active agers.  With this course, you will gain an understanding of how the aging process affects all the systems of the body, identify dietary changes that may be needed; and develop effective training strategies to improve flexibility, endurance, strength and optimal function in your mature clients.

You will learn how to individualize a training regimen that fits the physiological capabilities of mature adults, including those who are very frail and cancer survivors.

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