Rehabilitation to Manage Cancer Fatigue
In this episode of Kessler Foundation's podcast, Tiffany Kendig, PT, DPT, MPH, CLT, program director, ReVital Cancer Rehabilitation, Kessler Rehabilitation Center, and Sara Ilenko, MS, CCC-SLP, senior speech-language pathologist, Kessler Institute for Rehabilitation, present “Rehabilitation to Manage Fatigue in Patients with Cancer.” Cancer-related fatigue is an issue that often develops during treatment, and can last for months or even years. This conference podcast will focus on the impact, screening and management of the physical, physiological, emotional and cognitive sequelae.
This is part three of a five part series. Listen to the series as it's posted.
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Below is an excerpt from the lecture.
Tiffany Kendig: It's really exciting that rehabilitation is specifically called out in clinical practice guidelines, medical clinical practice guidelines, as an integral component of management of cancer-related fatigue.
Autonomic Nervous System Balance
Autonomic nervous system balance: that's an interesting one, and it has a direct impact on fatigue. An example of how physical activity or exercise can positively impact autonomic nervous system balance would be increasing heart rate variability, for example, which can help to facilitate the balance between the parasympathetic and sympathetic nervous system. And that has positive benefits, as well, that impact fatigue. And then last but not least, a beneficial impact on neurotrophic factors, so things that help to optimize brain function. All of these things, taken together, help contribute to reduction of fatigue in individuals experiencing cancer-related fatigue. So what we need to help our patients start to see and start to say is not, "Are you kidding me?" but, "There are all these benefits, how can I do this? And why?" So for us in this room to kind of get on that train, we need to look at a little bit of the evidence.
So if you go to Google scholar, and you put in exercise and cancer-related fatigue - and I did this yesterday - you will get about 274,000 results. So as you can probably deduce from that, it is one of the most commonly studied and most published upon interventions related to fatigue. In the interest of time and having friends after this talk, I'm going to focus on a few of those studies, okay? So a number of meta-analyses that you see here show that exercise has strong efficacy for reducing fatigue. We know that that reduction can occur over time, and there are these changes, positive changes in severity of fatigue after a 12-week intervention. We know that, as compared to controls, so people who don't exercise or perform physical activity, the fatigue is better for individuals who are more active. And we know that there are certain time points where the benefit of exercise may be greater than others. But overall, we do know there's a big benefit across populations from diagnosis through survivorship, and including end-of-life.
Exercise Benefits Fatigue
So in summary, given all of that evidence in the clinical practice guidelines, we know that physical activity and exercise is feasible, beneficial, and more than highly encouraged but is also spelled out and supported in our clinical practice guidelines. We need to screen for cancer and treatment-related effects, just like we need to screen for fatigue. So if an individual comes to see me with shoulder pain after a mastectomy, I'm going to be asking that person pointedly about fatigue. And when I'm creating my care plan, I'm going to be integrating aspects of exercise that are going to be beneficial not only for that shoulder but to help combat fatigue. The exercise prescription again, aerobic exercise component with a resistance exercise component. What has come out from some of the Canadian exercise groups, they do recommend again 150 minutes per week, moderate intensity, so that's 3 to 6 met levels, or a 12 to 14, on a 6 to 20 boric scale, or 50 to 70% heart rate max. Teaching your patient to self-monitor is hugely important there. And then again, 3 to 5 days per week. As far as strengthening or resistance exercise, the general recommendations to address fatigue, two sets of 10, right, reps affecting at least 8 to 10 of the major muscle groups.
And then, a group - again, additional research is needed because there is so much variation in terms of what's out there for exercise prescription - and then a group or a supervised setting is preferred. So there are a lot of good studies out there but that helps to empower and optimize compliance with exercise. So the big take-home message is we as therapist understand that fatigue can be debilitating and how it impacts individuals is very different, and what is important to each individual in their day-to-day routine is very different. We are in a unique position to empower them and give them a program that can help them achieve those goals. And with anything in life, with exercise to keep that, "Are you kidding me?" from being the reality, we need to show them the evidence, but we also need to give them ways to balance their activity. So with that, to talk a little bit more about how we will balance activity, energy conservation, and pacing, I'll just hand you over to Kelly.
Kelly Walloga: Energy conservation refers to the way activities are performed to minimize muscle fatigue, joint stress, and pain by using your body efficiently, and doing activities in a sequential manner, can help you save your energy. Work simplification and energy conservation techniques will allow you to remain independent and be less frustrated by your illness, that way your energy can last throughout the day.
Why resting is important
Short rest breaks allow your mind to rest while focusing again, that way your mind doesn't have to struggle to focus on those tasks. Balancing activities and rest: so doing an activity and incorporating a rest break and doing another activity, like I said, alternating. Pacing yourself: recognizing that you're going to have good days and bad days, and not overdoing it. Positioning: sitting whenever possible, use of assistive devices, like a walker, a cane, a cart, a scooter, crutches, grab bars, use of adaptive equipment like I mentioned earlier with getting dressed. By allowing yourself to save energy without having to bend or reach, avoid heavy lifting. And then, learning to set priorities about necessary stressful situations about some battles that are not worth fighting. And maintaining a pleasant work environment as often as possible: irritation, frustration, worry, and competitive feelings can waste energy. Next, I'm going to jump into work and leisure. So, balancing activity and rest, planning ahead, setting priorities, understanding activity, talent, and work simplification. Work simplification can be divided into concepts of good body mechanics, elimination of unnecessary movements, and efficient use and organization of workspace. And again, taking short rest breaks to allow your mind to rest again, so that way your mind doesn't have to struggle. And, like the quote from Susan, the thing is that you're not only physically tired, but you're mentally tired. So I'm going to have Sarah come up and talk about mental fatigue, which also plays an important role.
Cognitive Impairment
So cognitive impairment due to fatigue, like I said, is a frequent problem. It's difficulties that patients experience with memory, attention, your processing of information, your executive functioning, and your ability to concentrate. Cognitive reserve is that innate undeveloped cognitive capacity which is influenced oftentimes by genetics, your education level, occupation, your lifestyle, and cognitive-simulating activities. Persistent fatigue often reduces disability to refresh that cognitive reserve, so those patients who have that persistent fatigue have difficulty refreshing our cognitive reserve. Similarly, if you or I are working on a project at night, we're dealing with home life or we went out with friends, you have difficulty starting your workday the next day.
You need that cup of coffee to really help you kick off and be productive. Patients with cancer who have this chronic fatigue have difficulty refreshing that cognitive reserve, and that cup of coffee really isn't going to do the trick for them, so that persistent fatigue that then, in turn, affects their cognitive abilities. So fatigue impacts on cognition, specifically. So executive functioning: so your ability to problem solve, your hierarchical thinking, your ability to execute and plan a project perhaps at work or at home, your ability to schedule events or coordinate different schedules. Your processing speed also takes a hit. So, your ability to process different information that's incoming towards you at work or at home. It affects your attention, your memory, and your problem-solving and sequencing.
