An 80-year-old gentleman had recently completed difficult chemotherapy, crossing the finish line in remission. Throughout, he'd pushed himself to take short walks. I asked for his advice to patients about exercising during treatment. Exercise helps you mentally through an arduous time. Don't give up trying to stay active, even when you don't feel like doing anything. Curious, I asked him what had motivated him. Someone who'd been through it told me exercise was important. Otherwise, I wouldn't have known or tried.
That got me thinking. We have consensus in the oncology community that physical activity is safe and beneficial for most cancer survivors. How many patients are not benefiting? Hoping to improve on whatever that number, I'm setting the bar low: Find quick ways for clinicians to motivate ambulatory patients to walk.
Effective encouragement addresses obstacles patients may face, many of which I experienced over the years of my survivorship. Ideas and mantras that helped me may help other patients.
Common Obstacles to Exercising
Bottom line: It's harder to exercise during and after cancer treatment. Imagine gearing up to exercise while queasy, fatigued, guarding fresh incisions, grieving, or dealing with other effects of illness. Time constraints pose an obstacle when the demands of illness keep interrupting or overtaking the daily rhythm of life. Even highly motivated patients may wonder, Where do I find time?
For some patients, safety concerns frighten them off, even when taking walks is not an issue. For athletic patients whose illness makes their usual exercise unwise or impossible, the idea of walking for exercise may feel like another loss, even if only temporary. For sedentary people, the idea may seem like another unpleasant therapy foisted on them-one that feels more elective than cancer therapy because skipping out doesn't carry the same grave consequences.
My Experience With Exercise During Treatment
My first cancer diagnosis challenged everything I knew about my 36-year-old self. Exercising had always ranked alongside eating and sleeping on my list of life's necessities. After peaking as a college athlete, my only exercise while in practice was taking the stairs instead of the elevator while rounding on patients and squeezing in occasional gym workouts.
My chemotherapy in 1990 caused anemia and chronic nausea. To lift my spirits, I wore colorful clothing and cute earrings. On good days, I mounted the cheap stair-stepper in my bedroom. Despite setting the resistance at the lowest level, I tired easily. After 5-10 minutes, I was done.
Exercising at home, like glancing at the mirror before showering, forced on me a self-image of illness. A transient ripple of sadness gave way to a more enduring wave of inspiration. Those measly mini workouts were enough to tap into my inner athlete cheering me on-You go girl!-and help me hold on to my sense of "me." When giving updates, my summary report of symptoms and news proudly included, I'm still exercising, if only for a few minutes.
My Experience With Physical Therapy
My experiences with physical therapy (PT), a very different experience from taking walks, helped me further understand the obstacles to taking walks while ill. At the time, progressive marrow failure was stirring fear that my time on earth might be short. My internist had prescribed PT for an age-related back issue.
While driving to my first session, the rain matched my mood as I grumbled about PT encroaching on my happy spaces. I'd gotten darn good at making life the best it could be by not thinking or talking about health when I didn't have to. With the addition of PT, I had to focus on the brokenness of my body while reviewing my medical history yet again, reporting symptoms at follow-ups, and losing chunks of time with sessions and daily home exercises.
On arrival, the physical therapist instructed me to warm up on a stationary bike. Peddling slowly, a thought flashed through my mind: Doctors don't recommend PT to someone dying. I peddled faster, perceiving the prescription for PT as an act of hope for a better tomorrow.
I'd always seen prescriptions as acts of hope. This felt different because fulfilling the hope of PT depended on me in ways that fulfilling that of cancer therapies didn't. With radiation and chemotherapy, I took pills as directed and showed up for appointments, where I let the members of my medical team do their exams, IVs, radiation treatments, whatever. My contribution to the work of killing cancer cells felt passive and the outcome felt out of my hands. Because they were. All I could do was wait helplessly for the test results.
Not so while undergoing PT. The healing agent was not a drug manufactured in a lab or a high-tech intervention administered by professionals. The desired physical changes were triggered by my stretching, my lifting, my pushing, and my pulling. From week to week, my body told me whether the therapy was working. I didn't feel the least bit helpless. Quite the contrary.
Feeling responsible for the success of therapy was good and bad. Regaining a sense of control was very good at a time when so much else felt out of my control. But compliance required heftier doses of willpower and self-discipline than cancer treatments. Let's face it: It was asking a lot for me to muster energy to do boring exercises while feeling sick and to sacrifice "happy" time while feeling urgency to seize the day.
Steps that motivated me to comply with PT may foster patients' compliance with taking walks, such as:
* Seeing walking as a healing effort under their control.
* Envisioning doing things made possible by recovery.
* Making daily walks a "happy space" by listening to music or talk shows and/or by finding a walking partner.
Prescriptions for Walking
These stories illustrate how little it may take to motivate patients. Given the power of your words, it may be enough to say something like: Moving is important during and after cancer treatment. I'm prescribing a short walk every day. This is one way to help your body, especially if you feel tired.
To further inspire and support patients, consider...
* Informing. Exercise during active treatment has been shown to lessen fatigue; help preserve fitness and strength; and, in some patients, improve quality of life and reduce anxiety and depression (JCO; Vol 40, Issue 22; 5/21/2023).
* Reassuring. Walking is safe during and after treatment. If you develop problems or ever have worries, stop exercising and contact us.
* Encouraging. Find ways to make your walk fun or calming. Use it as an escape from illness.
Encouraging ambulatory patients to walk a little may help optimize patient outcomes. That's nowhere near the ideal of prescribing personalized pre-habilitation, rehabilitation, and, where indicated, PT. I'm okay with that. As stated in Moving Through Cancer. An Exercise and Strength Training Program for the Fight of Your Life (Chronicle Prism; 2021): "A little is a lot more than nothing" when it comes to survivors benefiting from moving.
WENDY S. HARPHAM, MD, FACP, is an internist, cancer survivor, and author. Her books include Healing Hope-Through and Beyond Cancer, as well as Diagnosis Cancer, After Cancer, When a Parent Has Cancer, and Only 10 Seconds to Care: Help and Hope for Busy Clinicians. She lectures on "Healthy Survivorship" and "Healing Hope." As she notes on her website (http://wendyharpham.com) and her blog (http://wendyharpham.com/blog/), her mission is to help others through the synergy of science and caring.