exercise considerations for the neuro-oncology patient

Exercise Considerations For the Neuro-Oncology Patient

Frannie Westlake PT, DPTBoard Certified Neurologic and Oncologic Clinical Specialist

Oncology Rehab: Denver, CO

Objectives

• Review Current Statistics of Brain Tumors in the US• Treatments for Brain Tumors and the Effect on Exercise• Discuss Current Methods of Exercise Prescription and Testing in the

Oncology Population• Review Current Guidelines for Exercise Interventions in the Oncology

Population

Benign Brain Tumors Malignant Brain Tumors

• Mass of cells that microscopically do not have the characteristic appearance of a cancer

• Found by CT or MRI brain scans

• Usually grow slowly

• Do not invade surrounding tissues or spread to other organs

• Often have a clear border or edge

• Not life threatening

• Brain tumors containing cancer cells

• More difficult to localize

• Often grow rapidly

• Invades and spreads to other organs

• Have no clear border or edge

• Life threatening ; Interfere with vital functions

www.abta.org

Metastatic Tumors

• A metastatic, or secondary, brain tumor is formed by cancer cells from a primary cancer elsewhere in the body that have spread to the brain

• Typically from:• Lung CA• Breast CA• Melanoma• Colon CA• Kidney CA

Signs and Symptoms

• Increased intracranial pressure• Headache• Nausea• Vomiting• Decreased level of consciousness• 6th nerve palsy (one of the first CN to be compressed)

• Can be secondary to tumor mass, surrounding edema, or obstruction hydrocephalus

Signs and Symptoms• Seizures

• Presenting symptom in 1/3 of all cases• Usually focal• Frontal lobe gliomas produce seizures in 60% of cases

• Altered Mental Status• Presenting in 20% of cases• Can range from subtle changes to severe problems• Can notice decreased LOC

Signs and Symptoms

• Focal Neurological signs• Weakness – motor cortex (frontal)• Sensory loss – sensory cortex (parietal)• Speech disturbance (left frontal or temporal)• Visual (occipital)• Balance (cerebellum)• Vestibular deficits (cerebellum)

Medical and Surgical Management

• Traditional surgery – craniotomy (partial or complete)• Chemotherapy• Radiation • Stereotactic Radiosurgery

Chemotherapy

• Independent treatment or adjuvant to other types• Not effective for all types of tumors• Use of chemotherapeutic agents (combination preferred)• Mechanism: chemotherapeutic drugs arrest replication of cells, aim is

to stop division of cancer cells• Given in cycles: oral or intrathecal chemotherapy (into CSF)• Examples: Nitrosoureas (permeates BBB), methotrexate, Cisplatin

Temodar

• Generic name: Temozolomide• Classified as alkylating agent

• It acts as “pro-drug” and needs to be transformed to its active form by the body’s metabolism

• Used for anaplastic astrocytoma and glioblastoma multiforme brain tumors• Given orally and recommended to take on an empty stomach• NADIR: 7-10 days; Recovery: 22-28 days

• Clinical Application/Patient Profiling: • Central Neurotoxicity – dizziness, balance problems, hemiparesis, seizures, excessive

sleepiness• Fatigue is also a common side effect

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Avastin

• Classified as a “monoclonal antibody” and “anti-angiogenesis” drug• New type of targeted therapy• Inhibits human vascular endothelial growth factor (VEGF)• VEGF is a growth factor that leads to new blood vessel formation or angiogenesis

• Used to treat metastatic colon or rectal cancer, non-squamous non-small cell lung cancer, metastatic breast cancer, glioblastoma multiforme, metastatic renal cell carcinoma

• No NADIR information available• Clinical Application/Patient Profiling:

• Nose Bleeds• Diarrhea • Muscle weakness and joint pain

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Side effects of Chemotherapy

• Destroys all rapid growing cells including• Hair follicles• Cells of digestive tract• Blood cells needed to fight infections• Results:

• Hair loss• Nausea/loss of appetite• Decreased immune system• Fatigue

Chemotherapeutic drugs side effects

• Short-term and long term effects• Peripheral neuropathy• Paresthesias, numbness• Malaise, fatigue• Dizziness• Myelosuppresant – bone marrow suppression (decline in immunity,

anemia)• Muscle weakness

Implications for PT

• Adjust treatment plan based on side effects• Consider patient’s participation in therapy

• Successful treatment plan is flexible

• Consider optimal time for therapy• Try to get baseline outcome measures if possible before starting

chemotherapy

Radiation Therapy

• Independent treatment or adjuvant to other types• Treatment option for large tumors or inaccessible for surgical

resection• Profound metastasis may not be suitable for radiotherapy• Mechanism: ionizing radiations disrupt cell structure and stop growth• Types: external radiation (5 days/wk x several wks); Implant radiation

(loose radioactivity delivered each day)

Side effects of Radiation

• Destruction of healthy cells• Loss of hair• Fatigue• Fibrosis• Cognitive deficits (learning problem in children)• Osteoporosis• Radiation necrosis

Implications for PT

• Adjust treatment plan based on side effects• Consider patient’s participation in therapy• Consider optimal time for therapy• Irradiated areas should be protected from skin injury• No heat or cold agents or topical agents until skin damage is cleared

Stereotactic Radiosurgery

• Delivery of a high dose of ionizing radiation, in a single fraction, to a small, precisely defined volume of tissue. A variety of machines used to produce the radiation:

• Gamma Knife• LINAC• Particle accelerator• CyberKnife

• Most beneficial for: centrally localized lesions (<3 cm); patients with increased surgical risk

Optune Device

• Optune is a wearable, portable, FDA-approved device indicated to treat a type of brain cancer called glioblastoma multiforme (GBM) in adult patients 22 years of age or older.

• Newly diagnosed GBM• If you have newly diagnosed GBM, Optune is used together with a chemotherapy called

temozolomide (TMZ) if:• Your cancer is confirmed by your healthcare professional AND• You have had surgery to remove as much of the tumor as possible

• Recurrent GBM• If your tumor has come back, Optune can be used alone as an alternative to standard medical

therapy if:• You have tried surgery and radiation and they did not work or are no longer working AND• You have tried chemotherapy and your GBM has been confirmed by your healthcare

professional

Craniotomy

• Either conventional or image guided• For tumor resection or for biopsy• Mandatory in large tumors presenting with ICP problems• Partial resection – malignant tumor; Complete resection – benign

tumor

Side effects of Craniotomy

• Prolonged general anesthesia• Extended hospital stay (infection)• Invasive technique: cerebral edema, cerebral damage, seizure

disorder• DVT, PE• Increased ICP in post-op period

Implication for PT

• Aim is to mobilize patient• Positioning concerns in the acute post-op period• ICP concerns: avoid valsalva maneuver• Pain consideration

A Cancer Population Specific VO2peak Assessment:

University of Northern Colorado Cancer

Rehabilitation Institute Multistage Treadmill Protocol

VO2max

• Max volume of oxygen consumption (VO2max) is the best measure of overall heart function (Hayward et al., 2013)

• Establishing an accurate VO2max is critical to have for a cancer survivor (CS), as it allows Cancer Exercise Specialists to create an individualized exercise prescription

VO2max

• VO2max is often achieved from a maximal treadmill test using gas analysis• Gas analysis is the MOST ACCURATE method of determining VO2max, but is expensive and not readily

available

• VO2peak is often used instead• Highest VO2 achieved during a test

• Doesn’t need gas analysis

• No cancer-specific treadmill protocol exists, so cancer survivors are forced to use apparently healthy protocols

Bruce Treadmill ProtocolStage Time Speed % Grade

Warm-Up

2-3 Min. 1.7 0%

1 3 min. 1.7 10%

2 3 min. 2.5 12%

3 3 min. 3.4 14%

4 3 min. 4.2 16%

5 3 min. 5.0 18%

6 3 min. 5.5 20%

7 3 min. 6.0 22%

UNCCRI ProtocolStage Speed Grade Time0 1.0mph 0% 1 min1 1.5mph 0% 1 min2 2.0mph 0% 1 min3 2.5mph 0% 1 min4 2.5mph 2% 1 min5 3.0mph 2% 1 min6 3.3mph 3% 1 min7 3.4mph 4% 1 min8 3.5mph 5% 1 min9 3.6mph 6% 1 min10 3.7mph 7% 1 min11 3.8mph 8% 1 min12 3.9mph 9% 1 min13 4.0mph 10% 1 min14 4.1mph 11% 1 min15 4.2mph 12% 1 min16 4.3mph 13% 1 min17 4.4mph 14% 1 min18 4.5mph 15% 1 min19 4.6mph 16% 1 min20 4.7mph 17% 1 minCool-Down ** 0% *

Statement of Purpose

• To assess the validity of the UNCCRI multi-stage treadmill protocol for a cancer-specific population against standard metabolic gas analysis and the Bruce treadmill protocol.

Four different values were compared

1. VO2peak obtained from UNCCRI Gas Analysis Protocol (UGA)

2. Estimated VO2peak calculated from the last completed stage of UGA using ACSM’s walking/running equations (UEV)

3. VO2peak from Bruce treadmill protocol (BTP)4. VO2peak calculated from UNCCRI without Gas Analysis Protocol (UNGA)

Results

• No significant difference between UGA and UEV

• Significant difference between Bruce and UGA (p<0.05)

Bruce vs. UGA UEV vs. UGA

0

10

20

30

40

50

0 20 40

VO2p

eak

from

Bru

ce (m

L·kg

-1·

min

-1)

VO2peak via UGA (mL·kg-1·min-1)

0

10

20

30

40

50

0 10 20 30 40 50

UEV

(mL·

kg-1

·min

-1)

VO2peak via UGA (mL·kg-1·min-1)

A B

Conclusion

• VO2peak did not significantly differ between UGA and UEV

• Gas analysis is not necessary

• VO2peak significantly differed between UGA and BTP

• BTP not accurate or suitable for cancer survivors

• UNGA treadmill time was significantly higher than UGA treadmill time

• Gas analysis equipment may actually hinder treadmill performance

• UNCCRI protocol is designed for CS’s suffering from cancer and treatment-related side effects

• Allows further progression and a higher, more accurate VO2peak

Conclusion

The UNCCRI protocol provides patient comfort and a valid VO2peakvalue, and should be the standard VO2peak assessment for cancer

rehabilitation clinics and facilities.

FITT Principle

Frequency

• Number of sessions per week• 3x/week of vigorous

activity (> 20 min/day)• 5x/week of moderate

activity (> 30 min/day; bout > 10 min)

Intensity

• Increase time before intensity• Always “triangulate”

with RPE

FITT Principle

Time

• Total amount of time spent exercising or total caloric expenditure• Adjust to patient’s Fitness

level• Shorter periods, multiple

bouts, 3x/10 min/session• Goal: 1 x 30 min/session• Increase time before intensity

Type

• What is available?• What does the patient want to

do?• What is safe for the patient?• Aerobic, strength, and

flexibility training

Phase Training Model

Phases of Cancer Rehabilitation

• Who: Patients during treatment (chemotherapy and/or radiation)

• Goal: Attenuate the deleterious effects of chemotherapy and radiation treatment

• There may be no improvement of physiological parameters during this phase, but there should be little to no declination

• Exercise Training: Low intensity: 30-45% HRR and 1-RM; RPE of 1-3; 2/3 sessions per week

• Timeframe: During treatment or for up to three months

Phase 1:

Phases of Cancer Rehabilitation

• Who: Patients graduating from Phase 1, or clients who have had surgical and/or hormonal treatment (no chemo/radiation)

• Goal: Build a foundational base using functional and corrective training

• Exercise Training: Low intensity: 40-60% HRR and 1-RM. Purpose is to incorporate foundational, technique-oriented exercises. Improvements should be seen in core strength, pelvic floor and shoulder girdle strength, ROM, and to progress from close-chained exercises to open-chained exercises. RPE of 3-6; 3 sessions per week

• Timeframe: 3 months

Phase 2:

Phases of Cancer Rehabilitation

Phase 3:

• Who: Patients graduating from Phase 2 • Goal: Improve physiological and psychological values

beyond baseline. Improvements should be seen in cardiovascular fitness, pulmonary function, muscular strength and endurance, balance, and flexibility. Psychological improvements should be visible e.g. QOL, Fatigue, and Depression

• Patients should be back to functional health or “apparently healthy”

• Exercise Training: Moderate-to-high intensity: 60-85% HRR and 1-RM; RPE of 4-8, 3 sessions per week

• Timeframe: 3 months

Phases of Cancer RehabilitationPhase 3:

• Continued: Phase 3 marks the end of true cancer rehabilitation, therefore a primary focus should be to encourage clients to build intrinsic motivation and self-efficacy with exercise

• Patients need to learn proper form and how to develop their own exercise intervention

Phases of Cancer Rehabilitation

• Who: Patients graduating from Phase 3• Goal: Continue improving in physiological and

psychological parameters. Improvements should be seen linearly during training.

• Exercise Training: Moderate-to-high intensity: 65-95% HRR and 1-RM; RPE of 6-10, 3 or more sessions per week. Interval training, group fitness, and open gym training is appropriate

• Timeframe: Limitless

Phase 4:

Updated ACSM Guidelines

45

Exercise is Medicine (2019)

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Questions???

References• Daniel Yoon Kee Shackelford, Jessica Marlene Brown, Brent Michael Peterson, Jay Schaffer,

Reid Hayward, The University of Northern Colorado Cancer Rehabilitation Institute Treadmill Protocol Accurately Measures Vo2 Peak in Cancer Survivors, International Journal of Physical Medicine and Rehabilitation, Volume 5 Issue 6, 2017

• Jessica Marlene Brown, Daniel Yoon Kee Shackelford, Maria Lynn Hipp, Reid Hayward, Evaluation of an Exercise-Based Phase Program as Part of a Standard Care Model for Cancer Survivors, Translational Journal of the ACSM, Volume 4, Number 7, 2019

• Kristin L Campbell, Kerri M. Winters-Stone, Joachim Wiskemann, Anne M. May et al, Exercise Guidelines for Cancer Survivors: Consensus Statement from InternationalMultidisciplinary Roundtable, Medicine and Science in Sports and Exercise, 2019

• Quinn T Ostrom, Gino Cioffi, Haley Gittleman, Nirav Patil, Kristin Waite, Carol Kruchko, Jill S Barnholtz-Sloan, CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2012–2016, Neuro-Oncology, Volume 21, Issue Supplement_5, October 2019, Pages v1–v100.

• www,abta.org• www.cancer.org