Working with breast cancer survivors can be one of the most rewarding aspects of your career as a health and fitness professional, both personally and professionally. To provide your clients with safe and effective cancer-recovery programs, however, it is critical that you seek out proper training regarding both the acute and chronic side effects of cancer surgery and treatment.

Though most commonly associated with women, breast cancer actually affects both men and women, and they experience similar side effects following a mastectomy and/or treatment. Surgery and radiation is often followed by a build-up of scar tissue and adhesions that cause the shoulders to become protracted, a condition known as upper-crossed syndrome. The pectoralis muscles may react by going into painful spasm, which can lead to chronic pain due to the ischemia (lack of blood flow).

A comprehensive postural assessment and shoulder range of motion measurements, taken with a goniometer, must be completed before you start designing your client’s program. Without conducting these tests, you may select the wrong combinations of exercises, which could end up being ineffective at best, and harmful at worst.

Your client may have limited shoulder range of motion on the affected side following surgery, node dissection and/or radiation. Prior to adding any form of resistance in that plane of motion, provide your client with stretches and range-of-motion exercises to do on a daily basis until range of motion is 90% or better for the norms in that plane (more information on this is included in the Cancer Exercise Specialist Advanced Qualification course). If your client jumps right into strength training, he or she will become stronger in that limited plane of motion and less likely to ever achieve full range of motion. Simple, home-based exercises such as the forward- and side-wall walk can be beneficial for increasing both abduction and flexion.

Once your client has achieved close to full range of motion, he or she may progress to performing strength-training exercises. Focus on exercises that will stretch the chest (chest fly) and exercises that will strengthen the opposing back muscles (row, reverse fly, lat pull-down). Exercises such as push-ups or chest presses only serve to “reinforce” the muscle imbalance.

In addition to correcting muscle imbalances and range-of-motion limitations, strength training can help clients increase bone density and lean muscle mass. Many women will either be of menopausal age or thrown into menopause due to their cancer treatment. The resulting lack of estrogen increases the risk of osteoporosis. Men on hormonal ablation therapy may also experience “menopausal-type” side effects, including weight gain and osteoporosis.

A painful and disfiguring complication of lymph-node removal and radiation is lymphedema, which is the swelling of an extremity following the removal of, or radiation to, the lymph nodes on that side. Reports indicate that 3-70% of breast cancer patients will get lymphedema at some point after their surgery/treatment. If untreated, lymphedema is progressive and can lead to an infection of the lymphatic system.

If your client has been prescribed a compression garment, he or she must wear it during the workout—no exceptions! The lymphatic pathways will no longer operate with the same efficacy that they did prior to surgery or treatment. Regardless of how fit your client may have been, it is impossible to know what his or her lymphatic system can currently handle. It is critical to START and PROGRESS SLOWLY. This allows for a gradual increase in frequency, intensity and duration of the exercise program. If at any point there is swelling, advise your client to stop exercising and see his or her doctor immediately to determine if, in fact, the onset of lymphedema has occurred.

A typical exercise session should begin with cardiovascular exercise. Start with five minutes at a very low intensity and gradually increase intensity and duration, barring any swelling or pain. Following the warm-up, have your client perform a series of lymph drainage exercise to open up the lymphatic pathways and prepare the body for exercise. These include neck stretches, shoulder rolls, isometric chest and back squeeze, shoulder elevation/depression and fist squeezes (this is only a sampling of the recommended exercises).

Next, determine your client’s areas of “need.” Remember to begin with stretching and range of motion exercises until he or she has close to “normal” range of motion. At that point, the focus becomes strength training and choosing exercises that will strengthen the weaker muscles and stretch the tight and shortened muscles. Weight/resistance should be gradually increased and attention paid to any potential swelling of the extremity. If the client has undergone reconstruction, focus on correcting muscle imbalances ensuing from amputation. If your client has had a lat flap (in which they use the latissimus dorsi to reconstruct the breast), avoid lat pull-downs and focus instead on scapular stabilization exercises like shoulder shrugs. Following an abdominal TRAM flap reconstruction, avoid “crunch” type exercises and focus on the obliques and spinal stabilizers. If your client currently has expanders, do not have her do ANY chest exercises until the expanders are removed and he or she is completely healed.

This is only a snapshot of the depth that you must go into in order to properly design an exercise program for a cancer .

ACE has partnered with the Cancer Exercise Training Institute to bring health and fitness professionals the comprehensive knowledge of individualized programming and exercise oncology that is necessary to safely, effectively and compassionately work with cancer patients and survivors. By becoming a Cancer Exercise Specialist, you can establish a rewarding career and position yourself as the go-to expert in training patients in a critical component of their recovery.