Resident's Corner
Prescribing Exercise to Reduce Cancer-Related Fatigue: A Case Report by David T. Cavagnino PT, DPT, MS Cancer-Related Fatigue (CRF) is a term used to describe a symptom reported by 58% of patients who have been diagnosed with cancer. Prevalence is even higher for patients following radiation or chemotherapy at rates of 60-93% and 80-96%, respectively.1 The literature on CRF contains varying definitions and attempts at establishing diagnostic criteria. Perhaps the most broadly defined and accepted is the definition of “a distressing, persistent subjective sense of physical, emotional, or cognitive tiredness (lethargy) related to cancer pathology and/or cancer treatment that is not proportional to recent physical activity and interferes with usual general functioning in ADLs”.1 Cancer related fatigue is the result of both “physiologic” and “situational” factors including physiological changes caused by the pathological tumor or treatment as well as anxiety and cumulative effects from vomiting and GI problems (anemia, pain, dehydration, and electrolyte imbalances).2 Research on CRF is relatively well established. A 2012 Cochrane Review found that supervised exercise interventions, aerobic exercise programs in particular, may significantly reduce CRF.3 Exercise should be of moderate intensity, defined as 55-70% of maximum age-predicted HR or a rating of 11-13 (“light” to “somewhat hard”) on the Borg RPE scale.1 Frequency, however, is not as well agreed upon. One source recommends exercise 3-5 times per week.1 Another merely recommends “an element of supervision.”4 The purpose of this case report is to determine the impact of a daily home exercise program (HEP) with weekly visits by a PT for a person who refused more than 1 visit per week but expressed willingness to participate in an HEP. This situation presented the opportunity to support patient self-efficacy while making judicious use of healthcare resources and improving her functional performance. Case Description An 87-year-old female, Betty, was referred to skilled physical therapy to address functional decline in standing transfers and gait in both household and community ambulation. Retired and living alone, she has a neighbor who has been recently hired for assist with showers, meal preparation, and supervision of medication timing. A daughter lives nearby and provides shopping assist, her primary socialization.
GeriNotes • March 2021 • Vol. 28 No. 2
Medical History Betty underwent surgical removal of a malignant tumor in her colon 3 months prior to referral. Post-surgical recovery was complicated by development of anemia from stool blood loss. After the GI bleed was controlled, she recovered for 2 weeks in an inpatient rehabilitation facility and 4 weeks in a subacute rehab facility. One fall without injury was recorded while at the subacute facility. After returning home, Betty complained of trouble ambulating due to feeling “tired and weak.” She refused to participate in more than 1 session of therapy per week but states that she will perform a home exercise program. Her current HEP involves seated heel raises, knee extensions, and marching. She performs these daily without change in her cardiovascular endurance. Other pertinent history includes congestive heart failure (CHF) and hypertension, for which the Betty takes an angiotensin II receptor blocker and furosemide. Diabetes mellitus type 2 is managed with insulin. She takes a statin for high cholesterol and Synthroid to address low thyroid hormone levels. She is blind in the right eye from macular degeneration and glaucoma. Other surgery includes a distant cholecystectomy. Prior Level of Function Prior to the cancer hospitalization and surgery, Betty was independent with all transfers, but was a limited community ambulator with use of a rolling walker. Her stated goals are to feel safe ambulating in her home and to be able to return to shopping with her aide or daughter. Physical Examination Betty was oriented to person, place, and time at initial assessment despite noted limited vision in R eye. Sensation to light touch on lower extremities was intact and CHF appeared well controlled with no lower extremity edema noted. She does not complain of pain, only persistent fatigue. Considering Betty’s history of CHF, anemia, and sedentary activity level, she required a combination of cardiovascular monitoring strategies including the Modified Borg Dyspnea Scale (MBDS), percentage of heart rate max, SpO2 percentage, and blood pressure response to exercise. Despite shortness of breath with moderate exercise and functional activities, her SpO2 remained above 97% during the initial evaluation session. She required minimal physical assistance to stand from a standard chair using the armrests; marked unsteadiness was noted
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