How can health and fitness pros who support and train women post cancer treatment help remove barriers to exercise, and encourage safe movement to improve quality of life?
Gynaecologist consultant Dr Karen Morton, and Sarah Marsh, exercise medicine physiotherapist and clinical lead on a programme of bespoke exercise programmes for cancer care, recently delivered our Rehabilitation, Recovery and Movement webinar.
Over 21,000 women in the UK are diagnosed with one of the six gynaecological cancers each year: womb, ovarian, fallopian tube, cervical, vulval or vaginal. We talked recognising gynae problems, plus pre-operative and post-operative care for those going through cancer.
Q. Dr Morton, in terms of gynae cancer and menopause what should women look out for and when should they see a doctor?
DM: Women 45 upwards are in the age group where cancers are more common. They should be mindful that odd bleeding between periods, or ongoing bleeding, shouldn’t be assumed to be perimenopausal bleeding. Where the stomach just doesn’t feel right, it shouldn’t be assumed that it’s a gastro-intestinal issue or indigestion. Being familiar with their bodies will help them to be more aware of what isn’t normal, checking themselves in the shower, so that they will notice if something’s not right and be able to get it checked out.
Q. In the event of a cancer diagnosis and surgery, what are your pre and post-surgery and treatment protocols?
DM: With a diagnosis of cancer, ‘pre-hab’ makes a huge difference to recovery. Menopause feeds into this, for example, sleep deprivation alone can make it difficult for a woman to be the best version of themselves, without the added pressure a gynaecological malignancy brings. Lifestyle, diet, movement taking vitamin D and strengthening lungs pre-surgery will all help post-surgery.
It’s hard to generalise depending on a woman’s age and health but for many women, surgery is only a third of the process - post-operative healing and ongoing self-care complete the trio. Healing and recuperation demand energy, so women should be ‘pathetic for a fortnight’, rest, sleep, allow themselves to be looked after, give themselves the chance to get bodily functions back to a rhythm and avoid exercise.
At two to four weeks, it’s gentle strolls and nothing that will get the heart rate up.
At four weeks, if possible, see a pelvic floor physiotherapist to start to engage the pelvic floor vigorously. Although by now, the bladder and bowel may not yet be back where they need to be.
At six weeks, if all is going well, it’s time to introduce activities to get the heart rate up.
Q. What are your take home messages for rehab and recovery?
DM: The aftereffects of surgery, plus additional chemotherapy or radiation can’t be under-estimated. For some, the impact of knowing they’ve had cancer even if there’s a surgical cure can be significant.
Expert psychological nurse and specialist group support can be crucial at this point, giving much-needed emotional, physical and mental health support in rehab and recovery, rebuilding confidence to help go back to meaningful activities.
Women in their 50s are in the thick of life dealing with work, teenagers, and older parents, so it can be hard for them to be the patient who needs to be looked after but they really must put themselves first.
Sarah Marsh is an exercise medicine physiotherapist and clinical lead of highly evidenced bespoke exercise programmes for cancer care at Genesis Care, designing better quality of life outcomes.
Q. Sarah, at what point can women start exercising again post-surgery?
SM: Don’t rush it! Pacing is so important, there’s plenty of time.
Initially, women may be getting enough movement in their day to day lives. Everything should be slow and steady for 6 to 8 weeks with gentle movement and walking.
There’s good evidence about the efficacy of moving more and oxygenating the tissue but it’s so individual taking into consideration: treatment plans, current ability, what people were doing before and where they want to get back. So, there won’t be a one size fits all programme.
Women should aim for optimal movement and try to normalise areas like the pelvic floor, rather than strengthening one particular area. They need to allow time for healing and settling as internal healing can take longer. As professionals, we can reassure women that they absolutely will get there without rushing it now, as the outcomes will be so much better in the end.
Q. Is it the same advice post-chemo?
SM: Some women will feel so ill with chemotherapy or radiotherapy. They will get to know just how they feel and what they can do. Working with these women, when they feel fatigued, we need to think with them and ask what we can work with before and around that time? Pace again!
Our support can help give women appropriate control again at a time when they feel the treatment is being done to them. In chemo weeks when they know they’re not going to feel so strong, look at walking and some gentle relaxation movements and on better weeks let’s encourage, saying, ‘Let’s try to progress you a little bit, doing what’s safe’.
Q. Is there any type of exercise that is better or preferable to get women moving post-surgery?
SM: Just after surgery or treatment, many women when asked about movement, report they have started walking again – this is great! But they need to be doing body weight work, upper limb and resistance work to stay strong.
Gynae cancer treatment & medications increase osteoporotic risk. Supporting and persuading women that movement and increasing strength is so important. Ask women what they like doing. The aim is to help them to get back to whatever they could physically do before treatment - play tennis, be able to lift the grandchildren, or do the garden etc - we have to help pace them back to this point.
This generation of women should have a maintenance programme of movement – building strength, flexibility and keeping everything moving - twice a week for 15 to 20 minutes, their older selves will thank them.
Q. What can health and fitness pros do to help women return safely to exercise?
SM: As a starting point, a practitioner should reflect on how comfortable they feel working with this woman? If they’re not comfortable, what do they need to know? Health and fitness pros should reach out to their network and discuss with others to get as well-informed as they can be. Then it’s a question of asking the client how best to help and support them, what would they like to do? If they like to run, women can start or continue, the pelvic floor may feel uncomfortable but with care, the muscles will respond to the effort, but they need to be careful.
At 7 to 8 weeks, add in a safe squat and other movements in day-to-day life. We then build up those movements, let’s not be over fearful as practitioners. Help the client to work with you.
At ten weeks, try a jog, ask a woman how she felt. How did her pelvic floor feel? What were the range of movements? Reassure women that the pelvic area is robust, nothing will fall out, but it needs strengthening.
The challenge of this diagnosis is to get movement going and see what else they need to strengthen. Nothing works in isolation.
Q. What weight can safely be lifted post-surgery?
SM: Post-surgery advice can be for women not to not lift more than eight kilogrammes. Whilst you absolutely shouldn’t start with eight kilogrammes. starting with two kilogrammes would be good. If the response is fine, move a bit more dynamically, build it up, three to four kilogrammes, and so on. Pace again! In this element of self-care, use boredom as a measure for bumping up to the next level, when a woman is bored of a weight it’s time to add another kilogramme or two. Test it, it can always be reversed.
Q. Can exercise damage my pelvic floor post-surgery?
SM: The short answer is no, it’s unlikely. However, it’s recommended that women have a professional assessment to measure pelvic floor strength.
Q. Is exercise safe after cancer?
SM: There is a period afterwards, where it is not appropriate, for a short time. But post-treatment there’s so much evidence to say that movement increases longevity, means less reoccurrence, and gives a better quality of life. Some medical consultants tell women not to exercise. If a patient is told this, they should be encouraged to get a second opinion to make a balanced, sensible decision. It’s a very individualised situation without a one-size, fits- all solution.
Q. Can women return to pretreatment fitness levels
SM: They will get back to pretty much where they were – anecdotally, the healthier the diet, and the fitter a woman is pre-treatment, the better they are set for better outcomes. But sometimes this group can push themselves too hard to regain pre-operative fitness levels. They may benefit from more restorative and softer work and be re-assured that with the right pacing, they will absolutely get back to pre-treatment fitness levels. There’s emerging evidence for mindful breath and movement, a yoga-based relaxation approach could be very beneficial to all.
As professionals we get to be the people women can talk to. This is an opportunity for women to talk to someone about who they were, how they feel now and where they want to go. It’s our chance to show them how movement and exercise will improve their quality of life, making them healthier, better and fitter and giving them back control.
Sarah Marsh can be contacted on Instagram @yogiphysiosarah
Further reading:
Dr Morton’s – the medical helpline: phone and online GP/gynaecology support
Sarah Marsh Physiotherapist and cancer rehabilitation
Pinc and Steel Cancer Rehabilitation
Vicky Fox: Yoga for cancer
