Swimming as Exercise Prescription for Breast Cancer Patients

Elizabeth S. Pittinger, MA and B. Sue Graves, EdD Department of Exercise Science and Health Promotion, Florida Atlantic University, Boca Raton, Florida Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journals Web site (http://journals.lww.com/nsca-scj).

ABSTRACT
NEW EVIDENCE AND RECOMMENDATIONS FOR PATIENTS TO EXERCISE DURING AND AFTER CANCER TREATMENTS ARE EMERGING AS MORE STUDIES FOCUS ON QUALITY OF LIFE AND HEALTH BENEFITS DERIVED FROM PHYSICAL ACTIVITY FOR THIS POPULATION. THIS ARTICLE DEMONSTRATES TO THE STRENGTH AND CONDITIONING PROFESSIONAL HOW SWIMMING IS A VIABLE FITNESS OPTION AND OFFERS MULTIPLE BENEFITS TO BREAST CANCER PATIENTS, INCLUDING POSTSURGICAL REHABILITATION, IMPROVED AEROBIC FITNESS, INCREASED SELF-ESTEEM, AND REDUCED FATIGUE. FOR A VIDEO ABSTRACT DISCUSSING THIS ARTICLE, SEE VIDEO, SUPPLEMENTAL DIGITAL CONTENT 1, HTTP://LINKS.LWW.COM/SCJ/A121.

INTRODUCTION

ntil recently, breast cancer patients were routinely instructed by medical teams to rest and not exert themselves during and after cancer treatments including surgeries, chemotherapy, and radiation. As more studies are focusing on this population, new evidence now contradicts these earlier recommendations. Schmitz et al. (8) (2009) outlined the positive effects of

weightlifting for breast cancer survivors with mild lymphedema. This study empirically showed the benets breast cancer patients receive from regular exercise, specically from strength and resistance training, completely contradicting previous physician recommendations not to lift groceries or even purses on the injured side. In 2010, the American College of Sports Medicine (ACSM) convened a roundtable of experts to review specic issues of exercise for breast cancer patients and survivors both during and after treatments. The roundtable concluded that exercise training for this population is safe and improves physical functioning, quality of life, and cancerrelated fatigue in several cancer survivor groups (9). As a result of these ndings, this article reviews the evidence for exercise training during and after cancer treatments. Additionally, the strength and conditioning professional will understand swimming as a viable form of physical activity for the breast cancer patient. Specic exercise prescription is provided with guidelines on how to work with breast cancer patients during and after recovery.
CURRENT (2010) GUIDELINES FOR PHYSICAL ACTIVITY IN THE BREAST CANCER PATIENTS

physical activity is better than none at all (9). The strength and conditioning professional should understand not all cancer, and therefore, not all treatments are the same; consequently, each individuals abilities and needs must be assessed. Getting to know the swimmers tness background, cancer diagnosis and treatments, and overall goals are very critical to providing the postoperative patient with the necessary support and care during workouts. Obtaining medical clearance from the oncology team to exercise, and more specically to swim, is important before beginning any workout regimen. Initially after treatment, the focus of aerobic intensity should remain within 4060% V O2max, 2060 minutes, 3 to 5 days per week (14). Monitoring the patients intensity levels with a session rate of perceived exertion (RPE) method using the Borg 110 scale is helpful (13). As with all exercise protocols, exercise should stop immediately if the patient experiences any adverse reactions (e.g., swelling, chest pain, dizziness). See Table 1 for initial questions to discuss with the breast cancer patient before structuring an exercise program. The order of cancer treatments will vary with each patient; therefore, the strength and
KEY WORDS:

The most recent ACSM recommendations (2010) now state cancer survivors should be as physically active as their abilities and conditions allow. Some

breast cancer; exercise; swimming; strength training

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Table 1
Questions and recommendations for the strength and conditioning professional What is the patients diagnosis? Prognosis? What treatment(s) is the patient receiving (past, present, future)? What was/is the patients precancer tness level? Has the patient been cleared by the medical team for exercise? For swimming? What level of swimmer is the patient? Correct form will be especially important to the postoperative patient What are the patients daily goals? Weekly? Monthly? Explain the Borg 110 scale for rate of perceived exertion. Moderate intensity is 36 on the 110 scale, depending on the patients tness level

underwent mastectomy with improvements in range of motion (ROM) (1).

SWIMMING AS PRESCRIPTION AFTER SURGERY

conditioning professional should become familiar with the effects different cancer therapies may have on the patient.
PART 1: OVERVIEW OF CANCER TREATMENTS AND EXERCISE EFFECTS OF SURGERY

One of the most debilitating treatments involves surgery. Whether the patient undergoes a single or double mastectomy or lumpectomy, almost all patients will also endure lymph node removal. In a mastectomy, the patients entire breast is removed down to the muscle; whereas, with a lumpectomy, a portion of the breast is resected. Additionally, lymph nodes will be removed, which involves cutting through muscle in the midaxillary area (armpit) to access the nodes. A possible side effect of lymph node removal is lymphedema, a very painful condition in which the patients arm swells with uid that cannot be drained because of the missed lymph node pathways. Patients who undergo surgery will need to recover from the trauma of the surgery before being cleared for exercise. Stitches need to heal, drains removed, and initial physical therapy exercises of deep breathing and light stretching should be employed before engaging in an exercise routine. The cancer.org website offers several examples of what the patient will experience in the days and weeks

immediately after breast surgery (12). A sense of tightness in the chest and armpit is normal and will decrease with exercise (12). As one can imagine, recuperation from these surgeries takes time; however, what type of exercise and rehabilitation treatment undertaken once the medical team clears the patient for exercise will depend on age, prediagnosis tness level, and personal goals.
EXERCISE AFTER SURGERY

With the mounting evidence that resistance training improves healing and ROM (1,6,8,10), how does swimming t into the equation of rehabilitation for the injured chest or arm muscles? The simple act of moving through the water provides a form of gentle stretch and resistance. During the freestyle stroke, the patient can initiate a controlled functional stretch. This action helps to strengthen and elongate the damaged muscles, which can help heal old injuries (15). Whether the patient is recovering from breast-altering surgery or lymph node removal, gentle stretch and resistance exercises help to improve strength, exibility, and ROM (1,6,8,10,12,15). All postsurgical patients need to employ various modications in their exercise programs. See Table 2 for exercise variations after surgery.
EFFECTS OF CHEMOTHERAPY

Strength training for breast cancer patients improves issues of lymphedema and improves strength (8). Until 2009, breast cancer patients were told not to use their arm (on the side of the lymph node dissection), not to lift more than 8 pounds, and not to engage in repetitive movements. Schmitz et al. (2009) dispelled this protocol and showed resistance training improves symptoms associated with lymphedema. This study was critical in changing how medical professionals now advise their patients to engage in physical activity. In a study examining home-based therapy of stretch and light progressive resistance, the researchers also showed exercise acted as a therapeutic intervention instead of worsening the lymphedema symptoms. Specically, resistance training with ex bands has been shown to be an effective form of rehabilitation in women who

Another consideration for the strength and conditioning professional to review is the effect of chemotherapy. Chemotherapy treatments will consist of a regular schedule. A common practice is for patients to receive treatments once per month or once every 3 weeks. Also, some patients receive a shot on the following day to boost white blood cells, which can cause severe side effects. Therefore, it is important for the strength and conditioning professional to learn about the patients treatment plan, timing, and openly discuss any side effects the patient is experiencing. Depending on the course of treatment, the patient may experience severe decreases in energy, loss of aerobic capacity, and increased risk of cardiac disease. Multiple resources are available to assist the strength and conditioning professional in reviewing the physiological responses to these treatments (National Cancer Institute, American Cancer Society, Livestrong).

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Swimming for Breast Cancer Patients

Table 2
Postsurgery modifications for the breast cancer patient
Swimming Strength training

Use ns to reduce stress on chest and arms Use a professionally tted compression sleeve when weight training Relax injured side (when applicable) on kick Use light weights board during kick sets No ip turns or pushing off the wall until able Make careful and deliberate to handle the stress of those movements movements Do not use swim paddles until completely healed from the surgeries and ROM has been restored
ROM 5 range of motion.

Aim for no more than 812 repetitions and 13 sets

numerous cardiovascular benets for the patient recovering from the debilitating effects of chemotherapy (7). Swimming provides an excellent means for the cancer patient to increase mitochondria, red blood cells, capillaries, and blood volume, resulting in an increase of oxygen delivery to the human organ systems. Improvements in energy and cardiovascular function are just some of the many benets to regular swimming. It is important to note that because immune systems are also compromised, timing of the swim workouts is important. To swim when the pool is crowded, particularly during u and cold season, may not be ideal. Choosing a time of day where fewer people are in the pool may be preferred.
EFFECTS OF RADIATION

EXERCISE DURING/AFTER CHEMOTHERAPY

Aerobic and resistance exercises improve self-esteem, physical tness, body composition, and chemotherapy completion rate without causing lymphedema or signicant adverse events (3). Specically, researchers had 78 breast cancer patients perform aerobic exercise at 6080% of V O2max, using elliptical, treadmill, and stationary bikes (3). Improved aerobic tness and increased chemotherapy completion rates, without adverse effects, were noted (3). Additionally, the American Cancer Society held a round table in 2011, where the panel concluded that breast cancer patients should be encouraged to exercise during all phases of treatment and efforts to facilitate exercise by reducing barriers should be employed (11). The new ACSM recommendation for cancer patients is to participate in aerobic activity in the 4060% V O2max range, 3 to 5 days per week (14). A confusing issue for many patients is the ability to exercise at high intensity one day and only 20% on another, even after months of posttreatment. The tness professional should pay very close attention to the breast cancer patients responses and tailor the workouts to the patients energy supplies each day (see Table 1 for other questions and recommendations to review with the patient). A good measure of the swimmers

exercise load is to monitor the session RPE using a 0-10 Borg scale (2, 13) where 0 equals rest and 10 equals maximum. For example, to keep the exercise levels at a moderate intensity, the average swimmer should report the rating of perceived exertion between 3 and 6. Patients who were in excellent physical condition before cancer treatments may be able to reach the 78 range; whereas, those who are just beginning exercise after a long period of inactivity should work toward maintaining a 24 range. This method is established as a gauge to assist both swimmer and coach in developing an appropriate exercise protocol.
SWIMMING AS PRESCRIPTION DURING/AFTER CHEMOTHERAPY

Some patients undergo radiation and may receive treatments daily for a certain period of time. Possible side effects include fatigue, soreness, and skin irritation. As with chemotherapy, patients can see a decrease in erythrocytes (red blood cells), which may result in fatigue and possibly anemia. Radiation patients are advised to wear loose clothing as the breast(s) may become tender throughout the treatments.
EXERCISE DURING/AFTER RADIATION

How can the scientic research statistically showing benets from aerobic and resistance training on the wellbeing of the patient during and after chemotherapy be applied toward the swimmer? Swimming is an excellent source of aerobic activity that uses the resistance of the water for the swimmer to move through (5). Furthermore, horizontal posture of the swimmer results in moderately increased stroke volume, improved cardiac output, and lower heart rates (5,7). Also, because the swimmer is not ghting gravity, an increase in exercise-related blood pressure does not occur. Swimming can offer

Moderate intensity aerobic exercise helps to reduce anemia and fatigue associated with radiation treatments (4,6,8). Many patients will prefer to alter their workout routines during radiation to focus mainly on indoor, dry-land activities. Weightlifting, aerobics, yoga, are all viable options during radiation treatments. Patients are at an increased risk of developing lymphedema after undergoing radiation, so a continuation of the stretching and resistance exercises discussed in the surgery section are important for this treatment group as well (1,4,6,8,10). As with chemotherapy patients, aerobic exercise is advised for the radiation patient. Aerobic exercise helps to reduce fatigue, improve body composition, and improve quality of life in breast cancer patients (3,4,6,8,10,11).

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SWIMMING AS PRESCRIPTION DURING/AFTER RADIATION

Precaution to swimming: patients undergoing radiation should receive clearance from the radiology oncologist before initiating a swim program. Some patients experience skin irritation as a result of radiation treatments. The chlorinated water may exacerbate those problems. Also, radiation patients are restricted from exposure to the sun; therefore, protective clothing may be needed if using an outdoor pool. If the oncology team allows the patient to swim, precautions to protect skin from sun and chemicals should be employed. Most radiation patients will probably choose to engage in light aerobics, instead of swimming, during radiation treatments for the reasons mentioned above. For a general review of treatments, precautions, and exercise benets, refer to Table 3.
PART 2: SWIMMING FOR THE BREAST CANCER PATIENT GENERAL SWIMMING RECOMMENDATIONS

injured muscle and cardiovascular function through aerobic and resistance exercise, swimming (which provides both) can be incorporated into the tness regimen. Many ways to structure a swim workout exist, but only a few will be explored here. The comfort and pretness levels of the swimmer should be incorporated in the goals. The individual responses should be evaluated each session. Immediately after surgery and during adjuvant treatment, the following is a basic program that can be tailored to the tness level of the swimmer and altered to address energy levels on any given day. Also, swimming with ns can assist in ameliorating muscle pain because of surgeries. See Table 2 for additional modications. Initially, the swimmer (postsurgery) will not be able to achieve full ROM with the freestyle stroke; however, after careful practice, ROM will begin to improve and each stroke will become easier. Anecdotal evidence shows some swimmers achieve ease of motion within several minutes of initiating the swim stroke; within weeks, complete ROM can be achieved. Using ns helps to reduce resistance for the arm pull, especially

in the beginning of the recuperative process. Another variation is to advise the swimmer to relax the injured arm (side of surgery) on the kick board during the kick sets when needed (Figure 1). The stretch should never be painful. Relaxing the injured arm, while the other is fully extended, helps the swimmer make the small incremental stretches that will improve with repetition. The question remains how the patient who has a double mastectomy or lymph node removal on both sides is to make accommodations as the ones described above? Again, each swimmer will need to try various positions until reaching a comfort level with the exercise. The strength and conditioning professional should explain how even very small reaching movements will help improve ROM and become easier over time. Also important is for the swimmer not to incorporate the use of swim paddles until muscular healing is complete. The paddles provide an additional source of resistance which is too much during the initial phase of training. When using the swimming workouts below, initially the swimmer should use drills focusing on lengthening the stroke, and thereby, improving stretch

Because the scientic data are beginning to show breast cancer patients can safely make improvements to

Table 3
Treatments, precautions, and exercise benefits
Treatment (effects) Precautions Exercise Benets

Surgery (swelling, tightness, decreased range of motion)

Stitches need to heal; drains Swimming, light strength training, ex bands, and removed; care should be stretching exercises taken to produce slow and deliberate movements; focus on stretching the muscles in a gentle fashion

Light stretches will aid in ROM improvements; movements will reduce pain and increase strength. Swimming will improve cardiovascular function, energy, ROM, and self-esteem

Chemotherapy (fatigue, anemia, Should go at individual pace; Swimming, aerobic activity, Improved completion rates, aerobic functioning, weight lifting as the a few minutes each day is nausea, reduced immunity, self-esteem, and strength patient can tolerate better than none sensitivity to the sun) Radiation (fatigue, anemia, sensitivity to the sun) Wear loose comfortable clothing; refrain from exposure to sun; protect skin from irritation Aerobics, yoga, and weight Improved energy, self-esteem, lifting and strength

ROM 5 range of motion.

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Swimming for Breast Cancer Patients

Figure 1. Kick board variation hold. Figure 3. 5 second stroke delay (initiate arm recovery). Figure 7. Finger drag drill (extend in front).

function of the injured side(s). These include: 5 second stroke delay (proper form is depicted in Figures 24 and in Video, Supplemental Digital Content 2, http://links.lww.com/SCJ/A122), nger drag (proper form is shown in Figures 57 and in Video, Supplemental Digital Content 3, http://links.lww.com/SCJ/A123), and catch-up drills (proper form is shown in Figures 810 and in Video, Supplemental Digital Content 4, http://links.lww.com/SCJ/A124). For detailed descriptions of these drills, refer to Table 4. The rst workout example in Table 5 provides light functional stretching for the injured chest/arm muscles and allows the swimmer to increase heart rate without pushing for speed. As ROM improves and strength gains are made, other drills can be added depending on the needs and interests of the swimmer. The strength and conditioning professional may nd that the swimmer is having a difcult time adjusting to the new normal resulting from cancer treatments. The goal is to move, not achieve time standards. Exercising to the level that allows the patient to return the next day is the objective. As with any

Figure 4. 5 second stroke delay (switch to left).

Figure 8. Catch-up drill (initiate arm).

Figure 5. Finger drag drill (initiate).

Figure 9. Catch-up drill (recover over water).

person, consistency is the key to improved health and tness, so making a goal to swim at least 3 days per week is helpful.

The next workout in Table 6 consists of 2,0002,600 m and is for the patient who has completed all treatments and is fully into the recuperative process. The

Figure 2. 5 second stroke delay drill (kick on right).

Figure 6. Finger drag drill (nger tips in water).

Figure 10. Catch-up drill (place hand in front with other hand).

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Table 4
Descriptions of swim drills for front crawl
Drill Description

5 s delay Finger drag

Swim on right side of body with right arm in front and kick for 5 s; rotate to the left side and repeat. Focus on long arm stretch above head Once the right back hand reaches the hip, think high elbow. Right arm goes into recovery (high elbow) but keep tips of ngers in the water as you gently move ngers along side body and extend in front. Fingers never leave the pool water. Repeat left side. Alternate for length of the pool

(Figure 11). Also, the swimmer should focus on achieving the streamlined position when pushing off the wall after ip turns. A continued focus on stretching the arms overhead will benet the patients ROM and tightness in the chest/ arm musculature will continue to diminish with effort and time.
CONCLUSIONS

Catch up Focus on rotation of body along axis. Always keep at least one arm extended in front. Example: Right arm is extended in front of right shoulder; catch-pull-recover with left and left hand goes in front of left shoulder to catch up to where the right hand is. Alternate and repeat

yardage and intensity should be increased or decreased depending on the swimmers energy level each day. The nal workout in Table 7 is for the patient who has almost fully recovered and has the energy and stamina to push the pulmonary, cardiovascular, and muscular-skeletal systems. Again, the challenge with workouts like the one in Table 7 is that the patient may be able to do this one week and not another or even one day and not the next. Understanding how energy levels ebb and ow for the cancer survivor is one of the trickiest elements to comprehend, not only for the patient but also for the strength and conditioning

professional. The patient may need to take breaks and change the intensity at any given moment. The tness professional needs to be in tune with the swimmers reactions and adjust the workout to meet the individuals needs each day. This is the reason the Borg scale is so helpful to the tness professional in assessing the patients swim load. By the time the breast cancer patient reaches the challenge workout described in Table 7, the swimmer should be able to do kick sets without the board. This is a great opportunity to stretch the arms high above the head in a streamlined position

In summary, breast cancer patients are no longer advised to lead sedentary lives during and after cancer treatments. Quite the contrary, because of multiple studies, evidence now supports breast cancer patients and survivors benet from both aerobic and resistance exercises during and after treatments. These exercises assist with the recuperative process after surgeries, help improve cardiovascular function, lessen fatigue, and improve ROM and quality of life. Before beginning any exercise program, the patient needs to obtain medical clearance from the oncology team and discuss exercise goals with the strength and conditioning professional. Although aerobic exercise improves issues of fatigue and increases red blood cells, extreme fatigue should be discussed with the medical professional, as there are medical treatments to improve issues of anemia. Swimming provides both resistance and aerobic benets and is a safe form of exercise for the patient. The tness professional needs to

Table 5
Workout postsurgery or during treatments: (3060 minutes)
Distance (m) Set Pace (Borg value) Notes

100400 100400 100400 100 s 3 (48) 100 8002,200

Warm-up Kick with board Drill/swim Swim Warm-down Total

Slow and easy (13) Easy-strong (35) Slow-easy (13) Moderate-strong with ns (46) Easy (13)

Will probably not do ip turns Relax injured arm on kick board Drill going out; swim back No ip turns; no push off wall

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Swimming for Breast Cancer Patients

Table 6
Posttreatment workout: (45 minutes1.5 hours)
Distance (m) Set Pace (Borg value) Notes

200400 200300 200400 48 3 50 1 3 200 2 3 100 4 3 50 400 200 2,0002,600

Warm-up Kick Drill 25 build; 25 rhythm Swim (free) Swim (free) Sprint Paddles + ns Warm-down Total

Easy (13) Moderate (35) Easy (13)

May/may not do ip turns; push off wall Rest arm on kickboard if needed Focus on stretching the injured muscle(s) Focus on stretch

Moderatestrong (26) Moderatestrong (26) Strong (46) Long and smooth (26) Easy (13) Do not use paddles until chest/arms have recovered from surgery

Table 7
Challenge workout: (11.5 hours)
Distance (m) Set Pace (Borg value) Notes

400 12 3 50 6 3 50 400 2 3 200 4 3 100 12 3 50 600 200 3,900

Warm-up Kick with board Kick on back Drill Stroke Swim Pulling Paddles + Fins Warm-down Total

Easy (13) Moderate to Fast (37) Moderate to Fast (37) Easy (12) Moderate-Fast (46) Strong (47) Descend by 3s Long and smooth (46) Easy (13) Slow-Moderate-Fast (repeat 4 sets) 10 s rest at wall Arms extended above head (15 s rest at wall) Focus on stroke and stretching the arms; incorporate all strokes if possible Stroke by 50s

Figure 11. Kicking on back in streamlined position.

become familiar with the physiological changes the breast cancer patient undergoes even months or years after treatment to provide a realistic exercise program for the patient. As more research is conducted in this area, studies specically calculating the time to achieve complete ROM after surgery comparing various exercise protocols will be benecial to this population. Also, understanding the

aerobic benets of low-to-moderate endurance exercise (comparing effects of running, stationary equipment, and swimming) would be an asset to this community. Enhanced exercise protocols will provide improvements in breast cancer patients overall health, quality of life, and longevity. Conicts of Interest and Source of Funding: The authors report no conicts of interest and no source of funding.

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Elizabeth S. Pittinger is a graduate teaching assistant in the ESHP department at Florida Atlantic University. B. Sue Graves is an Associate Professor, Exercise Science and Health Promotion at Florida Atlantic University.

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Schwartz AL, and the American College of Sports Medicine. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc 42: 14091426, 2010. 10. So HS, Kim IS, Yoon JH, and Park OJ. Effects of aerobic exercise using a ex-band on physical functions & body image in women undergoing radiation therapy after a mastectomy [in Korean]. Taehan Kanho Hakhoe Chi. 36:11111122. 2006. Available at: http://www.ncbi.nlm.nih.gov/pubmed/ 17211114. Accessed October 5, 2012. 11. Stout NL, Binkley JM, Schmitz KH, Andrews K, Hayes SC, Campbell KL, and Smith RA. A prospective surveillance model for rehabilitation for women with breast cancer. Cancer 118(8 suppl): 21872334, 2012. 12. Surgery for breast cancer. American Cancer Society Learn About Cancer. 2012. Available at: http://www.cancer.org/ Cancer/BreastCancer/DetailedGuide/ breast-cancer-treating-surgery. Accessed October 5, 2012. 13. Wallace L, Coutts A, Bell J, Simpson N, and Slattery K. Using session-RPE to monitor training load in swimmers. Strength Conditioning J 30: 7276, 2008. 14. Whaley MH, Brubaker PH, and Otto RM, eds. ACSMs Guidelines for Exercise Testing and Prescription. 8th ed., Baltimore, MD: Lippincott Williams & Wilkins, 2010, p. 231. 15. White ME. Classical stretch, the Esmonde technique. Breast Cancer Rehabilitation Post-Surgery. Available at: http:// breastcancerrehabilitation.com/technique. html. Accessed December 12, 2012.

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