Rehabilitation

Vol. 24, No. 3, 2006

Oncology
Published by the Oncology Section, American Physical Therapy Association

Rehabilitation Oncology
is published three times per year by the Oncology Section Table of Contents
of the American Physical Therapy As­so­ci­a­tion. Issues are
published on May 1, September 1, and November 1.
Assessment of Female Cancer Patients’ Interest in an
DEADLINES
Please submit all material for publication to the Editor by Exercise Program.............................................................. 3
April 1, August 1, September 1. Karen Hock, Julie Leffler, Patricia Schmitt, Sarah Brown,
SUBSCRIPTIONS Vernajean Eggleston
Members—included with Section dues
Nonmembers—$50.00 Random Control Clinical Trial on Effects of Aerobic
Institutions—$50.00
Exercise Training on Weight Management During
Back Issues:
Section members—$5.00 Radiation Treatment for Breast Cancer............................ 6
Nonmembers—$20.00 Jacqueline S. Drouin, Thomas J. Birk, John C. Wirth
Make checks payable to: Orthopaedic Section
Please send all items for publication to the Editor: Physical Therapy Management of Patients with Multiple
Steve Gudas, PT, PhD Myeloma: Musculoskeletal Considerations................... 11
Editor, Rehabilitation Oncology Spiridon G. Karavatas, E. Anne Reicherter,
Cancer Rehabilitation Box 980030
Nancy White, Aisha Strong
VCU/Medical College of Virginia
Richmond, VA 23298
HIV Abstracts................................................................. 17
804.828.4069, Fax 804.828.9477, sagudas@vcu.edu
The contents of articles appearing in this publication rep­re­sent
the thoughts and ideas of the authors and are not nec­es­sar­i­ly
those of the Editor, the Executive Committee of the On­col­o­gy EDITORIAL BOARD
Section, or general mem­ber­ship of the Section. The Editor
re­serves the right to edit submitted manuscripts or other ma­te­ Steve Gudas, PT, PhD – Editor
ri­al for pub­li­ca­tion. We en­cour­age comments and opin­ions VCU/Medical College of Virginia
concerning the con­tent of Re­ha­bil­i­ta­tion On­col­o­gy through Richmond, VA
Letters to the Editor.
Maggie Rinehart Ayres, PT, PhD
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 Rehabilitation Oncology
Vol. 24, No. 3, 2006

Oncology Section Officers

and Committee Chairs
PRESIDENT AWARDS COMMITTEE CHAIR
Nicole Gergich, MPT, CLT-LANA Eileen Donovan, PT
Breast Cancer Center UTMDACC
8901 Wisconsin Ave Work: 301-295-3899 5719 Spellman Rd Home: 713-723-4788
Bldg 10, 4 West Fax: 301-295-9076 Houston, TX 77096-6040 E-mail: esdonovan@cs.com
Bethesda, MD 20889-5600 E-mail: nlgergich@msn.com
LEGISLATIVE/PRACTICE CHAIR
VICE PRESIDENT Nancy J. Roberge, PT, DPT, MEd
Venita Lovelace-Chandler, PhD, PT, PCS Wellesley, MA E-mail: nroberge@comcast.net
Chapman University
130 Hashinger Sci Bldg EDUCATION CHAIR
One University Drive Home: 714-997-6755 Noel Garcia Espiritu, PT, GCS E-mail: ngespiritu@optonline.net
Orange, CA 92866 E-Mail: lovelacech@chapman.edu
PROGRAM AND PROFESSIONAL DEVELOPMENT CHAIR
SECRETARY Linda Doering, PT
Marisa Perdomo, PT, DPT Staten Island, NJ E-mail: lddoering@yahoo.com
Altadena, CA E-Mail: perdomo@usc.edu
NOMINATING/ELECTION CHAIR
TREASURER Kate Hummel-Berry, PT, PhD
Rick Wilson, PT, PhD Work: 813-974-8870 Tacoma, WA E-mail: hummel@ups.edu
School of Physical Therapy Fax: 813-974-8915
University of South Florida Email: rwilson@hsc.usf.edu MEMBERSHIP CHAIR
12901 Bruce B. Downs Blvd, Joy C. Cohn, PT Work: 215-614-0674
MDC 077 Penn Therapy & Fitness E-mail: cja44@aol.com
Tampa, FL 33612-4766 3624 Market St
Philadelphia, PA 19104
DIRECTOR-AT-LARGE
Leslie J. Waltke, PT Work: 414-219-7193 HIV SPECIAL INTEREST GROUP CHAIR
Milwaukee, WI E-mail: leslie.waltke@aurora.org Michaele R. Smith, PT, MEd
Bethesda, MD E-mail: michaele_smith@nih.gov
IMMEDIATE PAST PRESIDENT
Pamela Rand Massey, PT Work: 713-792-3190 lymphedema SPECIAL INTEREST GROUP CHAIR
3315 Plumb Street Fax: 713-745-1132 Lesli Bell, PT
Houston, TX 77005-2923 E-mail: pmassey@mdanderson.org Winooski, VT E-mail: lbellpt@aol.com

EDITOR, Rehabilitation Oncology Liaison FROM THE STUDENT ASSEMBLY

Stephen A. Gudas, PT, PhD Work: 804-828-4069
Cancer Rehabilitation Home: 804-752-2825
Box 980030 Fax: 804-828-9477
Medical College of Virginia E-mail: sagudas@vcu.edu
Richmond, VA 23298
Benjamin Scott Braxley, SPT E-mail: aptasa_sptdelegate@hotmail.com
Decatur, GA
Student Activities Chair
Anna E. Tensmeyer, SPT E-mail: atensmeyer@gmail.com

PUBLICATIONS CHAIR WEB

Maggie Rinehart Ayres, PT, PhD Work: 215-503-1647
Thomas Jefferson University Home: 215-885-1334
130 S. 9th St. Fax: 215-503-1647
Philadelphia, PA 19107 E-mail: margaret.ayres@jefferson.edu
RESEARCH CHAIR
Mary Lou Galantino, PT, PhD Work: 609-652-4408
Physical Therapy Program Home: 302-475-3258
Richard Stockton College of NJ Fax: 609-652-4858
Jim Leeds Road E-mail: galantinom@stockton.edu
Pomona, NJ 08240-9988
Loraine Lovejoy-Evans, PT E-mail: lovejoyevans@hotmail.com
Carlsborg, WA
Executive Office
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Publisher
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LaCrosse, WI 54601-7202 E-mail: sklinski@orthopt.org
Rehabilitation Oncology 
Vol. 24, No. 3, 2006

Assessment of Female Cancer Patients’

Interest in an Exercise Program
Karen Hock, MS, PT, CLT-LANA;1 Julie Leffler, PT, CLT;1
Patricia Schmitt, MA, CRC;2 Sarah Brown, MA, PC;3
Vernajean Eggleston, MSW, LISW4

1
JamesCare Dublin Rehabilitation Oncology, The Ohio State University Arthur G. James Cancer Hospital
and Richard J. Solove Research Institute
2
Director, JamesCare for Life, The Ohio State University Arthur G. James Cancer Hospital
and Richard J. Solove Research Institute
3
JamesCare for Life, The Ohio State University Arthur G. James Cancer Hospital
and Richard J. Solove Research Institute
4
JamesCare Dublin Social Work, The Ohio State University Arthur G. James Cancer Hospital
and Richard J. Solove Research Institute

ABSTRACT ment. The patients showed improvements in aerobic capacity,

Ninety patients with a diagnosis of cancer completed a survey
that assessed each patient’s prospective interest in an exercise
program. Participants had a history or current diagnosis of breast
or gynecological cancer. The average age of the participants was
52.4 years; average age at diagnosis was 49.8 years. Participants
were asked to rank each form of exercise from highest to lowest.
A number 5 was rated as ‘very interested,’ while a number 1 indi­
cated ‘not interested.’ Walking was rated the most interested form
of exercise with an average interest rating of 4.25. Dance/move­
ment, Yoga, and Pilates came in as the second, third, and fourth
most interested. Aquatics and Tai Chi received the lowest ratings
at 2.85 and 2.59, respectively. Fifty-seven of the 90 participants
stated they would be willing to pay a minimal fee for the exercise
program. The results indicate that this specific patient popula­
tion is interested in exercise programs. More research needs
to be conducted to further explore patients’ interests for future
programming.
BACKGROUND
A review of the research provides support that exercise is
beneficial to patients with cancer in a multitude of ways, both
physically and psychologically. McTiernan, Gralow, and Talbott1
indicate that not only does exercise decrease the risk for cancer,
but it can also reduce cancer-promoting growth factors in breast
cancer patients. Other research has indicated that exercise may
simply make people with cancer ‘feel better.’
In an article by the Lance Armstrong Foundation,2 the benefits
of exercise were documented to include reduction of symptoms,
such as weakness, loss of balance, fatigue, stiff joints, weight loss/
gain, problems sleeping, and restlessness. In addition to physi­
cal benefits, exercise is thought to improve mood. According to
the National Coalition for Cancer Survivorship,3 exercise also
reduces stress, promotes relaxation, improves confidence, and
increases ability to cope. Other studies have examined the impact
of exercise in patients who are undergoing chemotherapy treat­
physical capacity, and strength.4
Though the intensity, duration, and frequency of exercise
within a particular cancer diagnostic group have yet to be clearly
defined, the benefit of movement for a patient with cancer is
recognized. Patients with breast and gynecologic cancer share
many of the same rehabilitative issues in regard to the predisposi­
tion for lymphedema, the side effects of the chemotherapies used,
and issues related to sexuality, to name just a few. Given the
direction of the research thus far in regard to exercise and cancer,
a project team was formed at James Cancer Hospital and initiated
its inquiry with the development of a survey to determine what
type of exercise was preferred by women with breast or gyneco­
logic cancers. The survey also assessed interest and likelihood in
participating in a scheduled program of exercise tailored specifi­
cally for patients with cancer.
Recent contributions to the literature on exercise have docu­
mented the benefit of exercise in possibly reducing the risk of
developing breast cancer and reducing risk of recurrence for
women who have already been diagnosed with breast cancer.
The pioneering studies undertaken by MacVicar, Winningham,
and Nickel5 in the late 1980s showed that women undergoing
breast cancer treatment could improve their functional capacity
despite the side effects of chemotherapy. McTiernan, Gralow,
and Talbot1 report that exercise can reduce levels of estrogen
and cancer-promoting growth factors in the body. Exercise for
the patient with breast cancer can be an empowering modality in
quality of life and quality of survivorship.
Research is mixed regarding the role of exercise and
the incidence of gynecologic cancer, specifically ovarian
cancer.6-8 Exercise, as mentioned previously, can decrease the
level of estrogen available and can also reduce chronic inflam­
mation. As these are risk factors for the development of ovarian
cancer, it is plausible to think that exercise would have an inverse
association with the development of ovarian cancer. Thus far,
this has not been strongly proven in the literature.
 Rehabilitation Oncology
Given the other physical, and emotional benefits of exercise,
as well as the need to treat other co-morbid conditions of patients
with cancer such as heart disease and diabetes, exercise is still
a valid modality for the patient with gynecologic cancer and
certainly more study is warranted to assess its direct benefit.
Exercise preferences are important in trying to initiate an
exercise program and have the patient comply with the program.
Relatively few studies have been published that report the exer­
cise preferences of cancer patients. A research study by Jones
and Courneya9 examined the exercise preferences and exercise
counseling for cancer survivors. The study found that the major­
ity of respondents preferred to be counseled about exercise during
their cancer treatment. They also preferred to be counseled by a
professional affiliated with a cancer center. Walking was rated as
the most favorable type of exercise and morning was the chosen
time of day. In addition, most patients preferred moderate inten­
sity exercise to low or high intensity. Another study related to
exercise preferences10 studied patients between the ages of 74-85.
This specific patient population preferred an exercise class or
facility close to their home with walking as the most acceptable
method of exercise.
The impact on quality of life related to exercise has been
documented and the results demonstrate that exercise does favor­
ably impact how patients perceive their quality of life. A research
study involving breast cancer patients found that early interven­
tion exercise programs, whether home-based or group-oriented,
increased how the women perceived their quality of life. The
scores improved between 6 and 12 months after diagnosis.11
Another study examining patients with gynecologic cancer found
a relationship between quality of life and body weight.12 The
study found that the patients with a more significant body-mass
index reported a lower quality of life. The study also reported
that patients who met the public exercise guidelines felt that they
had a higher quality of life. Another study showed similar results
with patients reporting a higher quality of life after participating
in a physical fitness routine.13 The results of these studies support
the importance of exercise in this specific patient population.
METHODS
Participants were selected at random based on both their
availability and the permitting schedule of the administering
health care professional. The participants were patients over the
age of 18 with a diagnosis of breast or gynecologic cancer. The
surveys were administered in the outpatient ambulatory envi­
ronments while patients were waiting for appointments. Each
participant was asked if they were willing to complete the survey.
Upon verbal consent, the participants were given a private
area to complete their answers to the survey in order to protect
and assure confidentiality. The completed surveys were then
collected from the participants and placed in a secured cabinet.
Once all the surveys were completed, an analysis of the data was
conducted to determine which types of exercise were of most
interest to the respondents. The survey consisted of a checklist
Vol. 24, No. 3, 2006
of exercise options with blank areas to describe other activities,
if identified.
DATA
Ninety female participants completed the survey. The average
age of participants was 52.4 years, with average age at diagno­
sis 49.8 years. Of the 90 surveys completed, 53 patients had
breast cancer and 37 had a variety of cancer diagnoses, which
included ovarian, lung, melanoma, thyroid, and kidney cancer.
Participants were at different points in the continuum of care.
Forty-eight participants were currently being treated for their
cancer, while 25 were post-treatment.
Participants were asked to rank forms of exercise using a
Likert scale from highest to lowest. A 5 was rated as ‘very inter­
ested’ while a one indicated ‘not interested.’ Walking was rated
the most interested form of exercise with an average rating of
4.25. Dance/movement, yoga, and Pilates ranked second, third,
and fourth respectively. Aquatics and Tai Chi received the lowest
ratings of 2.85 and 2.59 respectively. Fifty-seven of the ninety
participants stated they would be willing to pay a minimal fee for
a structured exercise program tailored specifically for patients
with cancer. Twenty-eight participants were currently involved
in some type of exercise program.
DISCUSSION
The results of our study indicate that patients are interested
in participating in some type of exercise program. Most patients
surveyed were residing at a distance too far to easily participate in
an exercise program at our academic medical center. However, of
those patients who were interested in participating, walking was
the most popular form of exercise desired, followed by dance/
movement. The survey indicated that over half of the individu­
als surveyed would be willing to pay a minimal fee for services.
The findings also show that only 31% of the participants were
currently engaged in an exercise program. This small percent­
age suggests that patients should and need to be encouraged and
educated on the benefits of exercise both during and beyond
cancer treatment. The results indicate that exercise is an area of
interest in this patient population. More research needs to be
conducted on how exercise modalities can be more accessible to
this patient population.
REFERENCES
1. McTiernan A, Gralow JL, Talbot L. Breast Fitness: An
Optimal Exercise and Health Plan for Reducing Your Risk of
Breast Cancer. New York, NY: St. Martin’s Griffin; 2000.
2. Lance Armstrong Foundation-Healthy Behaviors: Detailed
Information. Available at: http://www.livestrong.org/site/
Detailed_Information.htm. Accessed July 7, 2005.
3. NCCS: Palliative Care & Symptom Management-Exercise.
(n.d.) Available at: http://www.cansearch.org/resources/
essential/exercise.aspx. Accessed July 7, 2005.
4. Adamsen L, Quist M, Midtgaard J, et al. The effect of a
Rehabilitation Oncology
Vol. 24, No. 3, 2006
multidimensional exercise intervention on physical capacity,
well-being and quality of life in cancer patients undergoing
chemotherapy. Support Care Cancer. 2006;14:116-127.
5. MacVicar MG, Winningham ML, Nickel J. Effects of aerobic
interval training on cancer patients’ functional capacity. Nurs
Res. 1989;38:348-351.
6. Hannan LM, Leitzmann MF, Lacey Jr. JV, et al. Physical
activity and risk of ovarian cancer: a prospective cohort study
in the United States. Cancer Epidemiol Biomarkers Prev.
2004;13:765-770.
7. Bertone ER, Newcomb PA, Willett WC, et al. Recreational
physical activity and ovarian cancer in a population-based
case-control study. Int J Cancer. 2002;99:431-436.
8. Cottreau CM, Ness RB, Kriska A.M. Physical activity and
reduced risk of ovarian cancer. Obstet Gynecol. 2000;96:609-
614.
9. Jones LW, Courneya KS. Exercise counseling and program­

ming preferences of cancer survivors. Cancer Pract.
2002;10:208-215.
10. Cohen-Mansfield J, Marx MS, Biddison JR, Guralnik JM.
Socio-environmental exercise preferences among older
adults. Prev Med. 2004;38:804-811.
11. Gordon LG, Battistutta D, Scuffham P, Tweeddale M,
Newman B. The impact of rehabilitation support services on
health-related quality of life for women with breast cancer.
Breast Cancer Res Treat. 2005;93:217-226.
12. Courneya KS, Karvinen KH, Campbell KL, et al. Associations
among exercise, body weight, and quality of life in a popula­
tion-based sample of endometrial cancer survivors. Gynecol
Oncol. 2005;97:422-430.
13. Kolden GG, Strauman TJ, Ward A, et al. A pilot study of
group exercise training (get) for women with primary breast
cancer: feasibility and health benefits. Psychooncology.
2002;11:447-456.
 Rehabilitation Oncology
Vol. 24, No. 3, 2006

Random Control Clinical Trail on Effect of Aerobic

Exercise Training on Weight Management During
Radiation Treatment for Breast Cancer*
Jacqueline S. Drouin, PT, PhD;1 Thomas J. Birk, MPT, PhD;2 John C. Wirth, PhD3

1
Department of Physical Therapy, School of Health Professions and Studies, University of Michigan-Flint, Flint, MI
2
Department of Health Care Sciences, Wayne State University, Detroit, MI
3
Division of Kinesiology, Health, and Sport Sciences, Wayne State University, Detroit, MI

*Platform presentation at the American Physical Therapy Association Combined Sections Meeting, Nashville, TN, February 2004.

ABSTRACT
Background and Purpose: This study examined aerobic
exercise training effects on kilograms (KG), body mass index
(BMI), and skin caliper measures (SCM) in females undergoing
radiation for breast cancer. Subjects: 20 sedentary females (50.0
± 8.2 years old) with breast cancer [Stage 0 (Insitu)-III]. Methods:
Participants were randomly assigned to moderate intensity aero­
bic exercise walking (AE) or placebo-stretching (PS) protocols
performed 3-5 times during 7 weeks of radiation. KG, BMI, and
SCM were measured one week before and after the radiation and
activity regimens. Wilcoxon Signed-Rank Test assessed pre-
post differences, Wilcoxon-Mann-Whitney U examined between
group differences (p < .05). Results: Baseline measures were not
significantly different between groups. Following the interven­
tions, KG, BMI, and SCM decreased significantly in AE partici­
pants (p < .01 for all measures) while PS changes were not signifi­
cant. Discussion and Conclusions: Aerobic exercise appears to
promote weight management during radiation for breast cancer.
INTRODUCTION maintain their body weight, while overweight and obese women
Women undergoing treatment for breast cancer commonly
experience increases in their weight and their body mass index.1
Women with breast cancer, who are overweight or obese, are
also at higher risk for developing post-treatment morbidities that
include lymphedema, heart disease, and diabetes.2 In addition,
overweight and obesity appears to be associated with reduced
survival rates in individuals with cancer.3,4 Therefore, methods
to safely prevent weight gain or manage obesity in women being
treated for breast cancer may be of benefit to reduce post-treat­
ment morbidity and improve breast cancer outcomes.
Two prior studies were found that examined the effects of
exercise training on weight management in women undergoing
treatment for breast cancer. Winningham and colleagues exam­
ined the effects of aerobic exercise on body weight and body
composition in 24 females during adjuvant chemotherapy for
Stage II breast cancer.5 Participants were randomized to an exer­
cise or a control group. The exercise group performed aerobic
exercise 3 to 5 days per week for 10 to 12 weeks at 60% to 85%
of their measured maximum heart rates. Following the interven­
tion, women in the exercise group gained 0.82 kilograms but lost
3.19 millimeters on skin caliper measures. Nontraining subjects
gained 1.99 kilograms and experienced increases in skin caliper
measures of 9.66 millimeters. Moreover, women in the exercise
group were reported to have gained 2.04 kilograms of lean mass
while nontraining women lost 1.26 kilograms of lean mass. The
authors concluded that even with a small sample and lack of diet
controls, aerobic exercise appeared to be beneficial in controlling
weight gain during adjuvant chemotherapy for breast cancer.
A subsequent study by Goodwin and colleagues examined the
effects of a multidisciplinary weight management program, that
included exercise, on body weight and body mass index (BMI) in
females with local and regional breast cancer receiving chemo­
therapy, tamoxifen, and/or radiation.6 In this study, 61 females
with Stage I-III breast cancer participated in 20 psychological
supportive-expressive group sessions that included individual
weight goals, and nutrition and exercise programs. The goal
of this study was that, over the course of one year, participants
with a normal baseline BMI of equal to or less than 25 would
with a baseline BMI of greater than 25 would exhibit a loss of
body weight and an improved BMI. Fifty-five of 61 participants
completed this study and 70.9% met the predefined goal crite­
ria. Women, who were overweight or obese at baseline, lost
1.63 ± 4.11 kilograms. The authors concluded that the strongest
predictor for weight maintenance or weight loss in their study
was participation in aerobic exercise. Weight changes specific
to women undergoing radiation treatment were not reported in
this study.
Although prior evidence suggests that aerobic exercise training
during treatment for breast cancer enhances weight management,
the effect of aerobic exercise training during radiation treatment
in women with breast cancer has not been previously explored or
described. Additionally, associations between changes in peak
aerobic fitness and anthropometric factors following training
have not been previously reported during radiation treatment.
Therefore, the purpose of this study was to examine the effects
of moderate intensity aerobic exercise performed during radiation
treatment for breast cancer on anthropometric measures of body
Rehabilitation Oncology
Vol. 24, No. 3, 2006
mass in kilograms (KG), BMI, and skin caliper measures (SCM)
and compare the results to those of nontraining females with
breast cancer who are undergoing radiation therapy. This study
also examined whether there were associations between changes
in physical fitness, as measured by peak aerobic capacity (peak
VO2), and the final anthropometric measures. This investiga­
tion was a secondary analysis of unanalyzed data from a train­
ing study that examined the effects of aerobic exercise training
on peak aerobic capacity, fatigue, and psychological factors in
females undergoing radiation for breast cancer.7
METHODS
Subjects
Following human subject committee approvals, women were
recruited through oncologists at an urban cancer center. Potential
subjects were provided with written and verbal information about
the study, informed that participation was voluntary, and that all
data would be confidential. Subjects who agreed to participate
in this study signed informed consent and then were randomly
assigned to the aerobic exercise (AE) group or the placebo
stretching (PS) group using a random number table.
Criteria for inclusion were female gender, aged 20 to 65 years,
and a breast cancer diagnosis [Stage 0 (Insitu) to Stage III].
Participants received medical clearance from their oncologist, a
Multiple Uptake Gated Scan (MUGA) for heart function, and a
symptom limited graded exercise test with electrocardiography.
Exclusion criteria were uncontrolled cardiovascular, pulmonary
conditions, orthopedic conditions that would prevent participa­
tion in the activities, refusal to be randomized, or participation in
exercise training within 3 months prior to entering the study.
Research Design
This investigation was a secondary analysis of unanalyzed
data from a prospective random-control clinical trial that used a
pretest, intervention, post-test design. The experimental condi­
tion was radiation and aerobic exercise and the control condition
was radiation and placebo-flexibility activities.
Tests and Measures
Tests and measures were obtained one week before and one
week after the radiation and activity regimens. Participants were
instructed to attend the testing sessions wearing exercise cloth­
ing and exercise shoes, and to abstain from food, caffeine, and
tobacco for at least 4 hours prior to testing. As the majority of
the tests were performed in the morning, most subjects fasted
overnight. All anthropometric measurements were performed
by a single investigator. KG mass measures were obtained using
the same calibrated balance scale with the subject wearing light­
weight exercise clothing but removing their shoes. Body mass
index is an assessment that ranks individuals into normal (BMI <
25), overweight (BMI 25-30), obese (BMI 30-40), and morbidly
obese (BMI > 40) categories. The factors required to compute
the BMI are the individual’s weight or mass in kilograms and
their height in meters. The calculation used was the individual’s
BMI was equal to their kilogram mass divided by their height

in meters squared. Mass was measured as described above and
height was measured using the same height measurement device
that extended from the top of the balance scale, with the patient
standing in the akimbo position facing away from the device, feet
slightly apart with hands resting on the hips.
Skin caliper measures were obtained using the same skin cali­
per device (Lange Skin Caliper). Standard skinfold measurement
sites and techniques were performed according to the guidelines
of the American College of Sports Medicine.8 The 7 skinfold
sites measured on the noninvolved side were the anterior axillary
fold, the posterior arm, the medial inferior border of the scapula,
the abdomen, the hip, the anterior thigh, and the posterior calf.
Calibration was performed prior to measuring each participant
and intra-rater reliability assessed prior to the study was within
3 millimeters or 2.3%. Hydrostatic weighing, a relatively accu­
rate method for measuring body composition through immer­
sion in specially designed water tanks, was not performed due
to concerns for exposure to infections in immune-suppressed
individuals.8 Body fat percentages were not calculated since the
body density measures required to complete this calculation are
not known for females with breast cancer at this time.
A symptom limited graded exercise test was administered
to measure peak aerobic fitness (peak VO2) and to assure that
training adaptations had occurred. Peak VO2 was measured
using continuous oxygen uptake analysis through open circuit
spirometry and indirect calorimetry of expired gases using
an automated metabolic cart (Jaeger, Model: Oxycon-Alpha,
Hoechberg, Germany) while the participant performed the exer­
cise test using a modified Bruce protocol. Exercise testing was
performed according to American College of Sports Medicine
guidelines with onsite physician supervision and screening and
safety factors specific for exercise in individuals with cancer
were followed.8-10
Interventions
Aerobic exercise training
Individualized exercise prescriptions were developed for each
participant in the AE group from the results of the initial symptom
limited graded exercise test. Aerobic exercise group participants
performed self-monitored walking using heart rate monitors to
record exercise duration and intensity. The aerobic exercise train­
ing regimen consisted of walking 20 to 45 minutes, 3 to 5 times
per week, at 50% to 70% of the individual’s measured maximum
heart rate, during 7 weeks of radiation.
Flexibility activities
Participants in the PS group performed flexibility activities 3
to 5 days per week during 7 weeks of radiation. The flexibility
activities included stretching for the cervical and lumbar spine,
and the upper and lower extremities. Each women in the PS
group received instructions on proper stretching techniques from
a licensed physical therapist.
Activity monitoring
Both the AE and PS participants kept activity journals and
 Rehabilitation Oncology
were contacted weekly by the principle investigator to monitor
exercise safety and adherence, and to answer questions about the
activities. All participants were instructed to contact their physi­
cian if they developed any undesirable symptoms related to the
radiation treatment or to the activities.
Radiation Regimen
Participants underwent breast surgery and then received exter­
nal beam radiation 5 days per week for 7 weeks. The involved
breast and regional lymph nodes were treated with a 4500 to 5000
cGy dose in 200 cGy fractions with a boost of 1000-1600 cGy
delivered to the primary tumor bed.
Statistical Analyses
Since data did not meet parametric assumptions, statistical
analyses were conducted using nonparametric assessments.11
The Wilcoxon Signed Rank Test (WSRT) evaluated differences
between pretest and posttest measures, the Wilcoxon-Mann-
Whitney U (WMWU) assessed between group differences, and
correlations were determined by Spearman’s Rho analysis with
probability at ≤ .05. Statistical analyses were performed using a
Statistical Package for Social Sciences software program (SPSS
10.1, Chicago, Ill).
RESULTS
Twenty-one subjects with breast cancer, Stage 0 (ductal
carcinoma in situ) to Stage III, completed the study; 13 in the
AE group and 8 in the PS group. One PS participant’s data was
not included in the final analysis due to moderate to severe fluid
retention during the initial test session which prevented accurate
anthropometric assessment. Aerobic exercise participants exer­
cised 3.68 ± 1.4 days per week and PS participants performed
flexibility activities 4.16 ± 1.1 days per week. Evidence for
Body Mass
Figure 1. Body mass in kilograms decreased by 2.1% (p =
.005) in the AE group following the intervention, while PS val-
ues did not significantly change (p = .367).
Vol. 24, No. 3, 2006
aerobic exercise training was the significant improvement in
peak VO2 measures of 6.3% (p < .001) in the AE group, while PS
participants exhibited a nonsignificant decline of 4.6% (p = .083)
during this time.
Statistical Results
The W-MWU analyses of pretest scores found no significant
differences between the AE and the PS groups for all baseline
measures; KG (p = .361), BMI (p = .374), SCM (p = .175), and
peak VO2 (p = .192). Following the intervention, AE measures
decreased significantly for KG from 81.6 to 79.9 kg. (p = .005),
for BMI from 30.8 to 30.1 (p = .004), and for SCM from 202.4
to 180.4 (p = .001). Placebo stretching measures did not change
significantly for KG (p = .367), BMI (p = .367), and SCM (p =
.458) (See Table 1).
Spearman’s Rho analysis revealed significant negative corre­
lations between changes in peak VO2 measures and KG (p=.018),
BMI (p=.016), and SCM (p=.016) (See Table 2).
DISCUSSION
A common problem experienced by women undergoing
treatment for breast cancer is weight gain which may be associ­
ated with higher rates of posttreatment morbidity and decreased
cancer survival rates. Goodwin and colleagues assessed anthro­
pometric measures on 535 females with a breast cancer diag­
nosis and found that 84% experienced a statistically significant
weight gain; of interest was that weight gain was not linked to
caloric increases.1 In the study by Winningham and colleagues,
nontraining subjects experienced increases in body mass of 1.99
kilograms and increases in skin caliper measures of 9.66 mm.5
In the present study, women in the nontraining group exhibited
negligible declines in weight or mass of 0.16 kilograms and in
body mass index of 0.04 and nonsignificant increases in skin
Body Mass Index
Figure 2. Body Mass Index decreased by 2.2% (p = .004) in
the AE group following the intervention, while PS values did
not significantly change (p = .367).
Rehabilitation Oncology 
Vol. 24, No. 3, 2006

caliper measures of 2.9 mm. Although flexibility exercises are

Skin Caliper Measures
Figure 3. Skin Caliper Measures decreased by 10.9% (p =
.001) in the AE group following the intervention, while PS val-
ues did not significantly change (p = .458).
not usually linked to weight management, perhaps the stretching
activity combined with positive attention during this time influ­
enced the placebo group outcomes.
In the study by Winningham and colleagues, women in the
training group gained 0.82 kilograms but lost 3.19 millimeters of
skin caliper measures following 10 to 12 weeks of aerobic exer­
cise during adjuvant chemotherapy for breast cancer. The authors
also indicated that the training group exhibited a significant
increase in lean body mass of 2.04 kg compared to a 1.06 kg loss
in the nontraining group. The present study also found signifi­
cant improvements in women who performed moderate intensity
aerobic exercise during radiation treatment for breast cancer.
Women in the training group exhibited decreases in mass of 1.8
kilograms (-2.1%), BMI of 0.67 (-2.2%), and SCM of 21.9 milli­
meters (-10.9%). Both this study and the present study exhibited
improvements in the training subjects; minor differences in the
improvements between the two studies may have been related to

Table 1. Summary Statistics

Variable Mean Standard Deviation % Change Pre-Post
AE KG
Baseline 81.63 21.60 - 2.1% p = .005*
Final 79.88 20.93
PS KG
Baseline 85.63 17.32 - 0.0% p = .367
Final 85.47 18.41
AE BMI
Baseline 30.76 7.57 - 2.2 % p = .004*
Final 30.09 7.34
PS BMI
Baseline 32.87 5.45 - 1.2% p = .367
Final 32.83 5.56
AE SCM
Baseline 202.38 72.61 - 10.9% p = .001*
Final 180.39 72.27
PS SCM
Baseline 237.21 59.50 - 0.8% p = .458
Final 239.14 61.46
* Significant change (p ≤ .05).

Table 2. Correlations
Mass in Kilograms Body Mass Index Skin Caliper Measures
Peak VO2
Correlation Coefficient -.473 -.478 -.482
Sig. (1-tailed) .018* .016* .016*
*
Significant (p ≤ .05)
10 Rehabilitation Oncology
Vol. 24, No. 3, 2006

differences in the length and intensity of training, differences in
the cancer treatment, and in the breast cancer stages.
The present study also found significant negative correlations
between the fitness measure of peak VO2 and the final KG, BMI,
and SCM measures, lending support to the benefit of aerobic
exercise training for in weight management during this time.
The major limitation of the present study was the small sample
size and the short training duration of approximately 8 weeks. A
second limitation was that there was no control of nutrition or
dietary intake during the interventions. A final limitation was that
although the exercise prescription was sufficient to cause positive
training effects, there were individual variations in training regi­
mens from 20 to 45 minutes and between 3 and 5 days per week,
which may have influenced the amount of KG weight lost or the
degree of changes in BMI and SCM.
CONCLUSION/RECOMMENDATIONS
Study results support the potential for moderate aerobic exer­
cise to be a safe, effective, and economical method for improving
weight management in females undergoing radiation treatment
for breast cancer. This study also found positive correlations
between changes in peak aerobic capacity and final anthropomet­
ric measures suggesting an association between endurance train­
ing and weight management during this time. Additional research
on this topic would be beneficial using larger samples, different
cancer diagnoses, and other cancer treatments to further explain
the impact of exercise on cancer and its treatments.
6. Goodwin P, Esplen MJ, Butler K, et al. Multidisciplinary
weight management in locoregional breast cancer: results of
a phase II study. Breast Cancer Res Treat. 1998;48:53-64.
7. Drouin JS, Armstrong H, Krause S, et al. Effects of aero­
bic exercise training on peak aerobic capacity, fatigue, and
psychological factors during radiation for breast cancer.
Rehabil Oncol. 2005;23:11-17.
8. American College of Sports Medicine’s Guidelines for
Exercise Testing and Prescription 7th ed. Philadelphia, Pa:
Lippincott Williams Wilkins; 2006.
9. Winningham ML, MacVicar MG, Burke CA. Exercise guide­
lines for cancer patients: guidelines and precautions. Phys
Sportsmed. 1986;14:125-134.
10. Drouin JS, Pfalzer L. Aerobic Exercise Guidelines for the
Person with Cancer Acute Care Perspectives. 2001;10(1 &
2):18-24.
11. Cohen J. Statistical Power Analysis for the Behavioral
Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum
Associates; 1988.

REFERENCES
1. Goodwin PJ, Ennis M, Pritchard KI, et al. Adjuvant treat­
ment and onset of menopause predict weight gain after breast
cancer diagnosis. J Clin Oncol. 1999;17:120-129.
2. Bentzen SM, Dische S. Morbidity related to axillary irra­
diation in the treatment of breast cancer. Acta Oncologica.
2000;39:337-347.
3. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ.
Overweight, obesity, and mortality from cancer in a prospec­
tively studied cohort of U.S. adults Commentary/Response:
Futterman R. DataBase: research and evaluation results.
[Commentary on] Overweight, obesity, and mortality from
cancer in a prospectively studied cohort of U.S. adults. Am
J Health Promot. 2004;18:333-334 (commentary); CINAHL
Acc. No.: 2004100222. New England J Med. 2003;348:1625-
1638.
4. Zhang S, Folsom AR, Sellers TA, Kushi LH, Potter JD.
Better breast cancer survival for postmenopausal women
who are less overweight and eat less fat. The Iowa Women’s
Health Study. Cancer. 1995;76:275-283.
5. Winningham ML, MacVicar MG, Bondoc M, Anderson
JI, Minton JP. Effect of aerobic exercise on body weight
and composition in patients with breast cancer on adjuvant
chemotherapy. Oncol Nurs Forum. 1989;16:683-689.
Rehabilitation Oncology
Vol. 24, No. 3, 2006
Physical Therapy Management of Patients with
Multiple Myeloma: Musculoskeletal Considerations
Spiridon G. Karavatas PT, DPT, MS, GCS;1 E. Anne Reicherter, PT, DPT, Med, OCS, CHES;1
Nancy White, PT, MS, OCS;1 Aisha Strong, PT, MPT1
1
Department of Physical Therapy/DAHS/CPNAHS, Howard University, Washington, DC
ABSTRACT
Multiple myeloma is a cancer of the plasma cells which
significantly impacts the musculoskeletal system. Physical ther­
apists may play an important role in various stages of the progres­
sion of this disease. The purpose of this article is to describe the
role of the physical therapist along the continuum of the disease,
in screening, in the management of skeletal muscle wasting and
cancer related fatigue, and in the prevention and management of
pathological fractures in the later stages of the disease. A patient
case example and clinical tips are used throughout the article to
illustrate key rehabilitation concerns surrounding the manage­
ment of the patient with multiple myeloma.
Key Words: multiple myeloma, cancer related fatigue, exercise,
physical therapy, bone metastasis, muscle wasting
INTRODUCTION
Multiple myeloma (MM) is a devastating disease that can
have severe effects on the musculoskeletal system. As with other
cancers, fatigue and skeletal muscle wasting can create a very
weak, debilitated patient who is at risk for falls and subsequent
musculoskeletal injuries. In addition, this disease can quickly
affect bone, creating pathological fractures which are painful
and can become very disabling, affecting the patient’s quality of
life (QOL). Early medical detection and treatment is critical to
forestall these detrimental secondary effects.
The purpose of this article is to illustrate, through the integra­
tion of a patient case presentation, the musculoskeletal consid­
erations for the physical therapy management of the patient
with MM across the continuum of practice settings. Red flags
during history-taking are highlighted; suggestions for stretching,
strengthening, and aerobic training are listed; and weight bearing
recommendations, falls prevention, and post-fracture care are
discussed.
MULTIPLE MYELOMA
According to the American Cancer Society, it is anticipated
that there will be 16,570 new diagnoses and 11,310 deaths from
MM in the United States in 2006.1 Multiple myeloma is more
prevalent in older adults between 50 and 70 years old. African
Americans are twice as likely to be affected as Caucasians and
men more than women. Currently, research has not been able
to establish the disease’s etiology, although it has been linked to
radiation exposure, and certain occupational hazards found in the
petroleum, leather, lumber, and agricultural industries.2,3
Multiple myeloma is a malignancy that increases the rate
of cell division of plasma cells produced in bone marrow.2,4
Multiple myeloma compromises the immune system due to the
11
inhibition of normal antibodies;2,4 it also causes severe anemia,
dysproteinemia, paraproteinemia, and hypercalcemia.2
Musculoskeletal symptoms reported by patients with MM
include bone pain in at least 75% of patients,5 skeletal muscle
wasting (MW), and generalized weakness (due to anemic effects
and MW).2,4 Muscle wasting affects approximately 50% of
persons with cancer and is reported to contribute to the cause
of cancer-related fatigue (CRF).6 Muscle wasting is an unin­
tentional loss of body weight (5%-10%) secondary to disuse
or pathology.7 It can occur from decreased physical activity,
decreased food intake, or imbalance between the rates of muscle
protein synthesis and degradation leading to muscle protein
depletion.6 Additionally, this disease process causes devastating
bone tumors and destruction.2,4
Abnormal (myeloma) cells migrate aggressively to multiple
skeletal sites, increasing osteoclastic activity. Frequently, the
first symptom of MM is back pain.8 The thoracic and lumbar
vertebrae, pelvis, and ribs are most often affected by the disease
and subject to pathological fractures, even with minor trauma.
Each year, 15% to 30% of patients with MM will incur a new
vertebral fracture.5
Clinical Tip
It would not be unusual for a person referred to out-patient
physical therapy with a diagnosis of “low back strain” to
actually have osteopenia or pathological fracture second-
ary to MM. It is imperative for all physical therapists (PTs)
to rule out MM as a differential diagnosis when they are
presented with a patient over the age of 50 with moderate to
severe pain, weight loss, and unexplained fatigue.
PATIENT CASE (PART 1)
A 63-year- old African American male was seen in an outpa­
tient physical therapy clinic with a complaint of lower back pain.
The patient described a gradual, insidious onset of pain over the
past 3 months that suddenly worsened while tying his shoes 2
weeks ago.
The patient described his symptoms as moderate to severe
pain to the mid-lumbar region. He denied radiation of pain into
the buttocks or lower extremities. There was no sensory loss
or localized weakness. However, there was a report of general­
ized weakness and fatigue in the lower extremities and recent
difficulty getting up from a chair and stair climbing. The pain
was constant but worsened with unexpected movements, and
frequently awakened him at night. The pain was not relieved
by rest or by changing positions. He had received no relief of
symptoms with over the counter NSAIDS. He mentioned a recent
unintentional 10-pound weight loss over the past 8 weeks.
12
The physical examination revealed diffuse tenderness to
palpation in the lumbar region with increased pain with percus­
sion over the L3 and L4 spinous processes. Active range of
motion revealed minimal limitation of movement, moderate
pain with all movements, and no change in location of pain with
movement. Neurological testing of the lower extremities was
normal, as was straight leg raising. Lower extremity strength was
4/5 for major muscle groups.
Clinical Tip
Because of the insidious onset of symptoms—age, gender,
and race of the patient; the recent weight loss; pain interfer-
ing with sleep; and inability to get relief with resting posi-
tions—the PT was unable to classify the patient’s symptoms
into a preferred practice pattern. The PT determined that the
patient should be referred for additional medical testing.
The patient was given basic instructions in more comfortable
sleeping and sitting positions and safer lifting and bending during
activities of daily living. No other interventions were initiated
pending further medical testing. This included MRI of the lumbar
spine, which revealed numerous foci with signal enhancements in
the cortical bone of several lower thoracic and lumbar vertebrae.
A core biopsy of a lytic lesion supported a diagnosis of multiple
myeloma. Laboratory studies revealed increased serum protein
concentration further confirming the disease. His treatment plan
included high-dose chemotherapy with stem cell support.
MEDICAL MANAGEMENT OF MM
Treatment decisions for MM are based on the patient’s age,
overall health, cancer grading, and staging. The 2 most common
therapeutic approaches used for MM are chemotherapy and stem
cell transplant. Other treatment approaches include radiation
therapy, bone marrow transplant, biologic therapy, and plasma­
phoresis.9 However, there can be musculoskeletal side effects
from some of the medical treatments.
Although radiation therapy has the potential of reducing the
progression of the disease, it creates soft tissue damage in all
irradiated body tissues, which can increase the risk of soft tissue
tearing, lung, and heart fibrosis.10,11 It can also produce secondary
bone softening,10, 12 which can lead to pathological fractures. The
rate of regeneration in compromised areas is depressed to such an
extent that bone does not regain full strength until 6 months after
completion of treatment.
As MM tends to produce osteolytic damage to bone, bisphos­
phonates are frequently administered to offset bone loss. These
medications interrupt the bone’s ‘microenvironment’ that is
conducive to opportunistic metastatic disease processes, inhibit
further osteoclastic activity, and appear to decrease bone pain.13-15
PATIENT CASE (PART 2)
The patient was then referred for home physical therapy inter­
vention. He is currently undergoing chemotherapy treatment for
MM and is experiencing generalized fatigue and skeletal muscle
wasting which has progressed over the past 2 months. He reports
weakness and imbalance when walking in his home and describes
difficulty coming from sitting to standing and with ascending
Rehabilitation Oncology
Vol. 24, No. 3, 2006
and descending stairs. He describes generalized low back pain
and aching in his hips and knees. He lives in his home with his
wife who is 60 years old and healthy. His goals are to remain in
his home, to maintain his independence as much as possible, and
to prevent falls. He is interested in participating in an exercise
program to restore his strength, balance, and energy level.
Examination revealed moderate atrophy throughout the
muscles of the trunk and extremities and that the patient was able
to stand, requiring significant use of his arms when rising from a
chair. He frequently used furniture and walls for stability when
walking. Standing balance was impaired when the patient stood
with a narrow base of support or with his eyes closed. He became
fatigued and short of breath after walking 50 feet and could not
walk without an assistive device.
The patient was determined to be at high risk for falls, and a
falls prevention program was implemented. This included the
use of a quad cane, bedrails, grab bars in the bath, and the instal­
lation of rails on the steps outside of his home. A therapeutic
exercise program was developed to include strength, balance,
and endurance components. This program was progressed as
the patient improved and modifications were made during the
active treatment periods to accommodate for side effects of the
chemotherapy.
THE ROLE OF PHYSICAL THERAPY IN THE
REHABILITATION OF A PATIENT WITH MM
Physical therapists have much to offer the patient with MM.
Since the 5-year relative survival rate is 32%,4 their expertise
in the development of safe and appropriate therapeutic exercise
programs can allow patients to stay active during the course
of their disease and potentially address the problems of MW
and CRF. It is important to address function and QOL along
the continuum of the patient’s cancer care.16 As MM primarily
affects older adults, they frequently have comorbidities such as
heart disease, high blood pressure, or diabetes. So, in addition
to the impairments and functional disabilities caused by the MM,
any other chronic diseases need to be addressed in rehabilitation
management.
The ability of PTs to implement falls assessment and preven­
tion programs can be a life saving intervention for the patient at
risk for pathological fractures. Research has also shown that hip
protectors may play an important role in decreasing the rate of
fractures among patients who have fallen.17-19 Additionally instal­
lation of grab bars and railings significantly reduces the risk of
falls during the execution of essential activities of daily living.20
Procedural Interventions
Since MW and CRF can have devastating effects on the QOL
of patients with cancer,21 PTs have a significant role to play in this
area as well. Numerous clinical studies have employed exercise
interventions to improve function, decrease MW and CRF, and
improve health-related QOL during or after completion of cancer
treatments.3,22
The exercises consisted primarily of aerobic training using
treadmill walking or cycling, resistance exercises, or both.23-29
The positive results obtained from the studies suggest that physi­
cal exercise, in the form of aerobic activity, has beneficial effects
Rehabilitation Oncology 13
Vol. 24, No. 3, 2006

in patients with cancer, improves physical functioning, functional
mobility, muscular endurance, and maximum oxygen uptake
(VO2max), thereby decreasing CRF.3 The results also show resis­
tance exercise can prevent or improve MW and improve muscle
strength and endurance. Coleman et al30 found that in a sample
of 24 patients with MM, those receiving an individualized home-
based exercise program of aerobic and resistance-band exercises
increased lean body weight. A suggested exercise protocol for
patients with MM is illustrated in Table 1.
However, despite the physical and QOL benefits of exercise,
during off-treatment periods, only 20.4% of patient with MM
exercise moderately on most days of the week. During active
treatment, the number of patients who exercise drops to 6.8%.27
Although the majority of oncologists support the benefits of exer­
cise for cancer patients, they recommend it to their patients with
cancer only 25% of the time.31
Based on these patterns, rehabilitation professionals can be
strong advocates for the role of exercise for patients with MM.
By addressing various psychosocial factors and using patient
educational techniques, PTs can enhance exercise adherence in
patients with MM. For example, encouraging and providing
tools to improve their ability to control many aspects of their
rehabilitation and enhancing their social support network have all
been shown to assist patients with MM in their exercise endeav­
ors.32,33
PATIENT CASE (PART 3)
A year later the patient was seen at the local emergency room
complaining of severe back pain and weakness in both lower
extremities upon returning indoors from gardening. Magnetic
resonance imaging revealed a T10 compression fracture with
spinal cord compression at that level. The patient was admitted
to the hospital, and the following day had surgery for decompres­
sion with T9-T11 spinal fusion. The postoperative physician’s
orders included the following precautions: No lifting (> 10 lbs),
no twisting or bending, log roll for bed mobility, out of bed with
Thoracic Lumbar Sacral Orthosis (TLSO) brace. Epidural medi­
cations were used for pain management.
The patient was referred to inpatient rehabilitation on post­
operative day 2. During the initial examination the PT docu­
mented back pain 5/10 on verbal analog scale, slight kyphotic
posture, poor proprioception, and decreased sensation of both
lower extremities. The patient exhibited fair standing balance
with minimum to moderate assistance of one for bed mobility
and transfers with TLSO Brace. He had very low ambulatory
endurance using a wheeled walker and moderate assistance of
one person. The lower extremity strength was assessed as fair (no
graded resistance performed due to pathological fracture).
Some of the patient problems addressed in this phase of the
disease process included functional mobility, lower extrem­
ity strength, standing balance, gait, cardiovascular endurance,
patient and family education, and discharge planning. The patient
was discharged to a tertiary rehabilitation hospital 1 week later
in order to maximize his functional mobility before returning
home.
Clinical Tip
When creating goals and a plan of care for a patient with
MM, the rehabilitation professional must consider the stage
of the patient’s cancer, treatments, recovery level, practice
setting, and social support.
ORTHOPEDIC MANAGEMENT OF MM
Currently, plain radiography and biomechanical modeling

Table 1. Exercise Protocol for Patients with MM to Decrease CRF and MW3

Trends and patterns identified from the evidence in the systematic review lead to the following recommendations for patients
with MM.
(1) Before patients begin the exercise protocol, they should undergo:
-medical screening
-physical examination
(2) Patients should have results from a recent bone scan
(3) Exercise precautions and contraindications according to ACSM should be followed
(4) Aerobic exercise should be performed 4-5 days a week for 15-30 minutes at moderate intensity (55-70% HR max or
RPE=11-16 on Borg scale). Examples of aerobic exercise that can be performed are self-paced walking, and cycling.
(5)Resistance exercise should be performed at 5-8 repetitions, 3 days a week for 20 minutes with the use of resistance
bands. Examples of resistance exercise that can be performed include chair stands, knee flexion, knee extension, bicep
curls, triceps curls, upright rows, and leg curls.
(6) Flexibility exercises should be performed 3 days a week using slow static prolonged stretches for a 10-30 second hold.
(7) Patients with bone metastases that have been medically cleared for exercise must follow an exercise protocol based on
current guidelines for bone metastases.
(8) Be aware that these recommendations should be used as a basic foundation to establish an individualized exercise
program tailored to each patient.
14
are used to objectively determine bone health, estimate future
fracture risk, and diagnose fractures.34-37 However, radiographic
measures are meant only as screening tools, as there is debate
concerning their sensitivity in identifying the degree of bone
loss and existence of pathological fractures. In fact, there may
be as much as 50% bone loss before the loss is visible to the
radiologist.12 Due to this, when estimating risk of fracture, it is
also recommended to not only examine bone structure, but other
aspects of the patient’s overall health status.
Clinical signs of the weakening of normal bone structure
frequently include pain, fractures, symptoms related to hyper­
calcemia, and spinal cord or nerve root compression. Other
considerations include: type and extent of the disease process,
life expectancy, patient weight, comorbidities, prior and current
functional activity level, patient and family expectations and
support, adherence, ability to weight bear on affected limb, local
and systemic pain levels, and medications.35
Stabilization of any potential and actual fractures must be
addressed. Open reduction with internal fixation has been found
to be more effective for extremity fractures, if the patient is
able to tolerate the surgical procedure.12,35,38,39 Closed treatment
results in a higher incidence of pain, disability, and non-union.40
Vertebroplasty and kyphoplasty procedures are being increas­
ingly performed to improve spinal instability.41 Orthoses, corsets,
and assistive devices, such as walkers and canes, may be used
when bony metastases are present11 to assist the patient with pain
management, control fractures, and decrease the chance of further
trauma.8
Clinical Tip
With the high rate of osteoclastic activity and the propen-
sity for pathological fractures with patients diagnosed with
MM—care should be taken to protect skeletal structures
during all aspects of the patient’s rehabilitation and ADLs.
Patient Related Instruction--Special Precautions
There is little clinical evidence to guide PTs related to the
amount of safe weight-bearing through cancer-lysed metastatic
bone during exercise, transfers, ambulation, and other ADL
tasks. Some general guidelines have been suggested for patients
with bony metastases42,43 (Table 2). As mentioned earlier, due to
questionable sensitivity of plain radiographs to identify lesion
severity, these recommendations must be used with caution.
The patient in the advanced stages of MM should not perform
unnecessary high impact weight bearing during ambulation,42
functional mobility, or therapeutic exercise.43 However, total
Table 2. Current Guidelines for Bone Metastases43
Plain radiograph cortical WB recommendations
metastatic involvement
>50% TD: NWB (use crutches/walker)
25%-50% PWB
0%-25% FWB
WB=weight bearing, NWB=non weight bearing, TD=touch down weight bearing, PWB=partial weight bearing, FWB=full weight
bearing, AROM-active range of motion
Rehabilitation Oncology
Vol. 24, No. 3, 2006
avoidance of weight bearing may worsen the bone weakness.44
This patient may be able to perform light aerobic exercise as
tolerated.45 Stretching and twisting types of exercises should be
avoided to prevent pathological fracture.10,42 For patient safety,
the most conservative approach must be used without completely
immobilizing the patient.3,44
Clinical Tip
PTs instituting therapeutic interventions for patients with
MM must consider the risk of pathological fractures, and
continually monitor for new pain symptoms that may indicate
a developing or new fracture.
Coordination of Care and Interdisciplinary Communication
There have been problems noted with communication and
coordination of care with patients with cancer.45 Varying systems
of health care coordination exist and there have been recommen­
dations that these be more systemized and improved.46 The lack
of interdisciplinary management and poor oncologist-orthopedic
communication are frequent concerns.16 Several models for
coordination of services for patients with chronic diseases have
been created43, 46 and the institution of comprehensive geriatric
assessment of patients with cancer has been recommended.47,48
Additionally, the PT must consider the role of the patient in the
family and the presence of a willing and able caregiver is critical
to the safety and rehabilitation of the patient. Lastly, the PT must
be aware of available community resources to assist those with
cancer and make the appropriate recommendations.
Clinical Tip
Coordination and communication amongst the various health
professionals caring for the individual with MM is impera-
tive. Skilled nursing care is essential for assessing and
managing pain, nutrition, and vital functions of the patient
including bowel and bladder management and wound care.
Occupational therapy involvement is highly recommended
for evaluation and management of self care skills, and need
for adaptive equipment.
CONCLUSION
The PT has special skills that can help enhance the QOL of
the patient with MM through exercise intervention, prevention
of injury, and maintenance of independence. Patients with this
disease often present with signs and symptoms that often mimic
common musculoskeletal pain of the type frequently treated by
PTs in out-patient clinics. Careful screening can result in an
Exercise recommendation
None
AROM (no twisting, stretching)
light aerobic (avoid lifting/straining)
Rehabilitation Oncology
Vol. 24, No. 3, 2006
appropriate referral and earlier diagnosis of the cancer. In the
mid-course of the disease, problems of MW and CRF might
best be addressed through an appropriate therapeutic exercise
prescription focusing on strength, endurance, and flexibility.
During later stages of MM, the risk of pathological fractures
secondary to osteoclastic activity can significantly interfere with
a patient’s QOL and independence. Falls assessment and preven­
tion programs instituted by PTs can be helpful in avoiding these
complications. During end-of-life, home assessment and adapta­
tion are critical areas in which the PT should be involved to allow
the patient to remain as independent and safe as possible allowing
QOL with family and significant others.
REFERENCES
1. American Cancer Society. How many people get multiple
myeloma? Available at: http://www.cancer.org/docroot/CRI/
content/CRI_2_2_1x_How_Many_People_Get_Multiple_
Myeloma.asp?sitearea=. Accessed July 17, 2006.
2. Kapser D, Braunwald E, Fauci A, et al. Harrison’s Principles
of Internal Medicine. 16th ed. New York, NY: McGraw-Hill;
2005.
3. Strong A, Karavatas SG, Reicherter EA. Recommended exer­
cise protocol to decrease cancer-related fatigue and muscle
wasting in patients with multiple myeloma: an evidence-
based systematic review. Top Geriatri Rehabil. 2006;22:172-
186.
4. Goodman CC, Boissonault WG. Pathology: Implications
for Physical Therapists. 2nd ed. Philadelphia, Pa: Saunders;
2003.
5. Body JJ. Effectiveness and cost of bisphosphonate therapy in
tumor bone disease. Cancer. 2003;97:859-865.
6. Al-Majid S, McCarthy D. Cancer-induced fatigue and skel­
etal muscle wasting: the role of exercise. Biol Res Nurs.
2001;2:186-197.
7. Mayer J. Muscle wasting and protein metabolism. J Anim Sci.
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8. Gudas S. Implications of oncology in elderly adults. In:
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2003;11:623-628.
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16
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Rehabilitation Oncology
Vol. 24, No. 3, 2006
HIV Abstracts
C���������������������
indy Pfalzer, PT, PhD
Professor, Department of Physical Therapy, University of Michigan-Flint
Rosso R, Di Biagio A, Bassetti M, Bassetti D. Treatment of
HIV infection in children. Rev Med Microbio. 2005;16:9-16.
For HIV-infected children, long-term management and sustain­
ing therapies issues are more complex than for adults. Although
the reduction in HIV-1-related deaths with HAART is similar
in adults and children, the extent of the changes of the two
important surrogate markers, HIV-1 RNA levels and CD4 T-
cell counts, differs widely. ‘Children are not small adults’: in
most paediatric studies virological response rates to HAART are
inferior to those in adults, while increased CD4 T-cell counts do
not correlate with the virological response. Several antiretroviral
agents have been introduced into paediatric use, but clinicians
should consider the role of baseline antiretroviral susceptibility
testing and TDM to identify the optimal treatment for each child.
In addition efforts to improve adherence require an intensive,
child-adjusted approach. Side effects of HAART are generally
mild, transient, and of gastrointestinal origin. Significant percent­
ages of patients, also lower than that in adults, have serum lipid
abnormalities and signs of clinical lipodystrophy. Approaches in
adults such as dietary modification, exercise, use of fibrates and
statins are currently under evaluation, but very little is known
about the best management of lipodystrophy in children. New
drugs such as tenofovir, emtricitabine, and enfuvirtide have been
rapidly introduced into antiretroviral treatments for adult patients.
Unfortunately, there are only few data available regarding the
use of these agents in children and information about the use
of antiretrovirals in younger children is becoming available at
a slow rate. The strategy of simplification may be a successful
way to improve adherence and quality of life of the HIV-infected
paediatric population.
Galantino ML, Shepard K, Krafft L, et al. The effect of group
aerobic exercise and T‘ai chi on functional outcomes and
quality of life for persons living with acquired immunodefi-
ciency syndrome. J Alt Compl Med. 2005;11:1085-10���
92.
Objective: This study aimed to assess the usefulness of two inter­
ventions in a group rehabilitation medicine setting to determine
strategies and exercise guidelines for long-term care of the HIV/
AIDS population with human immunodeficiency virus (HIV)
and/or acquired immunodeficiency syndrome (AIDS).Design:
This was a randomized clinical trial investigating the effects of tai
chi (TC) and aerobic exercise (EX) on functional outcomes and
quality of life (QOL) in patients with AIDS. Setting: Two outpa­
tient infectious disease clinics in a Mid-Atlantic state were the
setting. Subjects and intervention: Thirty-eight (38) subjects with
advanced HIV (AIDS) were randomized to one of three groups:
TC, EX, or control. Experimental groups exercised twice weekly
for 8 weeks. Outcome measures: The primary outcomes included
QOL as measured by the Medical Outcomes Short Form (MOS-
17
HIV) and Spirituality Well-Being Scale (SWB). Functional
measures included the functional reach (FR) for balance, sit and
reach (SR) for flexibility, and sit-up (SU) test for endurance. The
physical performance test (PPT) was used to determine overall
function, and the Profile of Mood States (POMS) was used to
evaluate psychologic changes. To consider the patients‘ expla­
nations for these measurements, qualitative data were collected
from subjects‘ journals, focus groups, and non participant
observation. Results: Thirty-eight (38) subjects were included
in data analysis: 13 in the TC group, 13 in the EX group, and 12
in the control group. Results of analysis of covariance showed
significant changes in the exercise groups in overall functional
measures (p < 0.001). The MOS-HIV showed a significant differ­
ence on the subscale of overall health (p = 0.04). The POMS
showed significant main effect for time in confusion-bewilder­
ment (p = 0.000) and tension-anxiety (p = 0.005). Three dominant
themes emerged from the qualitative data, including: positive
physical changes, enhanced psychologic coping, and improved
social interactions. Conclusions: This study shows that TC and
EX improve physiologic parameters, functional outcomes, and
QOL. Group intervention provides a socialization context for
management of chronic HIV disease. This study supports the
need for more research investigating the effect of other types of
group exercise for this population. This study sets the stage for a
larger randomized controlled trial to examine the potential short-
and long-term effects of group exercise that may prove beneficial
in the management of advanced HIV disease. Further research is
warranted to evaluate additional exercise interventions that are
accessible, safe, and cost-effective for the HIV population.
Nixon S, O’Brien K, Glazier RH, Tynan AM. Aerobic
�����������������
exercise
interventions for adults living with HIV/AIDS. Cochrane
Database of Systematic Reviews. 2005;2, CD001796:38.
Background: The profile of HIV infection is constantly changing.
Although once viewed as an illness progressing to death, among
those with access to antiretroviral therapy, HIV can now present
as a disease with an uncertain natural history, perhaps a chronic
manageable disease for some. This increased chronicity of HIV
infection has been mirrored by increased prevalence of disable­
ment in the HIV-infected population (Rusch 2004). Thus, the
needs of these individuals have increasingly included the manage­
ment of impairments (problems with body function or structure as
a significant deviation or loss, such as pain or weakness), activ­
ity limitations (difficulties an individual may have in executing
activities, such as inability to walk) and participation restrictions
(problems an individual may experiences in involvement in life
situations, such as inability to work) (WHO 2001). Exercise is
a key strategy employed by people living with HIV/AIDS and
by rehabilitation professionals to address these issues. Exercise
has been shown to improve strength, cardiovascular function
18
and psychological status in seronegative populations (Bouchard
1993), but what are the effects of exercise for adults living with
HIV? If the risks and benefits of exercise for people living with
HIV are better understood, appropriate exercise may be under­
taken by those living with HIV/AIDS and appropriate exercise
prescription may be practiced by healthcare providers. If effective
and safe, exercise may enhance the effectiveness of HIV manage­
ment, thus improving the overall outcome for adults living with
HIV. Objectives To examine the safety and effectiveness of aero­
bic exercise interventions on immunological/virological, cardio­
pulmonary and psychological parameters in adults living with
HIV/AIDS. Search strategy To identify the appropriate studies,
we conducted a search using MEDLINE, EMBASE, SCIENCE
CITATION INDEX, AIDSLINE, CINAHL, HEALTHSTAR,
PSYCHLIT, SOCIOFILE, SCI, SSCI, ERIC and DAI. We also
reviewed both published and unpublished abstracts and proceed­
ings from major international and national HIV/AIDS conferences
such as the Intersciences Conference on Antimicrobial Agents
and Chemotherapy (ICAAC), the Conference on Retroviruses
and Opportunistic Infections (CROI), the Infectious Diseases
Society of America Conference (IDSA) and the International
AIDS Conference (IAC). Reference lists from pertinent articles
and books were reviewed and personal contacts with authors
were used, as well as Collaborative Review Group databases.
Targeted journals were hand searched for relevant articles. There
were no language restrictions. Searches for the original review
covered the period from 1980 to July 1999. The first update
of this review included an additional search of the literature,
followed by identification of included studies that met the inclu­
sion criteria from August 1999 to January 2001. For the second
update, we conducted a search to identify additional studies
published from February 2001 to August 2003.Selection crite­
ria Studies were included if they were randomized controlled
trials (RCTs) comparing aerobic exercise interventions with no
aerobic exercise interventions or another exercise or treatment
modality, performed at least three times per week for at least
four weeks among adults (18 years of age or older) living with
HIV/AIDS. Data collection and analysis Data on study design,
participants, interventions, outcomes and methodological qual­
ity were abstracted from studies that met the inclusion criteria
onto specifically designed data collection forms by at least two
reviewers. Meta-analysis was conducted using RevMan 4.2
computer software on outcomes whenever possible. Main results
A total of 10 studies (six from the original search, two from the
first updated search and two from this second updated search)
met the inclusion criteria for this review. Main results indicated
that performing constant or interval aerobic exercise, or a combi­
nation of constant aerobic exercise and progressive resistive
exercise for at least 20 minutes, at least three times per week for
four weeks appears to be safe and may lead to significant reduc­
tions in depressive symptoms and potentially clinically important
improvements in cardiopulmonary fitness. These findings are
limited to those participants who continued to exercise and for
whom there was adequate follow-up data. Authors’ conclusions
Aerobic exercise appears to be safe and may be beneficial for
adults living with HIV/AIDS. These findings are limited by the
small sample sizes and large withdrawal rates of the included
Rehabilitation Oncology
Vol. 24, No. 3, 2006
studies. Future research would benefit from an increased atten­
tion to participant follow-up and intention-to-treat analysis.
Further research is required to determine the optimal parameters
of aerobic exercise and stage of disease in which aerobic exercise
may be most beneficial for adults living with HIV.
Sax PE. Strategies for management and treatment of dyslip-
idemia in HIV/AIDS. AIDS Care-Psych Socio-Med Aspects
AIDS/HIV. 2006;18:149-157.
With the improved survival of HIV-infected patients, there are
increased concerns about the long-term effects of treatment,
including protease inhibitor (PI)-related dyslipidemia. Some
50-70% of patients receiving combination antiretroviral therapy
(ART) involving PIs develop lipid abnormalities consisting
of elevated levels of total cholesterol, low-density lipoprotein
cholesterol and triglycerides that are well-known risk factors for
cardiovascular disease. Treatment of HIV dyslipidemia should
include lifestyle modifications such as a low-fat diet, increased
exercise, reduced alcohol consumption and smoking cessation.
In many patients, however, these changes alone will not correct
lipid levels. In some patients, changing the PI component of ART
to another PI or non-PI and/or lipid-lowering drugs has proven
successful. Each approach is associated with advantages and
limitations and the need to maintain viral suppression must be
balanced with the need to treat abnormal lipid levels.
Friese G, Lohmeyer J, Seeger W, et al. ���������������������
HIV-associated pulmo-
nary hypertension. Herz. 2005;30:481-485.
Pulmonary hypertension is a severe life-limitating disease often
affecting younger patients. The connection between HIV infec­
tion and the development of pulmonary hypertension is well
documented. The underlying pathobiology still remains unclear.
Given that the prognosis of HIV infection has been improved by
highly active anti-retroviral therapy (HAART), severe pulmonary
hypertension is becoming a life-limiting factor. HIV patients
suffering from exercise-induced dyspnea should be tested for
pulmonary hypertension, if other pulmonary or cardiac disorders
(e.g., restrictive or obstructive ventilation disorders, pneumo­
nia, coronary heart disease) can be excluded. The incidence of
pulmonary hypertension is 1,000 times higher in HIV patients
as compared to the general population. Estimated numbers of
unreported cases are not included. A suspected diagnosis of
pulmonary hypertension can be substantiated by noninvasive
diagnostic methods (e.g., echocardiography), however, right
heart catheterization remains the diagnostic gold standard. As
new therapeutic options with prostanoids, endothelin antagonists,
and phosphodiesterase-5 inhibitors are now available, early and
accurate diagnosis is essential.
Wohl DA, Tien HC, Busby M, et al. ������������������������
Randomized study of the
safety and efficacy of fish oil (omega-3 fatty acid) supplemen-
tation with dietary and exercise counseling for the treatment
of antiretroviral therapy-associated hypertriglyceridemia.
Clin Infect Dis 2005;41:1498-1504.
Rehabilitation Oncology
Vol. 24, No. 3, 2006
Background. Omega-3 fatty acids (fish oils) reduce fasting serum
triglyceride levels and cardiovascular disease risk in individuals
without HIV infection. Whether omega-3 fatty acid supplementa­
tion can reduce hypertriglyceridemia associated with antiretrovi­
ral therapy is not known. Methods. We conducted an open-label,
randomized trial that enrolled 52 patients receiving >= 3 active
anti-retrovirals who had fasting triglyceride levels of > 200
mg/dL and were randomized to receive nutritionist-administered
dietary and exercise counseling with or without fish oil supple­
mentation for 16 weeks. Results. Patients assigned to receive fish
oil experienced a 25% mean decline in fasting triglyceride levels
at week 4 (95% CI, - 34.6% to - 15.7% change), compared with a
2.8% mean increase among patients assigned to receive counsel­
ing alone ( 95% CI, - 17.5% to + 23.1% change) (). By week 16,
the mean reduction in Pp. 007 triglyceride levels in the fish oil
arm remained significant, at 19.5% ( 95% CI, - 34.9% to - 4.0%
change), whereas the mean decrease in the diet and exercise only
arm was 5.7% ( 95% CI, - 24.6% to + 13.2% change); however,
the difference between study arms was no longer statistically
significant (P=.12). Low-density lipoprotein cholesterol levels
had increased by 15.6% ( 95% CI, + 4.8% to + 26.4% change) at
week 4 and by 22.4% ( 95% CI, + 7.91% to + 36.8% change) at
week 16 in the fish oil arm but did not change in the diet and exer­
cise only group. Fish oil was well tolerated; only 1 patient experi­
enced treatment-limiting toxicity. Conclusions. Supplementation
with omega- 3 fatty acids in combination with dietary and exer­
cise counseling was well tolerated and reduced fasting triglycer­
ide levels in patients receiving antiretrovirals. To what extent the
increase in low-density lipoprotein cholesterol levels observed
in patients assigned this intervention is attributable to omega- 3
fatty acid supplementation and whether this increase attenuates
any benefit in lowering triglyceride levels is unclear. Given these
results, further investigation of omega- 3 fatty acid supplementa­
tion for the treatment of hypertriglyceridemia in HIV-infected
patients is warranted.
Ghosn J, Guiguet M, Jardel C, et al. �������������������������
Muscle and liver lactate
metabolism in HAART-treated and naive HIV-infected
patients: the MITOVIR study. Antivir Ther. 2005;10:543-550.
AB Objective: To assess the impact of nucleoside analogue reverse
transcriptase inhibitor (NRTI) combination therapy on muscle
and liver lactate metabolism in HIV-infected patients. Methods:
This cross-sectional study involved HIV-infected patients who
were either anti retrovira I-naive (Group 1) or were receiving
either a stable triple-drug combination including at least one d-
drug (zidovudine, zalcitabine, stavudine, didanosine; Group 2) or
a backbone of abacavir and lamivudine (Group 3). Lactataemia
was measured at rest. Muscle lactate metabolism was assessed
during a standardized exercise test and liver lactate metabolism
during intravenous lactate infusion. Mitochondrial DNA was
quantified in peripheral blood mononuclear cells. Results: A total
of 65 patients were enrolled (116, 31 and 18 patients in Group
1, Group 2 and Group 3, respectively). None of the patients had
symptoms of hyperlactataemia. Patients in Group 3 had received
d-drugs for a median of seven years before switching to abacavir
and lamivudine. Median baseline lactataemia, although within
19
the normal range, was significantly higher in both treatment
groups than in the naive patients (Group 2: 1.4, Group 3: 1.5, and
Group 1: 1.0 mmol/l, P=0.005). Muscle lactate clearance was
significantly lower in both treatment groups than in naive patients
(Group 2: 1.6, Group 3: 1.8, and Group 1: 2.1, P=0.01). Lactate
liver metabolism and mitochondrial DNA levels did not differ
among the three groups. Conclusions: In HIV-infected patients
without symptomatic hyperlactataemia, all NRTI-containing
HAART regimens appear to cause muscle mitochondrial damage
but to spare the liver. Absence of difference between Group 2
and Group 3 raises questions about the potential reversibility of
muscle mitochondrial dysfunction, and/or the ability of abacavir
and lamivudine to induce such mitochondrial damage.
Breuckmann F, Neumann T, Kondratieva J, et al. ��������Dilated
cardiomyopathy in two adult human immunodeficiency posi-
tive (HIV+) patients possibly related to highly active antiret-
roviral therapy (HAART). Eur J Med Res. 2005;10:395-399.
Human immunodeficiency virus (HIV) and acute immunode­
ficiency syndrome are known to be associated with cardiac
involvement. In this respect, a relation between HIV and dilated
cardiornyopathy has been described. Additionally, highly active
antiretroviral therapy (HAART) may independently contribute to
cardiac impairment. We here report two cases of severely reduced
left ventricular function detected in the context of a recent stan­
dardized screening of 132 HIV+ individuals of the German heart
failure network. Both patients presented in a poor overall condi­
tion and progressive exercise-induced dyspnea accompanied by
edema or angina pectoris, respectively Subsequent examinations
revealed left bundle-branch blockade, ventricular arrhythmia,
elevated serum BNP-levels as well as pathologic transthoracic
echo cardiography left ventricular angiography, electron beam
tomography and cardiac magnetic resonance imaging without
significant coronary stenoses or immunohistological signs of
an ongoing or prior myocarditis. Clinical signs of progressive
chronic heart failure developed slowly but constantly following
initiation of the HAART regimen. Patients were treated by an
implantation of a biventricular implantable cardioverter defibril­
lator beside conventional conservative standard therapy followed
by a significant improvement of clinical symptoms. Antiviral
medication could be maintained in both patients. Taking all
data into account, the diagnosis of a HAART-associated dilated
cardiomyopathy could be assessed. Even though the pathogen­
esis of secondary heart failure after HAART is still object of
investigation a mitochondrial impairment by antiviral drugs is
thought to contribute the development of dilated cardiomyopathy
However, due to the coexistence of an eminent HIV infection, a
direct effect of the HIV itself can not be completely excluded.
Cade WT, Peralta L, Keyser RE. Aerobic
�����������������������������
exercise dysfunction
in human immunodeficiency virus: A potential link to physi-
cal disability. Phys Ther. 2004;84:655-664.
Approximately 282,000 adults, adolescents, and children are
currently living with human immunodeficiency virus (HIV)
infection or acquired immunodeficiency syndrome (AIDS) in the
20 Rehabilitation Oncology
Vol. 24, No. 3, 2006

United States as of the year 2002.(1) With the advent of highly

active antiretroviral therapy (HAART), the life span of these
individuals has dramatically increased,(2) and HIV infection is
now considered a chronic illness with accompanying episodes
of exacerbations and remissions of symptoms.(3) Numerous
conditions such as lipodystrophy syndrome(4-6) and skeletal
myopathy(7-9) have been associated with HIV and its medical
management, many of which may result in physical disability
and diminished quality of life. Due to the chronic nature of this
condition, physical therapists will continue to manage many of
these conditions in increased numbers of people who are living
with HIV. Although guidelines for physical therapy evaluation
and management of this potentially disabling condition have not
been established, it appears that aerobic exercise training may
have a beneficial effect on the cardiorespiratory health of people
who are living with HIV. Thus, an understanding of the factors
that limit the oxidative metabolic response to physical activity
is paramount in developing effective exercise training programs
for people with this virus. The focus of this Update is to examine
the biological factors that might limit the oxidative metabolic
response to physical activity in people with HIV.
Citation: Stringer NW, Witt MD, Cao M, et al. Exercise
capacity in clinically stable HIV patients as a function of Highly
Active Antiretroviral therapy. Chest. 2005;128(4, Oct Suppl.
S):62S.

Oncology Section The Cancer Rehabilitation Program

of the Massey Cancer Center
Elections Virginia Commonwealth University,
A ballot will be mailed to you very soon so that you Medical College of Virginia
can vote for the following offices. The Treasurer will
be a voting member of the Section Board. Is pleased to present its 6th Biennial Conference
Cancer Rehabilitation: Dimensions
PRESIDENT-ELECT of Care Mind, Body, Spirit
(2007-2008, will serve as president 2008-2010)
Kathie Hummel-Berry, PT, MEd, PhD September 21-22, 2007
Richmond, Virginia
TREASURER (2007-2009)
Rick W. Wilson, PT, PhD The sixth biennial conference is designed professionals who
provide care for cancer patients and their families, includ-
ing physical therapists, nurses, physicians, social workers,
NOMINATING COMMITTEE MEMBER speech pathologists, and counselors. Join us for a dynamic
(2007-2010, chair in 2010) conference that will integrate dimensions of holistic care with
Jeannette Lee, PT, PhD cancer rehabilitation issues.

For information, please contact Carrie Cybulski, conference

Vote by Please make your voice heard by
Nov 11! returning your ballot by November 11!
If you have any questions, call
800/999-2782 x3238.
Secretariat, at 804-628-1918 or e-mail ccybulski@vcu.edu. A
reduced registration fee will be offered to all APTA Oncology
Section members. Poster presentations are also being solic-
ited; contact the conference secretariat for details.
Rehabilitation Oncology 21
Vol. 24, No. 3, 2006

Oncology Section at Combined Sections Meeting 2007

February 14-18, 2006
Boston, MA
Pre-Conference Course Thursday, February 15
Breast Cancer: Physical Therapy 11:30 am - 1:30 pm
Examination & Treatment for Breast Role of Remedial Exercise in Patients
Cancer Survivors with Cancer and Chemotherapy-Induced
Impairments
Tuesday, February 13 12:00 pm - 5:00 pm and Speaker: G. Stephen Morris, PT, PhD, UT M.D. Anderson
Wednesday, February 14 8:00 am - 5:00 am Cancer Center, Houston, TX
Nicole Stout Gergich, PT, MPT, CLT-LANA
Charles McGarvey, PT, MS, DPT, FAPTA Muscle wasting, cardiovascular and pulmonary defects,
Cindy Pfalzer, PT, PhD and functional deficits are a part of the pathology of cancer.
Margaret Rinehart-Ayres, PT, PhD Clearly these declines are, in part, the result of decreased
Heather Smith, PT, MHS, OCS activity, but increasing evidence demonstrates that these
changes are due to more than simple deconditioning.
• Diagnosis and Staging of Breast Cancer and Cancer Pathology
Changes in body chemistry secondary to the cancer itself
• Medical and Surgical Management of Breast Cancer
and/or the treatment programs appear to exacerbate the
• Examination, Screening and System Review
effects of deconditioning. The physical therapist is asked
• Measurement Issues in Lymphedema, Shoulder
to develop treatment plans for the oncology patient in the
Impairment, Fatigue and Function
context of these added challenges. The purpose of this
• Management of Patients after Breast Implants, TRAM Flaps
session is to discuss 1) treatment conditions faced by the
and Lat Dorsi Flap Reconstruction
oncology patient that may adversely their functional capacity
• Adherence to Treatment Such As Exercise
and 2) how the therapist might most effectively use exercise
Register at www.apta.org/csm
to treat these patients.
Upon completion of this course, you’ll be able to:
1. Discuss treatments which adversely affect the oncology patient, such as adverse reactions to chemotherapeutic agents, adverse
reactions to radiation treatment, adverse reactions to steroids, and development of fatigue.
2. Discuss and describe exercise interventions which are safe and effective in the context of these adverse effects. 2 CEU

2:00 pm - 4:00 pm Examination and treatment of chemotherapy-induced peripheral neuropathy

Speaker: Meredith A. Wampler, PT, DPTSc, San Francisco State University

Upon completion of this course, you’ll be able to:

1. Identify common chemotherapy agents that are toxic to the peripheral nerve.
2. Describe the clinical presentation of patients with chemotherapy-induced peripheral neuropathy and how this relates to docu­
mented anatomical and cell biological changes to the peripheral nerve after exposure to neurotoxic chemotherapy agents.
3. Perform a thorough examination (including impairments and functional limitations) of a patient with or at risk for chemother­
apy-induced peripheral neuropathy.
4. Develop a treatment plan to address the common impairments and functional limitations of patients who develop chemotherapy-
induced peripheral neuropathy. (Intermediate) 2 CEU

Friday, February 16
8:00 am - 11:00 am Breast Self-Examination: Review and Techniques Lab
1 hour will be didactic lecture, 1 hour will break the group down into 3 small groups and will rotate to different stations for 20 min.
a piece. The third hour will be for more directed small group demonstration. (Multiple Level) 3 CEU

Register by phone or online: www.apta.org/csm, 800/999-2782 x3395

Early Bird Deadline - 12/20/06
22
Friday, February 16 (cont)
1:00 pm - 3:00 pm
Transitions From Rehabilitation
to End-of-Life Care
Speaker: Richard W Briggs, PT, MA, Chico, CA
Upon completion of this course, you’ll be able to:
1. Recognize patient situations when a palliative care
approach is appropriate.
2. Integrate issues of dignity and independence in the end of
life process through physical therapy interventions.
3. Identify language of spiritual concerns in patient and family
language.
4. Integrate ways to manage stress and enhance personal
development while working with terminally ill persons.
(Multiple Level) 2 CEU
1:00 pm - 3:00 pm
HIV and AIDS Education in Physical
Therapy Education Programs
Speakers: Daniel Paul Drummer, PT, DPT, San Francisco,
CA; Judith R Gale, PT, DPT, MPH, OCS, Creighton
University, Omaha, NE
Upon completion of this course, you’ll be able to:
1. Describe the essential content of lectures on HIV/AIDS for
entry-level PT education.
2. Explain the model of HIV infection
3. Identify the major classes of drugs used in management of
HIV/AIDS.
4. Distinguish between the natural course of the disease and
the side effects of the drugs used to treat it.
5. Describe areas of concern to physical therapists in manage­
ment of the patient with HIV/AIDS. (Multiple Level) 2
CEU
2:00 pm - 5:00 pm Oncology Section
Platform Presentations
3:00 pm - 4:00 pm Oncology Section Hospice/
Palliative Care SIG Meeting
Moderator: Richard W Briggs, PT, MA, Chico, CA
Goals: To brainstorm projects for the SIG over the next year,
and determine existing needs in Physical Therapy in Hospice
and Palliative care. All are welcome!
6:00 pm - 7:30 pm Oncology Section
Business Meeting We will unveil the Section’s
new Mission, Vision and Goals, and gather member
ideas. Come learn more about what the Section is
doing to advance and promote Oncology PT!
7:30 pm - 9:30 pm Celebration of Life relative to compression bandaging.
Come have a drink, a bite, and a talk with PTs and
PTAs with common interests. Always a fun gathering!
Rehabilitation Oncology
Vol. 24, No. 3, 2006
5:00 pm - 6:00 pm Oncology Section HIV/
AIDS SIG Meeting
Moderator: Michaele Smith, PT, Med We’ll brainstorm proj­
ects for the SIG in 2007. All are welcome!
Saturday, February 17
8:00 am - 9:30 am HIV Roundtable
Speaker: Michaele Smith, PT, Oakton, VA (Multiple Level)
1.5 CEU
9:30 am - 11:00 am Oncology Section
Lymphedema SIG Meeting
Moderator: Lesli Bell, PT We’ll brainstorm projects for the
SIG over the next year. All are welcome!
1:00 pm - 4:00 pm Physical Therapy Clinical
Decision Making for the Complex Patient in
the Acute Care Setting
Moderator: Linda E Arslanian, PT, DPT, MS, Brigham &
Women’s Hospital, Boston, MA
Speakers: Meredith Albert, PT; Roya Ghazinouri, PT, MS,
Sloan Kettering Medical Center, New York, NY; Melanie
Parker, PT; Sharlynn Marie Tuohy, PT, New York, NY
Upon completion of this course, you’ll be able to:
1. Identify and describe multiple clinical reasoning strategies
that physical therapists use in the acute care setting.
2. Make clinical decisions based on a given clinical decision-
making model to manage and treat patients in the acute care
environment.
3. Identify and outline the skills needed to recognize the
relevant information from a complex patient’s history and
clinical findings.
4. Identify the critical knowledge necessary for successful
clinical reasoning and decision-making in the acute care
setting. (Multiple Level) .3 CEU
1:00 pm - 4:00 pm PTA Education Group
Programming - A Hands-on Approach to
Treating Swelling in the Orthopedic Patient
Moderator: Christopher G Scott, PTA, Westerville, OH
Speaker: Kim Salyers, MA Ed, PTA, CLT-LANA,
Washington State Community College, Marietta, OH
Upon completion of this course, you’ll be able to:
1. Differentiate between low and high stretch bandages and
the role of each in managing swelling.
2. Define the role of the lymphatic system in managing swell­
ing in the orthopedic patient.
3. Determine appropriateness of the application of
compression bandaging.
4. Identify indications, precautions, and contraindications
5. Demonstrate proper application of compression bandaging
in the lower extremity.
(Multiple Level) 3 CEU
Early Bird Deadline – 12/20/06
Rehabilitation Oncology
Vol. 24, No. 3, 2006
Instructions for Authors
GENERAL
The Oncology Section encourages the submission of manu­
scripts that address issues of relevance to oncologic physical
therapy in all spheres. All correspondence is sent to the first
author named on the manuscript, unless otherwise requested.
Research reports receive the highest priority for publication, but
case reports, technical reports, literature reviews, and perspec­
tive papers are all solicited on an equal basis. Rehabilitation
Oncology will accept a manuscript for publication with the
understanding that the manuscript, with any original research
findings or data, has not been published previously or is not
under consideration for publication elsewhere. Manuscripts that
have been presented elsewhere orally at a scientific or profes­
sional meeting should contain a footnote stating that fact, for the
benefit of the reader.
Manuscripts published in Rehabilitation Oncology are the
property of the Oncology Section, and may not be published
elsewhere without the permission of the Section. The Section
reserves the right to reproduce, publish, and distribute the
manuscript. For research reports, a statement that the rights of
animal and human subjects have been protected must be included
with the manuscript. Authors must obtain written permission
to publish photographs in which the subjects are recognizable.
Authors must also obtain and submit written permission from
original sources to publish illustration, figures, or tables taken
from those sources.
MANUSCRIPT PREPARATION
For format and reference style, please consult the American
Medical Association (AMA) Manual of Style, 9th edition, published
by William and Wilkins of Baltimore, Maryland. All manuscripts
should be typed double-spaced, including references, with pages
numbered; font size is preferred in 12-point type. Every manuscript
should contain a title page and a short abstract. On the title page,
include the title, author(s), and footnote containing basic autobio­
graphical data of the authors. The abstract should be 150 words or
less. Referencing is by Arabic superscripts that appear sequentially
in the text. The references should be a separate sheet(s) at the end
of the manuscript. Please use Index Medicus for abbreviations.
Tables should be numbered consecutively and placed after the
references. Figures should be numbered consecutively and appear
after the references and tables. Appendices should be numbered
consecutively and positioned at the end of the paper.
Kindly submit 2 copies of the paper, along with a computer
disc, and permission statements. A cover letter should accompany
the manuscript, giving the corresponding author’s address, day
and evening phone numbers, fax number, and E-mail address.
Manuscripts should be sent to the Editor of Rehabilitation
Oncology.
23
Oncology Section, APTA
Monographs/Publication
2006 Order Form
DEVELOPING AN ONCOLOGY REHABILITATION
PROGRAM: A GUIDE FOR PHYSICAL THERAPISTS
By Sharon Konecne, PT
Cost per Monograph: Oncology Section Member USA $20.00
Non-Section Member USA $30.00
Foreign (includes postage) $35.00
RESOURCE GUIDE: ONCOLOGY PHYSICAL
THERAPY & REHABILITAITON FOR PROFESSIONAL
DEGREE CURRICULUM
By Lucinda A. Pfalzer, PT, PhD
Cost per Monograph: Oncology Section Member USA $40.00
Non-Section Member USA $50.00
Foreign (includes postage) $55.00
RESOURCE GUIDE: ONCOLOGY REFERENCES
& READING LIST
By Lucinda Pfalzer, PT, PhD
This resource guide of references (revised 2000) is included in the
Oncology PT and Rehab for Professional Degree Curriculum
Cost per Monograph: Oncology Section Member USA $15.00
Non-Section Member USA $20.00
Foreign (includes postage) $25.00
ISSUES IN HIV REHAB
Edited by MaryLou Galantino, PhD, PT
Cost per Monograph: Oncology Section Member USA $45.00
Non-Section Member USA $55.00
Foreign (includes postage) $60.00
REHABILITATION ONCOLOGY 20-YEAR INDEX
1982-2002, Edited by Steve Gudas, PT, PhD $ 5.00
Send check to: Maggie Rinehart Ayres, PhD, PT
Thomas Jefferson University
130 S 9th St, Ste 830 Edison Bldg
Philadelphia, PA 19107 USA
Ph: 215.503.1647
margaret.ayres@mail.tju.edu
Make check payable to: Oncology Section, APTA
(No purchase orders will be accepted; prepayment is required.)
Name: ___________________________________________________
Facility: __________________________________________________
Address: __________________________________________________
Daytime Phone: ____________________________________________
_____ Faculty Resource Guide $ ________
_____ Developing Oncology Rehab $ ________
_____ References & Reading List $ ________
_____ HIV Monograph $ ________
_____ 20-Year Index $ ________
Total Enclosed $ ________
Rehabilitation Oncology Non-profit Org.
U.S. Postage
American Physical Therapy Association PAID
2920 East Avenue South, Suite 200 Permit No. 149
La Crosse, WI 54601-7202 LaCrosse, WI