the highly variable impact of exercise on symptoms in those undergoing treatment is needed (259).

Slower
progression may be needed compared to healthy adults. If exercise progression leads to an increase in fatigue or
other common adverse symptoms as a result of prescribed exercise, the FITT principle of Ex Rx should be
reduced to a level that is better tolerated.
Survivors who have completed treatment can gradually increase exercise duration when tolerated and without
exacerbation of symptoms or side effects for all activities. The frequency of aerobic exercise should be
−1
increased gradually from the current PA level to 3–5 d ∙ wk .
If tolerated without adverse effects of symptoms or side effects, the Ex Rx need not differ from healthy
populations. There is a recent indication that heart rate reserve (HRR) may be less reliable for monitoring
aerobic exercise intensity for cancer survivors currently undergoing treatment or early posttreatment due to
differences in resting and maximal heart rate (HR) values; educating survivors to use perceived exertion to
monitor intensity or using a percentage of maximal heart rate (HRmax) may be advisable (254).
Individuals with lymphedema should wear a compression sleeve during resistance training activity (194,196).
Survivors of breast and gynecologic cancer should consider beginning a supervised resistance training
program (48).
Flexibility exercise can be implemented even during active treatment. Focus on joints in which a loss of
ROM occurred because of surgery, corticosteroid use, and/or radiation therapy (177).
Evidence indicates even those currently undergoing systemic cancer treatments can increase daily PA
sessions over the course of 1 mo (258).
Several short bouts per day rather than a single bout may be useful, particularly during active treatment.
Special Considerations
Up to 90% of all survivors of cancer will experience cancer-related fatigue at some point (280). Cancer-
related fatigue is prevalent in patients receiving chemotherapy and radiation and may prevent or restrict the
ability to exercise. In some cases, fatigue may persist for months or years after treatment completion.
However, survivors are advised to avoid physical inactivity, even during treatment, given evidence that
aerobic exercise improves fatigue (32).
Bone is a common site of metastases in many cancers, particularly breast, prostate, lung cancer, and multiple
myeloma. Survivors with metastatic disease to the bone will require modification of their exercise program
(e.g., reduced impact, intensity, volume) given the increased risk of bone fragility and fractures (194).
Cachexia or muscle wasting is prevalent in individuals with advanced gastrointestinal cancers and may
limit exercise capacity, depending on the extent of muscle wasting.
Identify when a patient/client is in an immune suppressed state (e.g., taking immunosuppressive medications
after a bone marrow transplant or those undergoing chemotherapy or radiation therapy). There may be times
when exercising at home or a medical setting would be more advisable than exercising in a public fitness
facility. Swimming should not be prescribed for patients with indwelling catheters or central lines and feeding
tubes, those with ostomies, those in an immune suppressed state, or those receiving radiation.
Patients receiving chemotherapy may experience fluctuating periods of sickness and fatigue during treatment
cycles that require frequent modifications to the Ex Rx such as periodically reducing the intensity and/or time
(duration) of the exercise session during symptomatic periods.
Safety considerations for exercise training for patients with cancer are presented in Table 11.3. More
information on safety considerations for patients with cancer can be found elsewhere (194,196). In general,
exercise should not be performed immediately following surgery among those with severe anemia, a
worsening condition, or an active infection (258). As with other populations, the risks associated with PA must
be balanced against the risks of physical inactivity for survivors of cancer. As with other populations, exercise
should be stopped if unusual symptoms are experienced (e.g., dizziness, nausea, chest pain).
 O NLINE RESO URCES
American Cancer Society:
http://www.cancer.org
American College of Sports Medicine Expert Panel Report on Exercise and Cancer:
http://www.acsm.org
National Academies Press (From Cancer Patient to Survivor, 2011):
http://www.nap.edu/catalog.php?record_id=11468#toc
National Comprehensive Cancer Network:
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#supportive

CEREBRAL PALSY
Cerebral palsy (CP) is a nonprogressive lesion of the brain occurring before, at, or soon after birth that interferes
with normal brain development. CP is caused by damage to areas of the brain that control and coordinate muscle
tone, reflexes, posture, and movement. The resulting impact on muscle tone and reflexes depends on the location
and extent of the injury within the brain. Consequently, the type and severity of dysfunction vary considerably
among individuals with CP. In developed countries, the incidence of CP is reported to be between 1.5 and 5 per
1,000 live births.
Despite its diverse manifestations, CP predominantly exists in two forms: spastic (70% of those with CP) (169)
and athetoid (293). Spastic CP is characterized by an increased muscle tone typically involving the flexor muscle
groups of the upper extremity (e.g., biceps brachii, brachialis, pronator teres) and extensor muscle groups of the
lower extremities (e.g., quadriceps, triceps surae). The antagonistic muscles of the hypertonic muscles are usually
weak. Spasticity is a dynamic condition that decreases with slow stretching, warm external temperature, and good
positioning. However, quick movements, cold external temperature, fatigue, or emotional stress increases
hypertonicity. It is important to note that hypertonicity is observed in the extremities, and
hypotonicity is commonly found in the head, neck, and trunk. Athetoid CP is characterized by
involuntary and/or uncontrolled movement that occurs primarily in the extremities. These
extraneous movements may increase with effort and emotional stress.
CP can further be categorized topographically (e.g., quadriplegia, diplegia, hemiplegia).
Although its usage is now limited in sport, the Cerebral Palsy International Sport and
Recreation Association (CPISRA) functional classification may be relevant to Ex Rx (Table
11.4) (46). The table moves from those with the most severe spasticity and athetoid effects to
the least amount. Functionally, classes 1 through 4 are used to describe those who are
wheelchair users, and classes 5 through 8 are for those who remain ambulatory (46).