Osteoporosis is a progressive metabolic bone disease characterised by the loss of bone mineral density (BMD) and compromised bone strength. Osteopenia is considered a halfway point to osteoporosis; the bone density is lower than normal and treating it may slow the progressive bone loss that leads to osteoporosis.
Understanding exercise and bone health begins with understanding how bones are made.
We repeatedly place demands on our bones and these demands cause our bones to constantly re-modelling themselves. Bone re-modelling occurs in two phases. First, special bone cells called osteoclasts break down bone. Then, other bone cells called osteoblasts create new bone. Osteoclasts and osteoblasts can coordinate well for most of your life. Eventually, this coordination can break down, and the osteoclasts begin to remove more bone than the osteoblasts can create leading to osteoporosis.
Why is exercise important for Osteoporosis?
Exercise is a highly modifiable contributor to bone health (osteogenic). Physical activity generates external (ground reaction and inertial) and internal (skeletal muscle) forces on the skeleton. These forces cause very small amounts of deformation in the bone tissue, resulting in mechanical strain. This mechanical strain is sensed by cells (osteocytes) that reside in bone. When unusual strains are sensed, osteocytes initiate an adaptive response that produces new bone tissue (osteoblasts). The more vigorous the strain, the greater the response.
For a given external force, weak bones deform more, resulting in relatively large tissue strains, whereas strong bones experience low strains. This elicits a more robust biological, bone building response in the weaker bone that eventually results in stronger bone.
What types of exercises help?
Types of exercises that ARE osteogenic:
- Resistance training
- Jumping, landing, hopping, Running, jogging, very brisk walking
- Netball, basketball, soccer
- Dancing, impact aerobics
Types of exercise that are NOT osteogenic:
- Leisure walking
- Yoga, tai chi
- Lawn bowls
Structured osteogenic exercises: Where to start?
- Wholistic strength training
- Goal/s: Improve bone strength and ensure injury prevention.
- Frequency: 2 week Prescription: 2-3 sets of 5-8 repetitions (~8 exercises).
- Target major muscle groups attached to the hip and spine.
- Intensity: 8/10 (hard but not maximal)
- Impact exercise
- Goal: To induce relatively high bone strains (rapidly).
- Frequency: 4-7 days per week
- Prescription: Aim to work up to 50 repetitions over time (5 sets of 10 repetitions with 1–2 min rest between sets).
- Vertical and multidirectional jumping, bounding, hopping, skipping and bench stepping.
- Balance training
- Goal: Reduce the risk of falls, which can lead to fractures.
- Frequency: Up to 4 days per week.
- Can be built into a strength program.
- Prescription: <10 seconds per exercise, challenging, a variety of exercises
Tips and tricks:
Begin loading your bones slowly.
- Whilst impact training is encouraged, it is important you have the strength and stability to complete those movements without increasing the risk of injuring yourself. For example, you would never take up sprinting before jogging. Strength training is a good place to start.
Form is more important than anything
- Training with good technique (both strength training and impact exercise) is essential to reduce your risk of injury. Getting support and guidance from a trained individual is useful.
Introduce impact exercises into your daily life.
- Because you only need to do 10 impacts at a time, there is no reason why you can’t do them sporadically throughout your day.
Resistance and impact training should not be painful
- You may need to reduce or eliminate high ground reaction forces if you have joint or muscular pain (such as arthritis or lower back pain). You can slowly build intensity up over time. Managing your osteogenic exercise program can be challenging.
If you would like support, guidance or more information please call, email or visit the iNform Health website.
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Exercise as a cancer therapy
Over the past few years, exercise has emerged as a potential therapy (in conjunction with other standard treatments) to help delay cancer progression, reduce recurrence risk, and improve overall survival. Did you know that physical activity has been linked to between 30-60% risk reduction in cancer-specific mortality?
The mechanisms for the beneficial effect of exercise on cancer is complex and multifaceted. Here are a few ways exercise can work (in no particular order):
1. Improved immune system function
A good immune system is necessary to slow cancer growth. In fact, there is a whole type of treatment which aims to increase fight from your immune system called immunotherapy. Excitingly, aerobic exercise has been shown to increase the production of immune cells (i.e. natural killer cells), and infiltrate these cells into tumours. Natural killer cells can produce an approximate 60% reduction in tumour incidence. These immune cells are mobilised within minutes of your exercise starting, and maximal mobilisation of these immune cells is achieved after 30 minutes of exercise. This essentially means you need to have small doses often to get the best effects. Exercise once per week may not cut it. Exercise may also positively affect immune cell activity through muscle contraction-induced release of beneficial immune cells.
2. Increased blood flow to a tumour
The region surrounding a tumour is typically low in oxygen (hypoxic) because the body is not able to deliver enough oxygen amidst the disorganised and poorly working vessel structure of a tumour. During exercise, blood flow increases all over our body, including around any tumours. If we keep exercising, we can improve how arteries, capillaries and veins work within and around the tumour. All of which increases the delivery of our body’s own cancer killer immune cells and therapeutic agents such as chemotherapy drugs, making treatments more effective.
3. Regulating the way our genes express to help fight cancer
Epigenetics is a big word for changes in the way our genes express in the body without actually changing our DNA sequence (all of the those A, C, T, G’s that we learnt in science classes). Epigenetic alterations are necessary for cancer cells to grow and divide; however, on the other hand, exercise can modify the way our genes express and regulate and reduce the growth of cancer cells. This is a fairly new discovery, and more research is needed to understand what types of exercise are more effective for different, ages, races and cancer types. Exciting none the less.
4. Inflammation reduction
Chronic inflammation is widely recognised to encourage tumour growth in several ways: (1) Suppresses programmed cell death (apoptosis). (2) Promote cell growth (proliferation). (3) Improve the ability to spread to nearby tissues as well as distant organs (metastasis). Exercise can play a large role in reducing inflammation via several processes. Getting active can reduce pro-inflammatory markers (the bad ones) and increase the number of myokines (small secreted proteins that can reduce inflammation). All of which can prevent the growth of tumours.
It must be noted that research is still evolving in this area. The effects of exercise on different cancer types still needs more time and research funds. We cannot definitely say exercise will have a significantly positive effect on every cancer and will not cure your cancer in isolation. However, it is clear that being active has so many benefits for cancer patients.
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If you would like to read more:
Exercise protects from cancer through regulation of immune function and inflammation (2017)
Mechanisms of Exercise in Cancer Prevention, Treatment, and Survivorship (2020)
The Exercise and Sports Science Australia position statement: Exercise medicine in cancer management (2019)
Have you heard about how exercise and ADT should go together like sausages and bread? Research has shown exercise can help to reduce side effects of this treatment (without influencing the effectiveness of the drug). Prostate cancer, unfortunately, needs male hormones (androgens such as testosterone) to thrive, so one of the main types of drug therapy for this disease is androgen deprivation therapy (ADT). These medications aim to reduce or block the effect these hormones have. Whilst it can be an effective treatment, reducing the amount of testosterone in a man’s body does have a significant impact in the form of confronting side effects such as weight gain, loss of muscle mass and menopause-like symptoms. Here is a look at 6 different ways exercise can help you deal with treatment side effects:
1. Exercise and ADT: Improving body composition whilst on ADT
As a typical side of effect of ADT, men may notice an increase in abdominal fat and reduction of your muscle mass. However, did you know that exercise can lessen the change in your body composition? Research shows that if men complete 2-3 sessions of progressive resistance training per week, they will minimise the loss in muscle mass and strength. If men were taking ADT for a short time (3 months), a combination of moderate to high intensity aerobic and resistance training will help prevent changes in fat mass. However, if men are using ADT over a long period of time, they will have to also make changes with their diet to see changes in your fat mass.
2. ADT can impact your strength and endurance: Exercise can help!
ADT and the lack of testosterone can impact their day-to-day capacity/endurance and as such can affect their ability to do the fun things in life (playing with grandchildren, working in the shed, catching up with friends etc). The great news is exercise can help! Whilst it is not new that exercise can help keep everyone feeling fit and capable, the interesting thing is that the sooner men start/continue once ADT is commenced, the less ADT related capacity you stand to lose.
3. ADT can lead to excessive fatigue, but did you know exercise is one of the best treatments?
Due to the decline in androgen production (ie: testosterone) and other cancer-related issues, men may notice an increase in their fatigue levels. This may mean they do not feel as able or motivated to live life as they used to. Whilst it may be counterintuitive, research shows that progressive exercise (building up to 150mins per week) is arguably the BEST medical management strategy to reduce fatigue. That being said, it is important to learn how to regulate how much they do depending on how they feel. One day they may find the walk to the letterbox is moderately hard, whereas another day they may be able to complete a full 30 min moderate intensity brisk walk. Interestingly, the higher the fatigue levels, the greater the benefits from exercising.
4. Keeping the bones strong is really important when on ADT
Another side effect of ADT is a possible reduction in bone mineral density (and may even lead to osteoporosis and bone fractures). Preliminary research shows that at least 2 sessions of resistance training per week can mitigate losses in bone density. However, this exercise needs to be reasonably heavy and “impact” the bone – we want to challenge the bone enough to increase its density. We recommend that exercise is slowly progressed to this impact exercise so as not to increase the risk of injury.
5. Exercise can reduce your risk of other diseases whilst on ADT
Men are already dealing with a lot thanks to a prostate cancer diagnosis. SO it is important to note that due to the changes in hormone levels and a combination of other factors, there is an increased risk of developing other metabolic conditions such as type 2 diabetes, cardiovascular disease and high blood pressure in men on ADT. There is preliminary research showing positive changes in blood sugar, cholesterol and triglyceride levels. In other cancer populations, they have shown that exercise can provide a protective effect against the cardiometabolic diseases. So to reduce the burden, get on your bike!
6. Other side effects from ADT can be impacted by exercise
There are a few other benefits, which are fantastic for men on ADT! Did you know that new evidence suggests that exercise may help to preserve sexual activity and libido and lessen declines in sexual function? It may improve mood and reduce psychological distress, anxiety and depression making it a priority as suggested by an E.D. clinic. Finally, observational data suggests that is may even reduce the risk of dying from prostate cancer and even improve overall lifespan. If we could put all these benefits into a pill, would you take it?
The when, where and how of exercise for men undergoing ADT?
For many men, they are not exactly sure where to start, so here are a few ways:
- You can visit an accredited exercise physiologist who specialises in treating those with cancer who can set you up with an individualized program. This will help give you the tools and knowledge to exercise and get the benefits from it.
- There are a few online programs that can guide you if you do not want to or do not have the resources to visit an exercise specialist. Check out online!
- If you are comfortable exercising on your own, you can get straight into it. Much of the literature prescribes 2-3 resistance training exercise sessions per week plus building up to 150 minutes of moderate intensity aerobic exercise per week (but remember that you do not want to go to hard to quickly – building up is the best way!)
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Chemotherapy is prescribed to do a great number of things: to cure, aid other treatments, control the cancer, and help with symptom relief. It is a powerful tool, but as everyone knows, it brings with it a vast array of challenges, both during your cycles and after. But where does tailored exercise fit into this? Is it possible to stay active whilst undergoing chemo, and why on earth would you want to?
The plain and simple fact is that there is a growing body of evidence that shows tailored exercise during chemotherapy can reduce unwanted side effects, limit de-conditioning, AND now it is also being found to aid treatment. So, why are we not prescribing exercise like a drug? Why are we still not using it to its potential? Well, let’s talk about the benefits first…
1. Exercise creates a reduction in chemotherapy related neuropathy symptoms
Neuropathy is a relatively common side effect of chemotherapy. Essentially, it effects the hands and feet, creating symptoms like numbness, tingling and pain, cramping, difficulty handling small objects, and issues with gait and balance. Unpleasant! Multi-modal exercise, such as resistance exercises coupled with low to moderate intensity aerobic exercise like walking, creates significant reductions in both the severity and prevalence of neuropathic symptoms. Now that sounds to me like a pretty useful treatment!
2. Exercise reduces cancer related fatigue
Chemotherapy is associated with a crippling fatigue, known as cancer related fatigue. This can have a sudden onset and can impose a significant physical burden. It is also psychologically draining as it often means you are unable to do the things you love, and can impose a financial burden due to missed days as work. There are now hundreds of studies that show that exercise reduced fatigue levels. If you would like to know more, read my previous blog “Cancer related fatigue: Does exercise help or hinder?”
3. Exercise reduces de-conditioning
Research has shown that the loss of rapid muscle mass is accelerated 24-fold during chemotherapy in comparison to healthy people. It is no wonder people undergoing chemo feel fatigued when they lose so much muscle, so quickly. Luckily we have a treatment for that! Specific resistance training has shown to minimise this loss of strength. Completing targeted strength training means that carrying your children, doing the shopping, getting out of the car doesn’t become so fatiguing. That has to improve your quality of life.
4. Exercise reduce risk of cardiovascular disease
Due to the direct toxic effects of anti-cancer therapies as well de-conditioning, people undergoing chemotherapy have a risk of developing cardiovascular diseases such as heart failure, stroke, and coronary heart disease. A study in 2016 found that post-diagnosis exposure to exercise was associated with substantial reductions in newly diagnosed cardiovascular diseases or cardiovascular related death. That is massive!
5. Improved completion rates of treatment
Now, oncologists provide treatment doses based on what they think will create the best chance on achieving the treatment goal. However, completion can depend on how well you can withstand the treatment and it’s side effects. So, given that exercise therapy can reduce general pain levels, cancer related fatigue, and neuropathy it makes sense that it allows more people to fully complete treatment. This can give you the best chance of survival!
6. Exercise reduces risk of death
If you exercise when diagnosed with cancer, you will reduce your chance of dying. I know that is a massive statement, but a review of 71 studies in 2015 found that exercise was linked to reduced mortality in breast, colorectal, and prostate cancers (those were the only cancers these studies focused on). In one of those studies they found mortality reduced by 24%, 32%, 39% and 40% when individuals participated in low, moderate, vigorous and very vigorous activities respectively. What they essentially found was that there was a dose response relationship with exercise and mortality. Therefore, some exercise is definitely better than none and more is better than less. It depends on personal side effects of your chemotherapy treatment.
7. There are always caveats to exercising whilst undergoing chemotherapy
It is important to be aware of the caveats to exercising while undergoing chemotherapy. Exercise must be tailored to the current functional status and capacity of each individual patient and then must be progressed and regressed based treatment cycles. Overstretching areas around catheters should be avoided. Stoma’s should be cleaned before and after sessions and if you are feeling feverish. It is also important to monitor acute changes in your pain levels, gastrointestinal disorders (nausea, vomiting diarrhoea etc), changes in heart rate, and blood pressure and breathing rates.
As we mentioned, exercise prescription must tailored to the current functional status and capacity of each individual patient. Typically you can exercise directly after each chemotherapy dose but usually once side effects really hit, intensities will need to be modified. For the same reported feelings of exertion, your exercise may change from being able to jog around the block, to being able to walk to the mailbox. Then, as you progress through your cycle, your intensity can increase. Just remember, exercise may sometimes feel like the last thing you want to do, but just like any good medicine, it will help when prescribed appropriately!
If you have any questions regarding how and when you can use exercise, please feel free to contact Holly on 8431 2111.
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It can be really hard to be motivated to exercise. Much like most people in today’s society, we throw ourselves into a fast paced world where work, family and life are not always balanced. We are typically overtired, our to-do lists overflow and we tend to still say yes to things we maybe shouldn’t. On top of all this, we get told we need to look after ourselves. Eat well, move often, become more mindful etc etc. It is seriously tough stuff!
I know I should but I just don’t feel motivated to exercise!
I have recently gone back to study and I find myself sitting long periods attempting to use my brain (it’s hard work). By the end of the day, I am worn out. I am not sure what you feel like, but I feel like I have run a marathon. All from the confines of my small desk. Although I preach the joy and benefits you get from moving your body, to be honest sometimes it is the last thing I feel like doing. I want to go home, tick off annoying to-do list items and then if I have time I watch Netflix and cuddle with my dog.
Here comes the big but! I am a member of a pretty rocking hockey team and we train consistently on Tuesday and Thursday nights. So, no matter the weather, or how tired I feel, I peel myself off the couch and head out.
The tide turns once I move my body!
During the first 5 or so minutes, I am still not super excited to be running around but then a miracle happens. Slowly, I start feeling better, my energy returns, I don’t feel miserable and I am actually happy. We all tend to leave training in a better mood. I get home and tick off some to-do items and then I happily pass out for the night. I sleep really well, not only because exercise helps regulate my circadian rhythm, but because I know I have made my 10,000+ steps.
Acute changes to exercise: It is not a miracle, it’s science baby
- Exercise acts directly on our central nervous system to increase energy and reduce fatigue. Notably, the improvements in energy and fatigue are not related to increases in aerobic fitness.
- When your heart rate increases acutely it increase the brain’s blood supply. This makes you more alert, enhances your motivation to complete focused tasks, and improves mental clarity. It even creates neurons!
- Acute stress levels decrease post one exercise session thanks to increases in hormones that makes us feel awesome (serotonin, norepinephrine and dopamine). If you want to know more, read Jacinta’s blog on exercise, mood and stress.
- Also, psychologically we have achieved a mini-goal of exercising for that day so our confidence thanks to our sense of accomplishment (cue no internal guilt trip)
Some tips to help you beat the motivated to exercise fatigue barrier?
- Get into your active wear. It helps.
- Even if you don’t smash it, just show up. Something is better than nothing and you never know, it may become amazing.
- Ask yourself: Are you really exhausted or are you just tired (exhaustion may need sleep, tiredness/fatigue may need exercise)?
- Have an appointment – whether that is a group class, a specific time in your diary, an appointment with your EP/PT.
- Think about what you will feel like both during and after. You won’t regret it!
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