NEW YORK CITY—After bilateral mastectomies, one TRAM flap reconstruction and one implant reconstruction, heavy bouts of chemotherapy, multiple recontouring and preventative surgeries, and years of physical therapy, Annie Toglia, MES, ACSM, CSCS, still has a ready smile, a giddy laugh, and the conviction that exercise saved her life.
Speaking here last month at a Breast Cancer Rehabilitation Seminar at Beth Israel Medical Center, Ms. Toglia, a medical exercise specialist, related how she had always been heavily involved with exercise both professionally and personally.
In her career, she started in dance instruction and then became an in-demand sports medicine personal fitness trainer. In her personal life, she skated, rode horses, and roller-bladed. When she came face-to-face with breast cancer, Ms. Toglia had great reserves of strength with which to face the disease.
Even in the hospital, recovering from her surgeries, she said she tried to do as much exercise as her body would permit: “Exercise is an important component of recovery. Obviously you don't want to interfere with drains or risk infections, but if you start as soon as possible, you'll end up in a much better place both physically and psychologically. Exercise can help a patient decrease pain and discomfort and feel more like a whole person.”
She said she believes it was her commitment to exercise prior to and during her chemotherapy treatment that left her relatively unaffected by the severe nausea and vomiting that usually afflicts patients on her treatment regimen.
She related how as she progressed through her treatment, everyone from her surgeon (Anthony C. Cahan, MD, Physician-in-Charge of the Robert and Helen Appel Comprehensive Breast Service of Beth Israel) to the nurses and physical therapists she met along the way remarked on her unusual strength, resilience, and high energy. When she attributed her strengths to her exercise regimen, her health care providers encouraged her to formalize and share her program in order to benefit other patients.
The resulting book, Staying Abreast, Rehabilitation Exercises for Breast Cancer Surgery, sets forth a comprehensive exercise rehabilitation program suitable for any cancer patient (or even healthy individual), but particularly tailored for breast cancer patients.
Included are periodic exercises arranged chronologically in four phases ranging from immediate post-surgery exercises that can be performed in the hospital to more advanced aerobic and strength-training options designed to be performed at least 10 weeks after surgery.
A special section on adjuvant treatment recommendations contains gentle exercises designed to create reserves of energy and improve a patient's sense of well being with minimal effort.
All the exercises are illustrated with starting and ending positions and accompanied by instructional text. In addition to the book itself, Ms. Toglia has developed two posters that collect a number of beginning and intermediate exercises.
She donated books and posters from the first printing to charitable organizations and hospitals, and sells both on her Web site, www.stayingabreast.com, where a number of exercises are also illustrated for the general public.
“I think it's very important for every single breast cancer surgeon or oncologist to try to convince patients to exercise, even minimally,” Ms. Toglia said. “The patients don't have to use my program or buy my book, but they should be made aware of a good rehabilitation program.
“Breast cancer rehabilitation is not about the arms or the shoulders—it is about the entire body and preparing people for the side effects that will occur during or after treatment.”
Even if a patient is reluctant to exercise, Ms. Toglia suggests that doctors insist that the patient at least attend a few physical therapy sessions where the therapist may be able to convince the patient of the potential benefits of exercise.
“A patient who exercises makes life easier for the doctors too,” she noted. “If a patient heals better, the physician won't get phone calls from patients complaining about situations that could have been managed with exercise and stretching.
“Similarly, a bit of exercise and nutrition management can alleviate pressure on doctors by helping their patients to get through chemotherapy without becoming desperately ill.”
Have a Ball with Exercise
With the help of Mary Fischer, PT, Director of Rehabilitation Therapy at Beth Israel, Ms. Toglia put together the second annual Breast Cancer Rehabilitation Seminar. In her own presentation, she demonstrated many of her exercises that can be done in the home without the use of any fancy or expensive equipment.
“I took patient income into consideration when designing my program,” she said. “That's why I say that in certain exercises, a patient can use a pillow or a towel in place of [expensive equipment]. I know there are plenty of people who can't afford to go out there and purchase a $30 ball, or who may not have enough room in their homes to fit a ball, so I thought about space and economy in designing the program.”
Of course, for those who do have the space, Ms. Toglia also demonstrated a small trampoline designed to facilitate weight-bearing exercise for patients like herself who experienced the sudden onset of menopause and resulting problems with bone density as a side effect of therapy.
Flexibility and variety also play a large role in the way Ms. Toglia designed her workout. She encourages participants to pick and choose their favorite exercises at each level and repeatedly emphasizes the need to take things slowly and perform exercises appropriate for each of the body's healing stages.
The issue of putting the recovering patient's safety first is particularly close to her heart.
She said she has watched in horror as other exercise videos marketed to breast cancer patients show power-walkers vigorously pumping their arms and models performing crunches. Improper exercise can be far worse for breast cancer patients than no exercise at all, she said.
“I get upset when I look online and see exercise programs sponsored by hospitals that use little stick figures to demonstrate exercises and don't talk about breathing or body placement at all. Ninety percent of patients wouldn't have a clue what to do, and breast cancer patients who exercise wrong run the risk of bringing on immediate lymphedema or destroying their incisions.”
Ms. Toglia said that she has seen a recent dramatic increase in the interest levels of patients and physicians, nurses, and physical therapists in the importance of exercise for breast cancer patients.
Ms. Toglia has also been working with gyms, hospitals, rehab centers, and charitable organizations to create exercise programs for cancer patients based on the principles of Staying Abreast.
She said she is hoping to find a foundation grant to help her produce a DVD version of the book so that she could demonstrate beginning and intermediate exercises in a one-on-one personal training style.
General Goals of a Medical Exercise Program for Breast Cancer Patients
Annie Toglia, MES, ACSM, CSCS lists the following as the goals of a program for medical exercise for breast cancer patients:
- ▪ To elevate endorphin levels in order to relieve tension, depression, weakness, and fatigue.
- ▪ To prevent lymphedema by promoting drainage of lymph fluids.
- ▪ To prevent formation of scar tissue and frozen shoulder.
- ▪ To provide a comprehensive working knowledge of proper body mechanics related to one's specific needs and physical conditions.
- ▪ To restore upright posture after surgery.
- ▪ To relieve stiffness in the neck, back, chest, and shoulders.
- ▪ To restore and maintain range of motion, strength, and flexibility to the involved areas of the body.
- ▪ To increase lung capacity post-surgery/anesthesia.
- ▪ To improve cardiovascular and cardiopulmonary fitness.
- ▪ And most important, to increase one's fighting spirit.