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3

Start Living Well, Today!

Have you ever wondered if there is anything you can do to improve your quality of life while you are living with cancer?  Well, there is!  Regular exercise can help. In Moving through Cancer, we will give you basic information to help you get started.

What’s In It For You?Medical professionals, fitness professionals, and physically active cancer survivors agree that performing moderate exercise may improve your tolerance to cancer treatment, decrease your side effects, and improve your quality of life.

Benefits of ExerciseExercise is helpful both during and after cancer treatment. Moderate exercise during treatment improves tolerance to cancer treatment, decreases side effects, and improves sleep. Following treatment, an exercise program can improve mobility, strength, and cardiovascular fitness. Exercise need not be intense to promote these benefits.

Some of the physical benefits of exercise may include:

•  Improved rest and sleep

•  Improved aerobic fitness

•  Improved flexibility and range of motion

•  Improved muscle tone and strength

•  Increased oxygen to brain and tissues

•  Reduced fatigue

•  Maintenance of bone density

•  Weight management

The emotional benefits of exercise may include positive changes in:

•  Self-esteem

•  Mood, with reduced feelings of depression and anxiety

•  Relaxation

•  Feelings of independence

•  Shift of focus from illness to wellness

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Cancer Exercise Guidelines

Strength Training:

Perform 2 strength training sessions each week. Include exercises for major muscle groups.

Aerobic activity:

Perform 150 minutes of moderate intensity aerobic exercises each week.

Flexibility exercises:

Perform flexibility exercises everyday.

Getting StartedHere are a few pointers to help you take the first step towards your adding exercise to your daily routine.

Consult a Healthcare Practitioner First

When you are starting a new exercise program, we suggest that you check with your doctor or other health care professional that is familiar with your health. Find out if there are special precautions you need to take or issues that you, or your instructor/trainer, need to consider.  

Start Slowly

The key to most successful lifestyle changes is to start slowly, develop a routine that fits your lifestyle, and maintain that routine over time. This is especially true for beginning an exercise program if you are new to participating in regular exercise. Select one new activity and set an easy-to-attain goal for that activity. This new activity can be as simple as a single new exercise, the addition of a 5-minute walk to your daily routine, or 5 minutes of quiet breathing. Once you have successfully added this new activity into your lifestyle, then you can build on it until you have established your new routine.

AVOID INACTIVITY!

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Make it Fit into Your Lifestyle

It is easier to stick with healthy behaviors when they fit your personality and your lifestyle. Pick activities, environments, and times that fit with your current routine and personal preferences.

•  Do you enjoy the solitude of exercising or doing relaxation alone or do you need a group to make it more interesting and help you stay motivated?

•  Do you like to be in the privacy of your home or do you welcome opportunities to get out of your home?

•  Is it easier for you to get going in the morning or is late afternoon a better time for you?

•  What else do you need to make these healthier behaviors fun and interesting for you?

A Word of Caution

Balance your enthusiasm for starting your new wellness regimen with a healthy dose of caution. In general, if you experience anything unusual while you are participating in an activity stop immediately.

Cautions for Exercise

During exercise, stop immediately if you experience unusual symptoms such as shortness of breath, chest pain, dizziness, muscle pain, clamminess, headaches, irregular heartbeat, excessive sweating, or any joint or limb pain. If these symptoms persist, then contact your doctor.

Effects of Cancer Treatments

Cancer treatment may be damaging to normal tissue and normal body functions and affects individuals differently. Don’t be surprised if you continue to feel the effects of treatment once treatment is over. Some symptoms may take months to go away. Some of the complications from treatment may not appear for months, or even years. It is important to listen carefully to your body, and to communicate with your healthcare provider or exercise specialist about any changes or unusual symptoms. These changes may be slight or severe and may affect an individual for a day, or long term. 

Contact your doctor if you experience fever, unusual or excessive fatigue or weakness, chest pain, irregular heartbeat, unusual bleeding, sudden weight loss, severe vomiting or diarrhea, fainting, blurred vision, pale skin, or non-relenting pain (particularly at night). Adjustments to exercise can be easily made and will help ensure your safety.

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And You’re Off!

Moving Through Cancer is filled with helpful hints on how to incorporate exercise into your current routine. We have also included some references for you at the end of this booklet. We hope that you find something that works for you. 

There are different types of exercises, each with its own benefits. A balanced program includes regular activities from each of the circles in the chart below.

Aerobic Exercise

Warm Up Your Muscles

Spend about five minutes walking slowly to warm up your muscles. You can walk in place if you want. Increase your pace until you feel warm. Warming up your muscles reduces your risk of injury.

Preparation for Walking

Walking is a wonderful activity when just starting your exercise program. You can walk just about anywhere! Walking conditions the heart and lungs, and strengthens bones and muscles. Walking can also be very relaxing. We will give you the basic information for a home walking program and you can take it from there.

What Equipment Do I Need?

Shoes

Before beginning, it is important to make sure to wear shoes that give your feet good support. You should have shoes that are stable, have arch support and closed toes. Just lace them up and off you go!

Clothes

Loose fitting clothes with breathable fabric are best. Consider the weather and dress appropriately. Remember a hat and gloves if it is cold outside, and sunscreen!

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Wearable fitness tracker

You may wish to wear a fitness tracker or pedometer, a small device that measures the number of steps that you take and how far you have walked. There are a variety of fitness trackers available. The use of such a device may lead to increased physical activity. [1-2] 

When you begin to use your fitness tracker, wear it during waking hours for 1 week to determine your stepping baseline. Every evening for 7 days, write down the number of steps that your device records for that day. At the end of the week, add up the total steps for the week, then divide that number by 7 to get your “stepping baseline” (your average daily number of steps).

Is There a “Technique” to Walking?

Some things to think about when walking:

•  Keep your head held high, your shoulders back and down, and  your abdominal muscles held in.

•  Roll your foot from heel to toe.

•  Choose your routes carefully.

•  Make sure you have good lighting.

•  Avoid uneven surfaces if you have balance problems.

•  Make sure someone knows where you are going, or walk with  a partner.

•  Listen to your body – don’t be afraid to stop and take a break.

•  Enjoy the scenery, stop and smell the roses. That’s part of the pleasure!

How Hard Should I Exercise?It is useful to know how to measure the intensity at which you are exercising. Here are 3 common techniques for measuring exercise intensity: the talk test; rating of perceived exertion; and target heart rate. Choose the method that’s best for you.

OPTION 1: Talk Test

Try to talk while you are exercising. If you are so out of breath that you cannot carry on a conversation, you are probably walking too fast and should slow down.

OPTION 2: Rating of Perceived Exertion

This method is a self-rating of how hard you think you’re working on a scale that ranges from 1 to 10. Aim for at least moderate to somewhat hard intensity as you walk.

1     2       3       4       5       6       7       8       9       10___________________________________________________________________________________________

NOTHING  MODERATE  SOMEWHAT HARD  HARD  MAXIMUM

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OPTION 3: Target Heart Rate

Your heart rate, measured by your pulse, is the number of times your heart beats in one minute. Heart rate is lower when you are at rest and higher when you exercise because your body needs more oxygen-rich blood when you exercise. For this reason, your heart rate, or pulse, is a simple way to check how hard you are exercising. You gain the most benefit when you exercise at your “target heart rate.”  To use this method, consult with your fitness professional for instructions. 

Flexibility Flexibility exercises are also called stretching exercises. Flexibility exercises are important for full range of motion and make it easier to perform your activities of daily living. Flexibility is especially important if you have had surgery, radiation or injury. Flexibility exercises can be done daily after warming up the muscles. Stretch your muscles for about five minutes before general conditioning exercise, such as walking. Also stretch your muscles after your cool down. Stretching should be done gently, without pain. Each stretch should be held for 20-30 seconds.

Resistance TrainingResistance exercises are also called strengthening exercises. Resistance exercises are important for strong bones, muscle strength and performance of daily activities. Resistance exercises can be done at home or in an exercise facility, using weights, elastic bands or tubing, or using your own body weight. It is easy to do. To maintain strength perform resistance exercises one day per week. To improve strength, perform resistance exercises two to three days per week. Your muscles need about 24 hours to recover between resistance exercise sessions. A basic strength training program consists of 10-12 repetitions of the exercise done once or twice for major muscle groups of the body (chest, back, arms, legs, and core abdominal muscles). 

Cool Down After You ExerciseTo reduce stress on your heart and muscles, end each exercise session by walking slowly for about five minutes.

Stay HydratedMake sure to drink water before, during, and after any activity. It is important to your health to stay hydrated and especially important during treatment. During even the most casual activity, water is lost from the body. Get in the habit of carrying a water bottle at all times, as a constant reminder to drink.

Special Considerations for Exercise

It is helpful to know how treatment may change your ability to exercise, so that you can continue to exercise safely during and after your cancer treatment. Remember to listen to your body and exercise to tolerance. Check with your doctor if you have new or severe symptoms.

Chemotherapy-Induced Peripheral NeuropathyChemotherapy drugs may damage the nerves in your arms and legs, causing pain or numbness and tingling in your hands and feet. You might not feel an area of irritation from shoes if your feet are numb. Be sure to periodically check your feet for blisters or cuts. Numbness in the feet and legs may also cause you to lose your balance or increase your risk for falls.   Strength exercises for the ankle, as well as balance and coordination exercises might help you regain your balance and prevent falls.  However, you will need to be careful - have a chair, wall, or counter nearby as you perform these exercises. 

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Bone MetastasesA “metastasis” means that some cancer cells have broken away and lodged in another place in the body. If the cells lodge in a bone, the bone may become weak or painful. Doing weight bearing or resistance exercises may over-load the weakened bone and be difficult to perform. You might try swimming or a stationary bike, rather than walking or jogging. You don’t want to risk a broken bone if you fall during exercise, so make sure your exercise choice doesn’t require a great deal of balance.

OsteoporosisCertain treatments for cancer may cause osteoporosis, in which the bones become weak. This increases the chance that a bone will break (fracture) in a fall. Strengthening exercises and weight bearing exercises such as walking put weight through your bones, which will help keep your bones strong. Again, avoid activities that may put you at risk for falling.

Balance Considerations Balance is a person’s ability to orient the body in space and maintain an upright position while at rest or during movement.[3] Cancer and cancer treatments may lead to problems with your balance because of changes to one or more of the body systems that play a role in balance. Changes in sensation during and following chemotherapy may change your ability to feel small changes in posture, especially in your legs and feet, and may lead to changes in your balance.  Pain and/or fatigue may also affect your balance and your ability to tolerate being up on your feet. Stiffness and weakness in your legs and torso may affect your balance during standing and upright activities.  This is especially important to consider because some cancer treatments cause bone loss. The combination of bone loss and poor balance may place you at higher risk of fracturing a bone should you fall. 

Exercise helps improve flexibility, strength, and balance, so it’s important to work on your balance as part of your exercise program.  But it’s also important to be safe with your exercises should you be at increased for falls or fractures.  If you have a balance problem, have a chair or counter nearby that you can hold onto for support during standing exercises. If standing exercises are not yet safe for you, you can begin your exercises lying or sitting down.

Cancer-Related FatigueFatigue from cancer or cancer treatment can be very troubling. This type of fatigue can make your whole body feel tired and run down, even after rest. Exercise can actually help, but you will need to start out easy. You should begin exercising as soon as your healthcare provider says it is safe. 

Exercise to improve fatigue should be mostly aerobic, such as walking, swimming, and biking. You should start out easy, and gradually work up from 10 minutes to 30 minutes and from 3 days a week to 5 days a week.

Cardiopulmonary ComplicationsSome cancer drugs directly affect the heart muscle, which may lead to an irregular heart beat or reduced heart muscle function. If this happens, your doctor will need to give permission for you to take part in an exercise program. Symptoms such as shortness of breath, pale coloring, sweating, and fatigue during exercise, mean that you should decrease your exercise intensity. Your heart rate, breathing rate, and blood pressure should be carefully monitored during exercise if your heart or lungs have been damaged during your cancer treatment. 

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Myelosuppression The inner part of your bones contains bone marrow. Bone marrow produces new blood cells: red blood cells, white blood cells, and platelets. Red blood cells carry oxygen; white blood cells fight infection; and platelets help your blood to clot. Chemotherapy drugs and radiation therapy may decrease bone marrow activity. Low blood cell counts may mean that you have to be careful during exercise. Check with your healthcare provider before you start.

•  Anemia is a decrease in the number of red blood cells. Some of the symptoms of anemia include general weakness, fatigue, or difficulty concentrating. Anemia is assessed by measuring hemoglobin and hematocrit.

•  Neutropenia is a decrease in white blood cells, which are our defense against infection. Fewer white blood cells may make you more susceptible to fever and/or infection. You should avoid public areas or crowded places if your white cell count is extremely low.

•  Thrombocytopenia is a decrease in platelets. Decreased numbers of platelets may cause you to bleed or bruise more easily.

Blood test and normal values Exercise suggestions for reduced values [4]Hematocrit

   Men: 41% - 51%

   Women: 36% - 47%

> 30–32%: Ambulation and self-care as tolerated; okay to add resistance exercises if permitted

> 25%: Essential daily activities, assistance as needed for safety; light aerobics, light weights (1-2 pounds)

< 25%: Essential daily activities, assistance as needed for safety; avoid aerobic or resistance programs

Hemoglobin  

   Men: 14 - 17 g/dL

   Women: 12 - 16 g/dL

    (g/dL: grams/deciliter)

> 10 g/dL: Ambulation and self-care as tolerated; okay to add resistance exercises 

8-10 g/dL: Essential daily activities, assistance as needed for safety, light aerobics, light weights (1-2 pounds)

< 8 g/dL: Essential daily activities, assistance as needed for safety; avoid aerobic or resistance programs

White blood cells

   3,900 - 10,700 cells/mm3

> 5000 cells/mm3: Essential daily activities, assistance as needed for safety; light aerobics, light weights (1-2 pounds), progressing as tolerated

< 5000 cells/mm3: Essential daily activities, assistance as needed for safety

Platelets

   150,000 - 450,000 /mm3

>20,000/mm3: Exercise/bike with or without resistance

10,000 - 20,000/mm3: Exercise/bike without resistance

<10,000/mm3 and/or temperature  >100.5 degrees: No therapeutic exercise

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LymphedemaTreatment for cancer may damage lymph nodes or lymph vessels and may cause fluid to collect in the trunk, arm or leg on the side of treatment. The collection of fluid is called lymphedema, and it may develop long after cancer treatment has finished so you should know what to watch for. If you notice an increase in the size of your arm or leg you should consult your physician. Watch for feelings of a “full” sensation, or new or increased tightness of your clothes or jewelry.  

It is important for people at risk for getting lymphedema or who have lymphedema to stay physically active and maintain a healthy body weight. Exercise is an important part of managing lymphedema, and is safe for most people. Exercises should be started at low intensity and increased gradually. Research has shown that gradually increased strengthening exercises after breast cancer treatment did not result in arm lymphedema.[5-6] Another study showed that a combination of moderate aerobic exercise (such as walking) and strength training with weights, is safe for women with lymphedema following breast cancer treatment, and women should be encouraged to be physically active.[7] It is important to “start low” and “go slow”, and monitor for any new or increased swelling in your arm or leg. Stop an exercise if it causes pain, changes in skin color, increased swelling, or discomfort.

A visit to a lymphedema therapist will help you understand this condition and its management, and how to exercise safely.

For people with lymphedema The National Lymphedema Network [8] recommends:

•  Using a compression garment for the affected arm or leg during exercise 

•  Avoiding exercising the affected arm or leg to the level of fatigue

•  Modifying your exercise program to avoid overuse or injury to the affected arm or leg

•  Allowing a rest period between sets of exercises

•  Avoiding using weights that wrap around your arm or leg and cause constriction

CordingAxillary web syndrome, or cording, is a fairly common side effect of breast cancer surgery, sentinel node biopsy, or axillary lymph node removal. It is not clear yet what specific tissues are involved in cording, but research suggests that the cording is related to clotting or scarring in the lymphatic vessels. Cording may occur within days or weeks after surgery, and it often resolves on its own. If you develop cording, you may see or feel ropelike structures under the skin of armpit and inner arm. The cords are often painful and tight. Cording that extends from the armpit into the inside of your arm may limit your ability to fully raise your arm up over your head or out to the side, or to fully straighten your elbow. Cording in the forearm and wrist is less common but does occur, as does cording from the armpit to the breast or chest. If the cording doesn’t get better on its own, a lymphedema therapist can provide treatment for cording and to restore your arm flexibility, using specific stretches and massage techniques, and can instruct you in appropriate and safe exercises to perform. [9]

12

Soft tissue considerations

•  During and after reconstructive breast surgery: You may be asked initially to limit lifting your arm on the side of the surgery higher than shoulder level in order to avoid placing too much tension on the surgical incision. You may also be asked to avoid lifting anything heavier than 5 lbs. for the first few weeks after surgery.  Short, frequent walks (up to 5-6 times/day) are recommended to prevent blood clots and maintain cardiovascular fitness.  Check with your healthcare provider before starting exercise.  Once cleared for exercise, wear supportive garments until the surgical scar matures, which may take several months or up to a year.  Watch out for any change in color or temperature on the breast area or surgical scar, severe pain, or any unusual change in the shape of your breast.  

•  During and immediately after radiation therapy:  Your skin may be fragile or more sensitive to touch. You should avoid chlorinated swimming pools, which may irritate your skin.  You may also need to avoid aggressive stretching exercises, as these may cause skin tears. 

•  After radiation therapy:  Your skin that has been exposed to radiation is often more sensitive to the sun.  If you exercise or do activities outdoors, you can protect your skin by using sunblock rated SPF 30 or higher on the area was treated, and reapply periodically.  

Pelvic floor healthSome cancers and cancer treatments, particularly ones that are in or near the pelvic region, may damage, irritate, or put stress on the muscles and nerves that control the release of urine, resulting in urinary incontinence.  Urinary incontinence can take the form of stress incontinence,  where urine leakage occurs during coughing, laughing, or exercising; overflow incontinence, where it takes a long time to urinate and urine comes out in dribbles; urge incontinence, where there is a sudden, urgent need to urinate; or complete incontinence, where there is a total loss of ability to control urination.  Incontinence can also take the form of fecal or bowel incontinence (the inability to control bowel movements). Exercises that strengthen the pelvic floor, such as Kegel’s exercises, may help strengthen the muscles that control urination or bowel movements, as well as erectile dysfunction or sexual function.  Exercises that target the large muscles around the hip and pelvis may also be helpful in increasing blood flow to the area and help with these issues. 

While many find it uncomfortable to discuss incontinence or sexual concerns with others, it is important to discuss this with your healthcare provider, so they can answer your questions, or refer you to a specialist.    

13

References and Resources

References

1.   Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity and improve health. A systematic review. JAMA, 2007;298:2296-2304. 

2.   Tudor-Locke C, Hatano Y, Pangrazi RP, et al. Revisiting “how many steps are enough?”. Med Sci Sports Exerc, 2008;40(7 Suppl):S537-43. 

3.   Pollock BE, Driscoll CL, Foote RL, et al. Patient outcomes after vestibular schwannoma management: a prospective comparison of microsurgical resection and stereotactic radiosurgery. Neurosurgery, 2006;59:77-85; discussion 77-85. 

4.   American Physical Therapy Association Acute Care Section Lab Values Interpretation Resource.   http://c.ymcdn.com/sites/www.acutept.org/resource/resmgr/imported/labvalues.pdf.  [Cited March 1, 2016].  

5.   Ahmed RL, Thomas W, Yee D, et al., Randomized controlled trial of weight training and lymphedema in breast cancer survivors. J Clin Oncol, 2006;24:2765-72.

6.   Schmitz KH, Ahmed RL, Troxel A, et al.  Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med, 2009;361:664-73.

7.   Hayes SC, Reul-Hirche H, Turner J.  Exercise and secondary lymphedema: safety, potential benefits, and research issues. Med Sci Sports Exerc, 2009;4:483-9.

8.   National Lymphedema  Network Position Paper: Exercise. [cited March 1, 2016]; Available from:  http://www.lymphnet.org.

9.   Winicour J.  What is cording? Lymphlink, 2013, 25(2): 1-3 

Internet resources

American Cancer Society: http://www.cancer.org/docroot/home/index.asp?level=0

National Cancer Institute: http://www.cancer.gov/cancertopics/understandingcancer/cancer   

National Lymphedema Network: http://www.lymphnet.org/ 

Sunflower Wellness, Inc.: http://www.sunflowerwellness.org/

Acknowledgements:

We gratefully acknowledge UCSF Partners in Care for their generous support of Moving Through Cancer.  UCSF Partners in Care funds programs that provide comfort and well-being to patients and their families while visiting the UCSF medical center, to complement the excellent health care for which UCSF is renowned. 

The authors would like to thank David Cruz, President and Founder of WebExercises, Inc. and Bill Bain, PhD, Co-founder and Executive Director of Sunflower Wellness, for their assistance in the preparation of this resource.

14

The Exercises

Flexibility/Range of Motion

 Standing I.Y.T.W.I.

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 Foam Roller Series

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 Shoulder girdle depressions on foam roller

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 Snow angel

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 Arm cross on foam roller

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 Alternating arm raises on foam roller

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 Shoulder stretch on foam roller – arms together

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 Chest stretch at door– one side

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 Triceps stretch

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 Side stretch

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 Thread the needle

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 Hamstring stretch with strap

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 Sitting hamstring stretch

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 Quadriceps stretch

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 Straight knee calf stretch (gastrocnemius)

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 Bent knee calf stretch (soleus)

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 Low back stretch – double knee to chest

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 Figure 4 hip stretch

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 Foam roller hamstring self massage

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 Foam roller gluteal self massage

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 Foam roller iliotibial band self massage

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 Foam roller quadriceps self massage

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Core Exercises

 Medicine ball – squat and overhead lift

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 Medicine ball – diagonal squat and lift

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 Swing the bat

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 Pelvic tilt

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 Core stabilization progression

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 Curl ups

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 Bridge

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 Bridge with leg lift

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 Cat - Cow

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 Fire hydrant

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 Bird dog

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 Ball bridge/hip lift

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 Curls ups on ball – hands on chest

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 Curls ups on ball – hands behind head

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 Prone ball roll-outs

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 Superwoman/man

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 Prone on elbows

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Upper Body Strengthening

 Dumbbell press on ball

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 Forward punch with band

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 Wall push up

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 Modified push up

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 Shoulder shrugs

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 Standing rows

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 Scaption

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 Straight arm pull-backs with scapular      squeeze

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 Drawing a sword

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 Bent arm pull-backs with scapular squeeze

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 Shoulder lateral rotation

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 Shoulder medial rotation

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 Bicep curls

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 Triceps kick-backs

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Lower Body Strengthening

 Wall sits

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 Sit to stands

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 Wall sits – with ball

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 Forward lunges

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 Backward lunges

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 Side lunges

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 Leg curls on ball

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 Side step with resistance band

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 Step ups

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 Kettle bell squat and lift

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 Seated knee extensions

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Balance and Stability

 Standing toe and heel rocks

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 Single leg standing balance

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 Single leg balance - toe touch

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 Single leg standing balance on foam

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 Heel Toe Walk

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40

Stay Motivated

People who stick with a new behavior for 6 months usually make it a habit.  You now have some useful information on exercise.  Once you put some of these ideas into action, you will need some guidance on how to make your new program an important part of your ongoing routine.  

Set Attainable Goals

Goals will help you focus your energy and stay on track.  Here are the characteristics of attainable goals.  

•  Realistic - a plan may be within your power to achieve, yet still not be realistic.  The key here is to strike a balance between your dreams and what you can reasonably seek to achieve, given the limits of your current situation.  

•  Keep track of your progress - keeping a record of your progress will help you see where you started and how much progress you have made.  Over time it can serve as a source of inspiration.  Just think how good you will feel when you see how much you have achieved over a week, a month, a year, and beyond.  For example, for your exercise program you can document how many steps you take, the distance you walk, and how long it takes to walk that distance in a walking journal.  This will help you see your improvements over time.  

•  Vary your routine - plan several different options for variety.  For example, you can have different walking routes.  Sometimes things happen to keep you from sticking to a regular program.  Don’t be too hard on yourself when this happens.  You don’t have to let a few days off sabotage your plan to reach a higher level of fitness and improved health. Shrug it off as a temporary break in your exercise program.  

•  Re-evaluate your goals - from time to time, take a closer look at your goals and see if they are still attainable and relevant to your current lifestyle and health status.  Plan for changes and unexpected situations.  For example, if you are taking a trip or working overtime, think of strategies for incorporating your new routine into your day to keep your plan on track.  

41

Exercise Plan

Aerobic Activity

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  •

  •

Strength Training

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Balance

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  •

  •

Flexibility

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  •

42

Please record any exercise that you do over the next 7 consecutive days.

Date Day of the week

Time Type of activity

Duration (Minutes)

Heart Rate

Perceived Intensity

Nausea Fatigue

1-10 10=feeling

great

Comments

 Light  Moderate  Vigorous

_____ Nausea

_____ Fatigue

 Light  Moderate  Vigorous

_____ Nausea

_____ Fatigue

 Light  Moderate  Vigorous

_____ Nausea

_____ Fatigue

 Light  Moderate  Vigorous

_____ Nausea

_____ Fatigue

 Light  Moderate  Vigorous

_____ Nausea

_____ Fatigue

 Light  Moderate  Vigorous

_____ Nausea

_____ Fatigue

 Light  Moderate  Vigorous

_____ Nausea

_____ Fatigue

43

Notes