Weight-Lifting, Parent's Comments

A thread in the ped-onc survivors group concerned certain types of physical activity after treatment with anthracyclines. Some members had been told by their child's oncologist not to do specific activities:

my child should never lift over 50 lbs. for the rest of his life
they should not work in jobs where there is heavy lifting
he said he could swim, run, bike, but only low weight repetitive weight lifting
I told his onc that he had started lifting weights and she was immediately concerned

My question is, what's this all about? Why can they do all sort of aerobic exercise, but not weightlifting, isometric exercises? Before I began studying the functions of the heart, it made no sense. So we discussed it in the ped-onc survivors group. It turns out that we have a couple physical therapists who are parents of survivors. Although their advice is NOT medical advice, I think that these parent-to-parent explanations are easy to understand.

The best advice it to NOT lift weights. If you are going to ignore that advice, read on.

I don't have the answer for exactly what the medical specifics are in regards to the type of potential heart damage from treatment, but I do know what weightlifting does to the body. I've been working in physical therapy for 14 years. The Val Salva maneuver is basically "holding your breath" - which we all do from time to time as we do something strenuous. What this process does is to push up the blood pressure in quick, short rises, which is why this is a no-no when vessel wall damage exists, such as folks who have aneurisms, high blood pressure, weakened heart walls, etc.

I have to agree with the oncologist....I would advise against free weights. It would be really great for anyone affected by this to "learn" how to properly use nautilus or other such equipment---i.e. learn how to breathe while exercising----pursed lip breathing. The way I instruct patients is to inhale BEFORE you do the movement, and exhale while doing the movement. So, for example, if you were to do a sit-up, you would inhale before lifting your shoulders, and exhale AS you lift, blowing the air out slowly. NO breaks in the breathing, thus avoiding holding your breath.

I know that arm/upper extremity exercises are more taxing on the heart....learned that in school....don't think they ever explained why.

My opinion would be to stay away from free weights, and stick to nautilus----low weights with more repetitions. This is a much less stressful way to exercise, and what I usually use for someone who needs to avoid val salva.

Vicky

I grilled my son's onc about this because we were told the same thing about Doxorubicin. He told me it was the 'curling' type motion/exercise [arm curl]. I asked if that meant that pull-ups should be out? Yup. I joked that my son wouldn't be able to be a professional mover or stock person because of the repetitive up and down motions of his arms. The onc didn't think it was a joke and answered that I was right, that he should *not* do those things.

The onc said that the bottom line was that they simply didn't *know* for certain and that since some kids/people have died with the 'weightlifting connection' they caution everyone who has had Doxo *not* to weightlift. I was told that it was the arm curl [and similar motions] in particular.

Tea

We have never been told to avoid weight training. I know some oncs caution against it. My son has had echos and EKG's and they have all been ok. He received over 350 mg of anthracycline cocktails and is in the range of kids who need regular follow up. His oncs have consistently advised him to keep doing his normal activities, whatever he felt up to doing, and weight training was a normal activity for him. He lifts 4 days a week for about 60-90 minutes. He is currently using free weights (as opposed to weight machines), but he is in an environment with abundant supervision and spotters. I know if he were to start to hold his breath during a lift, he'd be stopped and corrected.

***CAUTION*** Weight training, like any sport, must be learned. There are proper lifting and breathing techniques involved. Ignore those behemoths you see on TV that lift 600 lbs while their face turns bright red. If anyone is going to begin a weight training program, they should receive instruction from someone other than the senior guy who has the weight room key.***

Considering that my son continues with weights and sports, I will be adamant about regular cardiac testing. I know late effects can show up years down the road. I wonder if oncs who restrict activity without any sign of cardiac changes are not handicapping kids prematurely. The heart is a muscle. Activity exercises that muscle and can make it stronger. At least that's my understanding. I know anthracyclines can wreak havoc with cardiac muscle and cause major problems. This is why our kids need regular cardiac testing. I'm just not sure that the issue of exercise/weights and survivors has very clear answers and suspect that when little is known, the automatic response is don't try it.

I hope that someday we have some more definite answers to this question. I think it's one of those late effects issues that are just now being addressed. Frustrating for us worrywarts who would like some real answers to our questions.

Missy

Our onc said that the Val Salva technique is a definite no-no. It places huge pressures on the heart. It is not good for anyone, and especially dangerous for anthracycline-treated people. Her advice is to always breathe through any weight-lifting type exercise.

Before this all started, I had no idea what "Valsalva" meant. Vicky's and Missy's explanations are clear, but I wanted some details. I didn't even know where to look. I'd checked some books on cardiology out from the Univ library, not much help there. So I plugged Valsalva into my search engine and find that it is a rock band. Oh, that's not it, I'm sure. I kept surfing, never give up. I find this "Valsalva maneuver: forced exhalation with closure of mouth and nose." Oh, that's what Missy and Vicky said. Getting closer. It seems that this maneuver has relevance to stuttering, trombone playing, weightlifting, and hiccups. Here is a good but somewhat technical link describing the maneuver: Valsalva. They discuss the observation that if one does the Valsalva technique while doing heavy resistance exercise, the blood pressure rises tremendously. Simply breathing through the exercises prevents this.

I went on to MedLine to search the medical journals. Why is isometric exercise/weightlifting without breathing so dangerous to an anthracycline-compromised left ventricle? I found this in an 80s article:

"One method for testing cardiac reserve is to increase arterial pressure by isometric handgrip exercise (IHE) which increases the afterload against which the left ventricle must eject blood. In previous invasive studies in patients with cardiac disease, decreased ventricular reserve during IHE was manifest by a marked rise in LVEDP and a fall in cardiac output and stroke work index."

So, isometric exercise increases afterload, and recall from the cardio-page that increased afterload is not good: it is a sign of anthracycline-induced heart damage. It puts a strain on something that is already strained.

The next abstract clarified it even more for me, so I'm linking to it. I hope MedLine doesn't mind me pasting the abstract here, too.

Cardiovascular responses to static exercise. Hietanen E. J Work Environ Health 1984 Dec;10(6 Spec No):397-402.
"Heavy static exercise is characterized by a failure of the local blood flow to adjust to the oxygen demands of the exercising muscles. Respiratory and circulatory responses are dominated by an incompetence to obtain steady-state conditions, and thus the worktime is short. After the cessation of heavy static exercise a sudden compensatory increase occurs in cardiac output and oxygen uptake. Due to the higher increase in blood pressure, even light static exercise causes much higher strain on the heart than an equivalent amount of dynamic exercise. The heart responds to the increased afterload by increasing contractility and heart rate and thus improves cardiac output. In persons with a poor cardiac reserve a rise in the left ventricular end-diastolic pressure is seen, along with a fall in the stroke work index in response to the increased afterload caused by static exercise. It is possible that a discrepancy exists between work capacity during tasks demanding also isometric muscle work and a dynamic exercise test performance. The decreased cardiac reserve may first appear after the great increase in afterload, even in relatively light static work."

My take-home lesson from this is that Valsalva places undue strain on the reduced-contractility and increased-afterload characteristic of anthracycline-induced cardiomyopathy. I take this to mean that even if damage has not yet been detected in a anthracycline-treated survivors' heart, small amounts of damage might be present and the strain placed on it by a Valsalva maneuver could bring on problems, such as symptoms of CHF. These symptoms would probably cause chest pain, fatigue, shortness of breath, perhaps to the point that the survivor would be hospitalized. I've read (somewhere, sometime, I can't find the references) that a few patients have died, but in most cases they probably will just get medical help and be put on a treatment plan.

Patty

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