1. Pre-Initial consultation paperwork
   1. Par Q
   2. Informed consent
   3. Pre-screening
   4. Bring all medication & vitamins into the clinic for initial consultation
      1. know possible side effects
         1. change frequency / intensity of exercise session
         2. when to refer back to GP
   5. Referral information
      1. GP
         1. DEXA
            1. bone density; borderline osteopenia
      2. Surgeon
      3. oncologist
      4. Blood workups
         1. WBC; 5000 mcl
         2. Hemoglobin; 11.2g/dl
         3. Absolute neutrophil; 1100 mm3
         4. Platelets; 250,000 mm3
         5. CEA; 19mg/ml
         6. HDL; 40mg/dl (2.2mmol/L)
         7. LDL; 98mg/dl (5.5mmol/L)
         8. Triglycerides; 30mg/dl (1.7mmol/L)
         9. Total Cholesterol; 138mg/dl (7.7mmol/L)
         10. Resting: 202mg/dl (11.2mmol/L)
         11. NOT anaemic
      5. Medical diagnosis
2. Initial Consultation
   1. Subjective Information
      1. Medical History
         1. Diabetes Mellitud type 2 - 1990
            1. Symptoms
            2. Past symptoms
            3. Frequent urination
            4. Lack of energy
            5. Excessive thirst
            6. Tingling or numbness in hands and feet
            7. Possible other symptoms
            8. Weight loss
            9. Increased hunger
            10. Lack of concentration or interest
            11. Blurred vision
            12. Frequent infections
            13. Slow-healing wounds
            14. vomiting or stomach pains
            15. Alleviators
            16. Medication
            17. Aggravators
            18. Stress
            19. Lack of medication adherence
            20. Rehabilitation?
            21. GP prescribed increased physical activity; walking
            22. No other health professional intervention
            23. Meds
            24. Diamicron
            25. Lowers blood glucose by increasing the amount of insulin
            26. Side effects experienced
            27. Currently
            28. none
            29. Ever
            30. Hypoglycaemia episodes
            31. Diarrhoea- when first on meds
            32. Possible side effects
            33. Upset stomach
            34. heartburn
            35. Constipation
            36. Increased bleeding
            37. Bruising
            38. Fever
            39. Vision problems
         2. Hypercholesterolemia - 1990
            1. Symptoms
            2. Past Symptoms
            3. High blood glucose
            4. High levels of sugar in the urine
            5. Frequent urination
            6. Excessive Thirst
            7. Possible other symptoms
            8. Ketoacidosis
            9. Shortness of breath
            10. Fruity breath
            11. Nausea
            12. Very dry mouth
            13. Alleviators
            14. Meds
            15. Exercise
            16. Aggravators
            17. Too much food
            18. Too little exercise
            19. Lack of diabetes treatment adherence
            20. Lack of meds adherence
            21. Stress
            22. Illness / flu
            23. Rehabilitation
            24. No other health professional intervention
            25. GP prescribed increased physical activity; walking
            26. Meds
            27. Crestor
            28. Lowers LDL cholesterol and raises HDL cholesterol
            29. Side effects experienced
            30. Currently
            31. None
            32. Ever
            33. Nausea
            34. Possible side effects
            35. headache
            36. Constipation
            37. dizziness
            38. stomach pain
            39. unusual tiredness
            40. itchy skin
            41. memory loss
            42. stiff or painful joints
            43. aching, weak or tender muscles
            44. difficulty swallowing, breathing coughing
            45. swelling of face, lips or eyelids
         3. Asthma -1970
            1. Chronic inflammatory disorder of the airways --> airway hyperresponsiveness -->wheezing, coughing, breathlessness & chest tightness. Morton et al, 2011
            2. Symptoms
            3. Past symptoms
            4. shortness of breath
            5. wheezing
            6. tightness of chest
            7. dry, continual cough
            8. Night
            9. during/after exercise
            10. Alleviators
            11. bronchodillator / reliever meds
            12. Aggravators
            13. Exercise
            14. Air pollution
            15. pollen
            16. bushfires
            17. smoke
            18. chemicals
            19. cold / flu
            20. Frequent hospitalisation
            21. Rehabilitation
            22. GP prescribed frequent swimming
            23. No other health professional intervention
            24. Typical practice in this era
            25. Meds
            26. Prednisone
            27. Anti-inflammatory STEROID that helps reduce airway inflammation
            28. lower dose taken everyday for long-term control
            29. Side effects experienced
            30. Ever
            31. muscle weakness
            32. growth suppression
            33. Currently
            34. DIABETES
            35. elevated BP
            36. elevated blood glucose
            37. Causing diabetes --> hyperglycemia
            38. Possible Side effects
            39. decreased urine output
            40. irregular heartbeat
            41. dizziness
            42. numbness/tingling in arms/legs
            43. SOB
            44. Weight gain
            45. Neuro problems- thinking/walking/speaking
            46. bone thinning
            47. DEXA
            48. Pulmicort
            49. CORTICOSTERIOD- reduce inflammation in the ariways
            50. Side effects experienced
            51. Ever
            52. thirsty
            53. Subtopic 3
            54. Currently
            55. irritation of tongue and mouth- sometimes
            56. Possible side effects
            57. headache
            58. fatigue
            59. nausea
            60. diarrhoea
            61. weight gain
            62. skin bruising / rash
            63. swelling of body parts
            64. Ventolin inhaler
            65. Bronchodilator
            66. Side effects experienced
            67. Currently
            68. none
            69. Ever
            70. mouth and throat irritation
            71. irregular heart beat/ tachycardia
            72. restlessness
            73. Possible Side effects
            74. headache
            75. nausea
            76. shaky
            77. Serevent Inhaler
            78. Unstable/Acutely deteriorating asthma- reverse airway obstruction, bronchodilator
            79. Side effects experienced
            80. Ever
            81. Palpitation
            82. headaches
            83. Currently
            84. hyperglycemia?
            85. Possible Side effects
            86. Tremor
            87. Muscle cramps
            88. rash
            89. for those receiving corticosteroids
         4. Stage 3 prostate cancer - 2011
            1. Cancer spread beyond prostate, may have invaded adjacent lymph glands/ seminal vesicles
            2. Symptoms
            3. Current symptoms
            4. Urination problems
            5. frequently at night
            6. sudden/urgent
            7. difficulty starting/stopping
            8. slow flow
            9. blood
            10. painful ejaculation
            11. inability to get erection
            12. decreased libido
            13. Possible sypmtoms
            14. May also be caused by operations / treatment / meds
            15. Meds
            16. Lucrin Injections
            17. Hormone Releasing Agonist- blocking secretion of hormones from testes--> slow/stop growth of prostate cancer
            18. Taken in 'pulses' on / off periods
            19. Side effects experienced
            20. Ever
            21. diarrhoea
            22. nausea
            23. urinating problems
            24. sleep disturbance
            25. Currently
            26. Pain, swelling, redness @ injection site
            27. inability getting/maintaining erection
            28. loss of libido & erection
            29. loss of distal body hair
            30. May also be caused by operations / treatment / meds
            31. Possible Side effects
            32. unusual fatigue/weakness
            33. insomnia
            34. Muscle, back or joint pain
            35. headache
            36. dizziness/light-headedness
            37. difficulty breathing
            38. change in testicular size
            39. hot flushes
            40. breast development
            41. bone loss
            42. Treatment
            43. Radial Prostatectomy
            44. Removal of prostate and affected lymphs
            45. retropubic- cut from belly button to pubic bone
            46. done so near my affected lymphs can be taken
            47. side effects experienced
            48. erection problems
            49. slight incontinence
            50. Possible side effects
            51. infection
            52. damage to rectum or urethra
            53. blood clots
            54. heart attack
            55. stroke
            56. External Beam Radiation therapy
            57. side effects experienced
            58. erection problems
            59. FATIGUE
            60. Possible side effects
            61. irritation of bowel
            62. damaged organs (predominately bowel and bladder)
            63. bleeding in stool
            64. Decreases in lean body mass, muscle strength, bone mineral density, increased adiposity and osteoporosis. Parsons et al, 2014
            65. Rehabilitation
            66. acute, prep for discharge
         5. Non-Specific Lower Back Pain - 2010
            1. Mild and short lasting
            2. Symptoms
            3. Alleviators
            4. NSAIDS- short bout
            5. rest / not performing lifts
            6. heat pack
            7. Aggravators
            8. current work
            9. incorrect lifting technique
            10. lifting above safe limits
            11. Meds
            12. NSAIDS
            13. Rehabilitation
            14. AEP
            15. 3 sessions
            16. core stabiliser exercises
            17. education on correct lifting technique
         6. interrelated
      2. Other symptoms
         1. Discomfort
         2. Joint pain
            1. slightly in both knees after a long day of work
         3. psychological
            1. frustrated
            2. unmotivated
            3. BARRIER
      3. Family History
         1. Cardiac
            1. Father died of heart failure
         2. Pulmonary
            1. nil
         3. Metabolic disease
            1. Cancer
            2. older brother dead of lung cancer 2008
            3. Diabetes
            4. Mother has diabetes mellitus 2 since 55 years old
            5. Wife pre-diabetic since 2013
         4. Stroke
            1. nil
         5. Sudden death
            1. nil
      4. Health Questionaires
         1. Cancer
         2. QOL
         3. Asthma
            1. Juniper Asthma Control Questionnaire
            2. Use of bronchodilators
            3. Cough
            4. Physical activity levels
            5. Pulmonary function
         4. Depression
      5. Exercise history
         1. Currently exercising?
            1. no
         2. Sports
            1. Currently?
            2. no
            3. Used to play
            4. cricket
            5. swimming
         3. Physical activities
            1. sedentary
      6. Work history
         1. Factory worker
            1. some job since 1989
            2. 10 hour days
         2. Physical activity level
            1. lifting boxes occasionally
            2. drives to and from work
            3. sits down at a conveyer belt majority of day
      7. Home life
         1. Social support
            1. supportive wife
            2. 2 grown boys who live close by
            3. close circle of friends- 3 other couples
         2. Barriers
            1. time
            2. work
            3. driving wife around
            4. does know how exercise can help
            5. worried exercise will worsen asthma and other symptoms
            6. FATIGUE
            7. money
            8. wife doesnt work
            9. mortgage
            10. only has 1 shared car
            11. 2 story house
         3. Subtopic 3
      8. Other habits
         1. Caffeine intake
            1. 1 coffee, 1 cola per day
         2. Alcohol intake
            1. 2-3 beers every other night
         3. Tobacco smoking?
            1. no
         4. Recreational (illicit) drug use
            1. no
         5. Sleep
            1. somewhat disturbed during hormone therapy
         6. Diet
            1. poor; high fat, high carb, high sugar
   2. Objective Information
      1. Anthropometric
         1. Weight; 60kg
         2. Height; 165cm
         3. Waist; 89cm
         4. Hips; 81cm
         5. Resting HR; 84bpm
         6. Resting BP; 135/89
         7. Diabetes:
            1. Cholesterol levels
            2. HDL; 40mg/dl (2.2mmol/L)
            3. LDL; 98mg/dl (5.5mmol/L)
            4. Triglycerides; 30mg/dl (1.7mmol/L)
            5. Total Cholesterol; 138mg/dl (7.7mmol/L)
            6. glucose;
            7. Resting: 202mg/dl (11.2mmol/L)
         8. Asthma;
            1. FEV1; 1.6
            2. peak flow; 300L/min
            3. controlled via meds
            4. dyspnoea scale; 2 (1-10)
            5. Oxygen saturation; 99
         9. Cancer / infection;
            1. CEA; 19mg/ml
            2. Platelets; 250,000 mm3
            3. Absolute neutrophil; 1100 mm3
            4. Hemoglobin; 11.2g/dl
            5. WBC; 5000 mcl
         10. Fatigue scale (1-10);
             1. Rest; 2
             2. During walking / work; 5
             3. After work; 6-6.5
         11. BMI;
         12. WHR;
         13. BMI; 23 (healthy range) H:W ratio; 1.1 (high risk)
             1. Endocrine changes from hormone therapy
             2. Fat mass distribution
             3. Decreased lean muscle mass
         14. Prehypertensive: (120-139/ 80-89)
3. Goals
   1. Patients
      1. Short term
         1. reduce fatigue
         2. reduce use of meds- esp bronchodilators
         3. loss weight around mid section
         4. complete all exercise sessions each week
      2. Long term
         1. be able to play cricket with sons again
            1. improve aerobic endurance
   2. AEP
      1. Short term
         1. decrease BP into healthy range- below 130/80
            1. eliminate prehypertension status
         2. decrease resting HR- below 72
         3. decrease LDL in healthy range- LDL: 35mg/dl (2mmol/L)
         4. decrease total cholesterol into healthy range- 70 mg/dl (4mmol/L)
         5. decrease fasting glucose into healthy range- 70-100mg/dl (4-6mmol/L)
            1. eliminate diabetes status
         6. improve peak flow rate - 400l/min
      2. Long term
         1. regain pre-cancer strength
            1. improve 1RM lower / upper body
         2. eliminate cancer / treatment / meds related fatigue
         3. improve lean body mass / muscle mass / bone density
4. Exercise Testing
   1. Aerobic
      1. Max vs Submax testing?
         1. Is max needed?
            1. Very deconditioned- submax!
            2. Determine workloads
      2. 6MWT
         1. Alibhai et al 2010
         2. Patient is worried that treadmill exercise will worsen asthma
      3. Graded treadmill test
         1. Treadmill better for BP monitoring but not always available
      4. Testing only needed if survivor plans on participating in vigorous exercise OR is at increased risk from other complications
   2. Strength
      1. Estimated 1RM
         1. Segal et al, 2003
      2. Upper body
         1. Chest pres
            1. Galvao et l 2007
         2. Seated row
         3. Grip strength
            1. Ensure safety when performing resistance exercises
            2. Alibhai et al 2010
      3. Lower body
         1. Leg press
      4. Abdominal strength test
         1. 30 sec sit-ups
      5. Assess muscle wastage
         1. girth of muscles
         2. MMT
         3. Cancer treatment and inactivity related Schmitz et al 2010
   3. flexibility
      1. ROM
         1. All major joints
         2. Can see if any lymphedema causes reduced mobility
   4. balance
   5. Function
      1. TUG
         1. Alibhai et al 2010
      2. Squat
         1. Matt finds getting out of a chair difficult
   6. Monitoring
   7. contraindictors / red flags
      1. Refer back to doctor
5. Exercise Prescription
   1. Aerobic
      1. Prescription
         1. Frequency; small sessions everyday due to deconditioning. At least 3-5 days week
            1. minimum of 2-3 days increased QOL in prostate cancer men. Keogh et al, 2012
         2. Intensity; low- moderate. 50-75% V02max. 60-80% HRmax. RPE 11-14. Baumann et al 2012
            1. moderate intensity can improve gylcaemic control (doesn't need to be vigorous)
            2. reduced need for diamicron / crestor
            3. stress the system without straining it. Morton et al, 2011
            4. Moderate aerobic training had a positive impact on cytokine levels, immune function and oxidative stress levels in prostate cancer men. Zimmer et al, 2013
         3. Duration; 3-5 minute intervals with rest periods. accumulating 20-30 mins. increasing duration until continuous without rest
         4. Progression; slowly / gradual as very deconditioned. Meet frequency and duration guidelines before increasing intensity
         5. Type; slow continuous walking, low intensity walking intervals, cycling
            1. start with low-level interval training until fiitness level improves, then move onto continous training. Morton et al., 2011
            2. Although swimming is optimal for asthmatics, it increases the risk of infection in surgical area + injection area + shouldn't be performed due to slight incontinous
            3. cycling ideal, as it is low impact exercise- important if neuropathy- diabetes
            4. Matthew would prefer cycling but would like to mix it up
         6. Warm up; adequate to reduce asthma flare up
         7. cool down; HR to 20bpm from resting HR
      2. improve aerobic endurance
      3. Decrease cancer medication side effects. Baumann et al, 2012
      4. weight loss
         1. visceral adiposity
            1. decrease waist circumference / hip:waist ratio
            2. Segal et al 2013
      5. Increases max expiratory ventilation
      6. Increases max oxygen uptake
      7. Increases max HR
      8. Windsor et al 2005
   2. Resistance
      1. Prescription
         1. Type; dynamic. concentric/eccentric contractions. functional movements
            1. Leg press; 96.3% muscular strength improvement 167.1% muscular endurance improvement
            2. Chest press; 40.5% muscular strength improvement 114.9% muscular endurance improvement
            3. Seated row; 41.9% muscular strength improvement
            4. significant improvements in muscle mass, quadriceps size and body fat percentage. Keogh et al, 2012
            5. Resistance training program by Galvao et al 2007
         2. Frequency; 1-3 times/week. Rest day between sessions
            1. 2-3 days yielded the highest strength gains in prostate cancer men with adrogen deprivation therapy
         3. Intensity; 50-70% 1RM. 6-12 reps max
            1. Young males & females experience increased testosterone levels after resistance training at 80% 1RM.
            2. Resting testosterone levels are seen in middle-aged, sedantary men after resistance training @ >80% 1RM
            3. Therefore, training intensity will not go above 80% 1RM to minimise risk of raising serum testosterone (risk factor for secondary cancer
            4. Higher risk of bone fracture @ >intensities
            5. Segal et al, 2003
         4. Duration; 6-10 exercises. major muscle groups. 1-4 sets per muscle group
            1. Larger muscle groups yield higher benefits for weight loss; decreasing diabetes (blood lipids)
         5. Progression; slowly / gradual as very deconditioned. Meet frequency and duration guidelines before increasing intensity
            1. increase load by around 2.5kg once Matt can lift > the reps successfully
         6. Start with supervised program
            1. Better for adherence and progression
      2. improves muscle, bone and immune, endocrine and nervous systems
      3. increases muscle strength
      4. lean tissue mass
      5. counteract side effects of cancer therapy (hormone therapy)
         1. reduced fatigue - Galvao et al 2007
   3. Flexibility
      1. ROM
         1. Help with lymphoedema
      2. Performed everyday exercise is done
   4. Core stability
      1. Further help with NSLBP
   5. Other
      1. yoga or thai chi
         1. Help with fatigue and mood
         2. Breathing techniques can lessen attacks
      2. pelvic floor
         1. recommended to patients after radical proctectomy. Burkert et al, 2012
            1. help with incontinence
   6. Monitoring
      1. 'Any changes to your health / conditions since our last session?"
      2. Diary of symptoms / side effects frequency and intensity
         1. Help indicate triggers
         2. Also can be used as an outcome measure
      3. BP
         1. Client is prehypertensive. Need to monitor throughout exercise
      4. ECG
         1. high risk of CV event
      5. HR
         1. Intensity indicator
      6. RPE scale
      7. pain scale
         1. Meds iInjection site
         2. chest tightness due to asthma
      8. dyspnoea scale
         1. Exercise induced SOB is common in asthmatics. Need to know the difference between SOB due to inflammation of airways and fatigue related SOB from high intensity exercise
      9. Fatigue scale
         1. FACT
      10. lymphedema
          1. Check for swelling and a decrease in ROM. Patient might indicate a change / struggle in certain movements that can be suggesting lymphedema
      11. Check feet & shoes (neuropathy- diabetes)
          1. distal extremity numbness is common. Patient might have hurt their foot and not realised. This could then lead to infection
      12. Testosterone levels
          1. Increased testosterone levels can increase the risk of further cancers / spreading
   7. Outcome measures
      1. Asthma symptoms;
         1. Episodes of wheezing or SOB
         2. Dyspnea
         3. Bronchodilator usage
         4. Number of symptom free days
      2. Muscular endurance
      3. Work capactity
      4. Walking distance (improved 6MWT)
      5. QOL
         1. questionaires
      6. Physiological measures
         1. PEFR
         2. VEmax
         3. FEV
            1. peak flow
         4. FVC
         5. VO2max
         6. Max HR
         7. MVV
         8. Glucose levels
      7. PSA reduction
   8. contraindicators / red flags
      1. If asthma meds do not control symptoms
      2. peak flow drops below 75% of resting
      3. oxygen saturation below 88
      4. severe dyspnoea
      5. Patient asks to stop
      6. No vigorous exercise- hypertension
      7. No Valsalva maneuver- hypertension
      8. Extreme fatigue
      9. Wound healing; surgery site
      10. Sustained tachycardia
      11. Chest pain
      12. Dyspnea on exertion
      13. Syncope
      14. Raising serum Testosterone levels due to increased resistance training
      15. client is prehypertensive
   9. Considerations
      1. Risks associated with disease vs complications from exercise vs complications of sedentary lifestyle
      2. Higher risk of fractures
         1. DXA, FRAX
      3. lymphedema
      4. Anemia
      5. Have an asthma action plan. Morton et al, 2011
         1. bring inhalers to every session
      6. medication timing
   10. Differences from original data collected from tests. Compared with normative data
6. Education
   1. diet / nutrition
      1. high in vegetables, fruit, whole grain cereals. Low in saturated fats.
      2. Legumes, soy products , tomatoes & fish may benefit men with prostate cancer
      3. Vitamin D & calcium for bones
      4. Healthy diets; cope better with side effects and aid healing of wounds or damaged tissue
      5. Also aid weight loss--> reduce diabetes and its side effects
   2. cancer related fatigue
      1. treatment
      2. illness
      3. deconditioned
      4. Exercise has been found to reduce cancer related fatigue. Even though exercise is seen as 'fatiguing'
   3. psychological side effects
      1. Depression is common with cancer patients
         1. Exercise can be used to decrease depression
   4. lifestyle and behaviour changes
   5. Asthma & exercise
      1. Increased exercise capacity decreases exercise induced bronchoconstriction and corticosteroid consumption
      2. VS exercise provokes brochoconstriction
   6. Strength gains are possible despite diminished testosterone. Baumann et al, 2012
      1. this resistance training will not increase testosterone and increase risk of cancer reoccurrence
      2. physical activity can reduce the probability of relapse. Newton, 2008