Several international guidelines and position statements have recommended that exercise should be embedded as standard practice in cancer care. The main argument for this has been symptom control, in particular for fatigue. Exercise during or after cancer treatment also improves quality of life, physical and role functioning, and reduces anxiety and depression. Following the 2018 ACSM Roundtable on Exercise and Cancer Prevention and Control, updated exercise guidelines for people living with or beyond cancer were issued. Simultaneously, practical recommendations were made regarding the implementation of exercise in clinical cancer care. Despite these and ongoing efforts, exercise is still not always addressed, and patients are not always referred.

An often-heard reason for non-referral is the notion that a patient is too physically unfit to join an exercise program during chemotherapy. However, poor physical functioning also leads to the postponement, alteration or premature cessation of chemotherapy treatment. Such deviations from the chemotherapy regimen may have detrimental consequences for treatment efficacy. In breast cancer in particular, there are survival implications if the relative dose intensity (RDI) drops below 85%.

In our study, published in the April 2022 issue of Medicine & Science in Sports & Exercise_®, we examined the relationship between physical fitness at the start of chemotherapy and chemotherapy completion rates in women with breast cancer. We reanalyzed the combined raw data of two previously conducted randomized controlled trials on exercise during chemotherapy for breast cancer. The PACES study compared two exercise interventions: The first was a low-moderate intensity, self-directed, home-based program with nurse support. The second was a moderate-high intensity, combined aerobic and resistance exercise program supervised by a physical therapist. The latter study, the PACT study, had one exercise arm, similar to the moderate-high arm in PACES. Both studies used a non-exercise control group.

We found that overall, patients with lower physical fitness at baseline had much lower odds of attaining 85% RDI, compared to fitter patients. We did not observe this association in the subgroup of patients who followed a moderate-high intensity exercise program during their chemotherapy, while the association was two times as strong in those who did not exercise during their chemotherapy.

It is understandable that patients who are not fit are reluctant to join an exercise program, or even discuss exercise during their medical appointments. It is also, to a certain extent, understandable that health care professionals may have doubts about referring physically unfit patients to exercise during toxic treatments. This is why it is important to recognize our finding that, in fact, these patients have the most to gain from being referred to exercise programs under the supervision of qualified professionals. In clinical practice, we have seen numerous examples of low-fit patients suffering from fatigue and nausea due to the chemotherapy who surprised themselves and their caretakers with their ability to exercise. We have observed again and again how exercising helps these patients remain resilient during cancer treatment. Scientific studies, including this one, have repeatedly confirmed such clinical observations.

Summarizing, our study underscores that while there is little to lose, there is much to gain by exercising during breast cancer treatment — also, or maybe especially, when one is not physically fit. Future studies will have to shed more light on which mechanisms drive these benefits. This will allow us to further optimize exercise prescription for people with cancer.

Martijn M. Stuiver, P.T., Ph.D., is a clinical epidemiologist at the Netherlands Cancer Institute, Center for Quality of Life and Division of Psychosocial Oncology and Epidemiology. He holds a chair as lector at the Amsterdam University of Applied Sciences Faculty of Health and is vice principal of the master’s program Evidence Based Practice in Health Care at the Faculty of Medicine, University of Amsterdam. He has a background in physical therapy and over 20 years of clinical experience in cancer care. His research focuses on functional recovery from cancer and its treatment, and in particular the role of exercise.

Anne M. May, Ph.D., is a professor in clinical epidemiology of cancer survivorship and the head of the Department of Epidemiology at the Julius Center, University Medical Center Utrecht, the Netherlands. She has been involved in exercise-oncology research for almost 20 years and has performed several multicenter randomized controlled trials showing positive effects of exercise on treatment-related side effects in patients with, amongst others, breast, colon or esophageal cancer. Currently, she is leading the international PREFERABLE consortium investigating effects of exercise in patients with metastatic breast cancer in Europe and Australia.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent positions or policies of ACSM. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

During their undergraduate academic careers, students majoring in exercise science-related fields contemplate various career paths and often seek guidance regarding the necessary steps to begin their career upon graduation. It is common to encounter soon-to-be graduates who want to work in the fitness industry but are confused about the wide breadth of certifications currently available. 

Who

The ACSM Certified Exercise Physiologist® (ACSM-EP) certification is ideal for those who want to work with generally healthy populations, and potentially clinical populations in the future. Most importantly, the ACSM-EP certification recognizes the certified professional’s educational background. All certified EPs must possess a bachelor’s degree in kinesiology or an exercise science-related field, which indicates that they have had in-class and experiential learning opportunities directly related to their work as an EP. This sets ACSM-EPs apart from certified professionals whose certifications lack such requirements. 

Why

Additionally, the ACSM-EP certification provides a stepping stone for those who have ambitions to become an ACSM Clinical Exercise Physiologist® (ACSM-CEP), which requires clinical experience in addition to a bachelor’s and/or master’s degree. Thus, being an ACSM-EP provides the certificant the opportunity to work with generally healthy individuals in nonclinical settings while gaining the required clinical experience in a supervised setting to become an ACSM-CEP.

How to apply

A qualified ACSM-EP candidate must possess these basic credentials, and master knowledge, skills and abilities within four domains:

Credentials —

1. Bachelor’s degree in an exercise science-related field (or be enrolled in the last semester of the degree program). View course requirements here.

   1. Starting August 15, 2027, candidates will be required to have a bachelor’s degree from an institution that is accredited through the Commission on Accreditation of Allied Health Education Programs (CAAHEP), which will further strengthen the credibility of the certification. Learn more. 

2. Currently CPR/AED certified 

Knowledge, Skills and Abilities —

1. Health and Fitness Assessment 

2. Exercise Prescription and Implementation 

3. Exercise Counseling and Behavior Modification 

4. Risk Management and Professional Responsibilities  

Access detailed exam content outline

Value to employers

Employers can expect ACSM-EPs to be highly knowledgeable in the aforementioned areas, such that they can immediately work with generally healthy individuals, as well as those with medically controlled diseases. An ACSM-EP should be able to successfully conduct proper client assessments, develop and apply evidence-based exercise programs, implement proper behavior-change techniques and minimize the risk of injury for clients and staff. 

Thus, employers should be eager to provide the ACSM-EP with the opportunity to enhance the lives of individuals that they serve and be confident in their ability to lead others through appropriate exercise programs and related tasks.

As a fitness professional, working with a client with intellectual and developmental disabilities (IDD) can present a uniquely difficult, though rewarding, experience. People with IDD face unique barriers to engaging in and adopting regular fitness regimens, including individual physical and cognitive limitations, time constraints and transportation restrictions, and access to facilities and appropriate programming.¹ Therefore, tailoring a fitness intervention to the individual client is of even greater importance in this population. 

Preference Assessment 

It is no secret that it’s easier for people to adopt a regular physical activity routine if they enjoy the activities they’re performing. Administering a preference assessment as part of a client’s pre-participation examination is a great way to find intrinsically motivating factors you can incorporate into their training sessions. A preference assessment is a short battery of questions — such as “What are your favorite upbeat songs?” “What are your favorite animals?” or “What do you like to talk to friends about?” — that tells you about your client’s likes and drives. The assessment should include a lot of open-ended questions so as to capture as many motivating factors as possible. Adapting your training sessions based on the information you collect in this preassessment can go a long way to improving your client’s enjoyment — and, therefore, long-term adoption — of regular exercise.

Practical Example: An ongoing trial in our lab involves VO₂ peak treadmill assessments for adults with Down syndrome (DS)². Along with the difficulty of the actual exercise, the participant also has to wear a lot of equipment during the assessment, including a silicon facemask and breathing valve. After learning about the participants through a preference assessment, we can make the mask and valve more relatable by saying, “This is your superhero mask” or, “You look just like an astronaut” to reduce the anxiety they might experience when wearing it.

Physical Differences

Understanding the physical differences certain conditions cause will improve your clients’ safety. For instance, clients with Down syndrome have increased levels of hypotonia (low muscle tone) and ligamentous laxity, both of which you’ll want to consider when introducing foundational movements and ensuring proper form. Those with other IDD may have an aversion to sound or touch, which is also important to gauge beforehand. Safety is paramount when working with clients with IDD, so administering a comprehensive pre-participation screening that involves an in-depth health history will allow you design a program that’s both safe and effective.

Practical Example: Roughly half of individuals with Down syndrome have congenital heart defects (CHD)³.Although small, exercise inherently increases the risk for heart-rhythm and other heart-related changes. Performing a pre-exercise screening will help identify any CHD so you know what clinical signs to be aware of during the client’s fitness assessments and exercise sessions.

Travel Barriers

It’s important to think outside the box when you’re addressing travel-related barriers to exercise. What can you do when your client can’t get to you? Virtual training visits via videoconferencing software and in-home training are both great ways of increasing your clients’ access to exercise, allowing them to exercise in a familiar environment that reduces distractions and potential sensory aversions. Although their access to equipment may be limited when using these methods, a well-developed fitness program allows for flexibility and adaptation to different environments. Using a combination of facility-based training, virtual visits and in-home training can benefit individuals with IDD by making the program more enjoyable. There are limitations, of course: Virtual training requires access to a device capable of running videoconferencing software, and the fact that you’re not physically present may make ensuring client safety more difficult. And in-home training requires you to travel, adding time and expense.

Practical Example: For several years, our lab has delivered remote group-exercise sessions to adolescents and adults with IDD as part of internally and externally funded trials. These sessions involve a staff member who instructs 4-8 participants via videoconference. These sessions are aimed at improving a particular component of fitness and adapt routine fitness movements to be more relatable. Weekly lesson themes include animal movements, winter sports, hiking, yoga, etc. With the obvious increases to access and reduction in caregiver burden also comes the benefit of an added social component — the interpersonal interaction that occurs participant-to-participant and participant-to-instructor.

Working with clients with IDD presents a unique experience for the fitness professional. It is important to understand barriers to physical activity and ways to mitigate them. Pre-participation health screenings and preference assessments will help you develop a safe, effective and relatable program. After all, the goal of any fitness program is long-term adoption, so implementing a multifaceted, adaptable approach will ensure a good experience for both you and your client.

References: 

1. Must A, Phillips SM, Curtin C, et al. Comparison of sedentary behaviors between children with autism spectrum disorders and typically developing children. Autism 2014; 18(4): 376-384.
2. Ptomey LT , Szabo-Reed AN,Martin LE, et al. The Promotion of Physical Activity for the Prevention of Alzheimer's Disease in Adults with Down Syndrome: Rationale and Design for a 12 Month Randomized Trial. Contemp Clin Trials. 2020. 19(1):100607.
3. Irving, C.A., & Chaudhari, M.P. Cardiovascular abnormalities in Down's syndrome: spectrum, management and survival over 22 years. Arch Dis Child. 2012. 97(4): p. 326–330.

Joseph Sherman, M.S., is a clinical research coordinator with the Division of Physical Activity and Weight Management at the University of Kansas Medical Center who specializes in physical activity modifications and lab-based fitness assessments for special populations, including individuals with intellectual and developmental disabilities.