Absolute

• A drop in systolic blood pressure (10 mm. Hg. from baseline despite increases in workload, when accompanied by other indications of ischemia)
• Moderate to severe angina
• Increasing nervous system symptoms (i.e. ataxia, dizziness or near syncope) Signs of poor perfusion (cyanosis or pallor)
• Sustained ventricular tachycardia ST segment elevation (1mm.) in leads without diagnostic Q waves (other than V1 or a VR)
• Technical difficulty monitoring the ECG or systolic blood pressure Subject's desire to stop

Relative

• Drop in diastolic blood pressure (10 mm. Hg.)
• ST or QRS changes such as excessive ST segment depression (less than 2 mm. horizontal or down-sloping ST segment depression) or marked axis shift
• Arrhythmias other than sustained ventricular tachycardia, including multifocal PVC's, triplets of PVC's, supraventricular tachycardia, heart block, or brady arrhythmias
• Development of bundle branch block or intraventricular conduction delay that cannot be distinguished from ventricular tachycardia
• Hypertensive response (Systolic > 250 mm. Hg., Diastolic > 115 mm. Hg.)
• Increasing chest pain
• Fatigue, shortness of breath, wheezing, leg cramps or claudication

(ACSM, Guidelines for Exercise Testing and Prescription, 6th Ed., 2000, Chapter 5, p. 104, Box 5-3)

In addition to the above general guidelines, certain precautions and contraindications are specific to cancer patients and should be noted and monitored:

• Monitoring physiologic responses (e.g., vital signs) to exercise is important in the immunosuppressed population. Watch closely for early signs of cardiopulmonary complications of cancer treatments, such as dyspnea, pallor, sweating, and fatigue during exercise. Patients should always monitor their pulse rate, breathing frequency, blood pressure and, when warranted, use pulse oximetry.
• The Rate of Perceived Exertion (RPE) should not exceed 11 to 13 for moderate intensity training or submaximal testing.
• Current guidelines recommend that patients should be advised not to exercise within two hours of chemotherapy or radiation therapy as increases in circulation may increase the effects of the treatments (Gerber, 2000).
• People with cancer are advised to contact their physician if any of the following abnormal responses develop:
  • Fever
  • Extreme or unusual tiredness or unusual muscular weakness
  • Irregular heartbeat, palpitations, or chest pain
  • Leg pain or cramps, unusual joint pain, unusual bruising or nosebleeds
  • Sudden onset of nausea during exercise
  • Rapid weight loss, severe diarrhea or vomiting
  • Disorientation, confusion, dizziness, lightheadedness, blurred vision, or fainting
  • Pallor or gray-colored appearance
  • Night pain, or pain not associated with an injury
• The activity level of someone with anemia also may require adjustments in exercise intensity and duration due to increases in pulse and respiratory rates from hypoxia leading to fatigue with minimal exertion. Interval exercise or bedside exercise programs should be performed during frequent but short sessions throughout the day and may be the only treatment possible in this circumstance.
• It is important to monitor the hematological values in patients receiving these cancer treatments. The PT must review these values before any type of vigorous exercise or activity is initiated.
• The following table is a helpful guideline to indicate when aerobic exercise may need to be re-examined in chemotherapy patients:

  	Normal Values/Units	No Exercise	Light Exercise	Regular Exercise
  Hematocrit Females: Males:	37% to 47%40% to 50%	<25%	>25%	>25%
  Hemoglobin Females: Males:	12 to 16 g/dl.14 to 18 g/dl.	<8 g/dl.	8-10 g/dl.	>10 g/dl.
  White Blood Cells	4,000 to 10,000/mm3	<500/mm3	>500/mm3	>500/mm3
  Platelets	200,000 to 400,000/mm3	<5,000/mm3	5,000 to 10,000/mm3	10,000/mm3

  
  (From Sayre & Marcoux, 1992; Pfalzer, 1988; Winningham, 1986)
• Exercise intensity determined by training heart rate may be difficult to use as some people have inappropriate heart rate responses to exercise and large physiologic changes on a day-to-day basis from the disease, the treatments, or changes in medications.
• Exercise intensity can be guided by heart rate response based on VO2 or metabolic equivalent (MET) levels along with monitoring of blood pressure, heart rate and rhythm, and Borg's rating of perceived exertion scale (RPE) (Pfalzer, 1987).
• Compromised skeletal integrity may prevent weight-bearing activities. Non-weight-bearing aerobic activities, which may be utilized for people with bone and joint disease, include cycling, rowing, and swimming [water activities may not be appropriate for the immunosuppressed, and people with severe muscular weakness may tolerate cycling better than ambulation] (Pfalzer, 1987).
• Energy-conservation techniques and work simplification may be necessary for the person with chronic fatigue and for those whose functional status is declining. Therapeutic exercise can be scheduled during periods when the person has the highest level of energy. Interval exercise may be preferred at first, with work-rest intervals beginning at the person's level of tolerance. This may include 1 minute of exercise activity followed by 1 minute of rest, then 1 minute of exercise, and so on. As the person's endurance level increases, the duration of work may be increased while the interval of rest declines.