OSU Patient Education Handout

Aromatase Inhibitor-Associated Musculoskeletal Syndrome in Breast Cancer

Refer to the Endocrine Therapy for Breast Cancer patient handout to receive more information regarding endocrine therapy, review of hormones and how this can be used for hormone-receptor-positive breast cancer.

What are aromatase inhibitors?

Aromatase inhibitors are medications that prevent the production of the hormone, estrogen, in postmenopausal and premenopausal women, if ovary function is suppressed, by blocking an enzyme called aromatase from making estrogen. Some common names of aromatase inhibitors include the following: Aromasin (exemestane), Femara (letrozole), Arimidex (anastrozole) and Megace (megestrol).

What are possible side effects with taking an aromatase inhibitor?

Musculoskeletal paino Joint pain including: hands, shoulders, hip, low back and feeto Most of these symptoms develop within the first two to three months of treatment

Osteoporosis Focal inflammation with edema Hair thinning Vaginal dryness Decreased sex drive

*Contact your medical oncologist if experiencing or have questions about any of the above symptoms

What are some ways to decrease the side effect of musculoskeletal pain?

Research suggests that two hours per week of aerobic exercise (an average of 120 minutes to 150 minutes) and 2 times per week of strength training over 1 year is optimal for improving AI-associated musculoskeletal syndrome. These exercises below can initially be completed without a theraband or weight, using a theraband then progressing to use free weights.

Exercise Program:

1. Warm up: consists of 5 to 10 minutes of aerobic activity of your choice2. Stretching: hold each stretch for 30 to 60 seconds on each side3. Strengthening: 8 to 12 repetitions of each exercise4. Cool down: repeat the stretches you completed to begin; holding each stretch for 30 to 60

seconds on each side

Stretching:

Complete each stretch once and hold each stretch for about 30 to 60 seconds. This should be performed in a pain free range. Remember to breathe while performing these stretches.

1. Trunk rotation stretcha. Lying on your back, bend both knees and press your back into the

surface.b. Place both arms at shoulder level against the surface.c. Drop both of your knees to one side of your body. Repeat on other

side.

2. Hamstring stretcha. Sitting at the edge of a chair, rest your heel on the floor with your knee

straight.b. Gently lean forward at your hips while maintaining a neutral spine

until a stretch is felt behind your knee/upper thigh. Repeat on other side.

3. Calf stretcha. Stand in front of a wall or sturdy object and step forward with one foot,

like a lunge position, while maintaining your toes on both feet pointing straight forward.

b. Keep the knee of the leg behind you straight during the stretch. c. Lean forward towards the wall while supporting yourself with your arms

as you allow your front knee to bend until a gentle stretch is felt along the back of your calf that is most behind you.

d. Move closer or further away from the wall to control the stretch of the back leg. You can adjust the bend of the front knee to control the stretch. Repeat on the other side.

4. Chest stretcha. In standing, place your arms on the side of the doorway with elbows

straight and arms about shoulder level.b. Step into the doorway to stretch. Be sure you are not leaning forward

with your trunk to stretch, instead taking a step into the doorway. You should feel this stretch across your chest.

5. Wrist flexor stretcha. In standing or sitting, put your arm out directly in front of you with your

elbow straight near shoulder level.b. Move your wrist back towards your body and use your other hand to

apply pressure at your palm and fingers towards your body. You should feel a stretch under your wrist and under your forearm. Repeat on other side.

Strengthening exercises:

Perform each exercise twice a week and complete 8 to 12 repetitions. Within the first month of this program, progress to completing 3 sets of each exercise. Each exercise can be used without a weight or theraband, with a theraband or with weight.

Upper Body Strengthening Exercises:

1. Bench PressUsing theraband

a. In standing, place the theraband across both shoulder blades and hold the theraband with both hands.

b. Keep elbows bent at your side with thumbs pointing up towards the ceiling.c. Press arms forward into theraband, straightening elbow and return to starting position

with elbows bent at your side.Using weight

d. In a seated position on a bench, lie down on your back with a dumbbell in each hand.

e. Start by positioning the weights near your chest with bent elbows and arms at shoulder height with feet planted flat on the floor.

f. Push the weights up towards the ceiling. Your elbows should move from a bent position to a straight or nearly straight position. Next, lower both dumbbells to starting position and repeat.

g. You can also use the bar as you progress with weight.

2. Latissimus Pull DownUsing theraband

a. In a standing position, tie the theraband in the doorway above shoulder level with a knot.

b. Hold the theraband with both hands in front of you and with your elbows straight.

c. Your arms should be elevated slightly above shoulder level. Next, pull the band downwards and back towards your side as you bend your elbows and squeeze your shoulder blades together.

Using machinea. In a sitting position, hold the bar above you with hands slightly wider

than shoulder width apart. Both hands are in front of you and your elbows straight.

b. Your arms should be elevated slightly above shoulder level. Next, pull the bar downwards and back towards your side as you bend your elbows and squeeze your shoulder blades together.

3. Seated or standing rowUsing theraband

a. Anchor theraband in doorway above waist level.b. While standing, with arms straight out in front of you, pull back on the

theraband with both arms. c. Bend your elbows and squeeze your shoulder blades together as you

bring the theraband towards your body.d. Maintain upright posture and make sure your shoulders are not

elevating.Using weight

a. While standing, with arms straight out in front of you lower than shoulder level and a free weight in each hand, bend your elbows back toward you

b. Squeeze your shoulder blades together as you bring the weights towards your body.

c. Maintain upright posture.d. This can also be done using a seated rowing machine.

Lower Body Strengthening Exercises:

1. Leg PressUsing theraband

a. Sit in a chair while maintaining upright posture.b. Place the theraband under your foot and bend your knee while holding

onto the theraband with both handsc. Press your leg forward into the theraband in order to straighten your

knee, but do not lock your knee and return to starting position.Using machine

d. Initially, set weight of machine.e. Sitting in the machine, put feet up onto plate positioning them so that

your knees are directly over ankles and knees are bent to 90 degrees.f. Push plate forward until knees are straight but not locked. Slowly

return to starting position.

2. Leg ExtensionUsing theraband

a. In standing, place theraband around ankle while anchoring it to your other leg that is stationary or to a stable piece of furniture.

b. Push leg in a backward direction. Do not swing your leg. Perform smooth and controlled movements.

c. Keep your trunk stable, stand upright and avoid arching your back during the movement.

d. Use your arms for support if needed for balance and safety.Using ankle weight or machine

e. In standing or using a machine, balance on one leg and move your other leg in a backward direction. Do not swing your leg. Perform smooth and controlled movements.

f. Keep your trunk stable, stand upright and avoid arching your back or moving your trunk during the movement.

g. Use your arms for support if needed for balance and safety.

3. Leg CurlUsing theraband, ankle weight or machine

a. In standing with upright posture and abdominals contracted.b. Slowly bend knee up towards your buttocks.

c. Make sure to keep thighs aligned; do not allow thigh of bent leg to move in front of standing leg.

d. Repeat on other side.

Core exercises:

1. Abdominal bracinga. Lying on your back with your knees bent, gently pull in your abdominal

muscles b. Make sure you do not suck in your abdomen forcefullyc. Hold for 2 to 3 seconds, then relaxd. When this becomes easy, add in arm movements overhead one at a

time; then marches with one leg at a time and opposite arm and leg at the same time.

Aerobic exercise protocol:

In order to complete about 120 to 150 minutes of aerobic exercise a week, set aside 25 to 30 minutes of time 5 days per week. This time can go by fast if you have a walking partner. Try to keep a log to track your progress!

These options include: Walking

o Treadmill or outside Stationary bicycling Stepper machine Elliptical

Weekly Exercise Log

Exercise type Sunday Monday Tuesday Wednesday Thursday Friday SaturdayAerobic exercise

Upper Body strengthening exercises

Lower Body strengthening exercises

Total time for aerobic exercise for the week:

To measure your effort when performing aerobic exercise, use the Rate of Perceived Exertion (RPE). This scale below tells you how you are feeling during exercise, from 0 to 10. Exercise should be performed around a RPE level of 6.

Rate of Perceived Exertion Scale (RPE)0 No effort1 Light effort2 Light effort3 Moderate effort4 Moderate effort5 Strong effort6 Strong effort7 Very strong effort8 Very strong effort9 Very, very strong effort10 Maximum effort