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‘Cancer-related fatigue is the main barrier to exercise’

‘Cancer-related fatigue is the main barrier to exercise’

Sports physiologist Cristina Gonzalez Castro talks about Nordic walking and the world of opportunities it presents in medicine and rehabilitation
Nordic walking (Photo by Anantha Subramanyam K)

Cristina Gonzalez Castro was serving lattes in a coffee shop in London and studying sports science when she was invited to the Nordic hometown of her flat mate, a Finnish girl, over the summer. While doing a bit of research for the trip, she learned about Nordic walking, the discipline of total body walking with the aid of poles.

At that time the sports aficionado, also a former rugby player, was in quest of an activity that would be gentler on the joints. Hence, Castro not only embraced Nordic walking but also, over the years, made it the bedrock of her life as a sports-science researcher.

As a radiation therapist, she worked in a hospital for a few years before moving outside the clinical setting — to promote Nordic walking among people with cancer, while also researching the activity and its impact on the human body.

Happiest Health finds out more from the sports physiologist about the significance of Nordic walking for recovery, the future of integrating sports and rehabilitation, and her study on physical exercises on breast cancer survivors. Excerpts:

Happiest Health: You have been training people in Nordic walking for the last 17 years. In your experience, how has it helped people with cancer?

Castro: In many ways. To begin with, cancer treatment is passive, something that comes from outside and that patients can’t really control. However, Nordic walking is something that they can do for themselves, and that makes them feel better. It is a low-impact whole-body exercise; however, the perceived exertion is low because we share the effort between the lower and the upper body. This is extremely important because cancer-related fatigue is the main barrier to exercise, and rest does not improve fatigue symptoms. So, exercising and not feeling tired while doing so is of great help for cancer patients. It is also very easy to learn, which helps with motivation. It improves cardiopulmonary function, blood and lymphatic circulation (which is great for those with lymphoedema), it helps with posture and with range of movement at the shoulder level and with joint pain.

The benefits are both physical and psychological. There is plenty of research on the benefits of exercising in the outdoors for mental health for the general population and this is also true for cancer patients. It is known that it improves subjective happiness — that is, how we perceive our happiness. It also improves life satisfaction and self-esteem, and importantly decreases depression, anxiety and feeling of loneliness. In fact, in cancer, a key aspect is the social support that the Nordic walking group provides and the role of the instructor to help them meet their goals.

When diagnosed with cancer, there is a general feeling of seeing no light at the end of the tunnel, but Nordic walking is a very nice way for people to take things step by step, literally! I have worked with many persons over the years and in my experience Nordic walking helps them to have a better life experience. Actually, group exercise in the outdoors is great to improve mental health regardless of whether you are a patient or not.

Happiest Health: You are also a meditation and mindfulness teacher. In your observation, how exactly does the activity help in improving mental health?

Castro: There is research out there on the psychosocial benefits of Nordic walking. To begin with, the perceived exertion is lower than walking at the same speed with no poles. This is a huge advantage on special populations that may not be willing to exercise because of fatigue. Also, it is very easy to learn, and it can be adapted to everyone irrespective of physical condition. As long as we can walk, we can Nordic-walk.

Importantly it provides a sense of physical exertion, the acknowledgment of being physically active as a compensation for a sedentary life. This means that practising Nordic walking empowers survivors to be involved in their own care and well-being.
Of course, it is social, and group support is extremely important during the cancer process – they create special bonds that help them to celebrate gains and cope with adversity. All these factors combined promote adherence, making sure that people engage with exercising on a regular basis, which is one of the main problems in exercise prescription.

Regarding meditation and mindfulness, Nordic walking is an excellent tool to practise. It really helps with body awareness, with feeling the environment, with bringing attention to our breathing and moving bodies.

Happiest Health: What have you learnt from your studies on the effects of Nordic walking on people undergoing radiotherapy?

Castro: The research I have published is based on potential benefits that Nordic walking could have in patients undergoing treatment, not only radiotherapy but also chemotherapy, hormone therapy and so on. I do not have the means to promote this kind of research directly on patients and 10 years on, I don’t know of any research group that has done this research. I would be very happy to see this happening.

Happiest Health: Your first scientific article, ‘Nordic Walking as an exercise to be prescribed in patients with lymphoedema secondary to breast cancer’, was published 10 years ago. There were hardly any papers on this topic at that time. Do you think things have changed now? Is there more interest in the field of Nordic walking and cancer?

Castro: There is definitely much more interest in exercise and cancer. In fact, research papers have soared in the last 15 years. However, there is still a long way to go in research on Nordic walking for women with breast cancer and specifically on its benefits, not only in cancer patients but also in other conditions including long Covid for instance. Also, there is a need for further research on special populations such as older adults. We have to bear in mind that life expectancy is increasing, and many older adults have several comorbidities. They can greatly benefit from being more active. Not to mention the potential in preventive healthcare and how a more active population saves a huge amount of money to national health systems.

Happiest Health: In the article, you also said that Nordic walking is a viable proposal and easy to implement in medical and healthcare centres in collaboration with specialised sports centres. Now, ten years down the line, do you see that happening?

Castro: There are some isolated initiatives, but in Spain (my home country) it is definitely not the norm. It is somehow heartbreaking to realise that ten years on we have improved so little. As I stated before, the potential Nordic walking has, not only with cancer patients but also with special populations in general and in preventive healthcare, is enormous and the cost is minimal. The biggest barrier, in my opinion, is changing mindsets, especially in the medical setting.

Happiest Health: Breast cancer-related lymphoedema (swelling of the limbs) is a significant issue for breast cancer survivors. In severe cases, people must undergo surgery. To what extent can Nordic walking help people with the condition? Does it work to an extent where one can avoid surgery?

Castro: Lymphoedema is a complex condition and once it appears, it is chronic. However, it can be controlled. So, an early diagnosis is crucial. Nordic walking can help with managing lymphoedema – it is safe, and research has found that it can even help with reducing the oedema. More research is needed but claiming that it can avoid surgery is, in my opinion, an overstatement. Breast cancer and Nordic walking should be used alongside complex decongestive therapy (provided by physical therapists), which includes skin care, specific exercises, MLD (manual lymphatic drainage) and compression therapy. Educating [people] on what cancer-related lymphoedema is, would be a great strategy to increase awareness and therefore help with early diagnosis.

Happiest Health: Could you tell us more about the study on physical exercises on breast cancer survivors that you carried out with Dr Andrea Di Blasio from the D’Annunzio University of Chieti-Pescara in Italy?

Castro: It is a very interesting piece of research lead by my dear colleague Dr Andrea Di Blasio. We assessed the effects on upper-limb circumferences of ten weeks of Nordic walking and walking, both alone and combined with a specific set of exercises to control lymphoedema called the Isa method. Those breast-cancer survivors who performed Nordic walking, alone or combined with the Isa method, and walking combined with the Isa method (but not alone) showed significantly reduced arm and forearm circumferences homolateral to the surgical intervention. Interestingly, we found that Nordic walking on its own only reports benefits if participants are technically skilled – this happens when there is an opening–closing cycle of the hands that produces the ‘pumping effect’. However, for beginners, this lack of technical skills can be overcome by specific exercises. It is therefore paramount that properly trained exercise professionals or physical therapists lead Nordic walking training in lymphoedema patients.

Happiest Health: Would you walk us through some of the case studies where you have seen the positive effects Nordic walking have had on people?

Castro: Of course, I have many inspiring stories not only of cancer patients. I remember, for example, a man with intermittent claudication, which is a painful circulatory condition. The first sessions he could barely walk 300 metres but by the end of the year he could do 5km and his doctor was so surprised that he asked for an interview with me to know what Nordic walking was about. And more recently I know about several people with long Covid who are benefiting greatly from Nordic walking. But there are many other stories in which Nordic walking has helped patients and non-patients both physically and psychologically. It is a very effective and easy intervention.

Happiest Health: Recently, you presented an exercise prescription model based on Nordic walking to improve survivorship at the European Rehabilitation and Survivorship Symposium in Copenhagen. Could you tell us more about that?

Castro: Yes, as I am not working in a hospital or a university, all I can do is try to bring awareness and educate people on exercise and cancer, and specifically on the potential benefits of Nordic walking. I presented a very simple prescription model based on three pillars:

  1. Physical activity education – educating on the benefits of physical exercise and Nordic walking in particular
  2. Making sure exercise practice is safe – that is, making sure that the correct technique is used
  3. Creating healthy habits – helping survivors to engage with exercise in the long term

It is a very simple, very easy to implement prescription model, but we need the medical team to engage with exercise specialists. Medics can bring awareness about the benefits of exercise, and the survivor should be referred to the appropriate professional, either an exercise specialist or a physical therapist if injury or comorbidities are present.

Happiest Health: You mentioned that several people with long Covid are benefiting greatly from Nordic walking. In what way is it helping them? Is it with muscle strength or lung capacity?

Castro: Both. Results from studies are still preliminary but very promising. I am the kind of person that always looks for the bright side of things. Of course, the pandemic has been terrible in many ways, but I think we could take some learning from it. On the one hand we have realised how important physical exercise is for physical and mental health. Also, we have acknowledged that we were not paying enough attention to nature and how good it is for us. Nordic walking combines both, and its potential in improving health and quality of life is great.

Happiest Health: Doctors don’t recommend Nordic walking to people whose vital lung capacity is reduced by 50 per cent or more. How cautious should people be when picking the activity?

Castro: Every person is different, so if in doubt I would always ask my doctor. I also recommend that all exercise professionals work in collaboration with doctors and physical therapists. The goal is to provide the best service and good professionals working alongside is the best way to do so.

Happiest Health: What is the future of Nordic walking in cancer, medicine and rehabilitation?

Castro: The potential is huge. I do hope that little by little we gain more attention from the medical setting.

Happiest Health: So, there is still a long way to go?

Castro: There is still a long way to go, but there are two settings in which it is growing at a good pace: the medical setting (prevention, control and rehabilitation) and sports competition. However, in my opinion, we should focus more on kids. In fact, some very interesting research done in Poland back in 2013 showed that Nordic walking was the preferred sport of kids who did not like sports. This has great potential to engage those who are more likely to be inactive. Our children are the future, and we should help them with gaining healthy habits from childhood.

Share Your Experience/Comments

2 Responses

  1. Qué interesante tu artículo sobre los beneficios de la marcha nórdica y la importantancia del ejercicio físico para la salud física y mental. Me está entrando el gusanillo de probar y animar a otros.

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