Physical Rehabilitation After Breast Cancer

Breast cancer is ranked the top in types of cancer that affects Singaporean women8. It affects up to 1-in-13 women during their lifetime4. Disease-free survival after diagnosis and treatment of breast cancer has been reported as between 63%-74% at 10 years, with an overall survival rate of 63-86% 5. Therefore it has become the focus of rehabilitation to optimise the quality of care and survival, as well as the quality of living of women diagnosed with breast cancer.

Types of breast cancer intervention include surgery, radiotherapy, chemotherapy & hormone therapy. A number of surgical procedures (Table 1) may be performed depending on the clinical presentation & histological results.

Table 1: Summary of surgical procedures for breast cancer

Surgical ProcedureDescription
Breast biopsy (lumpectomy)
Excision of a breast lump
Breast conservation (wide       local excision; quadrantectomy; tylectomy; partial mastectomy)Excision of tumour & surrounding breast tissue to give an adequate surgical margin from cancer cells. Axillary dissection performed in conjunction
Axillary dissectionRemoval of lymph nodes
Simple mastectomyExcision of all the breast tissue
Modified radial mastectomy (Patey)/MRMExcision of all the breast tissue, axillary dissection & pectoralis minor muscle
Radial Mastectomy (Halsted)As for modified radial mastectomy with the excision of pectoralis major muscle
Extended radial mastectomyAs for radial mastectomy with the excision of the underlying chest wall(ribs); a split skin graft is required to cover the surgical defect on the chest wall
Breast reconstruction (implants or myocutaneous flap
  1. Surgical implant (saline) with/ without prior use of tissue expanders
  2. Skin & muscle flap (latissimus dorsi, rectus abdominis) with/without intact blood supply is used to reconstruct the breast, nipple reconstruction/ prosthesis required.

Morbidity of primary breast cancer management

The aim of breast cancer treatment is to eradicate local disease & control the development of the disease – enhancing the survival of women diagnosed. However, there are potential problems such as:

  • Decreased shoulder movement & function secondary to axillary dissection; radical procedures; or fibrosis after radiotherapy.
  • Wound infection & delayed wound healing in the early postoperative period.
  • Seroma development on the anterior chest or axilla after wound drains are removed.
  • Lymphoedema of the arm &/ or breast secondary to surgical removal of or radiation damage to axillary lymph nodes & remaining breast tissue.
  • Neural disorders including,
    1. Sensory disturbances in the medial upper arm due to the dissection of the intercostobrachial nerve;
    2. Neuralgia;
    3. Nerve entrapment in the arm
  • Fibrosis of the skin & muscle of the chest wall after radiotherapy.
  • Psychological effects
  • Local recurrence or metastatic spread of breast cancer.

Physiotherapists play a significant role in the identification, prevention &/or management of the above mentioned, and also assist in the support of women before, during & after the treatment and follow-up period for breast cancer.

Physiotherapy is recommended, in accordance with the surgeons’ preferences for post-operative care, to improve the physical recovery of women after breast cancer surgery, by providing appropriate exercise prescription, and assist in the education of women after breast cancer surgery to facilitate their:

  • Recovery of shoulder range of motion (ROM) and physical function of the operated arm;
  • Awareness of lymphoedema, its prevention and early detection.

A planned approach to the physiotherapy management of women after breast cancer surgery with the ability to individualised exercise and education programmes is essential to ensure optimal quality of care and best practice.

Aims of physiotherapy management

  • Regain patient’s preoperative shoulder ROM & function within three months of surgery;
  • Maintain ROM overtime after surgery
  • Patient education- knowledge of lymphoedema, its prevention and awareness of its early signs;
  • Minimise the effect of developing secondary complications on their ultimate recovery.

Shoulder Range of Motion and Function

Early commencement of shoulder physiotherapy intervention after axillary dissection for breast cancer aids in the physical recovery of the patient. Nevertheless, the intervention is dependent upon each surgeon’s preference and protocol, and also issues of wound drainage, seromas, shoulder stiffness, complications and length of hospital stay. A physiotherapy management care plan (PMCP) (shown in Table 2) has been developed from literature and extensive clinical practice1, to help facilitate the recovery of women after breast cancer surgeries.

Table 2: shows a detailed general physical rehabilitation and management care plan for mastectomy.

Physiotherapy Management Care Plan
PREOPERATIVE VISITAssessment – shoulder ROM, functional questionnaire, limb size

Education – post-operative presentation & Exercises, preliminary lymphedema education

DAILY POST OPERATIVE VISITSHand/elbow exercises – start immediately

Shoulder movement- if no axillary dissection has been performed, start immediately post-op & progress within discomfort to full ROM; if axillary dissection has been performed, start at surgeon’s request or when wound drainage is < 100ml/24 hours or there is a marked decrease in drainage over 24 hour period; restricted to < or equal to 100 degrees for first 2 days of movement and gradually increase ROM using a limit of a discomfort rating of 3/10

Lymphedema prevention education progress as appropriate for each patient

DISCHARGE FORM HOSPITALReview home programme and limitation of activities initially, re-measure shoulder ROM, functional questionnaire and limb size.
1 MONTH POST-OPProgress exercises and stretches, advise on functional activity progressions, lymphedema prevention education, re-measure shoulder ROM, functional questionnaire and limb size.
2 MONTHS POST-OPAssess effects of therapy and modify or progress exercises/ stretches. Advise return to pre-operative function & activity levels.
FOLLOW-UP AT 3,6,12,18,24 MONTHSAssess progress with measurement of shoulder ROM, functional questionnaire and limb size. Modification of exercises as appropriate.

Other studies, such as Wingate7,8, found that women who received physiotherapy from Day 1 post-op had better outcomes in terms of shoulder ROM & Function but there was an increase in arm swelling. However, at 3 months post-op, the amount of swelling was insignificant. These findings were later repeated in a study by Wingate et al8. Gutman et al2 found that women who underwent wide local excision and axillary dissection with radiotherapy achieved their pre-operative ROM faster than those who had an MRM but all regained normal ROM within 3 months post-op. These authors recommend that while both groups require physiotherapy, the MRM group required more intensive and longer treatment.

Physiotherapy Management Care Plan

The principles of exercise after breast cancer surgery are:

  • Assisted movements initially
  • Slow & rhythmical
  • Sustained movements & stretches incorporated after 14-21 days
  • Limiting point is a discomfort (not pain)
  • Care with the vigour of exercises performed to minimise interference with the regeneration of lymphatic channels
  • Scar massage may be required to facilitate movement
  • Continued intervention 6-12 months post-op as soft tissues continue to remodel and contract during this period
  • Gradual progression of the type, duration and repetition of exercises with a warm-up and cool down.

References

  1. Box R & Reul-Hirche H 1995a Results of a quality improvement project evaluating a physiotherapy programme for women after breast cancer surgery. Proceedings of  22nd Annual Scientific Meeting of the Clinical Oncological Society of Australia, pg 69.
  2. Gutman H, Kersz T, Barzilai T et al. 1990 Achievements of physical therapy in patients after modified radical mastectomy compared with quadrantectomy, axillary dissection and radiation for carcinoma of the breast. Archives of Surgery 125:389-391
  3. Kelsey JL & Gammon MD 1991. The epidemiology of breast cancer. CA- A Cancer Journal for Clinicians 41(3):146-165.
  4. Jacobsen JA, Danforth DN, Cowan KH  et al  1995 Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. New England Journal of Medicine 332(14):907-911.
  5. Trends in Cancer Incidence in Singapore, 1968-2007
  6. Wingate L 1985 Efficacy of physical therapy for patients who have undergone mastectomies: a prospective study. Physical Therapy 65(6):896-900.
  7. Wingate L, Croghan I, Natarjan et al 1989 Rehabilitation of the Mastectomy Patient: a randomised, blind prospective study.  Archives of Physical Medicine and Rehabilitation 70(1): 21-24.
  8. Singapore Cancer Registry, Interim Report, Trends In Cancer Incidence In Singapore 2004-2008.

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