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July 2nd Lab Session
Chris Wilson PT, DPT, GCS
PTP 646 – Metabolic, Endocrine, and Integumentary
Condition Interventions in Practice
July 2013
Who needs Breast Cancer Rehab?
• Any patient that has had surgery
• Any patient that has had or will have
Chemotherapy
• Any patient that had or will have radiation
therapy
Indication for Rehabilitation
• Minimally 3 positive findings on the following questions, as
judged by a physician:
- Physical complaints
- Reduced physical capacity
- Psychological problems
- Increased levels of fatigue
- Sleep disturbances
- Problems with coping
Physical Therapy Patient
Evaluation
Subjective History
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Standard patient history
Current cancer status
Cancer surgery history
Previous treatment history
Future treatment plans
Current functional level
Previous exercise history
Co-morbidities
Tests and Measures
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Surgical incision status
Skin integrity
R/O infection
Swelling/lymphedema
Pain source
ROM
Tissue mobility
Cording
Differential Diagnosis of Pain
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Surgical
Nerve
Swelling
Cording
Soft tissue
Chemotherapy
Support drugs
Orthopedic
Recurrence
Differential Diagnosis of Swelling
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Post-surgical
Cording related edema
Chemotherapy related
Lymphedema
Infection
Blood clot
Evaluation and Prognosis
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Clinical impression
Differential diagnosis
Problem list
Goals
Goal potential/Prognosis
Intervention Plan
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Frequency & Duration
Treatment modalities
Exercise prescription
Self management program
Return to activity/work plan
Intervention Planning
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Based on indications & contraindications
Based on patient goals
Comprehensive
Variable
Start at minimal intensity
Progress may not be linear
No protocols
Advancement of Intervention Plan
• Advance slowly
– Reps
– Weight
– New activity
• May not be linear
• Based on patient input and goals
Completion of Episode of Care
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Full or maximized ROM
Minimal or no pain
Functional strength
Independent HEP
Educated in lymphedema risk reduction
Educated in infection risk reduction
Good self confidence
Action plan for questions or problems
Reducing risk of lymphedema
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Regain full mobility and strength
Gain or maintain ideal body weight
Teach infection risk reduction
Teach an action plan
Post Surgical Dysfunctions
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Postural changes
Pain
Postoperative vascular and pulmonary complications
Swelling
Soft tissue restrictions and shortening
Decreased ROM
Decreased strength
Loss of function
Increase risk for infections and lymphedema
Postural changes
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Scapular protraction
Forward head posture
Scapular elevation
Winging
Pain
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Incisional pain
– Transverse incision across
the chest and extends into
the axilla
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Posterior cervical and
shoulder girdle pain
– Muscle spasms
– Levator scapulae, teres major
and minor, and infraspinatus
often are tender to palpate
and can restrict active
shoulder motion
Post-operative Vascular and Pulmonary
Complications
• Decreased activity
• Incisional pain
– Reluctance to cough or breathe deeply
Swelling
• Lymphedema can occur almost immediately
after lymph node removal
• After radiation
• Or many months later
Soft tissue restrictions and shortening
• Chest wall adhesions
• Restrictive scarring
Treatment Contraindications
• Surgical drains
– A surgical drain prevents blood and
lymphatic fluid buildup under the skin
– No shoulder flexion/abduction over 90
degrees until drains are removed
• Open incisions
Treatment Contraindications
• Seroma
– is a pocket of clear serous fluid that sometimes
develops in the body after surgery
– most frequent postoperative complication after breast
cancer surgery.
– 30-90%
– If the seroma becomes very large then it can be very
uncomfortable and the stretching of the skin at the
mastectomy site can create some abnormal sensations.
– The Surgeon will drain off the excess liquid with a
simple needle and syringe. May need more than 1 time
• Undiagnosed swelling
Rehabilitation post-op week 2
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A/AAROM
Postural re-education
Scapula AROM
Scar Assessment (cording?)
Avoid climbing the walls
– Builds compensatory strategies in the
trapezius/deltoid/pec
Box et al Bres Ca Res Treat 2002
Johansson Acta Oncol 2005
A/AAROM
Shoulder girdle imbalance
• Pectoralis shortening
• Elongation of trapezius muscle fibers and
diminished muscle firing
• Diminished Rhomboid muscle firing
• Associated with poor shoulder outcomes
measures
– SPADI – Shoulder Pain and Disability Index
Shamley et al Bres Ca Res Treat 2007
Shoulder Program
• Focus on strengthening of
shoulder blade and postural
muscles
• Shoulder range of motion
exercises
• Shoulder strengthening exercises
• Therabands : star, rows
• Free weights – Houghstons and
external rotators
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P.N.F.
Scapular Mobilizations
Massage
Myofascial Release
Passive R.O.M.
Machines – seated row, lat pull
downs, triceps
• Foam Roller
• Physioball
Resisted Middle Trap
Resisted Lower Trap
Resisted ER
• A caution about RTC
strengthening!
– Assure adequate scapular
stability PRIOR to cuff
exercises
– Poor stability will enhance
compensatory mechanisms
and perpetuate overuse
• Incorporate once scapular
stability can be maintained
against resisted ER
Pectoralis Stretch
• Consideration for posture
• Consideration for breast
reconstruction techniques
Pectoralis Stretch
Pectoralis Stretching
• Focus on varying fibers of
the pectoralis
Post-op treatment Frequency
• 2x/week in general
• 3x/week if pain is significant
• 4-5x/week if pending radiation treatment
Side Effects of TRAM Surgery
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High rate of trunk instability
Low back pain
High rate of abdominal hernia
Postural Deficits
Core Stabilization after TRAM
• Exercises – focus on abdominal strength
– Pelvic Tilts, Abdominal Curls
– Press – Ups
– Foam Roller
– Physioball Exercises
– Core Exercises - planks
– Elliptical
– Treadmill – backwards
– Theraband Exercises
Trunk Range of Motion
Lumbar Stabilization
Lymphatic Cording
Lymphatic cording
Lymphatic Cording
• Cording occurs as a result of an axillary node dissection
• Cording is a palpable tight and painful band of tissue
down the arm towards the hand
• Cording can be felt at any part of the arm
• Cording is a kind of soft tissue tightness usually seen in
the axilla.
• It can extend from the mastectomy or lumpectomy or
even the drain scar down the arm to the wrist. It is
painful and can sometimes recur.
• Cording is probably due to changes in the arm's lymph
vessels and can appear six to eight weeks following
surgery or even months afterwards.
Post-op Dysfunctions Lymphatic Cording
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Pain
Visual/palpable “cords”
Loss of shoulder ROM
Loss of elbow ROM
Decreased arm strength
• Decreased arm function
• Decreased ADL’s, vocational and social
function
Physical Therapy Goals
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Decrease reactivity/inflammation
Minimize/eliminate pain
Minimize/eliminate swelling
Restore maximal tissue flexibility
Restore strength
Restore ADL, vocational and recreational activity
Safe reintroduction to arm activity
Educate in infection/lymphedema risk reduction
Treatment Contraindications
• Activities that increase symptoms
• PREs (?)
Treatment of Cording
• Treat with cording
stretches and skin
traction
• Treat soft tissue
restriction/ROM
• Treat weaknesses
• Treat cardiopulmonary
system as indicated
Myofascial Release
• Soft Tissue technique
– Some kinds of therapeutic massage would be too
strong or aggressive for the radiation-weakened skin
and sore muscles of a patient who has undergone
breast surgery
• MFR is a gentle technique that uses
approximately five grams of pressure
• The therapist holds a particular stretch for
90 to 120 seconds, gently applying
pressure in the area of restriction until
sensing the release
• Take up slack and reapply
Cancer Related Fatigue
Cancer Related Fatigue
• Causes of Fatigue
– Anemia
– Pain
– Emotional stress
– Sleep disruption
– Altered nutrition
– Altered activity
– Medical issues – thyroid, heart, infections
Treatment of fatigue
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Exercise
Treatment of medical issues
Nutritional support
Evaluation of stress
Sleep support
Post Radiation Dysfunctions
Radiation Therapy & Skin Impairment
Effects classified in 3 stages:
• Acute: (1-4 mos)- desquamation and
healing of superficial tissue
• Sub acute: (4-12mos)- microcellular
changes, fibrosis of vasculature and
lymphatics, adhesions to collagen
• Chronic: (1-8+yrs)- progressive immobility
and adhesion of tissue
Cooper et al., Int J Radiat Onc Biol Phys 1995
Radiation implications
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Skin will burn
Mild to severe fatigue
Tissue fibrosis 6-36 months post radiation
May aggravate lymphedema and cording
Increase lymphedema risk
Potential weakness at site
Radiation Implications
• Once skin changes occur at about the 3rd
week no more manual therapy
• Resume manual a couple of weeks after
treatment completes
• Desquamation: the shedding of epithelial
elements, chiefly of the skin, in scales or
sheets.
Post Radiation Dysfunctions
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Decreased ROM
Delayed pain
Delayed Breast swelling
Delayed soft tissue dysfunction
Decreased strength
Fatigue
PT Goals
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Maximize / maintain ROM
Maximize tissue mobility
Minimize fatigue
Maximize functional level
Teach HEP or delayed radiation effects
Radiation Rx contraindications
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Anemia
Severe fatigue
Fever – no exercise
Skin color change – no manual
Bone Mets
Radiation related rehab
• Flexibility / ROM program
– Anterior chest wall
– Lateral chest
– Axilla
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Strength program
Treatment of lymphatic cording
Aerobic exercise
Address upcoming treatment (s)
Fibrosis management
Fibrosis Management
• Deep tissue work/MFR
– After sub-acute stage of healing
• Manual stretching
• Manual lymphatic drainage
– Compression therapy
• Maintain ROM
– Prevention of chest wall adhesion
• Muscle and nerve adhesion
Scar Tissue Management
• Scar mobilization
• Prevention of
hypertrophy and
adhesion
• Myofascial
release
• AROM/PROM
Physical Therapy Intervention
Manual Scar Mobilization
• Soften breast tissue for:
– Improved lymph circulation
– Improved UE and trunk ROM
– Improved cosmesis
• Provide desensitization
• Prevent adhesion of tissue
Exercise prescription
• ROM exercise
– May begin once drains are removed
• Upper Quarter stretch program
– Best if done supine
– Achieve both ROM and tissue flexibility
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Cane stretch
Butterfly stretch
Snow angel stretch
Trunk rotation stretch
Referred Symptoms.
Perform Medical
Screening
Active Physiologic
Movement Impairment?
YES
Passive Physiological
Movement Impairment?
YES
Passive Accessory
Movement Impairment?
Weakness
with MMT?
Neuromuscular
Coordination Syndrome
YES
Pain Syndrome
MMT
< 2/5 ?
Muscular Force
Production Syndrome
YES
YES
Myofascial Restriction,
Axillary Web Syndrome
Glenohumeral Capsular
Syndrome
Lymphedema Syndrome
Peripheral Neuropathy
Syndrome
Syndrome
Features
Interventions
Neuromuscular
Coordination
Syndrome
Poor quality of movement in the absence of joint or
peri-articular restrictions
Neuromuscular Re-education using tactile and
verbal cues, repetition, full and partial task
practice
Pain Syndrome
Patients whose primary limiting factor is the
presence of pain upon movement
Resting pain, Empty end-feel ,through & EndRange pain, Decreased AROM and full PROM and
perceived muscle weakness
Modalities (no US, heat judiciously)
Meds
Muscular Force
Production Syndrome
Presents with limitations in active movement but
normal PROM with no observable atrophy
Diminished MMT strength but good contractility
AROM more limit than PROM w/ Normal end feel
Strengthening regimen
Increase muscular force production
Restore length-tension relationships
Peripheral Neuropathic
Syndrome
Of one or several nerves which innervate muscles
of the shoulder joint complex.
Diminished strength < 2/5 with poor contractility
Muscle atrophy Joint deformity
AROM more restricted than PROM
Monitor re-innervation
Reduce postural effects
Protect joints
Bracing splinting
Myofascial Restriction
Syndrome
Soft tissue fibrosis, muscular trigger points or
axillary web syndrome. AROM=PROM
Palpable fibrosis
“Cording”
Myofascial stretching
Home stretch regimen
Trigger point release
Scar massage
Transverse friction massage
Glenohumeral
Capsular restriction
syndrome
Exhibit limitations in active and passive physiologic
motion with significant limitations in passive
accessory movements; Capsular end feel &
Capsular pattern (ER>ABD>IR)
Isolated GH limitations & Poor SH Rhythm
Joint Mobilization
Lymphedema
Syndrome
Pain upon movement or due to the appreciable
increased weight of the limb
Complete Decongestive Therapy
Vasopneumatic pumping
Chemotherapy Induced
Dysfunctions
Chemotherapy Induced
Dysfunctions
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Fatigue
Osteopenia
Muscle wasting
Myopathy
Neuropathy
Decreased cardiac function
Weight gain
Loss of function
Anxiety/depression
Physical Therapy goals
• Minimize fatigue
• Maintain weight and muscle mass
• Average 20 minutes aerobic exercise
– 3-5 x week during chemo
• Independent strength and flexibility program
• Promote sense of active role in recovery
Chemotherapy Exercise
Contraindications
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24 hours post chemo (?)
Fever
Infection
Fatigue
Lowered blood counts
– WBC
– RBC
– Platelets
Patient education
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protect the skin
signs of infection
gradual return to activity
self management
Protect the skin
• Keep arm clean and dry.
• Apply moisturizer daily to prevent
chapping/chaffing of the skin.
• Attention to nail care; do not cut cuticles.
• Protected exposed skin with sunscreen and
insect repellent.
• Use care with razors to avoid nicks and skin
irritation.
• Avoid punctures such as injections and blood
draws.
• Wear gloves while doing activities that may
cause skin injury.
Protect the skin
• If scratches/punctures to skin occur, keep clean
and observe for signs of infection.
• Gradually build up the duration and intensity of
any activity or exercise, and monitor arm during
and after for any change in size, shape, firmness
or heaviness.
• Avoid arm constriction from blood pressure
cuffs, jewelry and clothing
• Avoid prolonged (>15 minutes) exposure to
heat, particularly hot tubs and saunas.
Treatment Considerations
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Surgical drains
Open incisions
Seroma
Undiagnosed swelling
Sternal/rib osteoporosis or osteopenia
Infection
Post operative treatment
• Flexibility/ROM program
– Rx for anterior chest, lateral chest and axilla
• Stretching
• Manual therapy
• Strength program
• Treatment of lymphatic cording
• Address upcoming treatment(s)
Post-op Treatment Frequency
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2x/week in general
3x/week if pain is significant
4-5/week if pending radiation therapy
1x/week
1x/month
3 – 12 month follow ups
Teaching an Effective
Home Exercise Prescription
Upper Quarter Stretch Program
• Best if done supine
• Achieve both ROM and tissue flexibility
ROM Exercise
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May begin after drains are removed
Directed at soft tissues not the joint
Mild to moderate intensity
5-90 second duration
Done 1-7 days /week for ~ 18 months postsurgery or radiation
Upper Quarter Stretch Program
• Acutely:
10 reps with 5 – 10 second hold
• Subacutely: 10 reps with 15 – 30 second hold
• Chronic:
3-5 reps with 30 – 120
second hold
Strength Program
• UE PREs
• LE PREs
• Core PREs
– 3 – 5 x/ week
– During treatment
– lifelong
Aerobic Exercise
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Any mode
Light to medium intensity
1- 3 hours/ week during treatment
1 – 5 hours/week lifelong
Cane Stretch
Butterfly Stretch
Snow Angel Stretch
Trunk Rotation Stretch
Nerve Glides for Cording
• Radial Nerve
• Median Nerve
• Ulnar Nerve
Movement Disorders after Surgery
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Pain
Loss of shoulder ROM
Arm weakness
Weakness at donor site (TRAM, Lat Flaps)
Postural dysfunctions
Deconditioning
Balance issues (TRAM flap)
Decrease in ADL, Vocational, & social function
Treatment Considerations
• Untreated infection
• Open incisions
• ROM < 90 degrees for 3 weeks for flaps using
thoracodorsal vessels
• Abdominal hernia
• Pec strengthening during tissue expansion
(?)
Rehabilitation Goals
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Restore/normalize ROM at shoulder
Restore/normalize strength
Restore full function
Independent Home Exercise Program
Rehabilitation Goals: flaps
• Strengthening to donor
site – post 6 weeks
• Stretching to donor site
• Restore trunk mobility
• Restore posture
• Mobility of breast
mound and chest wall
tissues – post 3 weeks
• Restore/normalize
ROM at shoulder
• Restore/normalize
strength
• Restore full function
• Independent Home
Exercise Program
Rehabilitation Goals: expanders
• Decrease pectoralis
spasms
• Minimize postural
changes
• Minimize pain
• Maximize ROM
• Facilitate tissue
lengthening
• Restore/normalize
ROM at shoulder
• Restore/normalize
strength
• Restore full function
• Independent Home
Exercise Program