Breast Cancer Rehabilitation

Breast Cancer Rehabilitation   

With breast awareness campaigns worldwide, women are now aware of the importance self examination and regular breast screening. It has recently been rumoured that an extension programme to the current screening available to women between 50-70 will now be extended to 47-73 by 2016. This could lead to finding any signs of the disease much earlier, providing a much wider range of options for the patient. 

The Facts

 Breast cancer accounts for 31% of all female cancer cases. In 2008 alone, there were 48,034 newly diagnosed breast cancer cases in the UK, affecting predominantly women, with a reported 1% prevalence in men.

 Breast cancer is normally associated with age, 81% of cases occuring in women aged 50+ years with half of those cases being within the 50-69 years age group. However, there are many women that are younger and has been reported to be the second most common cancer in women under the age of 35 years. The lifetime risk of developing breast cancer equates to 1 in 8 in women and 1 in 1014 in men. (1)

 The most common risk factors for breast cancer are:

•                Female, age

•                Long interval between menarche and menopause

•                Older age at first full term pregnancy

•                Obesity and high fat diet

•                Family history of breast cancer

•       Geographic factors. (2)

 

It has also been reported that more affluent women and, women who migrate to a higher risk country, have an increase risk of breast cancer, suggesting that lifestyle is a major risk factor.

 In the 1990s, the increased incidence of breast cancer was associated with the use of hormone replacement therapy (HRT). Whereas, the increased prevalance over the past 10 years could be due to early detection. It has also been noted that more recent figures demonstrate a downturn which could also be associated with the reduced use of HRT as well the increased prevalence of regular screening. The good news that over 80% of breast cancer patients are still alive 5 years after the initial diagnosis demonstrating that early detection and treatment is a vital element in ensuring survival.

 Treatment

Breast cancer occurs when abnormal cells grow out of control within the ducts, the lobules or other parts of the breast tissue. The breast tissue comprises of fat, connective tissue, blood and lymph vessels. Lymph vessel carry lymph fluid back to the cardivascular system via the subclavian vien. All lymph vessels lead to lymph nodes with those under the arm being known as axillary nodes. If breast cancer reaches the axillary nodes, they cause swelling of the nodes which is more likely to spread to other organs of the body.

 There are five stages of breast cancer (Stages 0-IV) outlining the tissue affected and the size of cancer. These stages range from carcinomas being found in the ducts only to an increased spread to the breast tissue, viscera and the skeleton.

 Different surgeries and treatments are now provided for breast cancer patients ranging from a lumpectomy to a full radical mastectomy. Additional treatments such as radiotheraphy, chemotherapy and hormone therapy are often used in conjunction with surgery, or in some cases, instead of surgery. Each treatment have side effects ranging from fatigue, nausea, depression, weight gain, lymphedema, lack of mobility and strength to early menopause and increased risk of osteoporosis.

 Breast cancer patients want to return back to normal function as quickly as possible and are encouraged by the medical team to start walking immediately after surgery. Additional activities including gentle stretching and mobility exercises are also introduced within the first week post surgery. If radiation has been part of the treatment process, it may cause additional muscle stiffness and shortening, creating tightness and affecting overall posture. In extreme cases, frozen shoulder or similar symptoms may occur.

 Although all side effects must be monitored when teaching post operative clients, it is also important to have an understanding of lymphedema as it is considered to be one of the worst side effects. Lymphedema is a build up of tissue fluids in the upper arm and is a painful side effect of breast cancer. People with lymphedema suffer with swelling, inflammation and impaired mobility. This risk can be immediate or even as long as 27 years later post surgery. Most patients wear a support sleeve which reduces the risk of oedema in the upper extremity. Lymphatic drainage can help which must be performed by a qualified therapist whereas massage is should not be encouraged.

 Exercise has both its advantages and disadvantages as far as lymphedema is concerned. On the one hand, breathing and gentle movement encourages the flow of lymph; whereas increased intensity actually increases blood flow and therefore increases lymph production which may exasperate the condition further. Be cautious with forceful arm movements and weight bearing arms for long periods of time.

 Most of us as pilates instructors will not be involved with these patients until after their post 6 week surgery check with the medical team. Therefore, as with any individual, exercise should be introduced slowly. The aim with this particular group is to increase mobility, reduce muscle tightness and return to normal function. At first patients will not be able to lift their arm about their head or even their shoulder. With patience and gentle progression, over time this should be possible, however even 4+ years later with regular exercise, some clients may not have the same level of flexibility on the affected side. Low load and short levers to start with appropriate props used for support and comfort.

 After the initial surgery, some patients will then decide whether they want to wear prosthetic clothing, or choose to have a reconstruction, or implant. Each choice has  further impact on mobility and strength. For example, in some cases, in order to provide the best aesthetic appearance nerves running around the site may be severed. These include the pectoral nerves, long thoracic nerve and the thoracodorsal nerve. These nerves have a large impact on shoulder stability especially the long thoacic nerve as it innervates serratus anterior which may leave the patient with permanent winging of the scapula. As an instructor, you may have to forfeit some technique in order to encourage and praise your client due to these structures being affected, focussing on what they can achieve rather than what they cannot.

 The two main reconstruction used are:

 TRAM flap (Transverse Rectus Abdominis) and

LAT flap (Latissimus Dorsi).

 There are also two less common surgeries, one which involves the gluteus maximum and another involving micro-surgery.

 All of these surgeries will have a significant impact on the patients ability to perform exercise. The TRAM is where the the rectus abdominus and some abdominal fat is used to reconstruct the new breast. This operation provides the most aesthetically pleasing result, however, it is common for patients not to be able to stand up straight for 8 weeks. This also has a major impact on spinal flexion and posture.

 The most common side effects to the TRAM flap are:

 •                Tightness in abdominal region

•                Difficulty in standing

•                Tightness in hip flexors

•                Core muscles weakness

•                Poor posture

•                Lower back tightness.

The LAT flap is also a common surgery where a portion of the lattissimus dorsi and additional back fat is used to reconstruct the breast. Many women have weakness in their arm, shoulder and back following the surgery.

 The most common side effects are:

 •                Tightness in back

•                Reduced range of movement with waist rotation

•                Tightness in under arm

•                Limited shoulder movement

•                Tightness in chest

•                Inability to pull down

•                Poor posture.

 Sometimes the LAT flap patient has an additional implant to add volume to their reconstruction. The surgical team will place the implant under pec minor which can cause tightness within the pectoral muscles and cause anteriorly tipping and other issues with scapula stability. To ensure the breast sits in the right position, the pectoral nerve may be severed.

With this in mind, it is important for instructors to expand their knowledge before working with this client group. The initial surgery is only one part of the treatment procedure. Each procedure brings its own side effects and limitations. As instructors ensure that you feel confident with this patient group and that a radically modified approach to pilates-type exercises are needed.

 

Exercise guidelines

 

•                Make exercise positive, emphasising supportive cueing as the client is probably doing their best with the programmed exercise.

•                Avoid over correction as this will only create negativity and could affect the client's  depression if present.

•                Use additional props for support and comfort.

•                Support hands and affected limbs where necessary.

•                Avoid overhead movements or above shoulder height until the client has regained a pain-free range of movement in that area.

•                Less repetitions with delivered slowly focussing on quality.

•                Avoid overloading one area of the body, consider sequence of exercises and providing relevant rest.

•                Be familiar with patient treatment and side effects and what stage the client is currently at.

•                Long warm up and cool downs are essential.

•                Fatigue is often a side effect, reduce exercise intensity and duration. It may only be possible to perform 4-6 exercises within the first few weeks of working with the client.

•                Once client is strong enough, focus on shoulder mobility using external rotation and abduction as this appears to the the most restricted movement within this client group.

 Alison Salmond Freelance Pilates Instructor and STOTT PILATES Instructor Trainer UK.

 

References

 

1.             www.info.cancerresearchuk.org. Date accessed 17.6.11

2.             General and Systemic Pathology: 3rd Edition. J.C.E. Underwood (2000)

3.             Pink Ribbon Program Course Notes

4.             STOTT PILATES Breast Cancer Rehab Workshop Notes.

 

 Synopsis of Research Papers

 Silver, J. (2007). Rehabilitation in Women with Breast Cancer. Physical Medicine Rehabilitation Clinic North America. Vol 18, pp521-537.

 

•                Breast cancer third leading cancer in the world (after lung and gastric cancer), accounting for 23% of cancers in women.

•                US – 1 in 9 women of all ages develop breast cancer

 Complications

 •                Lymphoedema of the upper extremity is one of the complications associated with Breast cancer surgery with incidence varying from 10-30%

•                Karki et al (2005) surveyed 96 patients at 6 and 12 months post surgery and found impairments in activities were frequent and constant. Most comment impairement was the axillary scar tightness, axillary oedema and neck/shoulder pain.

•                Rietman et al (2004) surveyed 55 women who underwent a modified radical mastectomy or segmental mastectomy with axillary lymph node dissection. Follow up 2.7 years (mean) impairments included pain (60%) and reduced grip strength (40%).

•                Fehlauer et al (2005) surveyed age at diagnosis and found that physical functioning and sexual functioning were decreased in patients older than 65 years.

•                Gordon et al (2005) found that only the group received an early home-based physical therapy intervention experienced significat benefits in reduced arm morbidity and upper body disability and improved functional well-being.

•                Seromas are a frequent complication of breast cancer surgery in an increase 25-50% after mastectomy and up to 25% after axillary dissection.

•                Gonzales et al (2003) surveyed 359 patients – seromas occurred in 19.9% of patient who underwent modified mastectomy and 9.2% who underwent breast-conserving surgery.

•                The use of sentinel lymph node biopsy (SLNB) as opposed to axillary lymph node dissection (ALND) has rediced post-operative morbidity in the arm and shoulder region in women who have early-stage breast cancer. SLNB is perceived as leading to less disability in ADLs and better QoL.

•                Presence of metastatic disease in axillary lymph nodes is known to predict reoccurence.

•                Breast reconstruction – implants seen as less invasive

•                TRAM flap may need more follow up surgical procedures than implants or LAT flaps.

•                TRAM reconstructions experienced less than 20% long term deficit in trunk flexion (2 year analysis – Alderman et al 2006)

 Treatment

 •                Chemotherapy disability may be short or long-term depending on drugs used. Complications are neutropenia (decreased numbers of neutrophils (WBCs)) and gastric compaints with further increased risks to infections.

•                Long term disability includes cardiomyopathy (cardiac muscle disease) and neuropathy (neural disease)

•                Taxanes are commonly used for long periods which may increase their toxicity. These disrupt cell division.

•                Radiation – long term disability can be cardiac/pulmonary sequelae (secondary disease or medical condition resulting from the radiation), lymphoedema, brachial plexopathy, impaired arm/shoulder ROM and second malignancies.

•                Blomqvist et al (2004) surveyed 30 patients finding that radiation cuased a significant reduction in ROM and strength in arm/shoulder complex.

•                Beenken et al (2002) found that 10% of patients receiving grade 2 or higher radiation suffered from oedema, fat necrosis, skin fibrosis, decreased arm/shoulder ROM, neuropathy, pneumonitis and rib fracture.

•                Hormone treatment – tamoxifen (premenopausal women – 5 yrs) and aromatase inhibitors (post menpausal women)

 Exercise

 •                Therapeutic exercise helped in healing women who have a history of breast cancer and assisted in preventing reoccurence. (Holmes et al, 2005; McNeely et al, 2006; Dallal et al, 2007)

•                Many studies state the benefits of exercise to enhance physiological function and alleviate depression.

•                Exercise is extremely important and women should be encouraged to exercise, except in the presence of contraindications – even walking by using a pedometer.

•                Shamley et al (2005) supported the delaying of exercise to reduce seroma formation; however poor internal/external validity have been identified.

•                Ahmed et al (2006) found that 6 months of body weight training exercises did not increase risk of lymphoedema or exacerbate symptoms.

•                Exercise may be important in reducing upper extremity pathology and physical therapy can help increase shoulder ROM, promote upper body strength, decrease pain and reduce swelling,

•                Lauredsen et al (2005)  found the optimum time for physical therapy treatment was 6-8 weeks post operatively. Although 6 months post surgery good results were reported

•                At this time evidence-based guidelines do not exist.

 

Pain

 •                Pain can be present for a variety of reasons; musculoskeletal implications, neuropathy. Alleviating pain will  make patient more comfortable and improve her ability to function.

•                Pain relief modalities include: cryotherapy (decreasing body temperature), biofeedback, ionophoresis (drug therapy via a small electric charge – non-invasive), TENS and masage. Cautions such as deep heat, ultrasound directly over tumour sites are contraindicated.

 

Fatigue

 

•                Most common problem with breast cancer

•                Correlates to a decline in function

•                Reasons include chemotherapy, radiation or multifactoral.

•                Exercise has been shown to effectively treat fatigue

 

 

 Shamley et al (2006). Changes in Shoulder Muscle Size and Activity Following Treatment for Breast Cancer

 Clinical observations reported muscle morbidity in a number of muscles acting at the shoulder (shoulder stability). The timed interaction between muscles and stabilisers are essential to achieve the smooth scapulo-humeral rhythm.

 74 women treated for unilateral carcinoma

Completed Shoulder Pain and Disability Index (SPADI), EMG activity of 4 muscles was recorded during scaption on affected/unaffected side and muscle cross section from MRI.

 3 out of 4 muscles demonstrated significantly less EMG activity during elevation, with Upper Traps (UT) demonstrating the greatest loss. UT and Rhomboids (R) were associated with an increase in SPADI score (pain and disability) and increased time in surgery. Pectoral Major and Minor were significantly smaller on the affected side.

 Loss of muscle activity on downward phase indicates loss of eccentric control of shoulder girdle against gravity. Dropped Shoulder Syndrome includes decreases in UT activity, dropped shoulder, neck-shoulder pain, small pec major and minor, numbness, symptoms aggrevated by heavy breasts, heavy arms and carrying heavy objects. Symptoms believed to be pressure on the thoracic outlet space. (numbness, etc).

 Main activities affected are reaching up and carrying heavy loads.

 Pec and Serratus Anterior (SA) are in the field of surgery and are also affected. Reduced size of Pec major will affect patient reaching up, reduced pec minor = anteriorly tipping of scapula.

 UT and R were not in line with surgery and were the most affected demonstrating second effects of surgery. Patients reported weakness of up to 5 years after treatment with pain and functional ability only being associated with reduced UT and R activity. It would appear that secondary changes persist for long and are associated with the patients ability to perform pain free functional tasks. However, 25% reported no pain and 20% no disability.

 Risk factors for chronic pain = more invasive surgery, radiotherapy, acute post operative pain as patients may adopt protective posture, reducing use of arm, resulting in log term changes.

 AWS and scarring are also contributory factors to arm morbidity and pain. One year follow up women are still reporting tightness in breast scar (29%) and axillary scar (37%)

 Conclusion: Muscles associated with pain and disability are affected but are no in the direct field of surgery or radiotherapy. Primary muscle shortening and secondary loss of muscle activity may be producing a movement disorder similar to Dropped Shoulder Syndrome. The study states that the normal biomechanics of the shoulder complex is altered and there further guiddance in developing the exercise component of a rehav programme is essential. Exercise programmes should work on ROM, posture correction and education of potential long term effects.