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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 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 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. Morbidity of primary breast cancer management The aim of breast cancer treatment is to eradicate local disease & control the development of 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 post-operative 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 dissection of 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.
a core concepts musculoskeletal health group newsletter
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 opti-
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Physiotherapists play a significant role in the identification, prevention &/or management of the above mentioned, and also assist in the support of women
Table 1: Summary of surgical procedures for breast cancer
Surgical Procedure Breast biopsy (lumpectomy) Breast conservation (wide local excision; quadrantectomy; tylectomy; partial mastectomy) Axillary dissection Simple mastectomy Modified radial mastectomy (Patey)/ MRM Radial Mastectomy (Halsted) Extended radial mastectomy Description Excision of breast lump Excision of tumour & surrounding breast tissue to give an adequate surgical margin from cancer cells. Axillary dissection performed in conjunction Removal of lymph nodes Excision of all the breast tissue Excision of all the breast tissue, axillary dissection & pectoralis minor muscle As for modified radial mastectomy with the excision of pectoralis major muscle As for radial mastectomy with the excision of underlying chest wall(ribs); a split skin graft is required to cover the surgical defect on the chest wall 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.
Breast reconstruction (implants or myocutaneous flap)
Natarjan et al 1989 Rehabilitation of the Mastectomy Patient: a randomised. Discharge Form Hospital 1 Month Post-op MICA (P) 158/10/2010 This newsletter is produced by Core Concepts . complications and length of hospital stay. acobsen JA. Table2: Physiotherapy Management Care Plan for Mastectomy (PMCP) Physiotherapy Management Care Plan Preoperative Visit Assessment – shoulder ROM. Interim Report. Other studies. duration and repetition of exercises with warm up and cool down. 7. 8. These findings were later repeated in a study by Wingate et al8.mal quality of care and best practice. Barzilai T et al. A physiotherapy management care plan (PMCP) (shown in Table 2) has been developed from literature and extensive clinical practice1. • Minimise effect of development of secondary complications on their ultimate recovery. Proceedings of 22nd Annual Scientific Meeting of the Clinical Oncological Society of Australia. re-measure shoulder ROM. 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 a MRM but all regained normal ROM within 3 months post-op. Nevertheless. shoulder stiffness. at 3 months post-op. functional questionnaire. 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. found that women who received physiotherapy from Day 1 post-op had better outcomes in terms of shoulder ROM & Function but there was increase in arm swelling. to help facilitate the recovery of women after breast cancer surgeries. its prevention & an awareness of its early signs.sg 2 Months Post-op Follow-up At 3.6. pg 69. • Maintain ROM over time after surgery • Patient education. start immediately post-op & progress within discomfort to full ROM. However. the intervention is dependent upon each surgeon’s preference and protocol.A Cancer Journal for Clinicians 41(3):146-165. 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 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. Gutman H.com.Musculoskeletal Health. Wingate L. Trends In Cancer Incidence In Singapore 2004-2008. Danforth DN. if axillary dissection has been performed.coreconcepts. functional questionnaire and limb size. functional questionnaire and limb size. 4. Archives of Physical Medicine and Rehabilitation 70(1): 21-24. Advise return to pre-operative function & activity levels. 2. Archives of Surgery 125:389-391 Kelsey JL & Gammon MD 1991. We can be reached at T: 6226 3632 or E: enquiry@coreconcepts. 19682007 Wingate L 1985 Efficacy of physical therapy for patients who have undergone mastectomies: a prospective study. Aims of physiotherapy management • Regain patient’s preoperative shoulder ROM & function within three months of surgery. 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 Lymphoedema prevention education progress as appropriate for each patient Review home programme and limitation of activities initially. Modification of exercises as appropriate. 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. limb size Education – post-operative presentation & Exercises. Physical Therapy 65(6):896900. Trends in Cancer Incidence in Singapore. and also issues of wound drainage. such as Wingate7. the MRM group required more intensive and longer treatment. preliminary lymphoedema education Hand/elbow exercises – start immediately Shoulder movement. functional questionnaire and limb size. Progress exercises and stretches. 3. the amount of swelling was insignificant. Assess effects of therapy and modify or progress exercises/ stretches. axillary dissection and radiation for carcinoma of the breast. The epidemiology of breast cancer. blind prospective study. 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. 1990 Achievements of physical therapy in patients after modified radical mastectomy compared with quadrantectomy.12.sg W: www. References: 1.knowledge of lymphoedema. Box R & Reul-Hirche H 1995a Results of a quality improvement project evaluating a physiotherapy programme for women after breast cancer surgery. seromas.if no axillary dissection has been performed. lymphoedema prevention education.18. Assess progress with measurement of shoulder ROM. These authors recommend that while both groups require physiotherapy. CA. Daily Post Operative Visits 5. New England Journal of Medicine 332(14):907-911. Croghan I. Kersz T. 6.8. Singapore Cancer Registry. advise on functional activity progressions.com.24 Months MUSCULOSKELETAL HEALTH GROUP . remeasure shoulder ROM.