Breast Cancer Surgery and Physical Therapy | Postoperative Exercise

Breast Cancer Surgery and Physical Therapy - An Overview

There are an estimated 2 million breast cancer survivors in the United States and it is the most common form of cancer among women.^{2, 3} Following breast cancer surgery many patients experience neck, arm, and shoulder impairments. The most common complaints after surgery are restrictions in shoulder range of motion, pain, or a change in sensations of the arm and lymphedema.¹

Common Side Effects After Breast Cancer Surgery

Restricted Arm Mobility 

Women that experience restrictions in arm mobility following surgery report a lower quality of life and higher psychological distress.⁶  It is estimated that anywhere between 3.8–73% of women will have restricted arm motion following surgery.¹⁰

Lymphedema

Another common impairment following breast cancer surgery is lymphedema. This can happen when lymph nodes are removed or damaged through either dissection or radiation. The result is an accumulation of protein-rich interstitial fluid in the hand or arm. It is estimated that 6-50% of women will develop some form of lymphedema following breast cancer surgery.⁴   It is well documented that lymphedema is associated with anxiety, depression, reduced quality of life, impaired sexual functioning, and disturbed body image.^{10, 11, 12, 13} 

Axillary Web Syndrome

Axillary web syndrome (AWS) can occur following breast cancer surgery and occurs in approximately 28.1% of women.¹⁷ AWS occurs as visible cords of connective tissue or scarring beneath the skin, between 5 and 8 weeks after surgery, and can frequently also be felt in the breast, armpit, arm, forearm, and hand. Women report decreased motion in their elbow, shoulder, tightness and pain.¹⁸ AWS is believed to be caused during surgery to the axilla (armpit), by damage to the tissue, lymph, and venous system, resulting in an accumulation of lymphatic fluid.¹⁹

Treatments for Impairments After Breast Cancer Surgery

In a study published in the Support Care Cancer, Youngki Cho and colleagues concluded that many of these impairments can be addressed in physical therapy.²⁰

Shoulder Mobility After Breast Cancer Surgery

Two studies were conducted on the effectiveness of early rehabilitation in breast cancer patients following surgery.  One study conducted at the University of Sydney, compared a home exercise program to control patients who were not given an exercise or manual stretching program²⁶; while the second study, conducted at the Ankara Numune Training and Research Hospital, compared the effects of a physical therapist directed exercise program to the control patients who were given a home exercise program.²⁷  Both studies showed that manual stretching and physical therapy are effective in rehabilitation of shoulder impairment after breast cancer surgery.  

Restoring Range of Motion After Breast Cancer Surgery

Five studies concluded that exercise after breast cancer surgery was beneficial for increasing range of motion and one study found a decrease in pain as well.^{21, 22, 23, 24, 25}  In the study by Xie et al, the exercise program was more effective when directed by a physical therapist than when the patients did the exercises at home on their own.  

Chinese Research Professor, Xiadong Xie published a study alongside colleagues, observing the effects of exercise programs on breast cancer surgery patients.  Their team concluded that the exercise program was more effective when directed by a physical therapist than when the patients completed a home exercise program.²⁵

Physical Therapy for Rehabilitation After Breast Cancer Surgery

Based on this research, it is important to start gentle exercise early during the first few days following surgery. 

Recommended exercise program*: 

1. Start with mobilizing and pumping exercises for the wrist and elbow
2. After the wound has healed, around 7-10 days after surgery, intensity of physical therapy program can gradually increase to:
   1. gentle passive mobilizations 
   2. manual stretching 
   3. active exercises²⁹ 
3. Based on the long term effects of radiation and chemotherapy on soft tissues, patients should be given a home-exercise program and progress be followed for six months postoperatively. (Impairments may still develop after the six-month mark.)²⁸

Many impairments following breast cancer surgery can be effectively addressed with physical therapy. It is important that healthcare professionals and patients are aware that impairments in the arm and hand can affect mental health and quality of life as well. Speak to your healthcare team to see when physical therapy is appropriate for you and find a physical therapist in your area that can assist you in your recovery. Contact us to make an appointment or if you have any questions. 

References: 

1. Hack, Thomas F., et al. “Predictors of Arm Morbidity Following Breast Cancer Surgery.” Wiley Online Library, John Wiley & Sons, Ltd, 27 Oct. 2010

2. Kushi LH, Kwan ML, Lee MM, et al. Lifestyle factors and survival in women with breast cancer. J Nutr. 2007;137: 236S–242S

3. Ries LAG, Wingo PA, Miller DS, et al. The annual report to the nation on the states of cancer, 1973–1997. Cancer. 2000;88:2398–2424.

4. Didem K, Ufuk YS, Serdar S, Zumre A: The comparison of two different physiotherapy methods in treatment of lymphedema after breast surgery. Breast Cancer Res Treat. 2005, 93 (1): 49-54. 10.1007/s10549-005-3781-2.

Gartner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H: Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009, 302 (18): 1985-1992. 10.1001/jama.2009.1568.

6. Hack TF, Cohen L, Katz J, Robson LS, Goss P. Physical and psychological morbidity after axillary lymph node dissection for breast cancer. J Clin Oncol 1999;17:143–149

Kwan W, Jackson J, Weir LM, Dingee C, McGregor G, Olivotto IA. Chronic arm morbidity after curative breast cancer treatment: prevalence and impact on quality of life. J Clin Oncol 2002;20:4242–4248. 

Reitman JS, Geertzen JH, Hoekstra HJ et al. Long term treatment related upper limb morbidity and quality of life after sentinel lymph node biopsy for stage I or II cancer. Eur J Surg Oncol 2006;32:148–152. 

 Scalfani LM, Baron RH. Sentinel lymph node biopsy and axillary dissection: added morbidity of the arm, shoulder and chest wall after mastectomy and reconstruction. Cancer J 2008;14:216–222.

10. Ahmed RL, Prizment A, Lazovich D, Schmitz KH, Folsom AR. Lymphedema and quality of life in breast cancer survivors: The Iowa Women’s Health Study. J Clin Oncol 2008;26:5689–5696

11. Erickson VS, Pearson ML, Ganz PA. Arm edema in breast cancer patients. J Natl Cancer Inst 2001;93:96–111. 

12. Pyszel A, Malyszczak K, Pyszel K, Andrzejak R, Szuba A. Disability, psychological distress and quality of life in breast cancer survivors with arm lymphedema. Lymphology 2006;39:185–192.

13. Ridner SH. Quality of life and a symptom cluster associated with breast cancer treatment-related lymphedema. Support Care Cancer 2005;13:904–911.

 Langer I, Guller U, Berclaz G et al. Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients. Ann Surg 2007;245:452–461.

 Thomas-MacLean RL, Hack T, Kwan W, Towers A, Miedema B, Tilley A. Oncol Nurs Forum 2008;35:65–71. 

Wilke LG, McCall LM, Posther KE et al. Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol 2006;13:491–500

17. Bergmann A, Mattos IE, Pedrosa E, Nogueira EA, Koifman R (2007) Axillary web syndrome after lymph node dissection: results for 1004 breast cancer patients. Lymphology 40:198–203

18. Hack TF, Kwan WB, Thomas-Maclean RL, Towers A, Miedema B, Tilley A, Chateau D. Predictors of arm morbidity following breast cancer surgery. Psycho Oncology. 2010 Nov;19(11):1205-12. doi: 10.1002/pon.1685. PMID: 20099254.

19. Rashtak S, Gamble GL, Gibson LE, Pittelkow MR (2012) From furuncle to axillary web syndrome: shedding light on histopathology and pathogenesis. Dermatology 224:110–114. doi:10.1159/ 000337210 

20. Cho Y, Do J, Jung S, Kwon O, Jeon JY. Effects of a physical therapy program combined with manual lymphatic drainage on shoulder function, quality of life, lymphedema incidence, and pain in breast cancer patients with axillary web syndrome following axillary dissection. Support Care Cancer. 2016 May;24(5):2047-2057. doi: 10.1007/s00520-015-3005-1. Epub 2015 Nov 5. PMID: 26542271.

21. De Rezende LF, Franco RL, de Rezende MF, Beletti PO, Morais SS, Gurgel MS. Two 490 exercise schemes in postoperative breast cancer: comparison of effects on shoulder movement 491 and lymphatic disturbance. Tumori 2006;92(1):55-61. 

22. Wingate L, Croghan I, Natarajan N, Michalek AM, Jordan C. Rehabilitation of the  mastectomy patient: a randomized, blind, prospective study. Arch Phys Med Rehabil 494 1989;70(1):21-4.

23. Beurskens CH, van Uden CJ, Strobbe LJ, Oostendorp RA, Wobbes T. The efficacy of physiotherapy upon shoulder function following axillary dissection in breast cancer, a  randomized controlled study. BMC cancer 2007;7:166. 

24. Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furnival CM. Shoulder movement after breast cancer surgery: results of a randomized controlled study of postoperative 500 physiotherapy. Breast cancer Res Treat 2002;75(1):35-50. 501 

25. Xie X, Liu Z, Qu S, Guo F, Zheng Z, Liu Y et al. patients with postoperative breast cancer on exercising the function of limbs and investigating quality of life: a clinical study. Chin -Ger J Clin Oncol 2010;9(10):590-3. 

26. Kilbreath SL, Refshauge KM, Beith JM, Ward LC, Lee M, Simpson JM et al. Upper  limb progressive resistance training and stretching exercises following surgery for early breast cancer: a randomized controlled trial. Breast cancer Res Treat 2012;133(2):667-76. 476  

27. Cinar N, Seckin U, Keskin D, Bodur H, Bozkurt B, Cengiz O. The effectiveness of  early rehabilitation in patients with modified radical mastectomy. Cancer Nurs  2008;31(2):160-5.

28. Cheville AL, Tchou J. Barriers to rehabilitation following surgery for primary breast 419 cancer. J Surg Oncol 2007;95(5):409-18

29. Shamley DR, Barker K, Simonite V, Beardshaw A. Delayed versus immediate 460 exercises following surgery for breast cancer: a systematic review. Breast cancer Res Treat 461 2005;90(3):263-71.