July 2nd Lab Session Chris Wilson PT, DPT, GCS

PTP 646 – Metabolic, Endocrine, and Integumentary Condition Interventions in PracticeJuly 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

• 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

• Surgical incision status• Skin integrity• R/O infection• Swelling/lymphedema• Pain source• ROM• Tissue mobility• Cording

Differential Diagnosis of Pain

• Surgical• Nerve• Swelling• Cording• Soft tissue• Chemotherapy• Support drugs• Orthopedic• Recurrence

Differential Diagnosis of Swelling

• Post-surgical• Cording related edema• Chemotherapy related• Lymphedema• Infection• Blood clot

Evaluation and Prognosis

• Clinical impression• Differential diagnosis• Problem list• Goals• Goal potential/Prognosis

Intervention Plan

• Frequency & Duration• Treatment modalities• Exercise prescription• Self management program• Return to activity/work plan

Intervention Planning

• 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

• 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

• Regain full mobility and strength• Gain or maintain ideal body weight• Teach infection risk reduction• Teach an action plan

Post Surgical Dysfunctions

• 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

• Scapular protraction• Forward head posture• Scapular elevation• Winging

Pain• Incisional pain

– Transverse incision across the chest and extends into the axilla

• 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

• 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

• P.N.F. • Scapular Mobilizations • Massage • Myofascial Release • Passive R.O.M. • Machines – seated row, lat pull

downs, triceps • Foam Roller • Physioball

• 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

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

• 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

• 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

• 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

• 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

• 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

• Decreased ROM• Delayed pain• Delayed Breast swelling• Delayed soft tissue dysfunction• Decreased strength• Fatigue

PT Goals

• Maximize / maintain ROM• Maximize tissue mobility• Minimize fatigue• Maximize functional level• Teach HEP or delayed radiation effects

Radiation Rx contraindications

• 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

• 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

• Cane stretch• Butterfly stretch• Snow angel stretch• Trunk rotation stretch

Active Physiologic Movement Impairment?

NO Referred Symptoms. Perform Medical

Screening

YES

Passive Physiological Movement Impairment?

NOWeakness with MMT?

NONeuromuscular

Coordination Syndrome

YES

MMT < 2/5 ?

NO

NOPain Syndrome

NO Muscular Force Production Syndrome

YES

Peripheral Neuropathy Syndrome

YES

Passive Accessory Movement Impairment?

NO

Myofascial Restriction, Axillary Web SyndromeNO

Lymphedema Syndrome

YES

Glenohumeral Capsular Syndrome

Syndrome Features InterventionsNeuromuscular 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 movementResting pain, Empty end-feel ,through & End-Range 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 atrophyDiminished MMT strength but good contractilityAROM more limit than PROM w/ Normal end feel

Strengthening regimenIncrease muscular force productionRestore 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 contractilityMuscle atrophy Joint deformityAROM more restricted than PROM

Monitor re-innervationReduce postural effectsProtect jointsBracing splinting

Myofascial Restriction Syndrome

Soft tissue fibrosis, muscular trigger points or axillary web syndrome. AROM=PROMPalpable fibrosis“Cording”

Myofascial stretchingHome stretch regimenTrigger point releaseScar massageTransverse 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 TherapyVasopneumatic pumping

Chemotherapy Induced Dysfunctions

Chemotherapy Induced Dysfunctions

• 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

• 24 hours post chemo (?)• Fever• Infection• Fatigue• Lowered blood counts

– WBC– RBC– Platelets

Patient education

• 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

• 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

• 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 EffectiveHome Exercise Prescription

Upper Quarter Stretch Program

• Best if done supine• Achieve both ROM and tissue flexibility

ROM Exercise

• 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 post-

surgery 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

• 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

• 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

• 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