Exercise & Breast Cancer Recovery

Exercise & Breast Cancer Recovery

LEARNING OBJECTIVES Demonstrate an understanding of the diagnosis and treatment of breast cancer Demonstrate an understanding of how breast cancer surgery and treatment impacts physical mobility, posture, and activities of daily living Understand the signs and symptoms of upper extremity lymphedema and how to prevent and manage them Develop a comprehensive exercise program to help correct muscle imbalances and range of motion limitations while addressing other acute and chronic treatment side effects

WHAT IS CANCER? Cancer - develops when the genetic mechanism that controls a cells growth goes awry, allowing it to multiply without control Carcinoma in situ uncontrolled cell growth that remains in its original location Invasive cancer cancer that has spread beyond its original location and has begin to infiltrate previously healthy tissue

WHAT CAUSES CANCER? Heredity - less than10% Radiation - x-rays, ultraviolet, radioactive chemicals. Viruses - Epstein Barr, HPV, Hepatitis B. Obesity - 15%-20% of cancer related deaths Chemicals (oxidative stress)

SURGERY & RECONSTRUCTION Time since surgery/reconstruction Where is incision(s)? Muscle removed? Lymph nodes removed?

Potential Side-Effects of Mastectomies Skin tightness / adhesions especially under arm and across chest and shoulders Muscular weakness (primarily serratus anterior) causing instability of the shoulder girdle Painful and difficult movement of the arm and shoulder and possible frozen shoulder Numbness Recurrent infections Axillary web syndrome

Axillary Web Syndrome AWS is a painful and functionally limiting complication of breast cancer treatment most likely due to lymphatic thrombosis after lymph node resection. Patients describe cord-like structures in the axilla extending into the distal arm causing pain, limited shoulder ROM and functional compromise Lymphatic cording-a visible web of axillary skin overlying palpable cords of tissue. 6% incidence between 1-6 weeks May occur in the axilla, elbow joint, wrist, and/or trunk Physical therapist needs to perform long tissue stretching and Myofacial techniques Patient must do home-based stretching program Active ROM and passive ROM should improve, pain will decrease, but visible signs of cording may always be present

Reconstruction Saline implants - a balloon filled with saline and placed beneath the skin either on top of or beneath the chest muscle Tissue Expander - is only partially filled before placement. Over the course of 6 weeks it s gradually filled with more fluid. Complications: Capsular contracture - scar tissue around the implant hardens then contracts - It may cause deformity, pain, abnormal firmness of the breast - Frequent massage and exercise may help, but surgical correction may be necessary Implant rupture Loss or changes in nipple and breast sensation The pectoralis major may react by going into painful spasms

Lat Flap The muscle is used to form a breast mound, or more commonly, a pocket where an implant is placed. A tunnel is created under the skin of the armpit. The muscle is pulled through and out the mastectomy scar in front. The skin is then sewn into place with all of the blood vessels in tact Potential side effects: Weakness in the muscles supporting the shoulder blade Tissue death (necrosis) Blood clots Infection Prolonged healing time Loss or changes in nipple and breast sensation

TRAM Flap A football-shaped section of skin, fat, blood vessels, and muscle is taken from the abdominal area the muscle is pulled up through a tunnel under the skin of the upper abdomen and out through the mastectomy scar in front The muscle is used to form a breast mound and the skin is then sewn into place with all of the blood vessels in tact (3-8 hrs) Potential side effects: Abdominal and lower back weakness and pain Hernia Decreased trunk stability Difficulty standing erect Tissue death (necrosis) Blood clots Infection

Free Flaps Similar to TRAM in that a football-shaped section of skin, fat, blood vessels, and muscle are transferred to the chest. Instead of leaving all of the blood vessels in tact and tunneling it under the skin and up to the chest, everything is cut out in a section and then re-attached to the chest. It is much more complicated, lasting 9-12 hrs. Rectus Abdominis DIEP (muscle conserving abdominal skin/fat) GAP (muscle conserving gluteal skin/fat) TDAP (thoracodorsal artery perforator (muscle conserving upper back skin/fat) TUG (transverse upper gracilis) Potential side effects: Risk of tissue breakdown or death (necrosis) because blood supply may not be adequate Blood clots Infection Deformity where flap was taken from Postural implications will vary depending on where flap was taken form

TREATMENT Localized or systemic? Chemotherapy Radiation Hormonal Therapy Currently undergoing, or time since completion? Number of cycles? Acute/chronic side-effects Port?

LYMPHEDEMA Is swelling that occurs from damage to the lymph vessels caused by the removal of lymph nodes or radiation to the area Removal of the nodes and damage to the area prevent lymph fluid from draining properly, allowing it to accumulate in the tissue Pathways become restricted and cause a back-up of fluid

SIGNS AND SYMPTOMS Pitting Obvious swelling Feeling of heaviness or tightness Restricted ROM Aching or discomfort Recurring infections Hardening and thickening of skin (fibrosis)

CONSIDERATIONS Number of lymph nodes removed? What part of the body? Did they receive radiation? Is there pitting? Swelling? Have they been fitted for compression garment?

DURING SESSION Are they wearing compression garment? Go through precautions Begin with lymph drainage exercises Start and progress slowly Monitor for swelling Modifications

EXERCISE PROGRAMMING Currently undergoing treatment? Fatigue? At risk for lymphedema? Identify postural deviations and ROM limitations Comorbidities?

NEED-BASED PROGRAMMING Age and prior fitness level Amount and intensity of cardio Lymphatic drainage exercises 90% or better ROM before adding load in specific plane of motion Stretching vs. strengthening Balance and coordination (neurological)

SURVIVORSHIP Low self-esteem Altered physical appearance Loss of control over their body Fear of injury/pain Reluctance to resume, or begin, exercise program May have gone through painful physical therapy CES can provide a safety net Fitting in Quiet section of gym or studio/in-home training Group of cancer patients/comaraderie CES must develop a plan so that participants will experience SUCCESS Realistic goals Verbal praise

Medical Fitness Tour Rowan University Glassboro, NJ April 13-15 Medicalfitnesstour.org

BECOME A CANCER EXERCISE SPECIALIST www.thecancerspecialist.com TODAY ONLY SAVE $100 Call 503-502-6776 to Register

CONTACT Andrea Leonard Phone: (503)502-6776 empowersurvivor@earthlink.net Twitter: CETI@cancerexercise LinkedIn: Andrea Leonard Facebook: CETI & Cancer Exercise Training Institute Canada