Summer can make women cringe at the thought of baring most of their bodies yet finding just the right coverage for their breasts. Some scrounge for padded tops to pump up their actual A cup. Some seek the greatest amount of coverage to support every ounce of skin. And still others search for flattering tops to accentuate cleavage and minimize tan lines. Just like one swimsuit does not fit every woman, only one aspect of post-breast cancer rehab is not generally sufficient. A combination of exercise, mindfulness, and myofascial release may need to be implemented for optimal recovery.
Ibrahim et al., (2017) produced a pilot randomized controlled trial considering the effects of specific exercise on upper limb function and ability to return to work after radiotherapy for breast oncology. The study involved 59 young women divided into an exercise group or a control group that received standard care. The Disability of Arm, Shoulder, and Hand (DASH), the Metabolic Equivalent of Task-hours per week (MET-hours/week), and a post hoc questionnaire on return to work were all used and recorded over 6 time periods after the 12-week post-radiation targeted exercise program. Women who had a total mastectomy still had upper limb dysfunction, but no there was no statistically significant difference in DASH scores between groups. Both groups at 18 months had returned to their pre-illness activity levels, and 86% returned to work (at just 8.5 fewer hours/week). The authors concluded exercise alone does not change the long-term outcome of upper limb function post-radiation.
Mindfulness-based cognitive therapy (MBCT) for persistent pain in women after treatment for primary breast cancer was explored by Johannsen et al., in two 2017 articles, one concerned with clinical and psychological mediators and the other focused on cost-effectiveness. Each study included 129 women with persistent pain from breast cancer, placed in a MBCT group or a wait-list control group. The first study showed attachment avoidance was a statistically significant moderator, with subjects who had a higher attachment avoidance having lower pain intensity after MBCT. In the subjects undergoing radiotherapy, MBCT had a smaller effect on pain than those not having radiotherapy. The authors’ next study focused on the minimal clinically important difference (MCID) on pain intensity. Baseline and 6 months post-treatment data on healthcare utilization and pain medication were analyzed from national registries. The average total cost of the MBCT group was 730 euros less than the control group, and more women in the MBCT group had a MCID in pain than those in the control group.
A diagnosis of breast cancer means many different things to many different people. Regardless, receiving this diagnosis means some sort of treatment will likely follow. The types of treatment and outcomes are largely dependent on individual patient scenarios, however, one thing is for certain: A patient’s life will be forever changed after having received this diagnosis.Historically, comprehensive care for a patient with breast cancer has focused on treatment and prevention. However, more and more women are surviving breast cancer every year. Therefore, more attention needs to be paid to survivorship. Once someone has survived cancer, comprehensive, quality care should obviously focus on preventing recurrence, however, it may also include guidance and counseling on maintaining a healthy lifestyle and addressing physical and psychosocial changes.
A very recent 2016 article published in the Annals of Surgical Oncology discusses the subject of survivorship in breast cancer patients. This article suggests that the key to achieving successful outcomes for management of a breast cancer survivor is a multidisciplinary approach to help these survivors deal with the physical and psychosocial sequela resulting from their diagnosis.
As a pelvic rehabilitation provider, this is a very thought-provoking article as it outlines several areas in which I feel breast cancer survivors could benefit from physical therapy. A pelvic rehabilitation provider can be a valuable part of the multidisciplinary team that helps manage a breast cancer survivor towards positive and meaningful outcomes, ultimately enhancing their quality of life. The following are some areas addressed in the article in which a breast cancer survivor may need assistance to improve and support a meaningful quality of life.
Susannah Haarmann, PT, CLT, WCS is the author and instructor of Physical Therapy Treatment for the Breast Oncology Patient. Join her this September 24-25 in Stockton, CA to learn about the various diagnostic tests, medical and surgical interventions to provide appropriate and optimal therapeutic interventions for breast cancer patients.
I turned to the literature and found prominent articles discussing breast reconstruction and giving minimal consequence to shoulder function after resection of the latissimus dorsi muscle. As a physical therapist, this left me in a quandary, “Really? Harvesting a portion of the broadest muscle of the back then threading it through the axilla to recreate the breast mound won’t have an impact on shoulder function or back pain? Impressive!” However, this did not correlate with my clinical findings. Often, scapulohumeral rhythm was altered, range of motion restricted and activities limited due to pain and fatigue. Scrutinizing the literature, I found that those articles were mostly unsubstantiated. Here is a quick summary of two systematic reviews published in 2014 addressing what the research really found pertaining to shoulder function after ‘lat flap’ reconstruction:
Patient impressions: - Reported incidence of overall functional impairment is 41%. 8 - Overhead activities, lifting and pushing objects and high-level activities such as sport and housework were the most cumbersome. 1,7 - Subjective deficits did not resolve based on length of follow-up. 1
The American Society of Clinical Oncology convened their 2016 annual meeting over the weekend, and several of the presentations suggest new methods of preventing breast cancer recurrence.
Extended Hormone Therapy Reduces Recurrence of Breast Cancer
Breast cancer patients who are treated with aromatase inhibitor therapy are generally prescribed the the estrogen drugs for a five year course. A new study has suggested that by doubling the length of hormone therapy, the recurrence rate for breast cancer survivors drops by 34%. The study included 1,918 women who underwent five years of hormone therapy with the drug letrozole. After five years, half of the group switched to a placebo while the other half were given an additional five year treatment.
My first experience treating a patient with shoulder pain and limitations post-mastectomy just happened to be a local doctor’s sister. Luckily, I did not know this until a few sessions into her therapy. Ultimately, even more than normal, this patient’s outcome was a make or break situation for a future referral source. Her incredible spirit and optimism made the prognosis an inevitably positive one. Whether or not I had manual therapy training was a moot point, according to current research; however, from my perspective, I would not have been as competent in treating her without it.
In June 2015, De Groef et al. performed a review of literature to investigate the efficacy of physical therapy for upper extremity impairments after surgical intervention for breast cancer. Eighteen randomized controlled studies were chosen for review regarding the efficacy of passive mobilization, myofascial therapy, manual stretching, and/or exercise therapy after breast cancer treatment. In the studies reviewed, physical therapy began at least 6 weeks post-surgical intervention. Combining general exercise with stretching was confirmed effective on range of motion (ROM) by 2 studies. One study showed the effect of passive mobilization with massage was null for pain or impaired ROM. No study showed any effect of myofascial therapy, one poor quality study supported the use of passive mobilization alone, and one study showed no effect of stretching alone. Active exercises were found more effective than no therapy or simply education in five studies. Early intervention was found to be beneficial for shoulder ROM in 3 studies, but 4 other studies supported delayed exercise to promote wound healing longer. Ultimately, pain and impaired shoulder ROM after operative treatment for breast cancer have been treated effectively by a multifactorial approach of stretching and active exercise. The efficacy of passive mobilization, stretching, and myofascial therapy needs to be investigated with higher quality research in the future.
Another review of literature in 2010 by McNeely et al. used 24 studies to analyze the effectiveness of exercise intervention for upper extremity impairments after breast cancer surgical intervention. Ten of the studies focused on early versus late intervention, and all supported the earlier implementation of post-surgical exercises for ROM; however, wound drain volume and duration were increased in the subjects engaged in earlier exercises. Fourteen studies showed structured exercise intervention improved shoulder ROM significantly in the post-op period, and a 6-month follow up continued to show improved upper extremity function. No lymphedema risk was noted in any of the studies.
Milk duct blockage is a common condition in breast feeding mother’s that can cause a multitude of problems including painful breasts, mastitis, breast abscess, decreased milk supply, breast feeding cessation, and poor confidence with decreased quality of life. A recent study in 2015 in The Journal of Women’s Health Physical Therapy1, showed that physical therapy (PT) maybe a helpful treatment for the lactating mother experiencing milk duct blockage when conservative measures have failed. Common conservative measures typically recommended are self-massage, heat, and regular feedings. The World Health Association, the American Academy of Pediatrics, and Academy of Breast Feeding Medicine, all recommend breast feeding as the primary source for nutrition for infants. There are many benefits to both the mother, and the infant, when breast feeding is used as the primary source for nutrition in infants. Having blocked milk ducts make it difficult and painful to breast feed and can lead to poor confidence for the mother and a frustrated baby as the milk supply could be reduced or inadequate. The primary health concern for blocked milk ducts is mastitis. Mastitis is defined as an infection of breast tissue leading to pain, redness, swelling, and warmth, possibly fever and chills and can lead to early cessation of breast feeding.
A blocked milk duct is not a typical referral to PT, however, this study outlined a protocol used for 30 patients with one or more blocked milk ducts that were referred to PT by a qualified lactation consultant. This study was a prospective pre/posttest cohort study. As an outcome measure, this study utilized a Visual Analog Scale (VAS) for 3 descriptive areas: pain, difficulty breast feeding, and confidence in independently nursing before and after treatment. The treatment protocol included moist heat, thermal ultrasound, specific manual therapy techniques, and patient education for treatment and prevention of the blockage(s). The thermal ultrasound and moist heating provided the recommend amount of heat to relax tissue around the blockage. Ultrasound also provided a mechanical effect that assists in the breaking up of the clog and increased pain threshold for the patient to improve tolerance to the manual clearing techniques. Next, the specific manual therapy was provided to directly unclog the blockage(s), and lastly the education provided was to help the patient identify and clear future blockages to prevent recurrence. 22 of the 30 patients were seen for 1-2 visits, 6 were seen for 3-4 visits, and none of the mother’s condition progressed to infective mastitis or developed breast abscess’s.
The results of the study showed the protocol used was helpful to ease pain, reduce difficulty with breast feeding, and improve confidence with independent breast feeding for lactating women that participated in the study. Although treatment of blocked milk ducts in lactating mothers is not a common PT referral, this study shows that PT may be one more helpful treatment for a patient experiencing this problem that is not responding to traditional conservative treatment. Since breast feeding is important to both mother and infant and is the primary recommended source for infant nutrition, it is important that a lactating mother receives quick, effective treatment for blocked milk ducts to prevent onset of mastitis and breast abscess that lead to early cessation of breast feeding. The cited study recommends that women who suspect a blocked milk duct or are having problems with breast feeding always seek care from a certified lactation consultant first, and that PT may be a referral that is made.
Today we hear more from Susannah Haarmann, PT, WCS, CLT about how pelvic rehabilitation practitioners are suited to contribute to a breast oncology patient's medical team. Susannah will be sharing more insights and treatment tools at the Rehabilitation for the Breast Cancer Patient course taking place June 27-28 in Maywood, IL.
Most pelvic rehab practitioners are incredible problem solvers and independent thinkers. We understand that often our referrals from a physician occur after a battery of tests and ineffective medical interventions. We may agree to treat a patient only to find that the diagnosis is vague and the patient often feels lost and broken. So we take out our sleuth caps, ask as many subjective questions as it takes and see where our objective examination leads us. Afterwards we paint a picture of our findings, focus the patient on what is working, tell them where we are going to start and how we are going to build one brick at a time.
The same is true for rehabilitation and breast oncology. Most physicians don’t understand how our work as therapists can complement and alleviate the side effects of mainstream medical intervention, but when the pain medication no longer works, we are there. When the range of motion no longer exists to get the patient’s arm into a cradle for breast radiation, we are there. And when the patient walks in our door, we are there, quite often for a period of time that extends well beyond after treatments cease, because the potential side effects of breast cancer, if they occur, may take years or even decades to show up. The rehab practitioner understands how to prepare the patient, without fear, for what the road ahead may look like. The purpose of this education is to empower patients to serve as their own best advocates. Pelvic practitioners and breast oncology specialists are noted for their exceptional manual skills. We are also versed to pounding the pavement educating physicians, patients and other therapists alike about who we can serve and how we can be of service. We are definitely a unique breed of therapists.
Today we hear from Susannah Haarmann, the instructor for Rehabilitation for the Breast Cancer Patient. If you want to learn how to implement your pelvic rehab training with breast oncology patients, join Susannah in Maywood, IL on June 27th and 28th.
Effective pelvic rehab practitioners demonstrate many skills which are especially suitable to treat people with breast cancer, however, the first idea that comes to mind is that they understand what my friend refers to as, ‘the bikini principle.’ She remarked this week that I treat the ‘no no’ areas; the private places that we rarely share…with anyone. The reproductive regions of the pelvis and chest wall both consciously and subconsciously are associated with a plethora of personal psychological and social connotations. A pelvic health practitioner has a raised level of sensitivity to working with this patient population; there is no true protocol in this line of work, effective treatment will require a deeper level of listening and being present with the patient, and a person’s healing of the pelvic region is likely to go beyond the physiologic realm.