Early Shoulder Exercises for Reducing Complications After Breast Cancer Treatment
By Dorit Tidhar
Did you know that lack of movement of the shoulder after breast cancer surgery can lead to reduced function? However too much movement too early, can increase the risk for developing lymphedema.
The journey begins with the breast cancer diagnosis, the surgery, radiotherapy and chemotherapy. The journey begins, and for many women the journey ends with a return to full function. However a significant proportion of women continue to suffer from treatment-related sequelae such as reduced shoulder mobility and function, pain and lymphedema. All these problems can have a significant impact on quality of life.
Surgery for breast cancer includes axillary (underarm) lymph node dissection (ALND). Some of the removed lymph nodes may be looked at under the microscope to determine if the breast cancer has spread to axillary lymph nodes. ALND is usually done at the same time as the mastectomy or lumpectomy, but it can be performed in a second operation after sentinel lymph
node biopsy (the sentinel lymph node is the first lymph node to which cancer cells are most likely to spread from a primary tumor) which is a minor procedure of sampling one or two lymph nodes.
ALND or radiotherapy-induced fibrosis sometimes blocks the lymphatic drainage from the arm on the affected side, causing fluid to accumulate; this is called lymphedema.
Lymphedema is a progressive chronic condition. Post breast cancer swelling can build up in the breast, chest wall, the whole arm or just segments of the arm (hands and fingers, forearm or upper arm). It can produce significant physical and psychological morbidity. Heaviness, numbness, tightness and pain are frequent symptoms. (Best Practice Consensus Document, 2006)
Lymphedema incidence ranges from 25% to 61% of the women who undergo ALND, depending on lymphedema definitions. It also occurs in up to 3%-8% of women who have a sentinel lymph node biopsy
Dorit Tidhar, MScPT was trained in lymphedema therapy by Prof. Judith Casley-Smith in 1999 and was certified by her as a teacher in Self Management and Exercise for Lymphedema in 2003. Dorit designed a program of Aqua Lymphatic Therapy to help people who suffer from lymphedema maintain and improve the results of conventional treatment. She is now working at the McGill University Health Centre’s Lymphedema Clinic in Montreal as a clinician and an instructor.
(Ashikaga, 2010). Sometimes the swelling lasts for only a few weeks and then goes away. In other cases, the swelling becomes chronic and the tendency for the upper limb to swell becomes lifelong (Cormier, 2009).
Between 8% to 45% of breast cancer survivors have impaired shoulder mobility (Kuehn 2000). Chronic pain may also be a problem. In a study that surveyed impact on recreational activities for up to five years post-surgery, up to 29% reported pain that reduced their participation in recreational activities (Miedema, 2011) and was a reason for not resuming paid work (Quinlan, 2009).
The pain that is associated with breast cancer surgery results in pain-protective behavior. In other words, patients are more likely to protect their chest and use their arm less to avoid pain and this can potentially lead to disuse problems that include contractures and arm weakness. The inability to return to normal activity with the operated arm has been reported by researchers months and years following breast cancer treatment (Lee 2007).
Studies suggest that the surgeries (to the breast and the axilla) and radiotherapy are the main risk factors for upperlimb dysfunction in breast cancer survivors. Lymphedema in particular can also be induced by other risk factors such as
drain/wound complications or infection and seroma (an accumulation of fluid at or near a surgical wound).
The question is: what can be done to prevent these debilitating issues? Which exercises are safe?
Seroma formation, wound healing and fluid drainage are a major concern for women after surgery for breast cancer (Shamley 2005). Strategies for reducing seroma formation and improving wound healing include delaying arm exercises postoperatively, on the theory that immediate postoperative movement of the upper extremity causes an increase in seroma formation and delay in wound healing as well as decreasing fluid drainage. On the other hand, however, there is a concern that delaying exercises will cause limited movement of the operated arm and may potentially lead to residual shoulder dysfunction. Consequently, researchers have expressed conflicting views about the timing of postoperative exercises. In practice, many surgeons do not refer patients who have undergone breast cancer operations, especially those involving the axilla, to physiotherapy rehabilitation, because of the doubts about benefits, and fear of increas-
Exercise after Breast Surgery: A guide for women
2011
Delaying full shoulder mobilization appears to lead to less incidence of lymphedema.
ing the incidence of postoperative complications after early mobilization (Cinar 2008). The benefits of exercises on shoulder function have been suggested in several studies that show that exercise restores shoulder joint mobility and strength in the muscles of the upper limb, and reduces pain. In a study published in 2002 Box,R. showed that gradual progressive exercise facilitated the recovery of shoulder range of motion (ROM) without compromising the healing process of the surgery wounds and enabled restoration of lymph drainage. The ability to perform physical activities or tasks was improved when exercise was done in a progressive way over an extended period of time (6-12 months).
In their meta analysis, McNeely et al (2010) evidence of benefit on shoulder ROM from exercise interventions that include more structured instruction and/or supervision when compared to usual care (e.g., no exercise instruction, or exercise instruction via a pamphlet). The findings suggest a statistically and clinically significant benefit from exercise post intervention in both the short and long-term. McNeely et al (2010) concluded that postoperative exercises appear to lead to
better ROM at the shoulder joint. However, when should these exercises start, and which exercises should be done? If overhead movements of the arm are performed early, prior to removal of the drain, more wound drainage may occur. The metaanalysis showed that after one year there was no difference in symptoms (including lymphedema incidence) between groups that engaged in full range of motion (ROM) exercises early and those that delayed. It appears that delaying full shoulder ROM exercises until the drain is removed does not lead to more shoulder function problems in the long term than performing full ROM early, and allows for better healing of the surgical area.
This approach of delaying full shoulder ROM exercises for a few days until the drain is removed was evaluated in two very interesting studies.
In a randomized controlled trial of 116 women post breast cancer surgery, Todd et al (2008) examined the two approaches. One group started within the first two postoperative days with exercises of full shoulder ROM and the other group was limited to 90 degrees of elevation for the first week after surgery. The main outcome measure was the incidence of arm lymphedema which was defined as a volume difference of 200 ml or more compared with the untreated arm. Women were asked to carry out each element of the exercise regime three to four times, slowly and rhythmically, repeating the whole program four times per day until full shoulder ROM was restored and then once a day for the first year. After a year of surveillance, six (10%) women developed lymphedema in the delayed exercise group versus 16 (28%) women in the early group. There was a positive association between wound drainage and lymphedema. Cases of increased wound drainage volumes were more common in the early mobilization group.
In another controlled trial, Torres-Lacomba et al (2010) examined 120 women who were randomised either to an early intervention of physiotherapy rehabilitation plus
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lymphedema education, or to education alone. Both groups met three times a week for three weeks. The rehabilitation program was very comprehensive and included physiotherapy techniques for restoring shoulder ROM and strength, and manual lymph drainage. The authors found that significantly fewer women receiving physiotherapy developed clinically important lymphedema at one year (7%) compared with controls (25%). Since we cannot separate the effect of each component of the program, physiotherapists would need to be lymphedema specialists in order for them to follow a similar program.
These two studies were published after the meta analysis by McNeely et al was completed and thus support the idea that delaying full shoulder mobilization appears to lead to less incidence of lymphedema.
The Canadian Cancer Society has published a booklet that provides a series of exercises for women to do after breast cancer surgery. The publication is entitled “Exercises after breast surgery” and can be downloaded from their website: www.cancer.ca/Canada-wide/Publications.
Initially, during the time the drain is in place, exercises are performed with the arms near the body with elevation limited to 90 degrees. Then when the drain is removed the advice is to move gradually to full use of the arm by introducing exercises that engage full range of motion of the shoulder joint. These directives seem to
Are we providing appropriate postoperative exercise interventions in our local cancer centers? Do those interventions follow the evidence based recommendations (delayed full mobility)? Armed with this new knowledge, perhaps it’s time for an evaluation and a change of our practice in order to achieve the best possible outcomes following breast cancer surgery!
LP
Acknowledgment: The author thanks Pamela Hodgson, Carol Shay, and Dr. Anna Towers for their help in editing, writing comments and offering clinician perspective.
References:
1. Lymphoedema Framework (2006) Best practice for the management of lymphoedema. International consensus. MEP, London.
be consistent with the latest research. In conclusion, the evidence supports the usefulness of mobility after surgical removal of the axillary lymph nodes (ALND) to reduce the risk of developing lymphedema, control pain and restore shoulder function. The exercises should start within the first couple of days after surgery but should be limited to 90 degrees until the drain is removed, then, gradual elevation can be achieved over time based on our goal of reducing complications after breast cancer surgery.
2. McNeely ML, Campbell K, Ospina M, Rowe BH, Dabbs K, Klassen TP, Mackey J, Courneya K. Exercise interventions for upper-limb dysfunction due to breast cancer. Cochrane Database Syst Rev. 2010 Jun 16;(6):CD005211.
3. Todd J, Scally A, Dodwell D, Horgaan K, Topping A. A randomized controlled trial of two programmes of shoulder exercise following axillary lymph node dissection for invasive breast cancer. Physiotherapy. 2008;94:265-73
Additional references can be found at canadalymph.ca
