“Managing Today”

“Managing Today”
Lisa Marshall OTR/L
Course Objectives
• Identify the side effects of treatment for breast cancer and the role of
rehabilitation plays in the recovery process.
Course Objectives
• Identify signs and symptoms of Axillary Webbing Syndrome and
breast lymphedema.
• Identify the many benefits of staying active including exercise during
and post treatment.
Role of rehabilitation in Oncology treatment
Surgery, chemotherapy, targeted therapies and radiation therapy saves
lives but comes with side effects that may leave a person with residual
and sometimes devastating side effects.
The role of rehabilitation is to help the person improve his/her quality
of life through all phases of treatment and post treatment.
Side Effects of Oncology Treatments
Surgery Side Effects
• Scar tissue restrictions,
adhesions
• Limitations in ROM
• Postural changes
• Muscular weakness
• Fatigue
• Lymph node dissections may
cause lymphedema
Effects of Radiation
• Burns
• Fibrotic skin changes
• Fatigue
• Postural changes
• Edema
• Lymphedema
• Upper extremity, Breast,
Trunk
Chemotherapy Side Effects
Fatigue
Chemotherapy Induced Peripheral Neuropathy
Weakness
Breast Cancer Rehabilitation
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Post Mastectomy/Axillary Dissection/segmental mastectomy
Treatment for cording/axillary webbing syndrome
Preparation for radiation therapy
Treatment for pain, weakness and scar tissue restrictions
Treatment for fatigue
Treatment for CIPN
Treatment for lymphedema
• Arm
• Breast/Trunk
• Post Reconstructive surgery
• Expander/Implants
• TRAM flaps or DIEP Flap
• Latissimus Dorsi Flaps
Phases of Axillary Webbing Syndrome, AWS
Phase 1 (Acute)
First 8-10 days on onset
• Severe pain axilla through cubital fossa and may extend to thumb or chest wall.
• Treatment should be very gentle; light manual traction and gentle stretches.
Phase 2
• Lasts to 4-5 months, can be longer. Visible cording that can restrict ROM especially
shoulder abduction with elbow extension. Symptoms may include edema with mild
pitting.
• Article 2001 a study done at University of Washington and published by The American
Journal of Surgery.
• Researchers suggest that AWS is a result of interruption of the axillary lymphatics during
axillary node dissection.
Axillary Webbing Syndrome
Treatment for AWS
• Slow sustained stretching.
• Find anchoring of the cording then carefully manipulate the point
of fixation.
• Gentle stretching of the cord with manual techniques.
• Scar stretching, myofascial release techniques.
• Follow up with manual lymphatic drainage.
• Home program of self stretches and gentle brachial plexus nerve
glides.
• Gradually increase activity as tolerated
Breast Edema and Lymphedema
• Now that physicians are conserving breasts we are seeing an increase
in breast lymphedema post radiation.
• Breast lymphedema may start post surgery and increase during
radiation and peak 4 to 6 months post radiation.
Signs and symptoms of breast or truncal lymphedema
• Post surgical and radiation swelling is normal, lymphedema is
persistent
• Breast feels heavy, full, tender, may have hard spots of fibrosis.
• May have discomfort with ADL
• Visible indentations from the bra in straps or seams that is seen on
the affected side only.
Treatment options for breast and truncal
lymphedema.
• Manual lymphatic drainage to: neck, abdomen, trunk, breast and
chest.
• Kinesiotaping
• Compression bandaging, garments, chip pads. Bellisse garment,
sports bras.
• Diaphragmatic breathing and therapeutic exercises while wearing
compression.
• Instruction on self drainage techniques.
Kinesiotaping
Lymphedema Management
Individualized treatment may include:
• Manual lymphatic drainage
• Low stretch compression bandaging
• therapeutic exercises
• aerobic conditioning
• compression garments
• instruction on skin care and self management techniques
• gradient sequential multi-chamber vaso-pneumatic pump
What Moves Lymphatic Fluid
• Diaphragmatic breathing
• Slow stretching
• Light strengthening; muscle contraction
• Manual lymphatic drainage
• Aerobic exercises
• With compression bandages if edema is present; however we incorporate all
exercises to keep the system healthy even if edema is not present.
• Research indicates exercise also helps reduce risk of recurrence
• Maintaining a healthy weight helps reduce risk of lymphedema
BENEFITS OF EXERCISE
According to the American College of Sports
Medicine (ACSM)
“Exercise training is safe and
beneficial for cancer patients when
the exercise is individualized to suit
the individual’s characteristics.”
According to NCI, Exercise (including walking) may help people
undergoing treatment feel better and have more energy. In
clinical trials, some patients reported the following benefits from
exercise:
• More physical energy.
• Better appetite.
• More able to do the normal daily activities
• Better quality of life.
• More satisfaction with life.
• A greater sense of well-being.
• More able to meet the demands of cancer and
cancer treatment.
Benefits of Exercise for a person in cancer
treatment
• Restore prior level of function
• Reduce functional limitation and disabilities
• Supply oxygen to cells (energy)
• Pain control
• Quality of life
• Reduce nausea and vomiting
• Enhance the immune system
• Natural endorphin release (depression)
• Counter cancer related fatigue syndrome
It is safe and beneficial to exercise with or
without lymphedema?
• Research indicates exercise helps reduce the risk of recurrence
• It is safe to exercise during your cancer treatments, just modified
• Exercise does not cause lymphedema
• If you have lymphedema you should exercise
• Exercise should be progressed slowly and gradually. If using resistance
low weights and gradually increase the resistance. If you have
lymphedema wear compression during exercise.
• Exercise is recommended for persons with or at risk of lymphedema.
• Weight management helps reduce risk of lymphedema
Exercises is not contraindicated for a person who received an
axillary dissection.
• Make sure it is slow and gradual.
• Avoid excessive repetitive activities
• Follow limb monitoring techniques
• If you have lymphedema then exercise with compression on: helps
treat the extremity and reduce the swelling
• Swimming: an excellent activity because the water acts as
compression. So you don’t need to use compression in the water.
ACSM Guidelines
• Exercise prescription for
intensity
• Adjusted as tolerated by the
patient
• Exercise frequency
• Determined by clinical status of
patient
• Strength training
• High reps, low weight
Precautions during treatment
• Sudden onset of shortness of
breath
• muscular weakness or unusual
fatigue
• Dizziness or blurred
vision/faintness
• Febrile illness
• Chest pain
• Recurring leg pain/cramps
• Bone, neck or back pain of recent
origin
• Acute nausea onset during
exercise
• Development of irregular or
resting pulse > 100 bpm
Formula for an exercise program
• Breathing
• Stretching
• Cardio
• Strengthening
Department of Health and Human Services 2008
Physical Activity Guidelines
• 2 hours and 30 minute of moderate activities (you can talk but not
sing)
• Muscle strengthening 2 or more days a week
• Aerobic activity should be performed in episodes of at least 10
minutes at a time and spread throughout the week.
• Goal: AVOID INACTIVITY by performing a combination of aerobic and
muscle strengthening exercises.
• http:www.health.gov/paguidelines/pdf/adultguide.pdf
Explore a variety of mind body exercises to reduce
stress and improve energy
• Walking meditation
• Yoga
• Breathing techniques
• Tai chi
• Qigong
• Meditation
Most of all find activities you enjoy!