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July 2nd Lab Session Chris Wilson PT, DPT, GCS PTP 646 – Metabolic, Endocrine, and Integumentary Condition Interventions in Practice July 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 • 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 • • • • • • P.N.F. Scapular Mobilizations Massage Myofascial Release Passive R.O.M. Machines – seated row, lat pull downs, triceps • Foam Roller • Physioball 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 Referred Symptoms. Perform Medical Screening Active Physiologic Movement Impairment? YES Passive Physiological Movement Impairment? YES Passive Accessory Movement Impairment? Weakness with MMT? Neuromuscular Coordination Syndrome YES Pain Syndrome MMT < 2/5 ? Muscular Force Production Syndrome YES YES Myofascial Restriction, Axillary Web Syndrome Glenohumeral Capsular Syndrome Lymphedema Syndrome Peripheral Neuropathy Syndrome Syndrome Features Interventions Neuromuscular 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 movement Resting pain, Empty end-feel ,through & EndRange 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 atrophy Diminished MMT strength but good contractility AROM more limit than PROM w/ Normal end feel Strengthening regimen Increase muscular force production Restore 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 contractility Muscle atrophy Joint deformity AROM more restricted than PROM Monitor re-innervation Reduce postural effects Protect joints Bracing splinting Myofascial Restriction Syndrome Soft tissue fibrosis, muscular trigger points or axillary web syndrome. AROM=PROM Palpable fibrosis “Cording” Myofascial stretching Home stretch regimen Trigger point release Scar massage Transverse 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 Therapy Vasopneumatic 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 Effective Home 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 postsurgery 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