July 2 nd Lab Session

1. July 2nd Lab Session Chris Wilson PT, DPT, GCS PTP 646 – Metabolic, Endocrine, and Integumentary Condition Interventions in Practice July 2013

2. 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

3. Indication for Rehabilitation Minimally 3 positive findings on the following questions, as judged by aphysician: - Physical complaints - Reduced physical capacity - Psychological problems - Increased levels of fatigue - Sleep disturbances - Problems with coping

4. Physical Therapy Patient Evaluation

5. 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

6. Tests and Measures • Surgical incision status • Skin integrity • R/O infection • Swelling/lymphedema • Pain source • ROM • Tissue mobility • Cording

7. Differential Diagnosis of Pain • Surgical • Nerve • Swelling • Cording • Soft tissue • Chemotherapy • Support drugs • Orthopedic • Recurrence

8. Differential Diagnosis of Swelling • Post-surgical • Cording related edema • Chemotherapy related • Lymphedema • Infection • Blood clot

9. Evaluation and Prognosis • Clinical impression • Differential diagnosis • Problem list • Goals • Goal potential/Prognosis

10. Intervention Plan • Frequency & Duration • Treatment modalities • Exercise prescription • Self management program • Return to activity/work plan

11. Intervention Planning • Based on indications & contraindications • Based on patient goals • Comprehensive • Variable • Start at minimal intensity • Progress may not be linear • No protocols

12. Advancement of Intervention Plan • Advance slowly • Reps • Weight • New activity • May not be linear • Based on patient input and goals

13. 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

14. Reducing risk of lymphedema • Regain full mobility and strength • Gain or maintain ideal body weight • Teach infection risk reduction • Teach an action plan

15. 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

16. Postural changes • Scapular protraction • Forward head posture • Scapular elevation • Winging

17. 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

18. Post-operative Vascular and Pulmonary Complications Decreased activity Incisional pain Reluctance to cough or breathe deeply

19. Swelling Lymphedema can occur almost immediately after lymph node removal After radiation Or many months later

20. Soft tissue restrictions and shortening Chest wall adhesions Restrictive scarring

21. 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

22. 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

23. 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 BresCa Res Treat 2002 Johansson ActaOncol 2005

24. A/AAROM

25. 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 BresCa Res Treat 2007

26. Shoulder Program • P.N.F. • Scapular Mobilizations • Massage • MyofascialRelease • Passive R.O.M. • Machines – seated row, lat pull downs, triceps • Foam Roller • Physioball • 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

27. Resisted Middle Trap

28. Resisted Lower Trap

29. 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

30. Pectoralis Stretch • Consideration for posture • Consideration for breast reconstruction techniques

31. Pectoralis Stretch

32. Pectoralis Stretching • Focus on varying fibers of the pectoralis

33. Post-op treatment Frequency 2x/week in general 3x/week if pain is significant 4-5x/week if pending radiation treatment

36. Side Effects of TRAM Surgery • High rate of trunk instability • Low back pain • High rate of abdominal hernia • Postural Deficits

37. Core Stabilization after TRAM • Exercises – focus on abdominal strength • Pelvic Tilts, Abdominal Curls • Press – Ups • Foam Roller • PhysioballExercises • Core Exercises - planks • Elliptical • Treadmill – backwards • TherabandExercises

38. Trunk Range of Motion

39. Lumbar Stabilization

40. Lymphatic Cording

41. Lymphatic cording

42. 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.

44. Post-op Dysfunctions Lymphatic Cording Pain Visual/palpable “cords” Loss of shoulder ROM Loss of elbow ROMDecreased arm strength Decreased arm function Decreased ADL’s, vocational and social function

45. 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

46. Treatment Contraindications Activities that increase symptoms PREs (?)

47. Treatment of Cording • Treat with cording stretches and skin traction • Treat soft tissue restriction/ROM • Treat weaknesses • Treat cardiopulmonary system as indicated

48. 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

49. Cancer Related Fatigue

50. Cancer Related Fatigue Causes of Fatigue Anemia Pain Emotional stress Sleep disruption Altered nutrition Altered activity Medical issues – thyroid, heart, infections