RECOVERING FROM MASTECTOMY

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Rehabilitation from breast surgery can and should begin even before the surgery itself.

Patients who are to undergo breast surgery, no matter the extent of the procedure, will benefit from a physical therapy program that includes a baseline evaluation before the surgery, followed by exercise that begins immediately after surgery - the most critical period of time for rehabilitation.

Why begin physical therapy so soon? Because the most common physical problems resulting from lumpectomy or modified radical mastectomy are in a large part, preventable. And because breast cancer patients need no more pain and dysfunction in their lives than cancer has already caused.

COMMON PROBLEMS
Mastectomy patients frequently experience:

• Limited upper extremity mobility (range of motion)
• Arm weakness and swelling
• Fatigue
• Shoulder dysfunction
• Chest pain

Patients may not immediately notice these difficulties, as they may have intentionally kept their arms immobile for fear of hurting the incision. It may be only when a patient tries to lift something, perform household chores, drive - or even zip up a zipper - that she realizes she cannot move her arm as she once could.

Several of the post-surgical problems are interrelated. The surgery itself and scarring from it can, for example, tighten the skin on the chest wall and form fibrous adhesions, which can cause shoulder joint dysfunction. This dysfunction can lead to improper joint use, in turn causing the joint to contract, or tendonitis to develop. The results are pain, muscle spasms, immobility and the loss of range of motion.

OTHER DIFFICULTIES
Additional difficulties may result from breast surgery may include:

• One of the most significant complications of breast surgery is lymphedema, or swelling of the arm. In addition to causing discomfort, such swelling can produce other complications, including infection as well as changes in posture and musculoskeletal problems related to the increase in the arm's weight.
• The scapula, or shoulder blade, is susceptible to problems after surgery. Trauma to the long thoracic nerve during surgery can cause temporary or permanent paralysis of the muscle that helps stabilize the scapula (the serratus anterior muscle). This may be first noticed when the patient tries to reach for something, or when headaches, low-back pain or interscapular pain occur.
• Nerve entrapment by adhesions or cutaneous nerve regeneration may cause chest wall pain and numbness. These conditions are often worse for patients who have undergone reconstructive surgery.
• Over-compensating for the loss of breast weight may cause prolonged spasms of the rhomboids or trapezius muscles.
• Chemotherapy can intensify the effects of immobility, when treatment causes fatigue and corresponding inactivity.
• Abdominal pain often occurs after reconstructive surgery.

The degree of difficulty patients encounter with any of these complications varies with the extent of the disease and the procedure, as well as age and prior orthopedic problems.

Recovery from breast surgery - which may take several years - is however, even more directly linked to the timing, intensity and quality of a rehabilitative physical therapy program.

TREATMENT
With a preventative goal, a physical therapist will begin treatment before surgery to:

• Establish a baseline functional ability and arm circumference.
• Instruct patient on how to prevent shoulder limitations.

Immediately following surgery - ideally while the patient is still hospitalized - a physical therapist will re-evaluate the patient to determine the extent of dysfunction, set rehabilitation goals and begin assisted and self-managed exercise.

A good physical therapy program, such as the individualized programs available through Family Physical Therapy Services, may include:

• Instruction in proper posture and relaxation techniques
• Gentle stretching
• Active assisted motion
• Range of motion exercises
• Strengthening exercises
• Massage
• Design of a home exercise program
• Wound and skin management
• Transcutaneous electrical nerve stimulation (TENS)
• Desensitization techniques
• Abdominal exercise for reconstructive surgery patients
• Education about and treatment for lymphedema and its prevention (including skin care, the avoidance of strain, the reduction of fluids, improving the skin's elasticity, reducing the risk of inflammation)

Because prevention in the key to recovery, Family Physical Therapy Services encourages mastectomy patients to begin treatment as soon as possible. All programs are customized to the specific needs of each patient and are administered with continuing communication with and support from the patient's physician throughout the duration of treatment.

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