PT WEEKLY: Physiotherapy in Breast Cancer Management
Cancer generally affects patients in so many ways and can really negatively impact a patient’s life. Therefore, treatment must be multifactorial and must involve considerations for a variety of factors. Treatment should focus on helping an individual obtain maximum physical functioning, but also should have considerations for social functioning, psycho-social welfare and ability to function at work and perform or participate in regular daily activities, within the limits imposed by the disease and its treatments.
Rehabilitation goals are;
Owing to the potentially progressive nature of cancer, the outcomes depend upon timely recognition of functional and other problems and prompt referral for rehabilitation.
This article focuses specifically on breast cancer (a disease in which malignant (cancer) cells form in the tissues of the breast), pre and post-surgical rehabilitation and the complications that are bound to arise post-operatively.
Risk Factors for Breast Cancer
A risk factor is anything that increases one’s chances of getting a disease, such as cancer. But having a risk factor, does not mean that an individual is sure to get the disease. While some risk factors can’t change (family history and aging), there are some risk factors that can be controlled.
Modifiable risk factors include but are not limited to:
1. Drinking alcohol
2. Being overweight or obese
3. Not being physically active
4. Birth control
5. Hormone therapy after menopause
6. Breast implants
Side Effects of Breast Cancer Treatment
1. Lymphoedema: refers to the accumulation of protein-rich fluid in the interstitial space caused by a compromised lymphatic system. Breast cancer-related lymphoedema (BCRL) of the upper limbs is a common complication following breast cancer surgery.
It causes limb and shoulder pain, heaviness, tightness, and decreased range of motion. Gross and fine motor skills are affected, the daily functions are restricted, and psycho social relationship is impeded
2. Bone Loss: The rate and magnitude of bone loss caused by cancer treatment is significantly higher than age-related bone loss in the non-cancer population. This is due to chemotherapy-induced early menopause and anti-estrogen therapies. Physiotherapists are able to confidently advise these individuals on safe exercise options to maximize bone integrity and decrease risk of injury.
3. Upper Extremity Dysfunction: Decreased range of motion, rotator cuff strain, adhesive capsulitis, paresthesia and weakness are all common developments in the upper extremity after breast cancer surgery and/or radiation therapy. Physiotherapy has been shown to be effective in managing post-surgical musculoskeletal symptoms.
4. Fatigue: It is a complex symptom with various overlapping causes, some of which include anemia, pain, sleep disturbance, thyroid dysfunction, and mood disorders. Physiotherapists can help manage fatigue through a focused history screening to determine the main contributors; by teaching the importance of planning and pacing their day, by designing a graduated exercise program to increase strength and energy levels and referring as soon as possible to the physician if the cause of the fatigue requires further investigation.
5. Pain and Neuropathy: Here is another complex symptom with multiple causes. This often requires a multi-disciplinary approach to management. A physiotherapist’s role in pain management comes in the form of exercise prescription, manual therapies and application of modalities, all of which have been shown to be effective treatments for pain in this population.
6. Bowel and Bladder changes and Dyspareunia (pain with intercourse): There are therapists who specialize in this particular field of treatment and can use exercise prescription, biofeedback and manual techniques to improve symptoms.
Physiotherapy plays an important role in pre-surgical rehabilitation, AKA Prehab. Prehab can improve psychological and physical outcomes of treatment. The goal of physiotherapy is to:
1. Assess baseline measurements: ROM of shoulders spine, and circumference of both upper extremities.
2. Identify any impairments that may affect recovery such as muscle weakness, postural dysfunction and pain.
3. Educate in lymphoedema and risk reduction.
4. Establish an exercise program for prior to and after surgery.
Post-Surgical Physical Therapy
The goal of physiotherapy after surgery and during cancer treatment (radiation, chemotherapy) is to minimize the side effects listed above and to optimize function. Physiotherapy interventions include:
Manual Therapy: Manual Therapy is defined as skilled hands on treatment to the joints, muscles, fascia and scar. This can help with restricted range of motion, pain and swelling.
This treatment includes manual lymphatic drainage, compression bandaging, taping, evaluation for garments, and instruction in exercise and self-care.
Postural Training: Physiotherapy will address the postural changes after surgery with postural specific exercises.
Exercise: Exercise through all the phases (prior, during and after) is of vital importance and has been proven to minimize or eliminate the side effects of treatment. A physiotherapist will provide an individualized program with specific goals.