After breast cancer

treatments -lumpectomy,

mastectomy, radiotherapy

and breast reconstruction

Has arm strength been affected?

Prepared by Denise Stewart on International Women’s Day 2013

The information provided on this presentation is for informational purposes only and is not intended as a substitute for advice from your physician or other health care professional.

You should not use the information on this site for diagnosis or treatment of any health problem or for prescription of any medication or other treatment.

You should consult with a healthcare professional before starting any diet, exercise or supplementation program.

Warnings….first

What is happening and

should we be concerned?

A well respected Brisbane study*revealed that 50% of women experienced one significant impairment of arm function at 6 years after their breast cancer treatment.

20% of the study experienced 2 or more physical impairments.

*Prevalence of Breast Cancer Treatment Sequalae over 6 years of Follow-UpS Hayes etal Cancer April 2012 pages2217- 25

Yes, I am concerned!

This presentation has been prepared to help women, who experience some discomfort after their breast cancer treatment, by providing information about:

Symptoms and Treatments

What arm symptoms?

Symptoms that were rated by women as being a significant concern in this study:

• Post surgical issues ( wounds, infections, seroma, lymphatic cording or axillary web syndrome)

• Skin/tissue reactions to radiotherapy

• Impaired upper body strength and endurance

• Impaired range of movement at the shoulder

• Pain, stiffness, tingling, numbness, weakness in the arm and hand

• Lymphoedema

• Fatigue

• Personal ratings of day to day tasks specific to upper body strength etc.

Why do these symptoms

occur?

Reality: When we move, walk or “work” – movement of all the soft tissues in our body occurs.

Hypothesis: Active scars impair how we move, walk and work.

Active scars interfere with the elasticity and movement of all soft tissue layers within the body.

What is an active scar:

• They do no move readily

• May be tender to the touch

• Skin fold (pinch) is thicker and tender and not as extensible

Scars and scarring

Scar tissue from (any) surgery can reduce skin stretch for years after.

Radiotherapy can reduce skin stretchability.

Breast reconstruction may result in many scars and in turn pose a risk of tight skin and muscles at the abdomen and chest.

The scar at the breast or underarm is only the surface – the surgeon has performed surgery at much deeper levels of the breast and armpit.

Surgery may have required cutting through muscles, so scar tissue may be deep to the surface scar.

How can I check?

This is a big but gentle stretch “out the back”.

This stretch can be used to see if there is any tight tissue at the chest that is limiting day to day performance.

Feel and see the difference

If this stretch is done on both sides, then you will see if there is a difference in how far “out the back” the arm will move.

A gentle stretch straight up

beside the head.

Reach up beside the ear?

Does tightness restrict movement on the operated side.

What is restricting movement ?

Expect full range of movement after your breast cancer treatments.

Tightness at the end of movement can be from scar tissue, axillary web syndrome or from tightness in muscles

There is a simple way to find out…..

Deep scar check

Skin and fascia check

Tight muscle check

A deep active scar may look

like this

A photo of the armpit at an “out the back” stretch. Lymphatic cording can be seen running into the arm

The deep scar tissue is linked to the cording and is down further … in this photo- where the thumb is.

Lymphatic cording running into the arm

Scar tissue may be deep to the scar at the skin

Is the skin over the chest

area soft and stretchy?

If the skin on the treated side is not stretchy ….. this will affect arm movement and strength and can be responsible

for pain and weakness.

Click on image to run short video

Skin stretchability

Use the same technique in the video ……to test stretchability of tissue at different depths at the breast/chest area especially near scars.

There is a need to remind you……… that this test can only be performed when all wounds are healed on the chest/ breast.

Deep fascia stretch

click on the photo to show movie

Assess the stretchability of the soft tissues between the breast and the rib cage.

There should be freedom of movement in all directions and at all depths.

Check with the side that has not had surgery.

Level 1 stretch

muscle tightness or scar?

Level 1 stretches as described by Prof KarelLewit – a world renown authority in rehabilitation medicine, Charles University Hospital, Prague.

Level 1 Lewit stretches are very gentle and offer a great way of gaining a “relax” and therefore lengthening of tight muscles …..especially those of the chest.

If Level 1 Lewit stretches do not offer an improvement (when movement is restricted) ……………. then scar tissue may be causing the problem.

The shoulder region is

complex

Although the surgery is on the front of the chest/ breast-active scars will interrupt the complex movements and stabilizing patterns of the neck and shoulder.

A therapist specializing in shoulder performance will best be able to test specific groups of muscles in the shoulder to determine if they are tight or not working efficiently.

What are some great

treatment goals

To have full range of movement at the shoulder and arm

To be able to perform day to day tasks without too much pain and discomfort.

What is Needed: Soft and flexible muscles at the neck and shoulder for best shoulder strength and endurance.

Skin and fascia over the radiated area to be stretchy (and at all depths over the rib cage area).

Scar to be not tender to the touch.

Soft breast tissue under the scar.

Good core stability to achieve best shoulder strength.

Treatments……….

when stretches have not been

enough!

Very simple treatments can improve these problems after surgery and radiotherapy:

For some women treatments may need to be used over a much longer time than expected…. depending on how active the scar is for the individual.

Skin and fascia release technique (eg K. Lewit fascia stretch)

Gentle “contract relax” stretches ( eg Lewit level 1, )

Kinesiotape

Low Level Laser treatments for scar tissue

Tight muscle release techniques eg triggerpoint , scapular stabilizing retraining , neck and hip alignment)

How hard is it to get treatments for

physical impairments after breast cancer?In America*, many barriers have been identified for women who need expert treatment for these problems.

• Fractured delivery of cancer services across the hospital systems.

• Lack of comprehensive rehabilitation services within each system of care.

• An expectation that some problems are “normal” and should be tolerated

• Lack of referral to rehab specialists.

• Lack of trained rehab specialists

Is this the same experience in Australia and in your region?

Lets start sharing this information and help women better assess and manage these types of problems sooner.

* Prospective Evaluation of Physical rehabilitation Needs In Breast Cancer Survivors Schmitz etal Cancer April 2012 Pages 2187-90

If you wish to gather more information then contact Denise Stewart on deniseot@bigpond.net.auorYou can make an appointment with Denise:Mater Private Breast Cancer Center BrisbaneQueensland , Australia07 3163 1166

Denise Stewart is a private Occupational Therapist who has provided a range of services to women experiencing physical complications secondary to their breast cancer treatments for the last 25 years.

Treatments are now focused on early interventions and prevention strategies to minimise the potentially chronic problems which can occur: pain, upper body dysfunction and lymphoedema.

The model of practice is based on treatments suitable to the different medical treatment phases for breast cancer and has a strong focus on self-management through improved understanding, home treatments, posture and performance skills.

Lymphoedema enquires: www.nlpr.asn.auThe first national register of lymphoedema practitioners in Australia and New Zealand. Find a lymphoedema practitioner in the Australia or New Zealand.

Other Contacts: • Occupational Therapy Association in your

state – search for Soft Tissue Therapist.• www.riancorp.com/Australia– therapists with

a low level laser in Australia