**4. Rehabilitation**

Rehabilitation for breast cancer survivors can be very heterogenous [3] depending on the different complaints and symptoms. It aims at restoring the best possible state of health, in a somatic as well as a psychic manner. In the first weeks after surgery, some precautionary measures have to be taken to not impede proper wound healing. This includes not carrying or lifting heavy weights or children with the affected arm and avoiding exhausting household tasks, such as vacuum cleaning, window cleaning, lawn mowing, snow shoveling, or lifting out heavy cooking pots. On the other hand, women are encouraged to use their arms increasingly, for example, body hygiene, such as teeth brushing or hair combing or easy household tasks, for example, dusting off. This is relevant to not becoming accustomed to prolonged "cradling of the arm" protectively against the body, which compromises shoulder ROM and/or arm swing during walking and furthermore affects posture badly.

In case of long-lasting side effects, patients should be taught compensatory mechanisms and ways to improve and economize their ADLs. This also includes supplying the patient with several necessary tools, for example, a long-handled reacher.

Even in the case of cancer recurrence, with improved medical possibilities and treatments, many patients are facing several years of life to come. This shows the need for body-oriented therapies and approaches to improve patients' symptoms and facilitate the patients' ongoing life in the aspect of mobility, edema, or pain. These recommendations should be considered even if disease progression is complicating therapy application increasingly [16]. If necessary, relatives or other caregivers should be involved in the therapy procedure to facilitate ADLs and transfers. In palliative contexts, this not only empowers and strengthens these people but also simplifies the relationship between the patient and her caregiver at home.

#### **4.1 Shoulder joint**

During the second week after surgery and after suture removal, shoulder joint mobility progresses without any limit [11] to reach high ROM as soon as possible. This is not only important for the patient herself, but is also paramount for starting an RT, which requires a certain patient position with maximal arm flexion and/or abduction to reach the axillary region. Otherwise, the RT could be delayed with unfavorable patients' outcomes [17]. Therefore, it is recommended to employ several techniques and exercises. Patients have already been taught their individualized home exercise program, which they should apply at least three times a week but better daily for 3 more months [15] with 10−20 repetitions for each exercise. Flexion, abduction, and

#### *Physiotherapeutic Management in Breast Cancer Patients DOI: http://dx.doi.org/10.5772/intechopen.108946*

external rotation are the most limited shoulder movements, so the focus lies on these motions. Scar treatment and muscle stretching are in close connection with shoulder ROM and complete the program enriched by relaxation techniques.

While exercising, patients are lying supine or sideward, sitting on a stool, or are standing securely on even ground. Exercise and stretching can induce a certain feeling of discomfort but should not trigger pain. If so, this exercise has to be finished or slightly varied until the pain subsides. Patients are using their own arm weight as a means of resistance or easily available tools, such as a rubber band, little hand weights or dumbbells, a broomstick, a towel, or filled small mineral water bottles as a weight substitute.

External rotation can be exercised with a yellow or later red rubber band fixed on a door handle while standing. The patient is holding her arm in a neutral position and the elbow close to the trunk with a 90° elbow flexion and is holding the loose end. She is then pulling against the rubber band resistance for the maximal possible external rotation and slowly easing back, which induces both concentric and excentric muscle activities.

For the so-called "elbow clam exercise" to enhance shoulder abduction, the patient is lying supine, both hands are crossed behind the head, and elbows together in front of the face. Now, the patient is abducting her arms, ideally, until the elbows touch the ground, left, and right (cp. **Figure 2**). She is holding this final position for at least 10 seconds, breathing steadily, and then moves slowly back.

Flexion can be enhanced, for example, with the "cleaning the door exercise." The patient stands facing the door, and the hand of the affected arm is resting on the door

**Figure 2.** *Elbow clam.*

panel with a small cloth in between. Now the arm is slowly gliding upward as high as possible at the time given and back to breast level. The arm's weight is resting partially on the door. During the exercise, the patient is instructed to maintain an upright body posture and not to lean back as a form of compensatory movement. Arm flexion is combined with inhaling and extension with exhaling.

#### **4.2 Posture**

Out of 82% women, after breast cancer surgery, only 35% of women develop a bad body posture [18]. This includes shoulder elevation, shoulder protraction, subacromial space reduction, trunk rotation, head rotation, and thoracic spine kyphosis [19–21]. Explainable reasons for these are pain, high muscle tension, axillary seroma, and a disproportional weight distribution after mastectomy without a breast prosthesis or a heavy-weight external prosthesis. The kyphosis also correlates with a kind of "startle pattern" so as not to show the missing/operated breast to their surroundings. The misguided postures lead to prolonged shoulder immobility, as the humerus cannot glide freely. Furthermore, muscle tension triggered pain [22] or even gait changes can follow.

Remedies are the bilateral arm exercises with the proprioceptive neuromuscular facilitation (PNF) concept [23]. This combines shoulder flexion, abduction, and external rotation with rubber-band resistance. Besides shoulder ROM improvement, trunk erection is also involved (cp. **Figure 3**). The patient is sitting on a stool, with her feet fixing both loose ends on the floor. The band is then crossed at lower legs height and fixed around both palms. In the beginning, the left hand is resting on the right knee and *vice versa*. She then starts the movement by lifting, abducting, and rotating both her arms, which inhibits unwarranted trunk movements until her maximal shoulder position is possible. The tension at the final position is to beheld for a few seconds, then the movement is slowly reversed back until both hands are resting on the knees as in the beginning.

While executing the so-called popular PT exercise "block game," the sitting patient is taught to actively feel, correct, and erect her three blocks, that is, the head, the trunk, and the pelvis in a vertical axis, one on top of the other. She then stabilizes and strengthens the now erect trunk by deploying both abdominal and back musculatures by moving the trunk slightly forward and backward without leaving the erect spine position.

Self-mobilizing exercises with the arm resting on a soft flexible ball while sitting sideward to a table correct the humerus direction caudal by activating the scapula (rhomboid muscle, transverse trapezius muscle) toward the spine, while simultaneously giving pressure on the ball and slightly abducting the arm by rolling the ball sideward (cp. **Figure 4**).

Humerus correction direction dorsal is achieved by the patient while standing with the face toward a wall. Both arms are lifted to 90° arm flexion, elbows 90° flexed, and the lower arms and hands in connection with the wall. She then approaches the sternum toward the wall slightly for correcting the humerus position, because the humerus is gliding posterior at this very moment. Secondly, she pushes her trunk slightly back from the wall. The latter also strengthens the serratus anterior muscle, which is sometimes weakened because of the possible corresponding nerve damage during surgery (cp. **Figure 5**).

The therapist instructs the patient to a) recognize and b) correct her posture. This can involve lowering the shoulder, straightening up, and de-rotating the trunk and/or head. In most cases, the trunk is pathologically rotated with the operated side moving

*Physiotherapeutic Management in Breast Cancer Patients DOI: http://dx.doi.org/10.5772/intechopen.108946*

**Figure 3.** *PNF arm flexion/abduction/external rotation with a rubber band.*

forward, while the head is rotated backward in the other direction to keep clear sight in front of the head. A mirror helps the patient to control herself and adjust her position accordingly.

## **4.3 Muscle stretching and strength**

Different muscles incline to shorten, above all the pectoralis major and minor and the latissimus dorsi muscle because of pain, RT, or non-usage. Stretching is possible as a hands-on (cp. **Figure 6**) and a hands-off procedure by the patient herself. Other muscles, such as the trapezius, levator scapulae, or deltoid muscle [24], but also the rectus capitis or semispinalis capitis muscle [25] tend to develop an often painful

**Figure 4.** *Self-mobilizing humerus caudal.*

**Figure 5.** *Self-mobilizing humerus dorsal.*

**Figure 6.** *Therapeutic pectoralis major stretching.*

hypertonus. Pain and the described "arm-cradling" imply muscle weakness. The overall loss of strength lies at 25% with an incidence of 18−23% [15], all of which can lead to shoulder instability [26] and even rotator cuff dysfunctions [19].

For auto-stretching, yoga exercises are appropriate means. The "Crocodile position," that is, "Makarasana" is an ideal exercise to stretch the pectoralis muscle and secondly to induce a deep breathing cycle at the affected trunk side. This is also important to counteract possible RT skin and lung and connective tissue side effects, such as long-term fibrosis. The arm position can be varied according to the patient's shoulder ROM and possible lymphedema. A pillow should then ensure that the arm is supported and that the hand is in the highest position that facilitates lymphatic flow.

Another yoga asana is the adapted "Cow face" or "Gomukhasana." With the aid of a towel or a belt, one arm is extended behind the back, while the other one is flexed over the head, both with flexed elbows, holding the towel/belt with both hands. The goal is for both hands to reach out to one another as close as possible. The healthy arm is supporting the affected arm by a pull on the before-mentioned belt or towel. This enhances flexion, extension, and both in- and outward rotations.

Strength training should be focused on but not limited to the affected arm, but also include the trunk for posture, the other arm for symmetry, and the lower limbs for easier ADLs. To combine upper limb strength training with additional balance training, patients should assume a standing position while exercising with both upper and lower limbs simultaneously. One can eventually combine a) squats and double-sided elbow flexion aggravated by hand weights (0.5−1.5 kg; cp. **Figure 7**), or b) "good morning" exercises, that is, bending the trunk forward by flexing the hip combined with horizontal abduction of both arms while both hands are behind the head, or c) lower limb lunges with both arms shoulder extension aggravated by hand weights.
