Physiotherapeutic Management in Breast Cancer Patients

*Margit Eidenberger*

### **Abstract**

Breast cancer treatment can lead to various physic and psychic long-term morbidities, such as restricted shoulder joint range of motion, lymphedema, impaired muscle strength, or cancer-related fatigue. Physiotherapy is a body-oriented approach to tackle these different complaints. This chapter starts with possible prehabilitation approaches until therapy or surgery. It continues with early post-op mobilization and shoulder-arm exercises during the early stages and additionally breathing exercises. In the following rehabilitation period and after hospital discharge, the focus lies on shoulder joint range of motion, muscle strengthening, and body posture to regain normal activities of daily life. This is supported by easy learnable exercises and therapy measures. Lymphedema prevention and treatment are discussed as well as sports therapy, which is divided into endurance and strength training. Therefore, an active lifestyle is encouraged by also considering necessary precautions while training during chemotherapy cycles. Common symptoms and problems, such as cancer-related fatigue and chemotherapy-induced polyneuropathy, are tackled with techniques, such as yoga or balance training. Scar therapy and radiation-induced lung injury are delineated followed by massage therapy proposals and specified exercises to enhance oxygen uptake.

**Keywords:** prehabilitation, rehabilitation, shoulder joint mobility, lymphedema, endurance training, strength training, relaxation

#### **1. Introduction**

Breast cancer is the most common cancer type in women. The latest improvements in early detection and therapy have led to a 10-year overall survival rate of up to 78% [1] in central Europe. At the time of diagnosis, most women are between 55 and 69 years old [2], but also younger women are increasingly affected, every one of these interested in an ongoing high quality of life after completing therapy. This has necessarily brought attention to the treatment of morbidities following the diagnosis and/or side effects of modern breast cancer treatment [3]. Women not only resume their working position but also want to return to sports after breast cancer treatment and/or reconstructive breast surgery and therefore need support, advice, and medical expertise.

Physiotherapy is a body- and patient-oriented approach for tackling different complaints of breast cancer patients after surgery (breast-conserving surgery BCS, mastectomy, and/or breast reconstruction), radiation therapy (RT), chemotherapy (CT), or hormone therapy. It aims at shoulder joint immobility, pain, scar complaints, or lymphedema with means of "hands-on techniques." Patients are furthermore educated to perform customized exercises, that is, "hands-off exercises" to regain their mobility and strength [4] and in doing so act as their own therapist.

The physiotherapeutic process starts with a thorough patient anamnesis, inspection and palpation, and further assessments to figure out the reason for the patient's problem. Afterward, the physiotherapist suggests a suitable treatment approach according to her/his expertise, medical research evidence, and the patient's values and preferences. Patient adherence to therapy is crucial for ongoing success.

This chapter gives an overview of different physiotherapeutic approaches, therefore guiding breast cancer patients through different stages of cancer treatment and afterward. Various common complaints and deficits are depicted followed by evidencebased exercise and therapy suggestions. It describes physiotherapy as an important part of the whole therapy concept contributing to a patient's better quality of life. Even in case of cancer-recurrence or metastasis, and during palliative stages, adapted training and activity of life guidance is possible and can facilitate the patient's remaining life.

## **2. Prehabilitation**

Prehabilitation is the approach to start therapy shortly after definite breast cancer diagnosis to make use of the remaining time until surgery (30 ± 17 days) or other medical treatments are planned. Prehabilitation has been able to improve bodily functions, shoulder range of motion (ROM), activities of daily life (ADL), and led to a shorter recovering period after surgery [5]. Acknowledging the fact that patients' activities will inevitably diminish post-surgery, by employing prehabilitation, women can guarantee that the percentage change will be of lesser consequence. Physical as well as psychological parameters can be improved during the weeks until the therapy starts.

To achieve this, patients are encouraged to take longer walks or go for Nordic walking (30−60 min) at an average or higher walking speed (4−5,5 km/h) on flat ground and even on gradient tracks. This leads to better oxygen uptake and cardiopulmonary function. They are instructed to do specific shoulder exercises to enhance a) shoulder ROM and b) shoulder girdle muscle strength by resistance training [6]. The training furthermore affords an opportunity to distract patients from disease-centered thoughts and can divert constant and circulating worries. It should, therefore, be complemented by an easy-to-learn kind of relaxation therapy, for example, deep breathing exercises [7] or Jacobson's progressive relaxation.

### **3. Postoperative phase**

Out-of-bed mobilization starts on post-surgery day one for BCS and mastectomy. With certain reconstructive breast surgeries, this is delayed for one or two more days. Early mobilization improves patients' independence for basic ADLs and protects against deep vein thrombosis. In a short time, patients are independent to use the toilet, to take meals at the table or to perform basic body hygiene for themselves.

Patients should train and/or walk two times a day for overall 10−20 minutes with an assured blood pressure of a minimum of 105/70 to a maximum of 150/90 and a heart rate of (180 minus age minus 10%). The walking speed is set at 60−80 steps per minute, which corresponds to a low intensity of 25−50 Watts. A recumbent bike can

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

be used after removing urinary catheter and drains. When using the (new) BORG Scale as an intensity level parameter, patients should specify their personal level of exhaustion at 1−2/10 during training sessions.

Patients are educated to perform their own breathing exercises and thrombosis prophylaxis, that is, calf-muscle pump, by moving and circling their ankles. In their own interest, this should be done every hour with 20−30 repetitions and 2−3 sets. While lying or sitting upright in bed or in a buxton chair in their room, the pursed-lips technique is used for exhaling combined with a deep breathing technique, preferably through the nose, while inhaling. The breathing is guided to the thoracic flank, the abdominal region, or the pulmonal apex region stimulated by the patient's own hands. From 12 to 15 breathing cycle repetitions are necessary for three series, interrupted by 30−60 sec breaks. Breathing exercises can also be combined with low-level shoulder exercises [8], such as shoulder shrugs, shoulder circles, arm flexion, and arm abduction.

Patients are lying supine in bed, and the affected side's arm is supported by one or more pillows to ensure low pain levels and to enhance lymphatic flow. A heart-shaped pillow placed in the axillary region can reduce pain and muscle tension after axillary lymphadenectomy. Patients are provided with such a pillow as an individual present at the ward. For reconstructive breast surgery, such as the DIEP flap or the TRAM flap, even more pillows or a positioning block is needed to support the calves/legs to relieve the abdominal region from exorbitant scar tension.

Arm exercises at the wrist and elbow level also start on day one. This improves wound healing, pain, and quality of life [9–11]. Shoulder exercises start on day three for BCS, but are restricted to 90° flexion and abduction and should respect lower levels if patients report pain [12]. Starting too early or in a too progressive regime could lead to an enhanced risk of seroma formation [13], lymphedema, or higher fluid drainage [8]. Mastectomy patients should wait with shoulder exercises until day 5 to diminish the risk of bleeding [14]. Arm lever, and therefore, weight during shoulder exercises, should be reduced in the beginning by maximal elbow flexion, which places the fingers at the corresponding shoulder. To remember these exercises correctly, patients are receiving a written information leaflet with precise instructions and further precaution measures to be taken in the following weeks and months.

After removing surgery drains [15], which is approximately on day 2−6 for breast and axillary drains, respectively, with the axillary drain normally remaining longer than the breast drain, the physiotherapist (PT) can induce passive and passiveassisted hands-on techniques in different directions. This will enhance scapular and humerus movements and can reduce excessive muscular tensions, for example, in the rhomboid or trapezius muscle and therefore pain (cp. **Figure 1**).

#### **Figure 1.**

*Scapular movements: Cranial/caudal; ventral/dorsal and in diagonal shape (anterior elevation/posterior depression).*

The patient is discharged from the hospital on days 2−14, depending on type of surgery (longer for several breast reconstructions), eventual complications, and personal wound healing. Given this possible short in-patient time, it is crucial to ensure that patients are provided with all information necessary and behavior tips to pay attention to after discharge. This can be supplemented by a list of available outpatients' services if they are in need of further therapy or advice. The wound and the scar need support and protection for at least 4−6 weeks. Exercises started during the in-patient period are to be prolonged for the following weeks and maybe even months depending on the individual symptoms. In case of breast and trunk, RT thorax stretching and breathing exercises are recommended for several months to counteract tissue fibrosis.
