**4.4 Lymphedema**

About 20−25% of women after axillary lymph node dissection [27] and about 5% after sentinel lymph node biopsy [28] develop lymphedema (LE), most of them within the first 2−3 years [29]. As an incurable condition, LE has grave consequences

**Figure 7.** *Combined squats and resisted elbow flexion.*

for patients' physical and psychic quality of life. LE is divided into four stages: 0 = subclinical; I = pitting edema; II = non-pitting edema, and III = elephantiasis. LE can possibly be preceded by an axillary web syndrome, also called cording, with visible and palpable cords in the middle of the axilla and the upper arm. Other early factors proved to contribute to LE formation are high BMI (≥26), skin puncture, mastectomy, RT, or wound infection [30–32]. Taxan-based CT can furthermore compromise lymphangiomotoric function, that is, lymphatic contractions [33]. To capture LE early, a preoperative circumference or volume assessment is recommended. For high-risk patients, post-surgery indocyanine green lymph scintigraphy can be indicated. Women should be educated on early symptoms and how to perform regular self-measurements (pitting test, stemmer's test, and arm circumference with

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

a one-hand tape measure). Measurements should be taken for at least one, better three-year post-surgery [34]. The gold standard for measuring and capturing LE is perometry or the water displacement method. Overall, arm edema incidence is reclining, whereas breast edema incidence is inclining [35]. Therefore, medical staff should be familiar with the corresponding symptoms and signs and be attentive.

The standard treatment for LE is complex decongestional therapy (CDT), which consists of manual lymphatic drainage (MLD) [36], compression therapy (CT), exercises, skin maintenance, patient education, and if necessary, dietary programs. CDT is divided into two phases, that is, intensive and maintenance phase. If primary edema volume exceeds 40%, in comparison with the healthy arm, patients are asked to complete first an inpatient rehabilitation continued afterward with phase II at home. MLD is a very gentle kind of massage, with the intention to redirect lymphatic fluid to non-compromised body quadrants by using accessory lymph paths. These are the non-affected axilla *via* ventral and dorsal, the neck and the ipsilateral inguinal region by improving lymphangiomotoricity. A thorough MLD includes treatment of the neck, the unaffected breast and back, the affected breast and back, and the whole of the arm, including the fingers. Afterward, in phase I, the patient is provided with a multi-layer compression bandaging inclusive of extended padding. In phase II, a customized compression sleeve and/or bra is prescribed to be worn daily from morning till evening. The most prescribed upper limb compression is class II, which ranges from 23 to 32 mmHg. If a glove is also necessary for finger or hand edema, this should be separated from the sleeve for easier donning. In lymphedema stage I, the patient is instructed to adopt elevated arm positions while resting; later on, this has no effect on the now chronic edema. Patient's adherence to CT is crucial for therapy success [37], which makes patient information and education even more important.

Exercises consist of a) endurance exercises and b) resistance exercises. The compression must be worn during these exercises to avoid lymphatic backflow. Possibilities are fist-pumping exercises or squeezing a little ball with the hand (30 repetitions, 3 series) [38] or moving a hand ergometer at 10−25 Watts [15], or any other exercise which incorporates parts of the arm musculature. If possible, the arm exercises should be combined with high arm positioning. Nordic walking [39] is also recommended as a whole-body endurance therapy and for achieving an upright walking posture. Enhanced breathing during this endurance training leads to a suction of the lymph fluid from the thoracic duct into the central veins (subclavian, jugular internal vein).

For skin maintenance, the patient applies suitable moisturizers or lotions on their arm after doffing the compression sleeve and before going to bed. While doing this, she should always distribute the lotion by stroking from the distal hand to the proximal arm. Keeping healthy and well-nourished skin is paramount for erysipelas prophylaxis. Patients should further carry along a little bottle of disinfectant at all times. In case of little wounds, for example, insect stings, thorn injury, the disinfectant should be applied immediately to protect against bacteria and secondly, erysipelas.

Patient education can be administered single-wise or group-wise [40]. Patients are learning to interpret early symptoms [41], do their self-assessments as mentioned before, and learn about arm mobility, everyday behavior, hygiene, erysipelas and lymphedema prophylaxis, wound-healing, and scar formation [42]. All these measures improve patients' health literacy [43] and facilitate ongoing shared decision-making.

Dietary measures are important if patients are overweight, that is, have a BMI exceeding 26. A correlation has been established between this high BMI and the lymphedema stage, so patients are advised to maintain or reach a healthy body weight [31]. This is achieved by a) diet and b) sports therapy.

#### **4.5 Sports therapy**

Women should be encouraged to start or re-start sporting activities. This is rewarded by easier ADLs, a better quality of life, better coping with the disease, and a better adherence to ongoing cancer therapies. Furthermore, women can reach a reduction of overall and disease-specific mortality as well as an extended recurrence-free time [44].

In the beginning, an oncologic physician's assessment to evaluate heart and kidney condition by taking the blood pressure, ECG, echocardiography, and fitness level is indispensable. A 6-minute-walk-test supports in assessing the patient's actual fitness level and is afterward used to define her walking speed during walking exercises. Lastly, a multiple repetition maximum test determines the possible repetitions for resistance exercises within different muscles/muscle groups. Sports therapy can be conducted during and after oncologic treatment with certain adaptations and precautionary measures. All in all, 150 minutes of activities per week with a level of 3−6 METs (metabolic equivalent of tasks) are recommended [45]. For example, brisk walking takes place at an intensity of approximately 5 METs. To ensure safety, patients should wear a portable heart rate monitor or watch. If dyspnea has to be taken into consideration, also, oxygen saturation should be measured during the training session and be constant above 90%. During all kinds of exercises, the compression sleeve should be worn [46]. The most popular sports after breast cancer surgery are gymnastics, walking, Nordic walking, and swimming. Women should be discouraged from dangerous and arm-exhausting sports such as judo or climbing. Other precautions are necessary in case of a port-a-cath or a PICC (peripherally inserted central catheter), which should not be under local mechanical pressure, or get dislocated or wet.

No sports therapy can be executed on the day of CT and the following day, even if patients are feeling well. There is too high risk of cardiotoxicity and nephrotoxicity. Afterward, the highest possible heart rate should be set between 40 and 60% maximal heart rate if patients still are in between chemo-cycles. Training should of course be postponed if patients have fever, are dizzy, or feel otherwise unwell.

It is possible to start with sports therapy about 4−6 weeks after BCS and 6−8 weeks after mastectomy. In the beginning, types of movement, which focus motoric load on lower limbs, such as walking or stationary cycling, are to be preferred. A combination of endurance training and resistance training promises optimized outcomes in terms of patient-reported outcomes and overall fitness [47].

In the case of bone metastases, training is only possible supervised in not metastasis-affected body regions, For example, the patient can train with the lower limbs if metastases were detected in the humerus. Moreover, the radiologist or oncologist has to give her/his approval if the bones are robust enough for the training. The training focus should have lain on activities of daily life promoting exercises. The potential benefits and harms must be weighed for each individual patient [48]. Manual techniques that rely on heavy stretching or give lots of pressure, resistance, or vibrations on the tissue are contraindicated for these patients because of possible pathological fractures.

#### *4.5.1 Endurance training*

Endurance training (ET) takes place if a minimum of 1/6−1/7 of the whole-body musculature is involved in the training. Breast cancer patients are advised to perform ET because their average activity level is about 30% less than that of age-wise comparable inactive women without breast cancer [12]. ET can have positive effects on the cardiopulmonary capacity, for example, heart muscle contractility, quality

of life (QoL), and sleeping quality, and can be a means to control the patients' BMI. Furthermore, it was suggested that ET fosters cerebral plasticity in the case of "chemobrain" [12], and therefore, cognitive functions can improve.

Training is possible during as well as after CT, many training regimes are combined interventions of ET and strength training (ST) [49]. Outdoor activities are recommended for better mental health and an increase in vitamin D levels [50]. As previous or ongoing CT can change heart rate, heart rhythm, and cardial function, the usage of the heart rate as an intensity parameter has to be interpreted with caution. Alternatively, the VO2-max or lactate levels can be determined.

The ideal training type is interval endurance training, as it turns out to be less exhausting and is also feasible in patients with other co-morbidities. One- to twominute intervals interchange with 30−60 seconds active breaks. The whole training session should last 10−15 minutes at a minimum (training and break minutes added) with an intended increase of 30 minutes over time. Training heart rate is set between 60−80% of maximum heart rate. As the training proceeds, training intervals are intensified, that is, prolonged, as breaks are shortened or even omitted. Recent research was able to demonstrate that even high-intensity interval training, a time-efficient method for improving cardiovascular capacity, is possible in breast cancer patient cohorts, but should be supervised [51]. In high intensity interval training (HIIT) patients are exercising short periods at high intensity (i.e. > 75% VO2 max), followed by low-to-moderate intensity recovery periods (40–50% VO2 max). However, HIIT did not improve outcome when compared with regular ET [52]. While exercising, patients should determine their subjective exhausting level, that is, rate of perceived exertion or BORG Scale with 4−5.5/10 (i.e., moderate). To enhance patient's motivation, the type of ET, for example, walking, running, cycling, and cross-country-skiing, needs to be matched with her preferences and experiences. Overweight women should possibly select a training style with reduced body weight for the lower limbs, that is, (stationary) cycling or swimming to protect the limbs' joints.

#### *4.5.2 Strength training*

Strength training is recommended because inactivity, fatigue, cancer cachexia, and CT side effects on protein synthesis deteriorate muscle strength [53]. ST is capable to increase fast twitch muscle fibers type II, improving posture, ROM, coordination, and by facilitating ADL, it secondly optimizes QoL [54]. It can be performed in supervised and unsupervised settings, provided that patients are instructed properly. In former years, strength training was mainly avoided out of concern of triggering lymphedema, a hypothesis that was falsified [55]. Strength training should involve both upper and lower limbs, and a great effect size (ES = 0.99) can be expected [56]. Low-intensity strength training implies an intensity of 30−40% 1-RM (repetition maximum) with 15−30 repetitions or 40−60% with 10−15 repetitions. An increase to 50−80% 1-RM with 8−12 repetitions, that is, moderate intensity is possible [55]. Two or three sets of each exercise incorporating various muscle groups for an overall 30−45 minutes are recommended. The multiple repetition maximum test defines the exact individual training capacity while avoiding the hazards of a real 1-RM test.

A warm-up phase (5−10 minutes light endurance exercise on the treadmill or stationary bike) in advance as well as a cool-down phase (stretching exercises, relaxation) afterward is mandatory. Strength training is recommended two times a week with a minimum of 48 hours in between to recover. If adherence to this training frequency is problematic, even a once-a-week ST could show an increase in muscle

strength and could therefore be an alternative for frail patients [57]. ST can be performed with free weights or rubber bands, own body weight, or strength-training machines. Changing body positions can facilitate or aggravate the training intensity by implementing or eliminating gravity and/or balance and coordination. ST should be postponed if thrombocyte counting is less than 20.000, if hemoglobin falls short of 8 g/dl or if the patient is suffering from arterial hypertension as well as on the days of CT and the following day.

Specific exercises, including arm flexion, above head height should not be implemented for three-month post-surgery. The patient is supposed to maintain steady breathing through all kinds of exercise to avoid a Valsalva mechanism and therefore high intrathoracic pressure. Common exercises are the seated row, leg extension, chest press, or the latissimus pull-down, when exercising with machines. Body weight-driven exercises are squats or lunges, combined with shoulder press, arm abduction, or resisted upper arm curls (cp. **Figure 7**).

Most efficient exercises involve muscles with trunk-associated insertion to furthermore improve spine bone density. This is of special interest in the case of (hormone therapy-associated) osteoporosis. To enhance this effect, patients are exercising while standing, also combined with an unstable surface, such as a balance pad or a tightly rolled-up gymnastic mat.

#### **4.6 Cancer-related fatigue syndrome**

Cancer-related fatigue syndrome (CRF) is one of the most troublesome symptoms after cancer and/or its treatments and is often present even after years [58]. Firstly, the patient should keep the so-called "energy-diary" for at least 14 days. Therein, low- and high-exhausting activities and the state of exhaustion should be noted with a numeric rating scale (1–10). This serves to identify energy-robbing activities, which should be avoided, if possible, or split up into smaller segments.

Exercise has been proven to be an efficient means of CRF, and it enhances QoL and depression [59, 60]. Low endurance training [61], that is, 40−60% of the heart rate maximum is recommended, that is, (treadmill) walking at a speed of 4−5 km/h or stationary cycling. Additionally, low-level resistance training with incorporating great muscle groups is indicated. Patients start with only a 5-minute sequence, subsequently increasing the session up to 30 minutes over weeks and months. Concerning endurance training, interval training, that is, alternating training and resting intervals suit these patients' demands better. They start with a 30−60 seconds training period, followed by 60−120 seconds resting period, representing a 1:2 frequency. Training time can be divided into two sessions per day. Patients should assess their personal rate of perceived exertion (BORG Scale) with "very easy" to "easy" (1−2/10). Strength exercises should be chosen with particular consideration of functional ADLs.

Relaxation training is another important part of CRF treatment. It aims at diminishing fear, depression, or sleeping problems. Jacobson's progressive muscle relaxation [62] or very gentle yoga exercises [63], for example, the "Dead Men's Position," "Shavasana," or the "The lying Butterfly," "Supta Baddha Konasana" are recommended in these circumstances. In each of these, the patient is concentrating on her own body, its' functions, and her personal breathing cycle. The positions can be practiced for up to 7−10 minutes. Alternatively, the patient can try a verbally guided relaxation exercise, which takes her to a virtually preferred environment, such as a gentle tropical beach or a lush-green forest surrounding.

#### **4.7 Chemotherapy-induced polyneuropathy**

Chemotherapy-induced polyneuropathy (CIPN) affects approximately 30−60% of patients. It affects sensory, motoric, and autonomous nervous system and deteriorates QoL. As a consequence, patients suffer from pain, paresthesia, and tingling sensations. They are furthermore at a high risk of falling [64]. Upper limb ADL dexterity problems, for example, closing buttons, counting coins, or holding cutlery are equally common. Training is even more effective if it is launched in advance of the symptom onset of CIPN [65]. Patients are advised to start walking training [66] and balance training on even and uneven grounds, for example, a rolled-up gymnastic mat, a balance pad, gravel underground, or a soft forest surface. Different standing positions with normal to small-positioned feet, semi-tandem and tandem stance as well as squats or lunges are practiced. If necessary and to ensure safety, patients can grasp a wall or a table. To enhance the exercises' difficulty, patients can close their eyes during exercise or add other motor or cognitive tasks simultaneously [67], for example, open or close a zip while walking, counting while stepping, etc. Furthermore, electric vibration plates can be used combined with different positions, for example, standing, sitting, or bridging the tool with the feet while lying supine with bent legs.

For upper limb and hand, sensory functions patients can exercise using a "hedgehog ball" or a spiked acupuncture massage ball, which they move around in their palm. They practice finger dexterity by picking up small objects such as coins, pens, and marbles. Therapists can give patients a hand massage to relieve numbness and pain by increasing blood circulation.

#### **4.8 Scar therapy**

Scarring in breast cancer patients is not only a cosmetic issue but can affect patients' physical as well as psychological well-being [68]. Scars can induce pain and additionally impede shoulder joint and thoracic mobility. Furthermore, they can be an obstacle for lymphatic flow [69]. Scar formation in deeper layers can even lead to muscle weakness. Patients can report pruritus and feelings of disfigurement. A well-healed scar is thin and flat, showing a similar color to the surrounding skin. On the contrary, hypertrophic scars are red or pink and raised, while keloids are beyond the original scar region. After the wound-healing process is completed, the scar tissue is manually mobilized, massaged, and stretched by both the PT and the educated patient. The patient cares for the scar by applying special moisturizers. This is even important after RT, which induces skin and tissue fibrosis [70], followed by a deteriorated ROM. Starting too early, on the other hand, would have deleterious effects, for example, aberrant wound healing, such as hypertrophic scarring or even keloids, because of an ongoing inflammation process [71].

Different physiotherapeutic techniques, such as massage, manual lymphatic drainage, connective tissue massage, acupuncture massage, or compression therapy, can be employed to improve the before-mentioned symptoms [72]. Silicone-based wound dressings are recommended for scar management. They ensure hydration and reduce inflammation. Additionally, patients should avoid excessive sun exposure. Scar therapy is possible as a self-treatment after accordingly instruction for five to ten minutes daily. This aims to loosen agglutinated connective fibers, to improve the scar pliability, the itching sensations, the cosmetic outcome, the aberrant color, and the pain [72]. Lymph vessel growth should be induced by stretching the skin during MLD, which is supposed to release vascular endothelial growth factor VEGF-c [73]. Evidence suggests that the activation of lymphatic vessels is correlated with anti-inflammatory

mechanisms [74]. Therefore, it can be hypothesized that regenerated lymphatic function in scar tissue can avoid excessive scarring and scar-associated lymphedema.

It should be mentioned that clearly defined therapy regimes concerning duration, direction, frequency, or intensity are lacking until now [75]. In addition to that, robust scar treatment trials and therapy should utilize validated scar measurement tools.

#### **4.9 Radiation-induced lung injury**

Radiation-induced lung fibrosis is a long-term side effect after RT with an incidence of 1−5% in breast cancer patients. RT-induced tissue damages are followed by inflammation processes of the alveoli and lung fibrosis at the final stages. The patient suffers from dyspnea, chest pain or tightness, a dry cough, and low cardiopulmonary function [76]. All in all, this represents a restrictive lung syndrome with reduced lung volumes, lung compliance, gas diffusion, and decreased mucociliary clearance. The patient's dyspnea can be disproportionately in comparison with the radiation dose she was exposed to. The diaphragm's workload during inspiration is intensified because the lung's expansion is more difficult than in healthy conditions.

The compromised oxygen uptake capacity can be enhanced through endurance training (cp. chapter 4.5.1). The patient is educated the learn active diaphragmatic breathing techniques and different lung stretching positions, for example, the "moon position" (the body is forming a "C-shape" in a supine position, arms stretched over the head). Diaphragmatic breathing is facilitated by gravity if patients exercise in a vertical position, that is, sitting [77] and is guided by the hands lying on the abdomen. Additional oxygen can be prescribed for symptomatic relief. Self-mobilizing techniques for the diaphragm while lying supine with one's own fingers reaching up to the diaphragm *via* the short ribs can be taught. Airway secretion mobilization is crucial to avoid high bacterial load and concurrent infections. This includes postural drainage, the instruction of effective coughing techniques, and chest percussions by the therapist's cupped hand or massage machines to induce vibration [78].

## **5. Conclusion**

Breast cancer patients are present with a multitude of complaints and symptoms according to their type of surgery, oncologic treatment, and ongoing behavior. Physiotherapy, as a body- and patient-oriented approach, offers a wide range of hands-on and hands-off treatment modalities and techniques to enhance patients´ physical and psychological well-being. It is the therapists' task to a) assess the patient thoroughly, b) evolve a suitable therapy plan, c) implement, and d) evaluate this plan for effectiveness. Physiotherapy guides the patient from early postoperative mobilization back to daily independence, social participation, and better awareness of a healthy lifestyle and their own bodies. Physiotherapy is a means to complete state-of-the-art medical cancer treatment.
