By Carrie Myers Smith
Postmastectomy clientele need personal trainer expertise and specific exercises to restore their vital function and reinforce self-confidence.
ccording to the American Cancer Society, this year an estimated 192,000 women will be diagnosed with new cases of breast cancer. Almost all of these women will undergo some form of breast surgery. Some of these women may already be your clients; others will seek out a qualified, knowledgeable professional who can help restore their vital functions and perhaps more importantly, their self-confidence. Research about exercise and its relationship to cancer is generally favorable, showing such benefits as increased sense of well-being, strength and endurance, all of which cancer and its treatments can diminish. Researchers at Wake Forest University in North Carolina studied the effects of exercise on women ages 52 to 77 with breast cancer and found that it can increase a breast cancer survivor's quality of life (Wake Forest University 2001). Other studies report that exercise can also: I reduce daily fatigue in women with breast cancer receiving chemotherapy (Schwartz et al. 2001) I decrease psychological distress, fatigue, weight gain, premature menopause and changes in body image (Pinto & Maruyama 1999) I benefit postmastectomy patients in regaining their function and range of shoulder motion (Na et al. 1999)
Breast Cancer Basics Before you take on this special population as part of your clientele, it's important to have some general background knowledge about breast cancer, as well as the specifics of breast surgery and how it can affect a woman's physical abilities. After a woman is diagnosed with breast cancer, she will most likely have surgery to remove the affected part of her breast. This can be in the form of a lumpectomy, a procedure that removes just the malignant lump and immediate surrounding area, or a mastectomy, which removes the entire affected breast and sometimes the surrounding musculature. (See the following section for more about mastectomies.) In either case, the physician will probably do an axillary lymph node dissection, in which the lymph nodes in the armpit are removed to see if the disease has spread beyond the breast. This process of detecting how far the disease has spread is referred to as staging the disease. If the woman opts for breast reconstruction with an artificial implant, the surgeon likely will begin tissue expansions at the time of surgery. A soft, balloon-like sack is placed in a pocket that is made either just under the skin or under the pectoralis major. This expander is gradually filled with saline over the next several weeks, gently stretching the pocket in preparation for a permanent implant. Surgery is usually accompanied by other treatments including chemotherapy, radiation therapy, hormone therapy or monoclonal antibody therapy, all of which come with their own risks and side effects. Anatomy of a Mastectomy Mastectomies are classified according to the procedure. A simple or total mastectomy includes removal of the entire breast. A modified radical mastectomy, the
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most commonly performed mastectomy, includes removal of the breast plus some of the axillary lymph nodes. A radical mastectomy includes the removal of the entire breast, all the axillary lymph nodes and some or all of the pectoral muscles. The radical mastectomy is rarely done these days, since research shows that the other methods can effectively treat the malignancy. As far as physical functioning goes, the axillary lymph node dissection causes more problems than the mastectomy-- unless, of course, a radical mastectomy is performed, which in and of itself causes a host of problems. Once the tissue under the arm containing the lymph nodes is removed and the skin is drawn back together, the surface becomes concave and the skin is pulled tighter than it was before the surgery. As the incision heals, the skin puckers, causing folds to form along the incision site. In these skin folds are the severed lymph vessels, which dry up and draw taut, temporarily reducing shoulder mobility (Stumm 1995). Taking fewer lymph nodes decreases the postoperative complications with this procedure, and with today's tech-
nology, an accurate diagnosis is possible without taking so much tissue. "The lymph node dissection is more problematic if multiple nodes are removed," explains Diane Doster, MS, founder of CancerFit in Sedona, Arizona. "A sentinel node biopsy is less traumatic and decreases the risk for lymphedema compared to [removal of ] multiple nodes." According to Diana Stumm, PT, author of Recovering from Breast Surgery (Hunter House 1995), other possible complications of the axillary lymph node dissection are: I temporary loss of function of the serratus anterior muscle, one of the stabilizers for the scapula I innervation (Because the motor nerve that runs from the muscle to the brain lies in the armpit and may need to be moved to get to the lymph nodes, nerve action can be temporarily knocked out of order, causing the scapula to "wing out." Some symptoms that the client may notice are weakening in her arm when performing shoulder flexion and a sensation that the scapula is "out of place." Time usually takes care of this problem as the nerve "wakes up" and begins
functioning again.) temporary loss of function of the latissimus dorsi muscle, for the same reasons as above (This complication is rare.)
Breast Reconstruction Reconstructing the breast brings more possible complications. As previously discussed, foreign material is used in the implant expansion to reconstruct the breast. During the expansion period, painful spasms in the muscle can occur, restricting shoulder movement. Other methods, such as the transverse rectus abdominus myocutaneous (TRAM) flap, uses a woman's own body tissue (muscle, fat, skin and blood vessels) to reconstruct the breast. The TRAM flap is the most widely used nonimplant technique of breast reconstruction. There are two types of TRAM flaps: 1. Free Flap. For the free flap, a horizontal incision is made across the lower abdomen, dissecting a layer of fat and skin and completely detaching a section of the rectus abdominus muscle. This tissue is reattached to the breast area and molded into a breast. Besides resulting in a reconstructed breast, it
STUDY PROVES BENEFITS OF POSTMASTECTOMY EXERCISE
To prove his belief that upper-body exercise would benefit breast cancer survivors, rather than cause further complications, Donald C. McKenzie, MD, PhD, Faculty of Medicine, University of British Columbia, studied 25 women, ages 31 to 62, while dragon boating (McKenzie 1998). Not familiar with dragon boating? Picture a mini Viking ship that holds 22 to 26 paddlers, lining both sides of the boat--in this case with 12 paddlers to a side. But why dragon boating? According to McKenzie, dragon boating was chosen because it is a "strenuous, repetitive upper-body activity that projects a visible message to all people with breast cancer." He further explains that because it is non-weight bearing, it is associated with a lower risk of injury, and that given proper technique, "the paddler can recruit a reasonable amount of muscle mass and induce positive adaptations in the musculoskeletal and cardiovascular systems." Although dragon boating is a team sport that encourages team members to work in harmony, each participant's training intensity still may be individualized based on how hard she pulls. "This is important," McKenzie says, "because with a
wide variety in ages and athletic abilities, each paddler still can experience a training effect. For example, a request to paddle at 80 percent of maximal effort will provide the same relative training effect for each woman, even though the absolute amount of work might vary considerably." McKenzie's theory proved correct, and to this day none of the original participants, or any who have since participated, have contracted lymphedema. As a result of his research, the "Abreast in a Boat" project was founded to help women stay active after breast cancer. Participants engage in a progressive training program that includes stretching, strengthening and cardiovascular exercise, as well as proper paddling technique, preparing them for competition. "Abreast in a Boat Society formed," McKenzie says "to help people living with breast cancer understand that they can lead full, active lives despite the physical limitations imposed by the disease. We have a phrase that accurately describes our race experiences: "We seldom place, but we always win." A training manual is available for those interested in beginning a similar group elsewhere. For more information, contact Abreast in a Boat Society at www.abreastinaboat.com or call Shelley Kirk at (604) 999-1121.
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also offers a flatter stomach, thereby earning the distinction of "the reconstruction with a tummy tuck." 2. Pedicle Flap. A pedicle flap uses the same procedure, except that instead of totally disconnecting the abdominal tissue, a tunnel is formed and the tissue is brought up through it to the breast area. Removing part of the recti muscles has some obvious consequences. Dissection of the recti muscles weakens that area since part of the body's "girdle" has been removed. This can result in trunk instability, back pain and possible hernia. In addition, the abdominal incision may make it difficult to stand up straight. This forward flexion increases back pain and shortens abdominal muscles. Two other less popular tissue transplant techniques include the latissimus flap and the gluteus flap. These methods may be used if a woman is not a candidate for a TRAM flap. A new, very promising form of tissue transplant is the deep inferior epigastric perforator (DIEP) flap. Unlike the TRAM flap, the DIEP flap doesn't take muscle tissue and avoids some of the resulting complications and side effects that the TRAM flap can cause.
be any open wounds, either from radiation or the surgery. One of the main training guidelines, according to Gautieri, is that no strength training, other than isometric exercises, should be performed, until ROM is restored. Once restored, the surgeon's approval is needed to begin training with apparatus. Once weight can be used, it should be kept to a minimum, as weight training with more than five pounds has been connected to the development of lymphedema.
section in conjunction with the exercises. At first, the ROM exercises should be more passive, meaning that the unaffected arm should be doing most of the work, bringing the affected arm "along for the ride." This also will help with pain management. Once the client feels comfortable exercising this way, she can do more active ROM. Hold all stretches a minimum of 10 seconds and up to 30 seconds. Do three sets of each. Suggested exercises include:
Deep Breathing (Diaphragmatic Breathing). Breathe in through the
Sample Exercise Program The following sample exercise program is divided into three main phases. As with any special population, evaluation of the client's fitness and functional levels is necessary to determine when to move up to the next intensity level.
The Initial Assessment The initial assessment should include the following: I postural analysis I ROM (especially shoulder) I pain analysis I activities of daily living (ADL) (How are clients performing everyday activities? What are they having problems performing? Is pain involved?) I arm circumference (To observe for signs of lymphedema, measure both arms at the wrist crease, five inches above the wrist, at the elbow crease and five inches above the elbow. Conduct measurements weekly.) I general fitness assessments, including muscular strength and endurance, flexibility, cardiopulmonary and body composition assessments (The foregoing assessments are optional depending upon goals, desires and the client's stage of disease.) Phase I The main purpose of Phase I is to teach the client relaxation techniques to help decrease pain caused by the surgery. Exercise, ADL, and ROM exercises help restore her movement. Use the deep breathing protocol described in this
nose and out through the mouth, taking twice as long to exhale as to inhale. This should be mastered before beginning exercises.
Overhead Elevation (Pull-Over, Supine Overhead Raise). Lying on the back
Exercise Recommendations The surgeon's approval is required before a postoperative client can begin an exercise program. "The conservativeness varies among the doctors," says Doster, "but gentle range of motion (ROM) exercises one to two days postsurgery appear to speed recovery and prevent the chance of getting a frozen shoulder. Most [clients] already will have this information, and should be working on it prior to seeing their trainers." "The surgical drains should be removed before beginning a formal exercise program," adds Anne Marie Gautieri, PT, with the HealthSouth Reading Rehabilitation Hospital in Reading, Pennsylvania. The drains are usually removed a few days postsurgery. Another area to watch for is the skin integrity, says Gautieri. There shouldn't
with knees bent and feet flat on the floor (crunch position), hold a rod in both hands, resting over the hips. Slowly lift arms until the rod is directly over the face, keeping the elbows straight. Take a deep breath in and while exhaling, slowly lift the rod overhead, until the rod is resting on the floor. Hold the stretch. Release the rod back down to the hips. This also can be done without the rod, with the unaffected hand holding the affected one, doing the same movement. This exercise also may be performed standing or sitting. Butterfly Stretch. Lying in the crunch position with hands clasped behind the head, push the elbows down towards the floor. To release, lift the elbows back up towards the face. This exercise also can be done standing or sitting. Side-Arm Stretch (Head Walk). Sitting in a chair, grasp the hand of the operated side with the opposite hand and bring both hands to the top of the head. Pull the affected arm up over the head, bringing the forearm as close to the ear as possible. Repeat on the other side. Once this stretch can be done with ease, add a torso side stretch. Using a mirror will help the client do this exercise correctly. Wall Climb (Finger Wall Walk). Facing
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Lymph is a clear fluid that bathes the cells and transports metabolic waste products. The lymph nodes allow fluid to drain from the limbs. Lymphedema is a possible complication of the axillary lymph node dissection, and can happen at any time, including years after the surgery. Although your client should have already received instructions about how to prevent lymphedema, you should be aware of the following:
bridge upper- and lower-body stretches cardiovascular activity (Depending
1. Until you have the surgeon's permission, do not use any weight over five pounds for
on client's level, begin with just one to five minutes, two to four times a day, working up to 15 continuous minutes.) Phase III Continue with Phase II exercises. Consider adding ball work. Begin adding exercises to work the entire body, such as:
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2. Do not take blood pressure on the affected limb. 3. A supportive bra should be worn; underwires should not. 4. An ideal body weight should be maintained, as body fat impedes the flow of fluid from
interstitial tissue into lymph vessels.
5. Regular exercise helps stimulate the lymph system due to the pumping of muscles and
a wall, stand about six inches away. Place palms on wall, just above head. Walk the fingers of the unoperated side up the wall first until full extension is reached; do the same on the operated side. This exercise also can be done with the side of the body to the wall (working shoulder abduction). Pendulum. Bend over while supporting the resting arm on the thigh, a chair or a table. Dangle the affected arm; circle it in both directions. Repeat with the other arm. Supine Angel Wings. Lie on the back with knees bent. Hold arms flat on the floor in a 90-degree angle at the elbow, palms toward ceiling. Maintain the 90-degree angle and slowly slide the hands above head; hold at the point of discomfort. Diagonal Arm Abduction. Place straight arm on opposite thigh and lift diagonally overhead. Repeat on the other side. Skin Mobilization. Scar tissue can play a role in immobilizing the shoulder joint. Massaging the scar tissue helps avoid the formation of adhesions. It's a good idea to make scar massage a part of the exercise routine. Corner Pectoral Stretch. Standing approximately one arm-length away from a corner wall, place palms of hands about shoulder high, one hand on each wall. Slowly lower the body into the corner until a good stretch is felt. (This stretch is especially good
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for clients with tissue expanders.) Isometric Chest Press. Clasp hands together, bend elbows to a 90-degree angle, and bring arms up to shoulder height (upper arms are parallel to floor). While breathing normally, press hands together so client feels the contraction in the pectoral muscles; hold for five seconds. Relax. Repeat eight to 12 times. (This exercise is especially good for women with tissue expanders.)
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lateral raise seated row lying pull-over push-ups half-rep (ROM) chest fly leg extensions leg curls squats lunges calf raises bridge with leg variations alternating opposite arm/leg lifts on all fours oblique work upper- and lower-body stretches cardiovascular activity (Progressively
Phase II: Four to Six Weeks Postsurgery Continue the Phase I exercises and add more conditioning exercises. An exercise band or one- to five-pound weights may be added as appropriate and with the physician's permission. Depending upon the client's goals and fitness level, 1 to 2 sets of 8 to 12 repetitions may be performed. Some examples are:
increase to 30 minutes; consider cross training.)
prone press-ups prone opposite arm and leg lift,
initially done with pillows under the abdominal area
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camel-cat on hands and knees shoulder blade retraction (elbow squeeze) neutral spine tuck large backward arm circles lat pull-down with band wall push-up biceps curl triceps extension basic abdominal crunch
Function Then Fitness It's important to remember that initially, the goal for women who have had breast surgery is to restore function; fitness comes later. Being creative in your program design and taking your client's desires into consideration will increase adherence to the program. Including the client's partner in the recovery process can help him feel more involved and less helpless. One way to do this is to incorporate partner exercises for both stretching and isometric exercises. Provide proper instruction to both your client and her partner. Keep in mind that chemotherapy, radiation and reconstructive surgery may limit progress and recovery time. As treatments advance and breast cancer survival rates increase, more and more women will seek help in restoring their bodies, minds and spirits. As fit-
ness professionals, we can help fill this vital role. By learning all we can about breast cancer and by networking with medical professionals, we can be the bridge these women need to reach full recovery. Carrie Myers Smith is an exercise specialist and health, fitness and medical writer with a special interest in women's health. Be on the lookout for the launch of her new Web site, www.womeninwellness.com.
© 2001 by IDEA Health & Fitness Inc. All rights reserved. Reproduction without permission is strictly prohibited.