Early Physical Therapy Intervention
is Crucial for Breast Cancer Patients
Address to the June 2004 American Physical
Therapists Association Conference
“No body part is amputated, reconstructed or burned without Physical Therapy intervention as the first line in the rehabilitation process – except the breast. We must stop this discrimination now!"
Why is the breast different from other body parts? Why don’t breast surgeons routinely encourage Physical Therapy for patients who undergo breast surgery and/or radiation? Medical research has clearly shown that the ramifications of modified radical mastectomy or lumpectomy, with or without radiation, put patients at risk of reduced arm movement and strength, and possibly at risk for lymphedema. For patients who have had radiation, the risk of lymphedema is even greater – according to reports in the literature, perhaps as high as 40%! PT intervention can help ameliorate these physical side effects of breast cancer treatment, and simply makes good, logical sense to include it throughout the breast cancer treatment process.
PT intervention helps reduce the likelihood that breast cancer patients will be left with subtle losses in their shoulder and shoulder girdle, including their scapula. There is scar tissue left over from the surgery, and fibrosis left over after radiation. Radiation can have long term after effects on the tissue; changes can be noted for two or more years after radiation has ended! Patients who have had surgery and radiation lose their ability to use their arms in a very subtle, insidious way. These losses will become the impingement syndromes of tomorrow, and lead to the dysfunctions (including lymphedema) that so often lead women to needlessly resign themselves to lower functional levels and restricted or limited lifestyles. Women often seek help only when they have unbearable pain or a significant reduction in their functioning that women finally seek help. This does not have to happen!
The cornerstones of PT treatment for any condition are rehabilitation (in this case, following breast surgery or radiation), prevention (in this case, of arm or Truncal Lymphedema), and wellness (in this case, the goal is to restore people to their pre-cancer level of living and function and help patients maintain this level in the long term). In the breast cancer patient population, it is critical for PT intervention to begin right after the initial diagnosis, since many women have pre-existing shoulder conditions at the time of their diagnosis that can impact their arm and function during and after their treatment for cancer. If PT intervention is initiated early on, the results often aid the patient throughout their treatment: PT's get improve patients’ overall physical condition so that they can better handle the rigors of chemotherapy; PT's help restore the range of motion in patients’ arms before and during radiation so that patients won’t have to say, "I can't imagine that Medieval torture was any worse than what I experienced during my radiation." (This is an actual quote from a patient who already had shoulder problems before her breast cancer diagnosis, and who found radiation agonizing because of the restricted motion in her arm.)
Skin is never the same after radiation. This is well-known and well-documented. Radiation changes the collagen in the skin and therefore reduces its flexibility and elasticity. This is where compression bandages and compression bras come in. For instance, in an amputated limb, to aid healing and good skin care, compression bandages are used. Compression improves circulation in the healing skin by reducing edema in the scar tissue, allowing the skin to heal more thinly, which improves the flexibility of the scar. Compression also frequently reduces pain by supporting healing tissues and helping reduce uncomfortable edema from surgery or radiation. The chest and/or breast is no different. Women who get compression garments know how much they help; now we have to educate the lay public so that they know to ask for these items when they need them, and we have to educate the surgeons and nurses who care for these people so that they know to recommend compression garments as appropriate.
Physical Therapists who do manual therapy for breast cancer-related conditions believe strongly that early intervention makes an enormous difference for patients. Early manual therapy helps increase the blood and lymph flow in an arm and chest that will be challenged by surgery and radiation. Early intervention is also believed to promote collateral circulation. Finally, early intervention might be helpful in reducing the risk of lymphedema through a combination of manual lymphatic drainage, scar tissue mobilization and/or reduction, and education on preventive skin and limb care.
PTs deal with quality of life issues with every patient they treat! It is therefore imperative for PTs to be part of a patient’s treatment regimen from the moment of diagnosis onwards. PTs offer a wide range of treatments designed to optimize patient health and functioning, including manual therapy; therapeutic exercise instruction (range of motion, strengthening and re-conditioning); posture education and/or corrections; skin and limb care education; body mechanics instruction (for those who have undergone reconstruction options which might compromise their backs in the future); and osteoporosis prevention education to teach patients about the potential delayed side effects of hormonal therapies and/or premature menopause brought about by treatment. After all, after a patient has gone through a grueling, often torturous course of cancer treatment, they want their lives to be worthwhile. Historically, the medical field has thrown everything possible at the cancer patient in the hope of saving or prolonging her life. They have done such a good job that there are, thankfully, millions of cancer survivors – but now we have to ask: "What is the quality of life of these survivors?" If we are going to provide patients with the quality of life they deserve after treatment, early and continuing Physical Therapy intervention is vital.
About the Author
Nancy J. Roberge, PT, DPT, M.Ed has been a physical therapist for over thirty years.
She practices in Wellsley, MA.
Nancy first became interested in patients with breast cancer more than fourteen years ago when she traveled this journey with a close friend. This friend, who was also a physical therapist, did what her physical therapist’s intuition told her to do: she treated her own wound after surgery and radiation and she continued walking and exercising throughout her treatment. Her doctors were amazed at the results. She told them that she was a PT and that she had done for herself what she would have done for any patient who was undergoing the rigors of breast cancer treatment. It was after this experience that Nancy realized that all breast cancer patients would benefit greatly from physical therapy intervention.
Nancy began doing lunchtime in-service educational meetings for nurses and doctors in radiation oncology departments at the local Boston hospitals, in order to share her experience and vision that every breast cancer patient should have physical therapy for optimal rehabilitation. She has been focused on this patient population ever since. This population also includes men who have had axillary node dissection for other cancers.
Nancy is an active American Physical Therapy Association (APTA) member, and does advocacy work locally and in Washington, D.C. In addition to Oncology, she is a member of several sections, including Geriatrics, Women’s Health, and Health Policy and Administration. She has recently been appointed Legislative Chairman of the Oncology Section of the APTA
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