Vol. 24 • Issue 26
• Page 10
Reflections on Practice
Few breast cancer survivors receive manual therapy treatments following surgery and/or radiation to regain tissue elasticity/mobility to increase long-term functional outcomes.
A 2005 study by Karki, et al. has noted that two years out from surgery, patients experience weakness that can lead to loss of hand function. Adaptive devices used on five patients in the study did not result in functional improvement.
"There is an urgent need for developing systematic rehabilitation protocols for breast cancer patients to support their functioning and to prevent permanent, limiting disabilities," the researchers conluded. "Furthermore, these protocols should be specific for breast cancer patients with different operations and post-operative treatment, because the recovery pattern and postoperative impairments are discrete."
Other studies agree. Furthermore, there remains a gap in what kind of effective therapeutic approaches are being investigated and developed by therapists to care for this ever-growing population. What we consider simple everyday tasks such as brushing hair, pulling a sweater over the head, fastening a bra, doing up a back zipper and reaching overhead, are greatly affected. Add a lymphedematous arm to any of these activities, and task difficulty multiples immensely from the mere weight of the limb.
I could find few articles on how occupational therapists are involved with patients following breast cancer surgery and radiation. There are, however, many requests for physical therapists to become more involved with this population. The application of PT during the first postoperative week is seen as important in order to show the patients they are allowed to use their shoulder (Lauridsen et al., 2005, p.456).
Many patients develop cording or strings of the axillary lymphatic pathways following either Sentinel node or axillary dissections. These are very painful and won't disappear for months; in the meantime, patients become very limited in their ADL functions. They lose more shoulder abduction and flexion. Many times the axillary cords or strings develop during the first month post-op. These can be seen running from the chest wall diagonally through the axilla, and sometimes all the way to the wrist (Lauridsen, et al., 2005).
A Japanese study (Morimoto, et al., 2003) reviewed guidelines by the American Cancer Society, and therapists redesigned their program to integrate more stretching exercises commencing soon after surgery. Beginning the day after surgery, they measure ROM of the shoulder girdle as well as effects on ADL function and postoperative pain. In a conventional rehabilitation program for the shoulder following breast cancer surgery, the pectoralis major muscle can begin to develop rigidity, slowing functional recovery. This occurs due to the fascial planes adhering to the chest wall. But if the fascia has adhered, it won't matter what exercises or stretches you give a patient; she won't regain full ROM.
Treating the Edema
I have successfully used effective manual therapies with this population for over nine years. I wonder why other occupational therapists are not interested in developing manual skills to facilitate a more rapid and full recovery of breast cancer survivors. There are gaps many occupational therapists can fill if they are proactive and seek out courses that teach manual therapy that effects changes at the fascial level.
There are new, very effective therapeutic approaches to be used with these patients to address tissue fibrosis and lymphedema. I challenge you to stretch your knowledge base into the manual therapy world and find a mentor. The rewards of working with this population are endless, and further studies need to be completed.
References available at www.advanceweb.com/OT or upon request.
Deanna Sinclair is a 1997 graduate of the OT program at Eastern Michigan University. She is currently obtaining her master's degree in health science in OT from the University of Indianapolis. She has been a certified lymphedema therapist since 1999 and is employed by Clarian Medical Center in Carmel, NJ.