The guidelines identify therapeutic interventions for common impairments during the early postoperative period and those that could develop at a later time.

Special Considerations

Patient education. The length of stay for patients after surgery for breast cancer is short. Therefore, direct intervention by a therapist starts on the first postoperative day with an emphasis on patient education for prevention of postoperative complications and impairments, including pulmonary complications, thromboemboli, lymphedema, and loss of shoulder mobility. Recommendations for preventing lymphedema or for self-management if it develops are reviewed with the patient.

Exercise. The postoperative exercise program focuses on three main areas: improving shoulder function, regaining an overall level of fitness, and preventing or managing lymphedema. Early, but protected, assisted or active ROM of the shoulder is the key to restoring shoulder mobility. Postoperative risks that contribute to restricted shoulder mobility were summarized previously. These risks are highest during the early postoperative period until drains have been removed and the incision has healed.

Although strengthening exercises and aerobic conditioning are important for upper extremity function and total body fitness, moderation in an exercise program is imperative. Exercises must be progressed gradually, excessive fatigue must be avoided, and energy conservation must be emphasized, especially if the patient is undergoing chemotherapy or radiation therapy.

Management Guidelines-After Surgery for Breast Cancer

Potential Postoperative Impairments

Pulmonary and circulatory complications
Lymphedema
Restricted mobility of the upper extremity
Postural malalignment
Weakness and decreased functional use of the upper extremity
atigue and decreased endurance for functional activities
Emotional and social adjustments

Exercise Precautions and Treatment of Breast Cancer

· Exercise only at a moderate level and never to the point that the affected arm aches during or after exercise, even if there is no evidence of lymphedema.
· Monitor upper extremity girth measurements closely.
· Adjust the timing of exercise during cycles of radiation therapy or chemotherapy. With some chemotherapy medications, a patient can develop cardiac arrhythmia and therefore should not perform aerobic exercises, such as stationary cycling, for 24 to 48 hours after a chemotherapy session.
· Return to more physically demanding work and recreational activities gradually after completion of chemotherapy or radiation therapy.

Although early intervention for the prevention of lymphedema and upper extremity mobility impairments is often advocated by therapists and suggested in descriptive articles in the literature, patients often are not referred for postoperative rehabilitation until after impairments and functional limitations have developed. This may be due to concerns raised in the literature that early postoperative ROM could disturb drains or delay wound healing or that exercises, if performed too vigorously, could initiate or exacerbate lymphedema. In addition, few studies have rigorously investigated the efficacy of specific interventions or rehabilitation protocols. However, a recent review of the literature of exercise and cancer-related lymphedema revealed that exercise neither worsened preexisting lymphedema nor was associated with a significant increase in the occurrence of lymphedema.
· Integrate several interventions including exercise, massage, and use of compression devices into a patient’s comprehensive plan of care.
· Implement shoulder ROM exercises early in a postoperative program to prevent mobility impairments.
· Include moderate-intensity aerobic conditioning exercises to improve fitness and quality of life.
· Progress all forms of exercise gradually and avoid any form of high-intensity training.

Community resources. Reach to Recovery is a one-to-one patient education program sponsored by the American Cancer Society (www.cancer.org). Representatives of this program, most of whom are breast cancer survivors, provide emotional support to the patient and family as well as current information on breast prostheses and reconstructive surgery. The National Lymphedema Network (www.lymphnet.org) is another valuable source of information for patients at risk for or who have developed lymphedema.

Buy the Book that holds this excerpt: Therapeutic Exercise: Foundations and Techniques (Therapeutic Exercise: Foundations & Techniques)

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