Can PT after breast cancer surgery reduce risk of lymphedema?

Home Blog Can PT after breast cancer surgery reduce risk of lymphedema?

THE AMERICAN CANCER Society reports that 1 in 8 women will be diagnosed with breast cancer in her lifetime, and for many of these patients, surgery will be part of their treatment. These surgical procedures can be grouped into two main categories: breast-conserving surgery, such as a lumpectomy, or partial mastectomy, and mastectomy, where the entire breast is removed. Both of these surgical approaches may include the removal of some or all of the lymph nodes in the armpit region to determine whether the cancer has spread to nearby lymph nodes or possibly beyond.

However, removing lymph nodes puts you at higher risk for developing lymphedema – a condition in which a blockage in the lymphatic system causes swelling. This chronic condition develops in about 30 percent of breast cancer survivors because there are fewer lymph nodes in the area to help move lymphatic fluid through the region. In breast cancer patients, it can cause painful and potentially debilitating swelling in the arm and hand on the side where the lymph nodes were removed.

Researchers are learning more about the lymphatic system, what causes lymphedema and potentially how to ward it off. Physical therapy after surgery for breast cancer is often part of the solution, but physical therapy after breast cancer surgery is about more than just reducing the risk of lymphedema, says Debbie Mattera, a doctor of physical therapy and a clinical specialist in lymphedema at Memorial Sloan Kettering Cancer Center in New York City. "It's basically to allow patients to return to the function they had prior to their surgery and their diagnosis. We want to get them moving. We want to make sure they understand what their limitations are and what the precautions are and how to understand what's normal and what's not normal in terms of what they feel," she says.

Not every patient will need physical therapy, but Mattera says that generally speaking, the more extensive the surgery, the more likely the patient will need PT to restore range of motion. Other factors may determine whether a patient needs to work with a physical therapist, such as if there's pain after surgery or if range of motion doesn't return on a normal timeline.

Kate Howell, a doctor of physical therapy and certified lymphedema therapist at Zuckerberg San Francisco General Hospital and Trauma Center in California, says that one of the reasons breast cancer patients should consider seeking physical therapy after surgery is the nature of the surgery itself. "The objective of the surgery is to remove the cancer. The surgeons are trying to keep you alive," so it's an aggressive surgery, Howell says. "That's not to say the surgeons and physicians don't care about your general wellness, but their priority is your life, and they're less interested in your arm range of motion than they are about whether the tumor gets removed." This can lead to extensive surgery which can be compounded by reconstructive surgeries later if you opt to have that additional procedure.

All of this cutting of tissue and muscle causes the body trauma. Howell notes that after surgery many patients will unconsciously adopt a hunched, protective posture around the surgery site, which can lead to other orthopedic problems, such as back, neck and shoulder stiffness and pain over time.

When it comes to lymphedema prevention, Mattera says "it's not about the physical therapy preventing lymphedema, it's about the patient understanding what the precautions are to prevent lymphedema. So, knowing to start exercise slowly, to avoid certain things," such as sunburn or injury to the arm, and to learn that "if they feel some swelling, to report it to their physician. It's not quite that PT can prevent lymphedema, but the stronger that people are, sometimes the less likely they are to develop lymphedema."

Once you do start on physical therapy, the focus should be on a gentle reintroduction of movement and simple exercises that will be scaled up over time as you get stronger and as your range of motion improves. "The idea is to get the arm moving," says Dr. Electra Paskett, associate director for population sciences and program leader of the cancer control program in the Comprehensive Cancer Center at Ohio State University. "If you can get your muscles working again in the arm, the muscles work as their own natural compression and can actually help move the fluid back through the arm," which can reduce the chances of lymphedema developing. Howell agrees, giving the analogy of a river that's blocked with ice and debris. "Exercise improves your body's clearance capacity, so that your lymphatic channels aren't bound up like a river full of logs in the winter."

Howell says that exercise in general is also a good way to keep lymphatic fluid moving more freely throughout the body and may reduce the chances that you'll develop lymphedema. "Daily exercise is absolutely the No. 1 thing to do to reduce risk of lymphedema, to reduce the risk of recurrence of breast cancer and to reduce the severity of symptoms if you have lymphedema."

Exercise is also important during treatment to help alleviate side effects of chemotherapy. Howell says if you're struggling to get enough exercise or establish a good exercise routine during or after treatment for breast cancer, that's an appropriate reason to make an appointment with a physical therapist with expertise in treating breast cancer patients and survivors. The therapist may be able to help you build a gentle exercise program that's appropriate for your situation that will help you gain all the benefits that exercise has been shown to offer for those dealing with cancer.

Beyond simply regaining range of motion and potentially reducing risk of lymphedema, physical therapy has been shown to get breast cancer survivors back into their normal activities faster, Paskett says. In a study her team conducted and presented at the American Society of Clinical Oncology's 2018 Survivorship Symposium, Paskett found that when participants were offered both physical therapy and education about how to improve mobility and reduce lymphedema, they healed faster than women who were not offered physical therapy. "The women who received the exercise plus education [intervention] were able to regain full range of motion sooner than the women in the usual care arm of the study. So, by 12 months there were significantly more women in the intervention arm [of the study] who had full range of motion, whereas at 18 months, there was no difference. It was the return of the range of motion sooner."

Getting back to normal activities as soon as possible is important for anyone who's had surgery. Further, because breast cancer surgery involves the arm, an inability to perform daily activities because of pain or a lack of range of motion can have a big negative impact on daily life. A three-time cancer survivor who has also dealt with lymphedema herself, Paskett says regaining normal levels of activity and range of motion as quickly as possible has physical benefits, but it can also improve a patient's emotional response to breast cancer treatment.

Therefore, generally speaking when it comes to physical therapy, "sooner is better," Howell says. "It's a little surgeon-dependent – sometimes they do like to have people wait three weeks for things to be really healed up. But it really depends on how you respond" to surgery and how extensive your surgery was. While you wait to heal, Howell suggests you can still get moving on your rehabilitation. "You could start going to PT and learning about lymphedema and learning about other ways to manage symptoms without having treatment to your surgery site the week after surgery," she says.

"If you have surgery for breast cancer and are not referred [to a physical therapist], ask for a referral," Paskett says. And in looking for the right therapist near you, Mattera recommends looking for "someone who takes care of this population. You don't want to walk into just any clinic, or an athletic-based physical therapy clinic. You want someone who works with breast cancer survivors."

If you're already experiencing lymphedema, it's important to seek out a certified lymphedema therapist. Paskett says you should look for someone who's been certified by the Lymphology Association of North America. Howell adds that the value of massage and lymphatic draining are often underestimated, and a therapist specifically trained in these techniques for cancer survivors can help alleviate symptoms of lymphedema if they do arise.

You should also communicate with your care team about what you're experiencing. "It's always important to let your physician know what's going on and how you're feeling" after surgery, Mattera says. Don't just assume a lack of mobility is normal – ask to find out whether what you're experiencing is what the doctor expected and how to improve the situation. "If you think you're limited in any way, it's important to tell your doctor," she says.

Lastly, Howell cautions that you give yourself a break from time to time if you need it. "As a patient, you have a lot of appointments, and it's a marathon not a sprint. If you find, for example that you're going to radiation every single day and it's challenging to get to PT because you're just burnt out, then yeah, maybe take a week break. Find that balance so that you don't get really inundated with appointments."


1 comment

  • Ann Martin | Aug 22nd 2018 @ 1:26 PM

    I had not been told about Lymphedema when I had my double mastectomy 5 years ago. I was not referred to any resource for rehab. It was only after my first f3 month ollow-up appt that I showed my assigned oncologist the significant swelling in my right arm where 21 lymph nodes were removed. unfortunately even after months of treatment ( compression garments and massage) there is no improvement from the first checkup since my surgery. I can never wear a short or sleeve-less garment as a result. F

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