Physical Therapy for Patients With Breast Cancer

Section Key Points

• Postoperative breast cancer surgery physical therapy has shown to improve outcomes in both the short and long term and lowers the risk of long-term pain.

• Physical therapy presents patients with a high likelihood of regaining their preoperative ADLs, vocational, and social activities. Physical therapy does not increase the incidence of postoperative complications, including dehiscence, seroma, infection, or necrosis.

• Patients participating in postoperative physical therapy are less likely to overlimit themselves and preserve activity levels and strength, resulting in improved current and future treatment tolerability and outcomes.

• Postoperative breast cancer physical therapy does not increase adverse events, helps patients tolerate medical office visit burden, and is cost effective.

• Even patients without pain or limitation after surgery should be referred in the postoperative period to develop strategies and an exercise prescription for pending chemotherapy, radiation, and hormonal therapies.

Efficacy of Postoperative Breast Cancer Physical Therapy

Breast cancer procedures include biopsy, partial mastectomy, mastectomy, sentinel lymph node biopsy, axillary dissection, oncoplastic procedures, and breast reconstruction. Each of these surgical interventions is known to potentially result in ipsilateral breast, anterior chest wall, lateral chest wall, and/or axillary pain, soft tissue restrictions, soft tissue shortening, muscle weakness, limited shoulder ROM, edema, and cording ( Box 11.1 ).

This postsurgical morbidity of upper quarter pain and loss of normal tissue or joint mobility may lead to patient difficulties with ADLs, including decrease in functional tolerance, vocational capacity, exercise tolerance, quality of life and satisfaction, along with difficulty managing pending chemotherapy or radiation and an overall increase in distress. It is important to note that, because breast cancer operations typically do not alter glenohumeral or tendon, ligament or muscle function, most patients should expect eventual return to full pain-free preoperative function without restriction with physical therapy. This can set the realistic expectation that return to full pain-free preoperative strength, function, mobility, and activity is achievable for most patients with physical therapy. This, when presented to patients, helps reduce the fear of disability, worry, and distress which often accompanies a new cancer diagnosis.

Physical therapy post breast surgery is known to limit or eliminate postoperative morbidities, impairments, and disabilities. Patients receiving a physical therapy consult and education with treatment as needed have less opioid use, better shoulder, and upper quarter ROM, full or maximal arm and shoulder strength, a quicker trajectory to recovery, less distress, and improved patient satisfaction. This improves both short- and long-term outcomes for patients. Having less pain and mobility restores full function and independence allowing patients to return to preoperative comfort and activity which positions them to tolerate upcoming local or systemic cancer treatments.

Referral to Postoperative Breast Cancer Physical Therapy

An operation is usually the first medical modality in breast cancer treatment, making it the most common entry point for physical therapy. It should be noted, though, that patients receiving neoadjuvant chemotherapy should receive a rehab consult peri-diagnosis to develop an exercise prescription to combat treatment-related fatigue and musculoskeletal, cardiopulmonary, and functional loss (see section “Efficacy of Physical Therapy During Chemotherapy”).

Unlike other types of cancers, evidence does not support preoperative physical therapy for breast cancer operations as physical therapy interventions do not impact postoperative pain or function or decrease the length of the postoperative hospital stay. Breast surgeons and plastic surgeons should encourage patients to remain active, walk regularly after diagnosis, and after surgery as allowed within their restrictions. Referral of a patient to physical therapy in the postoperative phase and the associated postoperative patient restrictions is at the discretion of the referring surgeon. The most common factor impacting initiation of physical therapy is the presence of postoperative drains. Typically, physical therapy may start when the patient’s drains are removed. If patients have postoperative drains yet are reporting moderate to severe chest wall pain, axillary pain, symptomatic cording or have active ROM less than 90 degrees at either shoulder with pending radiation, they should be referred to physical therapy after discussion with their surgeon. Studies suggest earlier intervention is ideal.

Early rehabilitation in the presence of postoperative limitations and drains can still address modifications for ADLs, including a walking or aerobic program with a progressive resistive exercise prescription for noninvolved muscles. This intervention may minimize unnecessary distress, pain, and loss of function and help prepare them for any pending adjuvant systemic or local treatment.

Goals of Postoperative Breast Surgery Physical Therapy

The goals of physical therapy for patients after breast cancer surgery encompass three primary intents: (1) to return the entire upper quarter(s) to full or maximized pain-free preoperative tissue mobility and length, shoulder ROM, strength, and overall function; (2) to educate the patient in potential long-term and late effects of cancer surgery and how to minimize those risks, watch for them, and initiate an action plan if noticed; and (3) to promote patient compliance in a basic combined aerobic and resistive exercise program for pending chemotherapy, radiation, or survivorship and to ensure the patient understands the positive impact of this regular exercise on their treatment tolerability, overall health, cancer recovery, and decreased cancer recurrence.

Post–Breast Cancer Surgery Physical Therapy Subjective History

After surgery for breast cancer, patients may or may not have postoperative pain or functional limitation but still may benefit from physical therapy. Scar tissue development over the next few months may create soft tissue shortening and restrictions, pain, and decreased shoulder ROM, which could be prevented with a chest wall and axillary stretch program. Patients receiving adjuvant chemotherapy and/or radiation may benefit from the development of a personalized exercise prescription to mitigate treatment-induced fatigue. Patients need to be educated about long-term effects, including lymphedema, and learn their role in preventing these sequelae. Exercise may improve quality of life post breast cancer and decrease the risk of breast cancer recurrence.

Once the referral to oncology physical therapy is received, the physical therapist may consult with the referring clinician, the multidisciplinary cancer team, and the cancer nurse navigator, as well as complete a pertinent chart review. At the initial physical therapy evaluation, the therapist will take a subjective history and complaints, examine the patient, do tests and measures, and evaluate the results. Using these results, a determination can be made if the patient needs physical therapy treatment, and if so, what type of treatment, how much, and on what timeline.

In a standard subjective physical therapy evaluation, information is obtained on the patient’s past medical history, living situation, home environment, work status, and social and recreational activities. They will be questioned about their evaluation-related complaints, concerns, pain level, physical and functional limitations, and other pertinent information that may be impactful to their rehabilitation and recovery. Attention should be directed at previous injuries or physical dysfunction in the involved upper quarter(s), primarily at the glenohumeral joint(s).

Information should also be gathered on the patient’s past, current, and any pending cancer treatment. It is also of great importance to learn the patient’s exercise literacy, history, experience, preferences, access to exercise equipment, modes of exercise, and safe places to exercise, as well as any co-morbidities potentially affecting exercise compliance and tolerance. Gathering clinical data with standardized outcome tools are also warranted. Though not specific to breast cancer, subjective outcome tools such as the Quick Disability of the Arm, Shoulder and Hand (DASH), Lower Extremity Functional Scale (LEFS), Timed Up and Go, and the 6-Minute Walk Test will provide functional information to help develop a comprehensive physical therapy plan of care.

Post–Breast Cancer Surgery Objective Examination

At the postoperative objective examination, the physical therapist will assess the involved upper quarter for wound/incision healing and for the presence of abnormal swelling or redness. Any abnormal finding or signs suggestive of potential abscess, infection, dehiscence, or blood clot warrant immediate notification of the referring surgeon.

Because breast cancer surgery involves removing soft tissues, ensuing postoperative tissue restrictions, tissue shortening, and scarring may present over the next few weeks to months. As such, physical therapists, in addition to assessing shoulder, neck, and elbow ROM, should also assess the soft tissues in the surgical area. This involves testing length and mobility of the skin, connective tissue, and muscle at the anterior chest wall, lateral chest wall, and axilla. If the patient had lymph node surgery, the objective examination should look for the presence of cording at the chest, axilla, arm, hand, and/or fingers. The postoperative physical therapy exam should also include strength and functional assessment of the ipsilateral chest wall, scapular, shoulder, and arm muscles.