Mastectomy finaaaaal (1).pdf

Mastectomy By Reham Elkalla  Objectives By the end of this lecture the student should be able to Recall the breast anatomy Define mastectomy and differentiate between different types of mastectomy List the possible the postoperative complication after mastectomy. Conduct the e...

Mastectomy By Reham Elkalla  Objectives By the end of this lecture the student should be able to Recall the breast anatomy Define mastectomy and differentiate between different types of mastectomy List the possible the postoperative complication after mastectomy. Conduct the essential components of physical therapy Assessment Select the proper physical therapy program for each patient  Breast anatomy ▪ Male and female breast develop at the same rate till puberty. And became more prominent in females following puberty. ▪ Located between the 2nd & 6th ribs. ▪ Tail of Spence extends into the axilla. ▪ Cooper’s ligaments support the breast to the chest wall. ▪ The mammary glands are modified sweat glands. They consist of a series of ducts and secretory lobules (15-20). ▪ Each lobule consists of many alveoli drained by a single lactiferous duct.  Risk Factors for breast cancer Reproductive Being a female Radiation and Family History Therapy to the Race Menstruation Chest History Being Overweight or Lack of Physical Hormonal intake Alcohol Use Smoking Obese after Activity Menopause Age  Minimizing Risk ▪ Manage over weight. ▪ Be physically active. ▪ Limit your intake of alcohol. ▪ Breastfeed your baby. ▪ Stop smoking. ▪ Reduce exposure to chemicals  1- Screening SBE (self-breast examination) ammography udies show that regular breast self-exams, ned with an annual exam by a doctor, improves the es of detecting cancer early.  Steps to a Self Breast Exam Step 1 Look in the mirror, shoulders straight and arms on your hips. Look for size, shape, and color of breasts, is there any distortion or swelling present Report changes dimpling, puckering, bulging of the skin, change in nipple position, inverted nipple, redness, rash or swelling. Step 2 Raise your arms above your head and look for the same changes. Step 3 Lie down on the bed and palpate breasts using pads of a few fingers. Use a firm smooth touch in a circular motion. Cover entire breast – collar bone to top of stomach, armpit to sternum. Make sure to follow the same pattern on both sides so you can cover all area of the breasts.  Step 4 +Sit or stand and palpate the breast in the same manner as step 3. +Changes to report: lumps, irregularities 2- Mammography ▪ Breast imaging technique ▪ Identifies non-palpable masses and diagnoses palpable masses ▪ Procedure takes approximately 15 minutes ▪ Breast is compressed from top to bottom, and side to side ▪ New and old mammograms are compared ▪ Radiation exposure is equivalent to 1 hour in the sun ▪ Canadian Cancer Society recommends women between 50 & 69 years of age to have a mammogram every 2 years http://www.youtube.com/watch?v=Y-GmNmPeqHQ  Other investigations Breast ultrasound to show whether the lump is solid or fluid-filled Breast biopsy, using methods such as needle aspiration. Breast MRI to help better identify the breast lump or evaluate an abnormal change on a mammogram CT scan to check if the cancer has spread outside the breast PET scan to check if the cancer has spread Sentinel lymph node biopsy to check if the cancer has spread to the lymph nodes Needle Biopsy Open biopsy of the breast  What is mastectomy Mastectomy is surgical excision of the breast tissue and sometimes nearby tissues. The purpose is usually to remove or prevent the spread or development of breast cancer Indications of Mastectomy 1- Breast cancer. e,.g Patients with large, malignant or centrally located tumours, OR Ductal carcinoma ▪ Stages I and II (early-stage) breast cancer ▪ Stage III (locally advanced) breast cancer — after chemotherapy 2-Severe laceration of breast tissue(trauma). 3-Prophylactic: family history of breast cancer and high risk people Contraindications of mastectomy ▪ Patients with proven distant metastatic disease. ▪ Elderly patients with significant medical comorbidities. ▪ Patients of high risk mortality associated with surgery or anesthesia.  Treatment Surgery Chemotherapy Radiation Physiotherapy Types of mastectomy  1-Total (simple) mastectomy: involves removing the entire breast but leaving the muscles under the breast and the lymph nodes in place 2- Radical mastectomy: This involves removing of the entire breast, the underarm lymph nodes, and the chest wall muscles (the pectoralis major and minor muscles) Most extensive one.  3- Modified radical mastectomy This involves removing of the entire breast and underarm lymph nodes but leaving the chest wall muscles intact(the pectoral muscles are spared). 4- Skin-sparing mastectomy This involves removing of the breast tissue and nipple but leaving the skin intact. A surgeon also reconstructs the breast during the procedure.  5-lumpectomy (breast conserving surgery): removal of the breast tumor (the "lump") and some of the normal tissue that surrounds it. It also called partial mastectomy 2- Double mastectomy: This involves removing of both breasts, usually as a preventive measure — if genetic features indicate a high risk of breast cancer  Reconstructive surgery may be immediate or late Artificial Implant (silicone or gill Artificial Implant (Saline injection) filled implant  Breast reconstruction surgeries (transverse rectus abdominis latissimus dorsi myocutaneous flap muscle flap) Superior & inferior gluteal artery perforator flap  Post mastectomy complications Seroma or hematoma formation Wound infection Necrosis and adhesion Postmastectomy pain syndrome (pain in the chest wall, armpit, and/or arm) Respiratory complication Scar tissue in the incision site Neuropathy Postural changes Winging of scapula (injury to long thoracic nerve or serratus anterior muscle Axillary web syndrome (cording) Lymphedema Restriction of shoulder ROM (shoulder, neck& spine) and functional deficits Phantom breast pain Weakness and fatigue (deconditioning) Psychologic and socioeconomic dysfunction  Winging of scapula Axillary web syndrome with prominent cord in armpit extending down to elbow with multiple smaller Axillary hematoma visible cords Common postoperative musculoskeletal complication after mastectomy Physical therapy management  Essentials Of Assessment 1. History Personal history: History of previous shoulder injuries or surgical intervention Type of breast cancer and stage of the disease Surgical approach and intraoperative course Lancinating or burning pain at or near the surgical site Pain aggravated by shoulder movement and stretching Hypersensitivity around the surgical site Psychosocial state Difficulty at work. Physical activities. Reconstruction or plans for other surgical interventions Methods for chemotherapy, radiation treatment, hormonal treatments, immunotherapy  Essentials Of Assessment 2. Assessment of pain level Using visual analogue scale (VAS) Breast Cancer Pain Questionnaire. Brief Pain Inventory Short form of the McGill Pain Questionnaire 3. Measurement of Lymphedema for Upper extremity 1- The circumferential measurements are obtained by marking the bony prominence (olecranon process) then measuring and marking points 7.5 and 15.0 cm proximally and repeating the same procedure distally. 2- Figure of eight measurement for hands and feet. 3- Volumetric measurement. Classification of lymphedema Stages of lymphedema  Essentials Of Assessment 4. Assessment of respiratory function ▪ Assess chest mobility either by palpation or tape measurement. ▪ Assess the presence of chest secretion by percussion, auscultation or X-ray. ▪ Assess respiratory rate and breathing pattern. ▪ Use Incentive spirometer or electronic spirometer to measure forced vital capacity 5. Assessment of range of motion Active and passive ROM assessment by Goniometric Measurements Goniometric measurement for shoulder For upper limb, spine and neck joints hyperextension  Essentials Of Assessment 6. Assessment of muscle strength for upper extremity. Functional or group muscle test is recommended in acute postoperative stage Measure the strength of hand grip using hand dynamometer. 7. Functional assessment of upper extremity ▪ The Disabilities of Arm, Shoulder, and Hand Questionnaire (DASH) is a 30-item, self-reported questionnaire to measure physical function and symptoms for disorders of the upper limb to quantify general disabilities that are related to the arm. ▪ The total score is converted to a scale from 0 to 100 (100 = greatest disability, 0 = no disability).  Essentials Of Assessment 8. Assessment of postural changes Assessment of shoulder level Alignment of trunk and spine. Assessment of pelvis level Scapular movement in relation to movement of shoulder joint.  The Benefits of Physical Therapy Post Mastectomy Treatment Programs Improve Improve Decrease sensation shoulder Improve pain at the at the range of functional surgical surgical motion mobility site site Improve Improve Decrease Improve strength of posture edema on respiratory shoulder the function muscles affected side  Physical Therapy Role post Mastectomy 1-Pain management: TENS or IF According to the principal characteristics of the conventional TENS, the intensity and rate of the current is controlled by the patient who always kept the stimulations below a level causing muscular contraction The patient should feel comfortable strength and perceptible tingling or paraesthesia without muscle contraction or fasciculation Recommended parameter Two channel model ❖ Electrodes placement: para-incisional ❖ Frequency (Pulse rate): 100- 140 HZ ❖ Amplitude: sub-motor ❖ Pulse width; 80 Msec ❖ Treatment time from 20min –and may last to 2h & 3-6 times/day  2- Wound healing Laser therapy The probe of Laser should be perpendicular on the area of pain ▪ Dosage: 90 sec/cm ▪ Mode: continuous mode. Ultrasound ▪ low dose ultrasound 0.5 W/cm2, pulsed mode, 1 MHz, 5 minutes) or ▪ High dose ultrasound 1.5 W/cm2, continuous mode, 1 MHz, 5 minutes) for approximately 1 week to enhance wound breaking strength in an acute incisional wound. 3- Pulmonary physiotherapy  Diaphragmatic breathing exercise & Lateral costal ( segmental emphasis on collapsed areas)  Bronchial drainage and splinted coughing  Postural drainage  Incentive spirometer  4-Manual Therapy Manual chest stretch can be very effective for releasing scar tissue. Shoulder mobilization exercises. Proprioceptive neuromuscular facilitation (PNF) Myofascial release massage. 5-Exercise Therapy During treatment session or as home program. Exercise program must be tailored to patient’s general health, medical condition, and fitness ▪ ROM exercises Active ROM EX (wand exercise & elbow winging) Active assisted for shoulder using pulley system or shoulder wheel ▪ Stretching and flexibility exercises; to lengthen the shortened soft tissues. ▪ Strengthening exercises: should not started until 4 to 6 weeks after surgery. Strength building starts by using small hand weights and is increased slowly over time. ▪ Pendulum exercises to control pain and increase ROM ▪ Postural correction exercises ✓ Chin Tuck ✓ Scapular Retractions ✓ Middle and lower trap ✓ Seated row Seated row Overhead reach Scapular retraction Shoulder shrug Strengthening exercises Mobilizing shoulder exercises 6- Management of lymphedema ❖Complete decongestive lymphedema therapy (CDT) ❖Lymph taping ❖Positioning ❖Diet therapy  Complete Decongestive Therapy CDT includes a treatment phase and a maintenance phase: 1. Treatment phase It is a combination exercises, manual lymphatic drainage (MLD), and compression therapy. It may take a few days or up to several weeks to reduce the swelling 2. Maintenance phase Continue to look for skin and exercise regularly. Wearing the compression garments will help to maintain the improvements made in the treatment phase  1-MANUAL LYMPH DRAINAGE ▪ Manual lymphatic drainage (MLD), performed by a trained therapist, utilizes gentle massage to stimulate proximal lymphatic flow. ▪ Mild pressure is applied to the skin around the affected area to move fluid towards lymph nodes that are draining normally. ▪ MLD starts in the areas of the non-swollen parts of your body to open the well-working lymph collectors, make the lymph flow faster, and induce a suction effect. Then, therapist will continue with MLD in the swollen body parts to direct the fluid to the open lymph collectors. ▪ The gentle, rhythmic motions on your skin can also help to soften any hardened (fibrotic) tissue..  2-Compression Therapy Compression therapy involves applying graduated pressure to the affected area to reduce swelling and soften any thickened tissue. There are different ways to apply compression: 1. Bandages and wraps 2. Compression garments 3. Intermittent pneumatic compression.  2-Compression Therapy 1-Compression bandage/wraps : Uses inelastic (short-stretch) bandages or wraps Changed regularly as the swelling reduces Worn day and night (24 hours) 2-Compression garment: Used to maintain improvements Worn during the day as soon as possible after getting up; a lighter garment at night may be worn Available in different skin tones, sizes and grades of pressure Garments should be replaced every three months or sooner if they lose elasticity. Compression garments are typically worn during waking hours, with compression bandaging at night, if necessary  2-Compression Therapy 3. Intermittent pneumatic compression This machine inflates and deflates a plastic garment placed around the affected area to stimulate lymphatic fluid. It’s recommended to have MLD before using the pump. It can be used at home but it’s important to know how to use the pump and adjust the pressure. A compression pump may be used for people who are unable to wear a compression garment.  Parameters of intermittent pneumatic compression Procedure: Pressure for upper and lower limbs is the same. Pressure cycle may be: a) Fixed 30-45 seconds inflation and 15 seconds deflation. b) Variable inflation time can be increased to 60 seconds. Suitable outline plan: 1) Begin with 40mmHg for 30 min. and assess immediately and hour later. 2) Repeat treatment twice daily. 3) Pressure is kept the same and time is gradually increased up to 1 hour at the end of the week with 40mmHg pressure. 4) In the second week increase the pressure by 5mmHg per day until 65mmHg. 5) Treat for 1 hour twice daily. 6) If patient complain of pain use a lower pressure and more frequency.  e.g. 45 mm Hg three times daily or 30mmHg four times daily.  3- EXERCISE THERAPY most women with lymphedema can exercise the affected arm or other body part safely as long as they: 1- Wear compression garments 2- Do not exercise the arm or other affected body part to the point of fatigue 3- Make appropriate modifications to prevent trauma and overuse Exercises: + Start with gentle stretching and range-of-motion exercises that help the muscles contract and relax — which is thought to help push the lymph along — and also strengthen the lymphatic system. + “Some examples could include making a fist and extending the fingers; doing wrist curls; or gentle punching motions to extend and flex the elbow Advices to the patient and skin care: Use the limb as normal as possible Avoid injections on the affected side Avoid hot bathes since the limb will swell further. Cool bathes are allowed. Don’t wear tight clothes or rings on the swollen limb. Elevate the limb by putting the lower limb on a chair during the day and raise the foot of the bed at night. Support the upper limb in a sling or sit for short periods with the hand on the head. Don’t carry heavy cases with an affected limb. Wear footwear that support the foot Avoid minor injuries such as scratches which provide an entry for infection. If the area becomes red, swollen or hot, seek medical advice as soon as possible. Thank you