8th Lecture Mastectomy 1st Part - PDF

P.T Post Breast Cancer Dr. Kamaleldin Marie Lecturer of Physical Therapy for Surgery & Burn PhD of Physical Therapy Cairo University  NORMALANATOMICAL CONSIDERATION OF BREAST ORGAN Breasts are composed of: mammary glands, connective tissue, blood vessels, nerves-, and lymph vessels. Bre...

P.T Post Breast Cancer Dr. Kamaleldin Marie Lecturer of Physical Therapy for Surgery & Burn PhD of Physical Therapy Cairo University  NORMALANATOMICAL CONSIDERATION OF BREAST ORGAN Breasts are composed of: mammary glands, connective tissue, blood vessels, nerves-, and lymph vessels. Breasts is made up of lobules, which are milk glands that produce the milk, and ducts, which carry the milk from the lobule to the nipple during lactation (when milk is being produced). Each breast has 1520 lobes; each lobe has many small lobules. The ducts and lobules are connected like branches on a tree trunk, forming a closed system. The only openings out of the system are at the nipple. The ducts and lobules are surrounded by fatty breast tissue. The nipple is centered in the areola, a dark area of skin in the middle of the breast. PHYSIOLOGYAND FUNCTION OF THE BREAST The female breast is a modified apocrine gland that undergoes considerable structural changes during a woman's lifetime. Increased hormonal production by the ovary at puberty causes ductal budding and the initial formation of acini, which are proliferation of the terminal ducts lined with secretory cells for milk production. Lactation is the primary function of the breast, and it serves two equally important functions: it supplies the young with adequate nutrients and it lengthens the interval between births. The process of lactation is controlled by a series of complex hormonal and biochemical events. The levels of progesterone, estrogens, and placental lactogen all increase during the 40 weeks of gestation. The major components of milk are lactose, milk proteins, and milk fat.  ABNORMAL BREAST CANCER Definition: Breast cancer can be defined as a malignant tumor that starts in the cells of the breast; this cancerous growth inhibits the tissues in the breast. In this type of cancer, the cells in the breast region grow abnormally and in an uncontrolled way. Epidemiology: Cancer of the breast is the most frequent cancer among the Egyptian females and constitutes 25.5% of all their cancers. A ten years report, from the National Cancer institute, Cairo, showed that breast cancer is the most frequent malignancy among females attending the institute, accounting for 34.7% of all female cancer cases and 14% of all cases of cancer registered.  ABNORMAL BREAST CANCER Risk factors: It's not clear what causes breast cancer. Doctors know that breast cancer occurs when some breast cells begin growing abdominally. These cells divide more rapidly than healthy cells do and continue to accumulate, fanning a lump or mass. The cells may spread (metastasize) through breast to lymph nodes or to other parts of your body. Some risk factors include age, race, family history, reproductive history, weight, physical activity, environment, lifestyle, and unhealthy diet. Many of these factors are unavoidable, though their presence does not always mean that cancer will develop.  Gender is an important risk factor. Male are at risk for breast cancer, although the incidence is less than 1 % of the incidence in female. Lumps in the male breast are much more likely to be benign and the result of gynecomastia or other noncancerous tumors. Age-adjusted incidence of breast cancer continues to increase with advancing age of the female population. Relationship of family history and the risk of breast cancer: (1) there is a twofold to threefold excess risk of the disease in first- degree relatives (mothers, sisters, and daughters) of patients with breast cancer. (2) risk decreases quickly in women with distant relatives who are affected with breast cancer (cousins, aunts, grandmother). (3) the risk is much higher if affected first- degree relatives had premenopausal onset.  Staging of breast cancer Stage I: the tumor is no larger than 2 cm and no tumor cells are found in the lymph nodes. Stage II: the tumor is no larger than 2 cm but has spread to the lymph nodes or is larger than 2 cm but has not spread to the lymph nodes. Stage III A: tumor is larger than 5 cm and has not spread to the lymph nodes or is smaller than 5 cm, but has spread to the lymph nodes, which have grown into each other. Stage III B: tumor has spread to tissues near the breast or to lymph nodes inside the chest wall, along the breast bone. Stage IV: tumor has spread to skin and lymph nodes near the cervical spin or to other organs of the body. EXAMINATION AND INVESTIGATIONS FOR BREAST CANCER (A) Inspection : This is undertaken in four positions: 1. Firstly, with the patient sitting straight up. 2. Secondly, with the patient placing the arms on both hips. 3. Thirdly, with the arms raised above and behind the head. 4. Finally, the patient is asked to lean forward. Earlysignsof breast cancer (B) Mammography: More than 90% of all breast cancers are detected by mammogram (a low-dose x ray of the breast). Mammogram should be done to evaluate a suspicious lump. Screening mammogram should be ordered according to the physician's guidelines. Women with family history of breast cancer may want to have a mammogram every year after age 40. A typical mammography screening includes two views of each breast (one from above, and one from the side). If anything, irregular is detected, such as a mass, changes from earlier mammogram, abnormalities of the skin, or enlargement of lymph nodes, further testing may be recommended. (c) Ultrasonography: Is useful in differentiate between solid and cystic tumors (containing fluid). It can be used also guiding the clinician to aspirate the fluid, have a needle biopsy and to drain cystic nonmalignant lesions. (d) Biopsy: This could include an ultrasound of the breast, a biopsy or needle sampling. Biopsy of the breast is a removal of breast tissue for examination by a pathologist. An excisional biopsy is -a surgical procedure in which the entire lump area and some surrounding tissue is removed for examination. If the mass is very large, an incisional biopsy is done where only a potiion of the area is removed and analyzed. Needle biopsy can be done in two methods. An aspiration needle biopsy uses very fine needle to withdraw cells and fluid from the mass for analysis.  TREATMENT Breast cancer is usually treated with surgery and then possibly with chemotherapy or radiation, or both. A multidisciplinary approach is preferable. Hormone positive cancers are treated with long term hormone blocking therapy. Treatments are given with increasing aggressiveness according to the prognosis and risk of recurrence. Stage 1 cancers and Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. Ductal means that the cancer starts inside the milk ducts, carcinoma refers to any cancer that begins in the skin or other tissues (including breast tissue) that cover or line the internal organs, and in situ means "in its original place" have an excellent prognosis and are generally treated with lumpectomy and sometimes radiation. Chemotherapy is uncommon for stage 1 cancers. Stage2 and 3 cancers with a progressively poorer prognosis and greater risk of recurrence are generally treated with surgery (lumpectomy or mastectomy with or without lymph node removal), chemotherapy and sometimes radiation (particularly following large cancers, multiple positive nodes or lumpectomy). Stage 4 metastatic cancer, (i.e. spread to distant sites) has poor prognosis and is managed by various combination of all treatments from surgery, radiation, chemotherapy and targeted therapies. 10 year survival rate is 5% without treatment and 10% with optimal treatment. Standard surgeries include: 1. Mastectomy: Removal of the whole breast. 2. Quadrantectomy: Removal of one quarter of the breast. 3. Lumpectomy: Removal of a small part of the breast. If the patient desires, then breast reconstruction surgery, a type of cosmetic surgery, may be performed to create an aesthetic appearance In other cases, women use breast prostheses to simulate a breast under clothing, or choose a flat chest. Simple mastectomy: the breast is removed without lymph node dissection. Radical mastectomy: This involves removing the breast, skin and fat, pectoralis major and minor muscles of the chest, and all the lymph nodes under the ipsilateral arm. Modified radical mastectomy: the breast and axillary contents are removed through a horizontal incision, and the pectoralis muscles are preserved. Subcutaneous ("nipple-sparing") mastectomy: all of the breast tissue is removed, but the nipple is left alone. Subcutaneous mastectomy is performed less often than simple or (total mastectomy). Physiotherapy Intervention After Mastectomy Impairments & Complications Related to Breast Cancer Surgery Incisional pain Posterior cervical and shoulder girdle pain Postoperative vascular and pulmonary complications Lymphedema Chest wall adhesions Decreased shoulder mobility Weakness of the involved upper extremity Postural malalignment Fatigue and decreased endurance Psychological considerations Kisner, C, Colby, LA. Therapeutic Exercise: Foundations and Techniques, 5th ed. Philadelphia: F.A. Davis Company; 2007.  Do’s of Exercise… Before exercising actively, be certain that post-surgery swelling subsides and that surgical wounds are healing. Try to start moving as soon as possible after surgery. Keep arm elevated after surgery to prevent swelling. Use two pillows to support arm when lying down or sitting. Stretch both sides of upper body a few times per day. 3-5 slow repetitions of each stretch. Know the difference between discomfort and unusual pain. If pain or fatigue persists, stop and rest. After surgery, try to walk around (indoors) for a few minutes 2 - 3 times daily to regain stamina. Avoid lifting anything over 2-3 pounds, particularly with the involved arm. Enlist anyone you can to accompany you and encourage you to walk frequently.  Don'ts of Exercise… Let mastectomy arm hang down, especially when holding or carrying objects. Move arm quickly, or with jerking, pulling motions. Learn to move slowly and smoothly, especially when changing positions, lifting bags, opening doors, etc. Carry anything over two pounds after surgery until receiveing approval from physician. Limit carrying anything over 5 pounds indefinitely with involved arm to prevent swelling. Wear shoulder bags on involved arm. The pressure of the strap on the shoulder can cause lymphedema. Avoid use of shoulder bags indefinitely. Continue an exercise upon unusual discomfort or persistent pain. Continue an exercise upon unusual fatigue. Rest for a moment, breathe, relax, and then continue slowly and carefully. If fatigue persists, stop exercising.  Inpatient Postoperative Rehabilitation Immediately Post Surgery Initially… – Deep Breathing – Relaxation – Simple Postural Exercises—chin tucks, posterior shoulder rolls Next… – Active/Active Assistive shoulder mobility exercises – Self-ROM – Cane stretches – Wall-walking – Pulleys – Pendulums—occasionally Frequency and Intensity – Initially 5 repetitions 3-4 times per day – Progress by increasing the number of sets performed  Outpatient Postoperative Rehabilitation Weeks 1-3 Simple walking exercise program as a warm up to stretching Once drains are removed, progress exercises by including longer stretches and greater range – Bilateral and unilateral cane stretches – horizontal abduction – “Praying child” – Wall-walking – Pulleys Posture Education Arm Measurements Weeks 3-6 Adjuvant chemotherapy or radiotherapy Aerobic exercise at moderate intensity Progressively increase the intensity of current stretching exercise ROM—full ROM is usually achieved by 4-6 weeks postoperatively 4-6 weeks postoperatively—strengthening exercises using progressive Therabands or light weights Skin stretching and scar massage 1. WAND EXERCISE This exercise helps increase ability to move shoulders forward. Hold the wand across belly in both hands with palms facing up. Lift the wand up over head as far as he can. Use unaffected arm to help lift the wand until feel a stretch in affected arm. Hold for 5 seconds. Lower arms and repeat 5 to 7 times. 2. ELBOW WINGING This exercise helps increase the movement in the front of chest and shoulder. Clasp hands behind his neck with elbows pointing toward the ceiling. Move elbows apart and down toward the bed or floor. Repeat 5 to 7 times.  3. SHOULDER BLADE STRETCH This exercise helps increase shoulder blade movement. Sit in a chair very close to a table with back against the back of the chair. Place the unaffected arm on the table with elbow bent and palm down. Do not move this arm during the exercise. Place the affected arm on the table, palm down, with elbow straight. Without moving trunk, slide the affected arm forward, toward the opposite side of the table. patient should feel his shoulder blade move as he do this. Relax arm and repeat 5 to 7 times. 4. SHOULDER BLADE SQUEEZE This exercise also helps increase shoulder blade movement and improve posture. Sit in a chair in front of a mirror. Face straight ahead. Do not rest against the back of the chair. Arms should be at sides with elbows bent. Squeeze shoulder blades together, bringing elbows behind toward spine. Elbows will move with patient, but don't force the motion with elbows. Keep shoulders level as doing this. Do not lift shoulders up toward ears. Return to the starting position and repeat 5 to 7 times.  5. SIDE BENDS This exercise helps increase movement of your trunk and body. Sit in a chair and clasp hands together in front. Lift arms slowly over head, straightening your arms. When your arms are over head, bend trunk to the right keeping arms overhead. Return to the starting position and bend to the left. Repeat 5 to 7 times. 6. CHEST WALL STRETCH This exercise helps stretch chest. Stand facing a corner with toes about 8 to 10 inches from the corner. Bend elbows and put forearms on the wall, one on each side of the corner. elbows should be as close to shoulder height as possible. Keep arms and feet in place and move chest toward the corner. Patient will feel a stretch across his chest and shoulders. Return to the starting position and repeat 5 to 7 times. The picture shows stretching both sides at the same time, but it is more comfortable to stretch one arm at a time. Be sure to keep shoulders dropped far away from ears as during this stretch. Keep ears over shoulders to avoid making neck sore. 7. SHOULDER STRETCH This exercise helps increase mobility in shoulder. Stand facing the wall with your toes about 8 to 10 inches from the wall. Put hands on the wall. Use fingers to "climb the wall," reaching as high as caned until feel a stretch. Return to the starting position and repeat 5 to 7 times. The picture shows both arms going up at the same time, but it is easier to raise one arm at a time. Be sure keeping your shoulders dropped far away from your ears as you raise your arms. Keep ears over shoulders to avoid making neck sore. Pain control  Lymphedema: is the golden standard for reduce Lymphoedema: The first step of CDT is to reduce the swelling as much as possible and improve limb shape and skin condition. It consists of: – Manual Lymphatic Drainage (MLD): A light skin stretching technique that stimulates the lymphatic system. – Compression: Layered bandaging with foam or specially fitted garments that support the area to control swelling. – Exercises: With compression, special exercises will help to pump lymph out of the swollen area. – skin Care: Keeping the skin clean and moisturized will help prevent infections that often can happen with lymphedema. – Self-Care Management and Training: Learning how to manage lymphedema at home  Comprises two phases: – Phase I(the intensive phase) consists of the mobilization of fluid and the initiation of a decrease in the proliferated connective tissue. – Phase II(maintenance phase) maintains the swelling reduction and aims for optimization of connective tissue reduction.  Active Phase (Phase 1) – Phase I consists of the mobilization. of fluid and the initiation of a decrease in the proliferated connective tissue – The number of weeks depends on the amount of swelling and tissue firmness. – Complete decongestive therapy for one-hour sessions, 4 to 5 days per week. – Bandages with foam are worn about 23 hours per day and often only removed to bathe. Maintenance Phase (Phase 2) – Maintenance phase maintains the swelling reduction and aims for optimization of connective tissue reduction – Phase 2 should last for months or for years. – Elastic compression garments that fit like a second skin are worn during the day. – Often bandages with foam are worn at night to decrease daily daytime swelling. – Exercises are done while wearing compression. – Self manual lymphatic drainage is done for 20 minutes per day. Home Program: Home Program: