Matovina Gorana

Nedeljković Miroslav

Popović Lazar

Popović-Petrović Svetlana

Tomić Sanja

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Vojnosanit Pregl 2013; 70(4): 407–410. VOJNOSANITETSKI PREGLED Strana 407Correspondence to: Svetlana Popoviý-Petroviý, Oncology Institute of Vojvodina, Institutski put 4, 21 204 Sremska Kamenica, Serbia.Phone: +381 21 480 5489. E-mail: petrovic.svetlana@onk.ns.ac.rsPRACTICAL ADVICEFOR PHYSICIANSUDC: 618.19-006-089.168:615.8DOI: 10.2298/VSP1304407PEarly rehabilitation in patients operated for breast carcinomaRana rehabilitacija bolesnica operisanih zbog karcinoma dojkeSvetlana Popoviü-Petroviü*‡, Sanja Tomiü*‡, Miroslav Nedeljkoviü*,Lazar Popoviü†‡, Gorana Matovina†‡*Rehabilitation Department, †Internal Oncology Clinic, Oncology Institute ofVojvodina, Sremska Kamenica, Serbia; ‡Faculty of Medicine, University of Novi Sad,Novi Sad, SerbiaKey words:breast neoplasms; rehabilitation; rehabilitation centers;postoperative complications.Kljuÿne reÿi:dojka, neoplazme; rehabilitacija; rehabilitacioni centri;postoperativne komplikacije.IntroductionThe most often complication of breast surgery with dis-section of axilla is decrease in the range of shoulder joint ofthe ipsilateral arm motion, the feeling of heavy arm, secon-dary lymphedema of the arm, and very rarely pain andweakness of the arm’s muscles. Persistence of these symp-toms leads to permanent dysfunction of the arm 1–4.Decrease in the range of motion is a consequence ofsurgery and scarring of the healed wound, which decreasesthe amount of movement at each joint on the operated si-de 4, 5. A reduced range of shoulder joint motion is diagnosedin 2%–51% patients who underwent surgery for breast carci-noma 2, 4.Secondary lymphedema of the arm is a consequence ofmechanical insufficiency of the lymphatic system caused bythe surgery and later, by post-irradiation fibrotic changes,and is manifested by abnormal accumulation of interstitialfluid, rich in proteins 6. In the majority of studies, secondarylymphedema of the arm occurs in 10%–30% of patients fol-lowing the breast carcinoma therapy 4.For postoperative complications reduction, numerousrehabilitation programs and instructions were developed withthe aim of damage prevention, maximizing the occurred dam-age (range of motion, muscle power) and minimizing the riskfor development of secondary lymphedema of the arm 1–4, 7–12.In breast carcinoma patients, rehabilitation has become moresignificant due to quality of life awareness of the oncologicalpatients 8.It arises dilemma when to start with the rehabilitationprogram: most of the authors agree in that the programshould start in the first several days after the surgery 1–4, 7–12,while the other authors consider that early beginning of re-habilitation in patients with axilla dissection is associatedwith an increased risk from postoperative complications:longer drainage period, seroma formation, postoperative in-fection and consequential longer hospitalization 1, 2, 8. In acontrolled, randomized study, a hypothesis that exercises donot increase the risk of occurrence of secondary lymphedemaof the arm has been confirmed 13.Exercises are efficient, safe and preferred interventionsin a postoperative period 4. Early rehabilitation and laterhome-based exercises program, education 14, 15, as well as acontinuous follow-up of patients 7, 9 were identified as inter-ventions for the improvement of life in women with breastcarcinoma in all 4 dimensions: physical, emotional, socialand cognitive 15. Type, duration, frequency and intensity ofexercises vary in the studies 16. Education and follow-up ofpatients with breast carcinoma enable prevention, detectionof early and late occurrences of postoperative damages 8.A lack of rehabilitation interventions in patients oper-ated for breast cancer is a consequence of no standardizedexercises program avalable, so it is necessary to homogenizea reproducible regime 9.Early rehabilitation in breast carcinoma patientswho underwent surgery at the Oncology Institute ofVojvodinaThe Rehabilitation Department was founded in 1996 asan organizational unit of the Oncology Institute of Vo-jvodina. Its activities are designed for preventive oncologicalrehabilitation in breast carcinoma patients, and, to some lessextent, for other segments of oncological rehabilitation –restitute, supportive and palliative oncological rehabilita-tion 17. Cooperation with other medical personnel, based onStrana 408 VOJNOSANITETSKI PREGLED Volumen 70, Broj 4Popoviý-Petroviý S, et al. Vojnosanit Pregl 2013; 70(4): 407–410.the horizontal correlation from the moment of diagnosis,during the therapy and the post-therapeutic period, enabled acontinuous follow-up of all breast cancer patients by thephysiatrist at the Oncology Institute of Vojvodina (Figure 1).Based on the data from the literature, clinical experi-ence, presented results 18–21 and current possibilities, earlyrehabilitation algorithm in patients with breast carcinoma di-agnosis was defined in the Rehabilitation Department (Fig-ure 2).EvaluationBasic data – preoperative measuring includes measur-ing shoulder joint range of motion for both arms (flexion,abduction, external and internal rotation and extension); theborderline value of the motion reduction range is  10°;measuring the volume of both arms at 5 symmetrical, clearlydefined levels; the borderline value of the volume is  2 cm;psychological evaluation.SurgeonPsychologistPhysiatrist Oncologic Committee•internist•surgeon•radiotherapistPhysiatristRadiotherapistInternistSurgeon•Neuropsychiatrist•Social workerTherapy,examination•therapy•examinationExaminationtherapyEarlyrehabilitationFig. 1 – Significance and role of rehabilitation in the patients surgically treated for breast cancer at the Oncology Institute ofVojvodinaSurgeryMeasuringrange of motion,arms’ volumeExaminationPsychologistExercises EducationActive and aided exercisesfor a shoulder jointSelf-examinationArm’s skin careDeep breathingHome based exercisesStretching exercisesRecommendations fordamage preventionLymph flow and “musclepump” stimulationExaminationEarlyrehabilitationMeasuring therange of motionTherapyFunctionaldamagesMeasuring thearms’ volumeNo functionaldamagesFOLLOW-UPHospitalizationDiagnosticsFig. 2 – Early rehabilitation and follow-up in the breast cancer operated patients at the Oncology Institute of VojvodinaVolumen 70, Broj 4 VOJNOSANITETSKI PREGLED Strana 409Popoviý-Petroviý S, et al. Vojnosanit Pregl 2013; 70(4): 407–410.According to the defined algorithm preoperative meas-urements are not mandatory because the first contact thephysiatrist – the physiotherapist – the patient is most oftenimmediately after the surgery. If there are any functionaldamages, a preoperative evaluation of the functional status isperformed in cooperation with the surgeon.Also, psychological evaluation is not obligatory since itis impossible to have a permanenthy engaged professional(no legal obligation to employ a psychologist or a defectolo-gist) (Figure 1).Early rehabilitation program during hospitalizationKinesitherapy program starts on the 2nd postoperativeday. It includes active exercises for the hand, radiocarpaljoint and elbow to stimulate lymph flow and strengthening ofthe “muscle pump”; exercises with active and actively-aidedmovements in the shoulder joint (shoulder circling, wallclimbing, elbow pushing); deep breathing;  stretching exer-cises (neck movements, arm lifts).The exercises are designed to maintain or increase therange of motion, to provide and increase lymph flow, to pre-vent fibrous adhesions and maintain the muscle power. Theexercises are performed each day during hospitalization.In patients with signs of wound infection or febrile sta-te, kinesitherapy program is postponed until thay become isstabile.Educating a patient includes recommendation on latercomplications prevention (secondary lymphedema of thearm, brachial plexus damages), i.e. how to behave and whatto avoid (risk factors) 17; on skin care of the ipsilateral arm;and education on haw to notice any changes in the skin of thearm, postoperative cut, drain (self-examination).Home-based rehabilitation exercises include practisingthese exercises at home 3 times a day, 5–10 repetitions; up tothe pain limit. If infection occurs in the area of the postope-rative cut, the residue of the breast tissue or ipsilateral arm,the patient should stop the exercises (seroma formation is nota contraindication) and be referred to the surgeon forexamination.Follow-upFirst examination in the Rehabilitation Departmentfollows the Oncological Committee (4–6 weeks after thesurgery) in accordance with the “horizontal correlation“system (Figure 1), for examination by the physiatrist includ-ing measuring the range of motion and registration of theobtained parameters; measuring the volume of extremitiesand registration of the obtained parameters.The next examination is perfermed after 3 months,while the following ones comply with the therapeutic pro-cedures, or, if any of post-therapeutic complications ap-pears, it is necessary to make the diagnosis according to in-dications (magnetic resonance imaging, ultrasound diag-nostics, electromioneurography, etc.). The principles ofrestitute, supportive or palliative oncological rehabilitationare also applied.   This procedure in the Rehabilitation Department at theOncology Institute of Vojvodina, horizontal correlation of allmedical segments that participate in the breast carcinomatreatment, implementation of principles of preventive on-cological rehabilitation, continuous follow-up and early de-tection of complications, significantly reduce the number andseverity of post-therapeutic complications.Out of 360 randomly selected patients, surgicallytreated at the Oncology Institute of Vojvodina, in the period2000–2009, reduction of the range of motion in the shoulderjoint ( 10°) was registered in 96 patients (26.67%) (Table1). The most usual range reduction were in two movements(flexion and abduction). In more than half of the patients, thereduction was up to 30% for abduction and flexion move-ments and up to 20% for movements of internal rotation,external rotation and extension (Table 2).Table 1Incidence of  movement reduction in the shoulder joint inthe patients surgically treated for breast carcinoma at theOncology Institute of VojvodinaNumber of reduced movements Patientsn (%)0 264 (73.33)1 25 (6.94)2 27 (7.5)3 19 (5.28)4 18 (5.0)5 7 (1.95)Low incidence of secondary lymphedema of the arm incomparison to data from the literature 4 and high presence ofmild clinical forms are presented in Table 3 and Table 4 re-spectively.Damages of the brachial plexus were actually individualcases, mostly of less severe degree.Table 2Degree of the reduction in the shoulder joint motion range in the patients surgically treated for breast carcinoma at theOncology Institute of Vojvodina regarding the type of motionType of motion Mild reduction (%) Modest or severe reduction (%)Abduction 45.63* 54.37†Flexion 63.49* 36.51†Interval rotation 63.46• 36.54+Exsternal rotation 64.59• 35.41+Extension 92.68 7.32+*reduction range < 30º; • reduction < 20º; † reduction  30º; + reduction  20ºStrana 410 VOJNOSANITETSKI PREGLED Volumen 70, Broj 4Popoviý-Petroviý S, et al. Vojnosanit Pregl 2013; 70(4): 407–410.Table 4Clinical forms of secondary lymphedema of the arm in thepatients surgically treated for breast carcinoma at theOncology Institute of Vojvodina, 2003–2007Clinical forms Patientsn (%)Mild¹ 109 (63.74)Moderate² 43 (25.15)Severe³ 19 (11.11)¹ arm volume difference of 2–2.9 cm at at least 1 level;² volume difference of 3–4.9 cm; ³ volume difference of   5 cmThe results of postoperative breast cancer treatment inthe Rehabilitation Department including the designed algo-rithm were recognized by the National Committee for prepa-ration of the National Guide of Clinical Practice for BreastCarcinoma (one author of this paper is a member of theteam). This is the first time rehabilitation in breast carcinomais placed within the legal framework.In conclusion, our answer to the question “Is physio-therapy useful for the breast cancer patients?” 21 is: Yes, in-deed!REFERENCES1. Cinar N, Seckin U, Keskin D, Bodur H, Bozkurt B, Cengiz O. Theeffectiveness of early rehabilitation in patients with modifiedradical mastectomy. Cancer Nurs 2008; 31(2): 160î5.2. Chan DN, Lui LY, So KW. Effectiveness of exercise programson shoulder mobility and lymphedema after axillary lymphnode dissection for breast cancer: systematic review. J AdvNurs 2010; 66(9): 1902î14.3. McNeely ML, Campbell K, Ospina M, Rowe BH, Dabbs K, KlassenTP, et al. Exercise interventions for upper-limb dysfunctiondue to breast cancer treatment. Cochrane Database Syst Rev2010; (6): CD005211.4. Chan DN, So KW. Developing an evidence-based exerciseguideline on improving shoulder motion and lessening the se-verity of lymphedema for breast cancer patients after axillarylymph-node dissection. Clin Oncol Cancer Res 2010; 7(3):169î74.5. Lauridsen CM, Christiansen P, Hessov IB. The effect of physio-therapy on shoulder function in patients surgically treated forbreast cancer: a randomized study. Acta Oncol 2005; 44(5):449î57.6. Szuba A, Rockson GS. Lymphedema: classification, diagnosisand therapy. Vasc Med 1998; 3(2): 145î56.7. Fialka-Moser V, Crevenna R, Korpan M, Quittan M. Cancer reha-bilitation: particularly with aspects on physical impairments. JRehabil Med 2003; 35(4): 153î62.8. Na MJ, Lee SJ, Park SJ, Kang WS, Lee DH, Koo YJ. Early reha-bilitation program in postmastectomy patients: a prospectiveclinical trial. Yonsei Med J 1999; 40(1): 1î8.9. de Rezende LF, Franco RL, de Rezende MF, Beletti PO, Morais SS,Gurgel MS. Two exercise schemes in postoperative breastcancer: comparison of effects on shoulder movement andlymphatic disturbance. Tumori 2006; 92(1): 55î61.10. Morimoto T, Tamura A, Ichihara T, Minakawa T, Kuwamura Y,Miki Y, et al. Evaluation of a new rehabilitation program forpostoperative patients with breast cancer. Nurs Health Sci2003; 5(4): 275î82.11. Canadian Cancer Society. Exercises after breast surgery : a guidefor women. Toronto, ON: Canadian Cancer Society; 2006.12. Spence RR, Heesch KC, Brown WJ. Exercise and cancer rehabili-tation: a systematic review. Cancer Treat Rev 2010; 36(2):185î94.13. Ahmed LR, Thomas W, Yee D, Schmitz HK. Randomized con-trolled trial of weight training and lymphedema in breast can-cer survivors. J Clin Oncol 2006; 24(18): 2765î72.14. Kilgour DR, Jones HD, Keyserlingk RJ. Effectiveness of a self-administered, home-based exercise rehabilitation program forwomen following a modified radical mastectomy and axillarynode dissection: a preliminary study. Breast Cancer Res Treat2008; 109(2): 285î95.15. Springer AB, Levy E, McGarvey C, Pfalzer AL, Stout LN, GerberHL, Soballe WP, et al. Pre-operative assessment enables earlydiagnosis and recovery of shoulder function in patients withbreast cancer. Breast Cancer Res Treat 2010; 120(1): 135î47.16. Reigle SB. The prevention of disablement: a framework for thebreast cancer trajectory. Rehabil Nurs 2006; 31(4): 174î9.17. Popoviý-Petroviý S . Oncological rehabilitation. In: Jovanoviý D,editor. Bases of oncology and palliative care of oncologic pa-tients. Novi Sad: Faculty of Medicine; 2008, p. 376î82. (Ser-bian)18. Popoviý-Petroviý S. Risk factors for development of the secon-dary lymphedema of the arm in malignant breast tumors [dis-sertation]. Novi Sad: Faculty of Medicine; 2008. (Serbian)19. Popoviý-Petroviý S, Tomiý S, Popoviý M. Rehabilitation in oncology.Health MED 2010; c4(4): 815î8.20. Popoviý-Petroviý S, Vasoviý M, Nedeljkoviý M . Prevention andtreatment of secondary lymphedema of arm in breast cancer.Arch Oncol 2002; 10(2): 77î8.21. Johansson K. Is physiotherapy useful for the breast cancer pa-tients? Acta Oncol 2005; 44: 423î4.Received on May 9, 2011.Revised on September 13, 2011.Accepted on October 3, 2011.Table 3Secondary lymphedema of the arm (SLEA) in the patients surgically treated at theOncology Institute of Vojvodina, 2003–2007Year Number of surgicallytreated patientsPatients with SLEAn (%)2003 409 40 (9.78)2004 362 30 (8.3)2005 362 38 (10.5)2006 318 28 (8.81)2007 384 35 (9.11)

Early rehabilitation in patients operated for breast carcinoma

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