When you or your trainers work with breast cancer survivors who have had mastectomies, you must keep in mind their special needs and you must ensure you have the proper training to help them. Here are some things you should know before embarking on exercise programs that cater to this group.
The most common issues that plague post-mastectomy patients are upper-crossed syndrome and range of motion limitations in the affected shoulder. Upper cross syndrome is the combination of protracted (rounded) shoulders, forward head, cervical lordosis, winged-scapula and thoracic kyphosis. As a result of these postural deviations, mastectomy, lymph node dissection and/or radiation, the chest muscles may become tight, shortened and spastic. This not only exacerbates the postural deviations but may limit the ability of the patient to move their arm/shoulder through flexion, extension, abduction and external rotation. Although this is a general statement, the majority of patients will present with these symptoms. This is compounded even more if the woman undergoes reconstructive surgery because not only does it further exacerbate upper-crossed syndrome, but it also will create a muscle imbalance in the area of surgery if either the rectus abdominis or latissimus muscle are used for reconstruction.
The most important factor in the safety and efficacy of the exercise program is the initial assessment. At the least, it should include a comprehensive postural assessment, and shoulder range of motion measurements should be taken with a goniometer. The well-trained fitness professional will be able to deduce from the results which muscles need to be stretched and which need to be strengthened. By selecting the wrong combinations of exercises, the results may not only be undesirable, but they may in fact be detrimental. For example, if a client presents with moderate to severe upper-crossed syndrome, performing any kind of pushing exercise that would involve the chest muscles (chest press) could make the syndrome even more pronounced by causing the pectoral muscles to tighten and contract. Instead, the focus should be on stretching the chest wall and strengthening the opposing muscles in the back—particularly the scapular stabilizers.
Prior to adding a load (resistance) of any kind, the patient should have close to full range of motion through the particular plane of motion. Without correcting the range of motion first, the patient will reinforce the negative movement pattern by performing strength training exercises throughout a limited pattern of movement. Therefore, initially the focus should be on range of motion exercises. These may include basic exercises that the patient can do on their own: front wall walks, side wall walks, pendulum swings and corner stretch or active isolated stretching that can be executed with the assistance of a professional. The combination of both will increase the speed of improvement in most cases.
Once close to full range of motion is achieved, the emphasis can be on strength training. Not only will this help to correct the postural and range of motion deviations, it will help increase bone density and lean muscle mass. Many women will either be of menopausal age or thrown into menopause from their cancer treatment. With estrogen no longer being produced, the risk of osteoporosis increases. To make things even more complicated, the long-term side effects of chemotherapy include osteoporosis, diabetes and damage to the heart and lungs, all of which can be avoided or improved through proper exercise recommendations.
The last part of the equation is the risk of lymphedema of the affected arm/shoulder. Lymphedema is the swelling of the extremity after the removal of, or radiation to the lymph nodes on that side. Even if someone has undergone a sentinel node biopsy and only had one node removed, she can still get lymphedema. Lymphedema is progressive if untreated and can be painful and disfiguring. It can happen at any time after surgery—one hour or 50 years. The risk does not increase or decrease with time. However, a higher percentage of body fat, infection, age and poor nutrition can all increase the risk once someone is at risk. In my 16 years of working with cancer patients, I would say this is the number one overlooked issue among cancer patients. More often than not, they will not even be told about lymphedema. After lymph node dissection and/or radiation, the lymphatic pathways do not operate with the same efficacy that they did previously. Therefore, we no longer know what the individual’s exercise threshold is. It is critical to start and progress slowly. This allows for a gradual increase in frequency, intensity and duration of the exercise program. If at any point swelling occurs, the patient should be advised to stop exercising and see their doctor immediately to determine if, in fact, they do have the onset of lymphedema. They should come back with a medical clearance form, and the exercise instructor should take a step back with the frequency, intensity and duration of exercise to the point prior to the onset of swelling.
Putting all of these pieces together is like solving a mathematical equation. If you are missing any of the information, you will never solve the problem. A typical exercise session should begin with cardiovascular exercise. This should be gradually increased at a rate that the client is comfortable with and their body responds favorably to. They should stay well-hydrated, they should not wear tight-fitting or restrictive clothing on their upper body and they should not overheat. All of these factors can increase the risk of lymphedema. After the warm-up, they should be instructed to do a series of lymph drainage exercises to open the lymphatic pathways and prepare the body for exercise. I reference these exercises in CETI’s Cancer Exercise Specialist Handbook.
After the warm-up and lymph drainage exercises, the exercise specialist should determine what the areas of need are for the client. Remember to begin with stretching and range of motion exercises until they have close to normal range of motion. At that point, the goal becomes strength training and choosing exercises that will strengthen the weaker muscles and stretch the tight and shortened muscles. Weight/resistance also should be gradually increased and attention paid to any potential swelling of the extremity. Typically, I choose exercises that will stretch the chest (chest fly, corner or door stretch, assisted stretching) and will strengthen the back (low/high rows, reverse flies, lat pull-down).
After a node dissection, women often present with winged scapula. If this is the case, I will incorporate exercises that will strengthen the serratus anterior. If they have undergone an abdominal TRAM procedure, core work will be of the greatest importance in preventing or minimizing low back pain.
Because every muscle in the body works synergistically, an imbalance in the shoulder can lead to a multitude of imbalances from the hips to the knees to the ankles, etc. Choose your exercises carefully. Put emphasis on the areas of need. This is not and can never be a cookie-cutter workout. No two breast cancer patients are the same. Not only are you taking into consideration their surgery, reconstruction and treatment, but you also have to factor in the remainder of their health history and any additional orthopedic concerns.
I urge anyone who wants to work with cancer patients to undergo specialized training. It is complex, and the untrained professional can end up doing more harm than good.
Andrea Bruno is president and founder of the Cancer Exercise Training Institute, which offers a certification course for people wanting to work with breast cancer survivors. She can be reached at [email protected].