Breast cancer, its treatments, reconstruction surgery, and recovery bring with them many physical and psychosocial challenges. While there may be certain exercises you’ll need to avoid during certain times in your treatment and recovery (running, high impact aerobics, etc.), under the guidance of trained breast cancer rehab and/or exercise specialist, exercise is recommended by many respected organizations in oncology and exercise, including the Amercian College of Sports Medicine (ASCM) and the American Physical Therapy Association (APTA).
Cancer rehab and exercise are not necessarily panaceas for all that breast cancer brings, but they can certainly reduce pain and mobility issues, increase strength and stamina, and ramp up those feel-good endorphins that will help you manage the emotional ups and downs during this challenging time.
Various Breast Cancer-Related Impairments
There are several impairments directly related to breast cancer surgery, radiation and reconstruction surgery for which breast cancer rehab and exercise specialists are trained to identify and treat. Not every patient will experience one or more of these impairments, but I cannot stress enough the importance of early diagnosis and intervention to avoid or reduce potential long-term or permanent problems. If your physician has not yet discussed cancer rehab, put it on your list of things to talk about during your next visit.
I mentioned lymphedema earlier and with good reason. Approximately 40% of breast cancer survivors develop lymphedema. Lymphedema, caused by damaged or surgically removed lymph nodes, may occur immediately after surgery or radiation or even many months or years after treatment ends.
You may have lymphedema if you experience:
Swelling in the breast, chest, shoulder, arm, or hand
Your arm(s) feel full or heavy
Skin on your arm(s) changes texture, feels tight or hard, or looks red
Aching, tingling, or other discomfort in the arm(s)
Less movement or flexibility in your shoulder(s), hand(s), or wrist(s)
Trouble fitting your arm into jacket or shirt sleeves
Your bra doesn’t fit the same
Your ring, watch, and/or bracelet feels tight, but you haven’t gained weight
Lymphedema is not simply a cosmetic issue. It can cause permanent tissue damage when not treated properly. Early intervention and treatment using a combination of Complete Decongestive Therapy (CDT) is often the recommended course of treatment. CDT is an intensive program that combines several different treatment approaches, including bandaging, compression garments, manual lymphatic drainage, exercise, and self care education and has proved to be very successful. Of note, intervention in the very early stages of lymphedema (when symptoms are first noticed) can actually reverse the disease process and/or minimize its severity. Hence, the urgency to seek help as soon as symptoms begin.
According to the PAL (Physical Activity and Lymphedema) Trial conducted at the University of Pennsylvania Abramson Cancer Center, weight-lifting may improve your recovery after breast surgery and radiation therapy. According to the study, weight lifting:
Reduced by 50% the likelihood of lymphedema worsening
Reduced by 70% the likelihood of increased arm swelling in women who had five or more lymph nodes removed
Improved body image
Reduced body fat
Radiation fibrosis is not as widely discussed as lymphedema but can cause serious disability and may not manifest until well after treatment ends. Radiation, while very effective at destroying diseased cells, damages surrounding cells causing an abnormal production of the protein fibrin. This protein accumulates in radiated tissue and – depending on the radiated area – nerves, muscles, blood vessels, bones, tendons, ligaments, heart or lungs my be damaglog]
The best time to start physical therapy is during radiation treatment. Early intervention can help to minimize the damaging effects of radiation by helping to reduce inflammation, thereby minimizing scar tissue and progression to fibrosis. Physical therapy interventions can promote healing of the radiated and surrounding tissues, minimize pain and inflammation, reduce scar tissue formation, improve/maintain joint range of motion, and improve postural issues that are commonly caused by radiation and tissue changes. Radiation to the arms and upper body can cause arm, chest, and trunk pain ,limitations in range of motion of the shoulder, and postural issues.
Many chemotherapy drugs can damage the peripheral nervous system which leads to pain and discomfort in the extremities, or Chemotherapy Induced Peripheral Neuropathy (CIPN). CIPN often starts in the legs and feet but can also affect the arms and hands. Symptoms – tingling, shooting or stabbing pain, numbness, clumsiness and balance problems, mobility problems, weakness of hands or feet, and loss of touch sensation – can begin any time after the onset of chemo. The extent of the symptoms vary from person to person. Breastcancer.org provides a list of chemotherapy drugs that are known to cause neuropathy.
Rehab can be initiated to help with activity modification; lifestyle modifications; and orthosis prescription for impairments that are common with lower extremity CIPN, such as drop foot. Focus is on lower extremity muscles, gait training with an appropriate assistive device, balance training, and home modifications. Upper extremity neuropathy includes hand and arm strengthening.
Oftentimes, after breast cancer surgery and reconstruction, shoulder mobility can be affected on the side of the surgery leading to significant issues with pain, movement deficits and weakness. This can affect daily task completion and quality of life. If not addressed early on, shoulder mobility problems can worsen and cause a painful condition called adhesive capsulitis, or “frozen shoulder.” Frozen shoulder is an inflammation of the shoulder joint that may restrict movement and cause chronic pain.
Breast reconstruction often requires tissue expansion, an uncomfortable two to six month process. Rehab can provide excellent results during this time. Breast reconstruction is a fairly lengthy topic that I will address in a (near) future blog post.
Treatment-related fatigue, nausea, pain, chemo brain and depression are easily explained away or minimized, but there is absolutely no good reason to accept this as a new “normal.” While these side effects may not seem as important in the grand scheme of things, if your life or life-style are negatively impacted, it’s worth discussing with your physician and requesting an evaluation by a trained cancer rehab clinician or CES. The appropriate solution varies according to your symptoms and severity but your first appointment with a cancer rehab clinician and/or CES is used to evaluate your symptoms, establish a baseline, and determine the appropriate course of treatment. Periodic assessments will take place using your input and those initial baselines for comparison. This proactive approach leads to much earlier detection of problems.
Can You Do Cancer Rehab AND Cancer Fitness Training at the Same Time?
It depends on your medical condition and cancer treatment status. Even if you cannot actively participate in a cancer exercise training program while in rehab, discuss an appropriately modified exercise regimen with your cancer care team, cancer rehab clinician and a qualified CES.
Choosing a Breast Cancer Rehab/Exercise Specialists
Not everyone has access to a cancer-specific rehabilitation clinic like Oncology Rehab and Wellness Resources, but there are certain qualifications to look for in your rehab clinicians and fitness trainers:
PALS Certification – Based on the PAL (Physical Activity and Lymphedema) Trial mentioned earlier, PALS for Life provides fitness and lymphedema professionals with the training they need to work with breast cancer survivors. PALS for Life provides a list of PALS-qualified professionals on their web site. The PALS program the ONLY research-based exercise program for breast cancer patients and survivors.
Certified Lymphedema Therapist (CLT) – CLT is an approved method for treating lymphedema. There are several schools in the United States that offer a CLT program, including Lymphology Association of North America (LANA), Academpy of Lymphatic Studies (ACOLS), and Norton School of Lymphatic Therapy.
STAR/C Certification – STAR/C certification is a nationally recognized cancer survivorship certification that focuses on the physical and emotional rehabilitation of cancer patients and cancer survivors. Training is conducted through Oncology Rehab Partners.
Cancer Exercise Specialist (CES) – A CES is trained in the intricacies of working with cancer survivors and identifying potential problems that require modifying an individual’s program or referring a client back to rehab or the physician. The American College of Sports Medicine (ACSM) and the Cancer Exercise Training Institute (CETI) offer CES certification programs.
Talk with your physician BEFORE you have problems, and feel free to call us if you have questions about cancer rehab or cancer exercise. All of the staff members at Oncology Rehab and Wellness Resources are eager to provide you with all the additional support you deserve during your cancer treatment, recovery and survivorship.
You will need a physician’s referral for cancer rehab and medical clearance before participating in a cancer exercise program.
If you have questions or comments about this or previous blog posts, please contact Cheryl Guarna at (703) 789-0367 or email email@example.com.