After surgery, the patient will have limited movement until the incision heals, and may also experience muscle tightness and soreness of the shoulder and chest wall, explains Jane Kepics, MS, PT, MLDT, lymphedema specialist at Phoenixville Hospital, Phoenixville, Pa.
If the surgeon performed axillary lymph node dissection, the woman may experience numbness in the arm pit area or lymphedema, which can develop anywhere from days to years after surgery.This swelling of the arm is due to scarring of the lymphatic vessels, causing an accumulation of lymph in the affected region.2 A tumor invading the lymph nodes or vessels can also cause lymphedema, Kepics
says the patient's posture is an important issue to examine after surgery.Women generally hold the arm close to the body after surgery, she
says, causing the shoulders to round.
"From a postural standpoint, we need to make sure they are sitting and standing upright, with shoulders back and head right over shoulders.Promoting good posture is not only good for the muscles, but also facilitates lymph drainage and deep breathing ability," Kepics
Secondly, caregivers must consider range of motion in the arm and trunk.Some women develop tightness, or cords, that can extend from the incision all the way down the arm, Kepics notes.These cords, which may be caused by inflamed vessels or sclerosing lymphangitis, are sometimes very painful and limit range of motion, she
Treatment Plans The recovery process entails techniques ranging from pain modalities to complex exercise routines.To treat tightness and restore flexibility, Kepics
may start with well-padded moist heat along the anterior chest wall and shoulder, making sure it is not too hot as to cause an accumulation of fluid, or swelling.
Manual stretching and skin traction also help relieve cord tightness.
"After surgery, some physicians, especially plastic surgeons, may limit the patient's ability to lift the arm above 90 degrees for a short time.It's important to check with the doctor for any specific range of motion limits before beginning exercise therapy," Kepics
Basic exercises include opening and closing the hand and bending and straightening the elbow.Kepics also promotes functional activities like combing the hair and reaching behind the back.If the patient is going to have radiation following surgery, Kepics adds, she needs to be able to get her hand behind her head by externally rotating the shoulder.
"I encourage patients to do that early on in therapy, so that by the time they're ready for radiation, they are able to achieve full external rotation," she
If the patient develops lymphedema after surgery, she
will need additional treatment.
Any patient who's had axillary node dissection is at risk for developing lymphedema, and the risk increases if the patient undergoes radiation therapy.
Protective measures can be taken to reduce the likelihood of developing lymphedema.The National Lymphedema Network's "Eighteen Steps to Prevention" can be accessed at www.lymphnet. org/prevention.html.
Depending on the severity, often the first signs of swelling can be treated with antibiotics.
multi-modality treatment approach is called Decongestive Lymphatic Therapy (DLT).The program includes instruction in skin care, manual lymph drainage, compressive bandaging and exercise.
Education at the time of surgery is key to lymphedema prevention.Kepics
maintains, "The important thing is for patients to be able to recognize what it is and seek treatment immediately if they see it.The earlier they treat it, the better they can keep it under control."*
1. The Department of Defense Breast Cancer Decision Guide."Breast Reconstruction."