Working with a Client Post-mastectomy

Modified radical mastectomy – is the surgical removal of the breast, the nipple, many of the axillary lymph nodes, and the lining over the chest muscle. This procedure has replaced the radical mastectomy as the most common surgery for breast cancer. The patient may opt for immediate reconstruction or put it off for a later time. The nipple and areola may also be reconstructed later. The new nipple won’t have any sensation, and there will most likely be significant numbness in the remaining skin of the breast. 

level one BOSU(R) Cancer Exercise Training Institute
Beginner chest stretch on BOSU(R)

Most patients will remain hospitalized for 1-2 days; longer if immediate reconstruction is performed. With breast reconstruction, the patient may be in the hospital for 5-7 days. Full recovery may take 2-3 months depending on whether or not reconstruction was performed and if so, what type. Patients should begin doing gentle range of motion and deep breathing exercises the day after surgery (with surgeon’s permission). Patients should avoid strenuous activities, such as biking, jogging, weightlifting, or aerobic exercise, for 4-6 weeks; this includes housework and activities of daily living. Patients should not lift anything over two pounds for 4-6 weeks.

Prior to working with a breast cancer patient who has undergone a modified radical mastectomy, there are several things you must do:

  1. Obtain medical clearance
  2. Have the client complete a comprehensive health history
  3. Have the client sign a liability release
  4. Perform an initial assessment that includes goniometric shoulder measurements, postural assessment, and arm girth measurements (other assessment tests may also be used for a more comprehensive and individualized program)
  5. Carefully develop an individualized program that will address the client’s acute and chronic side-effects of treatment and surgery while taking every measure possible to ensure their safety.

If your client is currently undergoing treatment and functioning at a low energy level, workouts should be kept to 20-30 minutes. No matter where your client is in the treatment or recovery process, they should always leave a session feeling more energized then when they arrived. If that is not the case, the next session should be done at a lesser intensity with longer breaks.

Start with a five-minute cardiovascular warm-up. Lower-functioning clients should be kept between 20-40% of their Karvonen HR during treatment and 40-60% once treatment is completed. Clients that are fully recovered may work up to 80% of their Karvonen HR.

If your client has undergone (is undergoing radiation therapy) or has had lymph nodes removed, you will spend about then minutes having them perform lymph drainage exercises (discussed in lymphedema section of CES Handbooks).

Next you will address any range of motion (ROM) limitations with specific exercises designed to improve flexion, extension, abduction, internal rotation, and external rotation (discussed in goniometry section of CES Handbooks). Until client has 90% or better (of norms) ROM, continue to work on range of motion without adding resistance. When they reach the 90% mark, you can begin to add resistance exercises. For example, if your client has only 20 degrees of extension in their affected shoulder (norm is 40-60), in order for them to proceed to a weight bearing exercise, they should have at least 36 degrees of shoulder extension (90% of the lower number).

Begin with assisted shoulder extension with a weightless dowel, for example, and when 90% is achieved, try triceps press-downs or dips to add resistance.

After addressing ROM needs, you will focus on correcting muscle imbalances. Most breast cancer clients will present with Round-shouldered syndrome. Focus on exercises that will bring the head back into alignment (centered over shoulders), stretch the pectoral muscles, and strengthen the upper back muscles and scapular stabilizers. Avoid exercises like chest presses or push-ups as they will shorten the pectoral muscles and exacerbate the poor posture. Chest flies can be a wonderful exercise, but should be introduced very carefully, starting with limited range of motion (ROM) and no weight. As the client is able to tolerate it, and in the absence of any pain, swelling of the arm, or other contraindications, increase the ROM and very gradually increase weight and repetitions.

Compound back exercises such as rows and Lat-pulldowns can be a fantastic addition to the workout when executed with proper form. Once again, you will begin by having your client perform a few repetitions with very light weight. As the client is able to tolerate it, and in the absence of any pain, swelling of the arm, or other contraindications, increase the ROM and very gradually increase weight and repetitions.

* Chose two upper-body exercises to begin with so that you can easily monitor for swelling and narrow-down what the potential culprit (exercise) is/was. There is no limitation to what your client can do for their core or lower body, but you will need to take into consideration and breast reconstruction and/or previous orthopedic issues.

Finish your session with gentle stretching, deep breathing, and/or lymph-drainage exercises.