Post-surgical Therapy for Mastectomy and Implants, Part 2

Rationale for treatment modalities and self-care exercise
Paul Lewis
July 31, 2011
By Paul Lewis
Part 1 of this article provided an overview of scope of practice, assessment and consent, and general treatment considerations regarding massage therapy for post-operative patients who have underdone breast procedures. Part 2 of the article will provide an in-depth discussion of self-care exercises for these patients, as well as treatment approaches the author uses and the rationale for techniques and modalities utilized.

A REVIEW OF IMPORTANT CONCEPTS
To review and emphasize a point I made in part 1 of this article, client assessment is vital to confirming your hypothesis, helps to give you a base-line for measuring progress, and provides support for rationale regarding the choice of modalities and treatment techniques employed.
mastectomy1.jpg
Paul Lewis performs massage on a post-mastectomy patient.
As an RMT, I have worked with individuals who have undergone a biopsy, single and double mastectomy, augmentation, reductions and transverse rectus abdominis myocutaneous (TRAM). Just as the medical procedures differ, so should each client’s treatment plan. It should be unique to their set of circumstances. This requires personalizing the assessment, as well as any self-care exercises suggested to the client, so that the exercises are effective and realistic for the client to use in her particular lifestyle.
 
The goals influence the treatment
When is it appropriate to apply cold or warm hydrotherapy, to optimize circulation and drainage, to maintain or increase range of motion (ROM), to reduce myofascial restrictions, to apply joint mobilizations or to not engage the tissue at all?

There are many stages in the client’s post surgical cycle at which massage therapy treatment could be applied – one week post surgery, before radiation protocols, before chemo treatments begin, during radiation, during chemo protocols, post radiation, or post chemo protocols. At each of these stages in the client’s possible cycle, the goals of the massage treatment will differ and so will the modalities (tools) and techniques used to achieve the goals. The client’s health status and goals dictate the indicated techniques and modalities (tools) that may apply. In some cases engaging the tissue may be contraindicated, gentle joint play to one area and not to another may be indicated. Take, for example, a client undergoing radiation therapy. He or she may be experiencing pain, entry and exit burns, skin sensitivity or fragility, nausea, fatigue, nerve irritation andmany associated effects. The goal for this specific client during their cycle may be to reduce pain and distress and optimize available range of motion whereas prior to the radiation treatments, this client’s goals may be to increase range of motion, ease any myofascial restrictions, eliminate guarding and enhance drainage. At each of these stages, the goals and available tools used to achieve the desired results will differ.

Having reviewed these important concepts from part one of the article, I will now focus on post surgical, post radiation or post chemo therapy and addressing the client starting from four to six weeks post surgery. At this stage the client should be recovering and addressing any effects due to the surgery.
 
Reaching into the toolbox
To help achieve the desired outcome of post-surgical rehabilitative treatments, I use a variety of learned skills and treatment techniques (modalities), such as clinical/orthopedic assessment, Swedish massage, joint mobilizations, myofascial release, remedial exercises, Post Isometric Relaxation, hydro therapy, Dynamic Angular Petrissage (DAP) and breast massage, to name a few. I find DAP, an engagement technique, helps to augment the rehabilitative treatment, allowing me to engage the tissue at varying depths and enhancing  neuromuscular release. Furthermore, I find DAP is not stressful either for the client or the therapist.

mastectomy2.jpg  
A face cradle is used to support the arm, allowing the client to maintain a gentle stretch.

 
CLIENT PRESENTATION
Using the following client presentation, I will describe my approach to treatment. A client comes to see you three months following a surgical procedure. She had a mastectomy on the right that left her with a scar across the chest from the sternum to the axilla. About four or five nodes were removed from the right axillary area. She has restricted lateral rotation of her right shoulder (GH); feels pain when moving or lifting her right arm into flexion beyond 20 degrees; feels pain and restrictions at the scar when moving beyond 20 degrees and therefore avoids this movement; has rounded shoulders; restricted cervical movement due to tight (high resting tension) neck muscles; she is experiencing altered sensations in her thumb and forefinger in the left hand; and has shallow, apical breathing due to pain and discomfort when expanding the chest to breathe. When the client is in a supine (face up) position, she cannot let her right elbow rest on the table due to restrictions in slight extension of the shoulder.

TREATMENT PLAN
The treatment plan is, of course, based on the client request and the findings from the assessment.

After completing the assessment, I would start the client in a supine position with the goals of normalizing range of motion, reducing any restrictive adhesions or pain due to the scar, helping to normalize body mechanics, and helping with circulation and drainage. In the supine position, to allow the client to leave her arm in a comfortable, flexed position I would support the arm and forearm using the face cradle or pillow.

In short, following the principles of massage, my objective would be to release muscles holding the client in the anteriorly rotated positions, addressing the right side of the body followed by the left, the neck area, abdominals including the diaphragm, breast massage to the left side to help with drainage and circulation. If the client was unable to lay in a prone (face down) position I would work in a side lying position which would also allow you to treat the back and shoulders. In the supine position, the face cradle can be used to support the arm and help the client to maintain a gentle stretch without having to engage their own muscles to hold the arm in a laterally rotated position. As the range of motion increases I would continue to support the arm by moving the cradle closer towards the head. The client can use the same techniques at home to help with monitoring their own range of motion.

SELF-CARE
Lewis Circle exercise is an exercise that engages muscles in the upper thoracic, neck and shoulder area. The exercises require the client to perform movements with a shortened lever. The client is leading with their elbows and creating circles in one direction then the other. The benefits are to help with mobility and to warm up the tissue in the shoulder and upper thoracic area. Self-monitoring of range of motion, soft tissue restrictions and joint restrictions is easily achieved. The circular movements also help to contribute to joint mobility at the following areas: sternoclavicular, acromioclavicular, and glenohumeral joints. This exercise is simple and can be performed before or after any activity.

mastectomy3.jpg  
Lewis Circles are simple exercises that engage muscles in the upper thoracic, neck and shoulder area.  To view the exercises in full, visit www.paullewis.ca/index.php/continuing-ed/videos.

 
LEWIS CIRCLES – HOW TO
As you are moving, certain muscles are contracting and others are elongating, helping with circulation and joint health. You would start by placing your fingertips gently onto the tops of the shoulder.  Leading with the elbows, bring the arms together in front of the chest, contracting the pectoralis muscles and lengthening the interscapular and lateral rotator muscles of the shoulders. At the same time, lower the chin to the chest. You should feel a gentle lengthening of the posterior neck muscles. From here, you are using your elbows to create large circles (circumduction), bringing the elbows as close as possible to your ears.

You should feel lengthening of the pectoral muscles and an opening up of the chest area. The lengthening of latissimus dorsi, and the muscles attached to the shoulder blade will be felt as you lift the elbows close to the ears. First perform three slow controlled movements in one direction and then in the other direction.

Remember slow and controlled movement is best.

The feedback I have received concerning Lewis Circles from physiotherapists, RMTs, chiropodists, and personal trainers, to name a few, is positive. These professionals use the exercise for themselves and recommend it to their clients. Catherine S., a physiotherapist with the Hand Therapy program at Trillium hospital in Mississauga, writes, “I use the ‘Lewis Circles’ for my own self care and for the client after or prior to hand surgery as a preventative measure to minimize the chance of developing shoulder issues due to lack of mobility.”

People have a tendency to protect the part of the body that gets injured. Take the arm or hand as an example. After injury people tend to hold their arm in a flexed position close to the chest. If this position is held for extended periods of time without movement, various joint and soft tissue complications could develop.

My experiences include treating clients at their homes, hospital and at my clinic. In describing some treatment techniques that I have applied with some success during the rehabilitative process and offering the rationale for the modalities chosen, it is my hope that more RMTs will become engaged in helping post-surgical patients and raise awareness of the possible benefits that massage therapy has for the challenges these patients face.
 
Sources used for this article:
  • Curtis, Debra. Breast Massage. Toronto, ON: Curties-Overzet Publications, 1998.
  • Curtis, Debra. Massage Therapy and Cancer. Toronto, ON: Curties- Overzet Publications, 1998.
  • Lewis, Paul. Dynamic Integrative Massage Techniques for the Upper Body Vol 2. Toronto, ON: Paul Lewis Services Inc., 2010.
  • Rattray, Fiona and Linda Ludwig. Clinical Massage Therapy. Elora, ON: Talus Inc., 2000
  • Snyder, Goodman. Differential Diagnosis for
  • Physical Therapies. St. Louis, Missouri: Saunders Elsevier, 2007.
  • Travell, Janet G. and Simons, David G Myofascial Pain and Dysfunction vol.1. Baltimore, Maryland: Williams & Wilkins, 1999.
  • For additional information visit www.paullewis.ca .

Paul Lewis practises out of his clinic in Mississauga, Ontario, and will be presenting at various conferences and teaching engagements in Canada, Europe and the United States (CEUS). For more details visit www.paullewis.ca .

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