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Postmastectomy interventions

This is an excerpt from Clinical Guide to Positional Release Therapy With Web Resource by Timothy Speicher.

The classical treatment for breast cancer based on 2014 NCCN guidelines includes two options: breast conservation therapy consisting of a lumpectomy followed by radiation therapy, or a more aggressive approach such as mastectomy with or without radiation. Regardless of the option chosen, complications often result (Andrews et al. 2000) and can persist for several years or more if left unchecked (Ebaugh et al. 2011). Complications that often result from classical treatment are shoulder and chest wall pain, subcutaneous fibrosis, decreased shoulder range of motion, lymphedema, impaired scapulothoracic function, axillary web syndrome, shoulder girdle weakness and altered alignment (Fourie and Robb 2009), and shoulder girdle somatic dysfunction (Ebaugh et al. 2011). One reason a mastectomy patient may complain of shoulder pain and dysfunction is that the somatic dysfunction that ensues from surgery may cause rotator cuff disease (Ebaugh et al. 2011). Shoulder girdle somatic dysfunction, whether driven by active or latent osteopathic lesions, impairs range of motion, strength, and scapulothoracic rhythm (Lucas et al. 2004), which may inhibit the rotator cuff's ability to stabilize the humeral head in the glenoid fossa. This can result in the impingement of the supraspinatus tendon at the subacromial arch (Ebaugh et al. 2011).

Although early detection and survival rates have improved over time, no therapeutic interventions have been found to be superior in addressing the associated surgical complications of mastectomy (Ebaugh et al. 2011; Todd et al. 2008). In our clinical practice, we have found PRT to be an extremely effective tool to address postmastectomy pain, shoulder girdle weakness and range of motion deficits, and resultant shoulder and chest wall somatic dysfunction. Most patients report pain-free ADLs within six weeks.

The application of PRT to this population opens the door for effective rehabilitation to occur because it frees hypertonic tissues, thereby taking pressure off lymphatic and vascular tissues. This may improve perfusion-engendering tissue homeostasis, increase strength, and restore shoulder girdle function and range of motion. Most important, PRT dramatically reduces pain at rest and with ADLs, allowing postmastectomy patients to resume normal life and sport activities without physical impairment. Therapists should take the following into consideration when using PRT with mastectomy patients:

Clinician Therapeutic Interventions

Postmastectomy

• Perform an evaluation to determine the magnitude of shoulder girdle dysfunction.
• Examine the affected tissues for the presence of axillary web syndrome, which may need additional therapeutic and surgical interventions to resolve.
• Perform PRT first; then treat recalcitrant tissues with therapeutic ultrasound or another deep heating modality to facilitate collagen reorganization under range of motion restoration procedures.
• Use myofascial release and massage post-PRT treatment to increase blood flow, relax tissues, and further fascial unwinding.
• Educate the patient about chronic pain control methods such as meditation, visual imagery, ADLs, and palliative modalities.
• Initiate a progressive therapeutic program to address deficits found in the initial evaluation.
• Teach the patient how to self-release affected tissues.

Patient Self-Treatment Interventions

• Perform self-release daily.
• Perform a daily self-massage for five to eight minutes on affected tissues.
• Stretch affected tissues daily or after physical activity.
• Apply palliative modalities to control pain and spasm.
• Meditate or perform relaxation pain control techniques daily to reduce chronic pain.

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