Balneo Research Journal DOI: http://dx.doi.org/10.12680/balneo.2014.1069 Vol.5, No.

3, September 2014

INDICATIONS AND CONTRAINDICATIONS OF PHYSIOTHERAPY IN BREAST

CANCER PATIENTS

BORDINC Ecaterina, IRSAY Laszlo ,

Clinical Rehabilitation Hospital Cluj-Napoca

University of Medicine and Pharmacy Cluj-Napoca

Abstract
Breast cancer is a major public health issue. However, it is usually diagnosed when
already at an advanced stage.
In developed countries, the mortality rate can be lowered through mammography
screening so long as there is an infrastructure, funds and possibilities to allow the enforcement
of specialty treatment. Such a program and good compliance to treatment can lower the
mortality rate by up to 20% in women over 50 years of age.
It is compulsory that the malignity of the pathology is established prior to treatment in
order for discussions regarding the tests required for establishing the pretreatment and therapy
alternatives to be possible. Similarly to the other therapy options (surgery, chemotherapy,
radiotherapy, hormone therapy, targeted therapy, etc.), medical rehabilitation plays an
important role in establishing the patients body function and quality of life.
Keywords: breast cancer, physiotherapy, indications, contraindications

Incidence: the importance of preventing

In Romania, this is the most complications, disabilities and
frequently encountered malignant tumor in postoperative function limitations (lung
women with approximately 4,200 new complications, upper limb lymphedema,
cases and 2,500 deaths registered every mobility impairment, etc.).
year. The numbers are expected to increase The main objectives of medical
even further, but it must be noted that the rehabilitation include: pain management
mortality rate has stagnated at 60-70% over frequently neuropathic or secondary to
the past 20 years. [1, 2, 3, 4] chemotherapy or post-mastectomy,
improved scapulohumeral mobility,
The importance of physiotherapy: improved muscle strength, lymphedema
The course of treatment is reduction, ADL resumption, playing an
established based on the stage of the important role in establishing the patients
disease and the associated defects and can body function and quality of life.
consist of one or a combination of the Physical medicine and
following methods: surgery, chemotherapy, rehabilitation programs improve the
radiotherapy, hormone therapy, targeted quality of life by reducing fatigue,
therapy, medical rehabilitation, etc. increasing physical functionality and
Postoperative management It is improving pain or dyspnea.
very important that the therapist makes A relevant number of studies were
contact with the patient shortly after conducted between 2001 and 2011 to
surgery for the latter to acquire the self- identify general principles regarding the
care steps as rapidly as possible. rehabilitation of patients diagnosed with
Such surgical interventions are breast cancer. One of the basic principles
associated with short hospitalization times, addresses the rehabilitation of the upper
so the therapist should make contact with limb.
the patient the following day and highlight

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Postoperative complications that require application of bandages around the

rehabilitation techniques: affected arm or that of elastic
Lung complications or immediate compression bandages. The
or late blood flow complications elevation of the affected arm.
Upper limb lymphedema Exercises designed to increase the
Upper extremity mobility amplitude of movement. The
impairment avoidance of upper limb
Defective posture alignment immobilization.
Reduced muscle strength and 4. The reduction of the degree of
function of the upper extremity lymphedema if or when it occurs:
Fatigue and low physical endurance Daily use of the pneumatic
compression pump followed by
Emotional and social adaptation
wrapping of the upper limb.
difficulties [5]
Permanent elevation of the entire
Objectives of the medical rehabilitation
upper limb when the patient is at
program:
ease. Continuous wrapping of the
The correction of functional
upper limb in non-elastic or
deficiencies signaled during ADL
partially elastic compression
(activities of daily living)
bandages (whether the patient is
driving, sleeping, child care,
active or at ease). Manual
posture deformation correction.
lymphatic drainage massage. Daily
routines for lymphedema reduction.
In the short run, a significant
Use of compression bandages after
reduction of the motor area of the
the routine for lymphedema
shoulder can be identified after a period of
reduction and stabilization. Careful
2-3 months after the mastectomy. [6] In
nursing of the tegument.
the long run, a reduction of the motor area
5. The prevention of posture
of the shoulder can occur in 28% of cases
deformation: Preparation regarding
after a period of 1 year after the
the correct position in bed with the
mastectomy and a significant decrease in
central and symmetrical positioning
muscle strength required for shoulder
of the shoulders in relation to the
flexion and abduction after a period of 15
trunk prior to surgery or on the
months after the mastectomy. [7]
same day. Posture
acknowledgement training:
I. Exercise therapy (Kinetotherapy):
encouraging the patient to adopt a
Objectives:
correct position in order to avoid an
1. Preparing the patient for
abnormal shoulder position.
postoperative self-management.
Posture exercises with a focus on
2. The prevention of postoperative
scapular retraction exercises.
lung complications and
6. The prevention of blood pressure
thromboembolism: Deep breathing
problems and cervical muscle
exercises with special emphasis on
contraction or retraction: Exercises
maximum inspiratory flows and
designed to increase the amplitude
efficient coughing. Flexion
of movement in the cervical area
exercises for the lower limb.
and relaxation. Shoulder elevation
3. The prevention or minimization of
and rotation exercises. Soft
the risk of postoperative
massage at the level of the cervical
lymphedema: Elevation of affected
muscles.
extremities on pillows (at a 30-
7. The prevention of joint stiffness in
degree angle) while the patient is
the upper extremity: Exercises
sitting on a bed or chair. The

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designed to increase the amplitude Exercise therapy (Kinetotherapy) must be

of movement at the level of the initiated on postoperative day 1. A mild
shoulders, elbows and hands. The routine should be conducted starting
routine must be initiated as soon postoperative week 1. The active
after surgery as possible. It can also exercises can be initiated after a period of
be initiated in the presence of 1 week after surgery, once the drainage
drainage tubes, but maximum tubes have been removed. It is
attention is required. Once the recommended that they be continued for a
incision has healed, stretching period of 6-8 weeks until the full range of
exercises can be conducted at motion of the upper limb has been
shoulder level. restored. The patient must be trained to
8. The recovery of muscle strength massage the scarred area herself. The
and upper limb function: Low- postoperative clinical assessment should
intensity isometric exercises at be regulated within a year after surgery.
shoulder level initiated on [5]
postoperative day 1 or 2. Progressive resistance exercises
Resistance exercises conducted can be conducted using lightweights (0.5-
with lightweights or partially 1 kg) between postoperative weeks 4 and
elastic materials which act on the 6. It is important to provide careful
scapular or glenohumeral muscles. nursing, a proper hygiene of the upper
Scapular or glenohumeral limb and avoid trauma in order to
stabilization through exercises minimize the risk of infection and
conducted in orthostatic position, lymphedema.
hands pressed against the wall or It is important for the patient to
table. Use of affected limb for low- maintain an optimal level of activity after
intensity daily activities. surgery, initiate a resistance exercise
9. Increasing the patients effort routine and conduct average-intensity
tolerance, well-being and thus exercises for 30 minutes on a number of
reducing fatigue: Low-intensity days per week. This routine should also
aerobic exercises such as aerobics include exercise therapy (Kinetotherapy)
or gait. and occupational therapy.
10. The provision of information The physical routine must be
regarding the patients resources, established according to the patients
provision of support from the gender, age and type of cancer, among
family and her continuous others. Also, the intensity and duration of
education. the exercises should be set low initially
Precautions: The shoulder exercises must and then increased gradually.
be conducted at an elevation angle of up to Studies have also revealed that
90 degrees until after the removal of the physical exercise lowers the risk of
drainage tubes. The stitches and incisions femoral neck fracture, probably by
must be monitored carefully during lowering the risk of falls. However, it has
exercise. The difficulty of exercises must a low effect in terms of mineral bone
be increased gradually and very slowly, density preservation. The routine must be
especially if the patient undergoes adjuvant conducted on a daily basis with at least 30
therapy. [5] minutes of moderate physical activity
Clinical guideline recommendations for included.
the upper limb: Tai chi, physical therapy and
The function of both upper limbs dancing are considered good options to
must be evaluated prior to surgery in improve balance and prevent falls.
order to have a point of comparison.

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Studies have demonstrated that 5 and those of medical education only.

physical activity is mainly associated with The medical rehabilitation techniques
an improved quality of life at both included manual lymphatic drainage,
physical and functional levels. A stretching exercises, resistance exercises
combination between physical activity and the treatment of axillary web
and cognitive-behavioral therapy can syndrome (AWS), in the event of its
determine a significant improvement in occurrence. The study revealed a tight
the patients quality of life. The results of connection between the axillary web
the physical exercise programs become syndrome, the increased risk of
visible within a short period of time after lymphedema and the possibility to prevent
the initiation of the program. In the long it through the early initiation of recovery
run, better results can be obtained by therapy. Research is still being conducted
combining physical exercise and at present to identify the therapy
psychological therapy. A comparative components that can treat postoperative
study demonstrated the long-term benefits complications and the benefits of manual
of physical exercise on the well-being of therapy in the immediate postoperative
breast cancer patients as well as the period. [13]
beneficial effects of a program that Chemotherapy can trigger the
combines physical exercise and cognitive- development of peripheral neuropathies.
behavioral therapy. [8] Two different According to various studies, TENS
studies have emphasized the importance (Transcutaneous Electrical Nerve
of long-term physical exercise in Stimulation), acupuncture, exercise
improving the quality of life of breast therapy (Kinetotherapy) and occupational
cancer patients. The studies conducted by therapy can all be used in these cases,
Milne et al. (2008) revealed a significant along with therapeutic interventions and
improvement in the quality of life of the medical education.
participants after following a 12-week Three minor studies conducted on
program consisting of combined aerobic patients who performed progressive
and resistance exercises. Daley et al. resistance and stretching exercises (loading
(2007) highlighted the beneficial effect of the muscles antagonist to those affected by
an 8-week program involving regular neuropathy) showed a significant
physical exercise on breast cancer improvement in function, action and nerve
patients. A significant improvement in conduction velocity of the peroneal and
their overall mobility could be noticed sural nerve in peripheral neuropathy and
upon every assessment. muscle dystrophy treatment. The
Recent (randomized and controlled) physiotherapist must insist on muscle
trials have demonstrated that upper limb toning exercises with or without the
exercises do not influence the occurrence association of bio-feedback techniques,
or increase in volume of lymphedemas. proprioception facilitation or stimulation.
The intense activity of the upper Braces are useful for the consolidation of
limb affected after surgery or axillary stability and security in patients with motor
dissection does not appear to have any deficiencies (they protect and stabilize the
influence on the development or joints controlled by weak muscles,
occurrence of lymphedemas. [9, 10, 11, maintain the joints in functional positions
12] and complete the motor function that has
A recent study conducted by been lost). [14]
Torres Lacomba et al. compared the
benefits of medical rehabilitation II. Alternative methods:
associated with medical education Acupuncture is another alternative
initiated between postoperative days 3 and treatment method. A case study conducted

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on a small number of patients revealed that LASER (light amplification by

this treatment method led to improved stimulated emission of radiation) treatment
sensitive and motor functions, as well and electric stimulation are not
lower doses of analgesics being given. No recommended during the immediate
side effects were noticed. [14] postoperative period and in the proximity
of the neoplasm, based on the
III. Electrotherapy: insufficiency of clinical data to support
their use. [5]
TYPE OF PROCEDURE RECOMMENDATION
CONTINUOUS LOCALLY CONTRAINDICATED in
ULTRASOUND cases of suspected or proven malignity and
in patients with a breast cancer history in
the past 5 years presenting with pain
without the precise etiology being identified
PULSATILE LOCALLY CONTRAINDICATED in
cases of suspected or proven malignity and
in patients with a breast cancer history in
the past 5 years presenting with pain
without the precise etiology being identified
TENS LOCALLY CONTRAINDICATED in
ELECTRICAL cases of suspected or proven malignity, it
STIMULATION can be used for pain management purposes
in patients undergoing palliative care.
However, the antialgic effect may conceal
the first signs of metastasis.
NMES LOCALLY CONTRAINDICATED in
cases of suspected or proven malignity, it
can improve the quality of life in terminal
patients
HVPC LOCALLY CONTRAINDICATED in
cases of suspected or proven malignity and
in patients with a breast cancer history in
the past 5 years presenting with pain
without the precise etiology being identified
LLLT LIGHT LOCALLY CONTRAINDICATED in
cases of suspected or proven malignity and
in patients with a breast cancer history in
the past 5 years presenting with pain
without the precise etiology being identified
THERMAL SWT (>30-40 WATTS) LOCALLY CONTRAINDICATED in
cases of suspected or proven malignity
NON-THERMAL SWT (<34 WATTS) LOCALLY CONTRAINDICATED in
cases of suspected or proven malignity
ABBREVIATIONS: TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION),
NMES (NEUROMUSCULAR ELECTRICAL STIMULATION), HVPC (HIGH-VOLTAGE
PULSED CURRENT), LLLT (LOW-LEVEL LASER THERAPY-NON COHERENT LIGHT),
SWT (SHORT WAVE TERAPY)

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Continuous ultrasound therapy can

generate perceivable heat at tissue level THERMOTHERAPY (hot compresses, wax
whereas its pulsatile counterpart does not and other artificial heating agents)
usually cause this reaction; HPVC high- LOCALLY CONTRAINDICATED in cases of
voltage pulsed current (it is used for the suspected or proven malignity and in patients
stimulation of chronic injury healing and with a breast cancer history in the past 5 years
applied at sensory or subsensory presenting with pain without the precise
stimulation level); NMES neuromuscular etiology being identified
electrical stimulation (it uses the
postoperative period and in the proximity
stimulation parameters required to generate
of the neoplasm. [5]
a tetanic contraction of the muscles);
TENS transcutaneous electrical nerve
VI. Cryotherapy:
stimulation (it is applied at sensory level
and produces a paresthetic sensation with
the purpose of triggering analgesia or CRYOTHERAPY RECOMMENDED
hypoanalgesia); LLLT low-level laser
therapy (<500 mV it involves all lasers Cryotherapy involves cold compresses, ice
and non-coherent light sources belonging packs, ice baths, ice massaging, etc.
to Class II and Class III); SWT short [15,40]
wave therapy (in thermal doses, it
generates perceivable heat at tissue level, Conclusion:
increasing their temperature by a minimum
of 1 degree Celsius; in non-thermal doses, It has been demonstrated that
it does not generate perceivable heat at medical rehabilitation does not affect the
tissue level, but may increase their evolution of breast cancer and takes into
temperature). [15, consideration the TNM (tumor, lymph
16,17,18,19,20,21,22,23,24,25,26,27,28,29 nodes, metastasis) classification.
,30,31,32,33,34,35,36,37,38,39] Its main objectives include pain
management frequently neuropathic or
IV. Hydrotherapy: secondary to chemotherapy or post-
Hydrotherapy constitutes a mastectomy, improved scapulohumeral
comprehensive approach to physical mobility, improved muscle strength,
exercise in water designed to increase lymphedema reduction, ADL resumption,
strength, flexibility, resistance, blood flow etc.
and muscle relaxation. Numerous recent studies have
Water based exercise is not demonstrated the major utility of
contraindicated. However, sauna and physiotherapy and the need to initiate it as
thermotherapy are not recommended. soon after surgery as possible.
Underwater showers and compressed air Recent studies have demonstrated
baths can be recommended, while peloids the importance of early exercise therapy
are recommended for distant affections (Kinetotherapy) initiation in improving the
(e.g. knee or hip disorders). [8] quality of life by reducing fatigue,
increasing physical functionality and
V. Thermotherapy: improving pain or dyspnea.
Thermotherapy involves hot compresses, Based on a large body of evidence
wax and other artificial heating agents published in recent years, including
which can increase tissue temperature to a randomized trials and systematic reviews,
depth of 3 cm. [15] there is an urgent need for updating the
Microwaves and thermotherapy are not guidelines on upper extremity
recommended during the immediate musculoskeletal impairments and

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lymphedema. Furthermore, additional 7. Blomqvist, L., Stark, B., Engler, N.,

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