The Role of Physical Therapy in Breast Cancer

According to the American Cancer Society, breast cancer remained the most common cancer among women in 2019, and statistics suggest it will remain on top for 2020 (1). While survivorship continues to increase, cancer survivors face numerous hurdles created by a fractured health care system and poor integration of survivorship care (2). Often cancer patients feel common side effects are something they have to endure because they have cancer, due to a lack of proper education. Physical therapists can provide education and exercise before, during and after cancer treatments to help ease some anxiety and functional deficits that active patients and survivors face.  

COMMON EARLY SIDE EFFECTS OF TREATMENT FOR BREAST CANCER:

• Arm, neck shoulder blade or mid back joint stiffness and/or pain

• Axillary Web Syndrome

• Cardiopulmonary complications

• Lymphedema

• Osteoporosis

• Radiation fibrosis

• Reconstruction complications

COMMON LATE SIDE EFFECTS OF BREAST CANCER:

• Anxiety and depression

• Arthritis and musculoskeletal disorders

• Cancer related fatigue

• Cardiac toxicity

• Chronic pain

• Cognitive dysfunction

• Lymphedema

• Osteopenia or Osteoporosis

• Peripheral Neuropathy

• Pulmonary Disease

• Sexual dysfunction

• Sleep disorders

WHAT CAN BE DONE?

Prehabilitation, or care that occurs between the time of cancer diagnosis and beginning of acute treatment, has been shown to be effective, with the primary goal of reducing the incidence and severity of current and future impairments. Individuals will often receive baseline measurements in activity level, circumferential measurements, strength, motion and posture. Individuals will also receive education on reduction of lymphedema, reduction of Axillary Web Syndrome, infection concerns, breath, posture, motion exercises and scar management. This is often performed by your cancer care network or hospital, but is not exclusive to them. 

Rehabilitation during cancer treatment can help minimize side effects, reduce pain and increase energy.  Often performed by your cancer care network or hospital, but is not exclusive to them.

Rehabilitation post cancer treatment with or without breast reconstruction can help to minimize side effects, reduce pain, increase energy, improve abnormal movement patterns, improve everyday activities, improve abnormal breathing patterns, improve abnormal posture and provide individualized care and education.  This can be performed by any licensed physical therapist unless a lymphedema specialist is required.  

WHO IS A CANDIDATE FOR BREAST CANCER RELATED PHYSICAL THERAPY?

• Anyone diagnosed with breast cancer

• Anyone currently receiving breast cancer treatment

• Anyone who is a breast cancer survivor

IS PHYSICAL THERAPY EXCLUSIVE TO BREAST CANCER?

The simple answer is no.  Physical therapy can help any cancer patient with decreased functional status or quality of life due to current or previous cancer diagnosis.  

The bottom line is care does not have to stop once your cancer has gone into remission or you have been released from your oncologist's care  if your function or quality of life has not returned to normal.  Don’t be afraid to ask for help if you feel like you need it, or know someone who needs help. 

For more information of the role of physical therapy in cancer treatment, click on the following link:

American Physical Therapy Association: Physical Therapy Guide To Cancer

-Katie Chen, DPT, OCS, COMT

REFERENCES:

1.American Cancer Society: Cancer Facts and Figures 2018. Atlanta, Ga: American Cancer Society, 2018.

2. DeSantis, CE; Lin, CC; Mariotto, AB et al. (2014) Cancer Treatment and Survivorship Statistics, 2014 CA: A cancer journal for clinicians

Pregnancy-Related Sacroiliac Joint Pain

The sacroiliac joint (a.k.a. “S.I.” joint) is located at the junction where the spine meets the pelvis. Pain in this joint is often described as a shooting, stabbing, and occasionally burning. Pain may be felt in the back of the pelvis, buttock(s), groin, or inner thigh(s). Pain typically worsens with activities such as standing on one leg, walking, stair climbing, prolonged standing, rolling in the bed, and/or getting up from a low chair.

The pregnancy hormone Relaxin is responsible for increasing the laxity (looseness) of ligaments in order to accommodate the growing fetus and prepare the body for childbirth. Consequently, increases in this hormone can lead to instability in the joints. This instability may be more pronounced in women with already existing hypermobility. The altered biomechanics and muscle imbalances that occur during pregnancy further contribute to the symptoms listed above. Approximately 16-25% women experience pelvic girdle pain (PGP) during pregnancy, with some studies revealing rates as high as 76%. It is estimated that 93% of women with pregnancy-related pelvic girdle pain experience recovery six months postpartum[1].

POSTURES RELATED TO SI JOINT SYMPTOMS:

• Excessive anterior pelvic tilt

• Shallow breathing with flared ribs

• Forward head posture

• Jaw clenching

• Butt clenching

• Supinated or pronated foot/feet

• Sway forward

• Sway to one side

ROLE OF PHYSICAL THERAPY

• Prevention of the symptoms

  • Maintain good breathing pattern

  • Shallow breathing is a sign of inefficient diaphragm function

  • Maintain the strength in the core, hip and pelvic floor muscles

  • Maintain thoracic mobility

  • Avoid sudden and drastic change in the footwear or supports

  • Avoid single leg standing exercises especially if the SI joint symptoms start to appear

• Treatment

  • Patient education regarding the condition and prevention of the aggravating factors

  • Assessment of the breathing pattern and teach appropriate corrections

  • Guide the patient in proper muscle balance around the SI joint. Due to altered biomechanics, some muscles need to be activated whereas some may need to be relaxed or temporarily shut down while doing particular movements.

  • Foot assessment with subsequent arch strengthening and foot mobility exercise as they can have an impact on the hips and thereby influence the SI joint.

  • Manual therapy in the form of myofascial release and muscle energy techniques (MET) may be beneficial.

  • Use of SI joint stabilization belts have been shown to improve the symptoms[2].

  • Heat or ice packs for local pain relief.

If you are experiencing similar symptoms, please get in touch with a women's health physical therapist. Together, we can make your pregnancy a comfortable experience.

-Ishi Upasani, PT, MS

References

1. Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: an update. BMC Medicine.

2. https://www.ncbi.nlm.nih.gov/pubmed/16214275

Breastfeeding Ergonomics

The postpartum period can be quite stressful for new moms when the body is trying to heal while the mind and body are struggling to find some rest. A lot of time is spent holding and feeding the baby, breast or bottle. It is very easy to only focus on making sure your baby is taking enough milk, while ignoring your own comfort.

So what is the ideal posture? There is no "one fits all" rule here. What is ideal for one may not be for another and vice versa. However, little adjustments within your setting can go a long way in helping to achieve a position of maximal comfort. 
 
Here are some helpful tips for new moms:

1) PILLOWS!!! They are your best friends here. All those pillows you picked up from Target are finally going to come handy.  Place one behind your low back, under your arms and under baby's butt. Tuck them wherever you think would help to relax the muscles in neck, shoulders and back (like under the elbows/arms). Depending on your height and the chair you are using, the number of pillows can vary but these adjustments can make HUGE difference. For example, a small pillow at the hollow of your low back can put your diaphragm in a good position and thus assist in breathing more efficiently. Trust me, after the amazing feat your body has performed, you need all that oxygen for healing. So no matter whether it is cradle, cross-cradle, football or laid back, those pillows go a long way in making the whole process more comfortable for you. Also, consider using the nursing pillows available in the market. There is no such thing as too many pillows when it comes to nursing. 

2) Focus on your breathing. Is it shallow? Drop your shoulders, unclench the jaw and ease back into the pillow support. Take deep, slow breaths with full exhalation. It is important that you are able to draw in a deep breath after a complete exhalation. When you can find time during the day, try to meditate. When we breathe using only shallow-breaths, our sympathetic nervous system is activated, sending us into a fight-or-flight mode, which is our body's natural response to stress. Meditation can help in achieving a deep and calm breathing pattern, which will help you to feel more relaxed.

3) While we all want to gaze lovingly at our babies, this can negatively affect our posture. When you are feeding your baby, is your upper back hunched? Is your neck bent down? If and when possible recline back while nursing, while making sure your baby is able to breathe comfortably. An added bonus is the fact that this posture aids in the development of baby's neck control. With extended feeding durations (for both breast and bottle) the front of your torso and shoulders get shortened and stiff. This, in combination with hunched back and forward head posture, causes an imbalance in the muscles of the shoulders, back, neck and diaphragm. The diaphragm is the major muscle in our trunk that aids in respiration. The diaphragm works with both the abdominals and pelvic floor muscles for proper function. With good posture and deep breathing, mentioned above, you are giving these important muscle the best opportunity to work properly.

4) Whether you are nursing or bottle feeding, switch sides every 15 minutes. Not only is this great for establishing the milk supply but,  also for giving a break to the muscles on one side while the other side is working. Phone timers or alarms help. 

5) Use a small foot rest to bring the knees higher, thereby relaxing the low back and abdomen.

6) Therapeutic exercises go a long way in getting new mothers safely back to their daily activities. Specific exercises are safe to do from the first month after childbirth and can help relieve the muscle imbalances that occur during pregnancy.  Some of my favorite appropriate are listed in the references below. 

For more information on postpartum posture, breathing and exercises, please visit a physical therapist specializing in women’s health and pave a safe path to recovery!

-Ishi Upasani, PT, MS

References:

https://www.coreexercisesolutions.com/belly-breathing/

https://www.coreexercisesolutions.com/a-better-approach-than-belly-breathing-for-the-pelvic-floor/B