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

GUEST BLOG: Six Questions To Improve Your Health & Wellness

I’ve been reflecting on the importance of self check-ins. Basically a slightly extended version of asking yourself, “How am I doing?”. If we get into the habit of regular self evaluation we can notice positive changes and we can hopefully catch many of the small problems before they become the big problems. I’ve written before about the importance of contemplation - how it is crucial for us all to find ways to not just be productive but to also make sure we spend time with ourselves and slow down. This builds helps you build a relationship with you. Consider this daily practice of self check-in to be one of the tools of wellness. 

I’ve been compiling thoughts on what questions pack the biggest bang for the buck. If I was to ask myself five to six questions every day, which questions would help me really see how I’m doing? Which questions would help me see my progress and successes? Which questions would help me see changes that I need to address and attend to before those changes start building up into big problems? Many of these questions are research driven, highlighting important self-care behaviors that facilitate health  - physical, emotional, and relationship health. 

So here is the invitation - try my six questions each day for at least a week. Find 5 minutes at a regularly scheduled time - anytime that works for you, but keep it consistent. Write them down in a journal or somewhere on your phone or computer. Keep track of the scores to notice any changes - no change, healthy change, unhealthy change, big change, small change. Address changes as needed. Repeat, and repeat. If you have any feedback on the questions please send it my way! I’m all ears. 

Answer each question with a number between 0 and 10. There are a few bonus questions that you can ponder and write down thoughts if the questions feel relevant and helpful. 

1) How safe am I feeling? (0-10)

0 = constant sense of stress, threat, and/or danger

10 = secure, confident, protected

*Bonus - If you can identify the threat(s) - name it here:

2) What is my energy level? (0-10)

0 = complete fatigue and/or burned out 

10 = rested and/or energetic

3) How is my mental focus? (0-10)

0 = distracted all the time, difficulties concentrating

10 = able to manage thoughts and attention in meaningful ways

*Bonus - If score is low - what has been on my mind:

4) How clear is my sense of purpose? (0-10)

0 = I feel aimless and without much purpose

10 = I’m confident about what I'm doing. I have a clear sense of purpose

*Bonus: - What key personal values do I want to be focused on?

5) How are my relationships and sense of connection to others? Have I had positive interactions with others? (0-10)

0 = I am feeling disconnected or isolated. I am not getting enough positive support from others.

10 = I feel understood by others and good social support

6) Have I made time for play, fun, and/or creativity? (0-10)

0 = No - it all feels like work and busy-time, or I haven’t been doing anything fun

10 = Yes - I have a good feeling of balance between my productive time and my play time. I am able to be creative in ways that are important to me.

-Dr. Trevor Davis, PsyD, ABPP

How To (Properly) Calculate Your Target Heart Rate Zone

Monitoring our heart rate during exercise is an excellent way to determine and quantify the intensity of our workout. But what intensity should we be working out at and what is the best way to calculate this? The traditional method of calculating your target heart rate (Percentage of Predicted Maximum Heart Rate) factors in only your age (Predicted Max HR = 220 - Age). For example, world-class ultramarathoner Scott Jurek is 46 years old and therefore has a predicted maximum heart rate of 174 beats per minute (bpm). While using this traditional method, most recommend a target heart rate zone (the zone you want your heart rate in during exercise) to fall between 50-85% of your maximum heart rate. For Scott Jurek, we find his target heart rate zone to be roughly 87-148 bpm. The benefit of this method lies in the simplicity of the calculation. However, there are shortfalls of utilizing this method to calculate target heart rate zones. First, the range of this target heart rate zone is much too large and subsequently not very prescriptive. Second, the low end of this target heart rate zone may not be attainable during exercise, especially in older adults with higher resting heart rates. For example, the predicted maximum heart rate for a 75 year old woman is 145 bpm. Let’s assume this individual has a resting heart rate of 75, which is fairly typical. Utilizing the traditional method results in a calculated target heart rate zone of 73-124 bpm. As you can see, her resting heart rate is higher than the low end of her target heart rate zone for exercise. Therefore, the percentage maximum heart rate method of calculating her target heart rate zone would say she is exercising at rest, which is nonsensical. In other words, the traditional method often prescribes heart rates that are too low when working out at lower intensities, especially in older adults. Third, the traditional method fails to factor in your level of fitness, thus overly simplifying exercise prescription for a variable population. Since the traditional method of calculating your target heart rate fails to factor in your resting heart rate, it will prescribe the same target heart rate zone for Scott Jurek as an age-matched couch potato who smokes two packs per day. You see, as you become more fit, your resting heart rate will decrease as your heart becomes stronger and subsequently more efficient at pumping blood to the rest of your body. A highly trained athlete may have a resting heart rate of 48 bpm while the sedentary smoker may have a resting heart rate of 88 bpm. If they are both 40 years old, the traditional method of calculating target heart rate would recommend exercising between 90 and 153 bpm for both individuals. The traditional method therefore lacks this level of specificity.

So what is a better way to calculate your target heart rate zone? The answer is using the Karvonen method, otherwise known as the Heart Rate Reserve (HRR) method. The Karvonen method factors in both your age and resting heart rate, allowing for a more precise and effective target heart rate zone. The low end of the target heart rate zone tends to be at a higher heart rate than the traditional method of calculating target heart rate zones, while the predicted maximum heart rate is still the same. Those with a higher resting heart rate will see a higher number at the low end of the target heart rate zone as compared to those with a lower resting heart rate, to account for variability in the baseline levels of cardiovascular fitness within the population. Click on the link below to calculate your target heart rate zone using the Karvonen method:

TARGET HEART RATE CALCULATOR

Once calculated, it is recommended that you use this target heart rate zone to monitor your intensity during your workouts, in order to ensure that you are exercising at an intensity high enough to provide a cardiovascular benefit. This will help you get the most out of your exercise routine moving forward.

To find more information on heart rate or how to find your pulse, CLICK HERE.

-Grant Hennington, DPT

Seven Tips For Scar Management

Some people may look at their scar as a symbol of pride, or a battle wound of sorts, while others may not care much for a scar at all. This article is primarily written for the latter, although it is safe to assume no one wants the itching, stiffness, tenderness, or pain that often comes with a scar.

Whatever your thoughts about scars, let’s clear something up first: scar tissue is your body's glue, so to speak. Scar tissue doesn’t really discriminate between bone, skin, muscle, or tendon. No matter the tissue, the process is the same. The first step in the process is the inflammation stage. This is our body’s way to ward off infection and control bleeding. The process starts with cellular damage. Involved cells really don’t know if the damage is from stepping on a rusty nail or a major tendon strain. The damaged cells release chemicals to make the area swell in order to keep infection from spreading to other areas and slows bleeding. Pretty cool huh? Even so, it hurts! The second step is scar formation, otherwise know as the proliferation stage. This may sound bad to some, and, if uncontrolled, can be. However, we need and want it to happen for healing to occur. Scar is our body’s glue, right? This “glue” creates the scaffolding for new tissue to grow on/into. That is where this article centers around: how to manage scar tissue as it matures into the tissue it is trying to remodel. This process is known as the maturation stage.

WHAT TO EXPECT WITH A POST-SURGICAL SCAR

A lot of surgeries are performed by making a very small incision and inserting a camera to see inside. When performed to a joint, this is known as arthroscopy. Other procedures, such as a total knee replacement, or even a C-section, can leave behind a larger, more obvious scar that may take greater time to fully heal. In general, scars can take months to years to finish the maturation stage. If the healing goes as it should, the scar should be smooth and flush with the skin. Unfortunately, this does not always happen, as scars sometimes end up raised or widespread. There are two types of abnormal scars to watch out for:

• Hypertrophic scars are raised, but tend to stay in the confines of the original incision, containing mostly well-organized Type III collagen. The good news is that it is possible for hypertrophic scars to spontaneously improve over time.

• Keloid scars are excessive scars that grow beyond the confines of the original incision, containing mostly disorganized Type I and II collagen bundles. Keloid scars don’t improve on their own and tend to come back, even after being treated surgically. People develop keloid scars usually as a result of a genetic predisposition for abnormal scar formation, not necessarily because the surgical incision was done incorrectly. 

Although they can present differently, both hypertrophic and keloid scars can be managed similarly.

TIPS FOR SCAR MANAGEMENT

The first priority in scar management is to prevent abnormal scarring. While fancy treatment strategies, such as laser therapy, steroid injections, and surgery are available, these are costly and carry inherent risks. Consequently, here are treatment strategies you can do yourself to decrease abnormal scarring. 

1. Silicone Scar Gel is universally considered to be the gold standard for prevention and treatment of hypertrophic and keloid scarring. Silicone gel products are widely available over-the-counter and can even be used on scars that likely won’t become abnormal. When using a silicone scar gel, be sure the incision is fully healed before application. Silicone scar gels have been shown to decrease the size or thickness of scars, while often reducing itching associated with the scar.

2. Onion Extract-Based Gel: Quercetin is weirdly found in onion extract – and the main ingredient in Mederma, which also can be purchased over-the-counter. Quercetin has anti-proliferation and anti-inflammatory effects, helpful in stage one and two of healing. While it may sound counter-intuitive, sometimes the body overreacts during these stages. Recently, a couple of studies showed that even though Quercetin helped collagen organization, it did not improve scar appearance or symptoms when compared with use of a standard petrolatum ointment. 

3. Vitamin E: Vitamin E is believed to reduce the amount of reactive oxygen available during the inflammatory stage of healing. Many of our patients have noted improved scar appearance when cracking open a vitamin E capsule over their scar once a day during the healing process, but some studies have found no benefit from using vitamin E. 

4. Limit Scar Stretching During Healing: Keloid and hypertrophic scars usually occur in areas of the body frequently stretched during natural daily movements, like the front of the knee. This can be a catch-22 because your physical therapist will usually encourage you to bend the knee often, which is also very important. If you’re concerned about a scar becoming abnormal, talk to your physical therapist about taping or using silicone gel sheets (see above).

5. Compression: If you experience more widespread hypertrophic or keloid scarring, pressure garments can be worn while your incision is healing. Compression over the scar can decrease the production of collagen, decrease swelling and even reduce itchiness and pain. It's been reported that a minimum of 15 mmHg is needed to promote scar maturation (3rd stage). If you have ever worn compression socks, it feels about that tight.

6. Massage: Massage therapy can disrupt fibrotic tissue and increase the pliability of the scar. It can also improve swelling, thickening, and hardening of the scar tissue. Your physical therapist can show you how to properly massage your scar, but here is a good reference on deep friction massage. However, you should wait about 10-14 days before starting massage or after the incision is closed, as starting too soon can actually promote hypertrophic scarring.  Lastly, make sure your hands are clean and sanitized before starting massage.

7. Sunscreen: Be sure to keep your scar out of sunlight as much as possible until the scar has matured. UV radiation has been shown to increase scar pigmentation, making its appearance worse.

Rather than waiting until a scar becomes either hypertrophic or keloid, early treatment aimed at prevention is key. If you have any questions about your particular scar, reach out to your physical therapist, as they have seen a lot of them. If you are ever concerned about your scar becoming infected, call your surgeon immediately.

Be well!

-Tucker Schonberg, PT, OCS

Osteoarthritis: Misbeliefs About a Common Joint Condition

The term arthritis is defined as acute or chronic joint inflammation. Although there are many types of arthritis, including rheumatoid arthritis and psoriatic arthritis, osteoarthritis in the most common form. Osteoarthritis affects millions of active and sedentary adults worldwide.

Osteoarthritis involves changes in a joint’s cartilage and bone that may lead to joint pain and swelling. Osteoarthritis typically affects the joints of the knees, hips, lower back, neck, and small joints of fingers, thumb, and big toe. Pain associated with osteoarthritis is typically described as an aching or burning joint pain that gets worse with activity. The affected joint will often feel stiff and painful in the morning for about an hour and then feel sore again towards the end of the day.     

WHAT CAUSES ARTHRITIS?

A healthy joint will have solid layers of articular cartilage that allow smooth movement and force absorption between bones. These layers of cartilage are maintained by cells called chondrocytes. In an arthritic joint there is a shift in the chondrocyte activity leading to decreased cartilage production and impaired cartilage maintenance.  

This change in chondrocyte activity causes an increase in immune cell activity which can result in inflammation in the joint, with subsequent pain. Altered chondrocyte activity may be due to age, inflammation, joint injury, mechanical load and obesity, and genetics.

COMMON MISBELIEFS ABOUT ARTHRITIS

“Exercise will damage my joints more by increasing the force between the bones.”

Decreasing or stopping regular exercise due to osteoarthritis can lead to reduced muscle strength around the joint, decreased flexibility, weight gain, and difficulty with normal daily activities. Strengthening and stretching the muscles around an arthritic joint can actually decrease the friction and load on the joint. Regular exercise can keep the muscles around the joint strong, decrease bone loss, and can help control joint swelling and pain. Movement of joints also promotes the production of synovial fluid, which acts as a lubricant to reduce joint friction. It is well documented in research literature that regular participation in an appropriate exercise program can increase joint motion and strength, increase aerobic capacity, and improve physical and psychological function in people with osteoarthritis. 

“Arthritis is degenerative, so my pain and function are only going to get worse as I age”

As we age, osteoarthritic changes may become more pronounced on imaging, including x-rays and MRI. However, your strength, function, and pain do not have to worsen just because a joint is becoming more arthritic. Many people get concerned when they are told their x-rays are positive for osteoarthritis or signs of degeneration. However, even though your joint may look a certain way on imaging it does not mean you will have pain or difficulty using that joint in daily and higher level activities.  

“I have arthritis in my knees so I should only be doing low impact activities, like swimming and biking” 

Low impact exercises like swimming, biking, and elliptical machines can be great aerobic activities for people with osteoarthritis, especially if they are beginning an exercise program or have limited mobility due to their osteoarthritis. However, these exercises should be part of a program that also incorporates mobility and strengthening exercises. A good exercise program involves finding the right type of exercises that allow you to keep moving without high levels of pain.  If swimming and biking help accomplish this, then it is perfectly fine to make these a staple of the program. However, if you have a goal to walk with less pain, walking eventually needs to be a part of your program, with graded progressions in time or distance when appropriate.

“Running causes arthritis and will ruin your knees in the long-term”

Many of the long-term studies on runners suggest that, as long as your knees are healthy to begin with, running does not increase the risk of developing arthritis, even if you run into middle age or beyond. In some studies, runners show less overall risk of developing arthritis compared to less active individuals. Other studies have even suggested that regular loading of cartilage with appropriate rest periods may help encourage cartilage cells to divide and improve cartilage health in the long-term.  

IN SUMMARY: KEEP MOVING, STAY STRONG, AND FIND THE RIGHT PROGRAM FOR YOU!

Osteoarthitis can be painful and lead to impaired mobility and activity. However, finding the right combination of activities, improving your strength and flexibility, and staying consistent over time can result in decreased pain and improved function.  Remember that you are not your x-ray and pain-free activity may be possible despite what the imaging shows.  It may take time and work, but the right aerobic, strength, and flexibility program can go a long way in combating osteoarthritis pain.

-Sean Tyler, DPT