Healthy Lifestyles of the midlands (Oct 2009) – Occupational Therapy Program Helps Mastectomy Patients,

By Hima Dalal, OTR / L

Breast cancer is the most common cancer in women. Modified radical mastectomy continues to be the most frequent treatment for breast cancer. The diagnosis of cancer of the breast, and the subsequent loss of one or both breasts, can be very traumatic. Plastic surgeons can now offer the option of reconstructing the breast following the removal of cancer. Breast reconstruction serves as one element in emotional rehabilitation which minimizes the psychological trauma of the diagnosis.

Immediate breast reconstruction becoming more common because it can be performed immediately after the mastectomy, thus the client undergoes only one surgery. This procedure provides a reasonable facsimile of wholeness and contributes to maintaining the women's body image.

There are basically two types of reconstruction operations: silicone implants placed in a subpectoral pocket, and flap procedures using the clients' own tissues (autogenuous tissue reconstruction). The choice depends on the amount and suitability of tissue remaining at the mastectomy site, and the requirements to match the opposite breast. The reconstructive surgeon discusses these alternatives with woman in terms of what best suits her clinical situation.

Several types of flap procedures may be used. The most common is the Tranverse Rectus Abdominis Myocutaneous (TRAM) flap procedure (also known as a “Tummy Tuck”). The TRAM procedure uses tissues from the lower abdominal wall overlying the rectus abdominus muscle area. The transfer of muscle and skin from the lower abdomen to the chest results in tightening of the lower abdomen. The muscle and skin tightness, as well as the scar, results in a temporary decrease in hip extension and difficulty in deep breathing and coughing.

Both types of breast reconstruction surgeries, when combines with a mastectomy can lead to extrinsic internal rotator and abductor muscle group dysfunction (i.e. serratus-anterior, pectoralis major and pectoralis minor). However, the clients with silicone prostheses are sore and have more tightness secondary to the formation of the subpectoral pocket. Both operations lead to a temporary decrease in independence in activities of daily living secondary to the decrease in shoulder external rotation, horizontal abduction, horizontal adduction, flexion and abduction.

The occupational therapy reconstructive surgery program helps the client regain shoulder functions, decrease abdominal tightness, and increase hip extension to allow the client to regain independence in self-care, homemaking, vocational and avocational activities.

The program appears to shorten the physical and emotional adjustment period, but data is now being collected for efficacy of the program.

The client is initially referred to occupational therapy on the second post-operative day for evaluation by the occupational therapists. The occupational therapist performs the following assessments:

• Chart review, including identification of pre-existing medical conditions.
• Emotional/mental status, assessed via interview.
• Social status, vocational/avocational status, assessed via chart review and interview.
• Self-care, home-making assessment.
• Active and passive range of motion, muscle strength, endurance and grip strength of involved upper extremity, and uninvolved upper extremity.
• Hip flexion measurements for clients who have undergone flap surgery.
• Evaluation of posture.
• Evaluation of pain, done subjectively on a scale of zero to 10 at rest and zero to 10 in use.

There are several goals of the occupational therapy reconstructive surgery program, which are based on evaluation results, goals and treatment techniques utilized.

Goal one is that the affected upper extremity will achieve full active/passive shoulder range of motion as compared to uninvolved upper extremity.

Goal two is that the client reports decrease in pain on scale of zero to 10 at rest and in use.

To achieve these first goals, gentle passive range-of-motion exercises are performed on the involved upper extremity, and the client is gradually progressed from passive to active assistive range-of-motion exercises as tolerated. These include “wall climbing” exercises, which is done facing and perpendicular to the wall to increase shoulder flexion and abduction; “shoulder ladder” exercises which are also done against the wall; and towel and dowel exercises on an incline board, where the therapist manually provides assistance as necessary.

For all the above exercises, the client exercises to the point of gentle stretch.

As the client gains more range of motion and the pain decreases (about the third or fourth post-op day), she is progressed to active range-of-motion exercises. These exercises are performed in available should range and are done slowly, avoiding jerky movements. The exercises include cone stacking, which is performed to increase flexion, abduction and horizontal adduction; mushroom pegboard activities in an inclined position; and rotating the arm in a circle.

Goal three is that the affected upper extremity will achieve 5/5 muscle strength in all upper extremity muscle groups.

Goal four is that the affected upper extremity's endurance will be within normal limits (as compared to the unaffected upper extremity).

For these two goals, the client begins progressive resistive exercise after the drainage tubes and stitches are removed (approximately two weeks or less after the surgery). These include progressive resistive exercises using the BTE work simulator. Tool No. 802 is used for promoting flexion, abduction and horizontal adduction, abduction and external rotation. The resistance and the number of repetitions are increased gradually to increase strength and endurance in the involved shoulder.

The client is also given a home exercise program to increase strength and endurance. These include exercises using a hand helper, where the client is asked to squeeze the instrument and release it repetitively while the arm is stretched out in flexion and abduction. The client also learns Theraband exercises for increasing shoulder flexion, abduction and horizontal abduction.

Goal five is that the client sits erect in a chair, places her shoulder back, chest out and takes a deep breath and relaxes. She moves her scapula in elevation, depression, retraction and protraction. All the movements are incorporated with a deep breathing exercise.

Goal six is that the client with TRAM flap surgery achieves full passive range-of-motion in hip extension on both sides.

The client will perform deep breathing exercises while reclining supine on a mat. The client performs gentle AROM exercises for hip extension.

Goal seven is that the client achieves independence in self-care and light homemaking.

Goal eight is that the clients learn temporary and permanent precautions following the surgery.

If indicated, involved upper extremity and scar precautions are reviewed with the client before discharge fro the hospital. These precautions are taught to the client in conjunction with the physician, depending on the type of mastectomy and reconstruction procedure.

Clients receive therapy in groups of two or three, which helps to alleviate psychological problems much of the time. Clients whose self-esteem and body image does not improve with time are referred to a body image clinic or to a clinical psychiatric nurse, with the plastic surgeon's approval.

A vocational/avocational evaluation is done for the client as indicated and she is treated accordingly. Energy conservation and work simplification techniques are taught to the client who receives chemotherapy.

The client is discharged from occupational therapy services when she: regains full functional use of the affected upper extremity; understands precautions concerning the affected upper extremity; returns to full participation in home, family, vocational and social activities; and accepts the breast reconstruction by putting it into the proper perspective.

Some clients may suffer from post-surgical complication. For example the client may experience:

• Edema
• Limitation in upper extremity active range-of-motion, passive range-of-motion therapy and strength which do not respond to therapy. This has been noted in the clients with pre-existing upper extremity medical problems.
• Sensory muscular deficits.
• Reflex sympathetic dystrophy.

If any of the above occurs the clients is treated accordingly.

Early involvement of the occupational therapy rehabilitation program is essential for breast reconstruction surgery clients. It appears that this particular rehabilitation approach helps to shorten the adjustment period for the client's physical and mental well being, thus expediting the recovery process. Early and intensive therapy appears to prevent prolonged hospitalization. In addition, post-operative complications such as flap displacement, excessive drainage, etc. are not noted following therapy. The majority of the clients receiving expressed that the rehabilitation program was instrumental in healing their physical and mental scars.

Hima Dalal is an OTR/L who is working at University Hospitals of Cleveland. Her specialty is working with neurosurgical and oncology patients.
Dr. Windle is a Plastic and Reconstructive Surgeon at University Hospitals of Cleveland and an assistant professor of surgery at Case Western Reserve University.

References
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