5 Key Insights of Physical Therapy After Breast Cancer or Mastectomy

As a “local physiotherapist” in my small town in Savoie, France, I sometimes supervise the rehabilitation of women with breast cancer. Often, they have physical therapy sessions prescribed after an axillary curettage, a lumpectomy or a mastectomy .

Sometimes, before an operation, or “simply” to maintain physical activity during the different treatments, or after.

I therefore regularly research the subject to keep up to date with best practices and the most relevant things to offer.

In this article, I therefore answer the most frequently asked questions of people affected by breast cancer , and those of their loved ones (personal entourage or healthcare professionals).

As usual, you will find at the end of the article:

• all references to studies and recommendations on which I rely;
• a comment space to leave additional comments, feedback or questions.

Happy reading 🙂!

Last update: October 2023.
Declaration of financial interests: none directly related to the subject. My complete declaration of links of interest is in legal notices. Written by Nelly Darbois, physical therapist and scientific writer

Why rehabilitation in case of breast cancer?

It is very common for physiotherapy sessions to be prescribed after a diagnosis of breast cancer , regardless of the person’s age. This prescription can occur:

• from diagnosis;
• after an axillary dissection or total or partial mastectomy surgery;
• when certain annoying symptoms appear (fatigue, difficulty moving the arm, arm swelling, pain);
• during remission period, to gradually resume daily physical and cognitive activities.

Rehabilitation in case of breast cancer in general

Whatever your state of health and the stage you are at, when you see a physiotherapist for the first time, your physiotherapist will probably carry out a physiotherapy assessment by:

• asking you questions about your current feelings, about what you can or cannot do, about the discomforts you may encounter, about what you would like to be able to do again;
• looking at you holistically;
• co-defining with you objectives to achieve, or things that can be put in place in your situation, in relation to the needs and constraints that you describe.

It’s difficult to give a typical example of physiotherapy treatment in the event of breast cancer, because many parameters come into play. Including your own preferences, and the working habits of your physiotherapist .

Overall, the 2 main areas of physiotherapy treatment are:

1. guide you to establish or maintain a maximum level of physical activity based on your abilities and desires . For what ? Because :
   • it improves the quality of life of people with cancer by reducing fatigue, anxiety, depression and sleep disorders;
   • physical activity can help maintain muscle strength, endurance and mobility, which can help to tolerate treatments better and recover more quickly;
   • it limits the risk of recurrence in breast cancer survivors;
   • it can help alleviate some side effects of treatment, such as weight gain, decreased bone density, and musculoskeletal pain.
2. limit the appearance or worsening of side effects linked to treatments : loss of strength, loss of flexibility or mobility, edema of lymphatic origin, loss of elasticity of the tissues around the scar and formation of adhesions, pain.

Rehabilitation after axillary dissection

Depending on the type of cancer you have, you may have a surgical procedure called an axillary dissection. This procedure is sometimes also called sentinel lymph node ablation.

This involves removing the lymph nodes located in the armpit region, called the axillary region.

The main goal of an axillary dissection is to determine if the cancer has spread to the lymph nodes in the armpit. This helps assess the stage of the cancer and helps determine what further treatment is needed , such as adjuvant chemotherapy or radiotherapy.

When lymph nodes appear unaffected according to preoperative examinations, lymph node preservation techniques may be used to reduce the number of lymph nodes removed or avoid the axillary dissection procedure .

These techniques include selective sentinel lymph node biopsy, where only the “sentinel” lymph node closest to the tumor is removed for examination.

Other names given to this procedure: axillary lymphadenectomy or axillary lymph node dissection.

Rehabilitation after mastectomy or lumpectomy

Sometimes it is necessary to remove more tissue than just sentinel lymph nodes or all of the axillary lymph nodes.

In this cac, your surgeon performs a partial or total mastectomy , depending on many parameters.

In the event of a total mastectomy, we remove:

• the whole breast;
• and the tissue that covers the muscles of the thorax , the pectoral fascia).

But we do not remove:

• lymph nodes,
• nerves,
• and the chest muscles are left in place.

How long does it take to start physical therapy sessions?

Very often, you have prescriptions for physiotherapy sessions to be done after a mastectomy .

Here is a typical physiotherapy prescription made by an oncology department in France:

Very often, you will see written on the prescription “to start on post-operative day 15”.

This is worth saying in normal language 🙂 “your first physiotherapy session should ideally take place 15 days after the day of the mastectomy”.

From experience, I know that most people don’t pay attention to this mention. Or don’t understand it.

It’s not that serious. This information is given for information purposes only, as it is advisable not to force too much on the arm in the first weeks after the mastectomy.

You can definitely make an appointment with your physiotherapist beforehand, if you have any questions or anything else. Your physiotherapist will know how to adapt the treatment.

On the contrary, have you passed this deadline? It doesn’t matter either: the prescription remains valid, and if you feel the need, you can make an appointment with a physiotherapist at any time.

What physical therapy for lymphedema of the arm after breast cancer?

Depending on the breast cancer surgery performed, lymph nodes are sometimes removed in the armpit area.

Lymph node removal is an injury to the lymphatic system. This lesion will cause:

• a disruption of local lymphatic circulation,
• sometimes  lymphatic edema of the arm (“lymphedema”) = swelling of lymphatic origin = swelling linked to the accumulation of lymph in the arm.
  
  This happens in about 1 in 5 women who have breast cancer and a mastectomy (María Nieves Muñoz-Alcaraz 2010).

Lymph is a clear fluid that circulates through the lymphatic system, which is part of the immune system.

The lymphatic system is responsible for collecting fluids, cellular wastes and toxins from the body. We all have it, but sometimes it accumulates, circulates less well, and causes swelling.

In these circumstances, lymphatic drainage of the arms is part of the standard line of management in physiotherapy .

What are the possible negative consequences of lymphedema?

The possible (and not systematic!) negative consequences of arm lymphedema are:

• aesthetic discomfort 🪞 ; 
• functional discomfort , that is to say a reduced ability to use one’s arm in everyday life due to one’s weight ;
• the occurrence of shoulder pain due to the greater weight of the arm;
• the development of erysipelas (or erysipelas) , a bacterial infection of the skin 🦠. The skin is in fact under permanent tension due to swelling, which tends to weaken it.

What is the physiotherapy treatment for arm lymphedema?

The main points of management of arm lymphedema are:

• the implementation of a system of specific compressive bandages ;
• the practice of regular gymnastic exercises of the upper limbs 🤸;
• regular and thorough skin care of the arm (to prevent the risk of erysipelas) 🚿;
• manual lymphatic drainage , generally carried out before applying the bandages.

Does manual lymphatic drainage really provide added value compared to other measures?

What does the 2015 Cochrane review [5] say about lymphatic drainage in breast cancer?

Cochrane is an international non-profit organization. Its objective is to produce summaries of studies on the effectiveness of health treatments 📚 .

This is what she did in 2015 for manual lymphatic drainage (MLD) for lymphedema after breast cancer treatment. Here is an excerpt from the conclusion :

DLM is safe and may provide additional benefit to compression bandaging to reduce swelling. […] This result must, however, be confirmed by randomized data. […] The results were contradictory for function (range of movement) and inconclusive for quality of life.

In other words, the results at the time were not particularly exciting. Now let’s see what has happened since 2015.

Studies since 2015 on drainage, lymphedema and breast cancer

At least two new studies [6,7] cast doubt on the benefit of manual lymphatic drainage after breast cancer surgery.

The first, published in 2018 , concludes as follows (personal translation):

Manual lymphatic drainage does not provide additional benefit in terms of volume reduction in patients who have had breast cancer.

The second, published in 2021 , concludes like this (personal translation):

The study results indicated that both treatment approaches were effective for patients suffering from breast cancer-related lymphedema. However, no additional effect of manual lymphatic drainage was found regarding the percentage reduction in arm volume in the intensive phase of treatment.

The treatment protocol was therefore equally effective with and without manual lymphatic drainage. In other words, manual lymphatic drainage appears to have been ineffective.

Conclusion: what is the effective treatment for arm lymphedema?

For the record, the main points of management of lymphedema post-breast cancer surgery consist of:

• apply suitable compression bandages ;
• regularly practice exercises for the upper limbs 🤸;
• carry out regular and thorough skin care (to prevent the risk of infection) ;
• manual lymphatic drainage .

If we trust the results of the studies, it is quite possible that manual lymphatic drainage is unnecessary. Good news: everything else seems to work! 🥳

Why do we sometimes have pain and difficulty moving our arms after breast cancer?

After breast cancer surgery, it is common to feel pain in your arm and have difficulty moving it . Because :

1. of an inflammatory reaction linked to the surgical procedure . This automatic reaction of the body allows the nutrients and other elements necessary for their healing to be brought into damaged tissues;
2. edema of lymphatic origin ;
3. scar tissue that can restrict mobility and cause discomfort.
4. instructions you have had . You have probably been told not to use your arm too much to carry things for at least 3 to 6 weeks, and not to strain with the arm, to promote healing. This can lead to muscle stiffness and weakness, making arm movement more difficult.

Physiotherapists are among the health professionals who can guide you in :

• identify movements to limit and the level of activity relevant to your situation;
• find exercises adapted to the stiffness, pain or loss of strength you have;
• find positions that are more comfortable for you;
• once the healing period has passed, incorporate daily physical activities (or specific exercises) to regain all your previous abilities.

Here is an example of an exercise that is often recommended to be performed gently in the days and weeks following breast surgery, if you feel stiffness in the arm.

A few tips :

• You can do this simply lying on your couch or in bed . Widthwise, to have space behind to raise your arms behind your head
• You can take a broom, a stick, whatever you have at home
• You can also do it simply by bringing your two hands together and intertwining your fingers, without a stick . The arm with the least difficulty guides the other, and little by little, it will be the arm on the operated side which will participate more.

Get the advice of your physical therapist if you are not sure if it is suitable in your case, or if you cannot put it in place 🙂.

Superficial lymphatic thromboses: what are they and what is the treatment?

Lymphedema is the most common complication of breast cancer surgery.

There is another complication (which does not always occur) which takes different names:

• superficial lymphatic thrombosis;
• axillary web syndrome;
• Axillary bridle syndrome.

This syndrome:

• may appear within 2 months following surgery;
• disappears completely within 3 months following the operation, whatever we do . Which is very good news, compared to lymphedema which can sometimes become chronic.

How does this syndrome manifest , what are the symptoms, signs?

• a cord frequently appears in the armpit. Or sometimes along the upper limb, at the bend of the elbow and even up to the first finger;
• there is pain during shoulder abduction and flexion (raising the arm forward or to the side), which leads to loss of functionality and limitation of mobility of the upper limb;
• we see it on the ultrasound.

Here is the conclusion of a research team that identified and evaluated the best treatments for axillary cord syndrome:

Exercise and stretching are the most effective therapies in the field of physical therapy for the rehabilitation of axillary sling syndrome. They help restore joint mobility more quickly, reduce pain, improve quality of life and reduce disabilities.Manual therapy, scar massage, and myofascial release could help improve outcomes, but with less satisfactory results .Baltasar 2023

Source: Baltasar González-Rubino, 2023

How to find a physiotherapist specializing in breast cancer?

There are physical therapists / physiotherapists specializing in breast cancer.

By specialized, I mean:

• who try to take care of more people after breast cancer than the average . And who therefore have more experience in this care. Some people, moreover, do nothing but that;
• who train regularly (by following training or by obtaining documentation) on the subject.

Some physiotherapists group together in associations, are part of learned societies or networks with several professionals.

Depending on the departments and regions, things work differently.

Here are 4 different ways to find a physiotherapist who is used to caring for people with breast cancer :

1. Often, the department in which you were operated on (or simply monitored) can give you a list of private physiotherapists who are used to monitoring post-mastectomy, lymph node dissection, or other situations.
2. You can type in Google and GoogleMaps “specialized breast cancer physiotherapist” or “senology physiotherapist” plus the major city closest to you.
3. You can consult the physiotherapist lists in the following online directories (links at the end of the article):
   • Network of Breast Physiotherapists (you must however fill out a form with your information)
   • IPP: physiotherapists specializing in women’s health; 717 Physiotherapists listed as “Breast Cancer” throughout France
   • AKTL: French association of masseurs-physiotherapists for the research and treatment of lympho-venous disorders
4. You can approach the physiotherapists near you by telephone one by one by asking them the question.

There are directories of physiotherapists specializing in breast cancer , but you can also find physiotherapists not listed in these directories.

Brest cancer physical therapists in US, Australia & Canada

Here are some organizations and resources in the mentioned countries that can help you find breast cancer physical therapists:

United States:

• The American Physical Therapy Association (APTA): APTA’s website allows you to search for physical therapists in your area and filter by specialization, including oncology.
• The American Cancer Society: They provide information on cancer-related services and can guide you to professionals specializing in cancer care.

Australia:

• The Australian Physiotherapy Association (APA): The APA offers a “Find a Physio” tool on their website that allows you to search for physiotherapists specializing in various areas, including oncology.
• Cancer Council Australia: They offer information on cancer support services and may have recommendations for specialized physiotherapists.

Canada:

• The Canadian Physiotherapy Association (CPA): You can use CPA’s website to search for physiotherapists in your area and filter by specialization, including oncology.
• Canadian Cancer Society: They provide resources and support for cancer patients, which may include recommendations for specialized physical therapists.

Breast cancer physiotherapists in UK

In United Kingdom:

• The Chartered Society of Physiotherapy (CSP): CSP’s website offers a “Find a Physio” tool to locate physiotherapists in your area, and you can inquire about those specializing in oncology.
• Macmillan Cancer Support: Macmillan provides resources and support for cancer patients and may have information on specialized physiotherapists.

What breast cancer physiotherapy training to do?

There are numerous training courses dedicated to breast cancer , particularly for physiotherapists. This is what we call medical knowledge and practices concerning the breast and its diseases. 

In women as in men.

You have :

• University or interuniversity diplomas. 
• online or face-to-face training for the day, half-day or over a few days.

Personally, I cannot recommend one training course over another: I am not receptive to these forms of learning.

However, I can describe to you my method for self-training on these subjects: consult from time to time new studies on the subject indexed in Medline (Pubmed), read some international recommendations (in English), consult some French-speaking resources (France , Quebec) (sites, videos) mainly to learn about the practices of fellow physiotherapists.

Still have questions about rehabilitation during or after breast cancer? See you in the comments!

These articles might also interest you:

• Manual lymphatic drainage in physiotherapy: how effective?
• When is it appropriate to buy and put on support socks and stockings?

📚 SOURCES

There are thousands of studies on rehabilitation, recovery during and after breast cancer, or to prevent its appearance:

Directories (France):

• RKS Network of breast physiotherapists https://mailchi.mp/ reseaudeskinesdusein.fr/trouver-un-kine-du-sein
• IPP, Institute of Pelvi-Perineology of Paris. List of physiotherapists specializing in women’s health & breast cancer: https://annuaire.ippp.fr/ annuaire/activites/kinesitherapie-cancer-du-sein
• AKTL: https://aktl.org/

Other physiotherapy & breast cancer training organizations in France: https://mkngformations.fr/ ; https://www.kineautop.com/ prize-en-charge-au-top-de-la-femme-apres-cancer-du-sein/ ; https://www.itmp.fr/ formations/cancer-du-sein/ ; https://fknl.fr/training/cancer-du-sein-formation-kine/ _

International recommendations on physical activity and healthy lifestyle in case of cancer:

1. American Cancer Society (ACS): www.cancer.org
2. World Cancer Research Fund (WCRF): www.wcrf.org
3. American College of Sports Medicine (ACSM): www.acsm.org
4. National Comprehensive Cancer Network (NCCN): www.nccn.org / Guidelines/recommendations for breast cancer here (English and French; those for patients are freely accessible)
5. National Cancer Institute (INCA): www.e-cancer.fr/