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8. Upper Extremity Rehab after Axillary Dissection

Updated 5 March 2007

Limitation of shoulder mobility may occur in as little as two weeks following immobilization. Post-operative physiotherapy is useful for most patients.

This guideline applies to the provision of upper extremity rehabilitation, as well as hand and arm care, for women (or men) who have received axillary dissection as part of the management of breast cancer. Because breast cancer occurs predominantly in women, the remainder of the text will address women with breast cancer.

Recommendations

Upper Extremity Rehabilitation

  • Pre-operative, bilateral upper extremity function, e.g. active range of motion (ROM), strength, sensation, and limb circumference, should be assessed by the surgeon, family physician, or a physical therapist to provide a baseline prior to treatments (1-3).
  • Post-operative physical therapy should begin the first day following surgery. Gentle ROM exercises should be encouraged in the first week after surgery (1,2,4).
  • Active stretching exercises can begin 1 week after surgery, or when the drain is removed, and should be continued for 6-8 weeks or until full ROM is achieved in the affected upper extremity. Women should be instructed in scar tissue massage (1,2,3,5).
  • Post-operative assessments following surgery to include ROM, strength, sensation, limb circumference, and scar and chest wall tissue mobility (1,3,6).
  • Progressive resistive exercises, i.e. strengthening, can begin with light weights (1-2 lbs.) within 4-6 weeks after surgery. A compression sleeve should be worn during any resistive exercises or strenuous upper body athletic activity (2,3,4-7).

Hand and Arm Care

  • Careful hand and arm care, e.g. proper hygiene and avoiding trauma to the arm can minimize risks for infection and lymphedema (8-10).
  • Minimizing the extent of axillary dissection, preventing infection, and avoiding obesity may help prevent the development of lymphedema (9,11-13).
  • Generally, injections, vaccinations, venipuncture, and intravenous access in the axillary-dissected arms and shoulder have been contra-indicated (14-16).There is some evidence (Level V) that these restrictions can be relaxed (17).
  • Many suggestions regarding proper hygiene and trauma avoidance for the axillary-dissected upper extremity are sensible but there is little scientific literature to support these restrictions.

Electrotherapy Modalities

  • Laser treatment, electrical stimulation, microwave, and thermal therapy are not recommended at this time due to insufficient evidence to support their use as well as published precautions and contra-indications for their use in persons with neoplasms.(18-20).
  • Therapeutic ultrasound is contra-indicated over sites of possible metastasis in women with a history of breast cancer (19, 21-23).

Exercise for Cardiovascular Fitness:

Although these guidelines focus on upper extremity rehabilitation, women who have had breast cancer should be encouraged to engage in an ongoing, regular program of moderate, aerobic exercise (24-25). In a study published in 2005, women who exercised 3-5 hours per week (at an aerobic level equivalent to walking a 20-30 minute mile) significantly reduced their risk of recurrence as well as their risk of dying from breast cancer when compared to women who exercised less than 3 hours per week (26).

Objective

To provide evidence-based, clinical practice guidelines for choosing the most effective rehabilitation strategies and the most appropriate hand and arm care after axillary dissection for the management of breast cancer. Clinical practice guidelines are systematically developed to assist practitioners and consumers in making decisions about appropriate care in specific clinical circumstances. Rehabilitation of the upper extremity after axillary dissection in women with breast cancer is poorly addressed by practitioners. To identify the most effective rehabilitation protocols, the Breast Tumour Group at the B.C. Cancer Agency recognized the need for practice guidelines.

Options

Pre-operative assessment of upper extremity function, post-operative rehabilitation and reassessment of upper extremity function, and hand and arm care following axillary dissection.

Outcomes

Range of motion (goniometry), strength, functional mobility, return to pre-surgical activities of daily living and recreational activities.

Evidence

To develop the guidelines, a task force was set up by the Breast Tumour Group of the B.C. Cancer Agency. The task force included physical therapists, women living with breast cancer, medical and surgical specialists. Guideline authors were selected from the task force membership. After consensus was reached by the task force, the guidelines were sent out for external review.

These guidelines are based on a review of published data and expert opinion from the Cancerlit and Medline databases (1966-2000) and from recent breast cancer textbooks. Forty-seven references were reviewed. The treatment guidelines are, whenever possible, evidence-based using Sackett’s rules of evidence(27). The guidelines largely reflect evidence at Levels III-V and sometimes rely on consensus and common sense, due to limited clinical research in this area. Where evidence exists, it will be parenthesized, e.g. (Evidence Level III).

Values

Early post-operative physical therapy has been shown to be both safe (Evidence Levels I-II) and effective in enhancing shoulder ROM and functional abilities in women recovering from breast cancer (Evidence Level III).

Benefits, Risks, and Costs

Benefits include functional and timely recovery of the upper extremity and avoidance of lymphedema and/or cellulitis. There may be increased wound drainage if exercises are initiated too early post-operatively (Day 1). However a number of recent studies (Evidence Levels I-II) have supported both the safety and effectiveness of early post-operative exercise. Stretching exercises during the early post-operative period may assist in breaking up of sclerosed lymphatic vessels (which appear as fine, cord-like structures along the medial surface of the upper arm and forearm). Exercises should provide slow, prolonged stretches, particularly to the shoulder abductors and flexors, with minimal pain or discomfort.

To locate a physical therapist in your area who has special expertise in working with women facing breast cancer surgery or recovering from surgery, ask your doctors or women who had breast cancer, or go to www.bcphysio.org. You do not need a doctor's referral to access physical therapy private clinics. The Medical Services Plan of B.C. no longer covers the cost of private physiotherapy treatments unless you meet low-income criteria. Prior to scheduling your first appointment, discuss the costs for the initial assessment, follow-up appointments and cancellation policy.

Recommendations included in these guidelines, for standard pre- and post-operative assessments and treatments under the direction of a physical therapist would likely require fewer than 12 visits. In cases where complications arise, e.g. post-treatment lymphedema, additional physical therapy visits would be necessary. There may also be costs of compression sleeves, compression pumps, and antibiotic therapy in cases of infection. Many of these costs are covered, at least in part, through extended health plans.

Validation

These guidelines were reviewed by clinical practitioners and by representatives of the B.C. College of Physicians and Surgeons, the Registered Nurses Association of B.C., the College of Physical Therapists of B.C., and the B.C. Council on Clinical Practice Guidelines. The guidelines were then reviewed by the Breast Tumour Group of the B.C. Cancer Agency for final approval. These guidelines will be revised every two years to reflect new information.

Sponsors

This guideline was developed by a task force set up by the Breast Tumour Group at the B.C. Cancer Agency. The task force members included:
Dr. Sharon Allan (Medical Oncologist)
Dr. Carol Dingee (Breast Cancer Surgeon)
Ms. Faye Eddy (Physical Therapist)
Dr. Susan R. Harris (Physical Therapist, Co-editor and breast cancer survivor)
Dr. Brian Haylock (Radiation Oncologist)
Dr. Maria Hugi (Task Force Chair, Co-editor, Emergency Physician and breast cancer survivor with lymphedema)
Dr. Winkle Kwan (Radiation Oncologist)
Ms. Sherri Niesen (Physical Therapist)
Ms. Cynthia Webster (Physical Therapist)

Additional Resources

For more detailed information, refer to:

  1. Harris SR, Campbell KL, McNeely ML. Upper extremity rehabilitation for women who have been treated for breast cancer. Physiother Can. 2004;56:202-214.
  2. Harris SR, Hugi M, Olivotto IA, et al. Upper extremity rehabilitation after axillary dissection for the treatment of breast cancer: Clinical practice guidelines. Crit Rev Phys Med Rehabil. 2001;13:91-103.