Breast cancer is one of the most common malignant tumors that seriously endanger women’s physical health and psychological health. At present, surgery still occupies an important position in the comprehensive treatment of breast cancer. With the advancement and improvement of medical treatment, although the surgical methods have been improved and perfected, they still cause great trauma to the body, and the common postoperative complications – upper limb lymphedema and shoulder joint dysfunction – are still a major unsolved problem in clinical practice.
A large number of studies have shown that postoperative upper limb lymphedema seriously affects the quality of life of patients, and it has become an independent predictor of quality of life decline in breast cancer. The incidence of postoperative lymphedema is reported to be about 30% in foreign countries, while some domestic reports suggest that the incidence of postoperative lymphedema can be as high as 62% even with modified radical surgery.
If postoperative exercises are not timely or appropriate, resulting in local soft tissue adhesions in the shoulder joint, the function of the shoulder joint may be limited in all directions, and it may be difficult for the patient to take care of himself in daily life. The adhesions can also affect the blood circulation of the affected upper limb, and if the adhesions are heavy, they can aggravate edema.
Studies have also shown that timely and effective postoperative rehabilitation or exercise can help prevent the occurrence of edema and dysfunction of the affected upper limb. In order to improve the postoperative quality of life of breast cancer patients, improve postoperative shoulder joint dysfunction and prevent the occurrence of lymphedema, it is recommended that patients should actively perform rehabilitation exercises after surgery.
At present, there is no unified standard for postoperative upper limb functional rehabilitation training after breast cancer surgery, and it is often divided into several stages according to the postoperative time for different targeted exercises. Different rehabilitation programs may differ in terms of time division and specific movements, but it is generally agreed that functional exercise should follow the principle of early and gradual progress.
Based on the physiopathological characteristics of postoperative breast cancer and the feedback from patients after surgery, we have summarized our own set of postoperative rehabilitation exercises based on many years of clinical experience, in order to adapt to the functional exercises at different times after surgery. This set of rehabilitation exercises is divided into three stages according to the postoperative time, and the movements and requirements of different stages are different, as follows.
1.Phase I: The time range is about 0-7 days after surgery. In this stage, functional training of finger joints and metacarpophalangeal joints is the main focus. Attention should be paid to shoulder joint braking during training to guard against postoperative subcutaneous bleeding, which may affect wound recovery and cause other adverse effects.
Specific methods are.
(1) Finger stretching exercise: children’s game “rock, paper, scissors, cloth” can be played alternately, the affected side of the finger alternate finger flexion exercise one by one, suitable for 1-2 days after surgery.
(2) Ball grip and ball squeezing exercise: the affected side of the hand holds an elastic ball or metal ball, and the affected side of the thumb and index finger squeeze the elastic ball or metal ball, suitable for 3-4 days after surgery.
(3) Fingertip kneading exercise: Hold several sheets of paper one by one into a doughnut, and knead the doughnut surface with the fingertips of the affected side, moving clockwise and then counterclockwise, repeatedly, for about 5 days after surgery.
Practicing the above movements helps to ensure normal function of the metacarpal and finger joints, and also promotes peripheral circulation of the affected upper limb, which helps to relieve edema caused by surgical trauma. Each time is about 10 minutes, 4~5 times a day, or can be increased or decreased according to the patient’s post-operative physical condition.
2. Phase 2: The time range is about 7-14 days after surgery. This stage is based on shoulder joint inversion, forward flexion, back extension, and abduction movements, with an action angle of 30~45 degrees, the size of the angle may depend on the actual situation, but it is appropriate to elevate the shoulder joint no more than 90 degrees to avoid over-stretching the wound and affecting the normal recovery.
Specific methods are.
(1) Ball throwing exercise: The affected hand throws the elastic ball, and then catches it by means of the leather band, repeatedly. Especially suitable for patients with limited anterior flexion function.
(2) hair combing exercise: alternate the comb with the affected hand and the healthy hand, and repeat several times. Pay attention to the exercise to keep the head in a neutral position as far as possible, do not deviate or turn to the left or right. It is especially suitable for patients with limited adduction and abduction function. Also suitable for patients with limited supination function.
(3) Pendulum movement: in an upright position, arms straight and abducted, then inward and crossed, repeated several times, like a pendulum movement; or in an upright position, upper body leaning forward, hands swinging back and forth, slightly wider than shoulder width. This is especially suitable for patients with limited internal and external functions, and it is also helpful for patients with limited posterior extension functions.
(4) Shoulder shrugging exercise: The patient shrugs the shoulders and moves the shoulders in a circle, repeatedly. This is helpful to relax the local muscles of the shoulder joint.
(5) Wall climbing gymnastics: Use the hand on the healthy side to reach upward along the wall to the highest point, and use this as the target exercise for the affected limb. First, face the wall and start climbing upward along the wall with both hands from the shoulder, gradually raising the touching point of the upper limb on the affected side; then turn sideways to the wall, perpendicular to the wall, and start climbing upward along the wall with the upper limb on the affected side from the shoulder, gradually raising the touching point of the upper limb on the affected side. Note that after climbing to the highest point, stay for a moment so that the adherent soft tissues can be fully separated, and then slowly climb down from the highest point, which can avoid the severe pain when putting down quickly. When climbing the wall sideways, always keep the body upright and do not turn the upper body. It is especially suitable for patients with limited forward flexion and abduction function. Also suitable for patients with limited supination function.
(6) Windmill exercise: straighten both upper limbs to both sides as much as possible, repeatedly turn the palms up and down with the whole arm; or first abduct both upper arms, then bend the upper arm on the healthy side in front of the chest, abduct the affected arm, turn the waist to the affected side, return to double upper arm abduction, then put the affected upper arm in front of the chest, abduct the healthy arm, turn the waist to the healthy side, repeatedly alternate. Suitable for patients with limited adduction, abduction and posterior extension function.
(7) Rope pulling exercise: Place a rope belt on a clothesline or door handrail, hold both ends of the rope with both hands and pull the rope with the healthy hand to stretch the shoulder joint on the affected side. This is especially suitable for patients with limited abduction function. It is also suitable for patients with limited supination function.
(8) Back washing exercise: Place an elastic band or towel on the back, hold both ends of the elastic band or towel with both hands, with the healthy hand on top and the affected hand on the bottom, pull the elastic band or towel with the healthy hand to stretch the shoulder joint of the affected upper limb. This is especially suitable for patients with posterior extension dysfunction.
The above movements are designed to prevent and treat the dysfunction of the affected shoulder joint, loosen adhesions, promote blood circulation in the affected upper limb and shoulder, and prevent edema. Each time for 20 minutes, 4~5 times a day. If the dysfunction is obvious, you can focus on doing the corresponding training.
3. Phase 3: From about 15 days after surgery onwards, all belong to this phase. The rehabilitation training in this stage can extend the movements of the second stage, but the amplitude of the movements should be increased so that the shoulder joint activities in all directions can be normalized as much as possible.
(1) Thoracic expansion exercise: bend both elbows, clench both hands in front of the chest and brace the chest backward; abduct both upper arms and brace the chest backward with force, repeatedly and alternately. It is helpful for patients with limited posterior extension function.
(2) Upper arm exercise: extend both upper arms forward; gradually lower them to the sides of the body, then abduct and straighten both upper arms upward, repeatedly in that order. This is useful for patients with limited forward flexion, abduction and supination.
(3) Rotating arm exercise: Abduct both upper arms and rotate them outward and backward as much as possible with the shoulder level as the center. This is helpful for patients with abduction and posterior extension dysfunction.
(4) Over-the-top ear touching exercise: the upper limb on the healthy side goes around the top of the head and touches the ear; the upper limb on the affected side goes around the top of the head and touches the ear, alternating repeatedly. This is useful for patients with abduction and supination dysfunction.
(5) Item tied skirt exercise: place both hands behind the neck, back and waist, and do necklace tying, skirt trouser-like or close both fingers. It is helpful for patients with supination and posterior extension dysfunction.
This stage of rehabilitation training should be continued and should be done consciously during daily work and household chores. The number of times and the duration of the training should be such that the affected limb is not overworked until the affected limb fully recovers its function.
When exercising according to the above three stages, we should pay attention to the fact that due to the different characteristics of the patient’s condition, the chosen surgical method and physical constitution, the recovery status after surgery will be different, so it is better to carry out the specific training progress and intensity under the guidance of the physician for more targeted and better results.
Studies have shown that the incidence of lymphedema in the upper extremities tends to increase year by year as the postoperative period increases, with some studies suggesting that 77% of patients develop lymphedema within 3 years after surgery, and the incidence of lymphedema increases at a rate of 1% per year afterwards. Therefore, not only should we carry out active exercise after surgery, avoid as much as possible the factors that cause or aggravate edema in daily life, but also should consciously do more positive behaviors, such as from the third stage, we can use self-massage, perform centripetal patting and stroking, that is, gently patting from the hand to the shoulder direction, or pushing from the hand to the shoulder and axillary direction with certain strength, so as to promote blood and lymphatic circulation to prevent or relieve edema.