THE ROLE OF PHYSIOTHERAPY IN BREAST CANCER REHABILITATION

Source: http://www.unitehealth.com.au/the-role-of-physiotherapy-in-breast-cancer-rehabilitation/

Susan Czyzo (Bachelor of Physical Education and Health, Master of Science in Physical Therapy)

The Australian Institute of Health and Welfare estimates 16,084 new cases of breast cancer in Australia in 2016, amounting to 12.3% of all new cancer diagnoses (27% of all new cancers in females) and 6.5% of all deaths from cancer. Although the incidence of breast cancer has tripled in thirty years (1982 to 2012), the likelihood of surviving at least 5 years after diagnosis is currently at 90%. Being labelled a survivor of breast cancer, however, does not automatically translate to a clean bill of health. There are a number of additional health obstacles that many women experience following breast cancer treatment. Fortunately, physiotherapists possess the skills necessary to lessen or even eliminate these obstacles.

LYMPHOEDEMA

All women who undergo breast cancer surgery are at risk of developing lymphoedema, which may not appear until months or even years post surgery. Risk is higher for women who have undergone a full axillary lymph node dissection.  Radiation treatment may also cause, or if already present, exacerbate lymphoedema. Pain, loss of range of motion and strength in the upper extremity, as well as impaired function are common effects of lymphoedema.

As exercise has shown to be a safe and essential part of lymphoedema management, physiotherapy can play a meaningful role in prevention and treatment. It’s important to be aware that different types of exercise can be beneficial. For example, sustained periods of deep inspiration such as with aerobic exercise help by enhancing venous and lymphatic return. Flexibility training, alternatively, minimizes tightness associated with scarring, a contributor to the blocking of lymphatic flow. Hydrotherapy, with the movement of water exerting a healthy level of compression on the body, is also believed to aid in improving lymphoedema.

In addition to prescribing and supervising a specialized exercise program, kinesiotaping and education on activities or movements that trigger lymphoedema are other ways that physiotherapists can assist with lymphoedema management.

BONE LOSS

The rate and magnitude of bone loss caused by cancer treatment is significantly higher than age-related bone loss in the non-cancer population. Chemotherapy-induced premature menopause and anti-estrogen therapies, for example, are believed to contribute to the increased rate and magnitude in this population.

As within the general population, initial management for decreased bone density includes education on the benefits of a lifestyle that includes, among other interventions, regular weight-bearing exercise. Physiotherapists are able to confidently advise these individuals on safe exercise options to maximize bone integrity.

 UPPER EXTREMITY DYSFUNCTION

Decreased range of motion, rotator cuff strain, adhesive capsulitis, paraesthesia and weakness are all common developments in the upper extremity post breast cancer surgery and/or radiation therapy. Whether appearing independently or in combination, these impairments can severely impact activities of daily living and employment, resulting in functional disability and a decreased quality of life.

Physiotherapy has been shown to be effective in managing post-surgical musculoskeletal symptoms. For example, exercise rehabilitation has shown to result in clinically meaningful improvements in shoulder range of motion.

FATIGUE

Fatigue is a frequently reported yet poorly managed symptom reported by cancer patients. It is a complex symptom with various overlapping causes, some of which include anaemia, pain, sleep disturbance, thyroid dysfunction, and mood disorders. Physiotherapists can help their cancer patients manage fatigue through a focused history screening to determine the main contributors; by teaching the importance of planning and pacing their day; by designing a graduated exercise program to increase strength and energy levels; and through GP referral if the cause of their fatigue requires further investigation.

PAIN

Another complex symptom with multiple causes reported by cancer patients is pain, often requiring a multi-disciplinary approach to management. A physiotherapist’s role in pain management comes in the form of exercise prescription and acupuncture, both of which have been shown to be effective treatments for pain in this population.

THE IMPORTANCE OF PROMOTING AND PRESCRIBING PHYSICAL ACTIVITY

Engagement in regular physical activity is routinely stressed as a key preventive measure for many chronic health problems and breast cancer is no exception. However, it appears that historically healthcare professionals have been overly conservative with exercise prescription in cancer rehabilitation. The literature reports that many cancer survivors are not meeting standard exercise guidelines. Within breast cancer survivors, strength guidelines in particular are not being met. Today’s guidelines within cancer rehabilitation recommend the following:

Return to normal daily activities as soon as possible after diagnosis as early exercise interventions are showing to be more effective that delayed interventions. Exercise is safe during chemotherapy and radiation treatment and therefore patients should be encouraged to maintain their activity level during treatment as much as possible.

For substantial health benefits, patients should aim for at least 150 minutes of moderate aerobic exercise or 75 minutes of vigorous aerobic exercise per week. Strength training should be completed at least 2x/week. Gradual intensity weight-training is a safe way to improve upper limb strength without increasing the risk of lymphoedema.

PILATES AND BREAST CANCER

Clinical Pilates exercises taught by a physiotherapist are an excellent starting point for addressing any of the above listed health concerns post breast cancer treatment. With its focus on core engagement, precision and flow of movement, Pilates is an ideal exercise form for developing efficient movement; is safe for painful joints and muscles; and is easily adaptable to fit within pain, fatigue, and energy levels, as well as with upper extremity dysfunction. The focus on posture that Pilates involves also makes it a great option for addressing the postural changes that present post breast-cancer surgery. In addition, the diversity of Pilates allows it to be a challenging exercise option as strength and function improves post treatment.

SPECIAL CONSIDERATIONS

Be familiar with the common medical treatments for cancer and recognize that they are cancer-specific and are constantly changing. Keep in mind pre-existing health issues and fitness levels.

Adverse effects of cancer treatments may appear months or years after the completion of treatment and may present in multiple body systems.

 REFERENCES

Australian Institute of Health and Wellness. (2016). Breast cancer in Australia. Retrieved from http://www.aihw.gov.au/cancer/breast/

Loh, S. Y., & Musa, A. N. (2015). Methods to improve rehabilitation of patients following breast cancer surgery: a review of systematic reviews. Breast Cancer, 7, 81-98. doi: 10.2147/BCTT.S47012

Mc Neely, M. L., Campbell, K., Ospina, M., et al. (2010). Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database of Systematic Reviews. doi 10.1002/14651858.CD005211.pub2

Runowicz, C. D., Leach, C. R., Henry, N. L., et al. (2015). American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. Journal of Clinical Oncology. doi 10.1200/JCO.2015.64.3809

Schmitz, K. H., Courneya, K. S., Matthews, C., et al. (2010). American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Medicine and Science in Sports and Exercise.doi 10.1249/MSS.0b013e3181e0c112

University Health Network Princess Margaret Cancer Centre. (2015). Clinical Practice Guidelines, Breast Site. Retrieved from http://www.uhn.ca/PrincessMargaret/Health_Professionals/Programs_Departments/Documents/CPG_Breast_BreastCancer.pdf

Defending the Deadlift

  Source: http://www.healigo.com

Hollan Oliver DPT, OCS, SCS

Defending the Deadlift

By Matt Quinn

Introduction: 

Helen returns home from a routine trip to the grocery store with several bags. She decides to take the two heaviest bags into the house first. As she approaches her front door, she sets the bags down, retrieves her keys, and unlocks her front door. Helen then thinks about the safest way in which she can lift the bags off the ground. She first tightens her core and sets her back in tight extension. She then hinges at her hips, and lowers herself through slight knee flexion to bend over and grasp the bags. From here, Helen maintains the angle between her torso and hips, drives her feet into the ground and stands with fully extended knees and hips. Helen has just completed a safe, and successful deadlift.

One of the greatest risk factors for functional limitations and disabilities in middle-aged to older adults is muscular weakness (Volakis et al, 2015). Thus, a muscular strengthening component should be incorporated into fitness programs for individuals in this age range (“Why Strength Training”, 2010). Specifically, fitness instructors should aim to strengthen functional movement patterns that produce transferability into activities of daily living. Functional movements patterns are based on the way our bodies are designed to move, and they mimic the biomechanical demands life places upon us. Functional movements are multi-planar, multi joint, core to extremity movements. So, is the deadlift a functional movement? As we saw in the anecdote above, the deadlift presents itself in real life situations, but does it fit the other criteria? The answer is yes.

Multi-Planar

The deadlift requires motion or stability in all three planes. The first, and perhaps most obvious, is the sagittal plane. We move through the sagittal plane as we lift the bar up off the ground. The second plane of motion is the frontal plane, which represents side-to-side motion. As we lift the bar off the ground, we must stabilize the bar in a manner that allows both sides of the bar to be elevated off the floor simultaneously. A lack of stability in this plane would result in a lopsided bar as it is lifted. Finally, the deadlift also requires stability in the transverse plane. Stability in the transverse plane resists rotational movement of the bar (Robertson, 2012). If an individual were unstable in the transverse plan, they would twist or rotate as they lifted the bar.

http://santabarbarastrength.com/stack-the-bones/

Multi-Joint

The primary joints used for force production during the deadlift are the hips, knees and ankles. The deadlift requires activation in the ankle plantar flexors and knee extensors, but demands the most significant amount of activation from the hip extensors and knee flexors (Escamilla, 2000). To better understand movement at these joints, we will re-visit Helen’s task of lifting her grocery bags, starting from the ground and moving up.

Ankle plantar flexion is achieved primarily through activation of the gastrocnemius and soleus muscle groups. Plantar flexion is loosely defined as downward movement of the foot. A good example of plantar flexion is the “push off” motion of our foot during walking (Neptune, 2001). Although her feet would remain in contact with the ground, Helen would be using her plantar flexors to push into the ground and help initiate movement of the bar.

Knee flexion is achieved through activation of the muscles of the hamstring. Although her starting position is achieved mainly through hip flexion, slight knee flexion is required in order for Helen to position herself correctly. Ideally, the proper amount of knee flexion would place her shins perpendicular to the floor. This degree of knee flexion must be maintained as the bags are lifted until hip extension has been initiated.

The quadriceps muscles assist the gluteus maximus and hamstring in producing hip extension in addition to acting as the primary knee extensors (Frigo et al., 2010). As Helen lifts the bags off the floor, the contraction of her quadriceps would oppose the actions of the gluteus maximus and hamstring, thus stabilizing her knee position in slight flexion. With a fixed knee position, her gluteus maximus and hamstring can produce maximal hip extension once the bags have reached knee level. As she extends her hips and no longer requires knee flexion, the contraction of her quadriceps extends, or straightens, her knees from their previously flexed position.

http://imhealthtoday.com/abs-workout-legs-2.html

Core to Extremity

Lifting any object off the floor, particularly a heavy one, requires both movement and stability of our core, depending upon which plane of movement we consider. When discussing core to extremity movement, it is important to understand that our body’s core is comprised of many muscle groups that work in conjunction to move or stabilize the core. While some core muscles may be acting to move the core in the sagittal plane, others will be activated in order to stabilize our torso in the frontal and transverse planes. Multiple layers of abdominal, oblique, spinal, and hip musculature work in conjunction to move and stabilize the core (Di Jensen, 2013) (Conneely, 2006). Movement with a stable core is imperative so that we ensure structural safety through efficient production and transfer of force from the core to our extremities (Bliss, 2005).

The deadlift is the epitome of a core to extremity movement, requiring significant activation of primary core muscles (Hamlyn, 2007). We use the core musculature to stabilize the spine while simultaneously moving the trunk towards the ground in order to reach the object. From this position, our stable core allows for transfer and production of force through our ankles, knees, hips, back, and arms as we safely elevate the object from the floor.

https://memoirsofasecondyear.files.wordpress.com

Conclusion

The deadlift is often criticized as a dangerous exercise that simply leads to injury, when in fact it is a basic human movement. While it is possible to injure yourself without proper instruction, the deadlift is a functional movement that our anatomy is built to execute. The deadlift is one of the most effective ways to train not only the posterior chain and core, but it also aids in the development of the assisting muscle groups, like the quadriceps. These muscle groups are of critical importance to everyone, whether it is an elite athlete looking to improve performance, or a father wishing to be able to safely lift his son off the ground. For these reasons, the deadlift should be an integral part of most, if not all physical activity regimens in order to best prepare individuals for the demands placed upon them by their activities of daily living.

Healigo is a Boston-based technology company building a patient adherence platform that enhances the clinician-patient relationship. To find out how Healigo can help streamline your practice, drive referrals and improve outcomes click here. 

GET A FREE 30 DAY TRIAL OF HEALIGO

START YOUR FREE TRIAL NOW

About the Author: Matt Quinn is a graduate of UMass Amherst where he majored in Kinesiology and played quarterback for the Minutemen. In addition to being a medical student at Brown University, he has amassed over 1000 coaching hours as a crossfit instructor at Full Range Crossfit in Providence, RI. 

References

Bliss, L., & Teeple, P. (2005). Core stability: The centerpiece of any training program. Current Sports Medicine Reports, 4(3), 179.

Conneely, M., O'Sullivan, K., & Edmondston, S. (2007). Dissection of gluteus maximus and medius with respect to their suggested roles in pelvic and hip stability: Implications for rehabilitation?. Physical Therapy in Sport, 7(4), 176.

Di Jensen, E. (2013). What are the core muscles of the body?. Retrieved 5/10, 2015, fromhttp://www.livestrong.com/article/98988-core-muscles-body/

Escamilla, R., Fransisco, A., Fleisig, G., Barrentine, S., Welch, C., Kayes, A., et al. (2000). A three-dimensional biomechanical analysis of sumo and conventional style deadlifts. Medicine and Science in Sports and Exercise, 32(7), 1265--1275.

Frigo, C., Pavan, E., & Brunner, R. (2010). A dynamic model of quadriceps and hamstrings function.. Gait and Posture, 31(1), 100.

Hamlyn, N., Behm, D., & Young, W. (2007). Trunk muscle activation during dynamic weight-training exercises and isometric instability activities.  . Journal of Strength and Conditioning Research, 21(4), 1108.

Neptune, R., Kautz, S., & Zajac, F. (2001). Contributions of the individual ankle plantar flexors to support, forward progression and swing initiation during walking. Journal of Biomechanics,34(11), 1387.

Robertson, M. (2012). Saggital plane first. Retrieved 5/11, 2015, fromhttp://robertsontrainingsystems.com/blog/sagittal-plane-first/

Volaklis, K. A., Halle, M., & Meisinger, C. Muscular strength as a strong predictor of mortality: A narrative review. European Journal of Internal Medicine, (0)

Why strength training?. (2011). Retrieved 5/10, 2015, fromhttp://www.cdc.gov/physicalactivity/growingstronger/why/