Breast cancer related dysfunctions



Breast cancer-related dysfunction of the lymphatic system and subsequent lymphedema of the upper extremity is a somewhat common and potentially serious complication of the treatment for breast cancer. It is estimated that 15% to 20%63 or as many as one in four patients29 with invasive breast cancer develop upper extremity lymphedema during or sometime after the course of treatment. Current treatment usually involves removing a portion or all of the breast accompanied by excision or irradiation of adjacent axillary lymph nodes, the principal site of regional metastases. Axillary dissection places a patient at risk not only for upper extremity lymphedema but also for loss of shoulder mobility and limited function of the arm and hand.  In addition, chemotherapy or hormonal therapy may also be employed.

Breast Cancer

Guidelines for Management After Breast Cancer Surgery

Guidelines for postoperative management for the patient who has undergone a mastectomy or breast-conserving surgery and who may currently be receiving adjuvant therapy. The guidelines identify therapeutic interventions for common impairments during the early postoperative period and those that could develop at a later time.

Special Considerations

Patient education

 The length of stay for patients after surgery for breast cancer is short. Therefore, direct intervention by a therapist starts on the first postoperative day with an emphasis on patient education for prevention of postoperative complications and impairments, including pulmonary complications, thromboemboli, lymphedema, and loss of shoulder mobility. Recommendations for preventing lymphedema or for self-management if it develops are reviewed with the patient .


The postoperative exercise program focuses on three main areas: improving shoulder function, regaining an overall level of fitness, and preventing or managing lymphedema. Early, but protected, assisted or active ROM of the shoulder is the key to restoring shoulder mobility. Postoperative risks that contribute to restricted shoulder mobility were summarized previously . These risks are highest during the early postoperative period until drains have been removed and the incision has healed.

Breast Cancer

 Radiation therapy to the axillary and breast areas can delay wound healing beyond the typical 3- to 4-week period.  Even after initial healing of the incision, the scar has a tendency to contract and can become adherent to underlying tissues, which, in turn, can restrict shoulder motion. Although strengthening exercises and aerobic conditioning are important for upper extremity function and total body fitness, moderation in an exercise program is imperative. Exercises must be progressed gradually, excessive fatigue must be avoided, and energy conservation must be emphasized, especially if the patient is undergoing chemotherapy or radiation therapy.


 Shoulder exercise should be performed within protected ROM, usually no more than 90_ of elevation of the arm until after removal of drains. Observe the incision and sutures carefully during exercises. Avoid any tension on the incision or blanching of the scar during shoulder exercises. Avoid exercises with the involved arm in a dependent position. Progress graded exercise program very slowly, particularly if the patient is receiving adjuvant therapy.


Breast Cancer

Impairments and Complications Related to Breast Cancer Treatment

The following impairments and complications may occur in association with treatment of breast cancer. Many of these problems are interrelated and must be considered jointly when a comprehensive postoperative rehabilitation program is developed for the patient.

Postoperative Pain

Incisional pain

 A transverse incision across the chest wall is made to remove the breast tissue and underlying fascia on the chest musculature. The incision extends into the axilla for lymph node dissection. Postoperatively, the sutured skin over the breast area may feel tight along the incision. Movement of the arm pulls on the incision and is uncomfortable for the patient. Healing of the incision may be delayed as the result of radiation therapy. Delayed wound healing, in turn, prolongs pain in the area of the incision.

Posterior cervical and shoulder girdle pain

 Pain and muscle spasm may occur in the neck and shoulder region as a result of muscle guarding. The levator scapulae, teres major and minor, and infraspinatus often are tender to palpation and can restrict active shoulder motion. Decreased use of the involved upper extremity after surgery due to pain sets the stage for the patient to develop a chronic frozen shoulder and increases the likelihood of lymphedema in the hand and arm.

Postoperative Vascular and Pulmonary Complications

Decreased activity and extended time in bed increase venous stasis and the risk of DVT. Risk of pulmonary complications, such as pneumonia, also is higher because of the patient’s reduced activity level. Incisional pain may make the patient reluctant to cough or breathe deeply, both of which are necessary postoperatively to keep the airways clear of fluid accumulation.


As noted previously, patients who undergo any level of lymph node dissection or whose treatment regimen includes radiation therapy remain at risk throughout life for developing ipsilateral upper extremity lymphedema. Lymphedema can occur almost immediately after lymph node dissection, during the course of radiation therapy, or many months or even years after treatment has been completed. It is typically evident in the hand and arm but occasionally develops in the upper chest or back area.

In turn, lymphedema leads to impaired upper extremity function, poor cosmesis, and emotional distress.

Breast Cancer

Chest Wall Adhesions

Restrictive scarring of underlying tissues on the chest wall can develop as the result of surgery, radiation fibrosis, or wound infection. Chest wall adhesions can lead to increased risk of postoperative pulmonary complications, restricted omobility f the shoulder, postural asymmetry and dysfunction, and discomfort in the neck, shoulder girdle, and upper back.

Decreased Shoulder Mobility

It is well documented that patients may experience temporary and sometimes long-term loss of shoulder mobility after surgery or radiation therapy for treatment of breast cancer.

Weakness of the Involved Upper Extremity

Shoulder weakness

 If the long thoracic nerve is traumatized during axillary dissection and removal of lymph nodes, this results in weakness of the serratus anterior and compromised stability of the scapula, limiting active flexion and abduction of the arm. Faulty shoulder mechanics and use of substitute motions with the upper trapezius and levator scapulae during overhead reaching can cause subacromial impingement and shoulder pain. Shoulder impingement, in turn, can be a precursor to a frozen shoulder. If the pectoralis muscles were disturbed, which occurs with a radical mastectomy for advanced disease, weakness is evident in horizontal adduction.

Decreased grip strength

 Grip strength is often diminished as the result of lymphedema and secondary stiffness of the fingers.

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