M Y TWO CENTS: PT is short for “Physical Therapy.” My mom was a physical therapist and I didn’t realize what an important profession PT is until I became a patient undergoing PT. I was blessed to have a wonderful physical therapy team at Physical Therapy Advantage http://www.ptadvantagepc.com/ in North Aurora, IL that were treating me for another ailment just before I was diagnosed with DCIS. Rebecca Johnson has specific certifications for lymphodema (see Lymphodema page under Medical tab) and previous experience with mastectomy issues, so I underwent six weeks of PT for one hour three times a week to restore range of motion, lengthen my bicep tendon and break up my scar adhesions. NOTE: This is not a typical post mastectomy issue, but my body doesn’t seem to read the books or know what ‘normal’ is. If you’d like to visit a site for more information on movement after breast cancer surgery, Lisa sent me this link that she found helpful http://breastcancer.about.com/od/lifeaftertreatment/ss/arm_exercises_tutorial.htm.
Please read the Q & A with Rebecca below and visit the lymphodema page to get a better understanding of the importance of movement soon after surgery. Here are the questions I’ve asked Rebecca, so you can scan them and see if any interest you. Then scroll down to the one/s that you want to read.
1. Please tell me all your credentials and acronyms at the end of your name and what they mean.
2. Tell me about lymphedema and what happens to the body and why.
3. What types of exercises would you recommend for post op patients of a mastectomy? Would you have any illustrations you can share with readers?
4. What are the things you can recommend post mastectomy to avoid or minimize problems?
5. In a ‘perfect world,’ what role do you see yourself as having in the care of mastectomy and breast cancer patients?
REBECCA JOHNSON, PT, CLT, OCS, CMPT
DRAFT Q & A Interview with Rebecca Johnson, PT, CLT, OCS, CMPT – June 21, 2011
1. Britta’s Question: Please tell me all your credentials and acronyms at the end of your name and what they mean.
Rebecca’s Answer: I received my Master’s Degree in Physical Therapy (PT) in 1999 from Midwestern University, Downers Grove, IL. and soon after, became a Certified Lymphedema Therapist (CLT) in 2000. I continued my education and become an Orthopedic Certified Specialist (OCS) in 2011 through the APTA and a Certified Manual Physical Therapist (CMPT) through Andrew’s University, Berrien Springs, MI, in 2011. Currently, I am working towards a Chi Running instructor certification and in the future, I hope to collectively use my knowledge towards a Doctorate of Science degree in Physical Therapy through Andrew’s University. I enjoy getting the best results from my patients which means never settling with my current level of education. I strive to be a health care provider that my patient’s trust and feel confident in knowing they are receiving exceptional care.
2. Britta’s Question: Tell me about lymphedema and what happens to the body and why.
Rebecca’s Answer: The lymphatic system is another type of circulatory system made up of various vascular structures and regional and central lymph nodes. The entire system functions as a drainage and transport system of lymph fluid. Lymphatic fluid is made up of proteins, fat, cells, chemicals and even, foreign organisms like viruses and bacteria. Following a mastectomy, alteration of the lymphatic system can occur with the removal of cancerous lymph nodes. Once those lymph nodes are removed, the lymphatic fluid is unable to drain out of the regional area of a leg, arm, chest or abdominal wall or face depending on the involved region. The body will still attempt to function normally for example after a small cut or bruise, it will send increased lymphatic fluid to the area yet the body is unable to drain it naturally from the region. Another example, is with an increase in exercise, heavy lifting or pushing/pulling motions. This increased activity, increases muscle activity which increases blood flow to that region without the ability to drain naturally. Once diagnosed with lymphedema, it does not naturally go away on its own. Left unattended the symptoms will only worsen over time. With this being said, there is treatment to prevent the excessive build up of lymphedema. It is termed, Complete Decongestive Physiotherapy (CDP). CDP consists of four components: manual lymphatic drainage, compression bandaging, remedial exercises and meticulous skin and nail care. Seek out a physical therapy consultation for more detailed information and educational handouts.
STATS: 10-15% of mastectomy patients develop lymphedema in their lifetime.
1) Manual lymphatic drainage, which is a specific massage technique. The PT acts as the pump in the lymphatic system, routing the fluid around the area where there are no lymph nodes to another area (axilla or groin) of lymph nodes that are still working.
2) Compression bandaging – once you develop lymphedema you always have to have a certain amount of pressure on your arm (or affected area), otherwise it will continue to fill and flare up. It is tougher in the summer when it is hot out. Gardeners and teachers are susceptible to getting small cuts (and paper cuts) that can easily become affected.
3) Range of Motion (ROM) exercises
3. Britta’s Question: What types of exercises would you recommend for post op patients of a mastectomy?
Rebecca’s Answer: Overall I look at how well is the body responding with any type of reconstruction. I haven’t seen much with scar tissue adhesions, but any surgery with an incision can produce trauma to the body and a result can be the body overproducing scar tissue. I treat surgical incisions very similarly. The body sometimes doesn’t accept the implant well. There is not a whole lot PT can do, but they are a conservative approach and an alternative to surgery. Drains can be an issue. It is scar tissue and adhesions, but it has to do with direction. The line of scar tissue follows the line of their entrance. A drain is a line that pulls in towards the body; it is more like a puncture wound, which is more serious. The scar tissue is even deeper with a scar from a drain. A mild facial glide is the technique used. The shoulder can see a decrease in the range of motion, mostly from protective patterns. After a patient has a mastectomy the whole area is painful and the body tends to want to hunch and curl up in a ball to avoid pain. I tent to see that in our posture patients, even those that work at a computer. I work at getting those tissues to relax and increase the patient’s ability to reach to the sides and increasing ROM with affected joints. I use stretching and hands on manual therapy – a three planer mild facial release to loosen adhesions and scar tissue. As the skin is one large organ there are layers of connective tissue under the skin that can become tight and pull in different directions, causing pain. I look at it like a spider web and as far as scar tissue adhesions can pull in areas where you had the incision.
4. Britta’s Question: What types of exercises you can recommend post mastectomy to avoid or minimize problems?
Rebecca’s Answer: The initial phase of physical therapy (5-7 days following surgery) focuses on controlling pain, swelling and avoidance of developmental posture problems. Typically, patients are sent home with post-operative instructions to follow and yet, a problem area develops when a patient hold their arm close to their body in order to protect the surgical site. The surgical site is normally painful from surgery and uncomfortable due to the change in appearance yet holding the arm in such a position leads to shoulder tightness, excessive tissue adhesions (scar tissue) and increased pain. I educate patients on shoulder positioning with pillows at rest, posture exercises to avoid excessive protective postures and gentle shoulder movements to keep tissues gliding well throughout the shoulder region. Over the next 2-3 weeks, physical therapy focuses on shoulder and upper body range of motion and soft tissue mobility (easy gliding of the skin, incision, muscles, connective tissue). Incision areas can become problematic due to excessive scar tissue tightness. Treatments during this phase include gentle shoulder and upper body stretching, myofascial release techniques, ASTYM (form of manual therapy that releases scar tissue adhesions and increases circulation to healthy tissues) and gentle strengthening. At 4 weeks, gently strengthening begins and physical therapy continues posture exercise, range of motion and soft tissue mobility as needed.
5. Britta’s Question: In a ‘perfect world,’ what role do you see yourself as having in the care of mastectomy and breast cancer patients?
Rebecca’s Answer: In a “perfect world”, the physical therapist is a pre-operative team member to educate the patient on what to expect and what to be aware of following their mastectomy procedure. Unfortunately, we are typically consulted after the patient develops lymphedema and the patient doesn’t know what to do or what not to do. They are frustrated with the lack of information received from the surgeon or post-surgical nurse regarding the potential risk of developing lymphedema. It is vital to be proactive with the potential side-effects of a mastectomy rather than, reactive once lymphedema becomes a real diagnosis for a patient. I recommend that patients find a physician who provides lymphedema information, with the understanding that it may be overwhelming at first. In the “perfect world” of health care and post-surgical mastectomy patients, allow this information to be a preventative benefit to the patient.