Breast Cancer Rehabilitation Using a Pilates Based Approach

Report
Women onto Wellness™
Naomi Aaronson, MA OTR/L, CHT
Ann Marie Turo, OTR/L,
Pilates, Yoga, and Reiki Master
MAOT Annual Conference 2010
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Upon completion of this course,
participants will be able to:
Describe both local and systemic
treatments
List the effects of treatment and their
impact upon physical , psychological
and mental performance
Describe 2 Pilates exercises from each
phase
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List the rehabilitative and exercise
implications of breast cancer treatment
Identify the benefits of Pilates
List the principles of clinical Pilates
Describe a safe, effective and
appropriately challenging program using
Pilates
Describe the modifications, indications,
and “things to be mindful of” when
using a Pilates based approach
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Please be advised that breast cancer
treatment is continually evolving on a
daily basis. New research is regularly
performed which changes treatment
protocols. This can vary from one region
of the country to another. This course is
not intended to serve as a substitute for
medical advice ,but only to inform
health professionals regarding available
options at present. Please seek
consultation from your medical provider
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Each patient is unique, and requires
treatment tailored to their medical
status. Every patient should consult
their doctor before participating in this
or any rehabilitative or exercise
program.
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“Learning to live with cancer is an art,
not a science. Each person must find her
own way, in her own style. What is
important to realize is that a way can be
found regardless of the circumstances
and prospects.” Jane Brody
Can occupational therapy practitioners
help in that journey ???? ABSOLUTELY!!
We are the experts since we can
address all aspects of healing.
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Jane is a 48 year old lawyer who went
for her annual mammogram in November
of 2007. Her mammogram revealed
breast cancer in the right breast –
Infiltrating Ductal Carcinoma
This was determined after a biopsy,
hormone / HER-2 tests, blood tests, bone
scans, ER/PR tests, and physical
examination
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Staging is done 2x- once before and once
after surgery to determine the severity of
cancer
One considers whether the cancer is
invasive or not, tumor size, how many
lymph nodes are involved and where,
whether the cancer has spread, physician
recommendations, and patient accessibility
to medical facilities before recommending
treatment
Based on the size of tumor and it being
sensitive to hormones, Jane’s cancer was
determined to be stage 2 b cancer.
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Stage 2b cancer is cancer that is larger
than 2 cm but less than 5 cm. Her cancer
had spread to approximately 1-3 axillary
lymph nodes.
However, the staging is not definite until
after surgery. The tumor must be analyzed
by the pathologist.
Breast cancer is divided into 4 stages with
stage 1 being the least severe according to
tumor size or spread to lymph nodes
Stage 4 disease is metastatic disease or
cancer that has spread to the brain, bones,
or lungs
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Elizabeth Kubler-Ross - On Death and Dying
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Denial “ This isn’t happening to me !” “They read the
wrong mammogram.”
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Anger “ Why is this happening to me, I am a healthy
person!!
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Bargaining “ I will try to take better care of myself.”
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Depression “ I just don’t care anymore.” “Nothing
will help”
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Acceptance “ I have cancer but I will do my best to
beat this disease.” -May take a long time to achieve
or sometimes is never reached
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Loss- Loss of Hair( head, eye brows and lashes),
very traumatic, varies but occurs
approximately 14 days after the start of
chemotherapy.
Recommendation: Wig evaluation prior, head
wraps, light weight caps or hats. Revitalash
for eye lashes. Look Good Feel Better
Program
- Loss of a sexual organ
- Loss of Self, self worth, loss of role, fear of
loosing job
Fear of Death- Cancer is life threatening, and
a life altering disease.
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Physical Reminder:
- Loss of a Breast(s) disfigurement
- Lymphedema- clothing doesn’t fit, unable
to button sleeve, need to wear lymphedema
sleeve (hot), can’t wear jewelry, it is a
reminder of the disease on a daily basis
unable to get manicures, always a problem
IV’s, can effect work/family/leisure
participation.
Ganz, PA., Coscarelli, A., et al (1996) describe the psychosocial
concerns and quality of life of breast cancer survivors evaluated 2
and 3 years after primary treatment. Breast cancer survivors usually
attain maximum physical and psychological recovery after 1 year.
However, they reported a number of persistent problems associated
with sexual interest, sexual function, body, image and recreational
and physical activity participation.
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Loss of Femininity & Sexuality – Fobair, P.,
Stewart, SL.,al. (2006) found that among 549
women age 50 or younger, body image and
sexual problems were experienced in the early
months after diagnosis. Among sexually active
woman mastectomies were associated with
greater body image problems.
Early Menopause
Sensation- no longer the same
Know when to refer out for help, suggest a
support group. Psychopharmacology evaluation
may be needed.
Breast Cancer – affects men/women of all ages.
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“ Chemo Brain “ a real phenomena
CRCD- Chemotherapy Related Cognitive
Dysfunction
Approximately 20 -30 % of patients treated
with chemotherapy develop cognitive
problems.
Bender et AL. (2006) studied 3 groups of
women n= 46. There was a control group.
Women who receive chemotherapy plus
tamoxifen exhibited deterioration on measures
of visual memory and verbal working memory.
Those women who received no chemotherapy
or tamoxifen did not exhibit this deficiency.
Authors concluded that chemotherapy can be
associated with memory deficit.
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Learning new tasks, attention,
concentration, word finding, multitasking, and organizing can be
difficult.
Low Tech Ideas: Exercise, make lists,
keep a calendar, keep notebook of
tests and results, keep mind active,
get plenty of rest, leave messages on
answering machine , keep things in the
same place. Keep your mind sharp via
puzzles, games
Keep home exercise program limited
to 2-3 exercises.
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High Tech Ideas- Software Program
Posit Science Brain Fitness Program
Classic – is a series of 6 computer based
programs designed by neuroscientists.
The study was presented at the 28th
annual National Academy of
Neuropsychology (NAN). 2008
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Robbi Peele of Posit Science 19 women participated in the study who
were breast cancer survivors ,and who
had gone through chemotherapy. 94%
showed positive changes in quality of
life, improvements in cognitive
functions, and over all well being.
The study showed that when using this
program there was an improvement in
memory, and in the ability to process
information quickly.
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Based on her medical status, and physician
recommendation, Jane decided to have a
modified radical mastectomy. Surgery is
usually the first line of treatment. It is
considered to be a local type of treatment,
which means that it is focused on one part
of the body.
Size of the tumor, presence of multiple
tumors, whether the tumors are hormone
dependent or HER-2 positive, and lymph
node involvement dictate the surgical
options and treatment choices.
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Local treatment includes surgery and
radiation as they are done to a specific
area.
We will be taking a look at the surgical
options for breast cancer. Please note
the amount of tissue removed and think
about the musculoskeletal implications
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Radical Mastectomies- rarely performed
today; breast tissue/pectoralis
major/minor removed, and all lymph
nodes
Modified radical mastectomies
Simple mastectomies
Breast Conservation- lumpectomies
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Jane had removal of all of her breast
tissue plus level 1 and level 2 axillary
lymph nodes
This is the most common form of
mastectomy performed today
However, on rare occasions a radical
mastectomy may be performed which
involves removal of breast tissue, all
axillary nodes, pectoralis major/minor .
This is usually performed only when the
cancer has spread to the chest walls
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Jane felt that she was at high risk for
cancer in her left breast and decided to
have her left breast removed as a
precaution. In this surgery, no lymph
nodes are removed ,only breast tissue.
However, they can be removed at a later
date through sentinel node biopsy or
axillary dissection if necessary
Simple mastectomies are good for
prophylactic treatment or DCIS.
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Nipple/areola and the old biopsy scar
are removed
Remaining breast tissue is shelled out
from underneath the breast skin- most
of the breast skin is left intact
Plastic surgeon has more tissue to work
with and more natural result
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Although Jane was not felt to be a
candidate for this type of surgery, research
shows 5 year survival rates to be the same
for lumpectomies> radiation in early stage
BC compared to modified radical
mastectomies (Veronesi et al., 2002)
This is a less disfiguring surgery, as only
the tumor and a margin of tissue is
removed. It may or may not be combined
with an axillary node dissection or sentinel
node biopsy
Also known as breast conservation
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This is used in treatment of invasive
cancer. Jane had to receive this
procedure as well as removal of the
breast tissue
Extensive dissection predisposes one to
lymphedema
Usually a sampling of lymph nodes at
Level 1 and Level 2 are removed (10-15)
Jane had to stay overnight with drains in
place
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Drains are tubes attached to a vacuum
suction bulb that collects excess fluid
Emptied dailyust be empt
Usually
d/c ed
When < 2030 ml. in 24
hours
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There are 3 levels of nodes which are
determined by their relationship to
pectoralis minor
Level 1 nodes are lateral to pectoralis
minor
Level 2 nodes are below pectoralis
minor
Level 3 nodes are by the top border of
pectoralis minor
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A newer procedure is now being used for
stage 1 or stage 2 women without palpable
lymph nodes
This procedure is called a sentinel lymph
node biopsy
Dye is injected into the tumor to see which
node or nodes is the first to receive
lymphatic drainage called the sentinel
node. There may be 2 -3 nodes involved
No need for drain , faster recovery, less
pain and decreased lymphedema risk (still a
possibility)
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Breast
Lymphatic system
Skin
Neurological
Musculoskeletal
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Made up of lymphatic tissue, 1/3 fatty
tissue, connective tissue, and is a
mammary gland
Situated over pectoralis major, serratus
anterior, external oblique, and rectus
abdominas
The breast area is considered to start
proximally from the clavicle and end at
the last 4 ribs. Medially it begins at the
sternum and ends in the axillary area.
This is a huge part of one’s anatomy if
removed!
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Ducts are the milk passages
Lobules are the milk producing glands
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Helps the body to maintain fluid balance
while filtering out waste products
Made up of nodes, lymphatic capillaries,
ducts and collecting vessels
Has immunological function
30-45 nodes in the axillary region
Right side of the head and neck, right arm,
and upper right quadrant drain to the right
lymphatic duct
Left side including the left side of head and
neck, left arm and upper quadrant, lower
trunk, and both legs drain to the left
lymphatic duct via the left thoracic duct
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The lymphatic system works on changes in
pressure from muscle contractions which
allow protein rich fluid to return to the
heart
Deep abdominal breathing such as that
performed in Pilates enhances pumping to
the thoracic duct. In addition, muscle
contractions performed in a specific
sequence from proximal to distal can
promote lymphatic return
However, too much activity, infection, or
weight gain can increase the fluid that the
lymphatic system has to pump resulting in
lymphedema
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Effect of scar on mobility of the
myofascial system can decrease range
of motion and increase pain
Scar can also cause psychological as
well as physical pain
Needs to be managed efficiently and
effectively
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Brachial plexus runs under the clavicle and
through the axillary area
Lateral pectoral nerve innervates
pectoralis major and the medial pectoral
nerve innervates pectoralis minor. Nerves
can be severed during surgery
This results in numbness, motor atrophy,
and decreased sweat production in the
armpit and arm
Long thoracic nerve which innervates
serratus anterior and the thoracodorsal
nerve which innervate the latissimus dorsi
are vulnerable
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If the intercostobrachial nerve is damaged
during surgery, the consequences can
include numbness along the medial arm
which can result in a disabling pain
syndrome and diminished sweat production
Numerous cutaneous nerves which may be
damaged during surgery can cause
sensation changes in the upper arm and
chest wall
In addition, breast reconstruction using
flaps can result in a loss of sensation
dependent on where tissue has been taken.
It can be taken from the back, stomach,
and gluteal regions
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Many muscles are affected by breast
cancer surgery and axillary dissection
Prime muscles include the pectoralis
major/minor, serratus anterior, and
latissimus dorsi
In addition, the surgeries cause postural
changes and deviations which effect
shoulder mechanics
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Shoulder complex is made up of 4 joints
Gleno-humeral joint – ball and socket
joint
AC joint- where the acromion meets the
clavicle
Sterno- clavicular joint where the breast
bone attaches to the clavicle
Scapula- thoracic joint- where the
scapula glides along the rib cage
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Arises from the clavicle, acromion, and
external obliques and inserts on the
humerus
Responsible for shoulder adduction,
internal rotation and assists with flexion
Has implications for movement of the
chest, shoulder and back
Muscle most effected by surgery
Scar tissue!!!
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Arises from ribs 5-8 and inserts on the
scapula
Protracts the scapula which is
important for overhead movements
Axillary surgery and damage to the long
thoracic nerve can impact this muscle
resulting in a winged scapula
Scar tissue from lymph node removal
can impair lymphatic flow and inhibit
movement
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Originates on the spines of the lower 6
thoracic vertebrae and iliac crest and
insert on the bottom of the humerus
They internally rotate, extend and
adduct the shoulder
Scar tissue!!
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Arise from the clavicle (where breast
tissue begins) and inserts on the
humerus
Anterior part which flexes the shoulder
can be effected by mastectomy
Scar tissue!!
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Rotator cuff injuries- Trauma to the
chest and armpit after surgery weakens
the arm and shoulder setting up faulty
movement patterns. Shoulder very
unstable joint and rotator cuff may not
be strong to begin with.
Shoulder impingement- This occurs
when the humeral head is pulled up and
the tendons of the rotator cuff
(suprapinatus) are pushed against the
acromion
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Frozen Shoulder- This results from
inflammation of the fascia that
separates the scapula from the rib cage.
Since movement can be painful, the
scapula clamps down on the rib wall
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Ideally, patients should be seen prior to
surgery. However, many are not. It
would be a good time to review
lymphedema precautions, establish
baseline status and introduce HEP
Many patients are not recommended to
receive any rehabilitation at all-not part
of protocol
Integrated Rehabilitation and Fitness
believes:
Pre-surgery evaluation> surgery> rehab>
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Rehabilitation as needed which may
continue through chemotherapy and
radiation > fitness training
Treatment ends- weight gain, body
image ,shoulder issues, loss of sexuality
--------now what???? Fitness training> if
necessary referred back to
rehabilitation (lymphedema, pain, AWS,
poor shoulder ROM/pain)
Physician needs to provide prescription
for rehabilitation
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What happened to rehabilitation?
Need to establish pathway and referrals
back and forth to ensure patient safety
Who can refer for rehabilitation?
Oncologists, general practitioners,
surgeons, nurse practitioner (depends
on state licensure laws)
This is for the protection of our patients
Early identification is best!!
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ADL evaluation; show different types of
camisoles for support, Breast Rest
Sleep Evaluation: address positioning of
arm (elevated and supported), sleep
hygiene see appendix
Instruction in relaxation techniques
www.healingjourneys.com
Instruction in energy conservation and two
handed techniques
Equipment evaluation i.e. stocking aides,
long shoe horns ,reachers
Encourage daily walks, Silver, Julie K.
Super Healing use a pedometer
Reiki www.acs.org
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Reiki is a gentile
non-invasive
approach to help
relieve stress,
promote deep
relaxation, and
ease the effects
of chemotherapy.
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“No other body part is amputated,
reconstructed or burned without
Physical Therapy intervention as the
first line in the rehabilitation process
except the breast.”
Written by Nancy Roberge PT DPT June,
2004
How can occupational therapy
practitioners help after surgery?
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Instruction in deep breathing techniques
should be taught and practiced . Pilates
breathing is costal breathing (ribcage) /yoga
breathing abdominal breathing . Both activate
the diaphragm
Exercise should be encouraged several times
during the day within pain tolerance
It is better to perform exercises 2-3x during
the day
Gravity eliminated shoulder flexion/ extension
abduction/ adduction can be performed using a
table and ball, pendulums
If someone has no drains, then exercise can
proceed more rapidly i.e. with sentinel node
biopsies
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Do not lift more than 5lbs.
Refrain from push/pull activities like
vacuuming
Light housekeeping such as dusting and
light meal preparation are OK
Keep arm elevated above heart at night
to decrease swelling with pillows
Functional activities such as washing
your face and brushing teeth are
primarily elbow/wrist/ and hand actions
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Be sure to promote elbow flexion/ extension,
supination/ pronation, and foam squeezes to
reduce edema formation
Energy conservation- carts, sitting, rest periods
Can use magic circle for elbow
Usually patients can begin ROM to the shoulder
once drains d/c ed. However, this can vary
from doctor to doctor.
*** Many therapists are now recommending
shoulder flexion/ abduction to 90 with drain in
place within patient tolerance to prevent frozen
shoulders*** area of controversy
RED FLAGS: drainage complications, seroma,
infection
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Can arise after surgery
A seroma is a collection of serous ( lymph
and blood plasma) fluid around the
incision. Large seromas feel tight and
uncomfortable - may restrict movement.
Usually aspirated by physician
Can impact chest wall
Signs and symptoms include: reduced
levels of movement, tightness, bulging and
heaviness along the scar in axilla or in the
breast (not arm)
Exercise does not cause a seroma
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Goals include: Increasing range of
motion and function, decreasing pain,
initiating lymphedema precautions,
and facilitating independence
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AAROM using balls, towels, or dowels
Gentle stretches to pectoralis major/minor,
latissimus dorsi, and rotator cuff
Gentle scar massage/ scar remodeling if
scar has healed
Wireless sports bra or camisole for
support or comfort
Instruction -lymphedema risk reduction
strategies
Exercises should be performed regularly for
at least a year while scar tissue is forming
RED FLAGS** Acute edema, AWS, muscle
palsy, adhesions at surgical/drain sites
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Although sentinel node biopsies have
reduced arm morbidity such as
lymphedema and loss of range of
motion, there are still issues associated
with all surgical procedures including
loss of shoulder range of motion and
lymphedema!!!
In addition, functional difficulties are
noted during driving, ADLs, sleeping,
child care, and work along with
postural disturbances
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Patients may seek rehabilitation due to
other issues later on. Therefore,
complete medical history is important:
What type of breast cancer surgery?
Were any lymph nodes removed?
Did you receive radiation? Any signs or
symptoms of lymphedema?
If you received chemotherapy- what
type? Side effects?
Any other medical issues? Medications?
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Short term: Significant loss of shoulder
range of motion reported 2-3 months
post mastectomy (Gosselink et al. 2003)
Long term: Loss of range of motion
reported by 28% of women 1 year post
mastectomy (Blomqvist., et al., 2004)
Significant decrease in strength in
shoulder flexion and abduction 15
months post mastectomy (Blomqvist et.
Al, 2004)
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Post Breast Therapy Pain Syndrome
Phantom Breast Pain
Neuromas
Jung (2003) reports incidences of
phantom breast pain 3-44%,
intercostobrachial neuralgia 16-39% (all
breast surgeries) and neuromas 23-49%
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Pain at the surgery site is most
common, but depends on the type of
surgery performed. Less pain SLNB
compared to ALNB
Manifested in the chest, axillary area,
shoulder and back due to nerve damage
at the surgical site and removal of
tissue, nerve damage from
chemotherapy, and postural changes
Drain sites can be quite painful
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Mastectomy
Neck/ Shoulder
42%
Upper Extremity
26%
Breast / Chest wall 28%
Karki, et al., 2005
BCS
37%
15%
20%
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Recognized complication of breast
cancer surgery
Discomfort and sensory changes which
begins immediately or soon after
surgery in the anterior chest, medial
upper arm and axilla
Can result from irritation of one of more
nerves in the chest wall which may have
been cut during surgery or entrapped by
scar tissue. It is thought to be damage
to the intercostobrachial nerve.
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Radiation and chemotherapy may
aggravate the condition
Risk factors include: ^d BMI, improper
surgical technique, larger tumor size,
post-op complications
Symptoms persist after 3 months
(normal healing time)
Tx: Anti-inflammatory agents, pain
meds, guided imagery, biofeedback,
rehab to prevent frozen shoulder
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Neuroma pain is pain in the region of a
scar on breast, chest, or arm that is
provoked by percussion. If trapped in
scar tissue, can cause chronic
neuropathic pain
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Scar tissue may cause tightening under
the arm and around the incision, drain
sites, and reconstruction sites
You can begin gentle scar massage
once the drains and sutures are
removed, and the incision has healed –
approximately 2-3 weeks
Check with physician if scar massage
after reconstruction is appropriate
This is not for lymphedema
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Use 2 fingers at site
Apply deep pressure increasing the
amount as tolerated
Work clockwise and counter- clockwise
Use a mild lotion
Perform scar massage for 5 minutes 45x/ day
Teach patients how to do it
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Numerous randomized and controlled
studies have established that silicone
sheets are an effective scar treatment
Works well for both keloids ( progressive
accumulation of scar tissue) and
hypertrophic (scars with abnormal
depth) – both conditions of excess
collagen
Why they work is not completely
understood
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Poorly understood and relatively
underestimated
Incidence rates vary from 15- 49%
(Menses, KD and Mc Neess, MP, 2006)
Is incurable, but treatable
Early recognition is important for
treatment. Should manage early and
aggressively
Extent of axillary surgery as well as
radiation contributes to lymphedema
risk
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SLNB alone > significantly lower rate of
lymphedema 5 years post-op. However,
clinically relevant risk of lymphedema .
Risk factors included greater body
weight, higher BMI, infection, or injury)
SLNB > 5% lymphedema
SLNB /ALND > 16% lymphedema
(McLaughlin, S. et al, 2008)
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It is characterized by a feeling of fullness,
achiness, <d AROM, tightness, heaviness
or tingling in chest wall , arm, breast, and
or hand due to abnormal accumulation of
protein rich fluid. Deepening of skin folds
noted + Stemmer sign ( skin of dorsum of
fingers cannot be lifted )
Can develop immediately or months or
years after treatment
Lymph node dissection and scaring from
radiation blocks lymphatic flow
May be painful or limit activity
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No standardized definition therefore
confusion abounds
Methods to assess severity and extent vary
If there is noted to be a >2 cm. (3/4”) or
200 ml. limb volume difference from
affected to unaffected side, it is an
indication of developing lymphedema . No
general agreement exists.
Instruction should be provided in
lymphedema risk reduction strategies
If you note change in circumferential
measurement, refer to qualified
lymphedema specialist
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Stage 0- Latency -lack of lymph flow but no
clinical signs of lymphedema, may have fatigue
or heaviness in arm > education critical here
Stage 1- When pressure is applied for 5
seconds, there is pitting (mark left on arm)
Swelling reduced by elevation, no fibrosis
Stage 2- Edema starts to feel firm (not pitting)
Swelling does not reduce on elevation, chronic
inflammation, fibrosis , skin infections
Stage 3- Skin becomes thickened and leathery.
Warts and cysts develop on skin. Hypertrophy
of subcutaneous tissues, massive fibrotic
swelling
94
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Alteration in sensation in the limb
Loss of body confidence
Decreased physical activity
Fatigue
Psychological distress
Changes in role function
Pain and disability > work issues
(Ridner, SH, 2005)
95
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Infra- red technology can scan the limbs
using beams and sensors providing very
accurate information. Lymphedema able
to be diagnosed before it becomes
visible.
Once lymphedema was diagnosed,
condition managed using a light grade
compression garment
(Stout, N. Et al. Pre-operative
assessment enables the early diagnosis
Cancer 2008;112(12) :2809- 2819 )
96
97
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Be alert to signs of infection- redness,
swelling, heat in area, fever, flulike
symptoms
Infection can incite first lymphedema
episode or exacerbate existing
lymphedema
** Must see doctor as antibiotics
required
98
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Axillary Web Syndrome or “cording” may be
seen after axillary lymph node removal
Results from interruption of axillary
lymphatics
Complaints include inability to straighten
elbow and abduct shoulder girdle due to
pain from the arm into the wrist with a
visible tight cord from the axilla down arm
Tightness and tenderness in the axilla with
protracted posture and mild kyphosis
99
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May be underreported and under
recognized
Prevalence of 60-70% in post ALND and
20% in SLNB
MFR- arm pulls, stretching of pectoralis
major/minor , diaphragm release> AROM
wrist> shoulder
Other interventions skin traction and
scar release
Low grade moist heat with towels to
avoid triggering lymphedema (Kepics,J.
2004)
100
101
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Proceed cautiously and slowly when
adding weight if at lymphedema risk
Well fitting sleeves should be worn if
patient has lymphedema and will be
using weights
Recommendations at www.lymphnet.org
Do not >the repetitions the same time
as the weights
102
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> endurance and strength
Continue with walking/cycling program
to combat fatigue and treatment side
effects
Reduce lymphedema risk by adhering to
NLN guidelines
> strength and function in the affected
arm
>ability to perform ADLs, and IADLs
103
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Week
1
2
3
4
5
Weights
1 lb.
1 lb.
1 lb.
2 lb.
2 lb.
Exercise
Deltoid Raises
Deltoid Raises
Deltoid Raises
Deltoid Raises
Deltoid Raises
Reps
1 set
2 sets
3 sets
1 set
2 sets
Be sure to work the scapula stabilizers
and rotator cuff too!
104
105
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Recent randomized and controlled
studies have concluded that arm
exercise with women at risk did not
seem to influence the development of
lymphedema or increase lymphedema.
(Sagen, A. et al, 2008) High level activity
with the affected limb following breast
surgery /dissection did not seem to
influence development of lymphedema
106
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Schmitz, K. et al., 2009 PAL trial .
Hypothesis: Slowing > ing. wt. training
would gradually > the physiologic
capacity of the arm. 2x weekly
upper/lower body strength training with
ongoing lymphedema measurement.
Started with no wt> 1 lb.
Exercises included seated row, chest
press, lateral/frontal raises.
Compression garments worn. >QOL,
strength and <d lymphedema symptoms
107
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Jane was recommended to have
radiation after chemotherapy was
completed
Radiation –local treatment
High energy rays that damage cancer
cells.Given daily for 6-7 weeks
Reduces risk of local re-occurrence
Causes fatigue, skin irritations, burns
scar fibrosis, breast swelling and
lymphedema
108
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Can effect the quality of reconstruction >d rate of flap failure, more difficult to
recreate breast (skin does not heal)
Short term effects last from 12-24
months
Long term effects can include cardiac
and lung damage, lymphedema, brachial
plexopathy, impaired shoulder mobility,
and second malignancies
Bra’s may need to be d/c ed and
camisoles used
109
110
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Mammosite- used for lumpectomies for
5 days reducing travel issues. Source of
radiation inside body
www.mammosite.com
Tube with balloon attached to end is
inserted into lumpectomy site >Balloon
is inflated and filled with saline>
Radiation travels through the tube and
into balloon to deliver radiation
IMRT- Intensity Modulated Radiation
Therapy >tightly focused /angled dose
111
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This conforms to the tumors shape (can
Adjust intensity of dose) decreasing
radiation to healthy tissue . It is used in
combination with image guided
radiation- precise 3D location of tumor
112
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Goals are to maintain and regain
shoulder mobility and lengthen the
pectoralis group
Shoulder must be in full external
rotation with 90 abduction to receive
radiation
If shoulder/axilla included in the
radiation field, exercises are performed
with full gleno-humeral ROM
If only the breast> gentle pectoralis
stretches
113
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Skin reactions to radiation (blistering,
redness) may require modification /dc
of exercise until resolved
No hot/cold packs during radiation
Biafine- prescription cream to soothe
Use only mild cleansers ,lotions- Eucerin
Castor oil once redness has abated
Avoid deep tissue work> indirect
(myofascial release). Daily shoulder
ROM for at least 3-6 months after rad.
114
115
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Chemotherapy
Hormonal Therapy
Biological Treatments
116
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It was recommended that Jane receive
chemotherapy
Systemic treatments effects all body
systems including the gastrointestinal,
neurological, musculoskeletal, and
cardiovascular. Effects everyone
differently
Targets fast dividing cells in the body
Drugs administered orally/intravenously
Drugs received in cycles- every 3-4
weeks
117
118
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Jane’s chemotherapy – CAT (Cytoxan,
Adriamycin, and Taxol) for 6 cycles
Complications are related to the age of
the patient , as well as the
chemotherapy regimen and duration
Now many drugs to combat side effects
(Procrit, Aloxi)
119
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Adriamycin- mouth sores, nausea, hair
loss, heart failure
Cytoxan- hair loss, nausea, diarrhea,
stomatis
5- FU- myalgia, hair loss, muscle and
bone pain
Taxol- myalgia, hair loss, muscle and
bone pain, peripheral neuropathy
Taxotere- allergic reactions, fluid
retention, fever, chills, nail changes,
muscle pain
120
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Patients treated with radiation and an
increased dose of anthracycline based
chemotherapy are at a slightly >d risk
for cardiac toxicity (Shapiro, CL, 2001)
Most women older than 40 can expect to
become menopausal with chemo
Other side effects include <in platelets,
<rbc, and < WBC, fatigue, nausea,
weight gain, and infection risk
121
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Goals include improving physical
function as tolerated, continuing ROM
exercises and strengthening , decrease
side effects of tx., and improve
ADL/IADLs function
Balance, fine motor control, and
strength may be concerns
122
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Know CBC
Ask patients about treatment schedule
and recent lab values
Communicate with healthcare team
Platelet counts under 50,000 >d risk of
bleeding
WBC less than 3,000- increased risk of
infection. Avoid exposure to infectious
disease . If you are sick, do not work
with them
123
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Low red blood cell cont- anemia >d risk
of dizziness and weakness ,increased
fatigue. Ensure adequate fluid intake .
Adjust exercise intensity accordingly.
Breast Cancer treatment is cumulative.
There are long term effects which are
side effects that begin during treatment
or shortly after that can persist ie PN,
weight gain
Late effects are distinct from long term
effects in that they appear months or
years after ie arrhythmias
124
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Jane was on Taxol which often produces
peripheral neuropathy
There can be sensory, motor, and/or
autonomic deficits
Sometimes, these side effects can
resolve quickly. Other times symptoms
may last longer in others that impact
balance, strength and function
125
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Chemotherapy can cause early
menopause which can lead to
significant bone loss. Estrogen has a
protective effect on bone. Also, the
tumor itself can > the bone dissolving
activity of the osteoclasts
Women over 40 most likely to
experience chemotherapy induced
menopause
Must strengthen fx.
Sites: wrist,
spine, hips
126
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Some Pilates exercises may not be
appropriate for women with
osteoporosis /osteopenia of the
spine/hip
For these women, forward flexion,
forward flexion/ rotation, and lateral
flexion of the thoracic spine should not
be performed at all . Others can be
modified
Head on ground for abdominal work
/thoracic back extension
127
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Weight gain is a common and
distressing problem for patients who
receive chemo . Go to www.aicr.org
An average of 5-8 lbs. weight gain has
been noted in a year for women
receiving chemo . Some gain more/some
less. More problems> sexuality and self
image
Excess body fat can make it more
difficult for lymph fluid to pass through
tissues> d lymphedema risk
128
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Cancer related fatigue is a persistent
state of tiredness related to cancer or
cancer tx. Interferes with function.
Measured with a visual analog scale or
Piper Fatigue Scale
Most common problem associated with
all breast cancer therapies
Women who undergo surgery,
chemotherapy and radiation experience
the most fatigue . May persist for
months or years
129
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Common causes include anemia,
inadequate nutrition, sleep
disturbances, stress , depression, or
nausea
Not fully understood
Fatigue can affect ones’ sense of well
being, daily performance, ability to
perform ADLs, and relationships with
family and friends
130
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Aerobic exercise has been found to be
the best remedy for fatigue
Stationary cycles and walking are good
Treadmill and stair climbing machines
may not be appropriate for someone
with peripheral neuropathy
Other suggestions include: get plenty of
rest, plan and delegate activities, keep a
regular routine, exercise in the morning,
and prioritize activities
131
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Sarcopenia is the age related loss of
skeletal muscle mass , strength and
function
This is reflected by >d weight
Loss of lean muscle mass especially
noted in the gluteal. Quadriceps, and
hamstrings (Denmark, Wahnfried, W. et
al., 2001)
Can contribute to falls
Can impact walking or stair climbing
132
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It was recommended that Jane be on
hormonal treatment once her chemo
was completed. Tamoxifen was the
preferred drug.
Hormonal treatments include; Antiestrogens/ Aromatase Inhibitors
Anti- Estrogens such as Tamoxifen block
the effect of estrogen on breast cells
but act like estrogen on other organs
Side effects: blood clots, DVT, uterine
cancer, cataracts
133
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They cause menopausal like symptoms
including hot flashes, vaginal dryness,
weight gain and mood swings Given to
pre-menopausal/menopausal women
Aromatase Inhibitors prevent estrogen
from forming tumors –only given to post
menopausal women . They inhibit
Armatase : an enzyme that converts the
body’s androgens into estrogen in post
menopausal women .Side effects: mild
nausea, hot flashes, significant
jt./muscle pain
134
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Jane’s breast cancer was not found to
be sensitive to HER-2
HER-2 is a proto-oncogene that is
involved with cell growth/ regulation
Too many HER-2 receptors indicate a
more aggressive form of breast cancer
which is found in about 25% of the bc
Herceptin is a drug that binds/blocks
HER-2. Side effects: CHF, severe
allergic reactions, back pain, infusion
reactions, and lung problems
135
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Enjoy your break!
When we return, we will be learning all
about Pilates. Be prepared to practice
these Pilates based exercises later on.
136
137
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Pilates is a form of muscle conditioning
exercises designed by the late Joseph
Hubertus Pilates 1880 – 1967, born in
Dusseldorf, Germany
As a child, he suffered from asthma, rickets,
and rheumatic fever
He studied various forms of martial arts,
yoga, gymnastics to improve his health.
World War I – interned with fellow Germans in
a Prison Camp
1926- emigrated to the NYC where he met his
wife Clara and opened the first Pilates studio.
He combined Eastern and Western
philosophies “Contrology”
138
Once one learns the “Pilates Principles,”
you can use them when participating in
ADL’s, work, and play.
 Pilates is based on rehabilitation
principles.
- Stabilize before you move
- Breathe before you move
A stronger core can help you with distal
control of the extremities

139
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STOTT Pilates
Balanced Body University
Polestar Pilates
Professional Health & Fitness Institute
Pilates Method Alliance
International and nonprofit organization.
Their mission is to establish standards for
Pilates instructors and a certification exam.
140
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Must follow an order
of exercises with
mat-with other
apparatus it is not
necessary.
Over 500 exercises
that includes the
equipment
Variety of schools
and principles to
choose and follow.

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No need to follow
order
Can use a variety of
exercises with a
vast population of
patients
Can adapt the
Pilates principles for
the rehab population
141
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Includes
movements in trunk
flexion, extension,
lateral flexion, and
rotation but mostly
flexion
One must be
certified to teach on
the different types
of equipment

The use of a neutral
pelvis is evidence
based and provides
stability to the
lumbar spine which
decreases the load,
and is the most
shock absorbing
position when
performing
exercises.
142
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Neurological
Impairments- MS, CVA
Orthopedic: low back,
shoulder, and elbow
conditions
Joint Replacements:
knees and hips
Arthritis
Cancer
Osteoporosis
Post MVA
Scoliosis


Pregnancy
Chronic Fatigue
Syndrome

A series of body
awareness terms
used when
performing each and
every exercise, thus
allowing each
exercise to be
mindful, safe and
effective.
144

Breathing◦ Breathing connects the mind and the body and
the breath is the link.
◦ Breathing connects the sympathetic and
parasympathetic nervous system.
◦ Important to coordinate the breath with the
movement. Promotes oxygenation of the
blood.
◦ Promotes lymphatic flow
Breath pattern: Inhale through nose, ( feel your
rib cage expand )exhale through your pursed
lips ( through a straw) and draw the belly
toward the spine. The deeper the exhalation the
more the transversus abdominis is activated.
145
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Concentration : Required for stability.
This enhances proprioception and
neuromuscular recruitment of muscles.
Control : Minimal repetitions with
maximum control. Local muscles are
trained before global muscles.
 Stability- Pelvis and Scapula are
stabilized before you move
Center: “the powerhouse” , “core” .
145
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Relaxation: Breathing assists with the
relaxation of the muscles throughout
the body. Unwanted tension should be
released in the body before starting
the exercises.
Stamina: Muscle endurance is built in
the core and other small stabilizing
muscles.
147
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Fluidity: Movements look effortless and
flow from one to the other.
Alignment: “Start position” Important
that you are aligned before you begin
the exercises i.e., pelvis, rib cage,
scapula, head/neck, knees, and feet.
148
149
150
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-
-
The smaller
equipment can be
used in a variety of
ways :
To support or
stabilize an area
To help strengthen or
stretch
For positioning
151
Most of the exercises are
performed supine on a mat
( unless otherwise noted) with
spine in neutral and feet hip width
apart. 3--5 repetitions> 8-10 reps
 Breathe in to prepare for each
exercise, as scapulae/pelvis are
stabilized. Inhalation > facilitates
extension. Exhalation>flexion

152
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Close your eyes to concentrate on
feeling the movement
Coordinating the breath with the
movement is the goal. This may be
difficult in the beginning, so master
one first and then add the other.
The fitness circle helps to stabilize the
shoulders and activate the core along
with the small ball between the knees
to keep the adductors active and
assist to fire the TA.
153
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The pelvis is in neutral for all
exercises unless the feet are in the air
and the core is weak. Imprinting helps
to stabilize the body, protect the back
if abdomen is weak, and facilitates the
coordination of the TA and multifidus.
It is important to know Pilates
yourself. It is not enough to just teach
it, but also to feel it! Take a private
session with a Pilates instructor.
154
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The use of music with Pilates varies
from instructor to instructor – some do/
some don’t
When doing Pilates, shoes should be
taken off to feel the lengthening through
the body. If feet get cold, sneaker socks
are an alternative >slippery
Prone position> difficult after surgery.
May need to use towels, wedges/ balls
or omit.
155
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If you have pain in the shoulder, align
them by drawing the shoulder blades
down and lower range of motion
If clients cannot sit on sitz bones, try
bending knees or sit onto towel
If shoulders elevate, turn both hands so
palms are facing inward. This will help
to activate the latissimus dorsi.
If ribcage cannot be imprinted (scapulas
on floor) lift participants head by placing
it on folded towel / or arms at eye level
156
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If pelvis is unstable, lower legs to floor
during the hundred.
If there is lower back pain, bend knees
on floor and imprint spine.
157
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Able to perform exercises in many
different positions ; supine, side-lying ,
high kneeling, prone or seated.
Exercises and equipment can be
modified for any level.
Arm is not left dependent.
Principles keep one focused both
inside and outside the body.
Increases energy level.
158
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Breathing eases tension. Assists with
lymphatic drainage due to deep
breathing and activation of transversus
abdominis facilitating lymphatic flow
to thoracic duct. In addition, gentle
arm exercises done in combination
with deep breathing > significant
decrease in lymphedema (Mosely, A.L.,
et al., 2005)
Can be done 1:1 or in small group
setting.
159
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Can be combined with a walking
program, rebounder to help assist with
lymphatic drainage.
Improves scapulo-humeral rhythm by
strengthening the scapular stabilizers
(middle and lower trapezius, serratus
anterior, rhomboids, latissimus dorsi) >
increasing ROM.
Provides a gentle introduction or
reintroduction to exercise.
159
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Gentle/soft type of body conditioning.
Pilates energies you when you are
fatigued.
Increases muscle strength.
Increases ability to perform ADL’s ie
bed mobility
Increases mobility.
Improves proprioception and
kinesthesia.
161
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A recent pilot study( Keays,K. et al.,
2007) examined the effects of Pilates
exercises on shoulder ROM, pain, mood,
and UE function. Although there were
only 4 participants, a modest
improvement was noted in shoulder
abduction and external rotation.
Participants underwent 12 weeks of
Pilates 3x/week along with HEP
More studies need to be performed, so
tell all of your students!!
162
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A MD’s prescription to initiate any type of
exercise or rehabilitation is necessary.
Patients with Metastatic Cancer may be at risk
for fractures. **Know where metastatic sites
are before proceeding with exercise!!!
Therefore, must tread cautiously and modify.
Spondylosithesis- when one vertebral body
slips in relation to the one below
(between L5 & S1)>No trunk extension – tx:
emphasize trunk flexion.
Lumbar Stenosis- progressive narrowing of the
spinal canal due to degenerative changes.
163
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May have back pain, tingling, and other
motor deficits Tx: lumbar flexion
If client is at lymphedema risk, be sure
to proceed slowly and cautiously when
using weights. Should wear a well fitting
sleeve and gauntlet if recommended by
therapist
If patient has osteoporosis/osteopenia in
the spine, do not perform forward
flexion, forward flexion with rotation ,
and lateral flexion of the thoracic spine.
164
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If patient is undergoing other treatment,
adhere to traditional guidelines and
rehabilitative guidelines for phases 1-3.
If patient received a TRAM Flap
Reconstruction, abdominal exercises not
recommended until 6-8 weeks, no lying
prone until after 4-6 weeks.
Adhere to physician prescription and
guidelines for other types of breast
reconstruction i.e. implants (no push/pull).
165
Tranversus
Abdominis
.
Pelvic Floor
THE CORE
Or
Powerhouse
Multifidus
Diaphragm
166
167
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
TA controlled independently of other
muscles . Activation independent of
trunk movement .
TA linked to diaphragm and pelvic floor
muscles
TA appears to affect spinal support
through its attachments to
thoracolumbar fascia and close links to
intra-abdominal pressure
Activation of TA precedes limb
movement
168
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Stabilizes the spine> increasing
abdominal pressure
Occurs by the connection onto the
thoracolumbar fascia
Need to strengthen in people with low
back pain
Does not contribute to extension,
flexion, or lateral flexion of the trunk
Pilates appears to maintain better
lumbar – pelvic control than regular
curls (Herrington,L. Davis,R. , 2005)
169
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The Rectus Abdominus and obliques all
help to flex the spinal column and help
keep the internal organs intact
Obliques assist with spinal rotation
and lateral flexion
The Rectus Abdominus plays an
important role in respiration as it
assists with breathing.





Pelvic Core
Neuromuscular System
(PCNS)- Christina
Christie, PT. “ The Inner
Pelvic Core” describes
Roof- Respiratory
Diaphragm
Walls( front)- abdominals
Walls( back) – back and
hip muscles
Bottom- pelvic floor
muscles.
171
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Contraction of the pelvic floor muscles
causes increased activation of
transverse abdominas . Activation of
abdominal muscles results in increased
activation of pubococcygeus
There is a myofascial attachment from
the adductors to the pelvic floor. Thus,
activating them helps to recruit the
muscles in the pelvic floor
172
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Diaphragm- primary
muscle for
respiration
The Diaphragm
separates the
thoracic cavity from
the abdominal cavity
Contracts downward
for inspiration
Relaxes with
expiration
173
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
Does not flex the
spine but is
responsible for
spinal stability.
Covers entire
length of spinal
column.
Co-contracts with
transverse
abdominas when
spine is in neutral
174

Errector Spinea (3)
(Lateral) Iliocostalis
(Middle) Longissimus
(Medial) Spinalis
(Smallest)
Action: extension of
the spine and lateral
flexion
Scapular
Core
Rhomboids
Middle
Lower
Trapezius
Serratus
Anterior
Latissimus
Dorsi
175
176
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Don’t forget about
the rotator cuff and
it’s role in promoting
shoulder stability
Strengthen the Ex
Rotators, Stretch
Internal Rotators
177
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One must practice and feel the benefits
of Pilates
Practice makes perfect!
179

Please get out mats and situate
yourselves comfortably . You may need
to use a towel under the head to
promote proper neck and shoulder
placement into a neutral position .
180
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Are feet aligned with knees? (hip
width)
Are knees aligned with hip bones?
Is pelvis in neutral?
Is the transverse abdominas
engaged?
Is rib cage soft and down?
Are shoulders away from your ears?
Are shoulder blades down?
Is chin in and neck long?
181
182
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
Start: Supine, knees bent 90° and hip
distance apart.
Place heel of both hands on ASIS, make
a triangle with your hands. Thumbs will
be at the belly button, index fingers
toward the pubic bones. Lift your head
off the floor, and look at hands. Thumbs
and index fingers should be in the same
plane. They should be level ( this is
neutral). If not, tilt your pelvis so it
becomes level >halfway
Between anterior/posterior
183
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
Start: Supine, feet hip width apart,
knees bent
Exercise: Inhale and then exhale, as
you bring ASIS towards nose. Hold
position, and then exhale as you move
pelvis back down to neutral Cue: ”belly
button to spine”
Caution: Should only be used when legs
are above head, or when client does not
have control / stability in the core.
Imprinted spine held during exercise
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Exercise: Breathing
Equipment :Pad under head if needed
in supine
Start: Pelvis neutral when seated or
supine
Exercise : Inhale through the nose and
feel the ribcage go wide , Exhale
through pursed lips ( straw) .This will
assist in activating the TA, pelvic floor
EO, and multifidus.
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Equipment: Pad under head, ball
between knees.
Start : Supine, knees hip distance
apart, pelvis neutral.
Exercise: Prepare by inhaling. Exhale
as you tilt pelvis toward the nose and
activate core. Inhale and hold. Exhale
to return to neutral position.
Modifications: Can be done seated on
chair or therapy ball.
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Equipment : Pad under head, ball between
knees
Start : Seated/Supine with neutral pelvis,
knees hip distance apart, arms by side.
Exercise: Inhale to start & elevate shoulder
to ears. Exhale to slide scapulae down into
a V, and activate the lats, oblique's and
core. Repeat.
Caution: Keep shoulders against the mat,
don’t let them round forward. Supine allows
for more proprioceptive feedback.
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Equipment: Pad under head, ball
between knees
Start: Supine, knees bent, arms
reaching to ceiling or at 90 if seated
Exercise: Inhale and reach fingers
toward ceiling. Exhale and pinch
shoulder blades together using
rhomboids
Phase 3: Can add fitness circle, toning
balls, or theraband for resistance
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Equipment: Fitness circle, pad under
head, ball between knees
Start :Seated / Supine with pelvis
neutral, knees hip distance apart. Hold
fitness circle with slight bend in elbows,
fingers extended on circle.
Exercise: Inhale to prepare . Exhale as
you flex elbows( do not squeeze the
fitness circle). Inhale to extend elbows
and return arms to start. Keep scapulae
stabilized throughout this exercise.
Phase 3: Can squeeze circle
189
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Equipment: Pad under head, ball
between knees
Start: Supine with knees bent position,
arms at side
Exercise: Inhale to prepare. Exhale and
tilt pelvis towards the nose. Tighten
glutes and articulate spine off mat one
vertebrae at a time as you push up by
heels. Inhale at top, then exhale as you
reverse articulation returning to neutral.
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Cane Raises
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Equipment: Pad under head, ball between
knees
Start : Supine, knees bent and feet hip
distance apart.
Exercise: Inhale to start ,as you activate your
core and scapular stabilizers. Exhale as you
lift cane up to head. Inhale at top point and
exhale to lower cane. Maintain abdominal
connection.
Caution: Don’t let ribs pop out as you lift
arms .
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Equipment: Pad under head, ball
between knees
Start position :Supine, knees bent
Exercise: Inhale to stabilize , and exhale
as you raise arms as high as you can
towards head. Hold as you inhale and
then exhale as you abduct and circle
arms downward
Phase 3: Theraband/ toning balls
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Equipment: None
Start: Supine with legs hip width apart.
Exercise: Inhale to start, exhale split
arms, inhale back to center. Repeat,
splitting opposite arms.
Modification: Sit on towel or rolled mat
for a tight low back. Can use weighted
balls or bands
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Start : Sitting on one hip, knees bent
toward opposite side( like mermaids tail).
Exercise: Inhale reach arm up ( side you are
sitting on). Exhale and laterally flex to
opposite side. Inhale and hold, and then
exhale as you return arm to side and sit
back up. Change sides.
Modification: Seated with crossed legs,
place toning ball under hand that is on floor.
Allow ball to slide as you laterally flex.
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Equipment: Pad/towel, toning balls
Start : Side-lying( line body up with
edge of mat). Bottom knee bent for
support
Exercise: Inhale to prepare , and then
move ball with hand (as tolerated) into
flexion . Inhale and hold at highest
point. Exhale and return ball to start
Caution: Position other arm for
comfort . May not tolerate this
position. Pad under head may be
necessary
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Equipment- Pad under head
Start : Side-lying ,shoulders are
flexed to 90° and stacked palm/palm.
Exercise: Inhale to start and stabilize.
Exhale as you float arm up to ceiling
Inhale, hold. Exhale and return to
start. Change sides.
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Equipment: Towel or blanket under
knees and buttocks
Start : On knees with behind to heels .
Spine is rounded . Arms in front. Perform
Pilates breathing
Additional : Move arms to the left as
you move hips to right. Change sides
Great stretch for axillary area, and after
back extension exercises.
Modifications: Supine, hug knees to
chest.
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Equipment: None
Start: Supine with hands behind head,
knees bent with feet on ground. Bring
right elbow to left knee > back to center,
and then left elbow to right knee
Modifications: Knees in tabletop and
extend leg out as you bring elbow to
knee
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Equipment- None, pad between knees if
feet on floor
Start- Supine with knees bent and feet
flat on floor. Arms at side. Inhale as you
lift arms up, over the head and then
exhale as you bring them down
Modifications: Start with both head/
knees up (tucked position) and inhale as
you lift arms/legs into a V. Exhale as you
tuck back in
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Equipment: Pad under head and ball
between knees
Start: In supine with knees bent and feet
on floor . Arms are lifted shoulder height
Inhale as you nod your chin and exhale
as you lower arms to ground. Pump
arms up and down as you inhale for 5
counts/ exhale 5 counts
Modifications: Knees in tabletop,
decrease number of pumps, bring knees
apart/together
200
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Strengthening with the use of bands,
magic circle, weights, toning balls,
different positioning, or increased
repetitions
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200
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Equipment: Pad under head and under
working arm
Start : Side lying as in Part 1
Exercise : Inhale, and then exhale as
you lift top arm up into flexion >
abduction. Hold at point within
tolerance and inhale (can have pillow
under arm) . Eyes follow arms. Be sure
to rotate your ribcage. Exhale return
to start.
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Equipment: Foam roller, toning balls
Start: Prone, with shoulders flexed in
front with heels of hands on toning
balls, legs abducted and laterally
rotated
Exercise: Inhale and tighten glutes (to
protect lower back). Exhale and press
hands into balls. Draw balls towards
you. Slide scapulae into a V as you
extend spine. Inhale ,hold. Exhale return
to start
Modification: Do not lift chest off floor.
Keep ribs down, place hands wider
203
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Equipment: Pad under head, ball
between knees, toning balls, theraband
Start position :Supine, knees bent
Exercise: Inhale to stabilize , and exhale
as you raise arms as high as you can
towards head. Hold as you inhale and
then exhale as you abduct and circle
arms downward
Modifications: Theraband contour wts
.
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Equipment: Theraband, toning balls, or
contour wts.
Start: Seated legs crossed, arms
extended holding toning balls.
Exercise: Inhale to start, exhale split
arms, inhale back to center. Repeat,
splitting opposite arms.
Modification: No wts., sit on towel or
rolled mat for tight low back.
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Equipment: Fitness circle, toning balls
Start : Seated/prone .Arms adducted at
side. Can add resistance when
stronger
Exercise: Inhale as you stabilize, and
then exhale as you squeeze shoulder
blades together and lift thoracic
region. Hold position as you inhale.
Exhale to release to start position
Start seated > prone > resistance
206
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Equipment: Pad / pillow under head,
toning balls, theraband
Start : Side-lying, both knees bent to 90,
top arm adducted to waist in neutral
position, hips are stacked.
Exercise: Inhale, draw belly button
toward spine. Exhale and move top arm
into ER . Hold as you inhale, and then
exhale as you return arm into neutral
position
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Kendall and McCreary suggest suspending a
plumb line from over head with a plumb bob at
base. The plumb base is anterior to lateral
malleolus in a side view position.
Start by having person march in place for 30
seconds, shoes removed. Observe person from
head to toe, make note. Then have them stop
and not move or correct themselves. This will
be their natural stance. You will be evaluating
the body from both sides, front, and back.
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Modified Postural Assessment
A postural assessment is a way of
assessing and identifying areas of the
body that may be over compensating, or
misaligned secondary to either injury or
poor body mechanics.
There are four types of Postural
Alignment:
Ideal
Kyphosis-lordosis
Flat Back Sway-back* see appendix
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Full evaluation within the scope of your
practice and facility

Good Breast Cancer history should include:
Pain Evaluation
Circumferences at 4 points
ROM/ MMT (avoided if at lymphedema risk)
Sensation- light/deep touch, hot/cold
Grip/ pinch measurements
PMH
Type of Cancer, stage
Treatments – dates, type,
Medications
Scar Evaluations- length, color, and type
ADL and Work Evaluation
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FACT –B (take home) www.facit.org
Sleep Evaluation- Epworth Sleepiness
Scale (take home)
Fatigue Scale Piper Fatigue Scale (take
home)
DASH- Disabilities of Arm, Shoulder and
Hand (take home)
www. [email protected]
BERG Balance Test
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Occupational
Therapy
Eval- 97003
Physical Therapy
Eval- 97001
OT Re- Eval
97004
PT Re- Eval
97002
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97110 therapeutic
exercise
97112 neuromuscular
retraining
97140 Manual therapy
techniques- MLD
97530 therapeutic
activities
97532 development of
cognitive skill
97535 self-care/home
management training,
safety procedures
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Pilates – is neuromuscular retraining
and therapeutic exercise
Assessments used provide us with good
functional goals for the patients
We can do pre and post testing with the
evaluations
Can document progress on a daily basis
with grading of exercise, fatigue,
endurance, ROM, strength, ADL’s and
returning to prior functional status.
HEP
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Wellness is a positive approach to living
– it emphasizes the whole person and is
an integration of mind, body, and spirit
A wellness oriented lifestyle encourages
new behaviors that promote better
health and improved quality of life.
Pilates is one part of this equation. As
occupational therapists, we can address
many of the other issues of concern
such as fatigue, sleep issues, work, or
lymphedema and help
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Survivors live a more productive life.
This is our mission!
Wellness is a choice
Wellness is a way of life to reach higher
potential
Wellness is loving acceptance of yourself
Wellness is a process - a continuum
Who best to bring the wellness concept to
others than occupational therapists?????
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Pilates is an excellent adjunct to traditional
rehabilitation techniques.
Pilates allows one to reconnect body and
mind.
It can be considered to be neuro-muscular
reeducation or therapeutic exercise. Thus,
it is billable for insurance purposes.
Patients are looking for individualized
treatment. Pilates allows you to provide
exercises specially geared to each person
along with hands on treatment.
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Pilates can enhance other techniques
such as manual lymph drainage since
there is so much emphasis upon
breathing and proper posture.
Varied special populations including
individuals with hip/knee replacements,
autistic children, Parkinson’s Disease,
and osteoporosis have also benefited.
Therefore, it can be used with other
diagnoses that you may not have
considered.
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We encourage you to learn more about
the benefits of Pilates. There are many
different schools that offer clinical types
of Pilates programs for rehabilitation
professionals.
Thank-you for your attention!
Naomi is at [email protected]
Ann Marie is at
[email protected]
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