Exercises for Shoulder Flexion

Breast Cancer Rehabilitation For Physiotherapists

Updated Oct 2016

By Siobhan O’ Reilly Bracken MISCP PT MPA MSc CLT

Email questions and comments to Siobhan@theoreillycentre.ie

The early exercises to reduce pain and recover shoulder flexion.

This short sequence of exercises were developed by Siobhan O’ Reilly Bracken MISCP PT MPA MSc CLT after studying the evidence for early mobility exercises and lymphedema prevention. See the Pre-Reading List for references. Please email Siobhan with comments or questions Siobhan@theoreillycentre.ie

Indications, Precautions and Contraindications

These exercises are indicated when patients:

• Have early stage breast cancer and a non-capsular pattern of shoulder restriction (i.e. reduced flexion).
• Have flexion limitation that is directly related to breast cancer surgical scars, cording and radiation fibrosis.
• Have healthy bone i.e. patients do not have osteoporotic or metastatic bone lesions in the humerus, scapula, thoracic cage or vertebrae.
• Do not have shoulder pathology that pre-existed breast cancer treatment or a capsular pattern.

Physiotherapists assess and prescribe who is appropriate for these exercises and who is not. When a breast cancer patient presents with precautions or contra-indications the Physiotherapist will modify accordingly (i.e. add and subtract exercises and the number of repetitions).

Building patient’s confidence to mobilize.

The Physiotherapist may teach these exercises first in the clinic so patients master the technique and experience immediate positive benefits. When patients experience the positive benefits of the exercises, their confidence builds. Only when patients feel safe and confident will they be motivated to follow through with the prescribed Daily Home Exercise Program (DHEP).

The benefits of early exercise include: (See pre-reading list for references)

• Return of shoulder flexion.
• Reduced pain, suffering, fear and anxiety.
• Reduced guarding postures.
• Prevents shortening of the scapular, SCM, pectorals, biceps, triceps, forearm, thumb and finger muscles and their pumping affect on the local circulation and lymphatic system.
• Prevents adherent scars and adhesive capsulitis (which can inhibit the flow of the circulating, arteries, veins and lymph through the lymph vessels and nodes.
• Reduces disuse muscle atrophy, general deconditioning and reduced aerobic endurance (aerobic exercise keeps the diaphragm effective in breathing and in pumping lymph fluid through the Long Thoracic Duct for re-entry into the venous system at the clavicles).
• Exercise and movement mobilizes the skin of the chest, axilla and affected upper extremity so the superficial lymphatic system which is embedded in the skin.
• All of the above combined accelerate recovery and reduce a patient’s risk of developing secondary lymphedema.

Written instructions for home exercise program (HEP).

It is best practice to print up and share these instructions with the appropriate patients so they can follow through correctly at home in between Physiotherapy sessions.

Monitoring outcome measures.

Before starting these exercises the Physiotherapist will record the patient’s pain and flexion. She will record the patient’s pain status, using the VAS scale of 0 – 10 (where 0 is = “I do not have any pain now” and up to 10 = “I have intense pain now”).  It is best to advise patients to move gently and to avoid overpressure and that pain above 3/10 is unacceptable and should be managed.  Patients should experience a decrease in pain and not an increase when doing their exercises.

The Physiotherapist measures shoulder flexion out of /180 degrees, using a goniometer. Finally she may also take a photograph of the patient in supine with the arm in flexion (with the patient’s written permission) for before and after comparisons. These outcomes measures are used when recording patient’s response to exercise and when reporting Physiotherapy outcomes to the oncology team.

TABLE 1. Monitoring changes in pain and shoulder flexion.

	Unaffected	Affected	Affected	Affected	Affected	Affected
	R/L	R/L	R/L	R/L	R/L	R/L
DATE	DATE	DATE	DATE	DATE	DATE	DATE
PAIN -/10
FLEXION -/180
PHOTO	YES/NO	YES/NO	YES/NO	YES/NO	YES/NO	YES/NO

Equipment used:

• An exercise mat,
• A small pillow.
• A 500gm Sissel Shaping Ball

Starting position A: Activating the posterior chain

Patient lies face-up on a mat with a small pillow under they head, squeezing a 500gm Sissel Shaping Ball between the bent knees, feet hip distance apart.

1. Breathing: Patient places their hands on their lower ribs (over the diaphragm) inhales gently through the nose to a count of 4 seconds and exhales gently through the nose to a count of 8 seconds. Repeating up to 7 times.
2. Breathing and Bridging: Patient inhales through your nose, pushing through the heels, lifting the hips up into a bridge, again with the Sissel ball between the knees then gently exhales and lets the hips down. Repeating up to 7 times.
3. Breathing, bridging and flexing the arms: Patient inhales through the nose, lifting the hips up, squeezing the Sissel Ball and raising the arms up into flexion, then exhales and lets the hips and arms back down. Repeating up to 7 times.

TAKE A PAUSE AND REST

Starting position B: Stretching the axilla (underarm) and chest.

1. The patient rolls over and lies on their unaffected side, using the pillow to gently support the head.  First set up the lower body by asking the patient to lay the top foot over the bottom foot, the knee over knee and the hip over hip.
2. Stretches the underarm out at right angles to the body
3. Places the back of the top hand/the affected hand on their forehead (like a salute).
4. Inhales gently rotating their upper body back so the shoulder blades lie on the mat. This will strain the axilla. When the patient feels tension just hold the stretch and breath in and out gently up to 7 breaths, breathing and stretching the axilla, without over-pressure. Patient then returns to side lying and back to position A.

Finishing

Back in position A – the Physiotherapist re-assesses and records pain and shoulder flexion using the VAS scale and goniometer, and may re-photographs the new end point for the patient’s chart for recoding and reporting to the oncology team.

Home exercise prescription

Depending on the patient’s comfort level, the Physiotherapist will prescribe the number of repetitions for the Home Exercise Program (HEP) and print up the written instructions.

Comments and questions please to Siobhan@theoreillycentre.ie