Early rehabilitation in patients operated for breast carcinoma

The most often complication of breast surgery with dissection of axilla is decrease in the range of shoulder joint of the ipsilateral arm motion, the feeling of heavy arm, secondary lymphedema of the arm, and very rarely pain and weakness of the arm’s muscles. Persistence of these symptoms leads to permanent dysfunction of the arm . Decrease in the range of motion is a consequence of surgery and scarring of the healed wound, which decreases the amount of movement at each joint on the operated side 4, . A reduced range of shoulder joint motion is diagnosed in 2%–51% patients who underwent surgery for breast carcinoma 2, . Secondary lymphedema of the arm is a consequence of mechanical insufficiency of the lymphatic system caused by the surgery and later, by post-irradiation fibrotic changes, and is manifested by abnormal accumulation of interstitial fluid, rich in proteins . In the majority of studies, secondary lymphedema of the arm occurs in 10%–30% of patients following the breast carcinoma therapy . For postoperative complications reduction, numerous rehabilitation programs and instructions were developed with the aim of damage prevention, maximizing the occurred damage (range of motion, muscle power) and minimizing the risk for development of secondary lymphedema of the arm 1–4, . In breast carcinoma patients, rehabilitation has become more significant due to quality of life awareness of the oncological patients . It arises dilemma when to start with the rehabilitation program: most of the authors agree in that the program should start in the first several days after the surgery 1–4, , while the other authors consider that early beginning of rehabilitation in patients with axilla dissection is associated with an increased risk from postoperative complications: longer drainage period, seroma formation, postoperative infection and consequential longer hospitalization 1, 2, . In a controlled, randomized study, a hypothesis that exercises do not increase the risk of occurrence of secondary lymphedema of the arm has been confirmed . Exercises are efficient, safe and preferred interventions in a postoperative period . Early rehabilitation and later home-based exercises program, education 14, , as well as a continuous follow-up of patients 7, 9 were identified as interventions for the improvement of life in women with breast carcinoma in all 4 dimensions: physical, emotional, social and cognitive . Type, duration, frequency and intensity of exercises vary in the studies . Education and follow-up of patients with breast carcinoma enable prevention, detection of early and late occurrences of postoperative damages . A lack of rehabilitation interventions in patients operated for breast cancer is a consequence of no standardized exercises program avalable, so it is necessary to homogenize a reproducible regime .


Introduction
The most often complication of breast surgery with dissection of axilla is decrease in the range of shoulder joint of the ipsilateral arm motion, the feeling of heavy arm, secondary lymphedema of the arm, and very rarely pain and weakness of the arm's muscles.Persistence of these symptoms leads to permanent dysfunction of the arm [1][2][3][4] .
Decrease in the range of motion is a consequence of surgery and scarring of the healed wound, which decreases the amount of movement at each joint on the operated side 4,5 .A reduced range of shoulder joint motion is diagnosed in 2%-51% patients who underwent surgery for breast carcinoma 2,4 .
Secondary lymphedema of the arm is a consequence of mechanical insufficiency of the lymphatic system caused by the surgery and later, by post-irradiation fibrotic changes, and is manifested by abnormal accumulation of interstitial fluid, rich in proteins 6 .In the majority of studies, secondary lymphedema of the arm occurs in 10%-30% of patients following the breast carcinoma therapy 4 .
For postoperative complications reduction, numerous rehabilitation programs and instructions were developed with the aim of damage prevention, maximizing the occurred damage (range of motion, muscle power) and minimizing the risk for development of secondary lymphedema of the arm [1][2][3][4][7][8][9][10][11][12] . In brest carcinoma patients, rehabilitation has become more significant due to quality of life awareness of the oncological patients 8 .
It arises dilemma when to start with the rehabilitation program: most of the authors agree in that the program should start in the first several days after the surgery [1][2][3][4][7][8][9][10][11][12] , while the other authors consider that early beginning of re-habilitation in patients with axilla dissection is associated with an increased risk from postoperative complications: longer drainage period, seroma formation, postoperative infection and consequential longer hospitalization 1,2,8 . In acontrolled, randomized study, a hypothesis that exercises do not increase the risk of occurrence of secondary lymphedema of the arm has been confirmed 13 .
Exercises are efficient, safe and preferred interventions in a postoperative period 4 .Early rehabilitation and later home-based exercises program, education 14,15 , as well as a continuous follow-up of patients 7,9 were identified as interventions for the improvement of life in women with breast carcinoma in all 4 dimensions: physical, emotional, social and cognitive 15 .Type, duration, frequency and intensity of exercises vary in the studies 16 .Education and follow-up of patients with breast carcinoma enable prevention, detection of early and late occurrences of postoperative damages 8 .
A lack of rehabilitation interventions in patients operated for breast cancer is a consequence of no standardized exercises program avalable, so it is necessary to homogenize a reproducible regime 9 .

Early rehabilitation in breast carcinoma patients who underwent surgery at the Oncology Institute of Vojvodina
The Rehabilitation Department was founded in 1996 as an organizational unit of the Oncology Institute of Vojvodina.Its activities are designed for preventive oncological rehabilitation in breast carcinoma patients, and, to some less extent, for other segments of oncological rehabilitationrestitute, supportive and palliative oncological rehabilitation 17  the horizontal correlation from the moment of diagnosis, during the therapy and the post-therapeutic period, enabled a continuous follow-up of all breast cancer patients by the physiatrist at the Oncology Institute of Vojvodina (Figure 1).
Based on the data from the literature, clinical experience, presented results [18][19][20][21] and current possibilities, early rehabilitation algorithm in patients with breast carcinoma diagnosis was defined in the Rehabilitation Department (Figure 2).

Evaluation
Basic data -preoperative measuring includes measuring shoulder joint range of motion for both arms (flexion, abduction, external and internal rotation and extension); the borderline value of the motion reduction range is 10°; measuring the volume of both arms at 5 symmetrical, clearly defined levels; the borderline value of the volume is 2 cm; psychological evaluation.According to the defined algorithm preoperative measurements are not mandatory because the first contact the physiatrist -the physiotherapist -the patient is most often immediately after the surgery.If there are any functional damages, a preoperative evaluation of the functional status is performed in cooperation with the surgeon.
Also, psychological evaluation is not obligatory since it is impossible to have a permanenthy engaged professional (no legal obligation to employ a psychologist or a defectologist) (Figure 1).

Early rehabilitation program during hospitalization
Kinesitherapy program starts on the 2nd postoperative day.It includes active exercises for the hand, radiocarpal joint and elbow to stimulate lymph flow and strengthening of the "muscle pump"; exercises with active and actively-aided movements in the shoulder joint (shoulder circling, wall climbing, elbow pushing); deep breathing; stretching exercises (neck movements, arm lifts).
The exercises are designed to maintain or increase the range of motion, to provide and increase lymph flow, to prevent fibrous adhesions and maintain the muscle power.The exercises are performed each day during hospitalization.
In patients with signs of wound infection or febrile state, kinesitherapy program is postponed until thay become is stabile.
Educating a patient includes recommendation on later complications prevention (secondary lymphedema of the arm, brachial plexus damages), i.e. how to behave and what to avoid (risk factors) 17 ; on skin care of the ipsilateral arm; and education on haw to notice any changes in the skin of the arm, postoperative cut, drain (self-examination).
Home-based rehabilitation exercises include practising these exercises at home 3 times a day, 5-10 repetitions; up to the pain limit.If infection occurs in the area of the postoperative cut, the residue of the breast tissue or ipsilateral arm, the patient should stop the exercises (seroma formation is not a contraindication) and be referred to the surgeon for examination.

Follow-up
First examination in the Rehabilitation Department follows the Oncological Committee (4-6 weeks after the surgery) in accordance with the "horizontal correlation" system (Figure 1), for examination by the physiatrist including measuring the range of motion and registration of the obtained parameters; measuring the volume of extremities and registration of the obtained parameters.
The next examination is perfermed after 3 months, while the following ones comply with the therapeutic procedures, or, if any of post-therapeutic complications appears, it is necessary to make the diagnosis according to indications (magnetic resonance imaging, ultrasound diagnostics, electromioneurography, etc.).The principles of restitute, supportive or palliative oncological rehabilitation are also applied.
This procedure in the Rehabilitation Department at the Oncology Institute of Vojvodina, horizontal correlation of all medical segments that participate in the breast carcinoma treatment, implementation of principles of preventive oncological rehabilitation, continuous follow-up and early detection of complications, significantly reduce the number and severity of post-therapeutic complications.
Out of 360 randomly selected patients, surgically treated at the Oncology Institute of Vojvodina, in the period 2000-2009, reduction of the range of motion in the shoulder joint ( 10°) was registered in 96 patients (26.67%) (Table 1).The most usual range reduction were in two movements (flexion and abduction).In more than half of the patients, the reduction was up to 30% for abduction and flexion movements and up to 20% for movements of internal rotation, external rotation and extension (Table 2).Low incidence of secondary lymphedema of the arm in comparison to data from the literature 4 and high presence of mild clinical forms are presented in Table 3 and Table 4 respectively.
Damages of the brachial plexus were actually individual cases, mostly of less severe degree.The results of postoperative breast cancer treatment in the Rehabilitation Department including the designed algorithm were recognized by the National Committee for preparation of the National Guide of Clinical Practice for Breast Carcinoma (one author of this paper is a member of the team).This is the first time rehabilitation in breast carcinoma is placed within the legal framework.

Fig. 1 -Fig. 2 -
Fig. 1 -Significance and role of rehabilitation in the patients surgically treated for breast cancer at the Oncology Institute of Vojvodina

Table 4 Clinical forms of secondary lymphedema of the arm in the patients surgically treated for breast carcinoma at the Oncology Institute of Vojvodina, 2003-2007
¹ arm