It's breast cancer awareness month, and Dr. Alexes Hazen, a breast surgeon at NYU Langone Medical Center, Tamar Amitay, of Thrive Physical Therapy, and I have come together once again to send out an important message about breast cancer rehabilitation. After any surgery (removal of lymph nodes, chemotherapy, radiation, post mastectomy and/or reconstructive procedures) it is crucial that a therapeutic program of breathing and manual therapy be initiated quickly to prevent Lymphedema.
Lymphedema is any condition or procedure that damages your lymph nodes or lymph vessels. There are physical therapists like Tamar who are trained in lymph drainage therapy and they are emphasizing the importance of early intervention as well as the importance of teaching their patients how to practice deep breathing. Studies show that manual therapy coupled with deep breathing have proven to be essential components in the prevention of irreversible lymphedema, and early intervention is crucial! Tamar warns that during tissue healing, there is approximately a two week period of acute inflammation; treating a patient when they are at this latency stage of lymphedema can improve the transport capacity and prevent irreversible lymphedema.
As a breast reconstructive surgeon who works in tandem with oncologists and radiologists, Alexes points out that while surgery and radiation are necessary, they are a traumatic assault on the body. She points out that although a patient may not develop lymphedema, all patients' lymphatic and venous systemns are disrupted from these processes, at least temporarily. Treating and dealing with the swelling that results is a very important part of getting back to normal. Alexes strongly believes that early physical therapies can reduce the swelling and greatly speed up the process of recovery.
Ideally, two weeks after surgery, patients should begin a program with a physical therapist and initiate a deep breathing practice to help promote lymph circulation and drainage. Deep breathing stimulates the thoracic duct and in doing so strengthens the patient's ability to purposefully aid the return of the lymph to the venous system. Learning how to strengthen the pumping effects of our breathing system increases a breast cancer patient's chances for optimum recovery. By knowing how to connect to diaphragmatic breathing, one becomes better and better at producing the full, deep breaths that aid our venous system in the movement of blood and lymph fluids. Healthy full inhalations cause pressure within the thoracic cavity, and the movement of the diaphragm acts as a piston so that upon the exhalation, your fluids get a strong push back towards your heart. The enhancement of this automatic movement is important to the health of us all, but to someone with a compromised lymphatic system it must become a skill. More and more health issues are making us aware of the importance of mind/body control. The breath connects our minds to our bodies and is a great partner in times of health and a vital partner in times of healing. Tamar, Alexes and I, all believe strongly in mind/body awareness education. We all believe that learning how to breathe well is an important component in the treatment of lymphedema and I created the app Breathing Lessons so that people can become skillful at using their breathing as a health promoting and self-healing tool.
A good clinical example of how breathing, manual lymph drainage and exercise can help breast cancer survivors is the treatment of axillary web syndrome or cording. Physical therapists can and should educate patients about threshold symptoms such as heaviness, aching, fatigue, numbness and tingling -- warning signs that the patient is overdoing. Cording can occur both when patients are fearful to move their arm or overzealous (and ignore those warning signs). Normal movement can be restricted due to pain, surgical scar adhesions and/or postural dysfunction. Protective posturing, and increased lymph fluid backup, result in thin cords of engorged lymph fluid down the arm and into the breast. Overdoing it can also result in fluid backup and cording. Together, breathing, manual lymph drainage, ROM and gentle stretching can resolve cording, or at the least prevent it from worsening.
Breathing is a huge component of what I do. I always start and end a manual lymph drainage session with deep breathing exercises. I then have patients perform their ROM and strengthening exercises. Their home programs consist of checking in with their breathing on a daily basis, as well as ROM and postural exercises; I also always teach them some relaxation techniques.
Tamar has basic rules for her prescribed exercise programs:
-- Start with breathing
-- Do simple exercises first and then progress to more challenging exercises
-- Work at slow to moderate speeds.
-- Weights should NOT weigh more than 5 to 8 pounds
-- Start with fewer reps, no more than 10, and then build up to three sets of 12-14 reps
-- Stretches should be performed, but slowly and without pain
-- Always end with breathing.
Upon discharge from physical therapy Tamar encourages her patients to continue working with a knowledgeable Yoga or Pilates instructor. The focused breath work of Yoga and Pilates helps with postural re-education and may help with lymphatic clearance.