Mastectomy is the surgical removal of part or all of the breast. Physiotherapy management of mastectomy involves pre-operative and post-operative care. Pre-operatively, assessment is done and exercises are prescribed to maintain range of motion and strength. Post-operatively, the goals are to restore range of motion, reduce pain and swelling, prevent stiffness, and improve function. A protocol of exercises like deep breathing, walking, pendulums, and stretches are followed to regain mobility and strength while avoiding complications like lymphedema and limited range of motion.

1. MastectoMy
and it’s physiotherapy ManageMent
abcd
Shubham Singh

2. topic to be covered
 Introduction
 Assessment.
 Management.
 Post-operative reassessment.
 Discussion

3. Introduction
Mastectomy: medical term for removal of a part of breast or
entire breast and sometimes associated tissues and lymph
nodes.
MASTECTOMY: MAST + ECTOMY
Implies to
breast
surgical removal
of a part of body

4. Breast cancer is one of most common cause of mastectomy
 Noninvasive breast cancer: Ductal carcinoma in situ (DCIS) is
the most common type of noninvasive breast cancer. It forms in the
milk ducts and has not spread into breast tissue.
 Stage 1, 2, and 3 breast cancer:
 Inflammatory breast cancer: This is an aggressive form(chemotherapy
is recommended before surgery.
 Paget's disease of the breast: This rare type of cancer affects the skin
of the nipple and areola and involves either DCIS or invasive breast
cancer.
 Locally recurrent breast cancer: A mastectomy may be necessary if
cancer returns to a breast or area of the breast.
When and why mastectomy

5.  Age
 General health.
 Menopause status.
 Tumor size.
 Tumor stage (how far it's spread).
 Tumor grade (its aggressiveness).
 Tumor's hormone receptor status.
 Whether or not lymph nodes are involved.
 Whether the patient can tolerate radiation threapy.
Factors affecting mastectomy

6. Simple or total
mastectomy
Mastectomy
Radical
mastectomy
Modified
radical
mastectomy
Partial
mastectomy
Quadrantectomy
lumpectomy
Nipple sparing
mastectomy
Skin sparing
mastectomy

7. Simple or total mastectomy
- Removal of breast tissue, areola, nipple and skin.
- Sometimes lymph nodes are removed from underarm.

8. Partial mastectomy
- It’s is a breast-conserving method
- Women with stage I or stage II breast cancer may have this procedure
- The surgery is often followed by radiation therapy to the remaining breast tissue

9. Radical mastectomy
- Removal of breast tissue, areola, nipple and skin, underlying muscles
- Only recommended when the cancer has spread to the chest muscle

10. Modified radical mastectomy
- Less traumatic
- Removal of entire breast tissues along with the underarm lymph nodes.
- Chest muscles are left intact but the skin covering your chest wall may or may
not be

11. Skin sparing mastectomy
- Removal of breast tissue, nipple, and areola but saves most of the skin
over the breast.
- Used when breast reconstruction follows immediately after a mastectomy

12. In patients with high risk of breast cancer, to reduce the chances of
cancer preventive or prophylactic surgeries are performed
preventive mastectomy is recommended if :
 Mutations in BRCA1 or BRCA2: these genes help repair damaged
DNA. If they are not functioning properly, tumors can grow.
 A strong family history of breast cancer: family members have had
breast cancer before the age of 50.
 Lobular carcinoma in situ: it is an area of abnormal cell growth
 A history of radiation therapy: people who have had radiation
therapy in the chest area before the age of 30 years may opt for a
mastectomy.
Preventive mastectomy

13. Non-cancerous Mastectomy
 In sex reassignment surgery
 Fibrocystic breast disease
 Dense breast tissue
 People with a personal or family history of breast cancer as a
preventive measure(rare)

14. Fig: Breakdown of incision

15. Fig: Different techniques of Skin Sparing Mastectomy

16. Adjuvant therapies
Adjuvant therapies
Radiotherapy Chemotherapy
 Used particularly after breast
sparing operations
 Its aim is to irradiate any remaining
cancer cells
 Used mainly for pre-menopausal
women when cancer has spread
to the axillary lymph nodes
 To shrink the tumor facilitating
more conservative surgery
Note: Women who have estrogen-sensitive tumors also receive some form
of hormonal therapy to block the cancer promoting effect of estrogen

17. Assessment

18. Pre-operative assessment
Importance of pre-operative assessment
 It helps in determine the extent and time course of recovery of
shoulder impairment in subjects being treated
Pre-operative assessment
 Any existing musculoskeletal shoulder or neck problems that may
effect post-operative outcomes
 Identification of potential risk factors for reduced mobility or
lymphedema
 Shoulder mobility (flexion, abduction, and external rotation)
measured by use of a universal goniometer under standardized
conditions.

19. Post-operative assessment
Importance of post-operative assessment
 it helps in determine the extent and time course of recovery of
shoulder impairment in subjects undergone surgery.
General Assessment
 How you can expect to feel ?
 What daily activities the patient can’t do ?
 What exercises the patient was doing before and after surgery ?
What activities patient needs to do ?

20. What to look for ?
 Pain
 Numbness
 Palpation for tenderness
 Deficits of shoulder ROM i.e. limitation of functional activities
mainly overhead
 Lymphedema

21. Assessment of pain
Pain rating scales
 Visual analogue scale (VAS)
 Numerical rating scale (NRS)
 Faces rating scale (FRS)
 Behavioural rating scale
 Functional activity score

22. Visual analogue scale

24. Behavioural rating scale

25. Assessment of movements at shoulder
Range of motion at glenohumeral joint using goniometer
Flexion
Extension
Abduction

26. Complications
 Wound infection and delayed wound healing
 Seroma development on the anterior chest or axilla after wound
drains are removed
 Neural disorders including sensory disturbances in the medial
upper arm due to dissection of intercostobrachial nerve
 Neuralgia
 Cording (axillary web syndrome)
 Fibrosis of the skin and muscle of the chest wall after
radiotherapy

27. Management

28. Physiotherapy Management
The main goal of physiotherapy management for women with
mastectomy is
 Returning to their former level of physical function
 To improve an overall level of fitness and prevent
deconditioning.
 Emphasis on improving aerobic fitness, increasing range of
motion in the chest and shoulder
Physiotherapy management
 Include activities that improve balance and overall
coordination and function to increase activities of daily living.
 Facilitate a return to work and improve overall quality of life

29. #abcd
Principles of Physiotherapy Management
 Maintenance of airway and ventilatory capacity.
 Maintain and improve joint range.
 Strengthening and re-educate normal muscle function.
 Re-education of sensory awareness and motor function.
 Restoration of normal function.
 Motivation and psychological support

30. Pre-operative physiotherapy management
Why do we need pre-operative management ?
 Pre-operative exercise and education are recommended to
reduce the incidence of breast cancer related upper limb
dysfunction
 Preoperative education focus on post-operative presentation and
exercise helps in maintaining and improving the shoulder ROM
and strength
Importance of pre-operative management
 A pre-operative exercise reduces the rehabilitation period by
early regaining of ROM
 Reduces the development of secondary complications.
 The times invest before surgery, will shorten the recovery time.

31. Exercise
Education
pre-operative management
provides a clear picture about
 Surgical procedure
 Postoperative presentation
(drains, pain, deficits of shoulder
ROM, lymphedema, limitation of
functional activities)
 It prepares the subject for
surgery both physically and
mentally
 Minimize the effect of
development of secondary
complications

32. Post-operative physiotherapy management
Aim of post-operative management
facilitating and maintaining the recovery of shoulder movement i.e.
 To restore range of motion of arm i.e. to reduce after surgery
limitations.
 To promote circulation and lymphatic drainage thereby reducing
swelling.
 Reduce pain in chest, shoulders, neck and back.
 To reduce stiffness in joints.
 Improve muscle strength.
 Return to your daily activities faster such as dressing, bathing and
driving.

33. Post-operative complications
 Reduced shoulder ROM (inability to raise arm overhead), as per
study 73% of women reported decreased shoulder range of
motion.
 Pain
 Lymphedema
 Limitations in functional activities.
 Upper limb dysfunction is frequently reported squeal of early
stage breast cancer treatment.

34. General activities patient needs to do
 Using arm of surgery side for day to day activities(brushing
teeth, combing hair, dressing etc.)
 Short leisurely walks
 Deep breathing exercises
Activities patient needs to avoid
 Lifting heavier object (anything more than 5 kilograms) for 4
weeks after your surgery
 Any movements that are tiring and repetitive like vacuuming or
scrubbing until your drain is removed (if you have a drain)

35. Management
 Pain: normally managed with medication
- to educate about her injury, the phase of healing
- to encourage effective use of medication on a time linked
basis
- TENS, acupuncture, muscle imbalance treatment,
relaxation techniques
 Lymphedema: it is chronic and progressive swelling by a low
output failure of the lymphatic system resulting in the
development of high protein oedema in the tissue
 Cording/axillary web syndrome: tender, cord like structure that
are result of lymphangitis or lymphatic thrombosis
- arises from the chest wall to axilla, sometimes extending
down the arm
- it restrict the movement and cause pain
- gentle soft massage and movement relieves the pain

36.  Scarring: results in tightness and discomfort in axilla and
chest wall
- massage the scars once healed to improve pliability.
 Numbness: as a result of incised cutaneous nerves during
surgery
- results in sensory loss in axilla, lateral chest wall and
upper arm.
 Postural advice: post mastectomy results in weight imbalance
and shoulder protraction
- if uncorrected pectoral muscle will shorten and
tighten leading to muscle imbalance
- active and passive movements are advised

37. Fig: Cording/axillary web syndrome

38. S.No 1st week 2nd week 3rd week 4th week
1. deep breathing self-massage
same
protocol
followed
with
minimal
assistance
also same
protocol
with no
assistanc
e and
regain the
pre
operative
ROM and
functional
status
2. elevation of limb
(below shoulder
level)
pendular exercises
3. free exercises to
hand, wrist and
elbow
self-stretching’s (ant.
chest wall, hand
behind back towel
stretching’s).
4. self-assisted
exercises up to
pain free range
Protraction and
retraction exercises
5. walking wall climbing
exercises (flexion,
abduction)
6. postural
correction
Meanwhile post-
operative
complications will be
noted during this
period.
Table: Post-operative physiotherapy protocol

39. Deep breathing
 Easy to learn, and you can practice it almost anywhere
 It help with exercises and make it easier to relax
 Keep the lungs clear
 Lower or control your stress
How to do deep breathing:
 Find a comfortable position and lie face up.
 Take a slow deep breath in through nose.
 Let your chest and belly expand avoiding forceful inspiration.
 Breathe out slowly through mouth.
 Repeat this for 15-20 times.

40. Walking
 It is great way to improve strength and endurance after surgery.
 Improves your circulation (the blood flow) in your body, thus helps
with healing.
Tips for walking
 Start slow and rest often until you are able to return to your
normal level.
 If having some pain when walking, arm of affected side must be
supported your pain decreases

41. Exercises
 It is important to start moving arm on the side of surgery as soon as
possible after surgery
 Begin exercises slowly, without tiring or straining and avoiding any
forceful movements
 Includes activities at home, at work, or during sports and hobbies
Why to exercise ?
 Preventing scar formation, scar tissue could reduce the movement
 To return to daily activities sooner
It is advised do the exercises in front of a mirror to make sure to keep
good posture

42. Exercise protocol
Get back the full range of motion in shoulder
 being able to move your arm and
shoulder the same way you did
before your surgery
 starting with general movements
and slowly adding more to
repeat each exercise 5 to 10
times, 3 times a day
 holding each stretch for 3 to 5
deep breaths
Regain strength in shoulder
 start with light weights (about 2
to 3 pounds) or a light resistance
band and progress slowly

43. Pumping
reduce swelling after
surgery by using
muscles as a pump to
improve the circulation
in your affected arm
slowly straighten your elbow while
opening fist at the same time
lying on unaffected side with affected arm
straight out, resting on top of a pillow.
slowly bending elbow while making
a fist at the same time.
Repeat 15
to 25 times

44. Shoulder Circles
 help relieve tension in
your shoulders.
 can be done sitting or
standing.
gently rotate both shoulders
forward, and then slowly down and
back, making a circle.
lift both shoulders up toward
your ears, keep your chin
tucked in slightly.
make 5 slow circles in one direction,
then switch and make 5 slow circles
in the opposite direction.

45. Arm lift
It helps improve movement in your shoulders
Slowly lifting arms upward until a gentle
stretch, but no pain and holding it for 5
to 10 seconds and then slowly return to
the start position.
Clasping hands together in front of
chest and pointing elbows out.
Repeat 5 to 10
times

46. Shoulder Blade Squeeze
It helps to stretch your chest muscles
slowly bring elbows straight
backwards, while squeezing
shoulder blades together to feel a
gentle stretch and hold this position
for 5 to 10 seconds
hold arms at side against body
with elbows bent and
Repeat 5 to 10
times

47. Pendular Exercises
To encourage movement at shoulder joint
Performed with or without weight

48. 2nd week

49. unaffected arm will help lift the wand
higher and holding for 5 seconds,
then gently lower arms
lie on back with knees bent, hold the wand
with both hands and hands should be as
wide apart as shoulders.
lift the wand over head to feel
the stretch
Repeat 5 to
10 times
Wand exercise

50. Winging It
helps stretch the front of your chest and shoulder
Repeat 5 to 10
times
move elbows apart until a gentle stretch
is felt, but no pain and holding the
position for 5 to 10 seconds and then
slowly return to the start position.
Remember to keep breathing
throughout the stretch
lying on back with knees bent,
touch the fingertips to the ears
with elbows pointed to the ceiling.

51. Repeat 5 to 10
times
Snow angle
stretch the tight tissue in the armpit area and increases movement in shoulders.
move arms up over the head, leading
with the thumbs, eventually touching
fingers at the top then move arms back
down to sides (as if you’re making an
angel in the snow).
lying on back and extend arms out
at sides

52. Wall climbing
helps increase movement in your shoulder
A: Facing the wall
slowly slide the hand up the wall as
high as it can go to feel the stretch, but
no pain and hold it for 5 to 10 seconds
stand facing the wall while
placing the palm of hand of
affected arm flat against the wall
Repeat 5 to 10
times

53. A: Side wall stretch
slowly slide the hand up the wall as high
as it can go to feel the stretch, but no
pain and hold it for 5 to 10 seconds
Do not rotate the body toward the wall,
keep the body facing forward even if it
means you can’t go up as high.
stand facing the wall while
placing the palm of hand of
affected arm flat against the wall
Repeat 5 to 10
times

54. bend at waist to move the body to the
right by using right hand to gently
pull the left arm a little farther to the
right. Hold this position for 5 seconds
Sit in a chair and clasp the
hands together in the lap
slowly lift your arms over
your head.
Side bends
repeating the stretch to
the left side, using left
hand to pull right arm
farther.

55. Post-operative re-assessment
 Shoulder ROM
 Pain
 Lymphedema
 Functional activities
 Strength in limbs
 Scars if any

56.  also known as scar massage
 scar tissue formation along the incision line and drain site is a common
side effect following mastectomy
Why Scar Massage
 scar formation can lead to decreased flexibility and function due to
contraction and tightness
 to break the soft tissue adhesion
Scar tissue mobilization

57. Fig: Thumb pad massage

58. Fig: Techniques of massage

59. abcd
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for your
’active participation’ & ‘kind collaboration’