Range of Motion Exercises After Mastectomy
I previously overviewed my strategies for Post Op Management Strategies After Mastectomy. That article outlines what I learned as an occupational therapist from working with clients after surgery for breast cancer. I included the therapeutic needs most consistently encountered with my clients: range of motion, scar management, and lymphedema prevention.
In this article, I will elaborate on specific strategies for shoulder range of motion exercises for breast cancer clients after lumpectomy or mastectomy.
Guidelines for Resuming Activities
The key to resuming activity, including range of motion (ROM) exercises, is not to do too much too soon. I found doctors and surgeons to be pretty vague when clients posed questions such as “What can I do?”, “What should I avoid?”, “When should I resume normal activities?” Doctors tend to say things like “Just do what you can do.”
I don’t think necessarily that doctors are being intentionally evasive. I think they are busy, and that they tend to forget these things are not “common knowledge”. To some extent, they may be a little evasive. After all, they are not rehabilitation experts. Hopefully your therapist will be!
This article is meant to be a guide, to discuss with your doctor or therapist.
Shoulder Range of Motion
I found that most clients, after lumpectomy, mastectomy, or excision of lymph nodes, were too sore to begin range of motion (ROM) exercises for at least three to five days after surgery. I have not found it to have any significant negative impact on clients’ outcomes if structured ROM exercises are not started until seven to fourteen days or longer, after surgery.
While I think two to four weeks post op is an ideal time to start ROM exercises, movement in a short range is beneficial early after surgery. I prefer to get consults early after surgery to start general education, including gentle movement in a short range. Again, most clients are inclined to do too much, not too little, so early education is important.
Many women regain ROM after surgery with no intervention. Others regain their previous ROM gradually over a period of a few weeks or a couple months. Clients with diabetes or a previous history of frozen shoulder may be at higher risk for persistent ROM deficits. Women who will be undergoing radiation therapy will need to get their arm over their head, so obviously they need full shoulder ROM before beginning radiation.
I start my post-op clients off with shoulder pendulums, cane, pulley, wall walk and table slide exercises. ROM exercises should be done with no more than a one to three of 10 increase in pain above baseline pain. For more on rating pain, see my article on how to rate pain.
In general, clients do not have shoulder joint stiffness. ROM is restricted due to the soft tissue trauma related to the surgery. This discomfort should be respected. Exercises should be done so that you feel a mild to moderate stretch to the incision scar. Stressing the scar too much will cause increased scar tissue as a protective response, but is counter-productive to recovery.
While some clients find it easiest to do two or three exercise sessions per day, I recommend brief sessions with a few repetitions throughout the day. Imagine exercising for 30 minutes, two times a day, versus 10 minutes, six times a day. Which do you think is less likely to cause increased soreness or swelling? I recommend doing the different exercises at different times of day, depending on your routine.
Over time you may find some of the exercises more beneficial than others. If you are not feeling a therapeutic stretch from one of the exercises, you can probably stop that exercise. You may find that you are more drawn to certain exercises because they fit your routine. If this makes you more compliant overall, this is fine, unless the exercises you choose do not give you a therapeutic stretch.
Pendulum Shoulder Exercise
I recommend pendulum exercises for those clients with the worst shoulder pain. Not all clients need to do pendulums.
To do pendulums, stand next to a table or chair, holding to support yourself with the hand of your non-surgical side. Lean over at the waist. Let your surgical-side arm hang limp, as though you had a nerve block and absolutely could not move your arm. This is passive range of motion. Your surgical arm is being passively moved by some other means than its own power.
Generate arm movement by bending and shifting at the hips and knees. To change movement of the arm, come to a complete stop, reposition legs, then shift body by moving hips and knees again.
Do arm forward and back, side to side, in clockwise circles, and in counterclockwise circles.
Cane or Wand Exercises
Cane exercises can be done sitting, standing, or lying down, and I recommend trying each, because each is a different movement experience for your shoulder joint, muscles, and soft tissues.
Hold a cane, dowel, broomstick, or other suitable tool, with the hand of your surgical arm. Let your arm relax and be limp, as though you would have to Velcro your hand to the stick, but otherwise could not use your arm. This is another method for passive range of motion.
Use your other hand and arm to carry out the movement. Start with short, rhythmic movements in multiple directions to warm up your tissues. Gradually begin to increase the movement with your arm straight out in front of you, slightly to the side, a little more to the side, then finally all the way to the side as if you had your back and your surgical arm against the wall.
Gradually go to your end range, where you feel a gentle stretch, and hold for 8 to 12 seconds. Repeat in different positions.
Cane Exercises for Shoulder ROM
Pulley Exercises for Shoulder Flexion
Pulley Exercises for Shoulder Abduction
There are many pulley exercise devices available for about $20. Most of them hang over a closed door. We dispensed pulleys to our clients from our clinic.
Pulley exercises are usually done seated, but can be done standing. Hold onto the handles with each hand. As with the cane exercises, relax your arm of your surgical side, as though your arm was limp, and you had to Velcro your hand onto the handle. This also is a passive range of motion exercise.
Use your non-surgical arm, pulling down, to elevate your surgical arm. Use your non-surgical arm to control your surgical arm back down. Do this for forward flexion, or elevation of your surgical arm straight out in front of you.
Start with short range, gentle rhythmic motions. Gradually approach your maximum range of motion. Hold for 8 to 12 seconds for gentle stretch at end range.
Repeat to raise your surgical arm to the side (abduction), and partway between front and side.
Table Slides for Shoulder ROM
You can use a table or countertop to assist you in your shoulder range of motion. Place your surgical-side arm on the table surface. Glide your arm forward, using the surface to support your arm’s weight. This is active assistive ROM.
Glide straight forward in front of you, mid-way to the side, and out sideways. Start gentle, then work your way to your maximum tolerated ROM, where you feel a gentle to moderate stretch.
You can do table slides before or after a meal, when you are at a table. I had a client with a shoulder injury who said he arranged his computer desk so that he could do table slides, because the mouse reminded him of this exercise.
Another active assistive range of motion exercise is wall walks.
Place your hand of your surgical side on a wall, and walk your fingers the wall. Start gentle, then gradually walk up the wall until you feel a stretch.
You can then walk your hand back down a bit, relax, then go back up again. As your tissues warm up, you may be able to get your arm up further. Walk your arm back down.
Do this exercise with your arm straight out in front of you. Repeat this process with your arm to the side, and mid-way between.
Many of my clients do this exercise in the shower. While your arm is up, you can lather your underarm! My shoulder injury client reported he did wall walks when he turned light switches on or off.