Exercise can be very beneficial for reducing pain and swelling, improving range of motion and strength, and improving a person’s overall quality of life. There are many variations of exercise that can be done as well because different people require different intensities and types of exercise regarding their diagnosis and their treatment care plan. Post-treatment breast cancer patients experience a great amount of pain during and after their treatments. This pain can be caused by the surgeries like a lumpectomy, a mastectomy, or a double mastectomy. The pain may also be due to the type of chemotherapy, radiation therapy, or medicinal treatment they are receiving during or after the surgery is performed. One of the most common problems that women face post-surgery and treatment is lymphedema of the arm, axillary (armpit) area, and the shoulder according to Sagen et al. (15). This is common due to the removal of lymph nodes surrounding the tumor that is being excised (15). This brings up the category of strengthening the arm and shoulder areas. Since this is one of the most affected areas for breast cancer patients, its strength will need to be built up again after being weakened after surgery or treatment. These surgeries and treatments will cause a large amount of scar tissue that is built up which is discussed by Otoole J, Russell T, Taghian A. (14).
This makes recovery even more challenging when trying to reach or move the arms or the axillary area. The scar tissue problem can be dealt with by performing stretching exercises, whether it be in a pool or on land, as well as a therapist massaging the scar tissue out to loosen up the fibers (14). When this area is strengthened and stretched it helps break up some of the scar tissue formed in these areas. At first this may be done in a physical therapy setting where a therapist can perform active stretching to encourage the breast cancer patient to push their limits (4, 14, 15). This allows for an increased range of motion (ROM) (4,14,15). When the breast cancer patient starts to feel more independent, they may want to try and continue to stretch and strengthen with yoga. This stretching class helps the patients to alleviate pain and improve their quality of life (QOL) by doing something that may be considered more enjoyable than therapy (3). When patients are recovering from the treatments they have received, along with therapy, it is hard for them to stay motivated to be active. They are left feeling fatigued and sore. They are also instructed to wait for a certain allotment of time, typically eight weeks, before performing any physical activity (7,9). This takes a toll on the patient’s strength, and it is hard for them to build it back up. A way for patients to stay motivated, and reduce their pain, and improve their stretching and strength is through aquatic therapy. The aquatic environment is a soothing environment that promotes muscle relaxation while alleviating pain and improving the patients stretching and strength. The relaxation of the body is promoted by the water temperature which is typically around 28.3°– 30 ° C or 83° – 86° F, as stated by Aquatic Exercise Association (AEA) guidelines (1).
When the muscles are relaxed it allows for the body to be more mobile and looser. It helps to promote circulation and cardiac output throughout the body which leads to more blood in the upper part of the body. This is because in the water gravity is not acting against the patient (1). The aquatic environment promotes balance and stability as well since the water doesn’t allow for consequences for stumbling states Aqua hub Physical therapy (19). If patients are feeling ambitious or are looking for the next challenge while recovering, recent studies have shown promise for the future of aerobic exercise after breast cancer treatment. Aerobic exercise is not a typical treatment because it is more vigorous than aquatics, and arm and shoulder strengthening.
It is also not typical because patients are feeling so fatigued after their treatments, and there is also a certain time span that they must wait before participating. This exercise helps improve patient’s aerobic capacity along with their quality of living. Their aerobic capacity is improved when they perform moderate to vigorous activities, which gets their blood moving. After a few weeks their bodies will start to adjust and adapt, and the harder workouts will become normal. Aerobic exercise can be done in a group setting which can give the patient a sense of motivation to know that a friend is experiencing the same struggles they are. When researching the effects of exercise on post- treatment breast cancer patients, research has shown that different types of exercise have led to reduced pain, improved range of motion, and improvement in a breast cancer patients’ overall quality of life.
SIGNIFICANCE OF THE PROBLEM
Breast cancer is a continuously growing problem in the United States. One in every eight women in the US will develop some type of invasive breast cancer sometime within their lifetime according to the U.S. Breast Cancer Statistics (17). Not only that, but it also states that the rate of death caused around 40,000+ women to die in 2018 alone (17). It is also the second most cause of death among women today (8). This disease is very prominent in women now more than ever. There are two types of mutations in the DNA, the first is genetically inherited which is where the parent passes their gene to the child and the second one is changes that happen as a person ages or has some sort of chemical exposure. In 5%-10 % of breast cancers are the genetically inherited type (19). There are two types of the genetically inherited mutations. The first being the BRCA1 (Breast Cancer gene one) and the BRCA2 (Breast Cancer gene two). These are genes that everyone has, and they have the function of repairing damages and keeping systems growing like the breasts and ovaries. However, when this genetic mutation is passed down on the BRCA genes, then it is more likely for that child to develop breast cancer later in life (19). along with this there can be mutations in pieces of the chromosome called SNPs (single nucleotide polymorphisms) and researchers are finding that this is linked to an even higher chance of developing breast cancer in women that received the previous gene mutation and in women who did not (19).
REVIEW OF LITERATURE
Aquatics Aquatic exercise is very beneficial to post-treatment breast cancer patients. Some of the benefits include relaxation which is brought on by the comfort of being in the pool and the heat that the pool provides. The heat and relaxation help to alleviate some of the pain that patients experience. The main focuses of the three studies are deep water running (DWR) class, improving cancer-related fatigue, improving pain, improving overall health and quality of life. Cuesta-Vargas A, Buchan J, Arroyo-Morales M. (3) and Gonzalez-Angulo AM. (8) focused their studies on DWR and Cantarero-Villanueva I, Fernández-Lao C, Caro-Morán E, et al. (2), along with the previously mentioned studies, focused on aerobic workouts in the pool (2,3,8). Most of the scenarios were similar in that the pool was heated for comfort. There was an appropriate subject size in the trials that ranged from about 40-68 people within each article. The experiments’ timelines were eight weeks long or two months long. They all consisted of an experimental group and a control group. The experimental groups were typically assigned to some program that was about an hour long and consisted of a warm-up, a few interchangeable aerobic exercises, recovery techniques, and a cool down. The subjects usually met about three days a week. The control groups in each trial were either given a normal treatment at physical therapy or some type of pamphlet to read and work on. All treatments showed great signs of improvement in breast cancer survivors, including decreased fatigue and pain and increased strength. Some of the secondary focus that the breast cancer survivors wanted to come into play were the circumference of the waist, body mass index (BMI), and weight loss (2). It was found in Cantarero-Villanueva I, Fernández-Lao C, Caro-Morán E, et al. (2) study that patients had improved their waist circumference (2). The research found that aquatic exercise is very beneficial to women who have experienced different pain weakness because of breast cancer treatment. This has proven to be a great alternative for post-treatment breast cancer patients to explore. (2,3,8)
Strengthening Arm and Shoulder Area
There is a heightened importance for breast cancer patients to strengthen their arm and shoulder area after surgery because that is the area most affected by the surgeries they endure. Yoga is an effective and safe way for breast cancer patients to better their QOL and alleviate pain according to Eyigor S. et. Al (4). Mazor M, Lee JQ, Peled A, et al. (12) conducted study (4) that tested strength, arm volume and ROM. It was concluded that yoga will improve ROM and increase strength in the upper extremity of breast cancer patients. (4,12). Harder H, Holroyd P, Burkinshaw L, et al. (9) conducted a new app-based exercise program. It allowed for breast cancer patients to help come up with ideas when making the app and while the app was being used. The focus of the app was to allow post-treatment breast cancer patients to exercise their arm and shoulder areas at more convenient times for them. This study showed promising effects but still needs to be studied further (9). Progressive strengthening and training after breast cancer surgery is hoped to improve ROM, strength, swelling, pain, and QOL according to Kilbreath SL (11). However, in this study, testing this, there needed to be further research conducted to prove all the outcomes. Early physiotherapy to prevent lymphedema after breast cancer surgery is a study that Otoole J, Russell T, Taghian A. (16) conducted.
The patients in their study received manual lymphatic drainage, massaging scar tissue, and active stretching that was increased over time. The results showed that these methods could assist in the prevention of lymphedema (16). In another context, Sagen A et al. (17) discusses upper limb function after lymph node dissection. This is similar to (16) in the way that it involves lymphedema. Sagen A et al focused-on arm lymphedema, shoulder mobility, and pain intensity (15). It was determined that further research may need to be done, but overall breast cancer patients may benefit from participating in early physiotherapy, along with strength and resistance exercise (17). These studies focused on performing exercises that would help to improve quality of life, strength, and range of motion, and decrease swelling/lymphedema in the upper extremities. The studies were a bit new and even though there was evidence of some improvement in what is listed above, it is stated that further research will need to be done with a larger test size for a longer time frame. The studies lasted from 8 weeks – 2.5 years after treatment. There was certainly no lack of participants when these studies were combined! The subject size in these studies ranged from 42-391, although the (9) did not mention subject size. Each researcher integrated their own form of exercise program.
Most were broken into experimental and control groups, except for the app-based exercise program. The app-protocol was designed with the ideas of real breast cancer survivors and then was tested by them eight weeks after their surgery. For the other studies there was a wide variety of training done, like yoga (4,12), resistance training and stretching (11), lymphatic drainage and massages of scar tissue (16), active and progressive active and assisted shoulder exercises (17). Aerobic Exercise Moderate aerobic exercise is said to improve a patients QOL and physical functioning according to Murtezani A et. al (13). The vigorous aerobic exercise study focused on improving physical performance in breast cancer patients and its potential to affect bone mass according to Nikander R et al (15). Ng AV, Cybulski AN, Engel AA, et al. (14) study the effects of triathlon training on breast cancer patients. Their focus is on improving QOL of breast cancer patients. The result was an improvement of QOL and an increase in the breast cancer patient’s aerobic capacity (14).
The goals for these studies were to improve the patients’ quality of life and improve aerobic performance. The secondary improvements were focused on changes in the patient’s body composition, improving their weight, and improving BMI. The number of days per week that the subjects were in the group and at home varied from study to study. Some of the studies tested the maximal O2 uptake (VO2 Max test) to help determine where the participants were at physically (14). Along with the maximal test there were a few submaximal tests used like the 12-minute walk test, which is another way of estimating the maximal oxygen uptake (13). This also gives the subjects an idea on how they have improved aerobically after the trial is over if they choose to participate in the test again. The studies were found to be very beneficial for post-treatment breast cancer patients. They showed that there was an improvement in the patient’s quality of life, physical functioning, and aerobic capacity. Even though all the studies had positive outcomes, some of them suggested that there be further research to investigate into this topic more. It seems to be a newer topic however; these studies seem to show promising outcomes so far. (13,14,15)