Guest Columnist: Gary E. Mattingly, PT, PhD
Donna, Mary, Patty, Louise are four physical therapy patients. These four women have many things in common. All were diagnosed with breast cancer, all had mastectomies, all had radiation and chemo, all lost their hair, and all had complications resulting in tight painful shoulders.
Currently, conventional management for early stage breast cancer is mastectomy with either sentinel lymph node biopsy and/or axillary dissection. In addition, radiation therapy, chemotherapy, and hormone treatments may be used as additional therapies. Of those who have surgery, 7 out of 8 experience some ongoing problems with shoulder/arm function. Sometimes these problems are minor and other times these problems can have a major impact on the individual’s life. The shoulder and arm problems identified by women after treatment for breast cancer include arm and breast swelling (lymphedema), shoulder stiffness, weakness, pain and numbness. Most of these problems are present within 3 months of surgery and many do not resolve up to 2 years after surgery. Most of these symptoms are attributable to surgery involving the axilla (arm pit) and to radiation treatments but sometimes shoulder /arm complications can arise from lumpectomies or even simple biopsies.
Shoulder/arm problems caused by treatment of early breast cancer is associated with reduced quality of life. These problems cut across many aspects of quality of life including role, emotional, social, and physical functioning as well as body image and lifestyle. Women with these problems experience long-term difficulties in everyday activities which most of us take for granted, such as an inability to sleep on the affected side, drive, dress, and wash one’s hair. For some women, these impairments become a psychological burden possibly due to the belief that they may never return to full capacity. As a result, for many women, the “cure” produces another whole layer of health problems.
Physical therapy can be very effective in treating these shoulder/arm problems. Treatment for these shoulder complications always begins with a complete evaluation of the shoulder to determine the source and extent of the problem. A program is next developed to regain the lost shoulder motion and to reduce the pain and the swelling in the shoulder. Depending on the severity of the problem, treatment may last a few weeks to several months.
If you are experiencing shoulder problems following breast cancer treatment there are many things that you should do. First, make sure that your doctor is aware of these problems. Not everyone that undergoes breast cancer treatment has shoulder complications. Next, listen to your doctor. The doctor will give you simple exercises to address the problem. If you continue to have problems, physical therapy should be the next step. Seek out a physical therapist that has experience treating these specific problems.
The following are exercises that might prove helpful in treating shoulder problems associated with breast cancer treatment. Before you attempt these exercises, ask your doctor if these exercises are appropriate for your particular case.
Overhead Wand - For this exercise and all the following exercises you will need a light-weight pole or wand. Many common items can work quite well as a wand including a wooden dowel, plunger, old broom handle, a ski pole or cane. While lying on your back on the floor or on your bed, hold the wand with your hands being a little wider than shoulder length apart. With elbows straight, slowly raise the wand over your head. Stop the movement when you begin to feel a gentle stretch. Hold the stretch for 20 seconds. At no time should you experience pain.
Side to Side Wand - While lying on your back, grasp the wand with your hands being a little wider than shoulder length apart. With the wand reach straight up toward the ceiling. Next move the wand as far as you can to the right. Stop the movement when you begin to feel a gentle stretch. Hold the stretch for 20 seconds. At no time should you experience pain.
Behind the Back Wand - While standing with the wand behind your back. Move the wand up your back as high as possible. Stop the movement when you begin to feel a gentle stretch. Hold the stretch for 20 seconds. At no time should you experience pain.
Dr. Gary Mattingly is a physical therapist with a doctorate degree in anatomy. He is a professor at the University of Scranton, Physical Therapy Department. His research and clinical practice is almost exclusively dedicated to the shoulder. Recently, he has presented his research on the evaluation and treatment of frozen shoulder in post-mastectomy patients at a national medical meeting.
Visit your doctor regularly, and listen to your body.
In honor of National Breast Cancer Awareness Month and the Susan B. Komen “Race for the Cure,” I would like to share some very encouraging current research regarding improve breast cancer survival with exercise. I have discussed this research with local physicians, Dr. Joseph Bannon, Delta Medix Breast Care Center, and Dr. Richard Emanuelson, Hematology and Oncology Associates of NEPA, for their impressions with these findings. Both physicians state that they regularly council their patients about the value of exercise in the recovery of breast cancer. They usually recommend aerobic exercise such as walking and/or biking and mild resistance exercise. They also emphasize that a formal rehabilitation program is often necessary if surgery was performed to prevent frozen shoulder of the involved extremity. A recent study in the Journal of the American Medical Association from Harvard now shows that regular exercise can actually improve the survival of patients with breast cancer.
Previous studies have shown many benefits of exercise for breast cancer patients including improving immune functioning and controlling depression. However, new research recently presented at the American Association for Cancer Research annual meeting was the first report to conclude that physical exercise may improve survival in breast cancer patients. Additional studies have shown other benefits of exercise. For example, a study conducted at Vanderbilt University found that women who had high activity levels throughout life were less likely to develop endometrial cancer. At the Hutchinson Cancer Research Center in Seattle, researchers found that exercise with moderate intensity can reduce serum markers of inflammation (C-reactive protein), which, when elevated, are associated with chronic disease and poor cancer survival.
In the current study, conducted at Harvard University, researchers compared survival rates in women with breast cancer with exercise levels in terms of metabolic equivalent (MET) hours per week. While women with high activity levels of exercise had the best outcomes, even women with moderate exercise benefited.
In conclusion, current research supports the fact that exercise may improve breast cancer survival. The following guidelines are proposed:
Medical Clearance
Aerobic Exercise
Strength Training
This year when your warming up at the starting line to walk or run in the “Race for the Cure,” remember you are literally “RACING FOR THE CURE!”
Visit your doctor regularly, and listen to your body.
Over the past several weeks I have written several columns related to sports injury prevention, proper training techniques, hydration, nutrition, marathon recovery, tendonitis etc. However, I feel it is also my responsibility to report the effects of over training and over exercising. While the end result is mostly physical, the cause is often psychological. We all know the personality type: type A, hyperactive, goal-oriented, driven, possessed and highly organized - almost at all costs! By now, my family and friends are thinking that I am describing myself. While it may be true, I am not alone! Many Clarks Summit residents know Dick Kane, Pat Fricchone, and Dr. Joe Gronsky as the fitness nuts running through the streets at 5:30 AM for 6-10-15 miles each day. What they may not know is that later in the day they play golf, tennis, ski, swim, play sports with their kids. Well, after 20 years they are now suffering the effects of long term multiple micro traumas. They is suffering from what orthopedic surgeons at the University of Pennsylvania call "Boomeritis! Boomeritis is inflammation of the baby boomer from overuse. Lower back pain, hip, groin, and knee pain is almost a daily event.
As baby boomers continue to enjoy sports with the same vigor and intensity as when they were younger, they are finding that their older bodies just can't keep up. While these individuals often succeed in finding the balance of fitness and craziness, they have had times when they took it too far. Furthermore, nearly all compulsive exercisers suffer from over training syndrome. When take too far compulsive behavior is rationalized by insisting that if they didn't work to extreme then their performance would suffer.
*Each sign is worth 1 point:
• 1-3 Points = Normal compliance & disciplined behavior
• 3-5 Points = Caution but OK
• 5-7 Points = Reexamine goals
• 7-10 Points = Get Help
If you have two or more of the warning sings, consult your family physician to rule out potentially serious problems.
Visit your family doctor regularly, and listen to your body.
Guest Columnist: Janet M. Caputo, PT, OCS
Ergonomics is the process of changing your environment to encourage good body mechanics. This can be accomplished by a modifying a tool, work station, counter height, task, or job.
Performing tasks within the best work zones encourages safety and decreases risk of injury through facilitating neutral spine postures.
There are four major risk factors for developing a musculoskeletal injury:
Whether certain activities increase risk of injury, depends on the duration (how long), frequency (how often), and magnitude (how intense) of the exposure to the above mentioned risk factors.
Changing bad posture, poor body mechanics, and poor ergonomics is not easy. It takes time to think about using proper body mechanics to prevent injury. The key is perseverance! And remember, practice good body mechanics and ergonomics at all times, not just when you are in pain or recovering from an injury.
Guest Columnist: Janet M. Caputo, PT, OCS
Proper body mechanics are based on good posture. Proper body mechanics involve maintaining a neutral spine with transitions from one position to another during daily activities.
Place hands on side to lie down towards. Lower upper body down with hands while bringing legs up with hips/knees at right angles. Reverse for lying to sitting.
Bend hips/knees to right angles. Roll like a log (hips/shoulders move as a unit) onto side. Do not twist!
Move buttocks to edge of chair. Feet apart. Incline trunk at hips. Maintain hollow in lower back. Stand up by straightening hips/knees simultaneously. Pushing up with hands on armrests or thighs can assist.
Face work directly. To eliminate reaching, sit close. Tilt wok up with easel/holder. To eliminate twisting, consider chair that rolls/pivots. A headset avoids cradling phone. Put monitor at eye level. Attach a document holder to side of monitor. Consider an articulating arm or drawer under desk top to house keyboard at correct height for working.
Seatback should be vertical. Back/neck supported with chin level. Move seat close to allow knees to bend and feet to reach pedals. Knees are at same height or slightly higher than hips. With hands on wheel elbows are slightly bent and relaxed. Place hands on wheel at 9 and 3 o’clock to relax shoulders. A lumbar roll is recommended.
Face work directly. Adjust height of table to allow good posture. If not possible, get closer to work by sitting/kneeling. Elevate one foot on a stool or box (weight shift). Change feet every 5 to 15 minutes.
Push with foot to determine feasibility (if large in size/awkward in shape get assistance). Get close to/directly facing object. Feet apart, one ahead of the other with toes out. Perform weight-lifter’s squat. Tighten stomach muscles and lift using leg muscles. Do not look down. Hips/knees should straighten simultaneously. Stand upright without twisting/jerking. Reverse this procedure to lower object.
Get close to/directly facing object. Feet apart. Use waiter’s bow to slide object to edge. Then follow “lifting from floor”.
Hold object at belly button with elbows bent. Keep stomach muscles tight. Take small, slow steps. To change directions, use feet to pivot.
If higher than nose, use stepstool/ladder. Get close to object. Slide object close to edge. Lift with elbows bent and with two hands.
Easiest at waist height.
Never pull! Use leg muscles/body weight to move object. Get close to and in line with object. Same body mechanics hold for pushing as bending/lifting.
Stand up and bend slightly backwards to increase curve in lower back.
Consider all fours position since kneeling/squatting can injure the knees.
Good posture for prolonged periods or repetitive activity even with good body mechanics induces abnormal stresses on the body and leads to pain. Therefore, take breaks and move every fifteen to thirty minutes. This will help prevent muscle fatigue/tightness, joint stiffness, and reduced circulation.
Next week, Ergonomics - How to adapt your environment to encourage good body mechanics.
Guest Columnist: Janet M. Caputo, PT, OCS
Research suggests that many spine problems can be prevented with good posture and proper body mechanics. Poor posture and improper body mechanics subject the spine to abnormal stresses that, over time, can lead to degeneration and pain. Good posture and proper body mechanics can minimize current spine pain and prevent recurrent episodes. The next three columns, written by my friend and associate, Janet Caputo, OCS, will be dedicated to the topic of proper body mechanics, good posture and ergonomics in the workplace and other daily activities
Posture is the position in which you hold your body upright against gravity. Good posture involves positions that place the least amount of stress on the spine. Good posture maintains the spine in a “neutral” position. In a neutral spine, the three normal curves are preserved (a small hollow at the base of the neck, a small roundness at the midback and a small hollow in the low back). When viewed from the side, the upper back appears straight with a small hollow in the lower back.
Following these simple guidelines will assist in preventing or diminishing pain that originates from your spine. You can put good posture into action with next week’s article: “Good Body Mechanics”!
Guest Columnist: Janet M. Caputo, PT, OCS
Contributors: Dr. Louis DeGennaro & Dr. Mark Frattali, Dr. Seth Jones
Last week we discussed the causes of balance loss. Today, we will discuss treatment for this problem. Two primary treatments are medication and vestibular rehabilitation.
Medication requires a visit to your family doctor. In a more involved case, your family physician may refer you to a specialist such as an ear, nose and throat physician or neurologist. There are many medications available for loss of balance. While this can be complicated, the specialist will determine the most appropriate one for your balance disorder.
Vestibular rehabilitation is a great adjunct to medication to manage your balance disorder. It is a comprehensive program that addresses a wide range of problems that may cause imbalance such as: addressing the inability to tolerate motion, visual changes, providing balance rehabilitation, instruction in repositioning techniques for BPPV (benign paroxysmal positional vertigo), correcting postural dysfunctions and muscle weakness/joint stiffness, offering education for prevention, maintenance and self care after discharge. Through experience and motion, vestibular rehabilitation allows: formation of internal models (one learns what to expect from ones actions), learning of limits (learning what is safe and what is not) and sensory weighting (one sense, either vision, vestibular or somatosensory is selected in favor over another in maintaining balance).
In some minor cases, vestibular rehabilitation may be performed at home. However, more serious cases may require an evaluation by a physician specializing in the dizzy patient such as an ear, nose and throat physician or neurologist. These specialists will determine the nature of your problem and may enroll you in a more structured program under the direction of a physical therapist. Some examples of vestibular rehabilitation exercises are:
One fall increases your risk of another fall. It is imperative to determine what caused your fall and take action! Ask your physician to assess your fall risk.
Guest Columnist: Janet M. Caputo, PT, OCS
Contributors: Dr. Louis DeGennaro & Dr. Mark Frattali
Preventing a fall can not only save your independence but also your life! Preventing injuries from falls reduces the need for nursing home placement. Injuries from falls are the seventh leading cause of death in people over the age of sixty-five.
The following suggestions will assist you in minimizing your risk of a fall:
Following these helpful hints will keep you safe by preventing a loss of balance and a potential fall!
Guest Columnist: Janet M. Caputo, PT, OCS
Contributors: Dr. Louis DeGennaro & Dr. Mark Frattali, Dr. Seth Jones
Northeastern Pennsylvania is home to a large elderly population. Therefore, in the medical community many of the problems we expect to see are age related. Dedicated medical practitioners are in constant search for new knowledge and information to prevent or delay many age related problems. One of the most devastating problems associated with aging is falling. My associate Janet Caputo and I have been involved in case presentations and discussions with Dr. Louis DeGennaro and Dr. Mark Frattali, two local ENT physicians and Dr. Seth Jones, a local neurologist, who treat patients with balance disorders on a regular basis. Dr. DeGennaro and I recently attended a 5-day conference on vestibular disorders at the Cleveland Clinic in Ohio. It will be the purpose of this series of three columns to educated local residents about the risks, causes, treatment and prevention of balance disorders and falls prevention.
Loss of balance causes falls. Falls are a leading cause of injury and death. Thirty percent of women and thirteen percent of men over the age of sixty-five will fall. Twenty to thirty percent of these individuals suffer moderate to severe injuries.
Preventing falls is not an easy task. A good understanding of the causes of loss of balance and knowledge of a few fall prevention suggestions can enhance your balance and reduce your risk of a fall.
The causes of loss of balance which may lead to a fall are divided into three categories: age related changes, medical conditions and medications.
Age Related Changes affecting the sensory system, the musculoskeletal system as well as psychological behavior can negatively impact balance causing a fall:
Medical Conditions can also cause loss of balance increasing the risk of a fall:
Medications can also negatively effect balance and increase the risk of falls. Interactions between medications as well as the side effects of certain medications can cause dizziness or drowsiness resulting in loss of balance. Theses medications include: tranquilizers, sedatives, anti-depressants, alcohol, diuretics, blood pressure medications, cardiac medications, laxatives and pain killers.
In conclusion, determining who is at risk for a fall is a complex task since many factors including age, disease and medication can affect the outcome. Early intervention to prevent a fall can avoid many costly consequences.
Low back pain (LBP) and/or injury inhibit specific muscles that support and stabilize the spine and pelvis. Despite complete resolution of symptoms, recruitment of these crucial muscles is significantly diminished. Therefore, the probability of subsequent LBP and/or injury is increased, exposing the spine to further damage with each episode intensifying in severity.
Lumbar stabilization is the remedy for dysfunctional musculature of the spine and pelvis incriminated in recurrent LBP and/or injury. The focus of lumbar stabilization is the simultaneous activation of the lumbar multifidi and the transversus abdominus which will provide a deep, internal, protective corset around the spine maintaining stability during activity. The multifidi are the small, deep muscles attached directly to the spine. Weakness of the multifidi may cause excessive movement of the spinal joints resulting in instability. The transversus abdominus is the deepest abdominal muscle with direct attachments to the spine and pelvis. It is not only the first muscle to contract in anticipation of body movement but also an important stabilizer of the spine. This protective co-contraction of the multifidi and transversus abdominus is disrupted with LBP and/or injury.
To achieve proper performance of and progression through a lumbar stabilization program, identification of the neutral spine position (NSP) is imperative. This position is the most comfortable point between the extremes of an arched back position and a flat back position. This position is maintained during all lumbar stabilization exercises with progression into functional daily activities.
Determining the NSP is the most important aspect of the lumbar stabilization program. Maintaining the NSP allows the individual to sense and control inappropriate spinal motion which, in turn, will improve proprioception (sense of position) and kinesthesia (sense of movement) of the lumbar spine. Improved position and movement awareness reduces excessive spinal joint motion decreasing irritation at these segments that may produce pain. The NSP will eventually become automatic during all daily activities.
The lumbar stabilization program includes movements of the arms and/or legs while maintaining the NSP. These extremity movements are performed in a variety of functional positions: lying on the stomach, lying on the back, on all fours, sitting and standing. The program is advanced as follows:
Progression depends on the ability to maintain the NSP during the current exercise. A comprehensive lumbar stabilization program will also include exercises for:
Your physician can evaluate for a musculoskeletal source to your LBP. If your LBP is musculoskeletal in origin, a comprehensive rehabilitation program including lumbar stabilization may be recommended. Lumbar stabilization exercises require professional hands-on instruction since they are more difficult than they appear and will not benefit if performed incorrectly.
Example of Intermediate Lumbar Stabilization Exercise
Example of Advanced Lumbar Stabilization Exercise
Visit your doctor regularly and listen to your body.
