Senior Physiotherapist

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Limited shoulder movements/stiffness

Lymphoedema • Chest complications • Cording (axillary web

syndrome) • Decreased exercise tolerance • Psychological issues/Self-

image issues • Infections

Post-op Complications

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• Fear • Pain • Position during operation

Why shoulder limitations?

Pendulum Shoulder Rotation

Physiotherapy for the shoulder

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Shoulder flexion Wall Climbing

Physiotherapy for the shoulder

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Posterior Capsule

stretch

Hand behind back

stretch

Physiotherapy for the shoulder

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• Joint mobilisation • Soft tissue mobilisation • Progress of home exercises

• Stretching • Strengthening

Physiotherapy for the shoulder

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• The result of accumulation of fluid and other elements (e.g. protein) in the tissue spaces due to imbalance between interstitial fluid production and transport

• Damage to lymphatic vessels and/or lymph nodes • Can impact greatly on patient’s physical and

psychosocial health • Progressive, chronic condition • May be alleviated by appropriate management

Lymphoedema

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• Combination of 1. Education 2. Exercise 3. Manual lymphatic drainage (MLD) 4. Compression

Lymphoedema Management

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1. Education

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• Feeling of ‘heaviness/tightness/fullness’ • Aching • Tight sleeves/clothing/jewellery • Changes in density/appearance of skin • Limited movements of the affected arm • Observable swelling

Early Signs of Lymphoedema

(Lymphoedema Framework 2006)

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• Avoid • Tight bras, fitting clothing and jewellery • Exposure to extreme cold or heat • ‘Trauma’ to the limb

• Have a balanced diet • Maintain optimal body weight • Wear compression garments (if prescribed) • Wear well fitting compression garments with flying • Undertake exercise/movement and limb elevation (Lymphoedema Framework 2006)

Advice for ‘At Risk’ Limb

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• Lifting advice • 2-4 weeks (sentinel lymph node surgery) • 2-3 months (axillary clearance)

• Skin care • Skin and nails • Moisturize skin • Minimize the risk of cuts/bruises/burns • Immediate medical care if infected • Use high factor sunscreen and insect

repellent/mosquito nets (Lymphoedema Framework 2006)

Advice for ‘At Risk’ Limb

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2. Exercise

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• Avoid inactivity • Positive impact on body weight, overall fitness,

muscle strength, flexibility and quality of life (Courneya,

2012)

• Resistance exercises increase lymphatic flow • Significant reduction in lymphoedema with a 8 week

exercise programme (Guatam, 2011)

• Early physiotherapy with education after surgery for breast cancer associated with a lower risk of secondary lymphoedema (Lacomba, 2010)

• No increase in risk of lymphoedema with weight lifting exercises (Schmitz, 2010)

Exercise

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• Resistance training • Supervised programme • At least 16 weeks and start with very low

resistance • Monitor arm/shoulder symptoms • Beware of risk of fracture

(ACSM, 2010)

Exercise

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3. Manual Lymphatic Drainage

(MLD)

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• Slow and rhythmic • Light, circular superficial tissue stretching • Absolute contraindications

• Acute bacterial infection • Acute venous disorders • Sickness with associated fever • Congestive heart failure (Pritschow & Schuchhardt 2010)

• Safe and well tolerated • May offer additional benefit when added to

intensive compression bandaging (Ezzo et al 2015)

Manual lymphatic drainage (MLD)

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4.Compression

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• Can be applied via • Multi-layer inelastic

bandaging • Reduction phase • High working pressure • Lower resting pressure • Low compliance rate

Compression

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• Can be applied via • Compression hosiery

• Long term/maintenance phase

• Flat knit vs circular knit • Custom made garments

often flat knit • Can better

accommodate shape distortion

• Replaced approximately every 6 months

(Lymphedema Framework 2006)

Compression

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Compression