Van Vuuren Physiotherapist


Breast Surgery



Exercise helps to decrease any side effect after surgery and help you to return back to normal daily activities and also preventing shoulder stiffness after surgery.

Do:
• start using the arm on the affected side for light tasks (brushing your hair, using your mobile phone) the day after surgery.

• take adequate painkillers (as prescribed for you) to help you do your exercises properly.

• let pain be your guide – it is normal to feel a gentle stretch when you exercise but you should not feel pain.

• stand tall and try to keep your back straight. Good posture is very important after breast surgery to recover full arm function.

• your exercises daily as advised by your physiotherapist.


Don’t:

• use the arm on the affected side for heavy tasks such as hovering, hanging out washing or window cleaning for the first 6 weeks after your surgery.

• drive until your consultant until your consultant says you can.


You should do the exercises as often as possible. When resting the arm on the operated side supported the arm on a pillow and try not to let it hang down by your side.


1. Open and close your fingers as if making a fist.

2. Move your wrist up and down as if waving

3. Bend your elbow and straighten it out fully

4. Shrug your shoulders

5. Press your shoulder blades back together.

6. Turn your head from side to side

7. Join your hands and keep your elbows straight. Lift your arms up to eye level. This exercise can be done either sitting or lying. If you have had an axillary node clearance do not stretch your arms over eye level for the first 7 days post -surgery.

8. Sitting up in a chair or lying on your back, with your hands behind your neck and your elbows pointing forward. Move your elbows apart back to the chair or bed. You will need to achieve good flexibility in this exercise if you will require radiotherapy treatment.


Once the drains have been removed you can include the following exercises

1. Stand facing a wall. Walk your fingers up the wall as high as possible, reverse down in the same way.

2. Stand with your non- affected arm against the wall. Raise your arm up sideways toward your head with the thumb leading the way (like the arm of a clock).


You may have a burning, tingling, numbness or soreness on the back of the arm and or chest wall. The surgery can irritate the nerves. These feelings may increase a few weeks after surgery. Rubbing or stroking the area with your hand or a soft cloth can help make the area less sensitive.


Exercise to help improve aerobic (heart-lung) capacity is also important for women who have had breast cancer. There’s evidence that fitness and weight loss may even help lower the risk that some types of cancer will come back after treatment. Ask your doctor about fitness exercises during and after breast cancer treatment.


Other exercises are designed to help reduce your risk of lymphedema, or swelling in the arm on the side where you had surgery. The exercises shown here are mainly designed to help regain range of motion (flexibility) of the arm and shoulder. Ask your doctor about your lymphedema risk and if you should use exercises to help reduce that risk.

• Lymphedema is a build-up of lymph fluid in the fatty tissues just under your skin. This build-up causes swelling (or edema), most often in the arms or legs. Lymphedema can be the result from surgery or radiation therapy to treat certain cancers. During surgery for cancer the doctor may take out lymph nodes near the tumor to see if the cancer has spread.

• Our bodies have a network of lymph nodes and lymph vessels that collect and carry watery, clear lymph fluid, much like veins collect blood from distant parts of the body (like the hands and arms) and carry it back to the heart.

• Lymph fluid contains proteins, salts, and water, as well as white blood cells, which help fight infection. In the lymph vessels, one-way valves work with body muscles to help move the fluid through the body and control the flow. • Lymph nodes are small collections of tissue along the lymph vessels that work as filters for harmful substances and help fight infection. Taking out lymph nodes and vessels makes it harder for the lymph fluid in the arms, legs, or other body parts to flow to the chest where it can get back into the bloodstream. If the remaining lymph vessels cannot remove enough of the fluid in the area, the fluid builds up and causes swelling, or lymphedema.




The Lymph System



LYMPHOEDEMA


Common signs and symptoms you should watch for include:

• Swelling

• Part of your body (like your arm, feeling full or heavy)

• Skin changing texture, feeling tight or hard, or looking red

• New aching, tingling, numbness, or other discomfort in the area

• Less movement or flexibility in nearby joints (like your hand, wrist)

• Trouble fitting into clothes in one area, such as a sleeve.

• Collars, rings, watches, and/or bracelets feeling tight even though you haven’t gained weight


Treatment to contol the lymphedema:


• Manual lymphatic drainage (MLD). MLD is a specialized technique that involves gentle skin massage. It helps blocked lymphatic fluid drain properly into the bloodstream and may reduce swelling.

• Exercise. Exercising usually improves the flow of the lymphatic system and strengthens muscles. Ask your doctor or therapist when you can start exercising and which exercises are right for you.

• Compression. Non-elastic bandages and compression garments, such as elastic sleeves, place gentle pressure on the affected area. This helps prevent fluid from refilling and swelling after decongestive therapy. There are several options, depending on the location of the lymphedema. All compression devices apply the most pressure farthest from the center of the body and less pressure closer to the center of the body. Compression garments must fit properly and should be replaced every 3 to 6 months.

• Skin care. Lymphedema can increase the risk of infection. So it is important to keep the affected area clean, moisturized, and healthy. Apply moisturizer each day to prevent chapped skin. Avoid cuts, burns, needle sticks, or other injury to the affected area. If you shave, use an electric razor to reduce the chance of cutting the skin. When you are outside, wear a broad-spectrum sunscreen that protects against both UVA and UVB radiation and has a sun protection factor (SPF) of at least 30. If you do cut or burn yourself, wash the injured area with soap and water and use an antibiotic cream as directed by your health care team.

• Elevation. Keeping your affected limb elevated helps to reduce swelling and encourage fluid drainage through the lymphatic system

• Low-level laser treatments (LLLT). A small number of clinical trials have found that LLLT could provide some relief from lymphedema after removal of the breast, particularly in the arms.

• Medications. Your doctor may prescribe antibiotics to treat infections or drugs to relieve pain when necessary.

• Physical therapy. If you have trouble fusing your arm or fitting jewelry other issues resulting from lymphedema of the arm, you may need physical therapy.

DO’s after surgery:
• Moisturize

• Gentle exercise

• Well-fitting bra

• Good posture, optimal weight

• Treat cuts with Bactroban and Alcohol wipes

• Electrical shaver

• Gloves

• Elevate your arm

• Insect repellent


DON’TS after surgery:

• Carry heavy objects - traction injury

• Repetitive exercises, so sweeping/ breaststroke

• Narrow bra straps

• Cut nails too short

• Sauna/too hot bath, sitting in the sun

• Tight fit jewelry

• Pets scratch/ bite, avoid infection

• Heavy handbag

• NO blood test, injections, acupuncture, blood pressure cuffs on the affected side



Pelvic Surgery



HYSTERECTOMY:


Hysterectomy is the surgical removal of the uterus or womb.

• Total hysterectomy (or complete hysterectomy), involves removal of the uterus and cervix—the narrow end of your uterus where it joins to the top of your vagina.

• Partial hysterectomy (or subtotal hysterectomy) involves the removal of the uterus and leaves the cervix.

• Vaginal Hysterectomy is the surgical removal of the uterus and cervix through a small cut or incision high inside the vagina

• Total Abdominal Hysterectomy is the surgical removal of the uterus and cervix. A total abdominal hysterectomy usually involves a bikini-line incision made horizontally across the pubic hair line. A vertical cut can also be done to explore the lymphnodes.

• Radical hysterectomy is an operation done to treat some cancers of the cervix. The surgeon takes out the uterus and the ligaments (tissue fibers) that hold it in place. The cervix and an inch or 2 of the vagina around the cervix are also removed. The top of the vagina soon seals with scar tissue and becomes a closed tube. Ovaries may or not may be removed.


ABDOMINOPERINEAL (AP) RESECTION:


Abdominoperineal (AP) resection is a type of surgery that may be used to treat colon cancer. The lower colon and rectum are removed, and a colostomy is made so that stool can pass out of the body. Sometimes the uterus, ovaries, and even the rear wall of the vagina must be removed, too. The remaining vaginal tube must then be repaired with skin grafts or with a flap made of skin and muscle. Without a rectum, the vagina becomes scarred down to the tailbone. You may need to try different positions to find one that works. may be helpful.


VULVECTOMY (REMOVING THE VULVA):


Removing cancer of the vulva is called a vulvectomy.

o A partial vulvectomy removes only the cancer and an edge of normal tissue around that affected area.

o The modified radical vulvectomy removes the cancer and an edge of normal tissue, as well as some of the lymph nodes in the groin. If there’s cancer in or very near the clitoris, it may need to be removed to be sure all the cancer is taken out.

o A radical vulvectomy, the surgeon removes the whole vulva. This includes the inner and outer lips, the clitoris, and often the lymph nodes that drain the vulva. The vagina, uterus, and ovaries remain.

o After a vulvectomy women may feel:

 Discomfort if they wear tight slacks or jeans because the “padding” around the urethral opening and vaginal entrance is gone.

 Fear that their parners may be turned of by the scarring and loss of their genitalThe area around the vagina also looks very different.

 Less sensation around the vagina due to the scarring. If scarring narriws the entarnce to the vagina a light carees and the use of a lubricant can help to prevent painfyll irritation.Vaginal dilators and physiotherapy can help to stretch the tissue. Vaginal mosturizers is also important for the tissue.

 Swelling of the genital areas or the legs due to the remaoval of the lymphnodes in the groin.

 Difficulty to reach orgasm all depending onhow much of the vulva has been removed. If surgery has removed the clitoris and lower vagina, then orgasms may not be possible. Still, some women find that stroking the front inside part of the vagina, about 1 to 4 inches inside the opening, can feel pleasurable.

 Numbness in their genital area but the feeling may return slowly over the next few months.



PELVIC EXENTERATION:


Pelvic exenteration is used when cancer of the cervix or the rectum has come back in the pelvis after treatment.


In this surgery, the uterus, cervix, ovaries, fallopian tubes, vagina, and sometimes the bladder, urethra, and/or rectum are removed.


With a total pelvic exenteration 2 ostomies are created (1 stoma is for urine and the other is for stool). The vagina is usually rebuilt. Usually the outer genitals, including the clitoris, are not removed, which means a woman may still feel pleasure when touched in this area.



Chemotherapy & Radiation



CHEMOTHERAPY:


Women getting chemo often have symptoms of early menopause. These symptoms include:


1. Hot flashes


Treatment can include:

o Female hormones in a pill or patch can help with vaginal dryness and hot flashes.

o Medicines that control the nervous system’s reaction to a lack of estrogen e.g.. anti-depressants called serotonin reuptake inhibitors, like venlafaxine (Effexor®), fluoxetine (Prozac®), paroxetine (Paxil®).

o Estrogen in gels, creams, rings, or tablets for vaginal dryness by putting them right into the vagina.

o Exercise and relaxation techniques are also of help.


2. Vaginal dryness


Treatment can include:

o Lubricants

 Choose a water-based gel that has no perfumes, coloring, spermicide, or flavors added, as these chemicals can irritate your delicate genital tissues.

 Petroleum jelly (Vaseline®), skin lotions, and other oil-based lubricants are not good choices for vaginal lubrication. In some women, they may raise the risk of yeast infection.

 And if latex condoms are used, they can be damaged by petroleum products and lotions. Also, watch out for condoms or gels that contain nonoxynol-9 (N-9). N-9 is a birth control agent that kills sperm, but it can irritate the vagina, especially if the tissues are already dry or fragile.


o Vaginal moisturizers

 Vaginal moisturizers are non-hormonal products intended to be used several times a week to improve overall vaginal health and comfort and to improve the elasticity in the vagina.

 Vaginal moisturizers are designed to help keep your vagina moist and at a more normal acid balance (pH) for up to 2 to 3 days.

 Replens® and K-Y Liquibeads® are examples of vaginal moisturizers. Lubrin® and Astroglide Silken Secret® are other moisturizers that are marketed as longer lasting than typical lubricants. Vitamin E gel caps can also be used as a vaginal moisturizer


o Vaginal oestrogens

 Local vaginal hormones to help vaginal dryness. These hormones are applied to and absorbed into the genital area, rather than taken by mouth. They come in gel, cream, ring, and tablet forms. Most are put into the vagina, although some creams can be applied to the vulva. They focus small amounts of hormones on the vagina and nearby tissues, so that very little gets in the bloodstream to affect other parts of the body.


3. Vaginal tightness


o A vaginal dilator is a plastic or rubber tube used to enlarge or stretch (dilate) the vagina. They come in many forms.The dilator feels much like putting in a large tampon for a few minutes. Even if a woman isn’t interested in staying sexually active, keeping her vagina normal in size allows more comfortable gynecologic exams.

o Dilators work best when used regularly after radiation or surgery to keep the vagina from shrinking.


4. Irregular or no menstrual periods


5. Light spotting of blood after sex due to thinning of the vaginal wall


6. Irritation of the mucous membranes in the vagina which may become dry and inflamed


7. Yeast infection ( itching inside the vagina or on the vulva and also can have a thick, whitish discharge with a burning sensation during intercourse.)


8. Flare-up of genital herpes warts if a woman has had them in the past.


RADIATION:

Radiation to the pelvic area often affects a woman’s sex life. If the ovaries get a large radiation dose, they may stop working. If a woman has already gone through menopause, she may notice little or no change because her ovaries had already stopped making hormones. But if she hasn’t reached menopause, radiation may cause sudden menopause with hot flashes and vaginal dryness. Women who get radiation to the pelvis often become infertile.


o During radiation, tissues in the treatment area get pink and swollen and may look sunburned. A woman’s vagina may feel tender during radiation treatment and for a few weeks afterward.

o As the irritation heals, scarring may occur. The thick walls of the vagina may become leathery and tough. This means the walls might not stretch out as much during sex, which can cause pain.

o The scarring that can occur after pelvic radiation can shorten or narrow the vagina. A woman can often keep tight scar tissue from forming by stretching the walls of her vagina with vaginal penetration during sex at least 3 or 4 times a week or using a vaginal dilator on a regular basis).

o Radiation to the vagina can also damage its lining, making it thin and fragile. Many women notice some light bleeding after sex, even though they felt no pain at the time.



Physiotherapy



o Deep diaphragmatic breathing exercises

o Cough with wound support o Wound healing with low level laser therapy

o Scar mobilisation- Adhesions can cause mild to moderate pain. Physiotherapy can help to break down pelvic and abdominal adhesions and aid in increased mobility of the connective tissue and of the muscles

o Abdominal fascia mobilisation

o Pelvic floor exercises: Always try to use your pelvic floor muscles before you cough, laugh, sneeze or lift an object

o Correct toilet position

o Correct way to get out of bed will put less strain on your operation site. Correct way:

 Bend knees up and roll onto side (this avoids twisting the abdomen and incision).

 Hook your legs over the edge of the bed and push with your arms into a sitting position.

 Reverse these steps to get back into bed.



Some Advice



POSTURE & BACK CARE:


o A good posture will help prevent back ache, so stand tall and walk tall. Avoid holding your tummy with your hands and slouching forwards. Stand upright with shoulders back, and bottom and tummy tucked in. Contract your pelvic floor muscle.

o Sit upright in a supportive chair, with both feet on the floor. Do not slouch. You may find it helpful to place a small cushion or rolled towel in the small of your back to give support.


WALKING:


o This is a very valuable exercise. Try to walk for about 20 minutes at least once a day. Hills and stairs are quite safe but build up speed and distance gradually.


DRIVING:


o Check with doctor but do not expect to drive for about four or six weeks, depending on your surgery.


SEXUAL DYSFUNCTION:


o Hysterectomy shortens the vagina and may cause numbness in the genital area.

o Some ideas to help:

o Spending extra time on foreplay can help ensure that the vagina has lengthened enough to allow penetration.

o It’s also important for the vagina to have moisture to allow the tissues to stretch and move

o Create the feeling of more depth for the partner for instance cupping her hands around the base of her partner’s penis during sex and there are also rings that can be put around the base of the penis to reduce the depth of penetration.

o Changing positions like those where the partners are side by side or with you on top, limit the depth of penetration. If vaginal penetration remains painful, a couple can still reach orgasm by touching each other with their hands.


AVOID:


o Excessive weight gain as this creates extra load for the pelvic floor.

o Constipation as straining stretches the pelvic floor muscles.

o Strenuous heavy lifting as this place extra pressure on the pelvic floor, as does repeated lifting o Smoking, as a “smoker’s cough” can strain the pelvic floor

o Drinking too little (30mlper kg bodyweight in 24 hours)

o Sudden movements. Try to contract your pelvic floor muscles before coughing, sneezing, jumping, jogging etc. Habit formation. Try not to empty your bladder too frequently (6-8 times a day, every 3-4 hours)



Van Vuuren Physiotherapist


Suite 13, Netcare Pretoria East Hospital
Cnr Garsfontein Road & Netcare Ave
Pretoria East