Physiotherapy Management Following Left Mastectomy (10 Marks)

Introduction

Aims of Physiotherapy Management

1. Prevent post-operative pulmonary complications (atelectasis, chest infection)
2. Restore full, pain-free range of motion (ROM) at the shoulder and scapula
3. Prevent and manage lymphedema of the upper limb
4. Prevent postural deformity and scapular winging
5. Improve circulation and prevent DVT
6. Desensitize the scar and prevent adhesions/cording
7. Psychological support and improve quality of life
8. Early return to activities of daily living (ADLs) and work

A. Pre-Operative Physiotherapy

• Patient education about the surgery, expected drains, and post-op exercise protocol
• Teaching deep breathing exercises (DBE), effective coughing/huffing technique, and incentive spirometry
• Baseline assessment: shoulder ROM, chest expansion, posture, and limb girth (for later lymphedema comparison)
• Psychological preparation and reassurance to reduce anxiety, which improves post-op cooperation

B. Post-Operative Physiotherapy

Phase I - Day 1 to Day 2 (Acute/Bed Stage)

• Positioning: Semi-recumbent/propped-up position; affected arm elevated on a pillow to promote venous and lymphatic drainage
• Chest physiotherapy: Diaphragmatic breathing, thoracic expansion exercises, and assisted coughing to prevent basal atelectasis (splinting the wound while coughing)
• Circulatory exercises: Ankle pumps, toe curls, and gentle wrist/finger movements of the affected limb to reduce DVT risk and promote lymphatic flow
• Gentle active exercises of the fingers, wrist, and elbow of the operated side - shoulder movement is deliberately restricted in the first 24-48 hours (drain in situ) to reduce risk of seroma and wound dehiscence, a precaution also noted in surgical literature regarding early mobilization and complications (Fischer's Mastery of Surgery)
• Encourage early sitting out of bed and short ambulation as tolerated

Phase II - Day 3 to Day 7 (Sub-Acute Stage)

• Progress to active-assisted shoulder exercises: pendulum (Codman's) exercises, wall climbing, shoulder flexion/abduction to 90°, avoiding full overhead range until drain removal
• Scapular setting exercises (retraction/protraction) to prevent winging and maintain scapulothoracic rhythm
• Continue chest physiotherapy and mobilize the patient fully out of bed
• Begin gentle scar mobilization once the wound edges are stable, to prevent adhesion of skin to underlying chest wall fascia
• Monitor for cording (axillary web syndrome) - a palpable, tight fibrous band in the axilla/arm; managed with gentle stretching and myofascial release

Phase III - Week 2 Onward (Post Drain Removal)

• Progress shoulder ROM to full active range: overhead flexion, abduction, external/internal rotation, and combined movements (hand behind back, hand behind neck)
• Resisted/strengthening exercises for shoulder girdle and scapular stabilizers once wound has healed (usually after 3-4 weeks) to restore functional strength for ADLs
• Postural correction exercises to counter the rounded-shoulder, forward-head posture commonly adopted to guard the operative site
• Stretching for pectoralis major/minor to prevent contracture, especially important if radiotherapy is planned

C. Management of Lymphedema (Key Complication)

• Complex Decongestive Therapy (CDT): manual lymphatic drainage (MLD), multilayer compression bandaging, compression garment fitting, and remedial exercises
• Limb elevation and skin care education to prevent cellulitis
• Muscle-pump exercises (active contraction of the operated limb) — muscle contraction acts as an extrinsic pump facilitating lymphatic return (Fischer's Mastery of Surgery, 8e)
• Regular limb girth/volume measurement for monitoring
• Education to avoid extremes of temperature, tight clothing/jewellery, and trauma/injections in the affected limb

D. Other Considerations

• Pain management: TENS, gentle massage, and relaxation techniques for post-mastectomy pain syndrome/phantom breast sensation
• Psychosocial support: body image counselling, group therapy referral, encouragement toward prosthesis fitting or reconstruction discussion
• Cardiorespiratory fitness: graded aerobic exercise (walking, cycling) once wound healing permits, shown to improve fatigue and quality of life
• Precautions: avoid vigorous resisted exercise in the first 3-4 weeks, monitor for seroma/wound complications, avoid BP measurement/venipuncture on affected limb
• Home exercise programme and long-term compliance are emphasized, as this is a lifelong self-management issue given the persistent lymphedema risk

Outcome Measures

• Shoulder ROM (goniometry)
• Limb girth/volumetry for lymphedema
• Pain scores (VAS)
• Functional scales: DASH (Disability of Arm, Shoulder, Hand) or Constant-Murley Shoulder Score
• Chest expansion and respiratory function tests

Summary