Rose Mary has been an Occupational Therapist since 1987. She has treated children and adults with a wide array of conditions.
Post Mastectomy Exercises
In this article, I will elaborate on specific strategies for shoulder range-of-motion exercises for breast cancer clients after lumpectomy or mastectomy.
Guidelines for Resuming Activities
The key to resuming activity, including range of motion (ROM) exercises, is not to do too much too soon. I find that doctors and surgeons can often be pretty vague when clients posed questions such as “What can I do,” “What should I avoid,” and “When should I resume normal activities?" Doctors tend to say things like, “Just do what you can do."
I don’t think that doctors are necessarily being intentionally evasive. I just think they are busy, and they tend to forget these things are not common knowledge. To some extent, they may be a little evasive. After all, they are not rehabilitation experts. Hopefully, your therapist will be!
This article is meant to be a guide. You should still be sure to discuss your specific exercise and rehabilitation program with your doctor or therapist.
Shoulder Range of Motion
I found that most clients, after lumpectomy, mastectomy, or excision of lymph nodes, were too sore to begin range of motion (ROM) exercises for at least three to five days after surgery. I have not found it to have any significant negative impact on clients’ outcomes if structured ROM exercises are not started until seven to fourteen days after surgery, or even longer.
While I think two to four weeks post-op is an ideal time to start ROM exercises, movement in a short range is beneficial early after surgery. I prefer to get consults early after surgery to start general education, including gentle movement in a short range. Again, most clients are inclined to do too much, not too little, so early education is important.
Many women regain ROM after surgery with no intervention. Others regain their previous ROM gradually over a period of a few weeks or a couple of months. Clients with diabetes or a previous history of frozen shoulder may be at higher risk for persistent ROM deficits. Women who will be undergoing radiation therapy will need to get their arm over their head, so obviously they need full shoulder ROM before beginning radiation.
I start my post-op clients off with shoulder pendulums, cane, pulley, wall walk and table slide exercises. ROM exercises should be done with no more than a one to three of 10 increase in pain above baseline pain. For more on rating pain, see my article on how to rate pain.
In general, clients do not have shoulder joint stiffness. ROM is restricted due to the soft tissue trauma related to the surgery. This discomfort should be respected. Exercises should be done so that you feel a mild to moderate stretch to the incision scar. Stressing the scar too much will cause increased scar tissue as a protective response, but is counter-productive to recovery.
While some clients find it easiest to do two or three exercise sessions per day, I recommend brief sessions with a few repetitions throughout the day. Imagine exercising for 30 minutes, two times a day, versus 10 minutes, six times a day. Which do you think is less likely to cause increased soreness or swelling? I recommend doing the different exercises at different times of day, depending on your routine.
Over time you may find some of the exercises more beneficial than others. If you are not feeling a therapeutic stretch from one of the exercises, you can probably stop that exercise. You may find that you are more drawn to certain exercises because they fit your routine. If this makes you more compliant overall, this is fine, unless the exercises you choose do not give you a therapeutic stretch.
I recommend pendulum exercises for those clients with the worst shoulder pain. Not all clients need to do pendulums.
To do pendulums, stand next to a table or chair, holding it with the hand of your non-surgical side to support yourself. Lean over at the waist. Let your surgical-side arm hang limp, as though you had a nerve block and absolutely could not move your arm. This is passive range of motion. Your surgical arm is being passively moved by some other means than its own power.
Generate arm movement by bending and shifting at the hips and knees. To change the movement of the arm, come to a complete stop, reposition the legs, then shift the body by moving hips and knees again.
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Do arm forward and back, side to side, in clockwise circles, and in counterclockwise circles.
Cane or Wand Exercises
Cane exercises can be done sitting, standing, or lying down, and I recommend trying each because each is a different movement experience for your shoulder joint, muscles, and soft tissues.
Hold a cane, dowel, broomstick, or another suitable tool, with the hand of your surgical arm. Let your arm relax and be limp, as though you would have to Velcro your hand to the stick, but otherwise could not use your arm. This is another method for passive range of motion.
Use your other hand and arm to carry out the movement. Start with short, rhythmic movements in multiple directions to warm up your tissues. Gradually begin to increase the movement with your arm straight out in front of you, slightly to the side, a little more to the side, then finally all the way to the side as if you had your back and your surgical arm against the wall.
Gradually go to your end range, where you feel a gentle stretch, and hold for 8 to 12 seconds. Repeat in different positions.
There are many pulley exercise devices available for about $20. Most of them hang over a closed door. We dispensed pulleys to our clients from our clinic.
Pulley exercises are usually done seated, but can be done standing. Hold onto the handles with each hand. As with the cane exercises, relax your arm on your surgical side as though your arm was limp and you had to Velcro your hand onto the handle. This also is a passive range of motion exercise.
Use your non-surgical arm, pulling down, to elevate your surgical arm. Use your non-surgical arm to control your surgical arm back down. Do this for forward flexion, or elevation of your surgical arm straight out in front of you.
Start with short-range, gentle rhythmic motions. Gradually approach your maximum range of motion. Hold for 8 to 12 seconds for a gentle stretch at the end range.
Repeat to raise your surgical arm to the side (abduction), and partway between front and side.
You can use a table or countertop to assist you in your shoulder range of motion. Place your surgical-side arm on the table surface. Glide your arm forward, using the surface to support your arm’s weight. This is active assistive ROM.
Glide straight forward in front of you, mid-way to the side, and out sideways. Start gentle, then work your way to your maximum tolerated ROM, where you feel a gentle to moderate stretch.
You can do table slides before or after a meal when you are at a table. I had a client with a shoulder injury who said he arranged his computer desk so that he could do table slides because the mouse reminded him of this exercise.
Another active assistive range of motion exercise is wall walks.
Place the hand of your surgical side on a wall, and walk your fingers on the wall. Start gentle, then gradually walk up the wall until you feel a stretch.
You can then walk your hand back down a bit, relax, then go back up again. As your tissues warm up, you may be able to get your arm up further. Walk your arm back down.
Do this exercise with your arm straight out in front of you. Repeat this process with your arm to the side, and mid-way between.
Many of my clients do this exercise in the shower. While your arm is up, you can lather your underarm! My shoulder injury client reported he did wall walks when he turned light switches on or off.
This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
© 2010 rmcrayne
Nikki from Worcester, MA on October 20, 2015:
Thanks for the recovery info. I'm just at almost 3 wweeks post op mastectomy and tram flap. I may have some fluid or swelling in my breast and my surgeon said this might be due to too much activity , when I ask What I can and can't do they're vague and say no housework . It leaves a lot of gray area and is frustrating to say the least.
rmcrayne (author) from San Antonio Texas on October 05, 2013:
christryon I honor your experience with breast cancer, but feel you dishonored mine. I can only assume your intentions were good. I have added a few lines of additional clarification, but I stand by my post. Whereas your experience is with one client (you), and one surgeon (yours), my experience is with a couple dozen surgeons (general surgeons, oncology surgeons, and plastic surgeons), and probably a hundred or two clients over a period of about 7 years.
When I first started seeing these clients, I was fortunate to have an occupational therapy assistant (COTA) who had several years experience with a wound care team, including hyperbarics. “Stress” is actually essential to wound healing, but I never emphasize that because I find most clients are inclined to be too aggressive, not too conservative.
My disclaimer states that my article is not intended to substitute for the advice of one’s surgeon. I wrote the article however because I found that most therapists and doctors are not comfortable with breast cancer clients, and when they gave guidance, it was often too vague. I was the INFORMER.
As an occupational therapist of 26 years, I can tell you that “When doing ANY kind of exercise” you absolutely CANNOT “STOP IMMEDIATELY if you experience any pain”. There are many, many injuries and ailments from which you will not recover without painful therapy. Again, I am more conservative than most in breast cancer shoulder ROM exercises, and shoulder ROM in general. I instruct no more that 1 to 3 of 10 increase in discomfort above baseline pain. Other injuries, such as wrist and finger fractures are completely different. The ROM exercises, particularly the passive ROM performed on clients by therapy staff, will be quite painful.
My tip for you: Be careful of giving advice to those with more experience than you. Your use of CAPS, and language such as “misinformed” come off as arrogant and condescending.
christryon on September 26, 2013:
Good job explaining the appropriate exercises.
After having a double mastectomy nearly 2 years ago, I think you are a little bit misinformed about how soon to start Range of Motion exercises.
My doctor suggested that I not start them until AFTER I had my stitches removed, which was at around 3 weeks post op. Your body NEEDS at least that amount of time to heal. If a woman has had any lymph nodes removed, the time should be at least 4-6 weeks. You don't want to cause any additional trauma or prolong the healing process.
An added tip: When doing ANY kind of exercise, STOP IMMEDIATELY if you experience any pain.
rmcrayne (author) from San Antonio Texas on October 27, 2010:
Thanks quildon for the visit and comment.
Angela Joseph from Florida on October 27, 2010:
Very helpful and informative and also very timely.
rmcrayne (author) from San Antonio Texas on October 19, 2010:
Thanks for your support Pamela!
Pamela Oglesby from Sunny Florida on October 18, 2010:
Great hub with very important recovery information. Rated up!
rmcrayne (author) from San Antonio Texas on October 17, 2010:
Thanks for your great comment Lily Rose! You could probably do the cane exercises to get that last bit of ROM back.
When someone is extremely limited, I usually brought them in for clinic treatment 2 or 3 times a week. Sometimes supervised exercises and 1:1 stretching by the techs is necessary.
Lily Rose from A Coast on October 17, 2010:
GREAT info here, RM! The wall walks is about all I was told to do after my bilateral mastectomy (with lymph node excision). It was quite scary, actually, how limited my range of motion was for quite a while after my surgery as I've always been very flexible.
It was probably close to a year before my ROM was back to almost normal. I'm about 20 months out now and I feel I have full ROM on the right but a little limited on the left, which is where the cancer was and where the most nodes were removed.
Patients really do need to be proactive and seek the help they need because, as you said above, Doctors don't always know everything and they can be evasive - so true!