Further information Pharmacy Medicines Helpline If you have any questions or concerns about your medicines, please speak to the staff caring for you or call our helpline. t: 020 7188 8748 9am to 5pm, Monday to Friday Patient Advice and Liaison Service (PALS) – To make comments or raise concerns about the Trust’s services, please contact PALS. Ask a member of staff to direct you to the PALS office or: t: 020 7188 8801 at St Thomas’ t: 020 7188 8803 at Guy’s e: [email protected] Language support services – If you need an interpreter or information about your care in a different language or format, please get in touch using the following contact details. t: 020 7188 8815 fax: 020 7188 5953 NHS Choices – Provides online information and guidance on all aspects of health and healthcare, to help you make choices about your health. w: www.nhs.uk

Physiotherapy Department

Physiotherapy advice after breast reconstruction surgery using a latissimus dorsi flap with or without implant

Leaflet number: 2579/VER3 Date published: November 2014 Review date: November 2017 © 2014 Guy’s and St Thomas’ NHS Foundation Trust 20 

 

Notes

Contents p.3

Why do I need to exercise after my reconstructive breast surgery?

p.4

Your exercise plan – stage 1

p.6

Your exercise plan – stage 2

     

p.11 What can I do to aid my recovery? p.15 Can I still exercise after a seroma? p.15   How do I know if I need further physiotherapy?  

p.16   How do I arrange further physiotherapy?  

p.17 Contact details  

p.18 Notes  

p.20 Further information

     

2 

19 

This leaflet explains more about returning to your everyday activities after your operation, and provides you with some exercises to follow. If you have any further questions or concerns, please speak to your doctor or physiotherapist.

Notes        

Why do I need to exercise after my reconstructive breast surgery? It is important that you follow the exercise plan in this leaflet because it will: 

prevent shoulder stiffness



help you regain and maintain full movement in your shoulder



encourage your circulation and healing of your scar tissue



prevent or ease any back pain caused by the operation



encourage back movement and increase your abdominal (stomach) muscle strength.

If needed, these exercises will also help you to get into the required position for radiotherapy within a short period of time – see picture below for the radiotherapy position.

18 

3 

There are two stages to your exercise plan:

Appointments at King's

Stage 1

Start these exercises one to two days after your operation and continue to do them for four weeks (unless you have been advised otherwise by your doctor or physiotherapist).

Stage 2

Start these exercises in the fifth week after your operation (unless you have been advised otherwise by your doctor or physiotherapist).

We recommend that you continue with these exercises every day, even after you have regained full shoulder movement.

We have teamed up with King’s College Hospital in a partnership known as King’s Health Partners Academic Health Sciences Centre. We are working together to give our patients the best possible care, so you might find we invite you for appointments at King’s. To make sure everyone you meet always has the most up-to-date information about your health, we may share information about you between the hospitals.

Contact details If you have any questions or concerns about your exercise plan, please contact the Physiotherapy Department on 020 7188 5106 (Monday to Friday, 8.30am to 4.45pm).   For more information leaflets on conditions, procedures, treatments and services offered at our hospitals, please visit www.guysandstthomas.nhs.uk/leaflets

Link the exercises with something you do every day (such as mealtimes) and they will soon become part of your routine.

Your exercise plan – stage 1 Do these exercises for the first four weeks after your operation (unless advised otherwise by your doctor or physiotherapist). Frequency: Four times a day, five repetitions each. If you develop a seroma (a collection of fluid which can develop in the area where tissue has been removed from your breast), reduce the exercises to two times a day only.

4 

17 

How do I arrange further physiotherapy?  Ask your breast care nurse to refer you to the

outpatient physiotherapy department.  Call the oncology physiotherapy team at Guy’s

Hospital on 020 7188 5103 between 9am and 4.30pm, Monday to Friday. If your call is answered by our answerphone, please leave a message and we will call you back.  Call the hospital switchboard on 020 7188 7188 and

1. Place your hands at the back of your neck and raise your elbows out in front of you to 90 degrees (shoulder height). Then lower your elbows to your sides. Repeat five times.

2. Place your hands on your shoulders and raise your elbows outwards, away from your body, to 90 degrees (shoulder height). Then lower your elbows to your sides.

ask for the bleep desk. Ask for bleep 2744 and wait for a response. This will connect you to the senior oncology physiotherapist directly.  You can email the oncology physiotherapist for any

questions or to self-refer at [email protected]

Repeat five times.

3. Place your hand on your lower back. Repeat five times.

4. Keeping your arms by your side, push your shoulder blades forwards and then pull your shoulder blades back – squeezing your shoulder blades together.

   

16 

Repeat five times. 5 

Your exercise plan – stage 2

Can I still exercise after a seroma?

Start these exercises in the fifth week after your operation. It is fine to feel a stretch while you do these exercises but they should not be painful.

If you develop a seroma, you should stop overhead exercises and contact your breast care nurse. A seroma is a normal part of the healing process, but if it is severe, it will need to be drained by your surgeon.

Frequency: Four times a day, five repetitions each. These replace stage 1 exercises. If you develop a seroma, reduce the exercises to one to two times a day only and go back to your stage 1 exercises (see page 9 for more information). 1. With your elbows straight, move your arms out in front of you. Raise your arms until your fingers point to the ceiling. Finally lower your arms to the sides.

If you develop a seroma having progressed to stage 2 exercises, you should go back to stage 1. Once your seroma has been treated or is minimal, you can gently start your stage 2 exercises again. You should also reduce the frequency of your exercises to once or twice a day while you have a seroma or while it is being treated.

How do I know if I need further physiotherapy?

Repeat five times.

You may need further physiotherapy if:  you cannot reach the radiotherapy position due to

cording, scar tightness or a painful shoulder  your shoulder restriction is causing you problems in

your daily activities.

6 

15 

exercise and you can start building it up with breaststroke and side-stroke. You should avoid freestyle (crawl), butterfly and backstroke until eight weeks after surgery. Please note that you should not go swimming during radiotherapy or if you have any open wounds. This is because of the drying effects it has on your skin. Speak to your radiographer for more information.

2. With your elbows straight, raise your arms outwards from your sides, with your palms facing up. Continue raising your arms until your fingers point to the ceiling. Finally lower your arms to your sides. Repeat five times on the operated side.

Driving We advise you not to drive for six to eight weeks after your operation. Before you start driving again:  Check with your doctor that it is all right to do so. You

can do this at your first outpatient clinic appointment.  Check with your insurance provider to make sure you

are covered.  Ensure you are confident that you can perform an

emergency stop and handle the car in an emergency situation. Returning to work When you return to work depends on what your job involves. Your doctor or nurse can discuss your work with you and give you more specific advice. If you notice sudden changes in the colour, texture, temperature or size of your affected arm or breast after leaving hospital, you should contact your breast care nurse or GP.

14 

3. Stand with your side to a wall. Raise your arm straight out and place your hand on the wall. Gently ‘walk’ your hand upwards, moving closer to the wall the higher you get. You can mark the wall as a reference point, to see how you progress. Repeat five times.

7 

Lifting and housework  Avoid heavy activities and heavy lifting for the

first eight weeks after your operation – your physiotherapist can advise you on this. Also avoid activities that will strain the abdominal muscles, such as carrying heavy loads or any contact sports.

4. Repeat previous exercise, but stand facing the wall.  

 Think about any activities that you do during the

day which might cause your seroma to develop and try to reduce them. These may include: - static exercises or repetitive movements, such as working on a computer - knitting or writing, which you do for periods of time without moving around - small and fast movements, such as dusting and light housework.

5. With your arms up in front of you, push your shoulder blades forwards bringing your arms across in front of you, and take a deep breath in. Then pull your shoulder blades back with your elbows pushing back horizontally out to the side – squeezing your shoulder blades together.

Sport and leisure  Begin some form of gentle exercise, such as

walking – this can help maintain a good level of fitness. It is normal to feel tired after surgery and/or treatment such as chemotherapy or radiotherapy, so a sensible regime is recommended. It is difficult to put a time on how long you might feel tired – this will depend on the type of treatments you have had. Ask your doctor or physiotherapist for advice.

Repeat five times on each arm.

6. Move your affected arm behind your back towards your opposite shoulder, then change arms (aim for the same amount of movement on each arm).

 After eight weeks you can start building up to

more advanced upper body and abdominal exercises – generally you can start doing more active walking and using an exercise bike. Build up your exercise tolerance step-by-step. Your physiotherapist can advise you further about how to do this. For example, swimming is a great form of

Repeat five times on each arm.

8 

13 

will help reduce shoulder stiffness and prevent scar tissue from tightening up more.

7. Reach your hand behind head and down your neck. Repeat five times.

Massage  Massage your scar to increase skin suppleness –

once your scar has healed, massage it using your fingers or the palm of your hand. Move the top layer of skin on the underlying layers in a circular motion or away from the scar. The aim is to make your skin supple. This will help you to move your arm as well as you could before your operation. After your massage you can use a non-perfumed and lanoline-free cream. We recommend using aqueous cream (your local chemist will stock this).  Gentle stroking and tapping can ease discomfort

– following breast surgery you may experience changes in sensation over your breast and inner arm (for example numbness, tingling or extra-sensitivity). These sensations are quite normal and often pass a few months after your surgery. Sometimes gentle stroking or tapping of the affected area may ease the discomfort. However, you may be left with some numbness.

8. Touch your neck with your finger tips and raise your elbows to 90 degrees (shoulder height). Move your elbows out to the side and then back to the middle. Feeling a gentle stretch is ok. Repeat five times.

12 

9 

9. Lying on your back or standing, push your shoulder blades forward, and reach finger your tips up towards the ceiling and back again, squeezing your shoulder blades together.

What can I do to aid my recovery? Your exercise programme  Complete your exercises slowly and gently.  Do not do any painful stretches – you should feel a

gentle stretch when exercising but not pain. If exercising feels painful, take painkillers 30 minutes beforehand. It is important that you follow the instructions that come with the painkillers and do not take more than the recommended dose. If you have any questions, speak to your doctor or physiotherapist.

Repeat five times.

 Reduce ‘cording’ – after your operation, tight bands

10. Sit or stand, take your affected arm up and out to the side, and back again.

or cords may develop in your armpit, sometimes stretching down your arm. This is often called ‘cording’. You may experience a sharp pulling sensation, or pain, when you try to stretch your arm. Exercise will help stretch and relieve these cords, allowing you to move your arm freely again. Although they will gradually get better, please speak to your physiotherapist if you have any questions or concerns about cording, especially if you are unable to reach the radiotherapy position (see picture on page 2), or you find daily tasks difficult.

Repeat five times.

 Be aware of your posture – aim to keep your

shoulders levelled and try not to slouch.  Move your operated arm as naturally as possible

– this will help with the healing process. 11. Add in stretching your trunk to the side for a bigger stretch. Repeat five times.

10 

 Continue with your exercises until you are able to

use your arm as well as before your operation – you might have days where your arm feels stiff and days when it will not. Keeping up with the exercises

11 

9. Lying on your back or standing, push your shoulder blades forward, and reach finger your tips up towards the ceiling and back again, squeezing your shoulder blades together.

What can I do to aid my recovery? Your exercise programme  Complete your exercises slowly and gently.  Do not do any painful stretches – you should feel a

gentle stretch when exercising but not pain. If exercising feels painful, take painkillers 30 minutes beforehand. It is important that you follow the instructions that come with the painkillers and do not take more than the recommended dose. If you have any questions, speak to your doctor or physiotherapist.

Repeat five times.

 Reduce ‘cording’ – after your operation, tight bands

10. Sit or stand, take your affected arm up and out to the side, and back again.

or cords may develop in your armpit, sometimes stretching down your arm. This is often called ‘cording’. You may experience a sharp pulling sensation, or pain, when you try to stretch your arm. Exercise will help stretch and relieve these cords, allowing you to move your arm freely again. Although they will gradually get better, please speak to your physiotherapist if you have any questions or concerns about cording, especially if you are unable to reach the radiotherapy position (see picture on page 2), or you find daily tasks difficult.

Repeat five times.

 Be aware of your posture – aim to keep your

shoulders levelled and try not to slouch.  Move your operated arm as naturally as possible

– this will help with the healing process. 11. Add in stretching your trunk to the side for a bigger stretch. Repeat five times.

10 

 Continue with your exercises until you are able to

use your arm as well as before your operation – you might have days where your arm feels stiff and days when it will not. Keeping up with the exercises

11 

will help reduce shoulder stiffness and prevent scar tissue from tightening up more.

7. Reach your hand behind head and down your neck. Repeat five times.

Massage  Massage your scar to increase skin suppleness –

once your scar has healed, massage it using your fingers or the palm of your hand. Move the top layer of skin on the underlying layers in a circular motion or away from the scar. The aim is to make your skin supple. This will help you to move your arm as well as you could before your operation. After your massage you can use a non-perfumed and lanoline-free cream. We recommend using aqueous cream (your local chemist will stock this).  Gentle stroking and tapping can ease discomfort

– following breast surgery you may experience changes in sensation over your breast and inner arm (for example numbness, tingling or extra-sensitivity). These sensations are quite normal and often pass a few months after your surgery. Sometimes gentle stroking or tapping of the affected area may ease the discomfort. However, you may be left with some numbness.

8. Touch your neck with your finger tips and raise your elbows to 90 degrees (shoulder height). Move your elbows out to the side and then back to the middle. Feeling a gentle stretch is ok. Repeat five times.

12 

9 

Lifting and housework  Avoid heavy activities and heavy lifting for the

first eight weeks after your operation – your physiotherapist can advise you on this. Also avoid activities that will strain the abdominal muscles, such as carrying heavy loads or any contact sports.

4. Repeat previous exercise, but stand facing the wall.  

 Think about any activities that you do during the

day which might cause your seroma to develop and try to reduce them. These may include: - static exercises or repetitive movements, such as working on a computer - knitting or writing, which you do for periods of time without moving around - small and fast movements, such as dusting and light housework.

5. With your arms up in front of you, push your shoulder blades forwards bringing your arms across in front of you, and take a deep breath in. Then pull your shoulder blades back with your elbows pushing back horizontally out to the side – squeezing your shoulder blades together.

Sport and leisure  Begin some form of gentle exercise, such as

walking – this can help maintain a good level of fitness. It is normal to feel tired after surgery and/or treatment such as chemotherapy or radiotherapy, so a sensible regime is recommended. It is difficult to put a time on how long you might feel tired – this will depend on the type of treatments you have had. Ask your doctor or physiotherapist for advice.

Repeat five times on each arm.

6. Move your affected arm behind your back towards your opposite shoulder, then change arms (aim for the same amount of movement on each arm).

 After eight weeks you can start building up to

more advanced upper body and abdominal exercises – generally you can start doing more active walking and using an exercise bike. Build up your exercise tolerance step-by-step. Your physiotherapist can advise you further about how to do this. For example, swimming is a great form of

Repeat five times on each arm.

8 

13 

exercise and you can start building it up with breaststroke and side-stroke. You should avoid freestyle (crawl), butterfly and backstroke until eight weeks after surgery. Please note that you should not go swimming during radiotherapy or if you have any open wounds. This is because of the drying effects it has on your skin. Speak to your radiographer for more information.

2. With your elbows straight, raise your arms outwards from your sides, with your palms facing up. Continue raising your arms until your fingers point to the ceiling. Finally lower your arms to your sides. Repeat five times on the operated side.

Driving We advise you not to drive for six to eight weeks after your operation. Before you start driving again:  Check with your doctor that it is all right to do so. You

can do this at your first outpatient clinic appointment.  Check with your insurance provider to make sure you

are covered.  Ensure you are confident that you can perform an

emergency stop and handle the car in an emergency situation. Returning to work When you return to work depends on what your job involves. Your doctor or nurse can discuss your work with you and give you more specific advice. If you notice sudden changes in the colour, texture, temperature or size of your affected arm or breast after leaving hospital, you should contact your breast care nurse or GP.

14 

3. Stand with your side to a wall. Raise your arm straight out and place your hand on the wall. Gently ‘walk’ your hand upwards, moving closer to the wall the higher you get. You can mark the wall as a reference point, to see how you progress. Repeat five times.

7 

Your exercise plan – stage 2

Can I still exercise after a seroma?

Start these exercises in the fifth week after your operation. It is fine to feel a stretch while you do these exercises but they should not be painful.

If you develop a seroma, you should stop overhead exercises and contact your breast care nurse. A seroma is a normal part of the healing process, but if it is severe, it will need to be drained by your surgeon.

Frequency: Four times a day, five repetitions each. These replace stage 1 exercises. If you develop a seroma, reduce the exercises to one to two times a day only and go back to your stage 1 exercises (see page 9 for more information). 1. With your elbows straight, move your arms out in front of you. Raise your arms until your fingers point to the ceiling. Finally lower your arms to the sides.

If you develop a seroma having progressed to stage 2 exercises, you should go back to stage 1. Once your seroma has been treated or is minimal, you can gently start your stage 2 exercises again. You should also reduce the frequency of your exercises to once or twice a day while you have a seroma or while it is being treated.

How do I know if I need further physiotherapy?

Repeat five times.

You may need further physiotherapy if:  you cannot reach the radiotherapy position due to

cording, scar tightness or a painful shoulder  your shoulder restriction is causing you problems in

your daily activities.

6 

15 

How do I arrange further physiotherapy?  Ask your breast care nurse to refer you to the

outpatient physiotherapy department.  Call the oncology physiotherapy team at Guy’s

Hospital on 020 7188 5103 between 9am and 4.30pm, Monday to Friday. If your call is answered by our answerphone, please leave a message and we will call you back.  Call the hospital switchboard on 020 7188 7188 and

1. Place your hands at the back of your neck and raise your elbows out in front of you to 90 degrees (shoulder height). Then lower your elbows to your sides. Repeat five times.

2. Place your hands on your shoulders and raise your elbows outwards, away from your body, to 90 degrees (shoulder height). Then lower your elbows to your sides.

ask for the bleep desk. Ask for bleep 2744 and wait for a response. This will connect you to the senior oncology physiotherapist directly.  You can email the oncology physiotherapist for any

questions or to self-refer at [email protected]

Repeat five times.

3. Place your hand on your lower back. Repeat five times.

4. Keeping your arms by your side, push your shoulder blades forwards and then pull your shoulder blades back – squeezing your shoulder blades together.

   

16 

Repeat five times. 5 

There are two stages to your exercise plan:

Appointments at King's

Stage 1

Start these exercises one to two days after your operation and continue to do them for four weeks (unless you have been advised otherwise by your doctor or physiotherapist).

Stage 2

Start these exercises in the fifth week after your operation (unless you have been advised otherwise by your doctor or physiotherapist).

We recommend that you continue with these exercises every day, even after you have regained full shoulder movement.

We have teamed up with King’s College Hospital in a partnership known as King’s Health Partners Academic Health Sciences Centre. We are working together to give our patients the best possible care, so you might find we invite you for appointments at King’s. To make sure everyone you meet always has the most up-to-date information about your health, we may share information about you between the hospitals.

Contact details If you have any questions or concerns about your exercise plan, please contact the Physiotherapy Department on 020 7188 5106 (Monday to Friday, 8.30am to 4.45pm).   For more information leaflets on conditions, procedures, treatments and services offered at our hospitals, please visit www.guysandstthomas.nhs.uk/leaflets

Link the exercises with something you do every day (such as mealtimes) and they will soon become part of your routine.

Your exercise plan – stage 1 Do these exercises for the first four weeks after your operation (unless advised otherwise by your doctor or physiotherapist). Frequency: Four times a day, five repetitions each. If you develop a seroma (a collection of fluid which can develop in the area where tissue has been removed from your breast), reduce the exercises to two times a day only.

4 

17 

This leaflet explains more about returning to your everyday activities after your operation, and provides you with some exercises to follow. If you have any further questions or concerns, please speak to your doctor or physiotherapist.

Notes        

Why do I need to exercise after my reconstructive breast surgery? It is important that you follow the exercise plan in this leaflet because it will: 

prevent shoulder stiffness



help you regain and maintain full movement in your shoulder



encourage your circulation and healing of your scar tissue



prevent or ease any back pain caused by the operation



encourage back movement and increase your abdominal (stomach) muscle strength.

If needed, these exercises will also help you to get into the required position for radiotherapy within a short period of time – see picture below for the radiotherapy position.

18 

3 

Notes

Contents p.3

Why do I need to exercise after my reconstructive breast surgery?

p.4

Your exercise plan – stage 1

p.6

Your exercise plan – stage 2

     

p.11 What can I do to aid my recovery? p.15 Can I still exercise after a seroma? p.15   How do I know if I need further physiotherapy?  

p.16   How do I arrange further physiotherapy?  

p.17 Contact details  

p.18 Notes  

p.20 Further information

     

2 

19 

 

Further information Pharmacy Medicines Helpline If you have any questions or concerns about your medicines, please speak to the staff caring for you or call our helpline. t: 020 7188 8748 9am to 5pm, Monday to Friday Patient Advice and Liaison Service (PALS) – To make comments or raise concerns about the Trust’s services, please contact PALS. Ask a member of staff to direct you to the PALS office or: t: 020 7188 8801 at St Thomas’ t: 020 7188 8803 at Guy’s e: [email protected] Language support services – If you need an interpreter or information about your care in a different language or format, please get in touch using the following contact details. t: 020 7188 8815 fax: 020 7188 5953 NHS Choices – Provides online information and guidance on all aspects of health and healthcare, to help you make choices about your health. w: www.nhs.uk

Physiotherapy Department

Physiotherapy advice after breast reconstruction surgery using a latissimus dorsi flap with or without implant

Leaflet number: 2579/VER3 Date published: November 2014 Review date: November 2017 © 2014 Guy’s and St Thomas’ NHS Foundation Trust 20