From Surgery to Fit
Reconstructing a fitness program for mastectomy clients.
From Fitness Trainer September/October
Training After Masectomy
After her bilateral prophylactic mastectomy and reconstructive surgery, Sarah longed for normalcy. Previously active with kickboxing, running, and lifting, she’d gained weight and lost muscle and conditioning during her recovery. In addition to the physical challenges her surgeries caused, Sarah was no longer happy with her body’s appearance or performance. She had lost confidence in herself, was frustrated, and depressed on and off.
“I’ve been active all my life,” Sarah said. “But this past year I’ve had trouble losing the extra weight, and that’s never been the case before. I used to strength train, do boot camps, and kickbox, but I’m not sure if I’ll ever be able to do those things like I used to.”
With three young children and a history of breast cancer in her family, Sarah made the decision to have a double mastectomy when she learned she had the BRCA1 gene mutation. She chose the immediate-delayed procedure for breast reconstruction, in which surgeons place tissue expanders under the pectoral muscles during the mastectomy to make room for breast implants. Over the next few weeks, the plastic surgeon adds saline through a port to slowly stretch the tissue. After the tissue recovers from the mastectomies, there is a second, smaller surgery to exchange the expanders for long-term breast implants.
According to her healthcare providers, Sarah’s high level of pre-surgery fitness helped speed up her recovery. But Sarah was shocked by her severely limited range of motion after the mastectomies. For several weeks, she had only 60% of her normal shoulder flexion and was unable to comb her hair, put on a T-shirt, or drive.
Even after six weeks of physical therapy to restore her range of motion and address muscle imbalances, Sarah suffered from shoulder and neck pain and a feeling of tightness in her chest. She was fearful of training her upper body and found pushing movements to be uncomfortable and unnatural. The extra weight she’d gained during her recovery was stubbornly hanging on, as she’d also been thrust into menopause when she had surgery to remove her ovaries.
A mastectomy is a massively invasive surgery that can create a large gap in strength, stability, and mobility. More and more women are choosing this surgery preventively, and many more have mastectomies after a cancer diagnosis. Adding to a woman’s challenges is menopause, which can be brought on by cancer treatments, ovary removal, or simply by virtue of being menopausal at the time of the surgery.
How can you as a fitness professional safely and effectively help a client who is struggling with these emotional and physical challenges?
Building An Authentic Relationship With Your Client
It’s common for post-mastectomy clients to be grappling with both emotional and physical difficulties. She may have had negative experiences after her mastectomy that caused her to feel isolated, hopeless, or anxious. While it’s not possible to know exactly what she’s feeling, you can begin to build a client relationship that’s based on empathy and trust.
When you first meet and each time thereafter, have authentic conversations with your client that will help put her at ease and build positive feelings about her progress. Clients may see fitness professional as invincible pillars of strength, yet showing our own vulnerabilities can create a more genuine, trusting relationship. Instead of immediately giving advice when she talks to you, listen, be engaged, and clarify what you’re hearing.
Post-mastectomy or reconstruction, some women have fears about strength training. For example, you can reassure your client that strength training will not change the appearance of or dislodge her breast implants (she can also learn to relax the muscles and control the feeling of strong pectoral contractions over time).
The more empowered your client feels, the more likely she’ll stick to her program and be happy with its outcome. Showing acceptance and empathy for your client can help mobilize her to change and even enjoy the process of rediscovering her body.
Creating Success With The Assessment
In addition to making a meaningful connection with your client, the initial assessment is critical in uncovering mobility and postural issues. It’s likely your client will have any of the following conditions:
• Upper-crossed syndrome (a combination of protracted shoulders, forward head, cervical lordosis, winged scapula, and thoracic kyphosis).
• Shortened pectoral muscles and a feeling of tightness across her chest, like an “iron bra” or straight jacket.
• Limited arm and shoulder range of motion (flexion, extension, abduction, and external rotation) due to scar tissue.
• Tingling or numbness.
• Muscle aches, pain, fatigue, and/or weakness.
Taking a comprehensive history is critical, not only to uncover injuries, surgeries, treatments, and medications, but also to determine if your client has had lymph node biopsy or removal, which puts her at risk for lymphedema. Become informed about treatments or get specialized training before taking clients who have had cancer. Restricted movement is common after a mastectomy, even if your client had physical therapy. Thoroughly assess and observe your client for scapular stability and shoulder, humerus, thoracic, cervical, and lumbar mobility. Begin with a simple shoulder flexion assessment – does your client have the mobility to go into an overhead position or does she compensate to get there (for example, extend her lumbar spine, lower or elevate one shoulder, or shift her head forward in efforts to get her arms overhead).
Another piece to the puzzle is determining which muscles need strengthening or lengthening. Due to restricted range of motion, discomfort, or even fear-avoidance patterns, post-mastectomy client commonly present with muscle imbalances. It’s critical to address these issues before beginning any strength training. In particular, attempting to add loads to the pectoral muscles before they’ve been lengthened could cause imbalances to worsen.
As a complement to your own assessments, you can also connect with your client’s physical therapist for a status or guidance.
Body Stretching
Progress From The Beginning
You can help your client can feel substantially better simply by helping her body to move more freely. Help motivate her to continue daily physical therapy exercises or basic stretching on her own to reinforce new postural patterns. When she trains with you, begin your sessions with pectoral lengthening and range of motion exercises, such as doorway/corner stretches, wall slides, and the supine wand exercise. Overactive lats can also cause scapular depression/internal rotation and lumbar extension, so integrate movements like the exercise ball lat stretch with thumbs up and core stabilization.
While range of motion is being addressed, the two of you can continue to work on strengthening your client’s back muscles (particularly the scapular stabilizers) with straight-arm pulldowns, cable and bent-over rows, internal and external shoulder rotation, YTI’s, and rear delt raises. Help her build stamina as you also work on core strength and incorporate lower-body exercises.
If your client needs to shed fat, you can continue conversations about nutrition and integrate aerobic exercise as well. Menopause can make it more difficult to lose weight, so focus on her successes and emphasize the value of long-term consistency.
Strength Training After a Mastectomy
Food Diets
Before diving into chest training, I spent several weeks working with Sarah to correct her forward head posture and protracted shoulders. Since her shoulder and spinal mobility was good, we focused on back and core strengthening and scapular stabilization. (Strength training is typically recommended 4-6 weeks after surgery, but check with your client’s doctor first.)
After her assessments showed that she could maintain scapular stabilization during exercises like the standing cable row, we moved to gentle direct chest work like isometric holds, wall flys, light chest flys, and ball squeezes. Sarah needed to get used to the feeling of her pectorals directly under her skin instead of under a layer of fat as they’d previously been. She gradually became accustomed to her breast implants “shifting” with her pectorals when the muscles contracted, and we were able to move on to light presses and wall push-ups.
Chest Dumbbells
Fortunately, Sarah didn’t experience any chest tightness after gradually increasing the weight on chest presses, but we always stretched her chest thoroughly after training. (You’ll want to ask your client about how she felt after each workout to get feedback about this.)
We also worked on Sarah’s diet and added conditioning circuits to help her lose the extra weight. She continued her scapular stabilization exercises on a daily basis and integrated cardio and walking into her week. While personal training couldn’t fix the emotional scars after her surgeries, she began to feel more confident in her abilities and appearance – a step towards her “normal.”
No two breast surgery clients are the same and you’ll need to customize workouts for each. Factor in her diagnosis, treatment, recovery, complications, health history, and additional orthopedic issues. After a long recovery, your client may be deconditioned and demoralized. Practicing movement patterns and focusing on small, frequent successes will motivate her to keep going.
Common Types of Breast Surgery
• DIEP Flap: Fat, skin, and blood vessels are cut from the wall of the rectus abdominis and used in the chest to rebuild the breast.
• TRAM Flap: Fat, skin, blood vessels, and muscle are cut from the rectus abdominis to rebuild the breast. There is another less common procedure that mines muscle from the latissimus dorsi.
• Immediate-Delayed Reconstruction: Tissue expanders are placed under the chest muscle during the mastectomy to preserve space for implants. Saline is added incrementally to slowly stretch the tissue. Another surgery is performed after 10-12 weeks to insert the implants.
• Direct-to-Implant Reconstruction: Implants are placed in the breast at the time of the mastectomy.
• Lumpectomy: Removal of a benign or cancerous lump from the breast and can include removal of lymph nodes.
• Breast biopsy: Test that removes tissue or fluid from a suspicious area.
• Lymph node biopsy or removal: Test to determine if cancer has spread beyond breasts and can include removal of one or more lymph nodes as part of the biopsy.
• Breast Augmentation: Increasing the size of the breasts using implants or fat transfer.
Knowing The Risk of Lymphedema
While research shows that exercise can greatly benefit cancer survivors, side effects from treatments and symptoms can be far-reaching.
If a client had radiation, chemotherapy, or removal/biopsy of the lymph nodes, she could be at risk for lymphedema – a buildup of lymphatic fluid in the arms or legs.
While some research shows that gentle strength training decreases a woman’s risk for lymphedema, caution is advised by progressing gradually with gentle stretching and slow, low-load movements. Specialized training is desirable for trainers who work with cancer survivors.
Sample Beginner’s Program
The following sample plan is for a woman who is right out of physical therapy and has her doctor’s approval to exercise. Remember, you are not a physical therapist. You’re addressing muscle imbalances and range of motion, not diagnosing or fixing medical conditions.
Armed with information and empathy, you can help your post-mastectomy client become stronger, healthier, and more comfortable in her skin for life.
Partnering with Healthcare Providers
Breast disease patients work with a team of doctors at each stage of their treatment. Your client will appreciate it that you want to be fully informed and involved with her care, increasing her success.
If a client has been diagnosed with cancer, she’ll work with oncologists, radiologists, physical therapists, breast surgeons, and possibly plastic surgeons (although many women choose not to have breast reconstruction following a mastectomy).
• Healthcare providers can advise you about how treatments or surgeries might affect training, medication side effects, and recommendations for ongoing physical therapy exercises (for example).
• Get permission from your client to communicate with providers prior to reaching out, and adhere to HIPAA privacy rules if you work in healthcare setting.
• Upon first contact, share SOAP notes (subjective, objective, assessment, and plan) with providers to help them understand your approach.
Common Side Effects of Mastectomies
While many symptoms subside with time, some women have long-term side effects from a mastectomy:
• Feeling of tightness/heaviness across the chest and armpit(s)
• Burning, tingling, numbness, or soreness on the back of the arm, near the armpit, and/or chest wall due to nerve damage
• Scar tissue, which can result in restricted movement
• Numbness in the chest/breast, armpits, or arms
Suzanne Digre
Suzanne Digre is a National Academy of Sports Medicine (NASM) certified personal trainer and ACE-certified Weight Management Specialist in Denver, Coloardo. Suzanne is also a writer and editor and has a Bachelor’s in Journalism from Metropolitan State University of Denver. Her 20-year passion for weightlifting led her to found her blog, workoutnirvana.com, where she’s written more than 300 articles about muscle definition, nutrition, self-acceptance, and post-mastectomy training. Suzanne loves hiking the Rocky Mountains, cycling, and hanging out with her family.
