Exercise and Advice Class for patients receiving radiotherapy ...

Exercise and Advice Class for patients

receiving radiotherapy

for breast cancer

Rehabilitation and Support

A guide for patients and carers

Contents

Exercise and advice class ............................................................. 1

Arm Exercises .............................................................................. 2

Using the arm on the treated side during and after radiotherapy to the breast area. ........................................ 10

Questions you may have. .......................................................... 11

• Why might there be a problem? .......................................... 11

• How do I decide what I can do safely and what should I not do? ................................................... 11

Loss of sensation/hypersensitive areas around your breast and shoulder .......................................................... 13

• Will this improve? ................................................................ 14

• What is hypersensitivity? ...................................................... 14

Fatigue ..................................................................................... 15

• What is fatigue? .................................................................. 15

• What causes fatigue? .......................................................... 16

• What can I do to help? ........................................................ 17

Simple dietary advice for patients .............................................. 18

Local cancer information and support centres. .......................... 20

Exercise and advice classThis leaflet has been designed to support the information provided to patients attending the exercise and advice class (or seeing the physiotherapist individually) who are receiving radiotherapy to the breast area at Clatterbridge Cancer Centre - Wirral, or at Clatterbridge Cancer Centre - Aintree.

This leaflet explains some of the common side effects and ways in which you can reduce them when you are at home, and includes the following information

� Arm exercises

� Moving and using your arms during and following treatment

� Changes in sensation

� Fatigue

� Dietary advice

� Further contact information

Disclaimer

The advice given in this class is not a substitute for physiotherapy advice given as part of individualised and tailored care.

If you have problems relating to your exercises or shoulder movement during your treatment or in the two months afterwards, the physiotherapist can advise you. You can contact the physiotherapy department on 0151 556 5146, Monday to Friday from 8.30am - 5.00pm.

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Arm ExercisesAfter surgery and radiotherapy the tissues in the affected area (breast/underarm) need to repair themselves, they do this by forming scar tissue.

In the human body scar tissue can often tighten and cause structures to stick together, this can cause discomfort and pain on movement and even restrict some movements in the affected area.

Doing exercises as taught in the class can help stretch the scar tissue and in some cases can prevent it tightening in the first place. This will help reduce pain and discomfort and maintain better movement of the affected area.

These exercises should be done up to three or four times a day. You should continue to do them throughout your radiotherapy and for 3-4 months after your radiotherapy has finished. After this time, it is advisable to continue with the exercises twice a day, gradually decreasing to once a week or less over twelve months, for as long as you feel they are of benefit. Remember, everyone is different and it is up to you to decide if you are still benefitting from them at this time. Occasionally, you may experience some delayed tightening of the muscles that move your shoulder. We recommend you contact your GP for consideration of a referral to physiotherapy if this should happen.

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Sit or stand.

Lift your shoulders up as close to your ears as far as you can.

Relax and let your shoulders drop back down.

Repeat up to 10 times.

Sit or stand.

Roll your shoulders in both directions.


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Sit in a chair with your back supported.

Keeping your back pressed against the chair, clasp your hands - palms touching and fingers interlaced.

Take your arms above your head.

Use your arm on the non-treated side to help push the other arm a little bit further, just enough so that you can feel the pull in the muscles across your chest or, until your arm on your treated side moves fully.

Repeat this up to 10 times.

Alternative

Stand facing a wall.

‘Walk’ your fingers up the wall as high as possible. Reverse down in the same way.


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Sit in a chair with your back supported.

Place your hands behind your neck with your elbows pointing forwards.

Move elbows apart and back as far as you can go.

Then bring them forwards again.


Alternative

Stand near a wall as shown.

Slowly ‘walk’ your fingers up the wall, so that you feel a stretch.


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Stand or sit.

Bring your arms alternately behind your neck and back.


Alternative

Stand or sit.

With arm to be exercised bring a towel over your shoulder behind your back. Get hold of the towel with the other arm.

Pull downwards bringing the upper arm (the arm to be exercised) down as far as possible.

Then reverse your arm positions and now pull the arm to be exercised up your back by pulling up on the towel with the arm on your non-treated side.


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Sit with your back straight and feet firmly on the floor, or stand up straight.

Pull your shoulder blades forwards as far as you can, then pull them back together while taking your arms back and the thumbs pointing upwards behind you as far as you can.

If you are able to take your arms back at shoulder height you may feel a bigger stretch.


Sitting or standing leaning forward.

Let your treatment arm hang relaxed straight down.

You may hold a small weight ( for example a 500ml bottle of water).

Swing your arm gently forwards and backwards.


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Sitting or standing leaning forward.

Let the treatment arm hang relaxed straight down.

You may hold a small weight ( for example a 500ml bottle of water).

Gently swing your arm to your left and then to your right.

Repeat up to 10 times. If your skin becomes red and sore with treatment you can leave this exercise out.

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Cording - axillary and venous

Axillary cording

This condition can develop as a side effect of surgery and/ or radiotherapy. Surgery will sometimes involve removing just a few or more of the axillary, or underarm, lymph nodes, whilst radiotherapy treats the tissues in this area.

If you develop cording you may be able to see and/ or feel a web of thick, rope-like structures/ indentations under the skin of your inner arm, however it may be that you feel sensations of pain and tightness in that area.

You may first notice them when you’re doing something that involves raising your arm to shoulder level or above your head.

With cording, it’s possible to have one large cord or several distinct, smaller cords running down the arm. These cords usually start near the site of any scarring in the underarm region and extend down the inner arm to the inside of the elbow. Sometimes they can continue all the way down to the palm of your hand. In some people, cording can extend down the chest wall instead of, or in addition to, the inner arm.

Scar tissue from surgery and radiotherapy to the chest area to remove the cancer itself can also contribute to cording.

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Venous cording

This condition presents in a similar way to axillary cording. Venous cording develops as a side effect of chemotherapy. Some chemotherapy irritates the veins and causes scar tissue to be produced. If you develop cording you may be able to see and/ or feel a web of thick, rope-like structures/ indentations under the skin of your lower arm, elbow and sometimes upper arm as well as sensations of pain and tightness in that area.

Treatment

Doing the exercises as shown in the class can help, as can gently stretching the tissues in the area where you can see these tight structures. However, we would advise that if this is required you would benefit from seeing a physiotherapist.

Using the arm on the treated side during and after radiotherapy to the breast area

This advice applies throughout your radiotherapy treatment and for at least four months afterwards.

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Questions you may have.Why might there be a problem?Following surgery your body heals by forming scar tissue. Exactly the same thing happens with radiotherapy. Scar tissue tightens as it forms. This can lead to shoulder pain, stiffness and weakness because it affects the muscles on your chest wall. If you try to use your arm to do work that it is not strong enough to perform you may cause more damage and more scar tissue may form. This can lead to an increase in the potential to develop problems.

It is important that you use your arm or it will weaken even more, but it must be used appropriately and safely. As every person is different and every activity is different, it is not possible to give a list of jobs that you can do safely or those you should not do.

How do I decide what I can do safely and what should I not do?The best way to decide what jobs you can do safely is to stop and think before you do the job. You should ask yourself the following questions and then decide if you can do the job safely, or need to change how you do the job to make it safe to do. Sometimes, you may decide it is better to not do the job at all.

1. How are you feeling today? If you are feeling unwell, tired or not able to concentrate then

you should avoid doing complicated jobs, as you may easily make a bad judgement or mistake.

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2. Is your shoulder / chest area hurting you today? If your arm, shoulder or breast area is sore or painful, then the

muscles will not be able to lift weights or do hard work.

3. How heavy is the weight you are about to try and lift or move?

Be very certain you can easily manage the weight. If in doubt, then do not take the risk. Perhaps you can slide the object onto a trolley with wheels in order to move it.

4. What position will your arm be in when you are holding the object?

When your arm is at full stretch, in any direction, the weight in the hand becomes three or four times heavier to hold because

of the length of the lever, (your arm). To avoid damaging muscles because of this, hold weights in close to your body.

5. Is the object a living creature, such as a child or a pet dog for example?

Children and animals do not always do as you tell them. If you are holding them or helping them physically, they may move away from you suddenly. This could pull on your arm when you are not expecting it and your muscles in your shoulder could get hurt. It would be sensible to always try and hold the child or animal on the side that has not been treated.

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6. Is the job a long and repetitive job? Any job, even if it is lightweight, can tire a muscle if it is done

for long enough. As a muscle becomes tired, it becomes weaker and then is more easily injured. It is better to try and break up long, repetitive jobs into smaller manageable work periods.

You should ask yourself these questions before you do any job. How you feel can change through the day and from day to day. This will mean the answers may change even if the job is the same.

If you are in employment, you may have access to an occupational health nurse or doctor, who specialises in workplace health issues. Occupational health professionals draw on their clinical knowledge and an awareness of the specific duties and demands of your work role. Otherwise you may need to discuss with your GP.

Loss of sensation/hypersensitive areas around your breast and shoulderDuring surgery, the nerves to the skin are sometimes cut. This cannot be avoided, as they are impossible to see. If this happened during your operation, the healing of the nerves can cause a change in sensation in the areas of skin that the nerve supplied, most commonly across the breast/chest wall. These may include:

� A feeling of numbness or dull to the touch

�Becoming oversensitive to touch (hypersensitive)

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Chemotherapy can cause damage to the nerves in the hands, feet and lower legs and is known as peripheral neuropathy.

You may experience pain, sensitivity, numbness, or weakness in these areas.

Will this improve?How much the nerves re-grow and recover is not known and it varies from person to person. Some areas of numbness may recover completely; others may stay permanently numb or have a different sensation to normal.

If it stays numb, then eventually, over time, your conscious mind will adjust and you will become unaware of the numbness as you go about your everyday life.

What is Hypersensitivity?Sometimes an area of skin may become over-sensitive. A gentle touch can feel like a pain and cloth brushing against the area can feel like a burn. This is called hypersensitivity. If you are already having this problem, or if you develop it later, you can make the area less sensitive by taking some very simple measures.

� Do not be frightened to touch the area. Not touching the area can make the sensitivity worse. Try gentle stroking of the area that is sensitive to help over sensitivity settle down

� If you have this sensation in skin that has had radiotherapy, once any skin reaction has settled, try doing a firmer massage. Move the flat of your hand in slow circular movements over the area. Press firmly so that you move the muscle underneath. Do not rub the skin as this can irritate it and make it sore

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Please note

• If the skin is inflamed, red, hot or sore, for example due to the radiotherapy skin reaction, then DO NOT do this massage as it may make the skin condition worse

• If the sensitivity is caused by peripheral neuropathy, and symptoms are getting worse rather than better, then please ensure you contact your GP/oncologist for further investigations

FatigueFatigue – Don’t ignore it!

What is fatigue?

Often described as weakness or exhaustion, but also less obviously described as ‘I just don’t feel like myself’ or ‘I haven’t got any get up and go’.

Fatigue can mean:

� Being short of breath after only light activity, like cooking a meal or taking a shower

� Pain in the legs and difficulty climbing stairs or walking short distances are also signs of fatigue

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� Feeling tired or breathless after walking short distances

� Altering the way you feel or think

�Difficulty in concentration

� Loss of interest in things you normally enjoy

� Can make you impatient

It is important that you discuss feelings like this with your radiographer or doctor as there may be other causes, such as anaemia which can be corrected.

For most people fatigue is a normal experience after activity and is short lived. It usually goes away if you take a short rest or nap.However, fatigue related to treatment can last for a few months afterwards. Some people may experience chronic fatigue (long lasting) and this can affect the quality of their life. Unfortunately, many patients do not talk to healthcare professionals about this because they don’t understand what it is or think that feeling tired from the effects of cancer or treatment is normal.

What causes fatigue?No simple cause can be identified to explain fatigue in a cancer patient. It is important to remember that ‘normal’ fatigue is something that the body has and uses as a protective mechanism to prevent injury from over activity. The fatigue that comes from cancer treatments can add to this and this means recovery then takes much longer.

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What can I do to help?Everyone is different and will manage fatigue in their own way. Here are a few useful ways to help:

� Take several short naps or breaks rather than one long one

� Plan your day so that you have time to rest

� Take short walks or do light exercise if possible - some people find this improves their fatigue

� Try easier or shorter versions of the activities you enjoy

� Eat as well as you can and drink plenty of fluids

� Keep a diary of how you feel each day, this can help you plan activities and can help the multi-professional team plan any interventions to manage fatigue

� Go to bed at night at roughly the same time. Set the alarm clock and then turn your face away so you can’t see it. Get up when the alarm goes off

� If you cannot sleep within 30 minutes of going to bed, get up and do something - make a cup of tea; watch a little television, don’t lie tossing and turning

� Share your feelings - you can talk to other patients and staff and can often pick up hints and tips from them

� Finally, remember that you don’t have to do everything at once - save your energy for things that you feel are important

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Simple dietary advice for patientsOften, following a period of illness or surgery you may find that your appetite has changed. You may not feel inclined to eat at mealtimes, and the effort of preparing a meal can seem like a big chore. You may experience feeling full after eating small amounts.

If you are experiencing any nausea (feeling sick), vomiting or pain, please tell your radiographer, nurse or doctor so that they can further advise you on this.

If you are worried about weight loss or weight gain since your diagnosis, please discuss with your radiographer or nurse as they may be able to refer you to a dietitian.

You may find the following useful:

� Prepare simple meals which do not take a lot of time, better still if somebody else can do this for you

� If you experience nausea, eating dry foods such as toast, crackers, biscuits or crisp breads before you get out of bed, or after a nap may help

� Open windows or use an extractor fan when cooking to remove cooking smells if they make you feel sick. Cold foods can be helpful

� Make your mealtime a social occasion - sit up at the table where possible and for a short while after eating

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� Try to drink between meals, rather than with food. Ensure that you drink plenty of water - aim for 2 litres per day, about 8 - 10 glasses/mugs

� Chilled drinks may be more appealing to you - try drinking with a straw. Sometimes, fizzy drinks are helpful; try mineral water (plain or flavoured), soda water or lemonade

� If your favourite food tastes different, try something you haven’t had for a while

� Eating ginger can help reduce feelings of sickness - try ginger biscuits, ginger tea, ginger beer or crystallised ginger can be useful

� Ask your nurse, radiographer or doctor if you are allowed alcohol; a small sherry, brandy or glass of wine before a meal is a good way of stimulating your appetite

Try to eat a variety of foods each day as no one food group contains all the necessary nutrients (goodness from food) your body needs.

Eat whenever you feel hungry - even it is outside normal mealtimes. Eating several small meals and snacks throughout the day may be better.

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Local cancer information and support centresAs well as your own health care team, there are centres where you can find information about cancer. These local centres have leaflets, books, videos, internet access and people to help and advise you. You don’t need an appointment - just drop in. You can also phone the centres for advice and details of other organizations that can help.

Breast Cancer Information Sources

Macmillan Cancer Information CentreThe Clatterbridge Cancer Centre BebingtonWirral CH63 4JY

0151 556 5570

Website: www.clatterbridgecc.nhs.uk

Breast Cancer CareNational Helpline: 0808 800 6000Website: www.breastcancercare.org.uk

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Breast Cancer NowBreast Cancer Now5th Floor Ibex House42 - 47 MinoriesLondon, EC3N 1DY

Freephone: 0333 20 70 300.Website: http://breastcancernow.org/about-us/contact-us

Breast cancer (American site)http://www.breastcancer.org

References

http://www.csp.org.uk/publications/duty-care (members only)

http://www.breastcancer.org/treatment/side_effects/aws

https://be.macmillan.org.uk/be/p-284-coping-with-fatigue.aspx

http://www.macmillan.org.uk/information-and-support/coping/side-effects-and-symptoms/other-side-effects/peripheral-neuropathy.htmlhttp://www.macmillan.org.uk/information-and-support/coping/side-effects-and-symptoms/other-side-effects/peripheral-neuropathy.html

The Clatterbridge Cancer Centre NHS Foundation TrustClatterbridge Road, Bebington, Wirral, CH63 4JY.

Tel: 0151 556 5000

Web: www.clatterbridgecc.nhs.uk

Issue date: 01/12/16

Issue no: 4.0

Reference: LCRCBCARE

Review date: 01/12/19

If you have a comment, concern, compliment or complaint, please call 0151 556 5203.

If you need this leaflet in large print, Braille, audio or different language, please call 0151 556 5570.

How we produce our informationAll of our leaflets are produced by staff at The Clatterbridge Cancer Centre and this information is not sponsored or influenced in any way. Every effort is made to ensure that the information included in this leaflet is accurate and complete and we hope that it will add to any professional advice you have had. All our leaflets are evidence based where appropriate and they are regularly reviewed and updated. If you are concerned about your health in any way, you should consult your healthcare team.

We rely on a number of sources to gather evidence for our information. All of our information is in line with accepted national or international guidelines where possible. Where no guidelines exist, we rely on other reliable sources such as systematic reviews, published clinical trials data or a consensus review of experts. We also use medical textbooks, journals and government publications.

References for this leaflet can be obtained by telephoning 0151 556 5570.

Exercise and Advice Class for patients receiving radiotherapy ...

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