You should be instructed on how to exercise the arm if an axillary lymph node dissection was performed during surgery. Please feel free to print out the arm exercises here. I encourage women to begin them after the drain is removed.

EXERCISES AND ARM CARE AFTER BREAST SURGERY

After breast surgery, particularly after the lymph nodes have been removed under the arm, there are changes in sensation, ease of motion and the way that fluids circulate through the arm.  This booklet will outline the changes you can expect and ways to help minimize, prevent and control these changes.

I. Sensations:

Incisional Pain:

With any surgery there is discomfort and pain along the incision line.  This is felt immediately after surgery and decreases every day.  Your doctor has ordered medicine for you to manage this pain.  Every person is an individual so the pain may be different based on how you feel, how many days it has been since surgery and how active you are.  Remember that is takes 30-45 minutes for medication taken in pill form to work.  Please take your medication as soon as you feel uncomfortable to give it the best chance to work.  You may also want to take something to make yourself more comfortable to do the stretching exercises discussed later. This should be taken 30-45 minutes ahead of the time you plan to do the exercises. 

As you continue to heal and scar tissue is laid down, it is normal to feel tightness under the arm and across the chest wall if the breast has been removed.  The best way to relieve this tightness is to do the stretching exercises.  In order to feel comfortable doing the exercise, you may want to take some pain medication and/or take a warm shower before starting.

Referred Sensations:

During breast surgery, nerve endings in the area are affected by swelling, being moved or being cut.  It is normal to feel numbness under the arm from the elbow up to the armpit and over the chest wall if the breast has been removed.  Other sensations may be a feeling of water trickling down the arm or a "pins and needles" feeling.  These are called referred sensations.  Know that these sensations are normal and will get better with time.  The nerves are the slowest part of the body to heal so these sensations may last a month or up to a year.  The most effective way to make yourself feel better are stretching exercises discussed later and moving your arm normally during daily activities. 

If your breast has been removed, it may take a while for your nerve pathways to sense the loss.  It is normal to feel a sensation of heaviness as if the breast is still there and nipple twinges.  These sensations will disappear with time.

II. Exercises:

These stretching exercises are designed to help you move your hand, arm and shoulder as you did before surgery.  Your surgeon will tell you when to start them.  Exercises are usually begun after the drainage tube is removed.  This waiting period allows the skin to heal to the muscle and decreases the chance of fluid continuing to build up under the skin.  Once you have started exercising, you should continue to do the exercises three times a day until your arm moves as it did before surgery. Most people show normal movement within a 4-6 week period after surgery.   If you still have trouble moving your arm at this time, let your surgeon know.  Further rehabilitation may be needed to help you regain normal movement.

When you are doing the exercises, you must be able to tell when you have gone as far as you can go.  If you feel incisional pulling or discomfort, stop the exercises and take some deep breaths.  If the discomfort goes away, continue the exercises.  If not, slowly return to the start position of the exercise.

Exaggerated Deep Breathing:

Deep breathing is a good way to help you relax and make you more comfortable during your exercises.  Make yourself comfortable and place one hand across your belly.  Take a nice, slow, deep breath through your nose until you feel your belly expand.  Slowly breathe out through your mouth.  This may be repeated several times as long as you are breathing slowly and deeply.  If you feel dizzy, stop, rest and breathe normally.

Shoulder Rolls and Neck Exercises:

1. Sit up straight in a chair, at the edge of a bed or stand up straight.

2. Look straight ahead and keep your head up.  In one continuous motion, raise both shoulders upward, move them backward and then down, forward and up and around to the start position.  Repeat for ten circles.

3. Repeat circles beginning the movement upward then forward down and around.  Do ten forward motion circles.

4. Turn your head to the left so that your nose is even with or over your shoulder.  Move your head to the center or start position then turn your head to the right so that your nose is even with or over your shoulder.  Return to center or start position.  Repeat 5-10 times.

Wall Climbing:

1. The first time you do this exercise, stand facing the wall with your feet about six inches away from the wall.  With the arm on the side that has not had the surgery, reach as high as you can.  Make a mark on the wall with a pencil or piece of tape. This marks your normal range of movement and is the goal to reach for your arm on the side of the surgery.  If you have had surgery on both sides, you may set your goal with the arm that moves more comfortably.

2. To begin the exercise, face the wall with your feet about six inches away from the wall. Place  your hands on the wall, shoulder width apart and on the same level with each other.  Slowly "walk or crawl" your hands up the wall until you feel incisional pulling or discomfort.  Stop and hold this position for one minute.  You can use deep breathing to help relieve the pulling.  After one minute, slowly crawl your hands up the wall a little bit further, until you feel incisional pulling or discomfort.

3. After one minute, slowly "crawl" your hands down the wall until you reach the start position.  If you just drop your hands. This will release the stretch too quickly.  Remember the goal of this exercise is to stretch out the scar tissue.  It is not how fast you do it or how many repetitions.  It is the deliberate crawling and holding of the position that will help you reach your goal

Clasp, Reach and Spread:

1. Sit up straight in a chair, preferably facing a mirror.  Start the exercise with your hands clasped in your lap.

2. Slowly raise your hands toward your forehead keeping your elbows as close together as possible.  If your feel incisional pulling or discomfort, stop and rest your hands where they are (your chin, nose forehead, top of your head) and hold the position for one minute.  You may do deep breathing until the pulling subsides.  If it does not subside, slowly return to the start position.  If it does subside, continue the exercise until you feel pulling again.  Hold for one minute, then return slowly to the start position.  It may take several sessions for you to complete all the positions of this exercise.  Take your time and remember the goal is stretching to relax the scar.

3. As you are able to go further with the exercise, slide your hand over your head, keeping your elbows close to your ears.  Remember to keep your head up!!  Check your position in the mirror.  Slide your hands down until they reach the base of your neck.  When your hands reach the base of your neck open your elbows wide out to the side.  Hold this position for one minute.  Slowly reverse direction and return to the start position.

Side Wall Stretch:

Once you have reached your full range of motion with the above exercises, this exercise will help you to stretch a little more.

1. Stand perpendicular (sideways) to the wall with the arm on the side of surgery facing the wall and your feet about a foot away from the wall.  Reach your arm up to the wall and put the heel of your hand on the wall.

2. Lean into the wall so that the heel of your hand slides up the wall until you feel incisional pulling.  Hold this position for one minute.  Return to the start position.

3. Repeat this exercise until you are comfortable at the full height of the position.

III. Reducing Immediate Post-Operative Swelling:

Immediately after surgery and over the next six weeks, some swelling may occur in the arm on the side of surgery.  This swelling is temporary and will gradually go away.  To help relieve this swelling follow the steps listed below.

1. Elevate your arm on two pillows while lying down.  One pillow is placed lengthwise along the length of your body from your shoulder to your waist or hip.  The second pillow is placed crosswise over the first pillow at the waist or hip level.  Place your wrist on the crosswise pillow, your elbow on the lengthwise pillow.  This should allow your arm to be in a gently elevated position with your wrist higher than your elbow and your elbow higher than your shoulder.  You should elevate your arm twice a day for 45 minutes each time.  (While watching TV is a good time.)

2. Exercise your arm while it is elevated by opening and closing your hand ten times each time you elevate it.  This tightens and relaxes the muscle in the arm so that they act as a pump to return fluids from your arm to the general circulation.

3. Use your arm normally during hair combing, bathing, dressing and eating.

4. Exercise your arm as described before in this booklet until you reach the level of movement you had before the surgery.

IV. Preventing and Controlling Chronic Swelling:

During surgery, the doctor removed lymph nodes from under your arm. The lymph system works together with the blood circulation system to circulate fluid and cells to fight infection.  Removing the nodes changes the way the fluid moves in and out of the arm on the side of the surgery.  Because of this procedure, you are at a greater risk for developing lymphedema or chronic swelling.  This is a slowly developing persistent swelling that may occur weeks or years after your surgery.  To help reduce chronic swelling, follow these basic guidelines.  These guidelines suggest the risk of "an ounce of prevention is worth a pound of cure" philosophy.  Many of these are probably steps you already take in your daily life.

1. Avoid wearing tight fitting clothing or jewelry.  If it makes a mark on the skin. it is too tight.

2. Avoid lifting things that do not lift easily, if you lift something that does not lift easily it can cause a muscle pull or injury and result in swelling.  Use the opposite hand or both hands to lift or carry your purse, packages or heavy load.  Do not hang a heavy shoulder bag on the side of surgery.

3. Have your blood pressure taken on the opposite arm.

4. Continue to do activities you did before the surgery.  Check with your doctor before engaging in strenuous exercise.

5. When planning a plane trip, elevate your arm as much as possible during the flight.  Some people find it helpful to wrap the arm with an elastic bandage or wear a fitted compression sleeve to prevent swelling in the arm caused by pressure changes.

If you do see swelling in the arm, elevate it as described before and do the hand squeezing as much as possible for a 24 hour period.  If the swelling does not go away, contact your doctor for additional help.

V. Preventing Infection and Burns:

Any opening in the skin on the hand and arm is a possible pathway for infection.  If an infection develops, the normal body process is to send fluid and cells to fight it.  Fluid will get in to the arm very easily, however it will not get out easily.  This is another way chronic swelling can happen.  By following the suggestions below you can reduce the chance of an opening or break in the skin.

1. Have injections (such as flu shots and vaccinations), blood drawn or intravenous lines placed in the arm not on the side of surgery.  If you have had surgery on both sides, special arrangements can be made.  Check with your doctor or nurse.

2. Keep your hands and cuticles soft by applying lotion or cream several times a day.  Use a cuticle stick to push back the cuticles, avoid cutting them.  Bring your own equipment to have a manicure done then take it home and clean it.

3. Wear canvas gloves when doing yard work gardening or chores around hot or sharp objects.

4. Wear rubber gloves when cleaning with harsh detergent, steel wool or hot water.

5. Wear a thimble when sewing; avoid needle or pin-pricks.

6. Use an insect repellent when necessary to avoid insect bites.  If you do get stung by a bee, see a doctor promptly to have the stinger removed.

7. Use an electric razor to remove the hair under your arm.  Since the sensation is numb under the arm, avoid using a straight edge razor or depilatory cream to remove hair.

8. Check with your doctor about when you can use deodorant or powder.

9. Wear elbow length padded mitts (barbecue mitt) when working near an oven, barbecue, stove or open fireplace.  Place pots on the stove as to avoid reaching over them when they contain boiling, steaming or frying contents.

10. Use sunscreen with an SPF of 15 or higher to avoid overexposure to the sun and sunburn.

VI. Caring for Cuts, Scratches and Burns:

Chances are that you will cut, scratch or burn yourself at some point on the hand or arm on the side of surgery.  Most times you will heal fine by doing the following.

1. Wash the area with soap and water.  If it is a burn, first run cold water over the area or apply a cold pack.  Then, wash with soap and water.

2. Cover the area with a clean, dry gauze or adhesive bandage.

3. Watch for signs and symptoms of infection such as redness, swelling, increased heat and tenderness at the area.  If these symptoms develop, call your surgeon immediately to prescribe antibiotics or evaluate the area.

VII. When to Contact Your Doctor:

1. If any part of your hand or arm on the side of surgery feels hot, looks red or swollen.  Heat, redness and swelling could signal an infection.

2. If you have a temperature over 101.

3. If there is swelling of the hand or arm, which does not go away after elevation for 24 hours.

VIII. Resources for Exercise and Arm Care After Breast Surgery:

1. Call your doctors office.

2. National Lymphedema Network
2211 Post Street, Suite 404
San Francisco, CA  94115
(800)541-3259

3. The Lymphedema Society of America
9350 Sunset Drive
Miami, FL
(305)279-6229

4.  North American Vodder
Association of Lymphatic Therapy (NAVALT)
(888)462-8258

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