A fast-paced approach for the management of Axillary Lymph Node Dissection impairments

Today, I heard that some health professionals are amazed at how quickly I take my patients through their paces. This feedback was given by some health professionals who attended a workshop I ran recently.

I was rather surprised, as this quick paced method is normal for me, when treating people after breast cancer surgery and radiotherapy. Let me explain more.

In May 2022 I presented a pre- conference workshop for health professionals attending the Australian Lymphology Conference in Hobart. The workshop was Axillary Lymph Node Dissection (ALND) : Assessment and treatment for physical impairments. I chose this topic because there is so little training and research investigation regarding the impairments associated with this surgery and radiotherapy protocol. And I see that ALND and radiotherapy remain a high risk combo for pain, arm movement limitations and lymphoedema for the last 20-30 years.

The session was 3 hours and I thought that this was enough time to:

1. Sketch your own upper chest with the important landmarks: dissection skin scar and where the nodes are removed. The workshop participants will see that there is a 10 cm or 2inches distance between both points.

2. Describe the 5 physical assessments that will identify how much scarring and adhesion is present

3. Describe at least 5 manual therapy interventions that can be tried.

4. And finally, demonstrate how this would look with a patient

This was a lot of information for 3 hours, but the same concepts were repeated in each segment (points above). The last segment was with a local volunteer; I wanted to show the workshop participants exactly how their new learning could look, if they skilled up. This segment was delivered in the same time I would use if I saw this lady in my private practice: 45-30 mins.

During this assess and treat the patient demonstration, I whipped through only 4 of the usual assessments and then 5 of the treatments that we had covered. I'm guessing that it was this segment that the feedback from the participants was referring to as "quick to put the patient through her paces ".

Five different assessments I use:

1. When the woman has difficulty raising their arm, I want to know how far she can reach and how coordinated the arm movement is. I can then compare what I see at the start to the movement the person has at the end of the session, to see how effective the treatment choices and session has been for that individual. I like my Arm to Ear test and Reach out the Back Test as these test much larger arm movements. Training for therapists to use this test are available in Therapists Resources at this website.

2. I locate tender areas at the upper chest and see how deep I can press ( compress the soft tissues) before pain is felt. A positive change for the patient would be pressing in further or deeper, before pain or less pain is felt. Testing is at the node dissection area at the bottom of pec minor.

3. Another great test is trying to lift the tissues at the ALND node dissection area. If these tissues are tight, the person will feel a local burning sensation. Again this can be retested after the treatment session.

4. I believe that the ability of the pectoralis minor to stretch is impaired and I have adapted a method to see how easy it is to lengthen the pec minor only. The person being tested feels stiffness or ease during this test depending on the stiffness or lack of stiffness in the muscle.

I find that each test can be done in 1-2 mins and that each one adds to the data available about that person's impairment level. So that's a total of 8 mins for these 4 tests.

This Questionnaire ( 5th test) was completed by the volunteer patient before she attended her "workshop" session.

What was found from the assessment:

1. Arm movement was really restricted in reaching behind and she was about 20 degrees away from touching arm to head.

2. There was local tenderness to pressure ( at 1cm) at the pec minor muscle, especially at the lower 4-5 rib insertion area ( this is were the nodes were removed)

3. Adapted cupping was painful on the surgical side and not painful on the unaffected side.

4. The volunteer felt stiffness when her pec minor was stretched on the surgical side and no feeling of stiffness on the other side.

Next is to run through the 5 treatments I demonstrated at the workshop. Be relieved that I'm not going to mention them in detail, but I'll offer a couple of reasons why I use 5 or more treatments in one session.

Reason 1

The soft tissues, nerves and arteries in the upper chest are really complex and there's no test to show which one impairment/ or "thing" is the primary problem. So as a therapist you need to work this out!

Reason 2

One treatment to a single impairment ( either skin, muscle, nerve, scar, artery stiffness) may not offer the gain we both want; a lot less pain and much easier arm movement.

Reason 3

Each of the treatments that I choose to use take 15 secs to 45 seconds. This means that I can choose a treatment and re- test, repeat by 4-5 times.

Yes, this is quick paced session for both the person and for me.

In one session, we are busy testing, treating and re-testing.

The same questionnaire was completed at week 3 following two treatment sessions: one at the workshop and another 3 days later. There are some significant changes in how often this person* experienced her symptoms.

There is no research study that has investigated a single treatment protocol or a combined treatment protocol for ALND associated impairments. This means that I can't say with any sense of confidence, that people will improve significantly with this treatment approach. But using this rapid and multi testing /treating method means that the individual has a single session opportunity to see if treatment is going to help them.

I think that's what people want: Can something be done to help change my symptoms?

And because I have upskilled in this area- it will take 45 mins to 30 mins sessions.

If you are a health professional interested in ALND impairment assessment and treatment training - connect now by email.

If you are a person who has been through Axillary Lymph Node Dissection ( lots of nodes removed) and radiotherapy, and you want to be put through your paces, we can do this in person ( Brisbane) or in an online video session.

Use the connect button on the webpage to connect by email and I'll answer any quick questions and email you the questionnaire ( same as above) .

* this example does not imply that the same results will be experienced by all persons- as symptoms and responses to treatment will vary. Your assessment and personalized treatment plan is important!

That's why pre test and post test is an important strategy for the treatment of impairments after breast cancer related ALND.