Customized Exercise Programming – Lat Flap Breast Reconstruction

Janna received a referral for a client with breast cancer. She recently became a Cancer Exercise Specialist and asked if she could hire me to help her with and teach her how to put together Luci’s exercise program. She completed her initial assessment and health history and shared the following information with me:

• Luci is 57 years old and exercised 5-6x a week in a variety of group exercise classes prior to her diagnoses
• Luci is 5’7 and currently 178 lbs. She has 20% bodyfat (Janna refers her to a registered dietician specializing in oncology to help her with her diet and losing the extra weight and body fat she has gained since she started hormonal therapy)
• She was diagnosed with stage three breast cancer in July 2020.
• She underwent bi-lateral modified radical mastectomies with Lat Flap reconstruction and a right axillary node dissection on July 18, 2020.
• She is on hormonal ablation therapy
• Her BP is 120/75 and her RHR is 73

Postural Assessment:

• Severe “forward head”
• Severe rounded shoulders
• Both shoulders elevated
• Moderate winged scapula both sides
• Left and right knee medially rotated static and dynamic
• Forward hip flexion during squat test
• Shoulder ROM measurements:
  • Flexion: L 130° R 125°
  • Extension: L 28° R 20°
  • Abduction: L 125° R 115°
  • Internal rotation: L18° R 17°
  • External rotation: L 55° R 65°
• She has unusually tight hip flexors and quadriceps on both legs (hyperextended knees on both sides)
• She has a moderate anterior tilt and complains of low back pain

I started by compiling my own notes and breaking everything down for Janna one step at a time.

1. Because Luci is at risk for lymphedema in her right arm, pec, lat area: Janna will take baseline measurements of both arms and give her a list of precautions to avoid lymphedema. She will also teach her how to do a “pitting” test and begin each exercise session with a warm-up and lymphatic drainage exercises. Because she does not know what her lymphatic system can handle, she will start and progress slowly with all exercises that will stress her right arm. She must gradually at time and intensity for cardio and start and progress very slowly with any resistance/strength training for her upper body (primarily the right side). When the time comes to introduce weight-bearing exercises, she will start with isometrics and that incrementally add resistance and repetitions. If there is swelling at any step along the way, she will refer her to her doctor to be evaluated for lymphedema. If the doctor prescribes a compression sleeve, Luci will have to wear it for all future exercise sessions. Luci should also get a new medical clearance from her doctor to return to exercise. Because Luci is not at risk for lymphedema in her lower body, she has no limitations other than correcting muscle imbalances.
2. Because her Lat muscles have been “tunneled” under her skin and brought out through the mastectomy sites, they are still intact neurologically. That means that if Luci were to do a Lat Pulldown exercise, her breasts would contract and relax with each repetition. This can interfere with the cosmetic affect as well as create an even greater muscle imbalance. Therefore, compound back exercises that involve the Lats should be avoided and attention should be paid to scapular stabilization.
3. Because she has breast implants under the Lat flaps, it will be important to avoid putting excessive pressure on that area during exercise. Close attention should also be paid to controlled range of motion in exercises like chest flys. There is always a slight chance that the implants could move out of their “pocket.”
4. Janna will need to incorporate strength training to help increase her bone density; she is at a higher risk for osteoporosis since she is now menopausal from hormonal therapy. Because she does not meet the 90% standard range of motion in any plane of shoulder motion, she will start with specific exercises that will help to improve flexion, extension, abduction, IR, and ER. In 8-12 weeks when she reevaluates Luci, if she meets or exceeds 90% in any of those planes, she will begin to add strength training exercises. She will begin with isometrics and start and progress slowly because of the lymphedema risk.
5. Because of the severe upper-crossed syndrome, Luci needs to stretch her chest several times a day. She will start with corner stretches and if she can do that pain-free, move on to a door stretch. There should never be any PAIN. Only a mild stretching sensation. She should focus on shoulder retraction and depression to stabilize her shoulder girdle. That will also help with the winged scapula, but Janna is going to have her do ceiling punches in a supine position to help strengthen her serratus muscles. 
6. Janna will perform active isolated stretches when they are together but will give Luci a daily stretching routine that she can do at home.
7. After Janna completed the Modified Thomas Test on Luci, she was able to determine that her left and right adductor complex were tight. Therefore, she would need to focus on hip abduction and avoid hip adduction-type exercises.
8. She believes that her tight quads are contributing to the knee hyperextension and gives her a series of quad stretches instructing her to hold each one for 20-30.
9. The anterior tilt may be attributable to tight hip flexors and weak/weaker glutes. Janna gives her a few hip flexor stretches as well as several hip extension exercises that will strengthen her glutes and simultaneously stretch her hip flexors.

Once I gathered my thoughts, I was able to come up with the following workout routine for Janna to facilitate with Luci for her initial 8-12 weeks.

DAILY – Luci will spend time each day to perform her range of motion exercises for her shoulders and stretch her tight muscle groups.

2 x PER WEEK – Janna wants to start building up lower-body strength while correcting the muscle imbalances. She starts with squats with a band around her thighs so that she can abduct her thighs throughout the motion. This will help to minimize the “knock-knees” and improve tracking of the patella. While she does not have to worry about lymphedema in her lower body, Janna starts with just body weight and 10-12 repetitions. She wants to make sure that Luci is not excessively sore or fatigued. She will gradually add resistance and increase the number of sets. She also has Luci doing hip extension with a cable. Luci can do this at home with resistance bands as well. She starts with 10 lbs. and teaches her how to keep her core engaged and minimize her anterior tilt. She will perform 8-12 repetitions on each leg. She will gradually add resistance and increase the number of sets. Luci will perform leg curls with a physio ball. This will strengthen her core and hamstrings while simultaneously stretching her quads. She will start with 6-8 repetitions.

For her upper body, Luci will perform 10-12 isometric shoulder blade retractions, elevation, and depression. She will also do isometric head retractions to counter her forward head. Lastly she will do 10-12 ceiling punches to strengthen her serratus followed by a 20-30 second rhomboid stretch on each side.

On two of the non-weight days she will go to a beginning yoga class. This will help her to strengthen her core and should help to minimize her low back pain.

4-5 x PER WEEK – Luci needs to improve her body composition so moderate-intensity cardio will help her to rev-up her metabolism and burn calories. She will start by training at 60% of her Karvonen heart rate and work up as tolerated. She will start with 5 minutes and in the absence of fatigue, pain, or swelling in the affected area of lymph node removal, she will add one minute per day as tolerated. They can manipulate frequency, intensity, and duration to find what works best for Luci.

Janna will re-assess Luci in 8-12 weeks and either continue with this routine, or progress to a few more strength training exercises and/or more weight. 

If you are in need of assistance with a special-needs or physically-challenged client, you can get Andrea Leonard’s help in with custom exercise programming