Exercise and Rehabilitation Methods in Breast Cancer Treatment

Breast cancer is among the most common cancers in women worldwide. Treatment may involve surgery, chemotherapy, radiotherapy, and hormonal therapy, with substantial effects on physical, psychological, and social health. Common effects after treatment include fatigue, lymphedema, muscle weakness, restricted mobility, and reduced quality of life. As an integral part of care, rehabilitation and exercise aim to improve quality of life, minimize treatment effects, and accelerate the return to everyday activities.

Treatment-Related Problems in Breast Cancer

Breast cancer treatment depends on stage, spread, and tumor biology. Surgery, chemotherapy, radiotherapy, hormonal therapy, and targeted treatments are frequently used. However, they may cause physical, psychological, and neurological problems that vary with general health, age, treatment response, and other factors. The main problems are discussed below.

Surgery-related problems:

1. Lymphedema
2. Capsular Contracture
3. Postoperative Wound-Healing Problems
4. Axillary Web Syndrome (AWS)

Chemotherapy-Related Problems

1. Fatigue
2. Neuropathy
3. Nausea and Vomiting

Hormonal Therapy-Related Problems

1. Menopause-Like Symptoms
2. Osteoporosis
3. Cardiovascular Problems

Rehabilitation for Lymphedema

Lymphedema results from impaired lymph drainage after lymph node removal during breast surgery or after radiotherapy. It can cause arm swelling, pain, and limited movement. Management and rehabilitation include:

Complex Decongestive Therapy (CDT)

Considered the gold standard for managing lymphedema, complex decongestive therapy (CDT) consists of four main components:

Exercise Programs

Gentle aerobic exercise, stretching, and strengthening help prevent and treat lymphedema. Resistance training should be performed carefully to avoid fluid accumulation in the arm. Low-impact activities such as Pilates and yoga may improve lymph circulation.

Laser Therapy

Low-level laser treatment may accelerate healing in lymphedematous tissue and reduce swelling by increasing blood flow and lymph drainage at the cellular level.

Rehabilitation Approaches for Axillary Web Syndrome (AWS)

Physiotherapy and rehabilitation are important in AWS. They may improve range of motion, relieve pain, and release hardened fibrous cords. The main approaches include:

Manual Therapy

Manual therapy provided by a physiotherapist can effectively help release the fibrous cords and hardened tissues associated with AWS.

• Soft Tissue Mobilization: Gentle massage techniques loosen fibrous cords and reduce tissue tension.
• Fascial Mobilization: Specific techniques improve the flexibility of fascia (connective tissue), helping release the cords.
• Lymphatic Drainage Massage: AWS sometimes occurs with lymphedema, so lymphatic drainage massage may reduce swelling.

Range-of-Motion Exercises

Stretching and range-of-motion exercises address restricted movement and improve shoulder mobility. They increase cord flexibility and reduce tightness. Examples include:

• Shoulder Wall-Walking Exercise: The arm rests against a wall and moves slowly upward to improve shoulder and underarm range of motion.
• Cobra Movement: Raise the arms overhead to stretch. Stretching the chest muscles helps loosen fibrous cords.
• Underarm Stretch: Use an exercise band or towel to gently draw the arm upward, stretching tissues affected by AWS.

Flexibility and Stretching Exercises

Stretching helps soften fibrous cords and improve flexibility. Targeting the underarm and shoulder can relieve arm discomfort.

• Chest Stretch: Place the hands behind the head and push the chest forward to stretch the chest muscles.
• Cat-Camel Position (Yoga): Yoga movements improve spinal flexibility and relax the shoulders. This movement may particularly help relax tissues after AWS.

Resistance Exercises

Resistance work should gradually be added to strengthen shoulder and arm muscles. Bands and light weights improve strength and support shoulder mobility.

• Shoulder Exercises With Resistance Bands: Working the shoulder through different angles with a resistance band helps strengthen muscles and improve stability.
• Weight-Lifting Exercises: Shoulder and arm exercises with light weights help restore strength.

Heat and Ultrasound Therapy

Heat improves local circulation, relaxing muscles and hardened tissues. Ultrasound produces deep tissue warming to help loosen fibrous tissue and increase range of motion.

• Warm Compresses: A warm compress before exercise makes stretching easier.
• Ultrasound Therapy: Ultrasound waves warm tissues beneath the skin and increase elasticity.

Education and Awareness

Patients should learn exercises they can perform themselves to manage and prevent AWS symptoms. Alongside exercise programs, education should emphasize avoiding excessive arm strain and stretching regularly.

Rehabilitation for Chemotherapy-Related Fatigue

Cancer-related fatigue is common during and after chemotherapy. It often accompanies other physical symptoms and substantially affects everyday life. Rehabilitation strategies include:

Exercise Therapy

Research identifies exercise as one of the most effective ways to reduce cancer-related fatigue. Regular programs include:

• Aerobic Exercise: Low-intensity walking, cycling, or swimming may increase energy and reduce fatigue.
• Resistance Exercises: Light weights or resistance bands build strength and preserve muscle mass, helping combat fatigue.
• Stretching and Yoga: Yoga and stretching reduce physical fatigue and promote mental relaxation.

Energy Management

Patients learn to plan daily activities and include rest periods to use energy efficiently. Short breaks help manage fluctuations in fatigue during the day.

Rehabilitation for Chemotherapy-Induced Neuropathy

Chemotherapy-induced neuropathy commonly causes numbness, tingling, or burning in the hands and feet. The main rehabilitation approaches include:

Physiotherapy

Physiotherapy preserves hand and foot muscle strength and improves mobility. Exercises addressing foot weakness may relieve neuropathy symptoms. Balance training and balance boards also reduce fall risk.

Transcutaneous Electrical Nerve Stimulation (TENS)

TENS devices aim to block nerve pain signals and reduce neuropathy discomfort. Electrodes placed on the skin deliver low-level electrical stimulation to ease perceived pain.

Acupuncture

Acupuncture is a traditional Chinese medicine practice intended to restore energy balance. It may be used as a complementary approach to relieve neuropathic pain and numbness.

Pain Management Techniques

Alongside medication, mind-body approaches such as meditation, deep breathing, and mindfulness may help manage neuropathic pain by changing pain perception and supporting stress management.

Preventing and Treating Osteoporosis

In patients receiving hormonal treatment for breast cancer, declining estrogen may reduce bone density and increase osteoporosis risk.

Managing Cardiovascular Problems

Targeted treatments such as trastuzumab may cause cardiotoxic effects, including heart failure. Rehabilitation requires specific approaches to manage these effects.

Cardiac Rehabilitation

Patients with heart failure or cardiovascular problems may receive cardiac rehabilitation. Programs include low-intensity aerobic exercise to improve cardiovascular capacity, such as walking, swimming, or gentle cycling.

Lifestyle Changes

Diet and lifestyle changes help protect the heart. Avoiding saturated fats and cholesterol, exercising regularly, and not smoking support cardiovascular health.

Regular Heart Assessments

Patients receiving targeted therapy need regular tests, such as echocardiography or ECG, to monitor cardiovascular health. Early detection and treatment may prevent progression.

Benefits of Exercise in Breast Cancer

Reducing Fatigue

Fatigue during breast cancer treatment often reflects reduced energy from chemotherapy, radiotherapy, or hormonal therapy and can make daily activities difficult.

Light-to-moderate aerobic activities such as walking, swimming, or gentle jogging increase energy, reduce fatigue, and help patients feel more vigorous. 

Increasing Muscle Strength and Endurance

Chemotherapy and other treatments may reduce muscle mass and strength, making independence harder, particularly in older patients, and increasing fall risk.

Regular resistance exercise with light weights or bands strengthens muscles and preserves or increases mass. Daily activities become easier, and overall endurance improves.

Protecting Cardiovascular Health

Some breast cancer medicines, particularly targeted therapies, may weaken heart muscle and increase heart failure risk. Reduced physical activity during treatment can also harm cardiovascular health.

Regular aerobic exercise, such as walking, swimming, or cycling, strengthens the cardiovascular system, supports circulation, and improves cholesterol and blood pressure, reducing cardiovascular complication risk.

Reducing and Managing Lymphedema

Lymph node removal during breast surgery may cause lymph fluid to accumulate in the arm, leading to swelling, limited movement, and pain.

Regular, low-intensity resistance exercise and stretching strengthen arm muscles, improve lymph circulation, and reduce swelling. Exercise with compression garments particularly supports drainage, reducing lymphedema risk and symptoms.

Protecting Bone Health and Preventing Osteoporosis

Hormonal therapies used for estrogen receptor-positive breast cancer may lower estrogen, reduce bone density, and increase osteoporosis risk.

Resistance and weight-bearing activities, such as walking, jogging, or lifting light weights, preserve and strengthen bone density and reduce fracture risk. Balance exercises also prevent falls and related fractures.

Improving Psychological Well-Being

Patients may experience anxiety, depression, and stress during treatment. Regular exercise increases the release of mood-related chemicals such as endorphins and serotonin. Aerobic activities and yoga ease depressive and anxiety symptoms and support confidence and control, improving quality of life.

Strengthening the Immune System

Chemotherapy and radiotherapy can weaken immunity, increase infection risk, and delay healing. Regular moderate exercise improves circulation and immune cell activity and reduces infection risk. It also supports immune function by lowering stress hormones.

Improving Quality of Life

Regular exercise improves general health, reduces fatigue, supports emotional well-being, and makes independent living easier. Studies show better quality of life during and after treatment among patients who exercise. Greater independence in everyday activities improves overall physical function.

Relieving Neuropathy Symptoms

Chemotherapy-induced peripheral neuropathy causes numbness, tingling, or burning in the hands and feet, making daily life difficult. Regular exercise, particularly walking, gentle resistance work, and stretching, supports the nervous system and reduces neuropathic discomfort. Resistance exercises strengthen weakened muscles, improve balance, and reduce fall risk.

Improving Sleep Quality

Stress, hormonal changes, and physical discomfort during treatment may disturb sleep. Regular exercise makes falling asleep easier and increases deep sleep. Aerobic activity and relaxation approaches such as yoga promote better, less interrupted sleep, supporting health and well-being and reducing fatigue.

Improving Metabolic Health

Chemotherapy and hormonal therapies may alter metabolism, causing weight gain and abdominal fat accumulation. Regular exercise reduces insulin resistance, balances blood sugar, and helps control fat tissue. Both aerobic and resistance training help prevent metabolic disturbances, support weight management, and improve general health after treatment.

Preserving Cognitive Function

Some patients experience “brain fog” after chemotherapy, with impaired memory, concentration, and mental clarity. Exercise increases blood flow to the brain and supports nerve cell function, improving memory, attention, and cognition. Mind-body practices such as yoga and meditation also reduce stress and help protect brain function.

Managing Stress and Supporting Mental Health

Breast cancer treatment may cause high stress and anxiety, increasing depression risk. Exercise increases endorphins, reduces stress, improves mood, and promotes calm. Yoga, meditation, and deep breathing offer additional support. Patients who exercise consequently have lower levels of depression and anxiety symptoms.

Types of Exercise for Patients With Breast Cancer

Exercises during and after treatment vary with physical capacity, treatment phase, and individual needs. Recommended approaches worldwide aim both to protect physical health and relieve treatment side effects. 

Rehabilitation After Breast Cancer Surgery

Surgery is among the most common breast cancer treatments. Postoperative difficulties such as limited movement, pain, swelling, and tissue stiffness can be managed through rehabilitation. The aim is to restore physical function, improve quality of life, and facilitate a return to daily activities.

The main postoperative rehabilitation approaches include:

Early Rehabilitation: The First Days After Surgery

Early rehabilitation supports wound healing, preserves mobility, and prevents complications. It generally begins in hospital and includes:

• Deep Breathing and Chest Exercises

Deep breathing after surgery, particularly under general anesthesia, increases lung capacity and reduces postoperative pneumonia risk. Gentle chest movements can also preserve mobility.

• Maintaining Shoulder and Arm Mobility

Breast surgery and lymph node removal may restrict shoulder and arm movement. Gentle early movement prevents stiffness. Passive and active range-of-motion exercises are recommended:

-Arm Elevation at the Shoulder (Pendulum Exercises): Let the arm hang freely beside the body and make small circles. This reduces joint stiffness and improves lymph circulation.

• Positioning

Appropriate positioning of the operated area and arm helps prevent swelling. Elevating the arm and using compression garments may reduce lymphedema risk.

• Range-of-Motion and Flexibility Exercises: The First 2-6 Weeks

During the weeks after surgery, restoring shoulder mobility and flexibility is a priority. Stiffness and muscle weakness may develop around the surgical area. Recommended exercises include:

1. Wall-Walking Exercise: Place the hands on a wall and slowly slide the arms upward to increase shoulder range of motion. This helps restore postoperative shoulder mobility.
2. Cobra Movement (Gentle Stretch): While lying on the back, raise the arms overhead and stretch the shoulders to improve chest muscle flexibility and reduce tissue stiffness.
3. Elbow Bending and Stretching: Raise and lower the arm, starting at shoulder level, to strengthen the shoulder joint. This is particularly helpful for postoperative pain or tightness.

• Preventing and Managing Lymphedema

Lymph node removal increases lymphedema risk after surgery. It causes arm swelling, heaviness, and restricted movement. Preventive and management approaches include:

1. Lymphatic Drainage Exercises: Gentle stretching promotes lymph circulation and prevents swelling. Slowly raising the arm encourages drainage. Aquatic exercise also improves lymph flow.
2. Compression Garments: Special compression garments reduce lymphedema risk by preventing fluid accumulation in the arm and improving circulation.

• Manual Lymphatic Drainage

If lymphedema develops, specialized massage directs lymph fluid toward lymphatic vessels and reduces swelling. A physiotherapist should perform manual lymphatic drainage, or the patient may do it after appropriate training.

• Restoring Posture and Muscle Strength

After surgery, particularly mastectomy or reconstruction, patients may develop postural changes and muscle imbalances. Chest muscle weakness or tissue loss can affect shoulder and back posture. Recommended exercises include:

1. Postural Exercises: Retracting the shoulders and straightening the trunk strengthens shoulder and back muscles. In patients who tend to lean forward, these exercises support spinal health.
2. Resistance Training: Light weights and resistance bands strengthen the chest and upper back. These exercises are particularly important when treatment causes muscle weakness. They restore strength while protecting spinal and joint health.

• Aerobic Exercise

Aerobic activity is important after surgery for fatigue and deconditioning. Walking, cycling, and water aerobics, as discussed earlier, increase cardiovascular endurance and support general health.

• Psychological Rehabilitation

Breast loss or altered body image after surgery may cause psychological difficulties. Support and exercise programs help improve mental health and restore confidence.

Mind-Body Exercise

Yoga and meditation support stress management and emotional well-being and may help patients cope with postoperative psychological difficulties.

Group Exercise and Social Support

Group programs strengthen social support and emotional well-being. Exercising with other patients may improve motivation after treatment.

Monitoring Exercise Programs in Breast Cancer

Monitoring and sustaining exercise are particularly important in post-treatment rehabilitation. Regular activity improves strength and emotional well-being, enhances quality of life, and minimizes complications. Important considerations include:

Exercise Logs and Diaries

Tracking and recording exercise helps make programs effective. Diaries allow patients to see progress and identify setbacks. They may include:

1. Exercise type, such as walking, yoga, or resistance training
2. Duration and intensity
3. Subjectively perceived fatigue
4. Any pain or discomfort

This tracking system encourages regular activity and increases motivation.

• Tips for Maintaining Motivation

Continuing exercise can be difficult, so strategies to sustain motivation are useful:

• Set realistic goals: Short-, medium-, and long-term goals with gradual progress increase the sense of achievement.
• Variety: Combine different activities to prevent monotony and sustain motivation. Alternating aerobic exercise, stretching, resistance work, and mind-body practices may help.
• Seek support: Exercising with a group or partner can increase motivation. Regular physiotherapist appointments and progress monitoring are also encouraging.

• Professional Support and Exercise Guidance

Seek professional help when starting a program. Physiotherapists or sports physicians can develop safe, effective plans for patients with breast cancer. Their guidance helps prevent injury and ensures correct technique.

• Ensuring Exercise Safety

Safety is as important as consistency in rehabilitation after breast cancer. Safe exercise can prevent complications and support recovery. Consider the following:

Gradual Progression

Avoid overly demanding activity initially. Increase intensity and duration gradually, planning according to physical condition, post-treatment status, and current exercise capacity.

Warm-Up and Cool-Down

Warming up prepares muscles and joints. Perform 10-15 minutes of gentle cardiovascular activity, such as walking, and stretching before each session. Cool down and stretch afterward as well.

Listen to Your Body

Pay close attention to bodily signals. Excessive fatigue, pain, dizziness, or breathlessness may mean stopping and resting. Exercise within your capabilities without overexertion.

Use Appropriate Equipment

Suitable equipment improves safety. Use light weights and resistance bands for resistance work. Appropriate footwear and clothing also protect joints and reduce injury risk.

Hydration and Nutrition

Drink enough water during and after exercise to maintain fluid balance. A balanced diet supports muscle health and general function. Adequate protein, vitamins, and minerals help recovery after activity.

• Medical Approval

Consult your doctor before exercising, particularly after breast cancer treatment. Treatment effects or complications may influence how you exercise. A program should therefore always have approval from a doctor or physiotherapist.