Effects of mastectomy on shoulder and spinal kinematics during bilateral upper-limb movement

Analysis of Shoulder Complex Function After Posterior Spinal Fusion in Adolescents With Idiopathic Scoliosis

BACKGROUND

Nonsurgically treated patients with AIS demonstrate altered scapular kinematics and decreased patient-reported shoulder function compared with typically developing adolescents. It is unknown whether surgical correction of the spine deformity has beneficial or detrimental effects on scapulothoracic joint function, as previous assessments of shoulder function following surgery have only focused on humerothoracic motion. The objective of this study was to perform a comprehensive analysis of scapular kinematics before and after PSF and compare postoperative scapular kinematics in AIS to those of a typically developing cohort.

METHODS

Typically developing adolescents (n=33) and patients with AIS (n=20) with a planned PSF surgery were recruited. Motion capture was used to analyze scapular kinematics at rest and in full abduction. AIS subjects were evaluated before surgery and at a 6-month follow-up. Individual changes following surgery were assessed, and postoperative scapular kinematics were compared with the typically developing subjects.

RESULTS

Patients with AIS patients in this study demonstrated significant losses of scapulothoracic range of motion for the convex side shoulder and gains of scapulothoracic range of motion for the concave side shoulder following PSF. When compared with typically developing adolescents, the resting scapular position of the postoperative AIS group seemed normalized, but the AIS group still exhibited altered scapular motion, particularly along the upward rotation and tilt axes.

CONCLUSIONS

Patients with AIS demonstrated significant changes at the scapulothoracic joint following PSF. Compared with typically developing adolescents, scapular resting position normalized, but the AIS group still demonstrated altered scapular kinematics, including patterns associated with shoulder pathology. The results of this study will inform the course of short-term postoperative rehabilitation by addressing the upper extremity implications of PSF for individuals with AIS.

LEVEL OF EVIDENCE

Level III.

Reduction in handgrip strength and electromyographic activity in women with breast cancer

BACKGROUND

Breast cancer survivors have side effects from surgical treatment and adjuvant that may acutely or chronically compromise the musculoskeletal system, resulting in loss of muscle strength.

OBJECTIVE

Handgrip strength and electromyography of the upper limbs and its relationship with dominance in women submitted to surgery for breast cancer.

METHODS

Were evaluated 28 women. The handgrip strength was measured through dynamometer associated with electromyographic, in the muscles: descending trapezius, biceps brachial, triceps brachial, extensor carpi ulnaris, radial extensor carpi and superficial flexor of wrist and fingers.

RESULTS

Reduction in grip strength on the side affected by the surgery, that occurred when the surgery was performed on the non-dominant side. The electromyographic showed significant differences in affected side. This shows the need to consider the affected side by surgery and dominance.

CONCLUSIONS

Decreased grip strength and lower electromyographic activity of upper limb affected by surgery for breast cancer, when the side affected was not the dominant this loss was greater.

Protective myoelectric activity at performing upper limb neurodynamic test 1 in breast cancer survivors. A cross-sectional observational study

Myoelectric activity and range of motion during ULNT1 were recorded in 62 breast cancer (BC) survivors who had axillary lymph node dissection (n = 30) or sentinel lymph node biopsy (n = 32) within the previous 18 months, and 63 age-matched healthy women. BC survivors' symptoms were reproduced by ULNT1 and exhibited greater myoelectric activity in the biceps brachii than healthy women (MD (95% CI): 21,26 (10,83-31,70)). No differences between the axillary lymph node dissection and sentinel lymph node biopsy groups (MD (95% CI): 8,47 (-7,84-24,79)) were found. Myoelectric activity in the triceps brachii was greater in the sentinel lymph node biopsy group (MD (95% CI): 2,70 (-2,06-7,60)). BC survivors exhibited less shoulder and elbow range of motion during ULNT1 than healthy women. Increased upper limb nerve mechanosensitivity in BC survivors was associated with a greater protective muscle response during ULNT1.

Examining upper limb kinematics and dysfunction of breast cancer survivors in functional dynamic tasks

BACKGROUND

Comorbidities within the breast cancer population can reduce quality of life. Current breast cancer survivor upper limb kinematic strategies unfortunately lack robust connection with performing important activities of daily living.

METHODS

Accordingly, fifty breast cancer survivors performed 88 dynamic tasks (divided into range of motion-reach, range of motion-rotate, activity of daily living, and work tasks). Humerothoracic and scapulothoracic angles were extracted from motion capture data. Bilateral differences existed for range of motion, and maximal and minimal scapulothoracic and humerothoracic angles.

FINDINGS

Generally, the affected side used less range of motion across task types. Humerothoracic angles on the affected side experienced 6.7° less range of motion in plane of elevation in range of motion-reach (p < 0.01), 2.3° less elevation angle range of motion in range of motion-rotate (p = 0.01), and 7.1° more internal rotation range of motion in range of motion-rotate (p < 0.01). Scapulothoracic angles on the affected side had 2° more anterior/posterior tilt range of motion in work tasks (p = 0.03), 3.4° less maximal protraction in activity of daily living tasks (p = 0.01), and 3.5° less minimum downward rotation in range of motion-rotate (p < 0.01).

INTERPRETATION

A reduced range of motion on the affected side suggests the breast cancer population had less varied movement strategies, keeping movements in narrower ranges to avoid disability, pain, or subacromial impingement. This investigation produced an unprecedentedly diverse collection of three-dimensional humerothoracic and scapulothoracic kinematics for a breast cancer population. Documentation of physical capability, dysfunction, and adaptive strategies is a crucial step towards developing targeted strategies for enhancing functional recovery in breast cancer survivors.

A review of recent advances in the management of breast cancer related pain

The incidence of breast cancer has stabilized over the past 10 years, while death rates have declined. Thus, many women are living with long-term effects of breast cancer, including pain syndromes relating to breast cancer. As our understanding of these types of pain syndromes improves, delivery of care to this population becomes paramount. In this review, we discuss advances in rehabilitation and interventional pain management to improve pain and symptom management. Appropriate use of physical therapy may significantly improve a patient's functional status, while fascial plane blocks can lead to pain relief which may last for months. Targeted therapies for pain relief may result in better quality of life for individuals suffering from breast cancer related pain.

The Functional Impact of Breast Reconstruction: An Overview and Update

As rates of bilateral mastectomy and immediate reconstruction rise, the aesthetic and psychosocial benefits of breast reconstruction are increasingly well understood. However, an understanding of functional outcome and its optimization is still lacking. This endpoint is critical to maximizing postoperative quality of life. All reconstructive modalities have possible functional consequences. Studies demonstrate that implant-based reconstruction impacts subjective movement, but patients’ day-to-day function may not be objectively hindered despite self-reported disability. For latissimus dorsi flap reconstruction, patients also report some dysfunction at the donor site, but this does not seem to result in significant, long-lasting limitation of daily activity. Athletic and other vigorous activities are most affected. For abdominal free flaps, patient perception of postoperative disability is generally not significant, despite the varying degrees of objective disadvantage that have been identified depending on the extent of rectus muscle sacrifice. With these functional repercussions in mind, a broader perspective on the attempt to ensure minimal functional decline after breast surgery should focus not only on surgical technique but also on postoperative rehabilitation. Early directed physical therapy may be an instrumental element in facilitating return to baseline function. With the patient’s optimal quality of life as an overarching objective, a multifaceted approach to functional preservation may be the answer to this continued challenge. This review will examine these issues in depth in an effort to better understand postoperative functional outcomes with a focus on the younger, active breast reconstruction patient.

Effectiveness of Botulinum Toxin A for Persistent Upper Limb Pain After Breast Cancer Treatment: A Double-Blinded Randomized Controlled Trial

OBJECTIVE

To investigate the effect of a single botulinum toxin A (BTX-A) infiltration in the pectoralis major muscle in addition to a standard physical therapy program for treatment of persistent upper limb pain in breast cancer survivors.

DESIGN

Double-blinded (patient and assessor) randomized controlled trial.

SETTING

A university hospital.

PARTICIPANTS

Breast cancer patients (N=50) with pain.

INTERVENTION

The intervention group received a single BTX-A infiltration. The control group received a placebo (saline) infiltration. Within 1 week after the infiltration, all patients attended an individual physical therapy program (12 sessions) during the first 3 months and a home exercise program up to 6 months after infiltration.

MAIN OUTCOME MEASURES

The primary outcome was change in pain intensity at the upper limb (visual analog scale, 0-100) after 3 months. Secondary outcomes were prevalence rate of pain, pressure hypersensitivity, pain quality, shoulder function, and quality of life. Measures were taken before the intervention and at 1, 3, and 6 months' follow-up.

RESULTS

No significant difference in change in pain intensity after 3 months was found (mean difference in change, 3/100; 95% confidence interval [CI], -13 to 19). From baseline up to 6 months, a significantly different change in upper limb pain intensity was found between groups in favor of the intervention group (mean difference in change, 16/100; 95% CI, 1-31).

CONCLUSIONS

A single BTX-A infiltration in combination with an individual physical therapy program significantly decreased pain intensity at the upper limb in breast cancer survivors up to 6 months. However, the effect size was not clinically relevant, and no other beneficial effects were found.

Foot posture in female patients 5 years after breast-conserving surgery: a case-control study

PURPOSE

Along with the improvement in the outcomes of breast cancer treatment being observed in the recent years, long-term studies to assess distant adverse effects of the treatment have become increasingly important. The objective of this study was to assess the foot posture in patients subjected to breast-conserving therapy. The assessment was made 5 years after the surgical procedure.

METHODS

116 female patients (mean age of 58.75 years) were qualified into a case-control study. Foot posture on the operated breast side (F1) as well as on the contralateral side (F2) was evaluated using a computer-based foot analysis tool as an extension of projection moiré-based podoscopic examination. Comparisons were made for the following parameters: limb load, L-foot length, W-foot width, L/W-Wejsflog index, ALPHA-hallux valgus angle, BETA-little toe varus angle, GAMMA-heel angle, KY-Sztriter-Godunov index, CL-Clarke's angle, HW-heel width.

RESULTS

Five years after BCT, patients placed higher load on the foot on the side of the healthy breast (p = 0.0011). No statistically significant differences were observed between F1 and F2 with respect to other foot posture parameters (p > 0.05). No statistically significant differences were observed in foot posture parameters in patients having undergone BCT + ALND (axillary lymph node dissection) procedure as compared to patients subjected to BCT + SLNB (sentinel lymph node biopsy) procedure (p > 0.05).

CONCLUSIONS

No changes in foot posture were observed in patients 5 years after the BCT procedure. The type of the surgical procedure related to the lymph nodes within the axillary fossa has no effect on changes in foot posture.

New approach to evaluate late arm impairment and effects of dragon boat activity in breast cancer survivors

To verify the applicability of a new approach based on the strength curves (SCs) methodology in late arm impairment in breast cancer (BC) survivors and to evaluate the effects of dragon boat (DB) activity on the late regaining of the muscle strength, upper limb impairment, and quality of life in patients undergoing surgery for BC.Retrospective observational study on 64 subjects (54.5 ± 9.7 years), 47 of them had undergone unilateral mastectomy surgery and were evaluated for late arm impairment. A clinical evaluation of the shoulder and compilation of functional assessment (DASH, Rowe, Constant-Murley) and quality of life (SF-36) scales were carried out. Assessment of muscle strength with SC obtained with isometric assessments and serratus anterior muscle test were performed.Differences between the SC are evident between healthy and operated subjects. Among the 3 groups of operated subjects the difference in strength is maximum at 0°. Statistically significant difference was found between operated and nonoperated only in SF-36 scale. No significant difference was found between groups for shoulder instability and winged scapula.The SC can be used in the study of upper limb impairment after surgery for BC: measurements carried out at 1st degrees of the range of motion are more useful for clinicians. DB activity is useful to reduce the late arm impairment.

Changes in shoulder muscle activity pattern on surface electromyography after breast cancer surgery

BACKGROUND AND OBJECTIVES

Alterations in muscle activation and restricted shoulder mobility, which are common in breast cancer patients, have been found to affect upper limb function. The purpose of this study was to determine muscle activity patterns, and to compare the prevalence of abnormal patterns among the type of breast surgery.

METHODS

In total, 274 breast cancer patients were recruited after surgery. Type of breast surgery was divided into mastectomy without reconstruction (Mastectomy), reconstruction with tissue expander/implant (TEI), latissimus dorsi (LD) flap, or transverse rectus abdominis flap (TRAM). Activities of shoulder muscles were measured using surface electromyography. Experimental analysis was conducted using a Gaussian filter smoothing method with regression.

RESULTS

Patients demonstrated different patterns of muscle activation, such as normal, lower muscle electrical activity, and tightness. After adjusting for BMI and breast surgery, the odds of lower muscle electrical activity and tightness in the TRAM are 40.2% and 38.4% less than in the Mastectomy only group. The prevalence of abnormal patterns was significantly greater in the ALND than SLNB in all except TRAM.

CONCLUSIONS

Alterations in muscle activity patterns differed by breast surgery and reconstruction type. For breast cancer patients with ALND, TRAM may be the best choice for maintaining upper limb function.

Participation in water-exercising long-term after breast cancer surgery: Experiences of significant factors for continuing exercising as a part of cancer rehabilitation

Although physical exercising has great benefits, little is known regarding factors of significance for cancer survivors to continue exercising within their rehabilitation. The objective was to describe factors experienced to be of significance for cancer survivors to continue with water-exercising long-term after breast cancer surgery. Women (n = 29) who had undergone breast cancer surgery (mastectomy 79%, axillary surgery 86%, and radiotherapy 86%) for median (md) 13 (25th-75th percentile 3-21.5) was followed up regarding their rehabilitation, arm function Disabilities of Arm Shoulder and Hand (md 14, IQR 7-32), EQ-5D score (md 0.8, IQR 0.73-1.0) and quality of life EQ health barometer (md 80, IQR 64-95). We performed qualitative focus-group interviews regarding the women's views (n = 24). The women had participated in water-exercising 1-46 semesters, md 8 (25th-75th percentile 3-21.5) semesters. Nearly all, 97%, participated in the water-exercising group every week, and 21 (72%) had participated in the water-exercising group at least half of the time since their breast cancer surgery, without complications. The women experienced that factors of significance to continue with water-exercising were the convenience of easily modified weightless exercising in the water, social interaction, and access to a private dressing room. These factors would be important to consider to encourage continuing in exercising.

Evaluation of shoulder girdle strength more than 12 month after modified radical mastectomy and axillary nodes dissection

BACKGROUND

Muscle strength is necessary for upper body normal function. Upper extremity function impairments have been reported in breast cancer (BC) survivors. It is not possible to know precisely if cancer adjuvant therapy such as radiation and chemotherapy had any effect on the unaffected arm. The aim of this study was to compare shoulder girdle strength among women with BC and similarly aged women without cancer.

MATERIALS AND METHODS

Thirty-three postmenopausal women (51 ± 6.46 years) with BC who underwent surgery, chemotherapy, and radiation therapy and 30 healthy postmenopausal women (53.26 ± 5.05 years) were selected. Muscle strength was measured using a handheld dynamometer for flexion, horizontal adduction, internal and external rotation, scapular abduction and upward rotation, scapular depression, and adduction. Data were analyzed by multivariate analysis of variance (P < 0.05).

RESULTS

The findings indicated significant differences between groups of 6 of the shoulder girdle strength measure (flexion (P = 0.003), internal rotation (P = 0.001), external rotation (P = 0.040), scapular abduction and upward rotation (P = 0.001), scapular depression and adduction (P = 0.025), and shoulder horizontal adduction (P = 0.00)). Patients showed significantly lower strength compared with healthy controls (flexion = 34.3%, abd = 64.2%, int.rot = 51.2%, ext.rot = 32.4%, hor.add = 58.06, and depression = 35.2%).

CONCLUSION

The results indicate that the shoulder girdle strength in women with BC decreased compared with healthy women without BC. Therefore, during the treatment of patients with BC, designing of training programs and rehabilitation programs need to be performed on shoulder girdle strength factors in patients undergoing mastectomy with axillary surgery and radiation therapy.

Accessory Joint and Neural Mobilizations for Shoulder Range of Motion Restriction After Breast Cancer Surgery: A Pilot Randomized Clinical Trial

OBJECTIVE

The aim of this study was to assess the methods to conduct a substantive clinical trial to evaluate the effects of accessory joint mobilization (AJM) vs neural mobilization (NM) techniques for shoulder motion restriction after breast cancer surgery.

METHODS

This pilot study was a prospective randomized and double-blind clinical trial in which 18 women who underwent unilateral breast cancer surgery and axillary lymph node dissection participated. The study was conducted at the Women's Health Research Group at the Physical Therapy Department of Alcalá University, Madrid, Spain. The intervention was AJM vs NM, with a 6-month follow-up. Primary outcomes included recruitment, adherence to treatment and retention rates, assessment procedures, and implementation of the 2 manual therapy techniques. Secondary outcomes included range of motion, sensory disturbance, pain, and upper limb functionality.

RESULTS

All participants accepted to be randomly assigned to study groups. One hundred percent retention was attained with all participants attending the 3-month and 6-month assessments. Adherence with treatment attendance was excellent. At 6-month follow-up, flexion range of motion had a mean change of 38.4° (±28.9) (P = .002) in the AJM group and a mean change of 36.8° (±21.8) (P = .002) in the NM group. Abduction range of motion had a median change of 52.4° (±43.6) (P = .004) in AJM group and a median change of 44° (±17.5) (P = .012).

CONCLUSIONS

These preliminary results of the effects of AJM and NM techniques in breast cancer survivors indicate that a full clinical trial will be worthwhile. The research methods tested and the modifications proposed within this pilot study offer a suitable foundation to conduct a substantive clinical trial.

Body Posture After Mastectomy: Comparison Between Immediate Breast Reconstruction Versus Mastectomy Alone

BACKGROUND

Immediate breast reconstruction has been increasingly incorporated as part of breast cancer treatment, especially for the psychological benefits. Currently, there are many options for breast reconstruction surgery, but the impact of the different techniques on body posture has not been widely studied. One study demonstrated that immediate breast reconstruction with a Beker-25 prosthesis could help to preserve body posture after mastectomy; however, there is no evidence regarding the effect of surgery on the body posture of women after breast reconstruction when using autologous tissue.

PURPOSE

The purpose of this paper is to compare the body postures of women who underwent immediate breast reconstruction using an abdominal flap with those of women who underwent mastectomy alone.

DESIGN

This is a cross-sectional study.

SUBJECTS

Seventy-six women diagnosed with breast cancer underwent mastectomy, between 1 and 5 years after the diagnosis, are the participants of the study. Two groups were defined: women who underwent mastectomy and immediate breast reconstruction (n = 38) and women who underwent mastectomy alone (n = 38).

PROCEDURE

To assess body posture, specific anatomical points for obtaining photographs were located and marked in anterior, posterior and right-side and left-side views. The photographs were analysed using Postural Analysis Software/Software de Análise Postural (PAS/SAPO).

RESULTS

In the left lateral view, there was a significant difference in the vertical alignment of the trunk (4.2 vs 3.1; p = 0.05). There were no significant differences between the two groups for the variables in the anterior, posterior or right-side views.

CONCLUSION

Women who underwent mastectomy alone, compared with women who underwent immediate breast reconstruction with abdominal flaps, showed differences in the vertical alignment of the trunk, with greater asymmetry between the acromion and greater trochanter, which can mean trunk rotation. No significant differences were found between the two groups in the alignment of the head, shoulders, scapula, or pelvis. Copyright © 2015 John Wiley & Sons, Ltd.

The impact of an external breast prosthesis on the gait parameters of women after mastectomy

BACKGROUND

An integral part of the recovery process after mastectomy involves the consideration of restorative options, including external prosthesis use; however, only few studies regarding the influence of breast prostheses on functional status have been done.

OBJECTIVE

This study aimed to determine whether wearing an external breast prosthesis affects gait in women after a mastectomy.

METHODS

Spatiotemporal gait parameters were collected in 40 women, postmastectomy, aged 37 to 70 years, divided into age subgroups of 37 to 54 years and 55 to 70 years, and in 38 healthy controls, women aged 38 to 69 years. Gait parameters were assessed with and without the breast prosthesis, including walking velocity, cadence, step length, step time, and left-right step time asymmetry.

RESULTS

Significant differences were found in the gait parameters of the younger age group with and without a prosthesis. No significant differences were found in the women of the older group with and without the prosthesis.

CONCLUSION

Gait parameters of the younger age group were closer to those of the healthy control group when they were wearing an external prosthesis, as compared with when they were not. This suggests a positive influence of breast prosthesis use on the functional status of women after mastectomy.

IMPLICATIONS FOR PRACTICE

Clinical practitioners should be aware of the study results suggesting a positive influence of breast prosthesis use on gait parameters after mastectomy surgery, which could improve the patient's functional status after surgery; however, further research is still needed on factors affecting changes in gait with a larger study population.

Changes in the loadings on the shoulder girdle in the case of scapulothoracic fusion

BACKGROUND

Scapulothoracic fusion (STF) may be an alternative and salvage procedure in the treatment of scapular winging. The biomechanical effects of this procedure on the shoulder girdle have not been previously considered. The purpose of this study is to demonstrate the relationship between STF and the stress distribution pattern of the shoulder girdle.

METHODS

Three-dimensional solid modeling of the shoulder girdle was carried out using virtual finite element modeling. STF was applied to the reference model obtained in a computer environment. Dynamic and nonlinear analysis was performed.

RESULTS

Stress distributions in joints and ligaments were calculated. With respect to loading on the joints, maximum equivalent stresses increased on acromioclavicular (AC) and GH joints in the case of STF during abduction and flexion respectively.

CONCLUSION

Results revealed that STF is a non-physiological, static procedure leading to load increase on GH and AC joint cartilages, which may be a cause of potential joint osteoarthritis. Copyright © 2015 John Wiley & Sons, Ltd.

Effectiveness of postoperative physical therapy for upper-limb impairments after breast cancer treatment: a systematic review

OBJECTIVE

To systematically review the effectiveness of various postoperative physical therapy modalities and timing of physical therapy after treatment of breast cancer on pain and impaired range of motion (ROM) of the upper limb.

DATA SOURCES

We searched the following databases: PubMed/MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, Physiotherapy Evidence Database, and Cochrane. Articles published until October 2012 were included.

STUDY SELECTION

Only (pseudo) randomized controlled trials and nonrandomized experimental trials investigating the effectiveness of passive mobilization, manual stretching, myofascial therapy, and/or exercise therapy and timing of physical therapy after treatment for breast cancer are reviewed. Primary outcomes are pain of the upper limb and/or ROM of the shoulder. Secondary outcomes are decreased shoulder strength, arm lymphedema, limitations in activities of daily living, decreased quality of life, and wound drainage volume. Physical therapy modalities had to be started in the first 6 weeks after surgery.

DATA EXTRACTION

Articles were selected by 2 independent researchers in 3 phases and compared for consensus. First the titles were analyzed, and then the selected abstracts and finally the full texts were reviewed.

DATA SYNTHESIS

Eighteen randomized controlled trials were included in the review. Three studies investigated the effect of multifactorial therapy: 2 studies confirmed that the combination of general exercises and stretching is effective for the treatment of impaired ROM another study showed that passive mobilization combined with massage had no beneficial effects on pain and impaired ROM. Fifteen studies investigated the effectiveness of a single physical therapy modality. One study of poor quality found evidence supporting the beneficial effects of passive mobilization. The only study investigating the effect of stretching did not find any beneficial effects. No studies were found about the effectiveness of myofascial therapy in the postoperative phase. Five studies found that active exercises were more effective than no therapy or information on the treatment of impairments of the upper limb. Three studies supported the early start of exercises for recovery of shoulder ROM, whereas 4 studies supported the delay of exercises to avoid prolonged wound healing.

CONCLUSIONS

Multifactorial physical therapy (ie, stretching, exercises) and active exercises were effective to treat postoperative pain and impaired ROM after treatment for breast cancer. High-quality studies are necessary to determine the effectiveness of passive mobilization, stretching, and myofascial therapy as part of the multifactorial treatment. In addition, the appropriate timing and content of the exercise programs need to be further investigated.

Shoulder morbidity after treatment for breast cancer is bilateral and greater after mastectomy

BACKGROUND

A recent study in our laboratory found significant differences in scapular kinematics between the affected and unaffected sides of women reporting shoulder pain following treatment for breast cancer. An earlier smaller study from our laboratory found reduced muscle activity from four key muscles and an association with greater shoulder pain and disability. The aims of this study were to: correlate altered muscle activity from a larger sample with observed movement deviations; compare within subject movement and muscle deviations in survivors with healthy variation; explore the impact of a mastectomy vs. a wide local excision (WLE) on the observed deviations.

METHOD

Cross-sectional study. One hundred and fifty-five women treated for unilateral carcinoma of the breast and 21 age-matched healthy women were included in the study. All patients filled out the Shoulder Pain and Disability Index (SPADI). Three-dimensional (3D)-kinematic data and EMG muscle activity were recorded during scaption on the affected and unaffected side. The association between kinematic data, EMG data, SPADI and covariates was determined using a two stage, random effects mixed multiple regression technique.

RESULTS

All scapula kinematic and muscle EMG parameters in both arms were altered in breast cancer survivors when compared to healthy participants. Altered movement patterns were different for left vs. right side affected. Mastectomy patients demonstrated greater movement deviations and reported significantly higher levels of pain than WLE patients.

CONCLUSION

Shoulder morbidity is bilateral, greater in patients having a mastectomy and is present for up to six years post-surgery. This study and others now provide ample evidence to support prospective surveillance programmes that can be integrated into Survivorship Programmes.

Early contralateral shoulder-arm morbidity in breast cancer patients enrolled in a randomized trial of post-surgery radiation therapy

INTRODUCTION

Shoulder/arm morbidity is a common complication of breast cancer surgery and radiotherapy (RT), but little is known about acute contralateral morbidity.

METHODS

Patients were 118 women enrolled in a RT trial. Arm volume and shoulder mobility were assessed before and 1-3 months after RT. Correlations and linear regression were used to analyze changes affecting ipsilateral and contralateral arms, and changes affecting relative interlimb differences (RID).

RESULTS

Changes affecting one limb correlated with changes affecting the other limb. Arm volume between the two limbs correlated (R = 0.57). Risk factors were weight increase and axillary dissection. Contralateral and ipsilateral loss of abduction strongly correlated (R = 0.78). Changes of combined RID exceeding 10% affected the ipsilateral limb in 25% of patients, and the contralateral limb in 18%. Aromatase inhibitor therapy was significantly associated with contralateral loss of abduction.

CONCLUSIONS

High incidence of early contralateral arm morbidity warrants further investigations.

Clinical reasoning for a patient with neck and upper extremity symptoms: a case requiring referral

The purpose of this case report is to describe a 56-year old female patient with a bizarre pattern of cervicobrachial symptoms. The patient was managed according to the McKenzie "Mechanical Diagnosis and Therapy" principles and the physical examination alongside the movement testing showed inconsistent findings. Due to the patient's cancer-related medical history, presence of night pain, general weakness and the non-response to treatment, a referral to a medical specialist was immediately made. Imaging studies revealed metastases to the axial skeleton in multiple sites and a metastatic lesion was established as a medical diagnosis. With many physical therapists becoming first-entry providers it is likely that encounters with cases other than the purely musculoskeletal will increase. Serious pathologies can mimic musculoskeletal disorders, confusing even the most experienced therapist and as a result, pernicious and possibly life-threatening disease might easily be missed. This would be crucial especially in cases when the patient should immediately be referred to a medical specialist. Physical therapists should hone their clinical skills not only in treatment aspects but also in screening procedures in order to prompt a referral when it is required.

The effect of yoga on women with secondary arm lymphoedema from breast cancer treatment

Background

Women who develop secondary arm lymphoedema subsequent to treatment associated with breast cancer require life-long management for a range of symptoms including arm swelling, heaviness, tightness in the arm and sometimes the chest, upper body impairment and changes to a range of parameters relating to quality of life. While exercise under controlled conditions has had positive outcomes, the impact of yoga has not been investigated. The aim of this study is to determine the effectiveness of yoga in the physical and psycho-social domains, in the hope that women can be offered another safe, holistic modality to help control many, if not all, of the effects of secondary arm lymphoedema.

Methods and design

A randomised controlled pilot trial will be conducted in Hobart and Launceston with a total of 40 women receiving either yoga intervention or current best practice care. Intervention will consist of eight weeks of a weekly teacher-led yoga class with a home-based daily yoga practice delivered by DVD. Primary outcome measures will be the effects of yoga on lymphoedema and its associated symptoms and quality of life. Secondary outcome measures will be range of motion of the arm and thoracic spine, shoulder strength, and weekly and daily physical activity. Primary and secondary outcomes will be measured at baseline, weeks four, eight and a four week follow up at week twelve. Range of motion of the spine, in a self-nominated group, will be measured at baseline, weeks eight and twelve. A further outcome will be the women’s perceptions of the yoga collected by interview at week eight.

Discussion

The results of this trial will provide information on the safety and effectiveness of yoga for women with secondary arm lymphoedema from breast cancer treatment. It will also inform methodology for future, larger trials.

Trial registration

ACTRN12611000202965

Predictors of functional shoulder recovery at 1 and 12 months after breast cancer surgery

The objective of this study are (1) to determine if upper extremity function, as represented by shoulder ROM, self-reported symptoms and upper extremity functional limitations in activities of daily living could be predictively related to demographic and cancer characteristics post-surgery for breast cancer. And (2) to examine if variables related to early onset impairment contribute to late onset impairments in women after breast cancer surgery. Subjects were assessed preoperatively and 1, 3, 6, 9, and 12+ months post breast cancer surgery for impairments and symptoms and at 12+ months for shoulder functional limitations using a physical therapy surveillance model. Body weight, shoulder ROM, manual muscle testing, and upper limb volume were recorded. At 12+ months, the Harvard Alumni Health Study Physical Activity Questionnaire, and an Upper Limb Disability Questionnaire were administered. Symptoms and ROM impairments were compared by functional limitations. Characteristics significantly associated with early ROM impairment (but not later impairment) were axillary lymph node dissection, removal of ≥15 nodes, mastectomy surgery and stage II breast cancer. Positive nodes, older age, and BMI≥25 were significantly associated with reduced shoulder ROM at 12+ months. At 12+ months, only 10 % of the patients experienced ROM impairments while rates of self-reported symptoms in the affected upper extremity at 12+ months were as follows: pain-49%, weakness-47.1%, numbness-55.9%, feeling tired-42.5%. The majority of patients used the affected upper extremity for reaching without limitation, but ≥35% reported limitation with household chores, carrying and lifting. Difficulty carrying and lifting could be predicted by BMI≥25 and use of the dominant affected upper limb. Different factors are associated with early versus later ROM loss. Symptoms reported by breast cancer survivors are frequently associated with functional limitations in upper extremity tasks and warrant intervention. Physical therapy using a prospective surveillance model of care may reduce severity of ROM loss, symptoms and functional upper extremity limitations 1 year after breast cancer surgery.

Exercise intervention for management of obesity

Obesity touches the lives of most Americans regardless of age. In adults, accrual of co-morbidities, including frank disability, impacts health in ways that mandate aggressive public health action. In children, the rising prevalence of overweight and obesity raises serious prospective concerns for life as these children enter adulthood. Action is imperative to provide medical interventions and preventive strategies to reduce the threat this condition poses to future generations. Obesity primarily results from an energy regulation imbalance within the body; understanding its origin and effects requires considering both the intake (via eating) and output (via moving) of energy. This article focuses on how exercise and physical activity (i.e., energy output) can influence the primary condition of obesity and its health sequelae. Components, strategies, and expected outcomes of exercise and lifestyle activity are addressed. Successful long-term participation in daily movement requires matching exercise regimens and physical activity outlets to individual preferences and environmental conditions. Activity habits of Americans must change at home and in the workplace, schools and the community to positively influence health. Although the goals of Healthy People 2010 to reduce sedentary behavior have not been met, success of other public health interventions (e.g., immunizations, use of bicycle helmets) suggests that social change to alter activity habits can be achieved. Failure to reach our public health goals should serve as a catalyst for broad-based action to help children, adolescents, and adults attain and maintain behaviors that reduce the risk of obesity and its health insults.

Shoulder impairments and their association with symptomatic rotator cuff disease in breast cancer survivors

Over 2.6 million breast cancer survivors currently reside in the United States. While improvements in the medical management of women diagnosed with breast cancer have resulted in a 5-year survival rate of 89%, curative treatments are associated with a high prevalence of shoulder and arm morbidity, which, in turn, can negatively impact a woman's quality of life. Breast cancer survivors frequently experience shoulder and arm pain, decreased range of motion, muscle weakness, and lymphedema. These symptoms can lead to difficulties with daily activities ranging from overhead reaching and carrying objects to caring for family and returning to work. Despite health care professionals awareness of these problems, a significant number of breast cancer survivors are confronted with long-term, restricted use of their affected shoulder and upper extremity. This problem may partially be explained by: (1) an incomplete understanding of relevant impairments and diagnoses associated with shoulder/arm pain and limited upper extremity use, and (2) the limited effectiveness of current rehabilitation interventions for managing shoulder pain and decreased upper extremity function in breast cancer survivors. Because breast cancer treatment directly involves the neuromusculoskeletal tissues of the shoulder girdle, it is understandable why breast cancer survivors are likely to develop shoulder girdle muscle weakness and fatigue, decreased shoulder motion, altered shoulder girdle alignment, and lymphedema. These impairments can be associated with diagnoses such as post-mastectomy syndrome, adhesive capsulitis, myofascial dysfunction, and brachial plexopathy, all of which have been reported among breast cancer survivors. It is our belief that these impairments also put women at risk for developing symptomatic rotator cuff disease. In this paper we set forth the rationale for our belief that breast cancer treatments and subsequent impairments of shoulder girdle neuromusculoskeletal tissues place breast cancer survivors at risk for developing symptomatic rotator cuff disease. Additionally, we identify knowledge gaps related to the current understanding of relevant shoulder girdle impairments and their association with symptomatic rotator cuff disease in breast cancer survivors. Ultimately, information from studies designed to meet these gaps will provide a scientific basis for the development of new, or refinement of existing, examination, intervention, and prevention techniques, which should lead to improved clinical outcomes in this population.