Three-dimensional scapulothoracic motion following treatment for breast cancer

Effects of Intra-Articular Triamcinolone Injection on Adhesive Capsulitis after Breast Cancer Surgery

PURPOSE

To investigate the effects of intra-articular glenohumeral joint triamcinolone injection in treating secondary adhesive capsulitis after breast cancer surgery.

METHODS

This study prospectively enrolled 37 participants, including 22 in the breast cancer surgery group and 15 in the idiopathic group. All participants received intra-articular glenohumeral joint triamcinolone injection in the affected shoulder joint. The clinical outcomes included the Shoulder Pain and Disability Index (SPADI), passive range of motion (PROM), and pain intensity on the Numeric Rating Scale (NRS), which were evaluated before the intervention and 1, 3, and 6 months after. The primary outcome of this study was the mean difference in the total SPADI from baseline to 6 months after the intervention.

RESULTS

The mean differences in the total SPADI scores from baseline to 6 months after the intervention were 36.2 ± 16.4 and 47.9 ± 15.2 in the breast cancer surgery group and the idiopathic group, respectively. There was no significant difference between the two groups (p = 0.1495). However, the improvements in the SPADI pain subscale at the 3- and 6-month follow-up visits (-31.2 vs. -48.8, p = 0.042; -34.1 vs. -50.7, p = 0.0006) and the PROM of abduction at the 3-month follow-up (52.4 vs. 70.3, p = 0.0072) were inferior in the breast cancer surgery group compared to the idiopathic group. There were no adverse events in either group.

CONCLUSION

Intra-articular triamcinolone injection is an effective and safe treatment option for adhesive capsulitis after breast cancer surgery; however, it has less effect than for idiopathic adhesive capsulitis.

Risk Factors for Upper Extremity Impairment after Mastectomy: A Single Institution Retrospective Review

Background

Patients with breast cancer treated with mastectomy are more likely to develop upper extremity dysfunction compared with those treated with breast-conserving therapy. This study aimed to identify cancer and treatment characteristics that may be risk factors for development of upper extremity dysfunction in patients treated with mastectomy.

Methods

The authors performed a retrospective chart review of patients at the University of Chicago who were treated with a unilateral or bilateral mastectomy from 2010 to 2020 and developed upper extremity dysfunction based on International Classification of Disease-10 codes. Patients were analyzed by side of body (left or right). Patient demographics and treatment characteristics were extracted from the electronic medical record.

Results

In total, 259 patients met criteria and were included in our study. A total of 396 upper extremities were recorded as experiencing dysfunction and were analyzed. Mean age was 60 years (range = 28-96), and mean body mass index was 28.4 (SD = 7.5). An estimated 54% of patients underwent breast reconstruction. After multivariable analysis, chronic upper extremity pain was found to be associated with ipsilateral radiotherapy (P < 0.001) and ipsilateral in situ cancer (0.041). Limited range of motion was found to be associated with ipsilateral invasive cancer (P = 0.01), any ipsilateral mastectomy surgery (P < 0.001), and ipsilateral radiotherapy (P = 0.03). Musculoskeletal dysfunction was found to be associated with no ipsilateral modified radical mastectomy (P = 0.033). No oncological or treatment characteristics were found to be associated with decreased strength or adhesive capsulitis. Furthermore, breast reconstruction (implant or autologous tissue based) was not associated with upper extremity dysfunction.

Conclusion

Breast cancer characteristics and treatment modalities may predispose patients treated with mastectomy to developing types of upper extremity dysfunction.

Shoulder proprioception changes in postmastectomy patients: an observational study

PURPOSE

Breast cancer surgery can cause changes in the anatomical structure of the shoulder and in shoulder mobility, leading to the increased possibility of long-term arm morbidity such as lymphedema. This study aims to evaluate the active shoulder joint position sense (AJPS) with and without lymphedema in postmastectomy patients.

METHODS

A total of 66 women, including 22 patients with lymphedema, 22 patients without lymphedema, and 22 healthy controls, were enrolled in the study. Pain severity was evaluated with the Numeric Pain Scale and edema severity was measured with circumferentially at 10 cm intervals. The normal range of motion of the shoulder joint was evaluated with the universal goniometer and the AJPS was assessed by active position repetition testing at 55°, 90°, and 125° shoulder flexion targets using the smartphone application "Clinometer."

RESULTS

AJPS at 55°, 90°, and 125° shoulder flexion target angles with and without lymphedema were different in all target angles compared to healthy controls (p < 0.01). There was a difference between the absolute error value of AJPS at 55° flexion (p < 0.05), and no difference at 90° and 125° flexion between the with and without lymphedema groups (p > 0.05).

CONCLUSION

This study shows that the AJPS was negatively affected in with and without lymphedema postmastectomy patients compared to healthy controls. This result emphasizes the importance of adding personalized methods for the restoration of joint position sense in addition to rehabilitation programs generally applied to the patient group.

Altered upper limb motor behavior in breast cancer survivors and its relation to pain: A narrative review

Breast cancer is the most commonly diagnosed cancer among women and many women suffer from persistent physical and psychological complaints following their cancer treatment. Altered motor behavior at the shoulder region and upper limb, that is, alterations in movement patterns, spatiotemporal movement characteristics and muscle activation patterns, is a common physical consequence of breast cancer treatment, that can have a clear impact on daily life functioning and quality of life. Furthermore, altered upper limb motor behavior is suggested to relate to upper limb pain, which is very commonly reported in breast cancer survivors (BCS). This review, prepared according to the SANRA guidelines, looks into the current understanding of alterations in motor behavior at shoulder and upper limb in BCS, by discussing the factors related to this altered behavior. In this, we specifically focus on the relation between motor behavior and pain. Results of our search show that cancer treatment modality is predictive for shoulder range of motion. Furthermore, single prospective studies show depressive symptoms, living alone, being non-white and low physical activity levels as predicting factors for reduced shoulder range of motion. Pain as factor related to altered motor behavior is only assessed in cross-sectional research, limiting its interpretation in context of being cause or consequence of motor behavioral adaptations, and on the underlying mechanism explaining their relation. It is concluded that studies which explain the mechanisms how and in which subgroup of BCS motor behavioral alterations are associated with pain at the upper limb, are necessary in future.

The prevalence and risk factors for physical impairments in Chinese post-cancer treated breast cancer survivors: a 4 years' cross-sectional study at a single center

The incidence of breast cancer in China was 19.2% in 2018, with a five-year survival rate of up to 80%. The impairments that may result from breast cancer treatment, such as lymphedema, pain, and symptoms related to nerve damage, could have long-term side effects. Its prevalence and symptom profile have been commonly reported in various countries, but such data are rarely available for China. Physical function was assessed in 138 breast cancer survivors (BCSs) in the study. The prevalence of lymphedema (65.9%) was higher than that of pain (31.2%), shoulder range of motion (ROM) restriction (20.3%), grip strength restriction (GSR) (21.7%) and paresthesia (11.6%). These impairments mainly appeared within 28 months after breast cancer diagnosis, but could happen in 10 years. Carcinoma in situ and radiotherapy (RT) were related to the occurrence of lymphedema (respectively B = -1.8, p = 0.003; B = 1.3, p = 0.001). RT and delayed rehabilitation time (DRT) may increase the severity of lymphedema (respectively p = 0.003, p = 0.010). Breast conserving surgery (B = -2.1, p = 0.002) and the occurrence of AWS (B = 3.1, p = 0.006) were related to the occurrence of pain. The occurrence of brachial plexus injury (BPI) (B = 3.1, p < 0.001) and pain (B = 1.9, p = 0.002) improved the occurrence of shoulder ROM restriction. The occurrence of BPI (B = 3.6, p < 0.001) improved the occurrence of GSR. The occurrence of pain (B = 2.1, p = 0.001) improved the occurrence of paresthesia. These findings prompt us to further investigate the actual rehabilitation needs of survivors and the specific barriers to rehabilitation in the following research.

The Importance of the Kinematic Evaluation Methods of the Upper Limbs in Women with Breast Cancer Mastectomy: A Literature Review

The kinematic assessment of the upper limbs in breast cancer (BC) survivors is one of the most common procedures to determine the recovery process after BC surgery. However, the methodology used is heterogeneous, finding various evaluation methods, which makes it difficult to compare results between studies. The objective of this review was to identify the technical features of the kinematic evaluation methods used in patients with mastectomy for BC. A literature review was conducted to search in electronic databases, such as PubMed, ScienceDirect, Clinical Key, Google Scholar, and Scopus. A total of 641 articles were obtained. After screening the title and the summary of the investigations, 20 manuscripts were kept for a deeper analysis. Different methodologies were found for the analysis of the kinematics of the upper limbs. Eight (40%) articles used the optoelectronic system, nine (45%) used the electromagnetic system, and three (15%) used other optoelectronic systems to assess shoulder kinematics. Each investigation studied different variables such as the type of surgery, the evaluation time, the age of the patients, the rehabilitation protocol, and so on. This makes the comparison among studies difficult, and the recovery process of the patients cannot be easily determined. In conclusion, the interpretation of the movement of the upper limbs should be easy to understand for oncologists, physiotherapists, clinicians, and researchers.

Combined effect of graded Thera-Band and scapular stabilization exercises on shoulder adhesive capsulitis post-mastectomy

PURPOSE

The main aim of the trial was to assess the combined impact of graded Thera-Band strengthening exercises and scapular stabilization exercises on shoulder pain, physical function, and quality of life (QoL) in post-mastectomy adhesive capsulitis (AC).

METHODS

Seventy females with unilateral post-mastectomy AC partook in the trial. Participants were subdivided equally into two groups at random. Both groups obtained the traditional physical therapy program; in addition, the intervention group received graded Thera-Band exercises for shoulder muscles and scapular stabilization exercises 5 days a week for 8 weeks. Range of motion (ROM) and muscle power of shoulder were assessed by digital goniometer and handheld dynamometer, respectively. Disability of the Arm, Shoulder, and Hand questionnaire (DASH) was utilized for assessment of shoulder function and visual analogue scale (VAS) for pain measurement while short-form (SF-36) for QoL assessment. All evaluation data was recorded prior to the trial and at the eighth week of interventions for both groups.

RESULTS

All participants achieved improvements in shoulder ROM, muscle power, pain, and all aspects of QoL; however, higher statistical improvements were reported in all measurements with respect to strengthening exercises group (p < 0.001).

CONCLUSION

The addition of graded Thera-Band strengthening exercises and scapular stabilization exercises in post-mastectomy AC rehabilitation program has significant benefits in shoulder function and patients' QoL.

TRIAL REGISTRATION

This study is retrospectively registered at ClinicalTrials.gov NCT05311839.

Forearm Muscle Activity During the Handgrip Test in Breast Cancer Survivors: A Cross-Sectional Study

INTRODUCTION/BACKGROUND

Breast cancer survivors (BCS) frequently show upper limb dysfunctions. The forearm muscle activity measured by surface electromyography (sEMG) in this population has not been studied. This study aimed to describe forearm muscle activity in BCS, as well as to assess its possible relationship with other variables related to upper limb functionality and cancer-related fatigue (CRF).

MATERIALS AND METHODS

A cross-sectional study was carried out including 102 BCS as volunteers at a secondary care in Malaga, Spain. BCS were included if they were aged between 32 and 70 years old, without evidence of cancer recurrence at the time of recruitment. The forearm muscle activity (microvolts, µV) was assessed by sEMG during the handgrip test. The handgrip strength was assessed by dynamometry (kg), the upper limb functionality (%) was measured by the upper limb functional index (ULFI) questionnaire and the CRF was also assessed by revised Piper Fatigue Scale (0-10 points).

RESULTS

BCS reported reduced forearm muscle activity (287.88 µV) and reduced handgrip strength (21.31 Kg), a good upper limb functionality (68.85%), and a moderate cancer-related fatigue (4.74). Forearm muscle activity showed a poor significant correlation (r = -0.223, P = .038) with the CRF. Handgrip strength showed a poor correlation with the upper limb functionality (r = 0.387, P < .001) and age (r=-0.200, P = .047).

CONCLUSION

BCS showed a reduced forearm muscle activity. BCS also presented a poor correlation between forearm muscle activity and handgrip strength. Both outcomes tended to lower values with higher levels of CRF, while preserving a good upper limb functionality.

Polymorphisms in COMT and OPRM1 Collectively Contribute to Chronic Shoulder Pain and Disability in South African Breast Cancer Survivors'

Chronic shoulder pain and disability is a common adverse effect experienced by >40% of breast cancer survivors (BCS). Pain management protocols for acute and chronic pain include the use of opioids and opioid derivatives. Furthermore, pain-modulating genes, such as COMT and OPRM1, have been linked to the aetiology of chronic pain. This study aimed to investigate the association between genetic variants of major pain modulator genes and chronic pain/disability in BCS. Assessment of pain, disability and combined (pain and disability) symptoms were determined using the Shoulder Pain and Disability Index (SPADI). Participants were grouped according to their scores such as no-low (<30%) and moderate-high (≥30%) groups of pain, disability and combined (pain and disability). Genotyping of the COMT rs6269 (A > G), rs4633 (C > T), rs4818 (C > G) and the functional rs4680(G > A) SNPs within the BCS (N = 252) cohort were conducted using TaqMan^® SNP assays. Genotype, allele, haplotype, and allele-allele combination frequencies were evaluated. Statistical analysis was applied, with significance accepted at p < 0.05. The COMT rs4680:A/A genotype was significantly associated with moderate-high pain (p = 0.024, OR: 3.23, 95% CI: 1.33-7.81) and combined (pain and disability) (p = 0.015, OR: 3.81, 95% CI: 1.47-9.85). The rs4680:A allele was also significantly associated with moderate-high pain (p = 0.035, OR: 1.58, 95% CI: 1.03-2.43) and combined (pain and disability) (p = 0.017, OR: 1.71, 95% CI: 1.07-2.71). For the inferred COMT (rs6269 A > G-rs4680 G > A) haplotype analyses, the G-G (p = 0.026, OR: 0.67, 95% CI: 0.38-1.18) and A-A (p = 0.007, OR: 2.09, 95% CI: 0.89-4.88) haplotypes were significantly associated with reduced and increased likelihoods of reporting moderate-high pain, respectively. The inferred A-A (p = 0.003, OR: 2.18, 95% CI: 0.92-5.17) haplotype was also significantly associated with combined (pain and disability). Gene-gene interaction analyses further showed allele-allele combinations for COMT (rs4680 G > A)-OPRM1 (rs1799971 A > G) and COMT (rs4680 G > A)-OPRM1(rs540825 T > A) were associated with reporting pain and combined (pain and disability) symptoms, p < 0.05. The findings of this study suggest that COMT and OPRM1 SNPs play a role in the development of chronic shoulder pain/disability in BCS in a unique South African cohort from the Western Cape.

Tearing down the barriers to exercise after mastectomy: a qualitative inquiry to facilitate exercise among breast cancer survivors

OBJECTIVE

Proper exercise immediately after breast cancer surgery (BCS) may prevent unnecessary physical and psychological decline resulting from the surgery; however, patients' attitude, barriers and facilitators for exercise during this period have not been studied. Hence, this study aims to explore the barriers and facilitators of exercise among patients with breast cancer through multiple interviews immediately after surgery through 4 weeks after BCS.

METHODS

We conducted three in-depth interviews of 33 patients with breast cancer within 1 month after BCS.

RESULTS

We identified 44 themes, 10 codes and 5 categories from interview results. Physical constraints and psychological resistance were identified as the barriers to exercise, while a sense of purpose and first-hand exercise experience were identified as the facilitators of exercise. By conducting the interviews over the course of 4 weeks after surgery, we monitored patterns of changes in barriers and facilitators over time. Overall, our analyses identified that professional intervention based on the time since surgery and the physical state after BCS is essential. The intervention would counteract the overwhelming psychological resistance in the early weeks by developing a sense of purpose in the later weeks.

CONCLUSIONS

We made suggestions for future research and exercise intervention programmes that can benefit breast cancer survivors based on the categories, codes and themes identified in this study.

Self-reported arm and shoulder problems in breast cancer survivors in Sub-Saharan Africa: the African Breast Cancer-Disparities in Outcomes cohort study

Background

Arm and shoulder problems (ASP), including lymphedema, were common among women with breast cancer in high-income countries before sentinel lymph node biopsy became the standard of care. Although ASP impair quality of life, as they affect daily life activities, their frequency and determinants in Sub-Saharan Africa remain unclear.

Methods

All women newly diagnosed with breast cancer at the Namibian, Ugandan, Nigerian, and Zambian sites of the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort study were included. At each 3-month follow-up interview, women answered the EORTC-QLQ-Br23 questionnaire, including three ASP items: shoulder/arm pain, arm stiffness, and arm/hand swelling. We estimated the cumulative incidence of first self-reported ASP, overall and stratified by study and treatment status, with deaths treated as competing events. To identify determinants of ASP, we estimated cause-specific hazard ratios using Cox models stratified by study site.

Results

Among 1476 women, up to 4 years after diagnosis, 43% (95% CI 40–46), 36% (33–38) and 23% (20–25), respectively, self-reported having experienced arm/shoulder pain, stiffness and arm/hand swelling at least once. Although risks of self-reported ASP differed between sites, a more advanced breast cancer stage at diagnosis, having a lower socioeconomic position and receiving treatment increased the risk of reporting an ASP.

Conclusion

ASP are very common in breast cancer survivors in Sub-Saharan Africa. They are influenced by different factors than those observed in high-income countries. There is a need to raise awareness and improve management of ASP within the African setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13058-021-01486-9.

Cognitions and physical impairments in relation to upper limb function in women with pain and myofascial dysfunctions in the late stage after breast cancer surgery: an exploratory cross-sectional study

PURPOSE

Upper limb (UL) function is one of the health outcomes that matters the most for women with breast cancer. However, a better understanding of the factors contributing to UL dysfunctions in the late stage after breast cancer surgery is needed. This study explores associations between impairment-related and cognition-related factors and UL function in women with pain and myofascial dysfunctions at the affected UL region in this late stage after breast cancer surgery.

METHODS

In forty-one women, UL function (dependent variable) was evaluated by the Disabilities of Arm, Shoulder and Hand questionnaire. As independent impairment-related factors, relative excessive arm volume (perimetry), pain intensity (maximum score on the visual analogue scale past week) and humerothoracic elevation and scapular lateral rotation (kinematic analysis) were assessed. As independent cognition-related factors, pain catastrophizing (Pain Catastrophizing Scale) and pain hypervigilance (Pain Vigilance and Awareness Questionnaire) were evaluated. Bi-variable analyses and a stepwise regression analysis were used to explore associations.

RESULTS

A higher pain intensity (r = 0.52; p < 0.001), more pain catastrophizing (r = 0.49; p < 0.001) and more pain hypervigilance (r = 0.40; p = 0.01) were related to more UL dysfunction. Pain intensity (p = 0.029) and pain catastrophizing (p = 0.027) explained furthermore 29.9% of variance in UL function.

CONCLUSIONS

Pain intensity and cognition-related factors are significantly associated with UL function in women with pain and myofascial dysfunctions, indicating the need of assessing pain beliefs in women in the late stage after breast cancer surgery.IMPLICATIONS FOR REHABILITATIONPain intensity and pain-related beliefs, including pain attention and catastrophizing, are related to the severity of upper limb dysfunctions in the late stage after breast cancer surgery.Impairments such as lymphedema and movement restrictions seem not related to upper limb function in the assessed sample.To understand upper limb dysfunctions in the late stage after breast cancer, assessing pain beliefs is needed.

Patient-Reported Shoulder Morbidity and Fatigue among Breast Cancer Survivors: An Insight from a Tertiary Care Cancer Hospital

Context: Breast cancer is the most common cancer in Indian women with an annual mortality of around 87,000. Treatment for breast carcinoma may lead to swelling of the ipsilateral arm, shoulder stiffness, arm pain, and cancer-related fatigue. Very few centers in India have reported the arm and shoulder morbidity treated in their hospitals. Aims: The aim was to evaluate the predictive factors of arm and shoulder morbidity and fatigue among breast cancer survivors. Settings and Design: This was a retrospective analysis based on a prospectively maintained database. Materials and Methods: Early and locally advanced cases of breast cancer patients were screened for the study during 2015–2018. Eligible participants were invited to fill up the predetermined questionnaire, and their demographic and treatment-related information was accrued from a file archive. Follow-up period was estimated from the date of tissue diagnosis to last contact/time of interview. Results: Shoulder stiffness was the most common complaint followed by arm numbness. Obesity and diabetes played a crucial role in most of the morbidities and fatigue. The median fatigue score was 34, and the median time of appearance of lymphedema was 13 months. Modified radical mastectomy and radiotherapy to axilla were statistically significantly (P = 0.04 and 0.01, respectively) associated with greater shoulder stiffness and arm swelling. Conclusions: Obesity, diabetes, type of surgery, the extent of axillary dissection, and radiation plan are the major predictive factors of arm and shoulder morbidity. Further prospective validation is necessary for future breast cancer survivorship programs.

The association of breast cancer-related lymphedema after unilateral mastectomy with shoulder girdle kinematics and upper extremity function

The purpose of this study was to examine the association of breast cancer-related lymphedema on shoulder girdle kinematics and upper extremity function. The study included 67 breast cancer survivors with and without unilateral lymphedema. Individuals were divided into non-lymphedema, moderate and severe lymphedema groups according to the volumetric measurement difference between the affected and unaffected upper extremities. A three-dimensional motion monitor-electromagnetic system was used to analyze scapular movements during the elevation and depression phases of the upper extremity elevation in the scapular plane. Shoulder range of motion was assessed with a digital inclinometer. Upper extremity function was assessed with the 'Disabilities of the Arm, Shoulder, and Hand Questionnaire-Short Form (Quick-DASH)'. The scapular upward rotation was lower for the severe lymphedema group than for the non-lymphedema group in the 90-60-30° depression phases of arm elevation (p < .05). The scapular anterior tilt was higher for the severe lymphedema group than for the non-lymphedema group in the 30° depression phase of arm elevation (p < .05). Shoulder abduction range of motion was the lowest in the severe lymphedema group (p < .05). The non-lymphedema group had the lowest quick-DASH score and the severe lymphedema group had the highest score (p < .05). There were statistically significant moderate associations between the quick-DASH scores and scapular movements in all groups (p < .05). The development, presence and/or severity of lymphedema were associated with impaired shoulder-girdle kinematics and decreased upper extremity function. However, a need exists for longitudinal studies comparing individuals with and without lymphedema and healthy controls.

Evaluation of Late Postural Complications in Breast Cancer Patients Undergoing Breast-Conserving Therapy in Relation to the Type of Axillary Intervention-Cross-Sectional Study

Purpose: The aim of the study was to evaluate posture in patients undergoing breast-conserving therapy (BCT) in relation to the type of surgical intervention to the axilla. Methods: The study was conducted on patients who had undergone breast-conserving surgical treatment for breast cancer 5–6 years earlier. In 54 patients, BCT+ALND (axillary lymph node dissection) was performed, while 63 patients were subjected to BCT+SLND (sentinel lymph node dissection). The control group consisted of 54 females. The study was conducted using digital postural assessment. Results: No statistically significant differences were observed with respect to the parameters between the BCT+SLNB and BCT+ALND groups (p > 0.05). However, the differences were highly significant between the CG (control group) and the studied groups (BCT+ALND, BCT+SLNB) for the following parameters: BETA angle of thoracolumbar spine inclination (p = 0.002), GAMMA angle of thoracic spine inclination (p = 0.0044), TKA (thoracic kyphosis angle) (p < 0.0001) and shoulder level inclination (p = 0.0004). The BCT+ALND patients were characterized by higher dependency of raised shoulder (p = 0.0028) and inferior angle of the scapula (p = 0.00018) on the operated side compared to BCT+SLNB patients. Conclusions: Postural imbalance occurs independent of the type of axillary intervention. Disturbances within the upper torso (abnormal position of shoulders and inferior angles of scapulae) are more pronounced in patients after ALND.

Examining assessment methods of scapular motion: Comparing results from planar elevations and functional task performance

BACKGROUND

Scapular kinematics of breast cancer survivors are most often evaluated during arm elevation. However, known compensations exist during functional task performance. The purpose of this study was to determine if scapular kinematics of breast cancer survivors during arm elevation are related to scapular kinematics during functional task performance.

METHODS

Scapular kinematics of 25 non-cancer controls and 25 breast cancer survivors (split by presence of impingement pain) during arm elevation in 3 planes and 3 reaching and lifting functional tasks were measured. Scapular upward rotation and scapulohumeral rhythm (SHR) at 30° increments of arm elevation were calculated. Between-group differences of upward rotation during arm elevation were evaluated with one-way ANOVAs (p < 0.05). The association of upward rotation angle and SHR during arm elevation and functional tasks was tested with Pearson correlations (p < 0.05).

FINDINGS

Scapular upward rotation was reduced for the breast cancer survivor with pain at lower levels of arm elevation in each plane by up to 7.1° (p = .014 to 0.049). This is inconsistent with functional task results, in which upward rotation decrements occurred at higher levels of arm elevation. Upward rotation angles and SHR during arm elevation had an overall weak-to-moderate relationship (r = 0.003 to 0.970, p = .001 to 0.048) to values from functional tasks. Arm elevation during sagittal plane elevation demonstrated scapular upward rotation that was most closely associated to upward rotation during functional task performance.

INTERPRETATION

Inconsistent relationships suggests that clinical evaluations should adopt basic functional movements for scapular motion assessment to complement simple arm elevations.

Comparison of Shoulder-Arm Complex Pain, Function, and Scapular Dyskinesia in Women With and Without Unilateral Lymphedema After Breast Cancer Surgery

INTRODUCTION

Lymphedema is the most important complication seen after breast cancer surgery. The study aimed to evaluate pain, shoulder-arm complex function, and scapular function in women who developed lymphedema after breast cancer surgery and to compare these with women without lymphedema.

MATERIALS AND METHODS

Fifty women with lymphedema (age, 54.34 ± 9.08 years; body mass index, 30.10 ± 4.03 kg/cm²) and 57 women without lymphedema (age, 53.68 ± 9.41 years; body mass index, 29.0 ± 5.44 kg/cm²) after unilateral surgery for breast cancer were included. Clinical and demographic information was noted. The severity of lymphedema with perimeter measurements (Frustum model), level of heaviness discomfort sensation with a visual analog scale, pain threshold with a digital algometer, shoulder-arm complex functionality with the Disabilities of the Arm, Shoulder, Hand Problems Survey (DASH), and scapular function with observational scapular dyskinesia and lateral scapular sliding tests were assessed. The t test, χ² test, and Mann-Whitney U test were used for analyses.

RESULTS

The follow-up duration after the surgery was 4.24 ± 2.97 years and 3.19 ± 1.76 years, and the upper extremity volume was 2106.65 ± 510.82 cm³ and 1725.92 ± 342.49 cm³ in the lymphedema group and in the no-lymphedema group, respectively. In the lymphedema group, arm-heaviness discomfort, pain threshold levels in the trapezius and deltoid muscles, and DASH scores were worse (P < .05). The rate of scapular dyskinesia (70.0%) and type 2 scapula (32%) in the surgical side was higher in patients with lymphedema.

CONCLUSION

The pain pressure threshold in the trapezius and deltoid muscles, heaviness sensation level, and inadequate upper extremity function are significantly higher in patients with lymphedema, and the scapular dyskinesia rate was higher.

Prevalence and Risk Factors of Adhesive Capsulitis in Asian Breast Cancer Patients Undergoing an Outpatient Community Cancer Rehabilitation Program

OBJECTIVES

To investigate the prevalence and risk factors for adhesive capsulitis in postoperative breast cancer patients up to 5 years after surgery who were attending an outpatient community cancer rehabilitation program, and to determine whether any significant relationship exists between arm lymphedema and adhesive capsulitis.

DESIGN

Cross-sectional observational study.

SETTING

National cancer rehabilitation center.

PARTICIPANTS

Asian women (N=135) who underwent breast surgery and were referred for an outpatient community cancer rehabilitation program.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Presence of adhesive capsulitis, lymphedema.

RESULTS

The prevalence of adhesive capsulitis and lymphedema in this population was 22.2% and 33.3%, respectively. A history of mastectomy (odds ratio [OR], 3.93; 95% confidence interval [CI], 1.23-12.63; P=.021), mastectomy with reconstruction (OR, 2.72; 95% CI, 1.27-30.54; P=.024), and lymphedema (OR, 7.92; 95% CI, 2.73-22.95; P<.001) were found to be significantly associated with adhesive capsulitis on multivariate analysis.

CONCLUSIONS

Adhesive capsulitis and lymphedema are common in breast cancer survivors. The design of cancer rehabilitation programs for breast cancer survivors should include surveillance and management of adhesive capsulitis, especially in the presence of lymphedema.

Effect of Exergaming on Muscle Strength, Pain, and Functionality of Shoulders in Cancer Patients

Objective: To compare the strength of the middle deltoid muscle by means of dynamometry and the Shoulder Pain and Disability Index (SPADI) in participants in treatment for cancer after the practice of an exergaming protocol. Materials and Methods: We conducted a randomized controlled clinical trial. Thirty-eight voluntary participants were divided into two groups: cancer group (n = 19; age = 61.46 ± 8.79 years; body mass index [BMI] = 28.36 ± 4.94 kg/m3) and control group (n = 19; age = 57.62 ± 7.57 years; BMI = 28.06 ± 3.74 kg/m3), and they participated in the study. All participants performed an exergame protocol by using Xbox 360 Kinect® (Microsoft, Redmond) with the game Your Shape Fitness Evolved 2012 two to three times per week for 20 sessions. They were evaluated through the isometric dynamometer in the middle deltoid muscle and the SPADI at three moments: preintervention (EV1), after 10 sessions (EV2), and after 20 sessions (EV3). Results: The cancer group scored higher on both the disability index, in all three evaluations, and the pain index, in EV2 and EV3, when compared with the control group. There was a significant reduction in the disability score in EV2 and EV3 when compared with EV1 in the cancer group, whereas pain was lower in EV2 and EV3 when compared with EV1 in the control group. There were no significant interevaluation or intergroup differences in the maximal isometric voluntary contraction of the deltoid muscle of both upper limbs. Conclusion: At the end of the exergaming, protocol reduced the disability of the shoulder joint of the cancer group and decreased the differences between the groups for disability and pain scores, without changing isometric force.

Electromyographic Analysis of Shoulder Neuromuscular Activity in Women Following Breast Cancer Treatment: A Cross-Sectional Descriptive Study

Certain secondary effects derived from medical treatment in breast cancer can favor the development of alterations in shoulder biomechanics. To the best of our knowledge, persistent peripheral pain as a key factor for the development of neuromuscular activity impairments has not been analyzed. A cross-sectional descriptive study was carried out. A total of 90 women were included and allocated to three groups: (i) 30 women with persistent peripheral pain after breast cancer treatment, (ii) 30 women without pain after breast cancer treatment, and (iii) 30 healthy women. Surface electromyography was employed to measure the onset and amplitude of the muscle activity of three shoulder movements. Statistically significant differences were found in the neuromuscular activity for all the muscles and shoulder movements among women with persistent pain versus healthy women (i.e., amplitude muscle activity variable p < 0.001). Statistically significant differences were also observed in the neuromuscular activity for certain muscles in shoulder movements among women with persistent pain versus women without pain, as well as between women without pain versus healthy women. Therefore, following breast cancer treatment, women showed alterations in their shoulder neuromuscular activity, which were more significant if persistent pain existed. These findings may contribute to developing a selective therapeutic exercise program that optimizes the shoulder neuromuscular activity in women after breast cancer treatment.

The influence of mastectomy and reconstruction on residual upper limb function in breast cancer survivors

PURPOSE

Breast cancer survivorship is common (90% of women survive 5 or more years), but many women are not able to return to full function and well-being after treatment due to functional limitations, persistent pain, and inability to perform daily activities. Since each surgical reconstructive option (e.g., autologous tissue flaps versus implants) can impact shoulder and arm function differently, it is important to understand how shoulder and upper limb strength, mobility, and function are influenced by the type of surgical intervention. Efforts can then focus on prehabiliation strategies to prevent the onset of limitations and on developing rehabilitation protocols that directly target shortcomings.

METHODS

The current paper presents a review summarizing how shoulder and upper limb function may be affected by surgical mastectomy and breast reconstruction.

RESULTS

Mastectomy and breast reconstruction with implants or autologous tissues present different functional outcomes for patients. Each surgical procedure is associated with unique sequelae derived from the tissues and procedures associated with each surgery. Characterizing the specific functional outcomes associated with each surgical approach will promote the development of targeted rehabilitation strategies that can be implemented into a multidisciplinary treatment planning pathway for breast cancer patients.

CONCLUSIONS

Surgical treatments for breast cancer, including mastectomy and breast reconstruction, can have negative effects. Focused efforts are needed to better understand treatment-specific effects so that targeted rehabilitation can be developed to improve patient function, QoL, and ability to return to work and life activities post-breast cancer.

Association between Shoulder Range of Motion and Pain Catastrophizing Scale in Breast Cancer Patients after Surgery

Background

Prolonged survival period as a result of early diagnosis and treatment in breast cancer has increased the importance of postoperative morbidities. The aim of the present study was to investigate the association of pain ca-tastrophizing with shoulder pain in patients with decreased shoulder range of motion in the postoperative period.

Patients and Methods

The present study included 53 patients who underwent surgery due to breast cancer. Patients who had bilateral mastectomy, distant metastases, cervical-cranial originated lesions, patients with problems involving one of the shoulders or upper extremities before the operation, and patients with cognitive impairment, heart failure, or low albumin levels (liver parenchyma disease or renal failure) were excluded. Shoulder range of motion was measured in the postoperative period, and two study groups were established: one with a limited shoulder range of motion level and the other with a normal level. Effects of pain catastrophizing and shoulder pain severity on shoulder range of motion limitation were compared between the two groups.

Results

The average age of 53 female patients who had breast surgery was 52.3 ± 10.5 years. In the group with limited shoulder range of motion, the median pain catastrophizing scale value was 27 (range 5-32) and the shoulder pain severity score was 4 (range 0-8), while in the group with normal shoulder range of motion these values were 11 (range 3-39) and 2 (range 0-6), respectively (p < 0.05). In addition, it was found that factors such as surgical treatment modality and postoperative radiotherapy did not significantly affect shoulder range of motion limitation.

Conclusion

Determining the pain catastrophizing scale of patients and controlling pain in the early postoperative period could have positive effects on shoulder range of motion.

A quantitative comparison of arm activity between survivors of breast cancer and healthy controls: use of accelerometry

PURPOSE

Survivors of breast cancer (BC) on the non-dominant side have more persistent deficits than those with cancer on the dominant limb. What is not known is whether those with BC use their involved upper limbs more, less, or at the same level as women without BC. Accelerometer use offers a quantifiable method to measure activity levels of upper limbs. The purpose of this study was to quantify the activity levels of the non-dominant involved limb among survivors of BC and compare these values to their dominant limb, as well as the non-dominant limb of a control group.

METHODS

Participants (n = 30) were women with unilateral BC on the non-dominant limb, diagnosed between 6 and 24 months prior to data collection, and a matched healthy group of women as controls. Participants completed the following questionnaires: medical and demographics, Brief Fatigue Inventory, Brief Pain Inventory - Short form, Disabilities of the Arm, Shoulder and Hand (DASH), and Beck Depression Index. Participants wore an accelerometer on each wrist during waking hours for 7 days. Arm activity was measured using vector magnitude activity counts extracted from the accelerometers.

RESULTS

There were no significant differences in total vector magnitude activity counts between groups for either limb. Within group dominant to non-dominant comparison was significantly different (p ≤ 0.001). No significant difference in pain was present but significant differences for fatigue (p = 0.002), depression (p = 0.004), and DASH scores (p = 0.035) were present.

CONCLUSIONS

Women with non-dominant BC use their involved limb similar to healthy controls but less than their dominant limb.

Impingement pain affects kinematics of breast cancer survivors in work-related functional tasks

BACKGROUND

Breast cancer survivors may encounter upper limb morbidities post-surgery. It is currently unclear how these impairments affect arm kinematics, particularly during functional task performance. This investigation examined upper body kinematics during functional tasks for breast cancer survivors and an age-matched control group.

METHODS

Fifty women (aged 35-65) participated: 25 breast cancer survivors who had undergone mastectomy and 25 age-range matched controls. Following basic clinical evaluation, including shoulder impingement tests, motion of the torso and upper limbs were tracked during six upper limb-focused functional tasks from which torso, scapular, and thoracohumeral angles were calculated. Between-group differences were evaluated with independent t-tests (p < .05). The breast cancer group was then divided based upon impingement tests and differences between the three new groups were tested with one-way ANOVAs (p < .05).

FINDINGS

Breast cancer survivors had higher disability scores, lower range of motion, and lower performance scores. The largest kinematic differences existed between the breast cancer survivors with impingement pain and the two non-pain groups. During overhead tasks, right peak scapular upward rotation was significantly reduced (d = 0.80-1.11) in the breast cancer survivors with impingement pain. This group also demonstrated trends of decreased peak humeral abduction and internal rotation at extreme postures (d = 0.54-0.78). These alterations are consistent with kinematics considered high risk for rotator cuff injury development.

INTERPRETATION

Impingement pain in breast cancer survivors influences functional task performance and may be more important to consider than self-reported disability when evaluating pain and potential injury development.

Mechanical properties of the shoulder and pectoralis major in breast cancer patients undergoing breast-conserving surgery with axillary surgery and radiotherapy

Breast-conserving surgery (BCS) and radiotherapy reduce breast cancer recurrence but can cause functional deficits in breast cancer survivors. A cross-sectional study quantified the long-term pathophysiological impact of these treatments on biomechanical measures of shoulder stiffness and ultrasound shear wave elastography measures of the shear elastic modulus of the pectoralis major (PM). Nine node-positive patients treated with radiotherapy to the breast and regional nodes after BCS and axillary lymph node dissection (Group 1) were compared to nine node-negative patients treated with radiotherapy to the breast alone after BCS and sentinel node biopsy (Group 2) and nine healthy age-matched controls. The mean follow-up for Group 1 and Group 2 patients was 988 days and 754 days, respectively. Shoulder stiffness did not differ between the treatment groups and healthy controls (p = 0.23). The PM shear elastic modulus differed between groups (p = 0.002), with Group 1 patients exhibiting a stiffer PM than Group 2 patients (p < 0.001) and healthy controls (p = 0.027). The mean prescribed radiotherapy dose to the PM was significantly correlated with passive shear elastic modulus (p = 0.018). Breast cancer patients undergoing more extensive axillary surgery and nodal radiotherapy did not experience long-term functional deficits to shoulder integrity but did experience long-term mechanical changes of the PM.

Mechanical Properties of Muscles around the Shoulder in Breast Cancer Patients: Intra-rater and Inter-rater Reliability of the MyotonPRO

BACKGROUND

Patients with breast cancer typically experience changes in the properties of muscles around the shoulder. However, there is no appropriate evaluation tool for these changes.

OBJECTIVE

The primary objective was to investigate the inter-rater and intra-rater reliability of muscle-related parameters measured by the MyotonPRO, a myotonometer device. The secondary objective was to investigate differences in properties of muscle around the shoulder between the mastectomy side and the other side.

DESIGN

Cross-sectional reliability study.

SETTING

Outpatient clinic in a tertiary care university-affiliated hospital.

PARTICIPANTS

Twenty-two patients with breast cancer who underwent mastectomy.

METHODS

Muscle tone, stiffness, and elasticity of the pectoralis major (PM), sternocleidomastoid (SCM), and upper trapezius (UT) were measured using the MyotonPRO. Rater 1 performed two sets of measurements with a time interval of 30 minutes to determine intra-rater reliability. Rater 2 performed measurements during the interval between the two sets of rater 1. Reliability was assessed using intraclass correlation coefficients (ICCs) and Bland-Altman analysis. A paired t-test was used to compare muscle properties between the affected and unaffected sides.

MAIN OUTCOME MEASUREMENTS

Frequency (tone, Hz), stiffness (N/m), and decrement (elasticity).

RESULTS

Intra-rater reliability was excellent (ICC > 0.75, 0.85-0.98) for all parameters of the PM, SCM, and UT in the affected and unaffected upper limbs of patients with breast cancer. Inter-rater reliability was fair to excellent for all parameters except unaffected PM elasticity (ICC = 0.34). There were significant differences in all parameters of the PM between the affected and unaffected sides. There were no significant differences in the parameters of the SCM and UT between the two sides.

CONCLUSIONS

Our findings indicate that the MyotonPRO device is a feasible tool to quantify PM, UT, and SCM muscle properties (stiffness, tone, and elasticity) in patients with breast cancer.

LEVEL OF EVIDENCE

III.

Comparison of Spinal Alignment and Mobility in Women With and Without Post Modified Radical Mastectomy Unilateral Lymphoedema

INTRODUCTION

Unilateral lymphoedema and breast resection after modified radical mastectomy might create impairment of spinal alignment and mobility. The aim of this study was to compare spinal alignment and mobility in women with and without post modified radical mastectomy unilateral lymphoedema.

MATERIALS AND METHODS

Twenty women with post modified radical mastectomy unilateral lymphoedema (lymphoedema group) and 18 healthy women (control group) were included in this study. The sagittal and frontal spinal alignment and mobility were assessed with a Spinal Mouse (Idiag, Fehraltorf, Switzerland). The severity of the lymphoedema was evaluated with circumferential measurements.

RESULTS

In the lymphoedema group, the volume difference of the arms was 448.31 ± 78.14 mL, known as moderate severity lymphoedema. It was seen that the sagittal thoracic curvature (P = .017) and the frontal inclination angle (P = .048) were higher in the lymphoedema group in comparison with the control group. In the lymphoedema group, the frontal inclination angle changed towards the unaffected side (P < .001). No significant differences were found between groups in the other parameters related to spinal curvature and mobility (P > .05).

CONCLUSION

The sagittal thoracic curvature and the frontal inclination angle towards the unaffected side increased in women with post modified radical mastectomy unilateral lymphoedema. The sagittal and frontal spinal alignment changes should be taken into consideration for the assessment and the treatment of unilateral lymphoedema.

The effectiveness of Botulinum Toxin A for treatment of upper limb impairments and dysfunctions in breast cancer survivors: A randomised controlled trial

OBJECTIVE

To examine the effectiveness of a single Botulinum Toxin A (BTX-A) infiltration in the pectoralis major muscle, in addition to a standard physical therapy (PT) programme on upper limb impairments and dysfunctions after breast cancer treatment.

METHODS

Fifty breast cancer patients with persistent pain 3 months after finishing treatment participated in a double-blinded randomised controlled trial. The intervention group received a single BTX-A infiltration. The control group received a placebo (saline) infiltration. Within one week after the infiltration, all patients attended an individual PT programme (12 sessions) during the first 3 months. Outcome parameters were active shoulder range of motion, upper limb strength, scapular statics and shoulder function. Measures were taken before the intervention, at 1, 3 (i.e. after the intervention) and 6 months follow-up.

RESULTS

No differences between groups were found for all outcome parameters over the course of 6 months. However, overall beneficial effects of the PT for active forward flexion shoulder range of motion and shoulder function were found in both groups.

CONCLUSION

A single Botulinum Toxin A (BTX-A) infiltration in the pectoralis major muscle, in addition to a PT programme cannot be recommended to treat upper limb impairments and dysfunctions after breast cancer treatment.

Effect of breast cancer surgery on chest tightness and upper limb dysfunction

This study aimed to investigate the possible changes in anterior chest tightness after breast cancer surgery. We also try to investigate whether anterior chest tightness is associated with upper-limb dysfunction after breast cancer surgery. Eighty-three women who underwent breast cancer surgery were evaluated before and 2 weeks, 3 months, and 9 months after surgery. Anterior chest tightness was measured using the length of the pectoralis minor muscle through 2 methods (length from the coracoid process to the fourth rib and linear distance from the table to the posterior acromion with supine position). Shoulder range of motion and the K-DASH (Korean version of Disability Arm and Shoulder Questionnaire) score were measured to quantify functional performance of upper limb. Anterior chest tightness of patients with breast cancer significantly increased after surgery. Upper limb dysfunction was observed such as reduced shoulder range-of-motion and increased K-DASH score over time. Increase in chest tightness was correlated with shoulder range-of-motion reduction. Chest tightness was not correlated with K-DASH score directly. However, shoulder range-of-motion reduction was significantly correlated with K-DASH score. Chest tightness and upper limb dysfunction increased in breast cancer survivor. Increase in chest tightness after surgery is associated with upper limb dysfunction and careful attention is required.

KDR inferred haplotype is associated with upper limb dysfunction in breast cancer survivors of mixed ancestry

Introduction: Shoulder pain and disability are well-documented sequelae of breast cancer treatment. Angiogenesis signaling may have a role in the development of shoulder pain or shoulder disability in breast cancer survivors. The aim of this study was to determine if polymorphisms in angiogenesis-related genes are associated with shoulder pain or disability following breast cancer treatment.

Participants and methods: A cross-sectional study was conducted on 220 South African breast cancer survivors. The study aimed to evaluate associations between shoulder pain/disability and seven single nucleotide polymorphisms (SNPs) within five angiogenesis-associated genes: KDR (rs2305948 C>T; rs7667298 C>T), NOS3 (rs1549758 C>T), MMP2 (rs708269 A>T), THBS2 (rs9766678 A>G) and TIMP3 (rs5754312 T>A; rs715572 G>A). In addition, associations between shoulder pain/disability and inferred haplotypes for KDR and TIMP3 SNPs were evaluated. Participants were grouped into no–low and moderate–high shoulder pain/disability based on total pain/disability scores: ≤30 and >30, respectively using the shoulder pain and disability index (SPADI).

Results: No independent associations with shoulder pain/disability categories were found for all SNPs. However, 1 inferred haplotype (KDR “TT”) differed significantly (P=0.014) between the shoulder disability categories. After adjusting for participants’ age, the differences in KDR inferred haplotype frequencies between shoulder disability categories became non-significant (P=0.052).

Conclusion: Our findings provide a preliminary suggestion of a possible association between polymorphisms in genes involved in angiogenesis and the presence of moderate–high shoulder disability among South African breast cancer survivors. A larger prospective cohort study is currently being conducted by our group.

Three-dimensional scapular kinematics, shoulder outcome measures and quality of life following treatment for breast cancer - A case control study

BACKGROUND

There are no conclusive results concerning changes in scapular kinematics associated with upper limb dysfunctions after breast cancer surgery.

OBJECTIVE

To compare the three-dimensional (3-D) scapular kinematics during elevation of the arm between women after breast cancer surgery and controls. Shoulder range of motion (ROM), muscle strength, pain intensity, upper limb function, and quality of life were also assessed.

METHODS

Forty-two women were assigned to two groups (surgery group, n = 21; control group, n = 21). 3-D scapular kinematics was collected during elevation of the arm in the scapular plane. ROM was assessed using a digital inclinometer, muscle strength using a manual dynamometer, pain with the Visual Analogue Scale (VAS), upper limb function with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and quality of life with the 36-item Short-Form Health Survey (SF36).

RESULTS

The surgery group presented decreased scapular upward rotation at 120° of arm elevation in the scapular plane (p < .05; d = -0.88), decreased shoulder external rotation ROM and strength of shoulder abduction and external rotation when the affected side was compared to the non-affected side and control group. Moreover, the surgery group also reported higher pain, increased upper limb disability and poorer quality of life compared with healthy controls.

CONCLUSION

Scapular upward rotation seems to be decreased at 120° of arm elevation in women following breast cancer surgery. In addition, shoulder external rotation ROM, abduction strength, external rotation strength, function, and quality of life are also impaired in these women. They also experienced pain during the studied movements.

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.

Prevalence of shoulder morbidity after treatment for breast Cancer in South Africa

PURPOSE

Breast cancer is the most frequently diagnosed cancer and leading cause of cancer death among women, representing a considerable public health burden in South Africa and other low-middle income countries. Short- and long-term complications of these treatments include shoulder morbidities such as pain, decreased range of motion, tightness, weakness, pain, numbness and lymphoedema and may be present for up to 6 years post-treatment. An understanding of baseline demographic and clinical risk factors can guide rehabilitation and management strategies for high-risk patients. The aims of this study were to quantify the burden of shoulder pain and disability in a tertiary academic hospital in Cape Town, South Africa, and identify potential risk factors for the development of shoulder morbidity.

METHODS

This study was a cross-sectional analysis of the prevalence of shoulder pain and dysfunction in women attending their post-treatment annual follow-up visit for unilateral breast carcinoma.

RESULTS

Three in four patients reported a presence of any pain or disability while only 9% experienced severe pain and disability. Multivariable ordinal logistic regression analysis identified race, side, axillary surgery, chemotherapy and age as significant predictors of pain and chemotherapy a significant predictor of disability.

CONCLUSION

The substantial burden of shoulder morbidity in this population represents a significant public health burden. The use of identified clinical and demographic characteristics may guide in the development of survivorship programmes incorporating surveillance and management of these high-risk patients.

Effect of breast reconstruction modality on the development of postmastectomy shoulder morbidity

BACKGROUND

The aim of this study was to evaluate the impact of breast reconstruction modality on the incidence of shoulder morbidity.

METHODS

Breast cancer patients who underwent immediate reconstructions using three modalities, namely, tissue expander-implant, latissimus dorsi (LD) pedicled flap, and deep inferior epigastric artery perforator (DIEP) flap, from 2008 to 2013 were examined. The cumulative incidence of shoulder morbidity was compared among the reconstruction modalities, and risk factor analysis was performed using multivariable analysis.

RESULTS

A total of 430 reconstructions (223 expander-implant, 44 LD flap, and 163 DIEP flap) in 420 patients were analyzed in this study. Shoulder morbidity developed in 95 patients (22.1%) and was most common in the LD group (43.2%) followed by the expander-implant (23.8%) and the DIEP (14.1%) groups over a mean follow-up of 52 (range: 24-120) months. The multivariable analysis showed that the expander-implant (odds ratio (OR) 2.15, p = 0.010) and the LD flap (OR 6.27, p < 0001) were significant risk factors for shoulder morbidity, compared to the DIEP flap. Old age (p = 0.041), presence of tumor-positive lymph nodes (p = 0.014), and receiving neoadjuvant chemotherapy (p = 0.002) were independent risk factors for the development of shoulder morbidity. Early rehabilitation within 2 postoperative-months reduced the risk of sustained shoulder morbidity.

CONCLUSION

The choice of reconstruction modality might affect the development of postmastectomy shoulder morbidity. Understanding the risk factors for shoulder morbidity would help to improve the informed consent process and assist surgeons in the early diagnosis and initiation of rehabilitation therapy to prevent chronic shoulder dysfunction after breast reconstruction.

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.

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.

Quantification of upper limb electromyographic measures and dysfunction of breast cancer survivors during performance of functional dynamic tasks

BACKGROUND

Upper limb morbidities within the breast cancer population can interfere with completing daily life activities. Current knowledge of upper limb capabilities is limited; previous increases in muscle activation on the affected cancer side suggest this population works at a higher fraction of their capability. The purposes of this study were to describe upper limb capabilities and dysfunction of breast cancer survivors through muscle activation monitoring via surface electromyography and muscle-specific strength tests during functional tasks.

METHODS

Fifty survivors performed 88 dynamic tasks (divided into range of motion-reach or rotate, activities of daily life and work tasks). Muscle activation was examined for functional and strength testing tasks.

FINDINGS

Total muscle effort (summation of integrated electromyography across measured muscles) was up to 5.1% greater on the affected side during work tasks (p=0.0258). Increased activations existed in posterior deltoid, supraspinatus, upper trapezius and serratus anterior (p<0.05) for several tasks, including daily living tasks. Reduced activation occurred in affected pectoralis major sternal during all tasks (p<0.0001-0.0032), and affected infraspinatus in all but daily living tasks (p=0.0002-0.0328). The affected side infraspinatus, supraspinatus and upper trapezius muscles demonstrated significant reductions in targeted strength testing (p=0.0001-0.0057).

INTERPRETATION

Both primary and secondary muscles (outside surgery and radiation fields) were affected. In general, this population works at higher levels of muscle effort for the affected side yet demonstrates weakness in strength testing, which may reflect tissue damage. Strengthening exercises for the posterior rotator cuff and upper trapezius may be the most beneficial.

The potential role of angiogenesis in the development of shoulder pain, shoulder dysfunction, and lymphedema after breast cancer treatment

Shoulder morbidity is a well-documented sequela of breast cancer treatment, which includes various manifestations such as pain, reduced range of motion, and lymphedema, among others. The multifactorial nature of such morbidities has long been appreciated, and research on reliable risk predictors of development thereof still continues. Previous studies have demonstrated the potential of different types of physical therapy to treat such shoulder problems, and the integration of such interventions into routine care for breast cancer survivors is a requirement in most high-income countries. Although patients at risk for developing shoulder problems would most likely benefit from posttreatment physical therapy, currently, there is no gold standard for identifying this patient group. This is particularly important in low- and middle-income countries where scarce monetary resources need to be directed specifically to those most in need. Modulators of the angiogenesis pathway have been implicated in noncancer shoulder conditions such as rotator cuff disease, adhesive capsulitis, and tendon injuries. The present review summarizes the role of angiogenesis in the development of shoulder morbidity among breast cancer survivors and sets forth the rationale for our belief that angiogenesis signaling may help explain a proportion of the reported clinical variability noted in the development of shoulder pain and dysfunction and upper-limb lymphedema after breast cancer treatment.

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.

Reproducibility of isometric shoulder protraction and retraction strength measurements in normal subjects and individuals with winged scapula

BACKGROUND

The strength of the shoulder protractors and retractors may be compromised in individuals with winged scapula (IwWS). However, no standard approach to measuring the strength of these muscles has been described. The aim of this study was to study the intra-rater and inter-rater reproducibility of a fixed-base isometric dynamometer and to describe cutoff scores for clinically meaningful change for protraction and retraction isometric strength.

METHOD

Twice during a week, 20 normal subjects and 20 IwWS were tested by 2 independent raters.

RESULTS

IwWS were significantly weaker (P < .001) than control subjects in their protraction and retraction isometric strength. Excellent intra-rater and inter-rater correlations were obtained in most combinations, leading to low cutoff scores for meaningful change expressed in terms of the smallest real difference.

CONCLUSION

When it is properly used, the technique described in this paper is recommended as an effective clinical tool for the quantitative assessment of protraction and retraction isometric strength, both for status determination and for monitoring of change in IwWS during and after rehabilitation.

Differences in Scapular Orientation Between Standing and Sitting Postures at Rest and in 120° Scaption: A Cross-Sectional Study

BACKGROUND

Scapular orientation may be influenced by static body posture (sitting and standing) and contribute to the development of shoulder pain. Therefore, a consistent body posture should be considered when assessing scapular orientation as well as enhancing optimal scapular positioning.

OBJECTIVE

To determine whether there are differences in scapular orientation between standing, neutral sitting, and habitual sitting, while adjusting for spinal posture.

DESIGN

A single group randomized repeated measures study.

SETTING

University laboratory.

PARTICIPANTS

Twenty-eight participants with shoulder pain were recruited from the community.

METHODS

Scapular orientation between standing and seated positions was compared, with the arm by the side and at 120° of glenohumeral scaption. Thoracic kyphosis and lumbar lordosis angles were used as covariates.

MAIN OUTCOME MEASUREMENTS

Scapular elevation, lateral translation, upward rotation, and posterior tilt.

RESULTS

Scapular orientation was marginally but significantly different between sitting postures for lateral translation (mean 0.5 cm; 95% confidence interval [95% CI] 0.2-0.7 cm); P < .001), upward rotation (mean 3°; 95% CI 1.1-5.0°; P < .001), and posterior tilt (mean 2.3°; 95% CI 0.2-4.3°; P = .009) in the arm by side position. A small-but-significant difference between standing and neutral sitting was found for upward rotation (mean 1.8°; 95% CI 0-3.7°; P = .02), and between standing and habitual sitting for lateral translation (mean 0.6 cm; 95% CI 0-1.1 cm; P =.02) in the arm by side position.

CONCLUSIONS

The results of this study suggest that scapular orientation can be slightly affected by body posture, although the clinical relevance is uncertain. To enhance scapular upward rotation or posterior tilt, it may be preferable to place the patient in neutral sitting.

LEVEL OF EVIDENCE

Not applicable.