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

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.

Short-term effects of a new resistance exercise approach on physical function during chemotherapy after radical breast cancer surgery: a randomized controlled trial

BACKGROUND

Approximately 30% of post-operative breast cancer patients develop shoulder joint movement disorders affecting routine upper limb movement. This study discusses the impact of a neuromuscular joint facilitation (NJF) method on the physical function of breast cancer patients experiencing shoulder dysfunction during chemotherapy after radical surgery.

METHODS

This study included 162 female patients who have unilateral breast cancer in a cancer hospital in China. They developed shoulder joint mobility disorders during chemotherapy within 1-3 months postoperatively. These patients were divided into three groups: NJF, conventional rehabilitation (conventional group), and control groups. The clinical examination included the maximum passive and active range of motion (ROM) of the shoulder (flexion, extension, abduction, adduction, and external and internal rotation). Other evaluations included a pain score using a visual analog scale (VAS), grip strength, and supraspinatus muscle thickness. All tests were evaluated pre-and post-intervention.

RESULTS

The NJF group showed a significant increase in all shoulder ROM angles post-intervention. In the conventional group, all other ROM values increased significantly, except passive external rotation ROM. In the control group, all other ROM values increased significantly, except passive and active external rotation ROM. All three groups had decreased VAS scores, increased grip strength, and supraspinatus muscle thickness post-intervention during active abduction. In the control group, the supraspinatus contraction rate decreased significantly at 60° and 90° abduction post-intervention compared to that at pre-intervention.

CONCLUSION

This study revealed that NJF during chemotherapy had positive clinical intervention effects, improving shoulder joint mobility disorders, pain, grip strength, and external rotation following radical breast cancer surgery.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry; https://www.chictr.org.cn/ (ChiCTR2300073170), registered (03/07/2023).

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.

Immobilization, Lymphedema, and Obesity are Predictive Factors in the Development of Adhesive Capsulitis in Breast Cancer Patients

OBJECTIVE

 Adhesive capsulitis is a condition characterized by shoulder pain and stiffness. Breast cancer treatment has been linked to the development of this condition, but its mechanisms are still little known. This study's objective was to identify predictors factors associated with the development of adhesive capsulitis in breast cancer patients.

METHODS

 A case control study was performed with women undergoing treatment for breast cancer in a single center. The sampling was nonprobabilistic and consecutive. Adhesive capsulitis was defined as constant pain associated with decreased active and passive shoulder movement in anterior elevation, external rotation at 0°/90° abduction, and internal rotation at 90° abduction. The study group consisted of patients with shoulder pain and range of motion limitations, while the control group consisted of women without any shoulder abnormalities. Sociodemographic and clinical variables were collected. A univariate logistic regression was used to assess the influence of variables on the studied outcome. For p < 0.20, a multivariate logistic regression was used. The probability of null hypothesis rejection was 5%.

RESULTS

 A total of 145 women were assessed, with 39 (26.9%) on the study group and 106 (73.1%) on the control group. The majority was under 60 years old. In the multivariate analysis, variables correlated to the outcome under study were shoulder immobilization (OR = 3.09; 95% CI: 1.33-7.18; p = 0.009), lymphedema (OR = 5.09; 95% CI: 1.81-14.35; p = 0.002), and obesity (OR = 3.91; 95% CI: 1.27-12.01; p = 0.017).

CONCLUSION

 Lymphedema, postsurgery immobilization, and obesity are predictive factors for the development of adhesive capsulitis in breast cancer patients.

The effects of the mirror therapy on shoulder function in patients with breast cancer following surgery: a randomized controlled trial

PURPOSE

Shoulder dysfunction is one of the most bothersome questions for breast cancer survivors. Studies show that mirror therapy can improve shoulder function in patients with a limited shoulder range of motion and shoulder pain. Here, this article reports the results of a randomized controlled trial investigating the effects of the mirror therapy on shoulder function in patients with breast cancer following surgical treatments.

METHODS

Totally, 79 participants were divided to two groups receiving active range-of-motion upper limb exercise based on the mirror therapy or active range-of-motion upper limb exercise respectively for 8 weeks. Shoulder range of motion, Constant-Murley Score, Disabilities of Arm, Shoulder, and Hand Questionnaire, Tampa Scale of Kinesiophobia, Visual analog scale, and grip strength were measured at baseline (T0), 2 weeks (T1), 4 weeks (T2), and 8 weeks (T3). The effects of the intervention on shoulder function were analyzed in generalized estimation equation, from group, time, and the interactions between group and time based on the data from participants who completed at least one post-baseline observation RESULTS: At least one post-baseline observation was performed by 69 participants (n=34 mirror group, n=35 control group). 28(82.35%) participants in the mirror group adhered to the exercise compared to 30(85.71%) in the control group. Generalized estimation equation model showed group had main effects on forward flexion (Waldχ²=6.476, P=0.011), with the Cohen's d=0.54. The effects of the group on abduction, Constant-Murley Score, and Disabilities of Arm, Shoulder, and Hand Questionnaire were significant when fix the effects of the time. At 8 weeks, participants in the mirror group showed an improvement in abduction compared to the control group (P=0.005), the Cohen's d was 0.70. At 8 weeks, participants in the mirror group had a higher Constant-Murley Score than control group (P=0.009), with Cohen's effect size value of d=0.64. The mirror group showed a greater improvement on the Disability of Arm, Shoulder, and Hand Questionnaire than control group at 2 weeks, 4 weeks, and 8 weeks (P≤0.032), but with a weak effect size value of all (r≤0.32). Group had main effects on Tampa Scale of Kinesiophobia (Waldχ²=6.631, P=0.010), with the Cohen's effect size value of d=0.56.

CONCLUSIONS

Mirror therapy improved shoulder flexion, abduction, shoulder function in daily life, and arm function and symptom of the affected shoulder in patients with breast cancer following surgical treatment, while decreasing fear of movement/(re)injury. Mirror configuration needs to be improved in further research to increase its feasibility.

IMPLICATIONS FOR CANCER SURVIVORS

Breast cancer survivors can try mirror therapy as a practical and effective method in shoulder rehabilitation for a promotion on effects.

TRIAL REGISTRATION

ClinicalTrial.gov Identifier: ChiCTR2000033080.

Effect of a 1-year tailored exercise program according to cancer trajectories in patients with breast cancer: study protocol for a randomized controlled trial

BACKGROUND

Patients with breast cancer undergo various treatments according to their tumor subtype and cancer stages within 1 year after being diagnosed. Each treatment may cause treatment-related symptoms that have negative impacts on patients' health and quality of life (QoL) The symptoms can be mitigated when exercise interventions are appropriately applied to patients' physical and mental conditions. Although many exercise programs were developed and implemented during this period, the effects of tailored exercise programs according to symptoms and cancer trajectories on patients' long-term health outcomes have not yet been fully elucidated. Therefore, this randomized controlled trial (RCT) aims to investigate the effect of tailored home-based exercise programs on short-term and long-term physiological outcomes in patients with breast cancer.

METHODS

This 12-month RCT includes 96 patients with (stages 1-3) breast cancer randomly assigned to the exercise or control groups. Participants in the exercise group will receive an exercise program tailored to their phase of treatment, type of surgery, and physical function. During post-operative recovery, exercise interventions will be emphasized to improve shoulder range of motion (ROM) and strength. During chemoradiation therapy, exercise intervention will focus on improving physical function and preventing loss of muscle mass. Once chemoradiation therapy is completed, exercise intervention will focus on improving cardiopulmonary fitness and insulin resistance. All interventions will be home-based exercise programs supplemented with once-monthly exercise education and counseling sessions. The main outcome of the study is fasting insulin level at baseline, 6 months, and 1 year post-intervention. Our secondary outcomes include shoulder ROM and strength at 1 month and 3 months, body composition, inflammatory markers, microbiome, QoL, and physical activity levels at 1 month, 6 months, and 1 year post-intervention.

CONCLUSION

This trial is the first tailored home-based exercise oncology trial to better understand the comprehensive phase-dependent short- and long-term effects of exercise on shoulder function, body composition, fasting insulin, biomarkers, and microbiome. The results of this study will inform the development of effective exercise programs tailored to the needs of patients with breast cancer post-operatively.

TRIAL REGISTRATION

The protocol for this study is registered with the Korean Clinical Trials Registry (KCT0007853).

Shoulder arthroplasty after prior external beam radiation therapy: a matched cohort analysis

BACKGROUND

External beam radiation therapy (XRT) is a commonly used therapeutic modality for the treatment of various chest wall and axillary malignancies. Despite the known risk of local soft tissue dysfunction, and possibly compromised bone ingrowth for cementless implants, there remains limited data on the impact of prior XRT in a shoulder arthroplasty (SA) cohort. This study evaluated the outcomes of primary SA in patients with prior XRT compared to a matched cohort (MC).

METHODS

Over a 27-year time period (1993-2020), 80 primary SAs (7 hemiarthroplasties [HAs], 29 anatomic total shoulder arthroplasties [aTSAs], and 44 reverse shoulder arthroplasties [rTSAs]) with previous XRT to the upper chest or axillary region and a minimum of 2-year follow-up were included. This cohort was matched (1:2) according to age, sex, body mass index (BMI), implant, and year of surgery with patients who had undergone HA or TSA for osteoarthritis or RSA for cuff tear arthropathy. Clinical outcomes including pain, active shoulder range of motion (ROM), strength, complications, and reoperations inclusive of revision surgery were assessed.

RESULTS

The XRT cohort consisted of 71 (88.8%) women with a mean age of 70.9 (range, 43-87) years, BMI of 30.9 ± 7.6, and follow-up period of 6.6 years (range, 2.0-28.2). In these patients, SA led to substantial improvements in pain, ROM, and strength across the entire cohort. When compared to the MC, the XRT group demonstrated a lower final postoperative forward elevation (FE) (111° vs. 126°; P = .013) and less improvements in pain (5.3 vs. 6.2; P = .002), FE (34° vs. 54°; P = .002), and external rotation (13° vs. 24°; P < .001). There were 14 (17.5%) complications and 7 reoperations in the XRT group, with rotator cuff failure after HA or TSA (n = 4 of 36; 11.1%) as the most common complication and no instances of loose humeral components. The XRT group had a higher rate of complications (17.5% vs. 8.1%; P = .03) but not reoperations (8.8% vs. 3.1%; P = .059). When evaluated by implant, rTSA demonstrated the lowest rate of reoperations followed by aTSA and HA (2.3% vs. 10.3% vs. 42.9%; P = .002).

CONCLUSIONS

Primary SA is an effective treatment modality for the improvement of pain, motion, and strength in patients with a history of prior XRT. However, when compared to patients without prior XRT, less clinical improvement and a higher rate of postoperative complications were observed.

Changes in pectoralis major stiffness and thickness following radiotherapy for breast cancer: A 12-month follow-up case series

Radiotherapy (RT) is a common and often essential treatment for breast cancer, but has been associated with pectoralis major (PM) muscle fibrosis and atrophy. In an initial prospective evaluation, we assessed muscle stiffness and muscle thickness of the sternocostal and clavicular regions of the PM with ultrasound shear wave elastography and B-mode imaging. Changes in PM muscle stiffness and thickness following RT can be detected within the first twelve months of RT completion. These parameters may potentially be useful for screening of patients who would benefit from post-RT physical therapy. Further studies with larger sample sizes that include patients who receive nodal radiation are necessary to confirm these findings.

Evidence of rotator cuff disease after breast cancer treatment: scapular kinematics of post-mastectomy and post-reconstruction breast cancer survivors

BACKGROUND

Breast cancer survivors may be at risk of experiencing rotator cuff disease after treatment. Biomechanical alterations following surgery potentially predispose survivors to develop this disorder.

OBJECTIVE

To examine scapular kinematics in breast cancer survivors with and without impingement pain during an overhead reach task.

DESIGN

A cross-sectional study.

METHODS

Three surgery groups were included: non-cancer controls, mastectomy-only survivors and post-reconstruction survivors. Breast cancer survivor groups were also categorized by the presence of impingement pain. Scapular motion was tracked during an overhead reach task, performed separately by both arms. Maximum scapular internal rotation, upward rotation and tilt were calculated. Two-way analyses of variance with interactions (p < .05) were used to test the effects of group (control, mastectomy-only, reconstruction) and impingement pain (pain, no pain) on each variable within a (left/right) side.

RESULTS

Scapular kinematics varied with the group by pain interaction. On the right side, the mastectomy-pain group had reduced upward rotation, while the reconstruction-pain group had higher upward rotation (mastectomy-only: 22.9° vs. reconstruction: 31.2°). On the left side, the mastectomy-pain group had higher internal rotation, while the reconstruction-pain group had reduced internal rotation (mastectomy-only: 45.1° vs. reconstruction: 39.3°). However, time since surgery was longer in the mastectomy-pain group than reconstruction-pain group, suggesting there may be a temporal component to kinematic compensations.

CONCLUSIONS

There are kinematic alterations in breast cancer survivors that may promote future development of rotator cuff disease. Compensations may begin as protective and progress to more harmful alterations with time.KEY MESSAGESScapular kinematics varied with surgery and pain interaction: upward rotation was lower and internal rotation higher in mastectomy-pain group, while upward rotation was higher and internal rotation lower in reconstruction-pain group.Kinematics alterations may also be associated with time since surgery, as the mastectomy-pain group had longer time since surgery than the reconstruction-pain group.Kinematic alterations may transition from protective to harmful over time.In-depth analyses by reconstruction type are needed to determine surgery-specific effects on kinematics and their potential impact on the development of rotator cuff disease.

The synergistic effect of physical activity and nutrition to improve the quality of life in breast cancer patients: a systemic review

PURPOSE

Medical recommendations for balanced control of exercise, physical activity, and nutritional intake after breast cancer diagnosis remain unclear. Therefore, this review aims to summarize effective exercise methods and dietary opinions by reviewing clinical trial results.

METHODS

We systematically reviewed studies that evaluated 1) the relationship between exercise methods and quality of life improvement in patients with breast cancer and 2) the recommendations for physical activity, exercise, nutrition, and potential ways to improve life after breast cancer. To conduct this literature review, we searched the PubMed database for articles published until October 1, 2022, using the terms "physical activity OR exercise," "breast cancer," and "nutrition." After a primary review of the retrieved articles, we included clinical trials in this systematic review.

RESULTS

We hypothesized that physical activity improves the quality of life after the onset of breast cancer, suggesting that a balanced approach to aerobic exercise and resistance exercise increases the efficacy of anticancer treatment. From a nutritional point of view, it is recommended that both physical activity and diet management are necessary for patients with breast cancer.

CONCLUSION

Customized exercise and diet can help with weight loss, the reduction of cancer-induced fatigue, the regulation of hormonal changes, the reduction of inflammatory factors, and the improvement of mental health and vitality. Understanding the integrated mechanisms of physical activity and nutritional balance will improve the quality of life of patients with breast cancer. Therefore, it is necessary to continuously advance exercise programs and develop an alimentary balance control program.

The role of physical arm function and demographic disparities in breast cancer survivors’ ability to return to work

Purpose

Ability to return to work (RTW) is an important aspect of breast cancer that is limited for many survivors. With 90% survivorship in the USA, it is imperative that focus shifts toward the improvement of physical arm function to improve survivors’ ability to RTW. This narrative review discusses the role of physical arm function and demographic disparities in breast cancer survivor RTW.

Methods

Literature on physical function, arm function, and demographic disparities following breast cancer treatment and their implications for RTW is discussed.

Results

The ability to RTW is a key component of recovery for breast cancer survivors, but challenges and inequalities persist. Treatment effects can induce and prolong functional disability, affecting survivors’ ability to RTW. These effects may be compounded for survivors whose occupation requires physical arm function. The RTW landscape, including the occupations survivors have, the physical function required for job tasks, and availability of workplace accommodations, is also unclear. Additional demographic disparities (e.g., income, live in rural area) exist, but the extent to which these factors influence RTW is not well understood. More work is needed to understand the compounded impact of treatment effects, demographic disparities, and occupational factors on RTW. Multidisciplinary rehabilitation that includes occupational counseling and exercise is a promising approach, but widespread adoption in the US healthcare model presents an ongoing challenge. Areas for further research are highlighted.

Conclusion

There is an incomplete understanding of the effects of treatment on physical arm function and the role of demographic disparities on breast cancer survivor RTW.

Effects of Ultrasound-Guided Injection Combined with a Targeted Therapeutic Exercise in Breast Cancer Women with Subacromial Pain Syndrome: A Randomized Clinical Study

In this randomized controlled study, we aimed to assess the effects of US-guided injections of the subacromial bursa followed by a personalized rehabilitation program for breast cancer (BC) survivors. We assessed patients with subacromial pain syndrome without tendon lesions and with a history of post-surgical non-metastatic BC. Thirty-seven patients were enrolled and randomly assigned 1:1 to receive US-guided corticosteroid injections combined with a personalized rehabilitation program (Group A; n: 19) or US-guided corticosteroid injections alone (Group B; n: 18). The primary outcome was pain relief, assessed using a numerical pain rating scale (NPRS). The secondary outcomes were muscle strength, shoulder function, and quality of life. No major or minor late effects were reported after the multidisciplinary intervention. Statistically significant within-group differences were found in terms of NPRS (p ≤ 0.05) in both groups. No significant between-group differences were reported after one week. However, the between-group analysis showed significant differences (p ≤ 0.05) after three months of follow-up in terms of pain intensity, muscle strength, shoulder function, and quality of life. Our findings suggested positive effects of a multidisciplinary approach including US-guided corticosteroid injections combined with a personalized rehabilitation program in improving pain intensity and quality of life of BC survivors with subacromial pain syndrome.

The impact of local therapies for breast cancer on shoulder muscle health and function

Advances in breast cancer treatment have improved patient survival but have also created complications, such as shoulder morbidity, impacting the patient's quality of life. Local therapies for breast cancer influence shoulder muscle health through changes to the muscular microenvironment, macroscopic muscle morphology, and neuromuscular function. Our findings suggest both surgery and radiation therapy compromise the healthy functioning of shoulder musculature. Mastectomy and post-mastectomy breast reconstruction directly affect shoulder function through muscle morphology and neuromuscular function alterations. Radiation therapy damages satellite cells and myocytes, causing cell death both during treatment and years after recovery. This damage creates an environment limited in its ability to prevent atrophy. However, research to date is limited to a small number of analyses with small experimental populations and a lack of control for covariates. Future research to uncover the pathophysiological mechanisms underlying shoulder morbidity after breast cancer treatment must integrate measures of shoulder muscle health and shoulder function.

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.

The impact of external beam radiation therapy on shoulder surgical outcomes: a case series study

HYPOTHESIS

External beam radiation therapy (XRT) is a commonly used treatment adjunct in patients with breast cancer and is known to cause soft tissue dysfunction. However, data on XRT as a preoperative risk factor for shoulder surgery is limited. The purpose of this study was to assess whether prior history of breast cancer treated with XRT has an impact on surgical complications or outcomes. We hypothesize that patients treated with XRT will have a higher rate of surgical complications and lower outcomes.

METHODS

A 20-year retrospective chart review across a large, academic health care system was performed. Inclusion criterion comprised any patient with history of breast cancer of the upper-outer or axillary region treated with XRT. Patients also must have undergone a surgical procedure to the ipsilateral shoulder with at least 1-year postoperative follow-up. Patients were stratified by demographics, hand dominance, and surgery type. Postoperative outcomes including range of motion (ROM) and visual analog scale (VAS) scores for pain were also collected.

RESULTS

Eighteen patients were identified (100% female) with an average age of 66.3 years (standard deviation 10.5 years). Ten shoulders underwent rotator cuff repair (RCR), 4 total shoulder arthroplasty (TSA), 3 reverse shoulder arthroplasty (RSA), and 1 arthroscopic superior labrum anterior to posterior (SLAP) repair. Four patients treated with RCR (40%) experienced postoperative complications related to their procedure. These included scapular winging, adhesive capsulitis, stiffness, and one retear. Two patients treated with shoulder arthroplasty (28.6%) experienced postoperative complications that included lymphedema and periprosthetic fracture following a mechanical fall in one RSA patient and periprosthetic infection in a TSA patient. ROM across all groups improved, most significantly in forward flexion and internal rotation among RCR patients (P < .001). Furthermore, a statistically significant improvement in VAS scores was achieved in each group (6.2 ± 2.14 preoperation, 1.06 ± 1.75 postoperation; P < .001).

CONCLUSION

When compared to national averages, complication rates in our cohort were higher (40% vs. 10%-17% in RCR patients and 28.6% vs. 4%-14% in arthroplasty patients). On further scrutiny, many of these complications were independent of a history of XRT and many resolved with appropriate therapy. Most importantly, functional outcomes as measured by ROM and pain scores showed appropriate improvement consistent with normal populations without history of XRT. Thus, our results suggest that performing shoulder surgery after ipsilateral XRT for breast cancer is likely safe and may offer improved pain and ROM compared to forgoing surgery without necessarily increasing the risk for postoperative complication.

Changes in shoulder outcomes using ultrasonographic assessment of breast cancer survivors: a prospective longitudinal study with 6-month follow-up

This study aimed to describe changes in supraspinatus tendon thickness, acromiohumeral distance, and the presence of fluid in the subacromial bursa as measured by ultrasound, as well as shoulder range of motion and strength, perceived shoulder disability, and health-related quality of life in women before and after breast cancer treatment. Women who underwent surgery for unilateral breast cancer who did not suffer from shoulder pain or difficulty performing activities of daily living in the 6 months prior to surgery were included. One pre-surgical (A0) and three post-surgical assessments at 7-10 days (A1), 3 months (A2), and 6 months (A3) after surgery were carried out. The thickness of the supraspinatus tendon on the affected side decreased between post-surgical (A1) and 6-month (A3) follow-up assessments (p = 0.029), although the minimal detectable change was not reached. The active range of motion of the affected shoulder decreased after surgery. Strength changes were observed in both shoulders after surgery. The intensity of shoulder pain increased between post-surgical and 6-month follow-up assessments. Shoulder function was decreased at the post-surgical assessment and increased throughout the follow-ups. Health-related quality of life declined after surgery. A trend of decreasing thickness of the supraspinatus tendon of the affected shoulder was observed. Detecting these possible structural changes early would allow for early or preventive treatment.

Signs of Central Hypersensitivity, Stress, and Anxiety following Treatment for Breast Cancer: A Case Control Study

Background

With treatment for breast cancer, women treated may present significant sensory abnormalities in the upper extremity. However, there are no conclusive studies that have evaluated pressure pain thresholds (PPT) in the shoulder of postoperated women for breast cancer. The aim of this study was to compare PPT in the shoulder, stress, anxiety, depression symptoms, and quality of sleep among postoperated women for breast cancer (PO group) and asymptomatic women of shoulder pain (control group).

Methods

40 women participated (n = 20, PO group, age: average ± standard deviation, 49.2 ± 8.3 years; body mass index (BMI): 27.5 ± 3.0 kg/cm²; surgery time: 22.2 ± 34.4 months; n = 20, control group, 46.9 ± 8.1 years; BMI: 26.8 ± 3.5 kg/cm²). The PPT was evaluated with a digital algometer at 32 points in the shoulder region and one control point in the tibialis anterior. Stress, anxiety, and depression were evaluated with the Depression, Anxiety and Stress Scale 21 (DASS-21) and the quality of sleep by the Pittsburgh Sleep Quality Index.

Results

Significant differences were observed over 1.5 kgf/cm² in 33 points evaluated (p < 0.01) with a small to high effect size (Cliff's delta range = 0.16; 0.92) and higher levels of anxiety and stress in the PO group (anxiety: median [first; third quartile], 5[3; 12.5]; stress: 9.7 ± 4.7 (7.8; 11.8)) in comparison with the control group (anxiety: 2.5[1; 4.8]; stress: 6.7 ± 3.31 (5.2; 8.3), (p < 0.05)). No significant differences were found between the groups in depression and sleep quality (p > 0.05).

Conclusion

Postoperated women for breast cancer present hyperalgesia in the shoulder anterior and posterior region, low PPT in the tibialis anterior, and higher levels of stress and anxiety compared to the control group.

A Targeted Approach to Post-Mastectomy Pain and Persistent Pain following Breast Cancer Treatment

Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.

Effect of different rehabilitation training timelines to prevent shoulder dysfunction among postoperative breast cancer patients: study protocol for a randomized controlled trial

Introduction

Due to advancements in treatment, the survival of breast cancer (BC) patients has significantly improved. Improving the postoperative quality of life has become a widespread concern for patients and doctors. At present, the staged rehabilitation training program for postoperative BC patients has been recognized. However, there is not yet a consensus about the optimal time to initiate rehabilitation training. We designed this study to investigate the optimal intervention times for postoperative BC patients to begin different stages of rehabilitation.

Design

This is a randomized controlled trial. Female participants with BC who are scheduled to undergo mastectomy, including unilateral total breast or breast-conserving surgery plus axillary lymph node dissection, will be enrolled in this study. The intervention includes the following: 200 participants will be allocated using a 1:1:1:1 ratio to the A, B, C, and D groups, which have four different rehabilitation timelines for four phases of rehabilitation exercises. A therapist will evaluate the patient’s overall health and then adjust the training intensity before initiating training. The assessments include upper limb mobility, grip, limb circumference, postoperative drainage volume (PDV), and pain. The training will last for 12 weeks, and patients will undergo follow-up twice within 6 weeks after discharge. Outcomes include the following: Constant-Murley Score (CMS) is the primary parameter. European Organization Research and Treatment of Cancer Quality of Life Questionnaire-BR23 (EORTC QLQ-BR23), SF-36, range of motion (ROM), strength, grip, circumference, PDV, and pain are the secondary parameters. All enrolled subjects will be assessed at 1 day, 3 days, 1 week, and 2, 3, 6, 9, 12, and 18 weeks after the surgery.

Discussion

This is a randomized controlled trial to evaluate the effect of different rehabilitation training timelines to prevent shoulder dysfunction among postoperative patients with BC. If the results are confirmed, this study will establish an optimal timeline for postoperative BC rehabilitation.

Trial registration

ClinicalTrials.gov NCT03658265. Registered on September 2018.

Estimating Muscle Forces for Breast Cancer Survivors During Functional Tasks

Breast cancer survivors have known scapular kinematic alterations that may be related to the development of secondary morbidities. A measure of muscle activation would help understand the mechanisms behind potential harmful kinematics. The purpose of this study was to define muscle force strategies in breast cancer survivors. Shoulder muscle forces during 6 functional tasks were predicted for 25 breast cancer survivors (divided by impingement pain) and 25 controls using a modified Shoulder Loading Analysis Module. Maximum forces for each muscle were calculated, and 1-way analysis of variance (P < .05) was used to identify group differences. The differences between maximum predicted forces and maximum electromyography were compared with repeated-measures analysis of variance (P < .05) to evaluate the success of the model predictions. Average differences between force predictions and electromyography ranged from 7.3% to 31.6% but were within the range of previously accepted differences. Impingement related pain in breast cancer survivors is associated with increased force of select shoulder muscles. Both pectoralis major heads, upper trapezius, and supraspinatus peak forces were higher in the pain group across all tasks. These force prediction differences are also associated with potentially harmful kinematic strategies, providing a direction for possible rehabilitation strategies.

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.

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.

Patient-reported pain and other symptoms among breast cancer survivors: prevalence and risk factors

OBJECTIVE

To investigate the prevalence and risk factors associated with chronic pain and other symptoms related to breast cancer 6 months after surgery.

METHODS

In an observational study of 261 female breast cancer survivors treated between January 2017 and January 2018, patients were asked about their pain symptoms using a questionnaire that utilized the Numeric Rating Score (NRS) and the Douleur Neuropathique Score (DN4) for neuropathic pain; it also addressed phantom sensations and functional disorders on the ipsilateral shoulder. A total of 218 women completed the survey.

RESULTS

A total of 105 patients (48.17%) reported chronic pain. Of these, 64% rated the pain with an NRS of 1-3 and 35% with an NRS >3. Neuropathic pain was reported in 65% of the sample, phantom sensations in 12%, disorders of shoulder function in 16%, and web syndrome in 2%. Multivariable analyses showed that chronic pain (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.094-5.942; p < 0.05) and neuropathic pain (OR, 2.988; 95% CI, 1.366-6.537; p < 0.05) were positively associated with surgical adverse events; phantom sensations were statistically associated with the weight of removed breast tissue (OR, 1.003; 95% CI, 1.001-1.005; p < 0.05).

CONCLUSIONS

Our study highlights the need to employ specific tools capable of detecting different kinds of chronic pain after breast cancer surgery to improve pain prevention and treatment. Surgical complications and the weight of removed breast tissue emerged as 2 of the risk factors for chronic and neuropathic pain development in breast cancer survivors.

Cancer Rehabilitation:: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 2

Cancer affects millions of individuals, and approximately half will develop functional impairments. Cancers that commonly, either from direct effects or from its treatments, result in functional impairments include breast, head and neck, brain, and spinal cord tumors. There is a plethora of potential impairments including pain, spasticity, dystonia, weakness, and neurogenic bowel or bladder. This article reviews the functional impairments frequently encountered in breast, head and neck, brain, and spinal cord tumors. The authors also discuss management and treatment options incorporated in comprehensive cancer rehabilitation to address these impairments to maximize and maintain function and quality of life.

Late locoregional complications associated with adjuvant radiotherapy in the treatment of breast cancer: Systematic review and meta-analysis

This systematic review with meta-analysis addressed late locoregional complications associated with adjuvant radiotherapy (RT) in breast cancer. Among 2120 titles, ten comparative studies in patients undergoing surgery vs surgery and radiotherapy reporting complications were evaluated. RT was associated with an increased risk of capsular contracture and decreased the mobility of the upper limb. A borderline association of lymphedema risk using RT was noted in the random-effects model but was significant in the fixed-effects model.

The Physiotherapy Intervention for Shoulder Pain in Patients Treated for Breast Cancer: Systematic Review

Pain and joint dysfunction of the upper limb following treatment for mammary carcinoma are defined as the most frequent side effects of surgery for mammary carcinoma by calculating a prevalence range in the USA that varies between 12% and 51% with regard to pain and between 1.5% and 50% for joint dysfunction. This objective of this study was to describe physiotherapy interventions that demonstrate efficacy based on the type of pain present in patients with shoulder pain who have been treated for breast cancer. We conducted a search for relevant publications in the last 10 years (2009-2019) on the PubMed, Medline, CINAHL, and Cochrane databases. The articles obtained were selected on the basis of correlation criteria, with themes concerning shoulder pain after mammary carcinoma and physiotherapy performed to treat this pain. Studies suggest treating musculoskeletal pain through active exercises, joint and tissue mobilization techniques, with accessory joint mobilization and neurodynamics performed by experienced physiotherapists. In order to treat radio-induced and drug-induced neuropathic pain, both aerobic and strengthening exercises are supervised by an experienced physiotherapist and carried out twice weekly for a total of 150 minutes of exercise. Finally, the treatment suggested to deal with chronic pain uses a multidisciplinary approach, including pain education interventions, pharmacological interventions, psychological interventions, and physiotherapy interventions. To conclude. the classification of different types of shoulder pain following mammary carcinoma treatments requires specific and targeted physiotherapy interventions in which active therapeutic exercise has a central role.

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 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.

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.

Effectiveness of myofascial release after breast cancer surgery in women undergoing conservative surgery and radiotherapy: a randomized controlled trial

PURPOSE

The scars derived from the treatment of breast cancer lead to adverse effects such as fibrosis or retractions of the connective tissue. Myofascial release (MR) seeks to reduce restrictions of the fascial system. Therefore, the aim of this study was to analyze the clinical impact of MR treatment on women survivors of breast cancer.

METHODS

We enrolled 24 women with breast cancer, 13 received myofascial release treatment (MR) and 11, a placebo manual lymphatic drainage treatment (PMLD). Both interventions were administered over a period of 4 weeks. The outcomes studied were pain, shoulder range of motion (ROM), functionality, quality of life (QoL), and depression, immediately after treatment and 1 month later.

RESULTS

After 4 weeks of treatment, only the participants who received MR experienced a significant decrease in pain intensity in the short and midterm (p < 0.05). This therapy also achieved a general improvement in ROM (p < 0.05), except for internal rotation, that persisted 1 month after treatment. Regarding functionality, both therapies achieved the level of significance (p < 0.05), but only MRG sustained the improvement in the midterm. General QoL, assessed with FACT-B, and its physical well-being dimension were significantly improved after MR implementation (p < 0.05), while the emotional dimension and the breast cancer subscale improved only with PMLD (p < 0.05).

CONCLUSIONS

In conclusion, an MR-based treatment shows physical benefits (i.e., overall shoulder movement, functionality, and perceived pain) in women after breast cancer surgery.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov NCT03182881.

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.

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.

Living with chronic pain: perceptions of breast cancer survivors

PURPOSE

Breast cancer treatments may lead to chronic pain. For some breast cancer survivors (BCS), this experience can develop into the perception of living with chronic pain. The majority of BCS are postmenopausal and have hormone receptor-positive (HR+) breast cancer requiring aromatase inhibitors (AIs). Neither the prevalence nor risk factors associated with the perception of living with chronic pain among this population are well defined.

METHODS

We conducted a cross-sectional survey among postmenopausal, HR+ BCS who previously took or were currently taking AIs. The primary outcome was patients' perception of living with chronic pain over the past 6 months. We measured pain and demographic and clinical variables. Multivariable logistic regression analysis was performed to evaluate risk factors associated with the perception of chronic pain.

RESULTS

Among 1280 participants, 167 (13%) reported having the perception of living with chronic pain before their breast cancer diagnosis; 426 (34%) reported this perception after completion of non-hormonal cancer treatment. Seventy-eight percent of BCSs reported experiencing at least one type of treatment-related pain within the past 7 days, with 23% experiencing at least three types. The most common types of pain were AI-induced musculoskeletal pain (49%) and pain at the surgery or radiation site (31%). Younger age (< 56), BMI > 25, and the perception of living with chronic pain before diagnosis were risk factors associated with the perception of living with chronic pain.

CONCLUSIONS

One in three postmenopausal, HR+ BCS considered themselves to be living with chronic pain. Effective interventions to reduce chronic pain are needed.

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.

Physiotherapeutic approach and functional performance after breast cancer surgery

Abstract Introduction: Surgery for breast cancer can impair range of motion (ROM) and functionality of upper limb (UL). Objective: To compare ROM and functional performance of homolateral UL after physiotherapeutic approach and to correlate these variables. Methods: A non-randomized clinical trial study enrolled 33 women who were submitted to mastectomy or quadrantectomy associated with axillary lymphadenectomy. ROM was assessed by homolateral UL and contralateral limb (control) goniometry. Functional performance was assessed by “Disability of arm, shoulder and hand” (DASH) questionnaire. The protocol consisted in 10 sessions (3 sessions per week during 60 minutes), involving passive mobilization of glenohumeral and scapulothoracic joint, soft tissue mobilization, neck muscles and upper limb muscles stretching, exercises in all planes of motion, applied alone or in combination. Weight bearing exercise with elastic bands and dumbbells from 0.5 to 1.0 kilograms were also applied. Results: There was a meaningful increase in ROM of all movements after physiotherapy; however, flexion, abduction and lateral rotation remained lower than control limb. DASH score decreased significantly from 28.06 ± 16.1 to 15.71 ± 10.7 (p = 0.001) meaning an improvement in functional performance of UL. No correlation was observed between ROM and DASH. Conclusion: Functional performance and ROM, after 10 physiotherapy sessions, improved significantly, however, a long-term follow-up can contribute to further improvement.

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.

A Pilot Randomized Controlled Trial on the Effects of a Progressive Exercise Program on the Range of Motion and Upper Extremity Grip Strength in Young Adults With Breast Cancer

BACKGROUND

The diagnosis of breast cancer in young women (aged 18-45 years) has been increasing. Women are commonly left coping with treatment-related disabilities of the upper limb that can persist for > 2 years postoperatively.

PATIENTS AND METHODS

A total of 59 young breast cancer patients (29 in the intervention group and 30 in the control group) participated in a pilot prospective randomized controlled trial to determine whether a 12-week postradiation exercise program would improve long-term arm mobility, pain, and handgrip strength. During an 18-month period, range of motion, handgrip strength, and pain with shoulder movements were evaluated at 6 points.

RESULTS

Although the differences were not statistically significant, external rotation and horizontal abduction of the shoulder improved in the intervention group immediately after the exercise intervention (3 months) and showed a trend toward less pain on movement. However, at 18 months after radiation the control and intervention groups both retained a residual loss of range and persistent pain with movement. Radiation to the axilla and/or chest wall yielded long-term (18 months) limitations in flexion and horizontal abduction compared with hypofractionation, which resulted in greater flexion and external rotation at 18 months. The median grip strength of the study participants corresponded to the 10th percentile of healthy aged-matched white women.

CONCLUSION

The exercise intervention timed shortly after radiation improved short-term shoulder mobility and pain; however, these gains were not sustained at 18 months after radiation.

Effects of Clinical Pilates Exercises on Patients Developing Lymphedema after Breast Cancer Treatment: A Randomized Clinical Trial

OBJECTIVE

The aim of the present study was to compare the effects of clinical Pilates exercises with those of the standard lymphedema exercises on lymphedema developing after breast cancer treatment.

MATERIALS AND METHODS

The study comprised 60 female patients with a mean age of 53.2±7.7 years who developed lymphedema after having breast cancer treatment. The patients were randomized into two groups: the clinical Pilates exercise group (n=30), and the control group (n=30). Before, and at the 8th week of treatment, the following parameters were measured: the severity of lymphedema, limb circumferences, body image using the Social Appearance Anxiety Scale, quality of life with the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ-BR23), and upper extremity function using the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure. Both groups performed one-hour exercises three days a week for 8 weeks.

RESULTS

After treatment, the symptoms recovered significantly in both groups. Reductions in the severity of lymphedema, improvements in the social appearance anxiety scale scores, quality of life scores, and upper extremity functions scores in the clinical Pilates exercise group were greater than those in the control group. Clinical Pilates exercises were determined to be more effective on the symptoms of patients with lymphedema than were standard lymphedema exercises.

CONCLUSIONS

Clinical Pilates exercises could be considered a safe model and would contribute to treatment programs.

A feasibility study to determine the benefits of upper extremity virtual rehabilitation therapy for coping with chronic pain post-cancer surgery

BACKGROUND

Persistent pain in shoulder and arm following post-surgical breast cancer treatment can lead to cognitive and physical deficits. Depression is also common in breast cancer survivors. Virtual reality therapy with integrative cognitive and physical rehabilitation has not been clinically trialed for this population. The novel BrightArm Duo technology improved cognition and upper extremity (UE) function for other diagnoses and has great potential to benefit individuals coping with post-surgical breast cancer pain.

OBJECTIVES

The aim of this study was to explore the feasibility of BrightArm Duo therapy for coping with post-surgical chronic pain and associated disability in breast cancer survivors with depression.

METHODS

BrightArm Duo is a robotic rehabilitation table modulating gravity loading on supported forearms. It tracks arm position and grasping strength while patients play three-dimensional (3D) custom integrative rehabilitation games. Community-dwelling women (N = 6) with post-surgical breast cancer pain in the upper arm trained on the system twice a week for 8 weeks. Training difficulty increased progressively in game complexity, table tilt and session length (20-50 minutes). Standardized assessments were performed before and after therapy for pain, cognition, emotion, UE function and activities of daily living.

RESULTS

Subjects averaged upwards of 1300 arm repetitions and 850 hand grasps per session. Pain intensity showed a 20% downward trend (p = 0.1) that was corroborated by therapist observations and participant feedback. A total of 10 out of 11 cognitive metrics improved post-training (p = 0.01) with a significant 8.3-point reduction in depression severity (p = 0.04). A total of 17 of 18 range of motion metrics increased (p < 0.01), with five affected-side shoulder improvements above the Minimal Clinically Important Difference (8°). In all, 13 out of 15 strength and function metrics improved (p = 0.02) with lateral deltoid strength increasing 7.4 N on the affected side (p = 0.05).

CONCLUSION

This pilot study demonstrated feasibility of using the BrightArm Duo Rehabilitation System to treat cancer survivors coping with upper body chronic pain. Outcomes indicate improvement in cognition, shoulder range, strength, function and depression.