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

Chronic Pain Following Breast Reconstruction: A Scoping Review

BACKGROUND

Breast cancer survival rates have increased significantly, underscoring the importance of enhancing long-term health-related quality of life. Breast reconstruction following mastectomy has emerged as a common approach that contributes to improved health-related quality of life. Nonetheless, chronic pain following breast reconstruction is a prevalent issue that has a negative impact on overall well-being.

METHODS

To examine recent findings on chronic pain after breast reconstruction and progress in pain management, we performed a review of the literature through independent searches using the MEDLINE database within NIH National Library of Medicine PubMed.

RESULTS

The review suggested that autologous reconstruction causes chronic postsurgical pain, especially at specific donor sites, whereas implant-based reconstruction does not seem to increase the risk of chronic pain. Moreover, certain operational and patient factors are also associated with chronic pain. Appropriate pain management can reduce chronic pain and prevent the transition from acute to chronic pain.

CONCLUSION

This scoping review evaluated the characteristics of long-term chronic pain after breast reconstruction. The findings provide patients with important treatment information and will assist with their decision on their preferred treatment.

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 effect of myofascial and physical therapy on trunk, shoulder, and elbow movement patterns in women with pain and myofascial dysfunctions after breast cancer surgery: Secondary analyses of a randomized controlled trial

INTRODUCTION

Secondary upper limb dysfunctions are common after breast cancer treatment. Myofascial treatment may be a valuable physical therapy modality for this problem.

OBJECTIVE

To investigate the effect of myofascial therapy in addition to physical therapy on shoulder, trunk, and elbow movement patterns in women with pain and myofascial dysfunctions at the upper limb after breast cancer surgery.

DESIGN

A double-blinded randomized controlled trial.

SETTING

Rehabilitation unit of a university hospital.

PARTICIPANTS

Forty-eight women with persistent pain after finishing breast cancer treatment.

INTERVENTIONS

Over 3 months, all participants received a standard physical therapy program. The experimental (n = 24) and control group (n = 24) received 12 additional sessions of myofascial therapy or placebo therapy, respectively.

MAIN OUTCOME MEASURES

Outcomes of interest were movement patterns of the humerothoracic joint, scapulothoracic joint, trunk, and elbow, measured with an optoelectronic measurement system during the performance of a forward flexion and scaption task. Statistical parametric mapping (SPM) analyses were used for assessing the effect of treatment on movement patterns between both groups (group × time interaction effect).

RESULTS

A significantly decreased protraction and anterior tilting was found after experimental treatment. No beneficial effects on movement patterns of the humerothoracic joint, trunk, or elbow were found.

CONCLUSION

Myofascial therapy in addition to a 12-week standard physical therapy program can decrease scapular protraction and anterior tilting (scapulothoracic joint) during arm movements. Given the exploratory nature of these secondary analyses, the clinical relevance of these results needs to be investigated further.

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.

Prehabilitation in Patients With Breast Cancer Receiving Neoadjuvant Therapy to Minimize Musculoskeletal Postoperative Complications and Enhance Recovery (PREOPtimize): A Protocol for a Randomized Controlled Trial

OBJECTIVE

The aim of this study is to assess the effects of a prehabilitation program (PREOPtimize), consisting of Nordic Walking and resistance training exercises plus health education among patients with breast cancer, who are receiving neoadjuvant therapy to enhance postoperative functionality of the affected arm. A secondary aim will be to compare the short-term effects of the intervention on other patient-reported outcome measures.

METHODS

This will be an assessor-blind, randomized controlled trial with a parallel group design conducted at a tertiary hospital. A sample of 64 patients with breast cancer scheduled for surgery and undergoing neoadjuvant chemotherapy will be recruited for the trial and randomly allocated to either (1) a prehabilitation program consisting of 2 weekly sessions of 75 minutes of Nordic Walking, muscle strengthening exercises, and health education sessions conducted between the fourth month of treatment and surgery or (2) usual care. Patients in both groups will be assessed at baseline, before surgery, and at 1 and 3 months after surgery. Assessed outcomes include functionality of the affected arm (QuickDash), arm volume, range of motion, handgrip strength, pain, fatigue, functional capacity, physical activity levels, and health-related quality of life. Adherence to the intervention in the prehabilitation group and adverse events will also be recorded.

IMPACT

Prehabilitation for patients affected by breast cancer is rarely implemented in clinical practice. The results obtained with the PREOPtimize trial could show that prehabilitation is a feasible intervention for patients with breast cancer receiving neoadjuvant therapy that might enhance postoperative recovery of upper arm function as well as improve overall physical performance and health-related quality of life.

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.

Shoulder Kinematics of Axillary Web Syndrome in Women Treated for Breast Cancer

OBJECTIVE

To better understand how the shoulder moves in breast cancer survivors with axillary web syndrome (AWS), we compared 3-dimensional (3D) shoulder kinematics during shoulder elevation among breast cancer survivors with and without AWS 5 years postoperatively. Although research consistently shows decreased shoulder range of motion with AWS, we do not understand the underlying biomechanics.

DESIGN

Nested case control study.

SETTING

University Academic Breast Center.

PARTICIPANTS

Twenty-five women who had surgery 5 years previously for unilateral breast cancer with the removal of at least 1 lymph node participated in this study (N=25). Twelve participants had AWS; 13 women did not have AWS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Three-dimensional shoulder kinematic data during shoulder forward flexion, scapular plane abduction, and coronal plane abduction were collected using 3D electromagnetic motion tracking. Kinematic data were extracted at 30°, 60°, 90°, and 120° of arm elevation for scapular upward rotation, internal rotation, and posterior tilt as well as for glenohumeral external rotation.

RESULTS

Women with AWS demonstrated 15.2° less scapular upward rotation at 120° humerothoracic elevation (95% confidence interval [-25.2, -5.2], P=.005), regardless of plane. No significant between-group differences were found for any other angle of scapular upward rotation, nor for scapular internal rotation, scapular posterior tilt, or glenohumeral axial rotation at any angle.

CONCLUSIONS

Five years after surgery for breast cancer, women diagnosed with AWS have altered scapulohumeral kinematics that may place them at an increased risk of shoulder pain based on existing kinematic literature in healthy cohorts. This information can help guide rehabilitation programs for breast cancer survivors to facilitate pain-free upper extremity function after treatment.

Towards precision pain medicine for pain after cancer: the Cancer Pain Phenotyping Network multidisciplinary international guidelines for pain phenotyping using nociplastic pain criteria

Pain after cancer remains underestimated and undertreated. Precision medicine is a recent concept that refers to the ability to classify patients into subgroups that differ in their susceptibility to, biology, or prognosis of a particular disease, or in their response to a specific treatment, and thus to tailor treatment to the individual patient characteristics. Applying this to pain after cancer, the ability to classify post-cancer pain into the three major pain phenotypes (i.e. nociceptive, neuropathic, and nociplastic pain) and tailor pain treatment accordingly, is an emerging issue. This is especially relevant because available evidence suggests that nociplastic pain is present in an important subgroup of those patients experiencing post-cancer pain. The 2021 International Association for the Study of Pain (IASP) clinical criteria and grading system for nociplastic pain account for the need to identify and correctly classify patients according to the pain phenotype early in their treatment. These criteria are an important step towards precision pain medicine with great potential for the field of clinical oncology. Within this framework, the Cancer Pain Phenotyping (CANPPHE) Network, an international and interdisciplinary group of oncology clinicians and researchers from seven countries, applied the 2021 IASP clinical criteria for nociplastic pain to the growing population of those experiencing post-cancer pain. A manual is provided to allow clinicians to differentiate between predominant nociceptive, neuropathic, or nociplastic pain after cancer. A seven-step diagnostic approach is presented and illustrated using cases to enhance understanding and encourage effective implementation of this approach in clinical practice.

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.

Changes in Spinal Alignment of Women Who Underwent Unilateral Mastectomy with Immediate Autologous Breast Reconstruction Compared To Mastectomy without Breast Reconstruction

INTRODUCTION

The impact of breast reconstruction on spinal alignment is not well studied, especially in immediate autologous breast reconstruction. Studies on body posture have shown greater asymmetry among those without reconstruction. This study compared the changes in spinal alignment pre- and post-operatively among women who underwent unilateral mastectomy without reconstruction (MA) versus immediate autologous breast reconstruction (IABR).

METHODS

A cross sectional, retrospective study analysed MA and IABRs performed from January 2007 to December 2017 and their pre- and post-operative anterior chest radiographs. The change in Cobb's angle (degrees) less than 1 year, 1 to 2 years, more than 2 years post-operatively were analysed using GE Healthcare Centricity Picture Archive and Communications Systems.

RESULTS

537 patients underwent mastectomy; 76 fulfilled the inclusion criteria (36 IABR, 40 MA). No significant difference existed between mean pre- and post-operative Cobb's angle change across all 3 groups, less than 1 year (MA 3.57±3.84, IABR 3.316±2.72, p=0.81), 1 to 2 years (MA 1.84±4.81, IABR -2.68±3.21, p=0.577) and more than 2 years post-operatively (MA -1.14±5.30, IABR -0.94±5.10, p=0.898). However raw data indicated IABR improved spinal alignment in the short and intermediate period post-operatively. Among IABR, free flap breast reconstruction improved spinal alignment compared to pedicled flaps [free flaps: 2.21±3.28, pedicled flaps: 0.01±3.67 (p=0.027)].

CONCLUSION

IABR has a positive impact on spinal alignment in early and intermediate post-operative period compared to MA, especially in women with larger breast volume. Physical benefits of IABR should be highlighted to improve patient's access to breast reconstruction globally.

The effect of breast cancer surgery on spine alignment: Whole-spine radiograph analysis

Breast cancer survivors may experience spinal deformity following breast cancer surgery. This study investigated the long-term effects of breast cancer surgery on whole-spine alignment. This retrospective study included 200 patients who underwent breast cancer surgery and ≥2 anteroposterior standing whole-spine X-rays. The curvature of the spine was measured using the Cobb angle; changes in Cobb angle between X-rays were compared among three groups according to breast cancer surgery type. The mean interval between initial and follow-up X-ray was 28.46 ± 13.39 months. The change in Cobb angle was 0.40 ± 1.65 degrees and the absolute value of that change was 1.25 ± 1.15 degrees in all patients with breast cancer. There were no significant differences in angular change among groups according to breast cancer surgery type. Most patients showed minimal changes in spinal alignment after breast cancer surgery. Our findings indicate that breast cancer surgery does not negatively affect spinal alignment.

The effect of upper limb lymphedema in posture of patients after breast cancer surgery

BACKGROUND

Upper limb lymphedema is one of the complications following breast cancer-related surgery. It is a fact that there are alterations in posture of the trunk following surgery, however, there is not much data on whether upper limb lymphedema has any effect on body posture.

OBJECTIVES

The main purpose of the study was to investigate the effect of upper limb lymphedema in the trunk posture and spine mobility of patients following breast cancer surgery.

METHODS

Twenty-seven women with lymphedema and 29 women without lymphedema with mastectomy or breast-conserving surgery participated in the study. Posture was evaluated by the New York Posture Rating Chart and spinal stability and thoracic mobility were evaluated by the Spinal Mouse device.

RESULTS

Posture and spine posture scores were significantly higher in the without lymphedema group (p= 0.004; 0.041; respectively). There was a significant difference between the groups in terms of lateral (p< 0.001) and posterior (p< 0.001) view of shoulders, spine (p= 0.027), upper (p< 0.001) and lower back (p= 0.009), and trunk postures (p= 0.001).

CONCLUSIONS

Body posture and spine are more affected due to upper limb lymphedema following breast cancer surgery. Alterations of posture mainly occur on shoulders, spine, upper and lower back, and trunk, but not on head and neck postures.

Differences in the Glenohumeral Joint before and after Unilateral Breast Cancer Surgery: Motion Capture Analysis

After mastectomy, women might lose mobility and develop kinematic changes in the shoulder. The objective of this research was to compare the kinematics of the glenohumeral joint in women, before and after unilateral breast cancer surgery. This was a longitudinal study with a pre- and post-evaluation design; in total, 15 Mexican women who had a mastectomy for breast cancer and who received a physical therapy program after surgery were evaluated. Flexion–extension and abduction–adduction movements of the glenohumeral joint were evaluated (15 days before and 60 days after mastectomy). For the kinematic analysis of the glenohumeral joint, an optoelectronic motion capture system was used to monitor 41 reflective markers located in anatomical landmarks. There was no significant difference in the range of motion of the glenohumeral joint when comparing pre- and post-mastectomy, flexion–extension (p = 0.138), and abduction–adduction (p = 0.058). Furthermore, patients who received chemotherapy (53%) before mastectomy were more affected (lower range of motion) than those who did not receive it. There were no significant differences in the kinematics of the glenohumeral joint after mastectomy in this group of patients who received a physical therapy program after surgery. Moreover, patients who received chemotherapy treatment before breast cancer surgery tended to have a lower range of motion than those who did not receive it. Therefore, it is necessary for the physical rehabilitation team to attend to these patients even before the mastectomy.

The effect of early arm exercise on drainage volume after total mastectomy and tissue expander insertion in breast cancer patients: a prospective study

BACKGROUND

In prosthesis-based breast reconstruction patients, the drain tends to be kept in place longer than in patients who undergo only mastectomy. Postoperative arm exercise also increases the drainage volume. However, to preserve shoulder function, early exercise is recommended. In this study, we investigated the effect of early exercise on the total drainage volume and drain duration in these patients.

METHODS

We designed a prospective randomized trial involving 56 patients who underwent immediate breast reconstruction following mastectomy using tissue expanders. In each group, the patients were randomized either to perform early arm exercises using specific shoulder movement guidelines 2 days after surgery or to restrict arm movement above the shoulder height until drain removal. The drain duration and the total amount of drainage were the primary endpoints.

RESULTS

There were no significant differences in age, height, weight, body mass index, or mastectomy specimen weight between the two groups. The total amount of drainage was 1,497 mL in the early exercise group and 1,336 mL in the exercise restriction group. The duration until complete removal of the drains was 19.71 days in the early exercise group and 17.11 days in the exercise restriction group.

CONCLUSIONS

Exercise restriction after breast reconstruction did not lead to a significant difference in the drainage volume or the average time until drain removal. Thus, early exercise is recommended for improved shoulder mobility postoperatively. More long-term studies are needed to determine the effect of early exercise on shoulder mobility in prosthesis-based breast reconstruction patients.

The effect of delayed breast reconstruction after unilateral mastectomy on spine alignment

Background

Mastectomy in patients with breast cancer causes spinal deformities. We evaluated the effect of delayed breast reconstruction in post-mastectomy patients on spine alignments.

Methods

The study included 68 patients who underwent delayed breast reconstruction by three plastic surgeons in a single tertiary hospital. We measured proximal thoracic (PT), main thoracic (MT), and thoracolumbar (TL) Cobb angles and coronal spinal balance from chest or whole spine radiographs.

Results

The median changes in the PT and MT Cobb angles were -0.33 and -0.34 degrees, respectively. The change in TL Cobb angle and coronal spinal balance were only measured in 29 patients with available spine radiographs. The median change in TL Cobb angle and coronal spinal balance were -0.69 degrees and 3.75 mm, respectively. The median preoperative and postoperative PT Cobb angles were 1.75 and 1.24 degrees. The difference between preoperative and postoperative PT Cobb angles was statistically insignificant (P=0.036). The median preoperative and postoperative MT Cobb angles were 1.32 and 1.09 degrees, respectively. The difference between preoperative and postoperative MT Cobb angles was statistically insignificant (P=0.221).

Conclusions

Delayed breast reconstruction did not result in clinically significant improvement in mastectomy-induced spinal deformity. This finding should be considered when choosing between immediate and delayed breast reconstruction.

Sensory signs and symptoms in women with self-reported breast cancer-related lymphedema: a case-control study close up

PURPOSE

It is not clear to what extent signs and symptoms other than arm swelling, including pain, altered sensory function, and body perception disturbances, differ between women with measurable and non-measurable breast cancer-related lymphedema (BCRL). A case-control study was performed to compare these signs and symptoms between (1) women with self-reported BCRL with objectively measurable swelling; (2) women with self-reported BCRL without objective confirmation; and (3) a control group with no self-reported BCRL.

METHODS

The three groups were compared for (1) the severity of self-reported signs and symptoms of BCRL, (2) problems in functioning related to BCRL, (3) pain-related outcomes, (4) sensory functions, and (5) body perception.

RESULTS

All self-reported outcomes related to signs and symptoms of BCRL and problems in functioning were significantly different between the control group and the other two groups with and without measurable self-reported BCRL (p < 0.001-0.003). Except for "skin texture" (p = 0.01), no differences were found between groups. For pain-related outcomes, sensory function, and body perception, significant differences were found for the mechanical detection threshold (p < 0.01) and self-reported disturbances in body perception (p < 0.001) between the self-reported BCRL groups and control group.

CONCLUSIONS

Diverse signs and symptoms related to BCRL, sensory function, and perception were different among women with self-reported BCRL compared to controls. No differences between women with and without measurable self-reported BCRL were found.

IMPLICATIONS FOR CANCER SURVIVORS

The presence of self-reported BCRL, with or without measurable swelling, is a first indication for the need of further diagnostic evaluation.

Functionality and factors associated with work behaviour among Brazilian breast cancer survivors: A cross-sectional study

BACKGROUND

Breast cancer treatments lead to several comorbidities in the upper limbs, such as pain and stiffness, hindering physical functions and the return to work.

OBJECTIVE

To explore the functionality and factors associated with work behaviour among manual and non-manual Brazilian workers who have recovered from breast cancer.

METHODS

This is an observational cross-sectional study involving Brazilian breast cancer survivors. The sociodemographic, work, and clinical aspects were assessed through clinical records, upper limb disability, and human functionality obtained from 62 women. Multiple and univariate logistic regressions were used to identify the association of variables on return to work, p < 0.05.

RESULTS

56.5% of women did not return to work, the mean time for returning to work was 16 months (±15.21), absenteeism from work lasted 41 months (±34.58). Modified radical mastectomy (OR = 5.13, 95% CI = 1.35 to 18.66) and moderate-to-severe disability levels in the upper limbs (OR = 6.77, 95% CI = 1.86 to 24.92) were associated with not returning to work. The loss of productivity was higher among non-manual workers (21.5%) (p = 0.040).

CONCLUSIONS

The rates of not returning to work after breast cancer treatment are high. Women who did not return to work presented higher levels of disability.

Body image and hopelessness among early-stage breast cancer survivors after surgery in China: A cross-sectional study

Aim

To examine the body image and hopelessness status of early‐stage breast cancer survivors who received a one‐time dressing change after surgery and were ready to be discharged from a hospital in China.

Design

A cross‐sectional study.

Methods

Participants were 211 women with breast cancer who had received a one‐time dressing change postsurgery. Spearman's correlation and structural equation modelling were used for data analysis.

Results

Participants in the 35–45 age group and those who underwent bilateral mastectomy presented higher scores for hopelessness. Married participants showed lower scores for the feelings about the future subscale compared to other subscales. Body image was significantly and positively associated with and had a positive effect on hopelessness. Women with a more positive appraisal of their body image tended to report lower levels of hopelessness. Healthcare providers should evaluate patients’ distress levels after a mastectomy to identify women who may require early psychosocial intervention.

Alteration in skeletal posture between breast reconstruction with latissimus dorsi flap and mastectomy: a prospective comparison study

Background

The latissimus dorsi (LD) flap is used in cases of immediate breast reconstruction after total or partial mastectomy. However, studies on the effect of unilateral LD flap reconstruction on skeletal posture and comparison with results from mastectomy-only have been sparse. Thus in this prospective, observational study, we compared skeletal posture and functional recovery in patients who underwent a mastectomy-only versus those who underwent breast reconstruction with a LD flap after mastectomy.

Methods

From January 2018 to February 2020, a total of 54 patients were enrolled. The control group included 23 patients who underwent mastectomy-only and the experimental group included 31 patients who underwent breast reconstruction using a LD flap immediately after mastectomy. We assessed the Cobb's angle in spine X-rays, parameters derived from photometry, computed tomography (CT), and 3D scanning preoperatively (T0), 6 months post-surgery (T1), and 1-year post-surgery (T2). We also evaluated functional outcomes, such as pain intensity, disability of the upper extremities, and quality of life.

Results

In the control and experimental groups, the average age was 58.7/46.2 years, body mass index (BMI) was 24.9/22.5, and excised mass weight was 386.8/259.1 g, respectively. In the control group, differences in the Cobb's angle were significant between T0 and T2 (P=0.003). There were significant differences in the Cobb's angle and time interaction effects between the two groups (P=0.015). The degree of change in the Cobb's angle between T0 and T1 was positively correlated with change in the vertical distance from the 3D scanner midline to the nipple (P=0.009).

Conclusions

The experimental group showed improved recovery in skeletal posture compared to the control group. Further, discovering the parameters that can predict the change of skeletal posture through a 3D scanner will have clinical significance. Accordingly, performing breast reconstruction by unilaterally applying the LD muscle is a safe, reliable, and useful method of autologous tissue transfer for breast cancer patients.

Post-mastectomy pain syndrome: A timely review of its predisposing factors and current approaches to treatment

Background:

Post-mastectomy pain syndrome (PMPS) has been reported to occur in 25–60% of patients following surgeries for breast cancer, the highest occurring cancer in women worldwide. There has been much research interest due to this high prevalence. However, there is still a lack of incorporation of PMPS prevention strategies in standard perioperative plans, and our understanding of this condition is still incomplete.

Objectives:

This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and treatment and potential directions for future treatment and research.

Methods:

A PubMed search with the relevant keywords was done for articles published in the last 10 years.

Results:

The incidence of PMPS can be reduced by early recognition and management of modifiable risk factors as well as the perioperative use of analgesics and regional nerve blocks. These also have a significant role in the management of established PMPS together with surgical interventions and physical therapy.

Conclusions:

PMPS is still poorly defined and hence underdiagnosed and undertreated at this point. Perioperative peripheral nerve blocks have a very promising role as preventive analgesia to reduce the risk of developing PMPS, but large-scale randomised controlled studies will need to be done to evaluate their comparative efficacy. There is a need to prioritise PMPS prevention as a standard inclusion into the perioperative plans of mastectomy patients.

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.

Self-reported signs and symptoms of secondary upper limb lymphoedema related to breast cancer treatment: Systematic review

INTRODUCTION

Breast cancer survivors with secondary upper limb lymphoedema (ULL) may report a wide range of self-reported symptoms. At the moment, no overview of ULL-specific symptoms is available. The first aim, therefore, was to compare the prevalence rates of self-reported signs and symptoms in people with and without secondary ULL due to breast cancer treatment. The second aim was to determine whether symptoms of lymphoedema could be predictive for the development of ULL. The third aim was to describe the association between the presence/severity of symptoms and the presence/severity of ULL.

METHODS

A systematic search was conducted in Medline, Scopus, CINAHL and EMBASE databases, with key words related to breast cancer, symptoms and ULL.

RESULTS

Twenty-nine articles were eligible. The most frequently reported signs and symptoms were swelling (80.9%) and heaviness (66.7%) in the ULL group and tenderness (37%) and numbness (27%) in the non-ULL group. Perceived larger arm size, as well as feelings of arm tightness, stiffness, puffiness, pain, sensory disturbances and functional changes were predictive for the development of ULL. Moderate correlations were found between the presence of swelling, firmness in the past year and tightness now and severity of ULL. There was also moderate correlation between the presence of swelling and heaviness now and the presence of ULL.

CONCLUSIONS

Swelling and heaviness are the most commonly reported symptoms in patients with ULL. The presences of these two symptoms are moderately correlated with the presence and/or severity of ULL. Although limited information regarding the predictive self-reported symptoms for the development of ULL was found. Further research with standardised definitions of ULL and validated questionnaires for self-reported signs and symptoms are needed to confirm which signs and symptoms are related to ULL and which to other upper limb morbidities.

Analysis of Radiation Dose to the Shoulder by Treatment Technique and Correlation With Patient Reported Outcomes in Patients Receiving Regional Nodal Irradiation

Background/Purpose

Shoulder/arm morbidity is a late complication of breast cancer treatment with surgery and regional nodal irradiation (RNI). We set to analyze the impact of radiation technique [intensity modulated radiation therapy (IMRT) or 3D conformal radiation therapy (3DCRT)] on radiation dose to the shoulder with a hypothesis that IMRT use results in smaller volume of shoulder receiving radiation. We explored the relationship of treatment technique on long-term patient-reported outcomes using the quick disabilities of the arm, shoulder, and hand (q-DASH) questionnaire.

Materials/Methods

We identified patients treated with adjuvant RNI (50 Gy/25 fractions) from 2013 to 2018. We retrospectively contoured the shoulder organ-at-risk (OAR) from 2 cm above the ipsilateral supraclavicular (SCL) planning target volume (PTV) to the inferior SCL PTV slice and calculated the absolute volume of shoulder OAR receiving 5–50 Gy (V5–V50). We identified patients that completed a q-DASH questionnaire ≥6 months from the end of RNI.

Results

We included 410 RNI patients: 54% stage III, 72% mastectomy, 35% treated with IMRT. IMRT resulted in significant reductions in the shoulder OAR volume receiving 20–50 Gy vs. 3DCRT. In total, 82 patients completed the q-DASH. The mean (SD) q-DASH=25.4 (19.1) and tended to be lower with IMRT vs. 3DCRT: 19.6 (16.4) vs. 27.8 (19.8), p=0.078.

Conclusion

We found that IMRT reduces radiation dose to the shoulder and is associated with a trend toward reduced q-DASH scores ≥6 months post-RNI in a subset of our cohort. These results support prospective evaluation of IMRT as a technique to reduce shoulder morbidity in breast cancer patients receiving RNI.

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.

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.

Dynamic body posture after unilateral mastectomy: a pilot study

BACKGROUND

Postural changes after unilateral mastectomy may appear in relation to the dominant hand, postoperative duration, and dynamic conditions. This study aimed to compare the postural changes by inclination angles and muscle activities in the static and dynamic sitting position between women with breast cancer who underwent mastectomy and women who did not have breast cancer.

METHODS

The observational study design was conducted. We evaluated 17 women who underwent modified radical mastectomy (MRM) more than 1 year prior to the study. They were categorized into the Rt. mastectomy group (n=7) and the Lt. mastectomy group (n=10). An aged-matched cohort of 8 healthy females was also included. The inclination angle in both static and dynamic sitting positions was measured using the balance board system (BBS), and the muscle activities of 8 muscles were measured in the dynamic sitting position.

RESULTS

There was no significant difference in demographic characteristics between the patients, and all patients were right-handed. The inclination angle of the anterior-posterior axis when leaning forward was significantly increased to the anterior side in the Rt. mastectomy group than in the Lt. mastectomy group. Meanwhile, the inclination angle in the static sitting position and when tilted backward to both directions did not differ among the 3 groups. The inclination angle of the right-left axis was statistically increased to the left side during tilting anterior-left direction in the Rt. Mastectomy group. The muscle activities of the thoracic erector spinae were significantly lower when tilted backward in the Rt. mastectomy group than in the Lt. mastectomy group.

CONCLUSIONS

Compared with left mastectomy, right unilateral mastectomy yielded more postural changes under dynamic sitting state in right-handed female patients with breast cancer. Thus, to maintain the trunk balance and prevent the postural changes after unilateral mastectomy, the postoperative exercise programs for the para-thoracic muscles will be helpful.

Impact of wearing a service vest on three-dimensional truncal motion in dogs

OBJECTIVE

To develop a 3-D kinematic model to measure truncal motion in dogs and assess changes in truncal motion in dogs when wearing each of 2 service vests.

ANIMALS

5 adult mixed-breed dogs.

PROCEDURES

27 reflective markers were placed on the pelvis, trunk, and scapula of each dog. Six infrared cameras were placed around a treadmill to track the location of the markers within a calibrated space. Dogs were recorded during walking and trotting on the treadmill. Local and global coordinate systems were established, and a segmental rigid-body model of the trunk was created. Dogs were then recorded while wearing a custom vest and an adjustable vest during walking and trotting on the treadmill. Range of motion of the trunk when dogs were and were not wearing vests was compared by repeated-measures ANOVA.

RESULTS

An anatomic coordinate system was established by use of markers located at T1, T13, and the xiphoid process. Range of motion of the trunk during a gait cycle did not differ significantly regardless of the day of the test for both walking and trotting gaits. Trunk motion of dogs when walking and trotting was significantly reduced when dogs were wearing a vest, compared with trunk motion when not wearing a vest.

CONCLUSIONS AND CLINICAL RELEVANCE

A 3-D kinematic model for measuring truncal rotation was developed. Results indicated measurable differences in the gait of dogs when wearing each of the 2 service vests, compared with the gait when not wearing a vest.

Quilting suture versus conventional closure in prevention of seroma after total mastectomy and axillary dissection in breast cancer patients

BACKGROUND

Total mastectomy and axillary dissection is a common procedure for breast cancer patients in our institution. Seroma is common. This study aimed to compare the quilting suture and conventional closure in prevention of seroma after total mastectomy and axillary dissection.

METHODS

This randomized comparative study was carried out from January 2018 to June 2019 in Yangon General Hospital. One hundred and forty patients (70 conventional and 70 quilting) were included. For quilting group, customized strategically placed interrupted alternate sutures were placed 2-3 cm apart with 3/0 vicryl sutures between skin flap and pectoral muscle.

RESULTS

Age, body mass index and tumour diameter were comparable between the groups. The mean duration of operation was 111.44 ± 7.045 min in conventional and 124.5 ± 6.39 min in quilting (P = 0.0001). The mean drain output for conventional group was not significantly different from quilting group. In quilting, some area developed dimpling which resolved within a week. A total of 21 (30%) patients in the conventional group and 10 patients (14.3%) in the quilting group developed seroma (P = 0.041). The mean frequency and amount of seroma aspiration were significantly lower in the quilting group. Shoulder movement limitation and analgesia use showed no significant difference.

CONCLUSION

Although total amount of drain output, duration of drain, hospital stay and post-operative complications were not different, the incidence of seroma was significantly lower in quilting group. Seroma is treated with more ease in the quilting group as the frequency and amount of aspiration were lower and less frequent follow-up visits were required. Quilting can reduce the seroma incidence in total mastectomy and axillary dissection for breast cancer patients.

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.

Does the weight of an external breast prosthesis play an important role for women who undergone mastectomy?

Aim

The aim of the study was an evaluation of daily functioning and activity in post-mastectomy women who use EBP, with particular focus on the weight of the prosthesis.

Background

There is a large group of breast cancer patients who need comprehensive care including professional help with EBP. Some researchers have reported the advantages and disadvantages of using EBPs in women who undergo mastectomy. Among the latter, dissatisfaction with the weight, comfort and movement of the prosthesis was identified.

Materials and methods

The study included 125 women who had undergone unilateral mastectomy. This was a survey with a self-constructed questionnaire which was administered to breast cancer women. In the second part, the author analyzed current objective studies about the implementation of EBP in body motion assessments.

Results

The analysis of the answers of the women studied showed that they used their first EBP about 6 months after mastectomy, and changed it every two years. The method of choosing EBP had a significant impact on satisfaction with EBP as well as on the prosthesis' weight. Patients who chose EBP themselves were more satisfied with it. There was no statistically significant correlation between the age of the women studied and their satisfaction with the EBP or its weight and size.

Conclusion

EBP plays an important role in the satisfaction with daily functioning and activity of breast cancer women who have undergone unilateral mastectomy despite the fact that the weight of EBP is not an important factor in an objective analysis of body motions in many studies in this group of patients.

The Influence of Soft Tissue Therapy on Respiratory Efficiency and Chest Mobility of Women Suffering from Breast Cancer

The aim of the following paper was to determine the influence of soft tissue therapy on respiratory efficiency and chest mobility of women suffering from breast cancer. This study was a controlled, randomized trial. Tests were carried out in a group of patients (n = 49) who were hospitalized in the Province Polyclinic Hospital, Konin, Poland. In the study group, irrespective of the standard physical therapy program, an additional therapy program was run. The program consisted of applying specific techniques of soft tissue treatment. All patients in each term were subject to pulmonary function tests, chest mobility, and pain assessment. Statistical analysis of the obtained results of spirometry and chest mobility assessment has revealed no differences in the analyzed parameters between the examined groups in the period of joint therapeutic treatment. In the period between the third examination and the end of the 11-month-rehabilitation treatment, statistically significant differences were observed in the analyzed spirometry parameters; however, there was no difference in the parameters describing airflow in small airways (maximal expiratory flow at 50% (MEF50), peak expiratory flow (PEF) between individual groups during consecutive examinations in the course of diversified therapeutic treatment. Chest mobility assessment of the patients, performed during diversified therapeutic treatment, revealed statistically significant differences between the groups. However, there was no difference between the examined groups as far as pain sensation is concerned. Enhancing the regular rehabilitation program by including additional therapeutic methods, which are based on myofascial release and post-isometric relaxation techniques, had beneficial effects regarding respiratory system efficiency.

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.

Risk factors for early postoperative psychological problems in breast cancer patients after axillary lymph node dissection

BACKGROUND

The purpose of this study was to investigate the factors related to early postoperative psychological conditions in breast cancer patients with axillary lymph node dissection 3 months after the surgery.

METHODS

The subjects of this study were 200 consecutive patients who underwent axillary lymph node dissection for breast cancer at our hospital. Age, body mass index, surgical side, work, marriage, presence of children, presence of co-resident household members, resection of the pectoralis minor muscle, preoperative chemotherapy, postoperative chemotherapy, postoperative hormonal therapy, postoperative radiotherapy, shoulder range of motion, upper limb function (Disabilities of the Arm, Shoulder and Hand; DASH), and psychological conditions were evaluated. In this study, a Distress and Impact Thermometer was used to classify patients with adjustment disorders, depression, or major depression and suicidal ideation into a group with psychological problems and the remaining patients into a group with no psychological problems.

RESULTS

Logistic regression analysis showed that only DASH was statistically significantly associated with psychological conditions (p < 0.05). Using receiver operating characteristic curve analysis, a DASH score of 18 or greater was found to be very specific for predicting psychological conditions.

CONCLUSIONS

The observation that somatic symptoms and disability of upper limb function are related to psychological conditions may indicate the importance of postoperative rehabilitation in breast cancer patients with axillary lymph node dissection.

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.

Changes in Spine Alignment and Postural Balance After Breast Cancer Surgery: A Rehabilitative Point of View

Breast cancer is the most common malignant tumor in female patients in developed countries. Recent articles indicate that one-sided mastectomy or minor breast surgery to treat breast cancer can have deleterious effects on posture and the musculoskeletal system. The purpose of this study was to investigate the alterations post-breast cancer surgery of the spine alignment associated to the balance not reported by the noninvasive instrumentation. We enrolled 30 women who had undergone treatment for breast cancer (BG) and were on a waiting-list for rehabilitation treatment and a control group of 30 healthy volunteer women (CG), matched by age and body mass index. The stabilometry was performed using a force platform (Kistler Instruments, Winterthur, Switzerland) test during quiet standing with closed-eyes (EC) and open-eyes (EO), recording the position of the center of pressure (CoP) for 51.2 sec. The stabilogram or the time plot of the two coordinates, X and Y, of the CoP was obtained, which represent anteroposterior and midlateral balance. Spinal posture was measured using the Formetric-4D rasterstereographic system (DIERS, International GmbH, Schlangenbad, Germany), and thoracic kyphotic angle, lumbar lordotic angle, and surface trunk rotation were evaluated. Sixty participants were analyzed (CG:30; BG:30). For the spine rasterstereography a statistically significant difference was shown with regard to anterior-posterior flexion of the trunk major in BG; pelvic inclination and twist of half-pelvis decreased in BG; normalized lumbosacral inversion point decreased in BG; surface rotation major in BG; and lateral deviation major in BG. Compared with the values for the stabilometry test with EO and EC, a statistically significant difference was observed, respectively, for ellipse length (mm; p = 0.04) and ellipse area (mm²; p = 0.04) with EO and in ellipse area (mm²) with EC (p = 0.05), increased in BG for both conditions. No difference was shown for CoP velocity and oscillations between the groups. Breast cancer survivors after prostheses or tissue expanders for mastectomy showed a spine's misalignment present both on the sagittal plane, both on the coronal and frontal plane, increased in BG regard to anterior-posterior flexion of the trunk, surface rotation, and lateral deviation. It is associated with greater energy expenditure for the postural balance control increased in BG with a major ellipse area in EO and EC conditions and major ellipse length in EC condition.

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.

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.