Musculoskeletal Dysfunction in Women During and Following Treatment for Breast Cancer

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Musculoskeletal Dysfunction in Women During and
Following Treatment for Breast Cancer
Jill Binkley, PT, MClSc, FAAOMPT TurningPoint
Womens Healthcare Breast Cancer Rehabilitation
and Wellness Programs A non-profit organization.
2
Common Rehabilitation Issues Related To Breast
Cancer

• I. Upper Quadrant and Trunk Dysfunction
• Restricted Shoulder Range of Motion and Pain
• Chest Wall Pain
• Donor Site Morbidity
• Weakness of Upper Extremity and Trunk/CORE
• II. Lymphedema
• Upper Extremity
• Breast
• Trunk
• III. Fatigue
• IV. Weight Gain
• IV. Psychosocial Issues
• V. Nutritional Issues

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Etiology of Musculoskeletal Problems During and
After Breast Cancer Treatment

• Surgery
• Mastectomy/ Breast Conserving Surgery (BCS)
  (Lumpectomy)
• Axillary Node Dissection (ALND)
• Donor Sites for Reconstruction
• Drain Sites
• Radiation
• Breast/Chest Wall
• Axilla
• Chemotherapy
• Fatigue
• Port Site Pain
• Joint and Muscle Pain
• Quality of Recovery Advice
• Women commonly advised to avoid exercise
• Lack of information regarding maximizing recovery
  
• Lack of understanding of role of rehabilitation
  in breast cancer

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Background Breast Cancer Surgery and Staging of
Breast Cancer

• Management of non-metastatic breast cancer
  involves surgery /- adjuvant chemotherapy and/or
  radiation and is determined by
• Size of Tumor
• Breast Size
• Tumor pathology and histology
• Number of positive axillary lymph nodes
• Surgery
• Modified Radical Mastectomy
• Breast Conserving Surgery (BCS) (Lumpectomy)
• Extent of Lymph Node Involvement
• Sentinel Node Biopsy /-Axillary Node Dissection

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Determination of Axillary Node Status

• Axillary Node Dissection
• 10 30 nodes removed same incision as
  mastectomy, separate for lumpectomy
• pathological examination
• Sentinal Lymph Node Biopsy
• Less invasive determination of axillary node
  status

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Determination of Axillary Node Status Utilizing
Sentinel Lymph Node Biopsy
Location of 1st Node from the Tumor Determined by
CT Scan and/or Geiger Counter
Radioactive Tracer /- Blue Dye Injected at Tumor
Site
Full ALND is avoided in women with negative SLNB
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Shoulder Restriction and Loss of FunctionPost
Surgery

• Short Term
• Significant loss of shoulder range of motion
  reported 2-3 months post mastectomy (Gosselink
  et al, 2003 Reitman, 2003)
• Long Term
• Loss of range of motion reported by 26 of women
  1 year post mastectomy 15 post BCS (Karki et
  al, 2005 Blomqvist et al, 2004)
• Nature of Restriction
• Flexion and abduction most limited (Blomqvist et
  al, 2004)
• Range of motion restriction greater for patients
  who
• Mastectomy versus BCS
• Received radiation (Blomqvist et al, 2004)
• Underwent AND versus SNB (Leidenius, 2005)

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Post-Surgical Pain

• Prevalence of Pain 1 Year Post Surgery (Karki et
  al, 2005)
• AND versus SNB only (10 month follow-up)
• Arm-shoulder pain reported by 21 of patients
  post SLNB
• 50-60 of patients post ALND
• (Barranger, 2005)

Mastectomy BCS
Neck-shoulder pain 42 37
Upper extremity Pain 26 15
Breast/Chest Wall Pain 28 20
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Weakness Post Surgery

• Significant decrease in strength in shoulder
  flexion and abduction 15 months post-mastectomy
  (Blomqvist et al, 2004)
• EMG abnormalities in upper trapezius and
  rhomboids with associated reduction in shoulder
  function post-mastectomy
• (Shamley, 2007)

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Axillary Cording (Web Syndrome)Leidenius et al,
2003 Moskovitz, 2001 Lauridson, 2005

• Painful, palpable cords in axilla, across
  antecubital fossa, in severe cases to base of
  thumb
• Tissue sampling demonstrated that cords were
  lymphatic and venous tissue (Moskovitz)

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Axillary Cording (Ledenius, 2003 Lauridson,
2005)

• Prevalence of 60 70 in post-ALND patients
  (MRM or BCS) in prospective studies
• 20 of patients following SLNB
• Cording is associated with limited ROM

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Axillary Cording
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Axillary Cording
Painful Drain Site
Trunkal Cording
Bilateral Mastectomy with TRAM reconstruction,
Chemotherapy, No radiation
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Breast Reconstruction

• Immediate or Delayed
• Performed in conjunction with traditional
  mastectomy or skin sparing
• Options
• Implant
• Autologous Tissue Reconstruction
• Latissimus Dorsi
• Transverse Rectus Abdominus Myocutaneous (TRAM)
• Other buttock (superior or inferior gluteal),
  thigh (tensor fascia lata)

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• Implant
• Tissue expander placed under pec major at time
  of mastectomy
• Silicone shell gradually expanded with saline
• Permanent saline or silicone implant once
  expansion completed and/or following adjuvant
  treatment

Pectoralis Major
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Transverse Rectus Abdominus Myocutaneous (TRAM)
Flap

• Abdominal Skin and Fat to Create Breast Mound
• Portion of TRAM muscle used to provide blood
  supply
• Pedicle flap attached at all times, tunnelled
  from abdomen to breast region
• Free flap spares more of TRAM muscle, micro
  vascular surgery to reattach deep inferior
  epigastric artery and veins

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Latissimus Dorsi Flap
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Morbidity Following Breast Reconstruction

• 2 Year Follow Up of 205 Women Post TRAM (n225)
  and Implant (n69)
• Roth et al, 2007
• Back Pain (26)
• Breast Pain (12)
• Abdominal Pain (16)
• Abdominal Tightness (42)
• Abdominal pain and tightness significantly more
  prevalent post TRAM
• Breast pain more prevalent post implant

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Morbidity Following Breast Reconstruction

• 2 Year Follow Prospective Analysis of
• Trunk Function Following TRAM versus
• Implant Reconstruction in 183 Women
• (Alderman et al, 2006)
• Significantly lower flexion peak torque in TRAM
  group range from 6-19 lower peak torque
• No significant difference in trunk torque between
  free and pedicled TRAM reconstructions
• Study limitations functional significance of
  decrease in torque not addressed

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Chest Wall Incision Tightness and Pain
Latissimus Dorsi Flap Reconstruction
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Donor Site Morbidity Tightness, Pain, CORE
weakness
TRAM Flap Reconstruction
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Effect of Radiation on Connective Tissue (Sassi
et al, 2001 Gerber, 1992)

• Acute effects inflammation, pigmentation, local
  pain
• Long-term effects fibrosis
• Increased turnover of type I collagen
• increased cross-linking of Type I collagen

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Morbidity Related to Radiation(Bentzen Dische,
2000 Cheville, 2007 Senkus-Konefka, 2006)

• Progressive loss of shoulder range of motion (1-4
  year latent period)
• Extent of morbidity is dependent on dose,
  concomitant systemic therapy, motion impairment
  pre-radiation
• Brachial plexopathy (up to 10 year latent period)
  
• Arm lymphedema
• Dose-response established