Title: Musculoskeletal Dysfunction in Women During and Following Treatment for Breast Cancer
1Musculoskeletal 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.
2Common 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
3Etiology 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
4Background 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
5Determination 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
6Determination 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
7Shoulder 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)
8Post-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
9Weakness 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)
10Axillary 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)
11Axillary 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
-
12Axillary Cording
13Axillary Cording
Painful Drain Site
Trunkal Cording
Bilateral Mastectomy with TRAM reconstruction,
Chemotherapy, No radiation
14Breast 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)
15- 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
16Transverse 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
17Latissimus Dorsi Flap
18Morbidity 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
19Morbidity 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
20Chest Wall Incision Tightness and Pain
Latissimus Dorsi Flap Reconstruction
21Donor Site Morbidity Tightness, Pain, CORE
weakness
TRAM Flap Reconstruction
22Effect 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
23Morbidity 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