Musculoskeletal Dysfunction in Women

During and Following Treatment for Breast Cancer

Jill Binkley, PT, MClSc, FAAOMPT

TurningPoint Women’s Healthcare Breast Cancer Rehabilitation and Wellness

Programs

A non-profit organization.

Common Rehabilitation Issues Related To Common Rehabilitation Issues Related To Breast CancerBreast Cancer

I. I. Upper Quadrant and Trunk DysfunctionUpper Quadrant and Trunk Dysfunction1.1. Restricted Shoulder Range of Motion and PainRestricted Shoulder Range of Motion and Pain2.2. Chest Wall PainChest Wall Pain3.3. Donor Site MorbidityDonor Site Morbidity4.4. Weakness of Upper Extremity and Trunk/CORE Weakness of Upper Extremity and Trunk/CORE

II. II. Lymphedema Lymphedema 1.1. Upper ExtremityUpper Extremity2.2. BreastBreast3.3. Trunk Trunk

III. FatigueIII. FatigueIV. Weight Gain IV. Weight Gain IV. Psychosocial IssuesIV. Psychosocial IssuesV. Nutritional Issues V. Nutritional Issues

Etiology of Musculoskeletal Problems During and Etiology of Musculoskeletal Problems During and After Breast Cancer TreatmentAfter Breast Cancer Treatment

• SurgerySurgery– Mastectomy/ Breast Conserving Surgery (BCS) (Lumpectomy)Mastectomy/ Breast Conserving Surgery (BCS) (Lumpectomy)– Axillary Node Dissection (ALND)Axillary Node Dissection (ALND)– Donor Sites for ReconstructionDonor Sites for Reconstruction– Drain SitesDrain Sites

• RadiationRadiation– Breast/Chest WallBreast/Chest Wall– AxillaAxilla

• ChemotherapyChemotherapy– FatigueFatigue– Port Site PainPort Site Pain– Joint and Muscle PainJoint and Muscle Pain

• Quality of Recovery AdviceQuality of Recovery Advice– Women commonly advised to avoid exerciseWomen commonly advised to avoid exercise– Lack of information regarding maximizing recovery Lack of information regarding maximizing recovery – Lack of understanding of role of rehabilitation in breast cancer Lack of understanding of role of rehabilitation in breast cancer

Background: Background: Breast Cancer Surgery and Staging of Breast Breast Cancer Surgery and Staging of Breast

CancerCancer

• Management of non-metastatic breast cancer Management of non-metastatic breast cancer involves surgery +/- adjuvant chemotherapy and/or involves surgery +/- adjuvant chemotherapy and/or radiation and is determined by: radiation and is determined by:

• Size of TumorSize of Tumor• Breast SizeBreast Size• Tumor pathology and histologyTumor pathology and histology• Number of positive axillary lymph nodes Number of positive axillary lymph nodes

• SurgerySurgery• Modified Radical MastectomyModified Radical Mastectomy• Breast Conserving Surgery (BCS) (Lumpectomy)Breast Conserving Surgery (BCS) (Lumpectomy)

• Extent of Lymph Node InvolvementExtent of Lymph Node Involvement• Sentinel Node Biopsy +/-Axillary Node DissectionSentinel Node Biopsy +/-Axillary Node Dissection

Determination of Axillary Node Status

• Axillary Node DissectionAxillary Node Dissection- 10 – 30 nodes removed same incision as mastectomy, separate for lumpectomy10 – 30 nodes removed same incision as mastectomy, separate for lumpectomy- pathological examinationpathological examination

• Sentinal Lymph Node BiopsySentinal Lymph Node Biopsy– Less invasive determination of axillary node statusLess invasive determination of axillary node status

Determination of Axillary Node Status Utilizing Sentinel Lymph Node Biopsy

Radioactive Tracer +/- Blue Dye Injected at Tumor Site

Location of 1st Node from the

Tumor Determined by CT Scan and/or

Geiger Counter

Full ALND is avoided in women with negative SLNB

Shoulder Restriction and Loss of FunctionShoulder Restriction and Loss of FunctionPost SurgeryPost Surgery

Short Term:Short Term:• Significant loss of shoulder range of motion reported 2-3 months post mastectomy Significant loss of shoulder range of motion reported 2-3 months post mastectomy

(Gosselink et al, 2003; Reitman, 2003)(Gosselink et al, 2003; Reitman, 2003)

Long Term:Long Term:• Loss of range of motion reported by 26% of women 1 year post mastectomy; 15% post Loss of range of motion reported by 26% of women 1 year post mastectomy; 15% post

BCS BCS (Karki et al, 2005; Blomqvist et al, 2004)(Karki et al, 2005; Blomqvist et al, 2004)

Nature of Restriction:Nature of Restriction: • Flexion and abduction most limited Flexion and abduction most limited (Blomqvist et al, 2004)(Blomqvist et al, 2004) • Range of motion restriction greater for patients who: Range of motion restriction greater for patients who:

– Mastectomy versus BCSMastectomy versus BCS– Received radiation Received radiation (Blomqvist et al, 2004)(Blomqvist et al, 2004)– Underwent AND versus SNB Underwent AND versus SNB (Leidenius, 2005) (Leidenius, 2005)

Post-Surgical PainPost-Surgical Pain

Prevalence of Pain 1 Year Post SurgeryPrevalence of Pain 1 Year Post Surgery (Karki et al, 2005)(Karki et al, 2005)

AND versus SNB only (10 month follow-up)AND versus SNB only (10 month follow-up)• Arm-shoulder pain reported by 21% of patients post SLNB Arm-shoulder pain reported by 21% of patients post SLNB • 50-60% of patients post ALND 50-60% of patients post ALND

(Barranger, 2005)(Barranger, 2005)

MastectomyMastectomy BCSBCS

Neck-shoulder painNeck-shoulder pain 42%42% 37%37%

Upper extremity PainUpper extremity Pain 26%26% 15%15%

Breast/Chest Wall PainBreast/Chest Wall Pain 28%28% 20%20%

Weakness Post SurgeryWeakness Post Surgery

•

• Significant decrease in strength in Significant decrease in strength in shoulder flexion and abduction 15 shoulder flexion and abduction 15 months post-mastectomy months post-mastectomy (Blomqvist et al, 2004)(Blomqvist et al, 2004)

• EMG abnormalities in upper trapezius EMG abnormalities in upper trapezius and rhomboids with associated and rhomboids with associated reduction in shoulder function post-reduction in shoulder function post-mastectomy mastectomy (Shamley, 2007)(Shamley, 2007)

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

• Painful, palpable cords in axilla, Painful, palpable cords in axilla, across antecubital fossa, in severe across antecubital fossa, in severe cases to base of thumbcases to base of thumb

• Tissue sampling demonstrated Tissue sampling demonstrated that cords were lymphatic and that cords were lymphatic and venous tissue (venous tissue (MoskovitzMoskovitz))

Axillary Cording Axillary Cording (Ledenius, 2003; Lauridson, 2005)(Ledenius, 2003; Lauridson, 2005)

• Prevalence of 60 – 70 % in post-Prevalence of 60 – 70 % in post-ALND patients (MRM or BCS) in ALND patients (MRM or BCS) in prospective studies prospective studies

• 20% of patients following SLNB20% of patients following SLNB• Cording is associated with limited Cording is associated with limited

ROMROM

Axillary Cording

Axillary Cording

Trunkal Cording

Painful Drain Site

Bilateral Mastectomy with TRAM reconstruction, Chemotherapy, No radiation

Breast ReconstructionBreast Reconstruction

• Immediate or DelayedImmediate or Delayed• Performed in conjunction with traditional Performed in conjunction with traditional

mastectomy or skin sparing mastectomy or skin sparing • Options: Options:

– ImplantImplant– Autologous Tissue Reconstruction Autologous Tissue Reconstruction

• Latissimus Dorsi Latissimus Dorsi • Transverse Rectus Abdominus Myocutaneous (TRAM)Transverse Rectus Abdominus Myocutaneous (TRAM)• Other : Other : buttock (superior or inferior gluteal), thigh buttock (superior or inferior gluteal), thigh

(tensor fascia lata)(tensor fascia lata)

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

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

Latissimus Dorsi Flap

Morbidity Following Breast ReconstructionMorbidity Following Breast Reconstruction

2 Year Follow Up of 205 Women Post TRAM (n=225) and 2 Year Follow Up of 205 Women Post TRAM (n=225) and Implant (n=69) Implant (n=69)

Roth et al, 2007Roth et al, 2007

• Back Pain (26%)Back Pain (26%)• Breast Pain (12%)Breast Pain (12%)• Abdominal Pain (16%)Abdominal Pain (16%)• Abdominal Tightness (42%)Abdominal Tightness (42%)

• Abdominal pain and tightness significantly more prevalent Abdominal pain and tightness significantly more prevalent post TRAMpost TRAM

• Breast pain more prevalent post implantBreast pain more prevalent post implant

Morbidity Following Breast ReconstructionMorbidity Following Breast Reconstruction

2 Year Follow Prospective Analysis of2 Year Follow Prospective Analysis ofTrunk Function Following TRAM versusTrunk Function Following TRAM versusImplant Reconstruction in 183 WomenImplant Reconstruction in 183 Women

(Alderman et al, 2006)(Alderman et al, 2006)

• Significantly lower flexion peak torque in TRAM Significantly lower flexion peak torque in TRAM group – range from 6-19% lower peak torquegroup – range from 6-19% lower peak torque

• No significant difference in trunk torque between No significant difference in trunk torque between free and pedicled TRAM reconstructions free and pedicled TRAM reconstructions

• Study limitations: functional significance of decrease Study limitations: functional significance of decrease in torque not addressedin torque not addressed

Latissimus Dorsi Flap Reconstruction

Chest Wall Incision Tightness and Pain

TRAM Flap Reconstruction

Donor Site Morbidity Tightness, Pain, CORE weakness

Effect of Radiation on Effect of Radiation on Connective Tissue Connective Tissue (Sassi et al, 2001; Gerber, 1992)(Sassi et al, 2001; Gerber, 1992)

• Acute effects – inflammation, pigmentation, Acute effects – inflammation, pigmentation, local painlocal pain

• Long-term effects – fibrosis: Long-term effects – fibrosis: – Increased turnover of type I collagenIncreased turnover of type I collagen– increased cross-linking of Type I collagenincreased cross-linking of Type I collagen

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

• Progressive loss of shoulder range of motion Progressive loss of shoulder range of motion (1-4 year latent period) *(1-4 year latent period) *– Extent of morbidity is dependent on dose, Extent of morbidity is dependent on dose,

concomitant systemic therapy, motion impairment concomitant systemic therapy, motion impairment pre-radiationpre-radiation

• Brachial plexopathy (up to 10 year latent Brachial plexopathy (up to 10 year latent period) *period) *

• Arm lymphedemaArm lymphedema

* Dose-response established* Dose-response established