Rehabilitation of PostmastectomySyndrome

Eric Wisotzky, MD

Director of Cancer Rehabilitation

MedStar National Rehabilitation Network

Assistant Professor of Rehabilitation Medicine

Georgetown University School of Medicine

Disclosures

• None

Objectives

• Therapy techniques for post-mastectomy syndrome

• Rehabilitation precautions for post-mastectomy

syndrome

• Medications for post-mastectomy syndrome

• Interventional procedures for post-mastectomy

syndrome

• Psychological considerations in post-mastectomy

syndrome

• Prevention of post-mastectomy syndrome

Therapy Techniques

Effectiveness of Postoperative Physical Therapy

for Upper-Limb Impairments After Breast Cancer

Treatment: A Systematic Review

De Groef, An et al. Archives of Physical Medicine and

Rehabilitation 2015;96:1140-53.

Therapy Techniques: Multifactorial

• Two studies showed multifactorial therapy

consisting of manual stretching and active

exercises effectively treated impaired shoulder

ROM at 6 months post-op

• De Groef, An, et al. Effectiveness of Postoperative Physical Therapy for Upper-Limb

Impairments After Breast Cancer Treatment: A Systematic Review. Archives of

physical medicine and rehabilitation (2015)

Therapy Techniques: Passive

Mobilization

• One study showed beneficial effects of passive

mobilization on shoulder pain and ROM

• De Groef, An, et al. Effectiveness of Postoperative Physical Therapy for Upper-Limb

Impairments After Breast Cancer Treatment: A Systematic Review. Archives of

physical medicine and rehabilitation (2015)

Therapy Techniques: Stretching

• One study investigating pectoral stretching

program did not find any added value

• De Groef, An, et al. Effectiveness of Postoperative Physical Therapy for Upper-Limb

Impairments After Breast Cancer Treatment: A Systematic Review. Archives of

physical medicine and rehabilitation (2015)

Therapy Techniques: Exercise Therapy

• Five studies investigated the effectiveness of

exercise therapy

– All found beneficial effect on shoulder ROM

– One found positive effect on pain

– Great variability in terms of type of exercises,

frequency, intensity, and duration of program

• De Groef, An, et al. Effectiveness of Postoperative Physical Therapy for Upper-Limb

Impairments After Breast Cancer Treatment: A Systematic Review. Archives of

physical medicine and rehabilitation (2015)

Therapy Techniques: Timing of Therapy

• Three studies showed early start (POD#1) more

beneficial for recovery of ROM

• Four studies showed greater incidence of

seromas and wound drainage in group with early

start vs those starting >7 days post-op

• De Groef, An, et al. Effectiveness of Postoperative Physical Therapy for Upper-Limb

Impairments After Breast Cancer Treatment: A Systematic Review. Archives of

physical medicine and rehabilitation (2015)

Therapy Techniques: Authors’

Recommendations

• First week post-op: low-intensity program

involving elbow/wrist

• 7-10 days post-op: gradually increase intensity

– Passive mobilization, manual stretching, active

exercises

• No recommendations can be made on timing,

content, intensity• De Groef, An, et al. Effectiveness of Postoperative Physical Therapy for Upper-Limb

Impairments After Breast Cancer Treatment: A Systematic Review. Archives of

physical medicine and rehabilitation (2015)

Postmastectomy Syndrome:

OT

• Patients need help with ADLs

• Difficulty with household chores, dressing

– Thomas-MacLean, Roanne L., et al. "Arm morbidity and disability after breast

cancer: new directions for care." Oncology nursing forum. Vol. 35. No. 1. 2008

Therapy Techniques for Specific

Syndromes:

• Incisional pain

• Cording

• Shoulder dysfunction

• Postreconstruction pain syndrome

• Neuropathic syndromes

– Intercostobrachial neuralgia

– Phantom breast pain

Incisional Pain

From local adherence of incision to chest wall

Presents with incisional hypersensitivity

Decreased mobility of incision

Therapy Management: Incisional Pain

• Scar massage/mobilization

• Desensitization techniques

Cording (Axillary Web Syndrome)

• Common after ALND shortly after surgery

– Incidence between 6-48%Torres Lacomba M, et al. Axillary web syndrome after axillary dissection in breast cancer: A

prospective study. Breast Cancer Res Treat 2009;117:625-630.

• Sclerosed/thrombosed lymphatics that feels like

“cords”

– Can be in axilla and into arm

– Radiation may be a risk factor

Cording (Axillary Web Syndrome)

• Restricts ROM

• Usually self limiting in 2-3 months

• NOT indicative of lymphedema

Therapy Treatment for Cording

• Soft tissue techniques

• Nerve glides

• ROM

• May have audible “snap”

Shoulder Dysfunction: Impingement

Protective posturing/radiation

Shortening of pec muscles

Decreased size of subacromial arch due to forward depressed shoulder girdle

Rotator cuff impingement

Shoulder Dysfunction: Range of Motion

in Breast Cancer

• Decreased planes of motion:

– flexion

– abduction

– external rotation

Levangie PK, Drouin J. Magnitude of late effects of breast cancer treatments on

shoulder function: a systematic review. Breast Cancer Res Treat 2009;116(1):1–15

Shoulder Dysfunction: Scapular

Mechanics

• Scapulothoracic motion altered in all planes• Shamley, et al. Three-dimensional scapulothoracic motion following treatment for

breast cancer. Breast Cancer Res Treat (2009) 118:315-322

Shoulder Dysfunction: Muscle

Performance in Breast Cancer

• Multiple studies have shown weakness in:

– Abduction

– Flexion

– Extension

– External/internal rotation

– Scapular upward rotation/depression/adduction

Based on above findings, a sensible PT

rx might include:

• Pec stretching

• Scapular stabilization/mechanics exercises

• Strengthening in all planes

Post-Reconstruction Pain Syndrome

(PRPS)

• Neuromuscular symptoms including:

paresthesias, dysesthesias, cramping, spasms,

or other characteristically neuropathic discomfort

in the chest wall, shoulder, upper arm, abdomen,

and/or back following breast surgery with

reconstruction for breast cancer.

Etiology of PRPS

PRPS Therapy

• Stretching of pectoralis and serratus

• Manual release of tissues around implant/tissue

expander

Intercostobrachial Neuralgia

Intercostobrachial Nerve

• Cutaneous branch of 2nd intercostal nerve (T2)

• Supplies the posterior and medial upper arm,

axilla, and lateral chest wall

– Much anatomic variation

• Increase risk of injury during ALND

Intercostobrachial Neuralgia Therapy

• Desensitization

Phantom Breast Pain

• May affect up to 53% of patients– Staps T, Hoogenhout J, Wobbes T. Phantom breast sensations following

mastectomy. Cancer. 1985;56:2898–901

Phantom Breast Pain Therapy

• Desensitization

• Mirror therapy

Therapy Precautions

• Caution to tissue expander/implant

• Common sense lymphedema precautions

– Avoid aggressive deep tissue work to

lymphedematous limb or limb at risk of lymphedema

“ABSOLUTE” Precautions

• Avoid physical agents or e-stim directly over

active tumor

• Avoid heat/ice in potentially ischemic or

insensate areas

• Avoid heat in patients at high bleeding risk

• Avoid heat/ice, e-stim, TENS in areas at risk for

fracture

• Avoid traction in area of malignancy

– Fracture risk

Postmastectomy Syndrome: Medications

Postmastectomy Syndrome: Oral

Medications

• Anti-depressants

– Venlafaxine showed significant pain relief vs placebo• Tasmuth, Tiina, Brita Härtel, and Eija Kalso. "Venlafaxine in neuropathic pain

following treatment of breast cancer." European journal of pain 6.1 (2002):

17-24.

– Amitriptyline 25-100 mg daily resulted in >50% pain

relief in 8/15 patients• Tiina, Tasmuth. "Amitriptyline effectively relieves neuropathic pain following

treatment of breast cancer." Pain 64.2 (1996): 293-302.

Postmastectomy Syndrome: Topical

Medications• Capsaicin

– 5/13 patients had >50% pain relief• Watson, C. Peter N., and Ramon J. Evans. "The postmastectomy pain

syndrome and topical capsaicin: a randomized trial." Pain 51.3 (1992): 375-

379

• Lidocaine patch

– 28 patients randomized to lidocaine patch vs placebo

patch

– No difference in pain scores between the two groups• Cheville, Andrea L., et al. "Use of a lidocaine patch in the management of

postsurgical neuropathic pain in patients with cancer: a phase III double-

blind crossover study (N01CB)." Supportive care in cancer 17.4 (2009): 451-

460.

Postmastectomy Syndrome: Other

Medications

Anti-inflammatories: topical or oral

Nerve stabilizers: gabapentin, pregabalin

Opioids

Topical compounds

Postmastectomy Syndrome:Modalities

• TENS no better than placebo for

postmastectomy pain– Robb, Karen A., Di J. Newham, and John E. Williams. "Transcutaneous electrical

nerve stimulation vs. transcutaneous spinal electroanalgesia for chronic pain

associated with breast cancer treatments." Journal of pain and symptom

management 33.4 (2007): 410-419.

Postmastectomy Syndrome:

Acupuncture

• Randomized controlled trial of acupuncture vs

usual care showed decreased pain and

improved ROM in the acute postoperative period

after breast surgery– He, J. P., et al. "Pain-relief and movement improvement by acupuncture after

ablation and axillary lymphadenectomy in patients with mammary cancer."

Clinical and experimental obstetrics & gynecology 26.2 (1998): 81-84.

Injections in Postmastectomy Syndrome

Can they be performed?

Injections in Postmastectomy Syndrome

Can they be performed?

Injections in Postmastectomy Syndrome

Can they be performed?

Yes for the most part…

Injections in Postmastectomy Syndrome

Can they be performed?

Yes for the most part…

Precautions to consider:

-Skin issues during radiation

-Blood counts during chemotherapy

-Lymphedema/infection risk

Injections in Postmastectomy Syndrome:

Musculoskeletal

• Rotator cuff impingement subacromial

injection

• Adhesive capsulitis glenohumeral injection

Intercostobrachial Neuralgia

Management

• Intercostobrachial nerve block

Intercostobrachial Nerve Block

Technique

Case Series for Intercostobrachial Nerve

Block

Patient Baseline 2 weeks 4 weeks 6 weeks 3 months

A 6/10 4/10

B 6/10 4/10 (2nd inj) 2/10

C 10/10 0/10

Neuroma Injections

• 19 patients injected

• 93% had complete relief of pain after injection of

T4 and/or T5 neuromas with bupivicaine and

dexamethasone

• http://cancer.ucsf.edu/videos/Esserman_v4.mp4

• Tang CJ, Elder SE, Lee DJ, et al: 2013 San Antonio Breast Cancer

Symposium Abstract P3-10-03. Presented December 12, 2013.

Neuroma Injections

Botulinum Toxin for Postmastectomy

Reconstruction Syndrome

• Consider injecting pectoralis major, serratus

anterior

• Don’t pop the implant!

– Can use ultrasound

Botulinum Toxin for Postmastectomy

Reconstruction Syndrome: Evidence

• 75-100 units botulinum toxin A in pec major

resulting in 100% pain relief

• 250 units of abobotulinumtoxin A into pec major

resulting in 100% pain relief– O'Donnell, Casey J. "Pectoral muscle spasms after mastectomy successfully

treated with botulinum toxin injections." PM&R 3.8 (2011): 781-782.

Psychosocial Factors in

Postmastectomy Syndrome

• Depression

• Anxiety

• Self-image

• Sexuality

Psychosocial Factors in

Postmastectomy Syndrome

• No association with surgical factors, disease-

related variables, radiation, or chemotherapy

• Catastrophizing, somatization, depression,

anxiety, stress, sleep disturbance association

with postmastectomy pain– Belfer, Inna, et al. "Persistent postmastectomy pain in breast cancer survivors:

analysis of clinical, demographic, and psychosocial factors." The Journal of

Pain 14.10 (2013): 1185-1195.

Postmastectomy Syndrome Prevention

Regional anesthesia 40 patients assigned to general anesthesia vs general

anesthesia plus paravertebral nerve block

Patients in the nerve block group had significantly less chronic pain than general anesthesia alone 4-5 months post-op

Ibarra, M. M., et al. "[Chronic postoperative pain after general anesthesia with or without a single-dose preincisional paravertebral nerve block in radical breast cancer surgery]." Revista espanola de anestesiologia y reanimacion 58.5 (2011): 290-294.

Postmastectomy Syndrome Prevention

EMLA

› 46 patients randomized to chest wall EMLA cream vs

placebo peri-operatively

› Pain intensity significantly less in EMLA group 3

months post-op Fassoulaki, Argyro, et al. "EMLA reduces acute and chronic pain after

breast surgery for cancer." Regional anesthesia and pain medicine 25.4

(2000): 350-355

Postmastectomy Syndrome Prevention

Gabapentin peri-operatively› Single dose of 600 mg gabapentin one hour pre-

operatively

› Treatment group had less post-op pain and less opioid consumption

› Grover, V. K., et al. "A single dose of preoperative gabapentin for pain reduction and requirement of morphine after total mastectomy and axillary dissection: randomized placebo-controlled double-blind trial." Journal of postgraduate medicine 55.4 (2009): 257.

Postmastectomy Syndrome Prevention

Minimizing pre-op pain/ROM restrictions

PREHAB!!

Intercostobrachial Neuralgia Prevention

• Prevention:

– Nerve sparing surgery may or not help prevent this

pain syndrome

• Meta-analysis showed that complaints when nerve is severed

are typically numbness which may be less bothersome

Warrier S, Hwang S, Koh CE, Shepherd H, Mak C, Carmalt H, Solomon M.

Preservation or division of the intercostobrachial nerve in axillary dissection for

breast cancer: Meta-analysis of Randomised Controlled Trials. Breast. 2014 Feb

24

Postreconstruction Pain Syndrome

Prevention

• Botulinum toxin injected into pec major, serratus,

rectus abdominus intra-operatively during

mastectomy and tissue expander placement

• Botox group had significantly less post-op pain

and narcotic use than control group – Layeeque, Rakhshanda, et al. "Botulinum toxin infiltration for pain control after

mastectomy and expander reconstruction." Annals of surgery 240.4 (2004): 608.

Summary

• Postmastectomy syndrome rehabilitation often

requires a multimodal approach

• Patient assessment should look for specific

cause of symptoms which will dictate treatment

options

• So much is still not known so plenty of research

possibilities

Questions???

Eric.m.wisotzky@medstar.net