Breast Cancer Patients - Musculoskeletal Problems Experienced

Original Editor - Lucinda hampton

Top Contributors - Lucinda hampton  

Introduction

MSK conditions group1.png

The breast cancer patient can also be susceptible to the development of musculoskeletal problems, the same as the general population. One common problem is symptomatic rotator cuff disease, which can be brought on through intrinsic factors such as age related physiological changes to the tendons, or through extrinsic factors brought on from cancer treatment such as lymphedema as well as shoulder girdle resting alignment. Tension overload on the rotator cuff tendons may be increased secondary to increased volume and weight of the effected limb with the presence of lymphedema. Due to pain, or fear of movement, for example, the breast cancer patient may adapt to a new resting position for their shoulder, and may tend to avoid using the limb, resulting in shortening of the muscles, and tightening of the joint capsule [1]. Moreover, patients tend to adapt a flexed and protective posture following surgery, further increasing the likelihood of muscle shortening. Pectoralis major is commonly effected. Tightness of these muscles tend to lead to a pull on the scapula, causing it to become protracted and depressed, leading to scapular winging, as well as shoulder impingement [2].

Post-Mastectomy Pain Syndrome (PMPS)

Pain which lasts longer than what is usually expected following various breast cancer surgery types. Generally neuropathic in nature, and can be due but not limited to:

  • Brachial nerve damage, *Intra-operative compromise of cutaneous innervating,
  • Neuroma formation,
  • Fibrotic entrapment. Patients often report neurological symptoms such as numbness or pins and needles, stabbing and burning pain to the same side as surgery in or around the surgical sites.

These symptoms can be exacerbated through a lack of pacing, or by lying on the side of surgery. Therefore, patient education, soft tissue massage, and other desensitising techniques are essential [2]. Other common problems include:

  • Subacromial Impingement Syndrome.
  • Adhesive Capsulitis (frozen shoulder) – idiopathic or traumatic (post-surgery).
  • Rotator Cuff pathology (e.g Symptomatic Rotator Cuff Disease)
  • Myofascial Dysfunction Lateral epicondylitis.
  • Scapular winging secondary to damage of long thoracic nerve during surgery.
  • Pain

Associated Neuromusculoskeletal Conditions Post Treatment

Neuromusculoskeletal conditions are common following surgery, some of which are illustrated in figure 1.4. Treatment protocols shall not be discussed, and the reader should refer to the basic principles of rehabilitation of musculoskeletal conditions. In light of this, it is important to briefly discuss a few points to consider.

  • Depending on the type of surgery that the patient needs to undertake, radiotherapy may be necessary following surgery.
  • A typical radiotherapy session will require the patient to position the treated arm to 90° flexion and abduction, as well as maximal external rotation, for up to 30 minutes [3]
  • Shoulder mobility is commonly affected post-surgery [4][5][6] so it is vital that physiotherapy aims to restore this to improve patient functional ability and to be able to place the shoulder in the required positions for radiotherapy.
  • Active, active assisted, and passive ROM exercises for the shoulder girdle are therefore good practice. Physiotherapy should aim to restore full shoulder ROM as well as minimising associated upper extremity morbidity [7].
  • Manual therapy techniques with the aim of further increasing available ROM have been shown to not be of any significant benefit when used in conjunction with active upper limb exercises [8].

References

  1. Ebaugh, D., Spinelli, B. and Schmitz, K.H., 2011. “Shoulder impairments and their association with symptomatic rotator cuff disease in breast cancer survivors”, Medical Hypotheses. Vol. 77, pp. 481–487.
  2. 2.0 2.1 Pacurar R, Miclaus C, Miclaus M. Morbidity associated with breast cancer therapy and the place of physiotherapy in its management. Timisoara Physical Education & Rehabilitation Journal 2011 05;3(6):46-54.
  3. Johnson, S. and Musa, I., 2004.Preparation of the breast cancer patient for radiotherapy planning. Physiotherapy. . Vol. 90, no. 4, pp. 195-203.
  4. Dahl AA, Nesvold I, Reinertsen KV, Fosså SD. Original Article: Arm/shoulder problems and insomnia symptoms in breast cancer survivors: Cross-sectional, controlled and longitudinal observations. Sleep Med 2011;12:584-590.
  5. Freitas-Silva R, de Freitas-Júnior, R. ( 1 ), Conde DM(2), Martinez EZ(3). Comparison of quality of life, satisfaction with surgery and shoulder-arm morbidity in breast cancer survivors submitted to breast-conserving therapy or mastectomy followed by immediate breast reconstruction. Clinics 2010 / 06 / 01 /;65(8):781-787.
  6. Harrington S(1), Padua D(2), Myers J(2), Battaglini C(3), Groff D(3), Michener LA(4), et al. Comparison of shoulder flexibility, strength, and function between breast cancer survivors and healthy participants. Journal of Cancer Survivorship 2011 / 06 / 01 /;5(2):167-174.
  7. Todd J, Topping A. A survey of written information on the use of post-operative exercises after breast cancer surgery. Physiotherapy 2005;91:87-93.
  8. Amaral MTPd, de Oliveira M,Maia Freire, Ferreira NdO, Guimarães R, Vidigal, Sarian L, Otávio, Gurgel MSC. Manual therapy associated with upper limb exercises vs. exercises alone for shoulder rehabilitation in postoperative breast cancer. PHYSIOTHER THEORY PRACT 2012 05;28(4):299-306.