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Musculoskeletal Dysfunction in Women During and Following Treatment for Breast Cancer

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 Breast Cancer.

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Musculoskeletal Dysfunction in Women During and Following Treatment for Breast Cancer

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  1. Musculoskeletal Dysfunction in Women During and Following Treatment for Breast Cancer Jill Binkley, PT, MClSc, FAAOMPT TurningPoint Women’s HealthcareBreast 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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)

  8. 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)

  9. 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)

  10. 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)

  11. 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

  12. Axillary Cording

  13. Axillary Cording Painful Drain Site Trunkal Cording Bilateral Mastectomy with TRAM reconstruction, Chemotherapy, No radiation

  14. 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)

  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

  16. 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

  17. Latissimus Dorsi Flap

  18. Morbidity Following Breast Reconstruction 2 Year Follow Up of 205 Women Post TRAM (n=225) and Implant (n=69) 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

  19. 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

  20. Chest Wall Incision Tightness and Pain Latissimus Dorsi Flap Reconstruction

  21. Donor Site Morbidity Tightness, Pain, CORE weakness TRAM Flap Reconstruction

  22. 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

  23. 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

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