Physical Therapy Intervention in the Patient with Breast Cancer

1. 1 Physical Therapy Intervention in the Patient with Breast Cancer April 12, 2006 DANA-FARBER CANCER INSTITUTE BRIGHAM & WOMEN�S HOSPITAL Nancy J. Roberge, PT, DPT, M.Ed. Chestnut Hill PT Associates Wellesley, Massachusetts Copyright: Nancy J. Roberge, PT, DPT, MEd. 2006. This information should not be copied or otherwise used without express written permission of the author. [nroberge@comcast.net]

2. 2 The Physical Therapist of Today Today's PT is a DPT Patients in 43 states have direct access to physical therapy care In Massachusetts, since 1982 The American Physical Therapy Association The Science of Healing. The Art of Caring. SM

3. 3 Cornerstones of PT Profession Quality of Life (ultimate goal of PT with every patient we treat) Prevention and Wellness Rehabilitation Physical Educators: �If I treat you, it is for today, If I teach you, it is for tomorrow� Author Unknown/Bible

4. 4 Paradigm Shift Think in terms of PT as: Part of critical pathway team that treats the patient with breast cancer Included at initial dx NOT for problems only: Historically �The patient has a problem, call PT� PTs address issues of: QOL Prevention (lymphedema, limitations, dysfunction) Wellness (restore to pre-morbid levels)

5. 5 Combined Sections Meeting (CSM) San Diego 2006 �A Qualitative Approach to Understanding Long-Term Effects on Shoulder Function After Treatment for Breast Cancer: Musculoskeletal Impairments, Functional Limitations, and Disability� Three Focus Groups PT BC Survivors PT Treaters (two groups) Meta analysis of outcome tools: Shoulder function: DASH, Penn Shoulder Score, ASES, SDQ QOL measures: SF-36 (excluded: no UE function), FACT-B, others What to measure? How to best measure? Need for controlled study.

6. 6 CSM Findings Patient Deficits, Dysfunctions, Disabilities [MDs have not been trained to distinguish the subtleties of joint limitations or muscle weakness which later creates joint dysfunction which in turn, results in ? function of ADLs and/or future disability] Pain Decreased ROM, strength Self-imposed reduced functional levels Integumentary issues: Scar Tissue Radiation Induced Fibrosis/RIF Lymphedema

7. 7 Deficits and Dysfunctions Cumulative Outcomes of Breast Cancer Treatment �. . . subtleties which end as deficits which create dysfunctions.� �Minimal limitations which may not cause functional or ADL limitations but over time become impingement syndromes� Pamela K. Levangie, PT, DSc, Sacred Heart University, Fairfield, CT � Karki, A., et al. (2005). Impairments, activity limitations and participation restrictions 6 and 12 months after breast cancer operation. Journal of Rehabilitative Medicine, 37, 180-188. Flores, A., Hodges, L., Brewer, L. (2004). Recovering shoulder function and quality of life after breast cancersurgery. Journal of the Section on Women�s Health, 28(3), 7-13.

8. 8 Sequelae of Surgery Lumpectomy, MRM, Reconstruction Options Incisional tightness/pain Delayed wound healing/seroma Impaired sensation: Intercostobrachial nerve Medial cutaneous Long thoracic Thoracodorsal MRM and/or Reconstruction Options : Postural asymmetries/deficits Can create significant balance issues Psycho-social impact (body image, intimacy issues etc.) MRM results in immediate psychological effects for the women. It is after all, an amputation although the word is not used.MRM results in immediate psychological effects for the women. It is after all, an amputation although the word is not used.

9. 9 Sequelae of Surgery Scar tissue/adhesions: surgical site and chest wall Axillary Web Syndrome (AWS)/Cording Post-op Swelling: surgical sites: breast/chest and axilla Loss of UE: ROM strength scapula stability/mobility function/ADL Reconstruction: TRAM, Lat. Dorsi, Perforator/Microvascular flaps (DIEP, SIEP, Gap-flap) Additional sites to assess and/or treat Core stabilization, teach good body mechanics (reconst.) Cording is not understood and often misunderstood. Some might suggest that it is Cephalic vein entrapment, others offer that it is Basilic vein entrapment and some offer that it is lymphangitis. What ever it is, the patient�s describe a painful, restricted condition.Cording is not understood and often misunderstood. Some might suggest that it is Cephalic vein entrapment, others offer that it is Basilic vein entrapment and some offer that it is lymphangitis. What ever it is, the patient�s describe a painful, restricted condition.

10. 10 Axillary Web Syndrome Sample articles on AWS Harris, S.R., et al. (2001). Upper extremity rehabilitation in women with breast cancer after axillary dissection: Clinical practice guide. Physical and Rehabilitation Medicine, 13 (2&3), 91-103. Moskovitz, A., et al. (2001, Feb. 14). Axillary web syndrome after axillary dissection. American Journal of Surgery, 181, 434-439.

11. 11 Axillary Web Syndrome/Cording

12. 12 Axillary Web Syndrome/Cording

13. 13 Post Mastectomy Pain Syndrome Selim, S., et al. Post breast therapy pain syndrome (PBTPS). Cancer Supportive Care Programs. Accessed 6/3/2005. Miguel, R., et al. (2001) The effect of sentinel node selective axillary lymphadenectomy on the incidence of postmastectomy pain syndrome. Cancer Control, 8(5), 427-430.

14. 14 Post Mastectomy Pain Syndrome Wascher, R. (2002). Post mastectomy pain syndromes: A surgeon�s perspective. CancerLynx. Accessed 6/3/2005. Wascher, R. Comments on post mastectomy syndrome. [Compilation of patient comments on subject matter.] Accessed 6/3/2005. Wascher, R. (2005, Feb. 28). Post breast therapy pain syndrome handout. Accessed 6/3/2005. Wascher, R. (2004). Post breast therapy pain syndrome�A study of Internet-based patient and healthcare provider education. Journal of ClinicalOncology, 22(14S), 8230.

15. 15 Single MRM

16. 16 Myofascial Strain Patterns

17. 17 Myofascial Strain Patterns

18. 18 Physical Therapy Intervention: Post Surgery Manual Therapy: Prep for Radiation & ? QOL Mobilization techniques Soft tissue/scar tissue: ? neuropathic pain Joint Scapula, GH, AC, SC Myofascial Release Myofascial release provides symptomatic relief from chest wall tenderness occasionally seen following lumpectomy and radiation in breast cancer patients. Int J Radiat Oncol Biol Phys, 34(5), 1188-1189. Therapeutic exercises Diaphragmatic breathing: ? lymph drainage and de-stresses patient Education and support

19. 19 Physical Therapy Intervention:Post Surgery Functional level [using FACT-B & FRS-S] �If a ROM deficit is not corrected before radiation, there is an increased chance of dysfunction for as long as 18 months after surgery� Flores, A., Hodges, L., Brewer, L. (December,2004). Recovering Shoulder Function and Quality of Life after Breast Cancer Surgery. Journal of the Section on Women�s Health, 28:3, 7-13.

20. 20 Sequelae of Chemotherapy Psycho-social effects: family, work Neuropathies (Taxol, Taxotere) Systemic: Foot/Hand syndrome Cardiac damage (AC) Decreased aerobic capacity Weight Gain/Loss (Sarcopenia) Premature menopause ? risk of osteoporosis: OP prevention strategies

21. 21 Sequelae of Chemotherapy General malaise Joint pain/arthralgias Cognitive dysfunction: �Chemobrain� Cancer Related Fatigue/CRF Herpes Zoster Hair loss, nausea, loss of appetite

22. 22 PT During Adjuvant Chemotherapy Help maintain level of conditioning Walking program Gentle stretching program Prep for radiation Mapping position: Manual therapy Chest wall, axilla, upper arm ROM exercises

23. 23 Radiation Therapy Woman in position for radiation treatment, from the front. Middle radiation beam is shown. A bright yellow indicates breast being treated B light yellow part of the beam, beam in air, not touching woman C opening of the linear accelerator D arm holder supports woman's right arm Source: www.breastcancer.org

24. 24 Sequelae of Radiation Therapy �I can�t imagine that medieval torture was any worse than what I experienced in radiation therapy� Source: Patient quote in 2004 due to her lack of adequate shoulder ROM for radiation therapy, 5 days/wk x 7 wks.

25. 25 Sequelae of Radiation Therapy Dermal Fibrosis: Radiation Induced Fibrosis/RIF Chest wall Radiated sites Fibrosis Disturbance of normal balance of resorption of old collagen fibers and formation of new ones Loose dermal tissue Increase in fibroblasts and inflexible, densely packed hyalinized tissue Scarring

26. 26 Sequelae of Radiation Therapy Pain Burns (1st, 2nd, 3rd degree) Brachial plexopathy Neuropathies

27. 27 Sequelae of Radiation Therapy Muscle impairments Intercostals Pectorals: major/minor Serratus Anterior (some speculate is the most important ms to shoulder function and scapula stability! SA palsy creates significant UE dysfunction) Latissimus Dorsi Subclavius Others ? Neck ROM (supraclavicular nodes)

28. 28 Footnote to:Sequelae of Radiation Pre-existing Joint Impairments ~75% of women with bc are > 50 yrs. old at Dx [http://Imaginis.com/breasthealth/bc_risks.asp?] Rotator Cuff issues #1 reason for ? integrity of RC is age (in the literature, multiple authors) Women have undiagnosed RC or other shoulder issues prior to BC Dx (sports injuries, trauma etc.) This compounds and complicates their recovery if not evaluated at original Dx

29. 29 Sequelae of Radiation Therapy Lung fibrosis ? inspiratory capacity Bone pain/damage ? rib fx risk Decreased skin healing Lymphedema Cancer related fatigue/CRF Long term after effects: 12-24 months! Harris, J., Lippman, M., Morrow , M., & Osborne, O. (2004). Diseases of the Breast (3rd. ed.). Philadelphia: Lippincott Williams & Wilkins.

30. 30 �Combination of Cardboard and Cement�

31. 31 PT During Radiation Therapy: Special Considerations Cancer related fatigue (CRF) #1 complaint Manual therapy: burn level, skin condition direct vs. indirect technique no deep soft tissue work! Therapeutic Exercises Arm ROM Walking Posture Skin Care Cellulitis is an emergent condition/state. Many patients have not had this warning and do not understand the impact of this condition/state.Cellulitis is an emergent condition/state. Many patients have not had this warning and do not understand the impact of this condition/state.

32. 32 Cumulative Effects of Chemo and Radiation Therapies on Nerves Nerve Damage Systemic impact: Chemotherapy (neurotoxic): Foot/Hand syndrome Nutritional deprivation Immune changes Hormonal changes Local impact: Radiation Therapy Radiated fields Surgical cuts ? UE ROM, strength, & function Neuropathies Scarring, adhesions, fibrosis, swelling

33. 33 Physical Therapy Interventions to Address Sequelae of Chemotherapy and Radiation Therapeutic Exercise ROM, Strengthening, Re-conditioning Manual Therapy: STM, MFR, Jt Mob ? Neuropathic paresthesia/hyperesthesia Lymphedema prevention education Support, empower, restore, re-condition

34. 34 Physical Therapists Provide: The first proactive participation by patient! ?control by the patient Mobility (early and late) ? Function Emotional support Stress reduction: Diaphragmatic breathing Meditation/visualization Education and information Lymphedema risk reduction Radiation recall/skin care issues (cellulitis)

35. 35 Exercise Considerations Seroma formation (immediately post-op) Swelling: post-op or possible lymphedema? Walking Softly flexed elbows/hand squeeze Posture assist Weight Training How much to lift? Recommendations are variable by MD, PT Compression sleeve use? High vs. low risk patients Swimming Weight Control: Sarcopenia Weight training and the limit to 10 lbs of wts. Varies by MD, PT and patient.Weight training and the limit to 10 lbs of wts. Varies by MD, PT and patient.

36. 36 PT Research and Exercise Considerations Drouin, J., et al. (2005). Effects of aerobic exercise training on peak aerobic capacity, fatigue, and psychological factors during radiation for breast cancer. Rehabilitation Oncology, 23(1), 1-7. Showed improvements in: Psych. Issues related to depression/dejection & anger & hostility Aspects of fatigue Control of body fat Physiological improvements in peak VO2 & anaerobic threshold & erythrocyte levels Humpel, N., & Iverson, D. (2005). Review and critique of the quality of exercise recommendations for cancer patients and survivors. Support Cancer Care, 13, 493-502.

37. 37 PT Research and Exercise Considerations Halverstadt, A., & Leonard, A. (2000). Essential exercises for breast cancer survivors. Boston: The Harvard Common Press.

38. 38 Lymphedema 77% of lymphedema appears 1-3 yrs Jeanne A. Petrek, MD ? Arm/Hand swelling = ? QOL (DOD Meeting, June 2005, Philadelphia, PA) Degree of AND (Level I,II,III) Determines ? risk (multiple authors/articles) Low to high risk depending on +/- radiation 20-40% (multiple authors/articles) SLNB 6.9% at six months Frangou C. (June 2005).General Surgery News, 32(6).

39. 39 Lymphedema Risk Reduction Drainage, swelling, healing history Drains, seroma formation, wound healing Skin care (cellulitis) Compression sleeve wear Risk Reduction strategies ADL: Limb protection Sports Recreation Work Weight control

40. 40 Lymphedema Prevention:Lymphedema is not overrated unless it is not your arm! "I would rather be in a prevention mode than in a treatment mode. When you have figured it out, call me and tell me I no longer have to wear my compression sleeve.� Patient comment, 2003 Reid Sleeve

41. 41 Complex Decongestive Physiotherapy/CDP Manual Lymphatic Drainage/MLD Therapeutic Exercise Skin Care Compression bandages

42. 42 Lymphedema

43. 43 Lymphedema

44. 44 Lymphedema Lifelong condition Swelling is easier to prevent than to get rid of Antihistamines??? Mediates the histamine response Immediate Rx post cut, burn, insect bite or any break in the integumentary or overuse of the limb (over use = ? blood flow=?lymphatic flow) Stay tuned for this exciting research! �Until we know more about the profile of those who are at risk for lymphedema, I am unwilling to play Russian Roulette with someone else�s arm and a lifetime of lymphedema� Nancy J. Roberge

45. 45 Lymphedema and QOL Beaulac, S., et al. (2002). Lymphedema and quality of life in survivors of early-stage breast cancer. Archives of Surgery, 137, 1253-1257. Accessed 12/03/2002. Burt, J., & White, G. (1999). Lymphedema: A breast cancer patient�s guide to prevention andhealing. Alameda, CA: Hunter House.

46. 46 Cost of Lymphedema Human Cost: Psychological implications Cosmesis Clothing Hospitalization for cellulitis Lifetime: Maintenance and/or treatment Real costs to health care system October 2005: $3,000 (3 day hospitalization and ER visit)

47. 47 Physical Therapy Intervention The earlier PT intervention in this patient population, the better, preferably at initial Dx because of the unique and special needs of the patient who has undergone breast cancer diagnosis, surgery and/or treatment.

48. 48 National Naval Medical Center, Breast Care CenterBethesda, MarylandPT Protocol Patients seen: Pre-op During active treatment (chemo and radiation) 1,3,6,9,12 18 months post-op (repeat all pre-op measures) 100% of women given pre-op flexibility program (re-start: when drains out and with surgeon clearance) 40% require multiple PT sessions for impairments Cording, dynamic/core stabilization (s/p reconstruction) Scar adhesions, pain 80% given strengthening exercises (for impairments that some patients aren�t even aware of) Scapula weakness, dyskinesia Altered shoulder biomechanics (Soft tissue and/or muscle tightness/weakness)

49. 49 Physical Therapist-generated Research Gerber, L., Augustine, E., McGarvey, C., & Pfalzer, L. (2004). Preventing and restoring function in breast cancer survivors. In Harris, Lippman, Morrow, & Osborne, Diseases of the Breast (3rd. ed., pp. 1405-1407).

50. 50 Physical Therapist-generated Research McGarvey, C. (Ed.). (1990). Physical therapy for the cancer patient. New York: Churchill Livingstone. Gergich, N., et al. (2005). One year outcomes of an early identification and intervention model to reduce upper extremity morbidity related to breast cancer treatment. In Breast Cancer: Research and Treatment 28th Annual San Antonio Breast Cancer Symposium 2005: Vol. 94, Supplement 1. Norwell, MA: Springer.

51. 51 Additional Resources Rowland, J., & Massie, M. (2004). Issues in breast cancer survivorship. In Harris, Lippman, Morrow, & Osborne, Diseases of the Breast (3rd. ed., pp. 1419-1452).

52. 52 Public Awareness of Survivorship Issues Pear, R. (2005, November 8). Study faults follow-up for cancer patients. The New York Times. Kolata, G. (2004, June 1). New approach about cancer and survival. The New York Times. Accessed 6/22/2004. Neergaard, Lauran. (2005, November 8). Cancer survivors need more follow-up, study says. The Boston Globe.

53. 53 Public Awareness of Survivorship Issues Brody, Jane. (2005, November 22). With cancer, treatment is only part of the picture. The New York Times. Accessed 11/27/2005.

54. 54  Annual Meeting Chicago, 2004 �No other body part is amputated, reconstructed or burned without Physical Therapy intervention as the first line in the rehabilitation process except the breast. We must correct this oversight now!� Nancy J. Roberge, PT, DPT, M.Ed., June 2004 This occurred to me as I prepared for a panel presentation in Chicago last June. We can not and must not wait for an engraved invitation. We must advocate for the patient with breast cancer. We must educate the public, nurses and doctors who work with these patients. This is a poignant example of how our profession is underutilized.This occurred to me as I prepared for a panel presentation in Chicago last June. We can not and must not wait for an engraved invitation. We must advocate for the patient with breast cancer. We must educate the public, nurses and doctors who work with these patients. This is a poignant example of how our profession is underutilized.