[aptaoncology] Re: Radiation and Musculoskeletal Impairments

  • From: Anna Buckmaster <annak08@xxxxxxxxxxx>
  • To: aptaoncology@xxxxxxxxxxxxx
  • Date: Wed, 13 Apr 2022 07:05:20 -0600

Hi! I think you’re getting many requests but could I also see your research? Also, are you using the low level laser? I think you had mentioned wanting to do a study with it involving patients receiving radiation. We just got one yesterday! Now have to figure out best way to use it. 
Thank you!! 
Anna 

Sent from my iPhone

On Apr 12, 2022, at 11:53 AM, Kristin Carroll <kristin.carroll@xxxxxxxxxxxxxxxxxxxxxxxxx> wrote:



This is amazing! I have started to have discussions with the surgeons both surg onc and plastics because have also noticed increase in adhesive capsulitis and general shoulder pain s/p breast cancer surgery and recon/ rad onc treatments.
One of the correlations I noticed is the number of surgeries these women have, partial mastectomy, back in again for clear margins then for reconstruction implant exchange. Each time the shoulder is abducted at 90 degrees putting stress on RTC and capsule, labrum, etc.

I asked if after dissecting out the axillary nerve/ vein if they surgeon could drop the shoulder below 90 degrees to see if that decreased the stress on the static joint position.

Radiation is causing definitive DNA structural changes on all msk, neuro, lymphatic structures as well. I co-wrote a seminar with a radiation oncologist regarding changes from RT and rehabilitation role.

Happy to share some of that research for anyone that would like it.

Cancer surgery and the other treatment interventions are certainly challenging for the body systems and the healing phases are not normal with the addition of RT therapies. RT is a game changer!

Great discussion!

Renata keep up the good work and look forward to hearing more!

 

 

Kristin M. Carroll, PT

Board-Certified Clinical Specialist in Oncologic Physical Therapy

 

"You are not merely here to make a living. You are here in order to enable the world to live more amply, with greater vision, with a finer spirit of hope and achievement. You are here to enrich the world.” – Woodrow Wilson

 

From: aptaoncology-bounce@xxxxxxxxxxxxx <aptaoncology-bounce@xxxxxxxxxxxxx> On Behalf Of Deborah Doherty
Sent: Tuesday, April 5, 2022 9:31 PM
To: aptaoncology@xxxxxxxxxxxxx
Subject: [aptaoncology] Re: Radiation and Musculoskeletal Impairments

 

You are amazing Renata.  I can't wait to read your dissertation! I hope that you will share it!

Deb

 

On Tue, Apr 5, 2022 at 7:05 AM Renata Braudy <rbraudy20@xxxxxxxxx> wrote:

Hi everyone-

 

That is the question that is driving my PhD dissertation after trying to figure it out in the clinic for so many years  - I hope to know more in 1-2 years & am hoping there will be good information to share :)

 

Shoulder impingement is so prevalent in this population (Up to 49% of breast cancer survivors have functional impairments and 64% have pain, swelling, or decreased shoulder mobility 10 years after surgery per Hauerslev(2020)), but as you pointed out we don't understand the etiology or the best treatment. We know that post radiation, the affected tissues (ie pectoralis major and/or minor among others) can be stiffer (Lipps et al 2019), and/or atrophied (though acutely there may be inflammation in the muscles/tissues due to acute radiation damage). Survivors often adopt the forward shoulder/and or kyphotic posture, which probably doesn't help with good scapulohumeral alignment and may increase impingement risk. If there is scar tissue due to radiation and/or surgery, it is not surprising that the biomechanics are altered, with more mechanical impingement or chemical irritation of local tissues. Then there's decreased use of the affected limb, weakness, altered motor recruitment (nerves get irradiated too) ... multifactorial to say the least. Biomechanics in the literature show both increased and decreased scapular upward rotation for example, but it really depends on surgery (lumpectomy/mastectomy), radiation (chest wall, axillary, +/or supraclavicular), lymph node surgery (SLNB or ALND), and a host of other factors. (see a few references below)

 

That being said, prevention would be ideal. Screening for shoulder issues prior to radiation & ensuring the patient can achieve full radiation overhead position would be optimal, but not always practical. Treating through radiation being careful of tissue health is also ideal, with follow-up afterwards and a long term (1-2 year) stretching plan for irradiated tissues.

 

I saw a ton of anterior impingement - ie bicipital - with superior impingement also common. I think the best we can do is educate about posture,  possible shoulder and trunk ROM limitations (we need to address the ribs and thoracic spine also, and identify pain/stiffness as early as possible to minimize impingement. Hopefully with all that, we minimize what impairments occur, address them early when they do, and follow up with long term understanding that we can strengthen the scapular stabilizers, gently stretch and strengthen irradiated tissues and as indicated, and educate our patients to not accept long term shoulder dysfunction as a status quo.

 

Not sure that helps or if it's too general, happy to chat more. We still don't know a lot. See a few references below. 

 

Renata

 

Renata Braudy, PT, MS, MA, OCS, CLT

PhD Candidate, University of Minnesota 

M Health Fairview / University of Minnesota Physicians

Minneapolis, MN

 

A few articles:

Hauerslev KR, Madsen AH, Overgaard J, Damsgaard TE, Christiansen P. Long-term follow-up on shoulder and arm morbidity in patients treated for early breast cancer. Acta Oncol (Madr). 2020;59(7):851-858. doi:10.1080/0284186X.2020.1745269

 

Lipps DB, Leonardis JM, Dess RT, et al. Mechanical properties of the shoulder and pectoralis major in breast cancer patients undergoing breast-conserving surgery with axillary surgery and radiotherapy. Sci Rep. 2019;9(1):17737-17739. doi:10.1038/s41598-019-54100-6

 

Borstad JD, Szucs KA. Three-dimensional scapula kinematics and shoulder function examined before and after surgical treatment for breast cancer. Hum Mov Sci. 2012;31(2):408-418. doi:10.1016/j.humov.2011.04.002

 

Spinelli BA, Silfies S, Jacobs LA, Brooks AD, Ebaugh D. Scapulothoracic and Glenohumeral Motions During Functional Reaching Tasks in Women With a History of Breast Cancer and Healthy Age-Matched Controls. Rehabil Oncol. 2016;34(4):127-136. doi:10.1097/01.REO.0000000000000033

 

Brookham RL, Cudlip AC, Dickerson CR. Examining upper limb kinematics and dysfunction of breast cancer survivors in functional dynamic tasks. Clin Biomech. 2018;55(April):86-93. doi:10.1016/j.clinbiomech.2018.04.010

 

Lang AE, Dickerson CR, Kim SY, Stobart J, Milosavljevic S. Impingement pain affects kinematics of breast cancer survivors in work-related functional tasks. Clin Biomech. 2019;70:223-230. doi:10.1016/j.clinbiomech.2019.10.001

 

 

On Mon, Apr 4, 2022 at 7:06 PM Marisa Gough <marisaptrn6@xxxxxxxxx> wrote:

Great question Drayton. I agree that secondary complications following RT are becoming increasingly more common. We have been following the surveillance model at my clinic, so we see most patients at pre-op, and on. However, even with "prehab", a lot of these women still experience a lot of shoulder issues. The only real pattern I've seen is that it is FAR more common in post-menopausal women, those with a lower BMI, and those who have a h/o thoracic kyphosis. The worse the posture is coming into therapy, the harder it is to avoid these issues. So... one thing I have been doing for every breast cancer patient is doing not just a posture assessment, but a tragus to wall (or occiput to wall) assessment, as well as flexicurve to assess spinal alignment. It gives me a good idea (and shows the patient) what they can do to try and reverse some of those abnormalities. 

 

I hope you find that helpful! Good luck,

 

Marisa Gough 

 

On Mon, Apr 4, 2022 at 1:11 PM Perkins, Drayton <Drayton.Perkins@xxxxxxxxxxxxx> wrote:

Good afternoon, all –

 

I am seeking any information from the therapists on this list serve, whether in the form of research articles or from clinical experience, related to post-breast surgery patients who, through the course of radiation, have developed impingement syndrome or other musculoskeletal-related shoulder impairments (e.g. impingement, rotator cuff tendonitis, bursitis, adhesive capsulitis, etc.). Our patients are typically supine with the shoulder on the affected lifted overhead in full shoulder flexion for prolonged periods of time, for many weeks on end throughout the course of treatment.

 

I am noticing an increase in diagnoses of impingement syndrome, rotator cuff tendonitis, bursitis, etc. in patients who are undergoing breast radiation or who have recently completed radiation. Does anyone else see these diagnoses for their patients receiving radiation? If so, how are you addressing them, not only from a treatment perspective, but also from a pre-radiation or early stages of radiation to reduce the incidence of or severity of these diagnoses? Currently we’re addressing impairments as they arise, but I would love any insight into how we can help these patients before these diagnoses are present.

 

Thanks in advance for your consideration and responses.

 

 

Drayton Perkins, PT, DPT, CLT

Doctor of Physical Therapy / Certified Lymphedema Therapist

Oncology Rehabilitation

Comprehensive Care and Research Center, Atlanta

600 Celebrate Life Parkway, Newnan, GA 30265

O: (770) 400-6493   F: (770) 400-6978  

E: drayton.perkins@xxxxxxxxxxxxx  W: cancercenter.com

Hospitals | Outpatient Care Centers

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Deb Doherty, PT, PhD

she/her/hers
Associate Professor

Chair of Human Movement Science Department

Chair Interprofessional Education Task Force

Coordinator of the Graduate Certificate in Oncology Rehabilitation
Oakland University
Physical Therapy Program
3176 Human Health Building Room
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Phone: (248) 364-8683; FAX: (248) 364-8660
E-mail:  doherty@xxxxxxxxxxx

 

 

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