Deb, Anya, Molly, Cheryl, and any others that are interested, here is my
reference list for this course that I taught as an online seminar with Dr.
Koneru.
The articles that I found particularly interesting are the healing properties
of radiated tissue. It gets into the physiology which helps to answer the “why”.
Both surgical positions, number of surgeries, and certainly RT interventions
are impacting the shoulder joint. It truly is a fascinating topic!
Thank you all for insights and contributions!
Learn so much here!
[cid:image001.jpg@01D84F7F.CDF55D40]
Kristin M. Carroll, PT<https://survivorshipsolutions.com/p/kristin-carroll>
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 kim@xxxxxxxxxxxxxxxxxxxxxxxxx
Sent: Wednesday, April 13, 2022 7:12 PM
To: aptaoncology@xxxxxxxxxxxxx
Subject: [aptaoncology] Re: Radiation and Musculoskeletal Impairments
I have been interested this topic as well. Older studies have conculded that
the labrum and cartilagionous structures are probably not affected by RT but
ligaments and tendons such as the corocohumeral ligament are adversely
affected. It makes me think that some of our impingment sydromes may due to a
shrink factor of the anterior shoulder structtres. That combined with an
eventual stretch weakness of the mid scapular muscles and subsequent tightness
of the upper trap from over compensation due to scapular substitution and it’s
a difficult, multi faceted problem to try and unravel. In the past evidence
seemed to support that there was a compomise of the subacromial space by
superior migration of the humeral head but recent scapular kinematic studies
demonstrate that scapular dyskinesis may be a greater factor than previously
thought. I sometimes use a Mulligan belt mobilization technique directed
towards a realignment of the shoulder girdle in a posterior direction
repositioning the scapula on the thoracic cage. That combined with IASTM ( I
use Astym) and weighted stetch on the anterior shoulder I have found to be
effective with these patients.
Good discussion overall.
https://pubmed.ncbi.nlm.nih.gov/8212806/
Hojan K, Milecki P. Opportunities for rehabilitation of patients with radiation
fibrosis syndrome. Rep Pract Oncol Radiother. 2013;19(1):1-6. Published 2013
Aug 8. doi:10.1016/j.rpor.2013.07.007
https://www.sciencedirect.com/science/article/pii/S1877065717304086
Kim Marshall, DPT, CLT
kim@xxxxxxxxxxxxxxxxxxxxxxxxx<mailto:kim@xxxxxxxxxxxxxxxxxxxxxxxxx>
12665 Garden Grove Blvd., ste 603
Garden Grove, CA 92843
Ph 714.643-9012
Fax 714.643-9015
From:
aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>
<aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>>
On Behalf Of Reynolds Molly ("MOLLY.REYNOLDS")
Sent: Tuesday, April 12, 2022 11:02 AM
To: aptaoncology@xxxxxxxxxxxxx<mailto:aptaoncology@xxxxxxxxxxxxx>
Subject: [aptaoncology] Re: Radiation and Musculoskeletal Impairments
Kristin, I would be interested as well!
Molly Reynolds, PT, MSPT
From:
aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>
<aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>>
On Behalf Of Perry Ashley
Sent: Tuesday, April 12, 2022 1:01 PM
To: 'aptaoncology@xxxxxxxxxxxxx'
<aptaoncology@xxxxxxxxxxxxx<mailto:aptaoncology@xxxxxxxxxxxxx>>
Subject: [EXTERNAL] [aptaoncology] Re: Radiation and Musculoskeletal Impairments
That sounds interesting Kristin I would be interested in seeing more on that
research.
From:
aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>
[mailto:aptaoncology-bounce@xxxxxxxxxxxxx] On Behalf Of Kristin Carroll
Sent: Tuesday, April 12, 2022 1:53 PM
To: aptaoncology@xxxxxxxxxxxxx<mailto:aptaoncology@xxxxxxxxxxxxx>
Subject: [aptaoncology] Re: Radiation and Musculoskeletal Impairments
[External Email: Do not click on any links or open attachments unless you trust
the sender and know the content is safe.]
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!
[cid:image004.jpg@01D84F7F.BF66B5D0]
Kristin M. Carroll,
PT<https://clicktime.symantec.com/3D4FQ4C7yAgZX6xLhomNLfH7VN?u=https%3A%2F%2Furldefense.com%2Fv3%2F__https%3A%2Fsurvivorshipsolutions.com%2Fp%2Fkristin-carroll__%3B%21%21ITNRIUeyEKaC%21LucuOo5to7zV2CrMS9IlieDGlnCZtmXnrc3_Bbwfb8lhNgP7KQ3J9OBfx-JBruoyZU93t3qYVBnx0FL9WgROX_YSN1c5GD5ioz5GUeLr_X_adA%24>
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<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>
<aptaoncology-bounce@xxxxxxxxxxxxx<mailto:aptaoncology-bounce@xxxxxxxxxxxxx>>
On Behalf Of Deborah Doherty
Sent: Tuesday, April 5, 2022 9:31 PM
To: aptaoncology@xxxxxxxxxxxxx<mailto: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<mailto: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<mailto: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<mailto: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
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