Thank you Deb! I am hoping there’s good useful info to share!
The only thing I wanted to add is that my previous email was more focused
on etiology not treatment because I think we need to understand the former
better to best address symptoms. But that being said, we as PTs are great
at addressing impairment and function . We dont fully understand the added
complication of radiation changes to tissue morphology… hoping to hear
other ideas here?
Renata
On Tue, Apr 5, 2022 at 8:31 PM Deborah Doherty <doherty@xxxxxxxxxxx> wrote:
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
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*O:* (770) 400-6493 *F:* (770) 400-6978
*E:* drayton.perkins@xxxxxxxxxxxxx *W:* cancercenter.com
<https://www.cancercenter.com/>
Hospitals <https://www.cancercenter.com/locations?loc=hospitals> |
Outpatient
Care Centers <https://www.cancercenter.com/locations?loc=clinics>
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--
Deb Doherty, PT, PhD
she/her/hers
Associate Professor
Chair of Human Movement Science Department
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Oakland University
Physical Therapy Program
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