Education about symptom management and simple exercises before initiation of treatments is an effective and simple way to prevent upper extremity dysfunction.— Jesuel Padro-Guzman, MD
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With an increased number of breast cancer survivors and patients with metastatic disease living longer, it is imperative for oncology care providers to manage issues of new and chronic upper extremity dysfunction as a result of the malignancy itself or its treatment. As one of my patients suffering from persistent shoulder and arm dysfunction following her breast cancer treatment said, “I am grateful to be alive, but what is life if I can’t comb my hair, can’t put my clothes on properly, and need help with almost everything?”
Studies suggest that approximately 60% of patients with breast cancer experience shoulder pain, and 67% have decreased strength in their upper body. A combination of factors can contribute to shoulder dysfunction, including age, weight, prior shoulder problems, surgical method, use of aromatase inhibitors, and cervical dysfunction. We also know that patients who undergo mastectomy, extensive radiation, and lymph node dissection have an increased risk of developing shoulder dysfunction compared with patients who have breast-conserving surgery or less-aggressive radiation treatment.
Contributing Factors to Shoulder Problems
The rotator cuff muscles produce arm movements and help to stabilize the glenohumeral joint. Although shoulder pain is common in the general population, alterations in shoulder biomechanics may explain the higher risk of injury in breast cancer survivors. Postsurgical pain, radiation damage, scar tissue formation, and protective posturing cause shortening of the pectoralis muscles, protraction of the shoulder, and narrowing of the subacromial space in which the rotator cuff tendons pass and ultimately lead to impingement, inflammation, and painful arm movements. When movement of the shoulder is reduced, it causes contraction and/or inflammation of the shoulder joint capsule and may result in the condition known as frozen shoulder.
In women with extensive lymph node removal, there is a higher risk of developing clinical lymphedema. The problem with lymphedema, in addition to the risk of infection and cosmetic deformity, is that it adds more weight and restriction to the arm, further limiting arm movement. Studies have shown that the muscles often directly affected by surgery or radiation—the pectoralis complex and the serratus anterior—are not the ones that have long-term dysfunction. Rather, it is muscles such as the trapezius and rhomboids that do not function properly—that is, they do not contract in a synchronous fashion during shoulder range of motion. This dysfunction is due to biomechanical changes beginning with pectoralis and serratus anterior shortening and subsequent maladaptive changes in the supporting muscles.
Rarely, extension of cancer to the axilla or a larger field of radiation may result in brachial plexopathy. Depending on the case, brachial plexopathy could present as severe pain and/or diffused weakness of the arm; it tends to occur years after radiation and is becoming increasingly uncommon.
Diagnosis and Treatment of Shoulder/Arm Problems
Physiatrists have a vast knowledge of neuromusculoskeletal conditions and should aid in both the diagnosis and treatment of upper extremity dysfunction. Education about symptom management and simple exercises before initiation of treatments is an effective and simple way to prevent upper extremity dysfunction. It is believed that a supervised program consisting of stretching and strengthening exercises can reduce pain and improve shoulder range of motion and function.
There are some cases in which diagnosis of shoulder/arm problems can be challenging, and we might need to use imaging tools to discern the extent of the problem. Magnetic resonance imaging (MRI) and/or musculoskeletal ultrasonography are the imaging methods of choice to evaluate shoulder dysfunction. MRI will clearly demonstrate rotator cuff tears and is the modality of choice in cases where bone metastasis is suspected, particularly in woman with advanced breast cancer. It is not unusual in our practice to find bone lesions in the humeral head as the primary cause of shoulder pain and rotator cuff injury.
Musculoskeletal ultrasonography provides the advantage of dynamic imaging and the convenience of performing the study immediately. Rotator cuff injury, signs of impingement, active inflammation, and bursitis can clearly be seen with ultrasound. Finally, electromyography, a diagnostic procedure frequently performed by physiatrists, can determine whether there is a neurogenic component of pain, such as radiculopathy causing weakness.
Sean Smith, MD
Physiatry in Oncology explores the benefits of cancer rehabilitation in oncology practice to screen survivors for physical and cognitive impairments along the care continuum to minimize survivors’ disability and maximize their quality of life. The column is guest edited by Sean Smith, MD, Director of the Cancer Rehabilitation Program at the University of Michigan Department of Physical Medicine and Rehabilitation in Ann Arbor.
The rehabilitation program should start as soon as pain and/or limited use of the upper extremity are reported. Controlling inflammation and providing analgesic medications are of vital importance and are the first steps in treatment. Depending on the case, oral anti-inflammatory medications or targeted injections to the shoulder should be considered along with analgesics. Although there are concerns about therapeutic injections in patients who are at high risk for lymphedema, in our practice we have not seen cases of sudden development of or worsening lymphedema. We do favor image guidance, either fluoroscopy or ultrasonography, to ensure the precision and accuracy of the injection. Once pain is better controlled, the patient should start basic range-of-motion exercises and a supervised rehabilitation program that includes stretching, muscle strengthening, soft-tissue mobilization, and postural/biomechanics training. In women who do not regain proper range of motion, we might prescribe assistive devices or braces to facilitate activities of daily living. After starting the supervised rehabilitation program, it is imperative to monitor a patient’s progress and provide long-term education, particularly if she is initiating a new exercise program, participating in recreational activities, or planning on returning to work. Strengthening the posterior/upper thoracic musculature is often indicated, as is stretching the anterior (pectoralis) muscles.
Patient education about proper ergonomics and lifting techniques as well as discussion about other potential pain triggers in patients’ daily lives are major components of physiatric management in this population and should not be taken lightly. Treatment must emphasize both restoration of function and prevention of injury. ■
Dr. Padro-Guzman is Assistant Attending in Rehabilitation Medicine in the Department of Neurology at Memorial Sloan Kettering Cancer Center and Assistant Professor of Rehabilitation Medicine at Weill Cornell Medical College, New York.
Rietman JS, Dijkstra PU, Hoekstra HJ, et al: Late morbidity after treatment of breast cancer in relation to daily activities and quality of life: A systematic review. Eur J Surg Oncol 29:229-238, 2003.