Transcript Jill Binkley presentation

Musculoskeletal Dysfunction
in Women
During and Following Treatment for
Breast Cancer
Jill Binkley, PT, MClSc, FAAOMPT
TurningPoint Women’s Healthcare
Breast Cancer Rehabilitation and Wellness
Programs
A non-profit organization.
Common Rehabilitation Issues Related To
Breast Cancer
I. Upper Quadrant and Trunk Dysfunction
1.
2.
3.
4.
Restricted Shoulder Range of Motion and Pain
Chest Wall Pain
Donor Site Morbidity
Weakness of Upper Extremity and Trunk/CORE
II. Lymphedema
1.
2.
3.
Upper Extremity
Breast
Trunk
III. Fatigue
IV. Weight Gain
IV. Psychosocial Issues
V. Nutritional Issues
Etiology of Musculoskeletal Problems During and
After Breast Cancer Treatment
• Surgery
–
–
–
–
Mastectomy/ Breast Conserving Surgery (BCS) (Lumpectomy)
Axillary Node Dissection (ALND)
Donor Sites for Reconstruction
Drain Sites
• Radiation
– Breast/Chest Wall
– Axilla
• Chemotherapy
– Fatigue
– Port Site Pain
– Joint and Muscle Pain
• Quality of Recovery Advice
– Women commonly advised to avoid exercise
– Lack of information regarding maximizing recovery
– Lack of understanding of role of rehabilitation in breast cancer
Background:
Breast Cancer Surgery and Staging of Breast
Cancer
•
•
•
Management of non-metastatic breast cancer
involves surgery +/- adjuvant chemotherapy
and/or radiation and is determined by:
•
•
•
•
Size of Tumor
Breast Size
Tumor pathology and histology
Number of positive axillary lymph nodes
Surgery
•
•
Modified Radical Mastectomy
Breast Conserving Surgery (BCS) (Lumpectomy)
Extent of Lymph Node Involvement
•
Sentinel Node Biopsy +/-Axillary Node Dissection
Determination of Axillary Node
Status
•
Axillary Node Dissection
- 10 – 30 nodes removed same incision as
mastectomy, separate for lumpectomy
- pathological examination
•
Sentinal Lymph Node Biopsy
– Less invasive determination of axillary node status
Determination of Axillary Node Status
Utilizing Sentinel Lymph Node Biopsy
Location of 1st Node
from the Tumor
Determined by CT
Scan and/or Geiger
Counter
Radioactive Tracer +/- Blue Dye
Injected at Tumor Site
Full ALND is avoided in women with negative SLNB
Shoulder Restriction and Loss of Function
Post Surgery
Short Term:
• Significant loss of shoulder range of motion reported 2-3 months post
mastectomy (Gosselink et al, 2003; Reitman, 2003)
Long Term:
• Loss of range of motion reported by 26% of women 1 year post
mastectomy; 15% post BCS (Karki et al, 2005; Blomqvist et al, 2004)
Nature of Restriction:
• Flexion and abduction most limited (Blomqvist et al, 2004)
• Range of motion restriction greater for patients who:
–
–
–
Mastectomy versus BCS
Received radiation (Blomqvist et al, 2004)
Underwent AND versus SNB (Leidenius, 2005)
Post-Surgical Pain
Prevalence of Pain 1 Year Post Surgery
(Karki et al, 2005)
Mastectomy
BCS
Neck-shoulder pain
42%
37%
Upper extremity Pain
26%
15%
Breast/Chest Wall Pain
28%
20%
AND versus SNB only (10 month follow-up)
• Arm-shoulder pain reported by 21% of patients post SLNB
• 50-60% of patients post ALND
(Barranger, 2005)
Weakness Post Surgery
• Significant decrease in strength in
shoulder flexion and abduction 15 months
•
post-mastectomy (Blomqvist et al, 2004)
• EMG abnormalities in upper trapezius and
rhomboids with associated reduction in
shoulder function post-mastectomy
(Shamley, 2007)
Axillary Cording (Web Syndrome)
Leidenius et al, 2003; Moskovitz, 2001; Lauridson, 2005
• Painful, palpable cords in axilla,
•
across antecubital fossa, in severe
cases to base of thumb
Tissue sampling demonstrated that
cords were lymphatic and venous
tissue (Moskovitz)
Axillary Cording
(Ledenius, 2003; Lauridson, 2005)
• Prevalence of 60 – 70 % in post•
•
ALND patients (MRM or BCS) in
prospective studies
20% of patients following SLNB
Cording is associated with limited
ROM
Axillary Cording
Axillary Cording
Painful Drain Site
Trunkal Cording
Bilateral Mastectomy with TRAM reconstruction, Chemotherapy, No radiation
Breast Reconstruction
• Immediate or Delayed
• Performed in conjunction with
traditional mastectomy or skin sparing
• Options:
– Implant
– Autologous Tissue Reconstruction
• Latissimus Dorsi
• Transverse Rectus Abdominus Myocutaneous (TRAM)
• Other : buttock (superior or inferior gluteal), thigh
(tensor fascia lata)
Implant
Pectoralis
Major
• Tissue expander
placed under pec
major at time of
mastectomy
• Silicone shell
gradually expanded
with saline
• Permanent saline or
silicone implant once
expansion completed
and/or following
adjuvant treatment
Transverse Rectus Abdominus
Myocutaneous (TRAM) Flap
• Abdominal Skin and Fat to Create Breast Mound
• Portion of TRAM muscle used to provide blood
supply
• Pedicle flap attached at all times, tunnelled from
abdomen to breast region
• Free flap spares more of TRAM muscle, micro
vascular surgery to reattach deep inferior
epigastric artery and veins
Latissimus Dorsi Flap
Morbidity Following Breast Reconstruction
2 Year Follow Up of 205 Women Post TRAM
(n=225) and Implant (n=69)
Roth et al, 2007
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•
•
•
Back Pain (26%)
Breast Pain (12%)
Abdominal Pain (16%)
Abdominal Tightness (42%)
• Abdominal pain and tightness significantly more
prevalent post TRAM
• Breast pain more prevalent post implant
Morbidity Following Breast Reconstruction
2 Year Follow Prospective Analysis of
Trunk Function Following TRAM versus
Implant Reconstruction in 183 Women
(Alderman et al, 2006)
• Significantly lower flexion peak torque in TRAM
group – range from 6-19% lower peak torque
• No significant difference in trunk torque between
free and pedicled TRAM reconstructions
• Study limitations: functional significance of decrease
in torque not addressed
Chest Wall Incision Tightness and Pain
Latissimus Dorsi Flap Reconstruction
Donor Site Morbidity
Tightness, Pain, CORE weakness
TRAM Flap Reconstruction
Effect of Radiation on
Connective Tissue
(Sassi et al, 2001; Gerber, 1992)
• Acute effects – inflammation, pigmentation,
local pain
• Long-term effects – fibrosis:
– Increased turnover of type I collagen
– increased cross-linking of Type I collagen
Morbidity Related to Radiation
(Bentzen & Dische, 2000; Cheville, 2007; Senkus-Konefka, 2006)
• Progressive loss of shoulder range of motion
(1-4 year latent period) *
– Extent of morbidity is dependent on dose,
concomitant systemic therapy, motion impairment
pre-radiation
• Brachial plexopathy (up to 10 year latent
•
period) *
Arm lymphedema
* Dose-response established