Cristian Breast Cancer Rehabilitation Women's Health...

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Rehabilitation of the Person with Breast Cancer

Adrian Cristian MD MHCMChief, Cancer Rehabilitation

Miami Cancer Institute

Disclosures

• Demos Medical Publishers

• Elsevier Medical Pulishers

Objectives• Definition of impairment, activity limitation and

participation restriction

• Case Study illustrating these terms.

• “Cascade of Disability”

• Cancer Related Impairments and their treatment in our Case Study

• Identify strategies to minimize barriers to early referral for cancer related impairments.

Neuropathy

Weakness

Balance impairment

• In Rehabilitation Medicine QoL is broken down into physical impairments

– Muscle– Nerve– Bone– Ligaments– Tendons

• To improve QoL need to address the impairments

QoL and Rehabilitation

Increased Risk of Falls in Patient and Decreased QoL

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• Heart rate

• Respiratory Rate

• Temperature

• Blood pressure

• Pain

• Physical Function

Physical Function as “6th Vital Sign”

The International Classification of Functioning, Disability and Health (ICF)

• Framework for describing and organising information on functioning and disability

• Impairment

• Activity Limitation

• Participation Restriction

Definitions

• Impairment

• Activity Limitation

• Participation Restriction

Impairments

• “Impairments are problems in body function or structure such as a significant deviation or loss.”

• Examples:

• Weakness of shoulder muscles

• Reduced range of motion in shoulder flexion, abduction and external rotation

• Swelling of upper extremity

• Reduced cardiac function

• Cognitive impairment-metastatic disease, chemotherapy

• Sensory deficits in fingertips and toes

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Activity Limitation

• “Activity is the execution of a task or action by an individual.”

• “Activity Limitations are difficulties an individual may have in executing activities.”

• Examples:• Self-care-brushing hair, washing back,

dressing of upper body

Participation Restrictions

• “Participation is involvement in a life situation.”

• “Participation Restrictions are problems an individual may experience in involvement in life situations.”

• Examples:Life roles-spouse, parent, School, WorkHobbies

Case Study

• 50 year old female with right breast cancer diagnosed in 2017

• PMH: Obesity, depression, HTN, right shoulder rotator cuff injury

• Cancer Treatment– Right breast lumpectomy, Axillary Lymph Node Dissection– Right breast mastectomy– Right breast reconstruction

• Complications: wound dehiscence, seroma, right breast debridement and right breast implant exchange

– Anastrazole

Case Study

• C/O

– Right shoulder pain and restricted motion that began after her second surgery

– Right arm swelling, numbness and tingling in the hands, pain at surgical site

– Generalized pains in hips, knees and wrists since starting anastrazole

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Case Study

• She lives with husband in apartment. Difficulty performing ADL’s with right arm.

• Not working-she had been an aide in a nursing home

• PE: obese, – Right arm- @30 degrees of shoulder active and

passive motion in flexion, abduction and ER; – “Cord-like” structures in axilla– Pitting edema of right arm– Hyperalgesia at surgical site

Impairments

• Lymphedema in arm

• Right-Adhesive Capsulitis ( “Frozen shoulder”)

• Aromatase Inhibitor Arthralgia

• Post-mastectomy syndrome

• Obesity

Activity Limitation

• Decreased ability to use her right arm for self-care

– Bathing, dressing, feeding, writing

• Decreased walking due to pain in knees

Participation Restriction

• Can’t work as a nursing aide

• No income or health insurance

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Layers of Disability

Age Related Changes (shoulder)



Co-Morbid Conditions ( obesity)



Co-Morbid Conditions ( obesity,)

Pre-existing Conditions (RC injury)




Pre-existing Conditions (RC injury)

Cancer Characteristics

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Pre-existing Conditions (RC Injury)


Cancer Treatment Related Toxicity




Pre-existing Conditions (RC Injury)


Cancer Treatment Related Toxicity

Cancer Related Impairments

Cancer treatments and impact on disability in Breast Cancer

• Chemotherapy

• Hormonal Therapy

• Radiation Therapy

• Surgery

Chemotherapy

• Doxorubicin– Cardiomyopathy, CHF, MI, myocarditis,

pericarditis• Cyclophosphamide

– Cardiotoxicity (myocarditis, CHF), arrhythmias• Risk increases in elderly, previous RT,

– Pulmonary toxicity-Pulmonary fibrosis, pneumonitis

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Chemotherapy

• Trastuzumab– Fatigue 29-35%– Myocardial dysfunction (left ventricular dysfunction)– Anthracycline-based therapy after trastuzumab

discontinuation may increase the risk of cardiac dysfunction

• Paclitaxel– Peripheral neuropathy– Arthralgias and myalgias– Cardiotoxicity, arrhythmias

Hormonal therapy

• Aromatase Inhibitors

– Anastrazole

• Arthralgias, myalgias

• Decreased bone mineral density

• Serious- DVT/PE; MI, CVA

• Tamoxifen

– DVT/PE

Radiation Therapy

• RT for BC: breast, chest wall, ipsilateral supra and infra-clavicular fossa, axilla and lymph nodes can also involve the shoulder.

• RT to axilla in BC linked with decreased ROM to shoulder (20-49%) in flexion, abduction and external rotation

Radiation Therapy

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Radiation Therapy

• 91% of BC patients treated with RT have some type of arm/shoulder morbidity, pain and limited flexion at 42 months follow-up

• 43% had moderate or severe symptoms

• Doses of 15Gy to shoulder were associated with arm pain, stiffness, swelling, arm numbness and reduced abduction

Johansen S 2014; Blomquist I et al 2004, Hidding 2014;

Surgery

• ALND- highest risk of developing impairments of the arm and shoulder…even 1 year afterwards.

• Reduced ROM, muscle strength, pain, lymphedema and decreased ADL’s have been reported.

• Lumpectomy was related to a decline in the level of activities of daily living.

Hidding 2014

Surgery

• Shoulder function deficits after breast reconstruction with:

• latissimus dorsi (LD) flap,

• the transverse rectus abdominis myocutaneous (TRAM) flap

• subpectoral prosthetic reconstruction

Surgery

• Shoulder dysfunction– Mastectomy has been linked with impaired

shoulder/arm function (abduction and flexion)

– Internal rotation restriction associated with breast conservation therapy

– Breast Reconstruction using LattisimusDorsi muscle flap associated with shoulder weakness and reduced mobility

Tsai Rj 2009; Blackburn NE 2018;

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Surgery

• Lymphedema

– Mastectomy has been linked with development of lymphedema more than lumpectomy, axillary dissection, RT

Surgery

• The pectoralis major and minor muscles decreased in size 6 months- 6 years after surgery.

• Altered muscle activity in 3 key muscles:

– Pectoralis major

– Rhomboids

– Upper trapezius

Shamely DR et al 2007

Cancer related impairments CRI’s in Breast Cancer

• Post Mastectomy Pain

• Axillary Web Syndrome

• Shoulder Dysfunction

• Lymphedema

• Aromatase Inhibitor Musculoskeletal Syndrome (AIMSS)

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Post mastectomy Pain• Persistent pain after healing from

mastectomy.

• Neuropathic in origin

• Surgery (axillary surgery; implants) and/or radiation often the cause.

• Dull burning, aching sensation in chest, axilla & arm, worse with shoulder movement.

Stubblefield 2014

Post Mastectomy Pain

• Damage to the inter-costobrachialnerve most often the cause,

• numbness, paraesthesias, pain in medial upper arm

• Frequency 4-56%

• Treatment: Pre-gabalin, DuloxetineStubblefield 2014

Axillary Web Syndrome

• Palpable “cord like” subcutaneous tissue from axilla to medial arm-elbow and to wrist.

• Pain with abduction of arm.

• Incidence-50%, however 36-72% post ALND

• Commonly seen in patients whom underwent axillary or sentinel lymph node dissection.

Stubblefield 2014; Koehler LA 2019


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• Associated factors

– Contra-lateral mastectomy,

– younger age, lower BMI, educated,

– exercise more frequently,

– have more lymph nodes removed,

– more extensive surgery, received adjunct chemo-RT.



• Usually presents in the first 2-8 weeks following surgery.

• Etiology is unknown

• Treatment focuses on range of motion restoration and manual therapy( soft tissue mobilization, myofascial release, manual lymphatic drainage, scar manipulation,


Shoulder Dysfunction Shoulder Dysfunction in Breast Cancer• 9-68% have shoulder/arm pain

• 1-67% have restricted ROM of shoulder

• 9-33% have decreased strength

• 6-70% have lymphedema

Ebaugh et al 2011” Shoulder impairments and their association with symptomatic RC disease

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Shoulder Dysfunction in Breast Cancer• Breast cancer patients don’t discuss their

shoulder /arm pain with their providers yet:• 63% have lymphedema• 66% have restricted shoulder motion

– Reasons cited:• Felt that the symptoms were normal.• Symptoms would get better over time• Lack of awareness of treatment

options

Maclean Rl et al: 2008

Shoulder Dysfunction in Breast Cancer• Reduced functional use of arm:

– Lifting/carrying objects– Reaching overhead– Care of family and return to work

• Decreased quality of life

• These problems may persist for years following treatment!

Ebaugh et al 2011

Shoulder Dysfunction in Breast Cancer• Risk factors

• Mastectomy

• Axillary lymph node dissection

• Radiation Therapy

• Weight gain

Ebaugh et al 2011; Hidding et al 2014

Shoulder Anatomy

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Shoulder Anatomy

• Rotator Cuff Muscles:

– Initiation of flexion, abduction, external rotation

– Establish optimal relationship between the humeral head and the glenoid fossa

• Degenerative changes in RC increase with aging ( RTC tears -20-55% in 60-69 yo)

Shoulder Anatomy

Shoulder Anatomy Shoulder anatomy

• Scapulo-thoracic (ST) movement

– Maintains alignment between the humeral head and glenoid fossa

– In breast cancer, there is decreased ST movement following mastectomy and breast conserving surgery.

Shamley D et al 2007

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Shoulder Malalignment• Tightness of the Pectoralis Major and

Minor- RT, pain, expanders

• Weakness: Trapezius, Serr. Anterior, Rhomboids, Rotator Cuff, Lat Dorsi

• Surgery: – positioning during surgery-arm at 90

degrees of abduction. – Scar formation in muscles;

Shoulder Malalignment

• Decreased Scapular-thoracic movement

• Lymphedema-Increased weight of arm

• Result: Impingement of Rotator Cuff tendons, bursitis reduced range of motion of shoulder and pain

Protracted Shoulder

Malalignment of Sub-acromial Space

Rotator Cuff Impingement

Reduced Range of motion

Weak Muscles, Pectoral tightness

Shoulder Dysfunction in Breast Cancer

Rehabilitation

• “Exercise for upper limb dysfunction due to breast cancer treatment significantly improved shoulder flexion that was maintained at 6 months follow-up with no increased lymphedema”.

Cochrane review McNeely 2010

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Lymphedema Lymphedema

• Disruption of lymphatic system.

• Accumulation of lymphatic fluid in the interstitial space.

• Limb swelling, heaviness, skin changes.

• Most common in 1st 6 months after surgery

• Clinical diagnosis (exclude DVT/mets)

• May worsen shoulder pain, CTS

Stubblefield 2014;

Lymphedema Risk

• The risk of developing lymphedema is a lifelong risk that doesn’t diminish over time

• Most of breast cancer survivors develop lymphedema within three years from the treatment

Lymphedema risk

• SNB: 0-7% of patients

• ALND: 15-20% of patients

• RT to axilla: 5-15% of patients

• ALND + RT: 25-40% of patients

• Patients have better long term outcomes when diagnosed with early lymphedema

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Lymphedema Stages

• Stage 0- No obvious limb swelling

• Stage 1-Pitting edema; limb feels heavy

• Stage 2-Non-pitting edema

• Stage 3-markedly enlarged limb; elephantiasis

Lymphedema Treatment

• Complete Decongestive Therapy

– Manual Lymphatic Drainage

– Compression Garments, Bandaging, pump

– Education about skin care

– Exercise

– Weight management

Manual Lymphatic Drainage Bandaging

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Compression Sleeves Exercise and Lymphedema

• Beneficial exercises:– Flexibility or stretching exercises,– Cardiopulmonary exercises, – Resistance or weight-lifting exercises

• Does not increase risk for lymphedema

• May help reduce lymphedema• Wear sleeve while exercising

– Combined resistance and aerobic exercises

Aromatase Inhibitor Musculoskeletal Syndrome (AIMSS)

• No standardized definition of AIMSS

• Prevalence rate-46% (20-73%)

• Predictors for development of AIMSS:

– BMI of <25 or >30 kg/m2

– Taxane-based chemotherapy

– Stage III cancer

– Duration of menopause of 5-10 years

– Previous anti-estrogen treatment

Beckwee et al 2016

AIMSS

• Only 50-68% of women comply with AI treatment at 3 years follow-up

• Estrogen deprivation cause of AIMSS (?)– Estrogen has a chondro-protective effect– Estrogen has anti-inflammatory

properties– Estrogen deficiency linked to increase in

pro-inflammatory cytokines)

.Partridge et al 2008; Gaillard S et al 2011; Nielsen RH et al 2008

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AIMSS-Presentation

• Symmetrical joint pains (wrists, hands, knees, hips, lower back and shoulders)

– Focal tenosynovitis ( hand and foot)most common presentation of AIA

– Trigger finger

– Bone, muscle and joint pain

– Morning stiffness

– Difficulty sleeping

AIMSS-Presentation

• Extra-articular symptoms: Carpal tunnel syndrome, neuropathy, fibromyalgia

– Decreased grip strength

– MRI: intra-articular fluid

• Symptoms start soon after initiation of AI-within 2-3 months ( 0.5-10 months; 1.6 mo. Avg)

AIMSS-Treatment

• Evidence is weak to moderate.• Switching to another AI or tamoxifen

– 1/3 of women that switch to another AI are able to tolerate the second one for 3-39mo.

• Acupuncture• Relaxation Techniques• Aerobic Exercise and aquatic exercise and

yoga ( not Tai Chi, Nordic walking)• Vitamin D supplementation ( Mixed results)• Omega 3 fatty acids (in obese women)

Kim 2018 Suskin J et al 2018; Roberts K et al 2017

AIMSS-Treatment

• Pharmacological– Duloxetine (30-120mg/day)– Acetaminophen, NSAID’s, opioids, – Calcitonin (200IU/day)– Prednisolone (5mg)– Biphosphonates (zoledronic acid)– Diuretics– Vitamin E– Glucosamine/Chondroitin

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“Cascade of Disability”Breast Cancer

Concurrent Chemo-RT and Surgery



Lymphedema

Neuropathy

Shoulder Dysfunction

Cognitive Impairment



Decreased ADL’s

Decreased IADL’s and

work

Lymphedema

Neuropathy





Decreased ADL’s

Decreased IADL’s and

work

Lymphedema

Neuropathy

Impaired balance

Falls



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Rehabilitation of our patient Impairments

• Lymphedema in arm

• Right-Adhesive Capsulitis ( “Frozen shoulder”)

• Aromatase Inhibitor Arthralgia

• Post-mastectomy syndrome

• Peripheral Neuropathy

• Obesity

Impairments

• Lymphedema

– Physical Therapy

• Complete Decongestive Therapy

Impairment• Shoulder Dysfunction

– Pharmacological-NSAID, oral steroids, – Interventional

• Suprascapular nerve block• Sub-acromial steroid injection

– `Physical Therapy• Range of motion exercises• Myofascial release techniques• Scapular-thoracic movements• Strengthening exercises to scapular

stabilizers, rotator cuff muscles,

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Impairment

• Post-mastectomy Syndrome

– Duloxetine

– Intercostal nerve blocks

• Peripheral Neuropathy

– Duloxetine

– PT-balance exercises; leg strengthening

Impairment

• AIMSS

– Duloxetine

– Acupuncture

– Exercise program

• Obesity

– Nutrition Referral

– Exercise program

Impairment

• Promote physical activity benefits:

– Reduces the risk of breast cancer in post-menopausal women

– Reduces death and breast cancer progression, new primaries and recurrence among breast cancer survivors

Goncalves AK 2014; Chen X et al 2019; Lahart IM 2015

Impairment

• Promote physical activity benefits during adjuvant treatment:

– Less fatigue

– Improved physical fitness

– Small to moderate improvements in health related QoL, emotional function, , perceived physical function, anxiety, and cardiorespiratory fitness.

Furmaniak AC et al 2016; Lahart IM 2018

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Activity Limitation

• Decreased ability to use her right arm for self-care

– Bathing, dressing, feeding, writing

• Decreased walking due to pain in knees

Activity Limitation

• Occupational Therapy-– ADL training; – Adaptive equipment evaluation– Home safety equipment

• Bathroom equipment (tub bench, grab bars, hand held shower)

– Energy conservation techniques for fatigue management

• Knee pain– Weight management; NSAID; intra-articular

injection


• Can’t work as a nursing aide

• No income or health insurance

• Depression interferes with social activities


• Workplace accommodations/modifications

• Complete disability forms for work

• Refer for vocational retraining

• Refer to mental health services

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