1. Jill Binkley, PT, MClSc, FAAOMPT A non-profit organization.
Musculoskeletal Dysfunction in Women During and Following Treatment for Breast Cancer
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)
Jill Binkley, PT, MClSc, FAAOMPT
TurningPoint Women’s Healthcare Breast Cancer Rehabilitation and Wellness Programs
A non-profit organization.

2. Common Rehabilitation Issues Related To Breast Cancer
I. Upper Quadrant and Trunk Dysfunction
Restricted Shoulder Range of Motion and Pain
Chest Wall Pain
Donor Site Morbidity
Weakness of Upper Extremity and Trunk/CORE
II. Lymphedema
Upper Extremity
Breast
Trunk
III. Fatigue
IV. Weight Gain
IV. Psychosocial Issues
V. Nutritional Issues
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

3. 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
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

4. 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
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

5. 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

6. Radioactive Tracer +/- Blue Dye Injected at Tumor Site
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

7. 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)
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

8. Post-Surgical Pain
Prevalence of Pain 1 Year Post Surgery (Karki et al, 2005)
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)
Mastectomy
BCS
Neck-shoulder pain
42%
37%
Upper extremity Pain
26%
15%
Breast/Chest Wall Pain
28%
20%
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

9. 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)
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

10. 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)
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

11. 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
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

12. Axillary Cording
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

13. Axillary Cording Painful Drain Site Trunkal Cording
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)
Bilateral Mastectomy with TRAM reconstruction, Chemotherapy, No radiation

14. 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)

15. Implant 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
Pectoralis Major

16. 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

17. Latissimus Dorsi Flap

18. Morbidity Following Breast Reconstruction
2 Year Follow Up of 205 Women Post TRAM (n=225) and Implant (n=69)
Roth et al, 2007
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

19. 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

20. Latissimus Dorsi Flap Reconstruction
Chest Wall Incision Tightness and Pain
Latissimus Dorsi Flap Reconstruction

21. Tightness, Pain, CORE weakness
Donor Site Morbidity
Tightness, Pain, CORE weakness
TRAM Flap Reconstruction

22. 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
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

23. 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
Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)