Effectiveness of Physiotherapy after breast cancer
Breast cancer is the most common cancer in women. Both screening and treatment of breast cancer have improved significantly over the last few years, resulting in higher survival rates. To improve quality of life of survivors, many recent studies have focused on the complications related to breast cancer treatment. Among other aspects, quality of life is reduced by impairments of the upper limb (e.g. pain, impaired shoulder mobility, decreased strength, arm lymphedema).
In the acute treatment phase of the cancer, breast and axillary surgery and radiotherapy cause scar tissue formation, wound formation, fibrosis, and shortening of soft tissues (eg, pectoral muscles). Initially, this may lead to upper-limb impairments, such as local postoperative pain and a subsequent decrease in range of motion (ROM). In a further postoperative stage, adhesive capsulitis, myofascial dysfunctions, and/ or nerve dysfunctions can also cause pain and impaired shoulder mobility. Forward shoulder position, induced by the shortened pectoral muscles and narrowing of the subacromial space, may lead to rotator cuff diseases, which can be painful and may limit upper-limb movements as well.
Besides pain and impaired shoulder mobility, decreased strength of the upper limb may be present in the short term and long term. These impairments of the upper limb may all lead to difficulties in performing activities of daily living. Another possible provoking factor of pain and impaired shoulder mobility may be lymphovascular disorders (e.g. axillary web syndrome) and the development of lymphedema.
In practice and clinical trials, 4 physiotherapy modalities are used:
1. passive mobilization techniques to restore joint mobility or prevent muscular shortening;
2. manual stretching and transverse strain to prevent tightness of the pectoral muscles;
3. myofascial techniques (eg, myofascial release techniques, sustained trigger point compression) since 45% of patients with breast cancer present with myofascial trigger points in the long term;
4. different types of active exercises should be added: stretching exercises, scapulothoracic exercises (increased posterior tilt, protraction, and decreased lateral rotation of the scapula are often observed) and strengthening exercises to restore arm strength and prevent difficulties in performing activities of daily living.
18 RCT's were included comparing these modalities, as well as the timing of therapy (early vs. delayed to avoid wound problems.)
Multifactorial physiotherapy (i.e. stretching, exercises) and active exercises were effective to treat postoperative pain and impaired ROM after treatment for breast cancer. High-quality studies are necessary to determine the effectiveness of passive mobilization, stretching, and myofascial therapy as part of the multifactorial treatment. In addition, the appropriate timing and content of the exercise programs need to be further investigated.
> From: De Groef et al., Arch Phys Med Rehabil 96 (2017) 1140-1153. All rights reserved to American Congress of Rehabilitation Medicine. Click here for the online summary.