4/2/2019 1 Rehabilitation of the Person with Breast Cancer Adrian Cristian MD MHCM Chief, 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
22
Embed
Cristian Breast Cancer Rehabilitation Women's Health ...cme.baptisthealth.net/womenscancersymposium/... · •Post-mastectomy syndrome •Obesity Activity Limitation •Decreased
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
4/2/2019
1
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
4/2/2019
2
• 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
• 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
Axillary Web Syndrome
4/2/2019
11
Axillary Web Syndrome
• 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.
Stubblefield 2014; Koehler LA 2019
Axillary Web Syndrome
• 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,
Stubblefield 2014; Koehler LA 2019
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
4/2/2019
12
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
4/2/2019
13
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
4/2/2019
14
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
4/2/2019
15
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
4/2/2019
16
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
4/2/2019
17
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