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AN ASSESSMENT OF SHOULDER RANGE OF MOTION, MUSCLE STRENGTH, AND HAND GRIP STRENGTH IN RELATION TO QUALITY OF LIFE AMONG BREAST CANCER SURVIVORS _________________________

A Thesis Proposal Presented to the Faculty of the Graduate School _________________________

In Partial Fulfillment of the Requirements for the Degree Master in Public Health _________________________

By:

Floriza P. de Leon May 2011

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CHAPTER I THE PROBLEM AND ITS BACKGROUND

INTRODUCTION Breast cancer is so far the most frequent type of cancer among women worldwide, resulting in over one million new cases each year and is the leading cause of female cancer-related deaths. In Asia, the

Philippines has the highest incidence rate of breast cancer with a survival rate that is much lower than the world average (GlaxoSmithKline Philippines, 2007). Treatment for breast cancer, such as surgery, radiation therapy, and chemotherapy, have the potential to cause upper extremity impairment on the affected side such as limited range of motion, poor muscle strength and hand grip strength. This is where the role of physical therapy takes place. Under Physical Rehabilitation, these problems are addressed through the application of therapeutic intervention. In

Philippine setting, post-surgical breast cancer patients are not usually referred to a physical rehabilitation institute for the reason that patients are given time to recuperate from the limitations brought about by the operation. Four to six weeks after operation, patients are then referred for

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further treatment such as chemotherapy and radiation therapy. Very rare, these patients are referred to undergo musculo-skeletal assessment.

Arm morbidity being one of the most troublesome complications of breast cancer treatment has a significant impact on the daily lives of breast cancer survivors. The most common impairments reported after breast cancer surgery include reduced range of motion of the shoulder; numbness of the axilla or lateral chest wall; reduced grip strength; and arm edema with a high degree of functional impairment and pain. With advances in the medical treatment of persons with cancer, including the combined use of surgical intervention, radiation therapy, and

chemotherapy, cancer survival rates (defined as a relative combined 5year statistic) are now above fifty percent (50%). As survival rates and survival time have increased, so have public attitudes and the willingness to discuss cancer care is not simply on survival, but on cancer rehabilitation which aims to improve functional status and quality of life (Veronika-Fialka, et al, 2003).

The concept of health-related quality of life (HRQOL) and its determinants have evolved since the 1980s to encompass those aspects of overall quality of life that can be clearly shown to affect health either physical or mental. On the individual level, this includes physical and

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mental health perceptions and their correlates including health risks and conditions, functional status, social support, and socioeconomic status. HRQOL questions about perceived physical and mental health and function have become an important component of health surveillance and are generally considered valid indicators of service needs and intervention outcomes. Self-assessed health status also proved to be more powerful predictor of mortality and morbidity than many objective measure of health (Center for Disease Control and Prevention Online, 2011).

In this light, the researcher assesses the shoulder range of motion, muscle strength, and hand grip strength of breast cancer survivors in relation to quality of life. The objective of the study is also the intention of this study to assess quality of life in terms of physical health, psychological, social relationships and the environment. It aims to

recognize the relationship between the shoulder range of motion, shoulder muscle strength and hand grip strength and levels of quality of life of breast cancer survivors. And lastly, its purpose is to know the implication of the results of the study for public health education. It is the hope of this study that the results could contribute for the eclectic approach in the total rehabilitation of breast cancer survivors. Rehabilitation doctors and

physical therapists can work hand in hand in the integration of new component of therapeutic intervention in the field of cancer rehabilitation. It will be anticipated also that with this study, physical rehabilitation will be

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of help to Physical Therapist on how they should conduct therapeutic intervention and that will result to breast cancer survivors recuperate in a shorter period of time and with a better quality of life.

STATEMENT OF THE PROBLEM This study assesses the shoulder range of motion, muscle strength, and hand grip strength of breast cancer survivors in relation to quality of life. Specifically, it seeks to answer the following questions: 1. How are breast cancer survivors be assessed in terms of: 1.1 shoulder range of motion (all planes) 1.2 shoulder muscle strength 1.3 hand grip strength 2. How may the breast cancer survivors be assessed in terms of their quality of life? 2.1 Physical Health 2.2 Psychological 2.3 Social relationships 2.4 Environment 3. Is there significant relationship between the following and levels of quality of life of breast cancer survivors: 3.1 shoulder range of motion (all planes) 3.2 shoulder muscle strength 3.3 hand grip strength

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4. What are the implications of the results of the study for public health education?

SCOPE AND DELIMITATION OF THE STUDY This study will be focused on the assessment of shoulder range of motion, shoulder muscle strength, hand grip strength and quality of life among breast cancer survivors in selected population. Assessment tools and procedures conformed to the standard method used in clinical practice such as the use of goniometer, manual muscle testing and dynamometer to measure hand grip strength. WHOQOL-BREF will be the assessment tool to be used to evaluate quality of life. This is an

assessment tool formulated by the World Health Organization (WHO).

This research will be conducted in Jose B. Lingad Memorial Regional Hospital (JBLMRH) Physical Therapy Unit were recruited subjects will be assessed by a trained physical therapist. Only one

physical therapist will assessed the participants to preserve validity and reliability of the results. Subjects who will be recruited to participate

should have completed active breast cancer treatment at six(6) months previously and should be at least 25 years of age, and has a good comprehension of the English language. Bilateral breast cancer, infection of the upper extremity, lymphangitis, pre-existing lymphedema, history of neuromuscular or musculoskeletal condition that would affect local upper

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extremity testing or current recurrence will be excluded from the study. Mann-Whitney ranked sum analysis and regression analysis are the statistical tool to be used for hypothesis testing of this study.

The focus of the study is to find relationship between shoulder range of motion, muscle strength and hand grip strength as to their quality of life. The study is limited to other factors that will affect quality of life such as current lifestyle, involvement in support groups, marital status and job satisfaction which are not presented in this study. This study will be conducted from May 2011 to June 2012.

DEFINITION OF TERMS For better understanding of the study on hand, the following terms are defined:

Assessment. It is an evaluation of the condition based on the patients subjective report of the symptoms and course of illness or condition and the examiners objective findings, including data obtained through physical examination, medical history, and information reported by family members and other health care teams (Mosbys Medical Dictionary, 2009). In this study, it refers to the assessment of shoulder range of motion, muscle strength and hand grip strength of the affected side of

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Breast Cancer. It is a type of cancer that forms in tissues of the breast, usually the ducts and lobules. It occurs in both men and women, although male breast cancer is rare (National Cancer Institute, online).

Breast Cancer Survivor. A breast cancer survivors is someone who is living with or beyond cancer (Breast Friends Online, 2011). In this study, this refers to breast cancer patients who underwent surgery, as in mastectomy (removal of the entire breast) or lumpectomy (removal of the lump) and other treatments such as chemotherapy and radiation therapy.

Dynamometer.

An

instrument

that

provides

objective

measurement of limb muscle group strength by having the patient exert maximal effort against a portable force-measuring device held by the examiner (Tan, 2006).

Hand grip strength. It is commonly measured by the used of a hand-held dynamometer (Fronteza et al, 2008).

Manual Muscle Testing. It is a procedure for the evaluation of the function and strength of individual muscles and muscle groups based of

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effective performance of a movement in relation to the forces of gravity and manual resistance (Clarkson, 2000).

Quality of Life.

Condition of an individuals perception of his

position in life in the context of the culture and value systems in which he lives and in relation to his goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the persons physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of their environment (World Health Organization, 2010).

Range of Motion. Range of motion is the maximum amount of movement that is possible in any particular joint (King et al., 1981)

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CHAPTER II REVIEW OF RELATED LITERATURES AND STUDIES

Related Literature Physical Assessment Physical assessment of the breast and axillae is part of periodic health maintenance examination for women of all ages. Breast cancer cannot be prevented, but early detection offers more treatment option and a greater chance of cure. Aside from physical assessment, a

musculoskeletal assessment is also being done to evaluate parameters of function such as flexibility, strength, and endurance (Hamer, 2010).

Physical therapists may be involved in the treatment of breast cancer patients at any stage of their disease. Newly diagnosed patients often treated with a combination of surgery, radiotherapy, chemotherapy and hormone treatments. physiotherapy intervention. experience problems with As a result of this, patients frequently require Following breast surgery, patients can pain, limited shoulder movement and

lymphedema. Radiotherapy to breast tissue can cause tissue fibrosis, resulting in movement limitation and lymphedema. Chemotherapy and hormone therapy can lead to changes in menopausal status and general

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Physical therapists knowledge of anatomy and normal

movement makes them ideally suited in treating this group of patients (Hamer, 2010).

Range of Motion One aspect of musculoskeletal assessment is flexibility. It is being measured in joint range of motion. Range of motion is the amount of motion that is available at a joint is called the range of motion (ROM). The starting position for measuring all ROM, except rotations in the transverse plane, is the anatomical position. Three notation systems have been used to define ROM: the 0-to 180-degree system, the 180- to 0-degree system, and the 360-degree system. In the 0- to 180-degree notion system, the upper and lower extremity joints are at 0 degrees for flexion-extension and abduction-adduction when the body is in anatomical position. A body

position in which the extremity joints are halfway between medial (internal) and lateral (external) rotation is 0 degrees for the ROM in rotation. A ROM begins at 0 degrees and proceeds in an arc toward 180 degrees. This 0- to 180-degree system of notion is widely used throughout the world. First described by Silver in 1923, its use have been supported by many authorities, including Cave and Roberts, Moore, the American Academy of Orthopedic Surgeons, and the American Medical Association (Norkin,1995).

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Normal ROM varies among individuals and is influenced by factors such as age, gender, and whether the motion is performed actively or passively. Numerous studies have been conducted to determine the

effects of age on ROM of extremities and spine. Most investigators who have studied a wide range of age groups have found that older adult groups have somewhat less ROM of the extremities than younger adult group. The effects of gender on the ROM of the extremities and spine also appear to be joint- and motion specific. Boone et al. found that

females across an age range of 21 to 69 years have less hip extension, but more hip flexion, than males in the same age groups. Females in the age range of 1 to 29 years had less hip adduction and lateral rotation than males in the same age groups. Beighton et al., in a study of an African population, found that females between 0 and 80 years of age were more mobile than their male counterparts (McFarland and Kim, 2006).

When evaluating a clients range of motion, a therapist should first observe the client during a function activity. This functional observation may be referred to as a screening because it is not a formal assessment, but a method to allow the therapist to determine quickly which joints need further assessment. By demonstrating proficient observation skills a

therapist will be able to save time in the fast-paced health care environment. If no deficits are noted during observation, the therapist can avoid spending excessive time on measuring the range of motion of each

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joint only to determine that all joints are functional or normal. In addition, this screening can be completed during another assessment such as activities of daily living (ADL). Once a deficit joint or joints are noted, the therapist will need to complete a goniometry assessment. The purpose of goniometry is to measure the arc of motion of joint. In order to measure this arc of motion, the therapist utilizes bony landmarks on the human body to place the goniometer. The goniometer is the most commonly used instrument to measure joint motion. shapes. There are many sizes and All

Some goniometers are plastic while others are metal.

goniometers have a body and two arms. The body is a full or semicircle with a center point called the axis or fulcrum. One arm is called the

stationary arm and the other is the movable arm (Clarkson,2000).

During the use of the goniometer, the axis or fulcrum is placed over the axis of motion being measured. The movable arm is also aligned with the plane of motion, but is distal to the joint being measured and follows the arm of motion. Now that the goniometer placement has been

determined, it is important to understand the planes and axis of joint motion. The planes are the surfaces along which movement occurs.

They are imaginary sheets of glass that run through the body. There are different planes (of glass) running through the body in different directions because the body moves in different directions. Movement of the body generally occurs in an arc or circular motion. The axis or fulcrum is the

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The axis of the body is a straight line running

through the body like an arrow. This axis also runs through a plane (sheet of glass). Because the axis runs through the plane, it must be

perpendicular to that plane. Each axis and plane that are perpendicular to each other create a partnership. The plane is the flat surface along which the movement occurs, and the axis is the location around which the movement occurs (Latella and Meriano, 2003).

Figure 1: Shoulder Range of Motion

Muscle Strength Assessing the patients ability to flex or extend the extremities against resistance tests muscle strength. The function of an individual muscle or group of muscles is evaluated by placing the muscle at a

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The quadriceps, for example, is a powerful muscle

responsible for straightening the leg. Once the leg is straightened, it is exceedingly difficult for the examiner to flex the knee. If the knee is flexed and the patient is asked to straighten the leg against resistance, weakness can be elicited. The evaluation of muscle strength compares the sides of the body to each other. For example, the right upper extremity is

compared to the left upper extremity. Subtle differences in strength may be evaluated by testing for drift. For example, both arms are out in front of the patient with palms up; drift is seen as pronation of the palm, indicating a subtle weakness that may not have been detected on the resistance examination. Clinicians use a 5-point scale to rate muscle strength. A 5 indicates full power of contraction against gravity and resistance or normal muscle strength; 4 indicates fair but not full strength against gravity and a moderate amount of resistance or slight weakness; 3 indicates just sufficient strength to overcome the force of gravity or moderate weakness; 2 indicates the ability to move but not to overcome the force of gravity or severe weakness; 1 indicates minimal contractile power (weak muscle contraction can be palpated but no movement is noted) or very severe weakness; and 0 indicates no movement (Hislop and Montgomery, 2007).

It is commonly recognized that a number of factors affect strength. The therapist must consider these factors when assessing a patients strength. First to consider is the age. Muscle strength increases from

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birth to a maximum point between 20 and 30 years of age. Following this maximum, a decrease in strength occurs with increasing age due to a deterioration in muscle mass. Muscle fibers decrease in size and number, connective tissue and fat increase, and the respiratory capacity of the muscle decreases. Another point is that, men are generally stronger than women. Muscle size also play an important role in the intensity of muscle strength. The larger the cross-sectional area of a muscle, the greater the strength of the muscle. When testing a muscle that is small, the therapist would expect less tension to be developed than if testing a large, thick muscle (Clarkson, 2000).

Figure 2: Manual Muscle Testing of the Shoulder

Hand Grip Strength Manual muscle testing evaluates only individual muscle or small muscle groups. In the forearm and hand movement, there are thirty five

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muscles involved, with many of these involved in gripping activities.

this reason, hand grip strength is difficult to assess by merely using the manual muscle testing. Hand function can be quickly assessed by

performing a number of movements to test overall function of the wrist and hand. Although the wrist, hand, and finger joints have the ability to move through a relatively large ROM, most functional daily tasks do not require full ROM. The optimum functional ROM at the wrists is approximately 10 deg flexion to 35 deg extension along with 10 deg of radial deviation and 15 deg of ulnar deviation. Normally, the wrist is held in slight extension and slight ulnar deviation and is stabilized in this position to provide maximum function for the fingers and thumb. Excessive radial deviation, like ulnar drift of the fingers, can affect grip strength adversely. Functional flexion at the metacarpophalangeal and proximal interphalangeal joints is approximately 60 degrees (Hoeger and Hoeger, 2009).

Figure 3: Testing Hand Grip Strength with a Dynamometer

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The most common method of assessment for grip strength is the use of handheld dynamometer. This is a form of what is referred to as a biomechanical measurement. Biomechanical measurements allow sports coaches to appreciate the bioenergetics and efficiency of sports movements; traning can then aim to achieve a maximal energetic output with minimal expenditure of energy, avoiding at the same time possible fatigue and stress lesions in the locomotory system. Handheld grip

strength dynamometry is used to measure the muscular force generated by flexor mechanisms of the hand and forearm (Hoeger and Hoeger, 2009).

Breast Cancer Flexibility and muscle strength are the primarily affected in breast cancer which is an uncontrolled growth of breast cells. The breasts, or mammary glands, consist of fat pads inside of which is a branching system of ducts. These ducts are designed to ferry milk from the milkproducing lobules to the nipples. Breast cancer develops as the result of malignant changes in the cells lining the ducts or the lobules. The first abnormalities that occur are not themselves cancer but are simply an overgrowth of normal cells in the ducts or lobules. These conditions are called intraductal hyperplasia. If these extra cells seem a bit odd-looking when examined under the microscope, the condition is called atypical hyperplasia. Atypical hyperplasia does not cause lumps and cannot be

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detected by breast examination or by mammogram. When it is discovered in the ducts or lobules, it is usually by accident, in the course of biopsying a suspicious lump. If cells lining the ducts or lobules become odder still and start to clog them, the condition is called carcinoma in situ. Ductal carcinoma in situ and lobar carcinoma in situ by definition remain confined to the ducts or lobules, but they can sometimes be detected by mammogram, and in rare instances may produce a lump that can be felt. If the abnormal cells break away from these parts of the breast to infiltrate adjoining cells, the condition is called invasive cancer. It is at this point that a discrete malignant lump starts to grow (Carlson et al., 2004).

Stages of Breast Cancer The stage of cancer is based on: the size of the tumor, whether the cancer is invasive or noninvasive, whether lymph nodes are involved, and whether it has spread beyond the breast and nodes.(Carvalho and Stewart, 2009). Once all of these factors are determined, staging of cancer can be done and is classified in the table below.

Table 1: Stages of Breast Cancer Stages Characteristics 0 Means that there is no invasion of the cancer cells 1 surrounding tissue Describes invasive breast cancer, in which the cells are breaking through to surrounding tissue and the tumor is 2

ANGELES UNIVERSITY GRADUATE SCHOOL centimeters or less in greatest dimension and no lymph 2 nodes are involved. IIA describes invasive breast cancer in which no tumor is

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found in the breast, but cancer cells are found in the axillary lymph nodes (lymph nodes under the arm), or

Tumor measures 2 centimeters or less and has spread to the axillary lymph nodes, or

The tumor is larger than 2 centimeters but less than 5 centimeters and has not spread to the axillary lymph nodes IIB

Tumor is larger than 2 but less than 5 centimeters and has spread to the axillary lymph nodes, or

3 IIIA -

The tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes. No tumor is found in the breast. Cancer is found in the axillary lymph nodes that are clumped together or sticking to other structures or the cancer has spread to the axillar nodes near the breastbone, or

The tumor is 5 centimeters or smaller and has spread to axillary lymph nodes that are clumped

ANGELES UNIVERSITY GRADUATE SCHOOL together or sticking to other structures, or -

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Tumor is larger than 5 centimeters and has spread to axillary lymph nodes that are clumped together or sticking to other structures

IIIB Tumor may be any size and has spread to the chest wall and/or skin of the breast, and Tumor may have spread to axillary lymph nodes that are clumped together or sticking to other structures or cancer may have spread to lymph nodes near the breastbone. IIIC There may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have spread to the chest wall and/or skin of the breast, and The cancer has spread to lymph nodes above or below the collarbone, and 4 The cancer may have spread to axillary lymph nodes

or to lymph nodes near the breastbone. Describes invasive breast cancer that has spread to other organs of the body, usually the lungs, liver, bone, or brain. It is also called metastatic breast cancer.

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TNM Staging System According to Harrisons Manual of Oncology, 2007, TNM (Tumor, Node, Metastasis) is another staging system researchers use to provide more details about how the cancer looks and behaves. Physician might mention the TNM classification, but he is much more likely to use the numberical staging system. Sometimes clinical trials require TNM

information from participants (Chabner et al., 2007)

Breast Cancer Symptoms The classic symptom of breast cancer is a lump in the breast, but many lumps are not cancerous. They are the result of normal hormonal changes or trauma to the breast. Although half of all breast lumps in postmenopausal women (and three-quarters of all breast lumps in women over the age of 70) are malignant, the younger a woman is, the more likely it is that her breast lump is benign. Pain in the breast is also highly

unlikely to signal breast cancer; only 6 percent of women with breast cancer have breast pain as a symptom. If a lump is cancerous, it is

generally difficult to move under the skin and often feels rock-hard with irregular edges. There is no sure way to distinguish a malignant from a benign lump by touch alone, however. For this reason, any woman who notices a change in her breasts such as a lump or thickening, clear or

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bloody discharge, change in contours, dimpling of skin, redness, or retracted nipple should consult a clinician (Carlson et. al.,2004).

Figure 4: Breast Cancer Symptoms

Breast Cancer Statistics About 1 in 8 women in the United States (12%) will develop invasive breast cancer over the course of her lifetime. (BreastCancer.Org, April 19, 2011). In 2010, an estimated 207,090 new cases of invasive breast cancer were expected to be diagnosed in women in the United States(U.S.), along with 54,010 new cases of non-invasive (in situ) breast cancer. About 1,970 new cases of invasive breast cancer were expected to be diagnosed in men in 2010. Less than 1% of all new breast cancer cases occur in men. From 1999 to 2006, breast cancer incidence rates in the U.S. decreased by about 2% per year. One theory is that this

decrease was partially due to the reduced used of hormone replacement

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therapy (HRT) by women after results of a large study called the Womens Health Initiative were published in 2002. These results suggested a connection between HRT and increased breast cancer risk (Dow, 2006).

About 39,840 women in the U.S. were expected to die in 2010 from breast cancer, though the rates have been decreasing since 1990. These decreases are thought to be the result of treatment advances, earlier detection through screening, and increased awareness. For women in the U.S., breast cancer death rates are among higher than those for any other cancer, besides lung cancer. Besides skin cancer, breast cancer is the most commonly diagnosed cancer among U.S. women. More than 1 in 4 cancers in women (about 28%) are breast cancer. Compared to African American women, white women are slightly more likely to develop breast cancer, but less likely to die of it. One possible reason is that African American women tend to have more aggressive tumors, although why this is the case is not known. Women of other ethnic backgrounds Asian, Hispanic, and Native American have a lower risk of developing and dying from breast cancer than white women and African American women. In 2010, there were more than 2.5 million breast cancer survivors in the U.S. A womans risk of breast cancer approximately doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer. About 20-30% of women diagnosed with breast

cancer have a family history of breast cancer. About 5-10% of breast

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cancer can be linked to gene mutations (abnormal changes)inherited from ones mother or father. Mutations of the BRCA1 and BRCA2 genes are the most common. Women with these mutations have up to an 80% risk of developing breast cancer during their lifetime, and they are more likely to be diagnosed at a younger age (before menopaue). An increased

ovarian cancer risk is also associated with these genetic mutations. In men, about 1 in 10 breast cancers are believed to be due to BRCA2 mutations and even fewer cases to BRCA1 mutations. About 70-80% of breast cancers occur in women who have no family history of breast cancer. These occur due to genetic abnormalities that happen as a result of the aging process and life in general, rather than inherited mutations. The most significant risk factors for breast cancer are gender (being a woman) and age (growing older) (Breastcancer.org, 2011).

Breast Cancer Risk Factors The rapidly increasing and high incidence of breast cancer over the past few decades supports the hypothesis that factors determining breast cancer risk have changed. Some of this change can be directly

attributable to a reduction of protective factors (e.g. increasing parity, early age at first birth) in a higher proportion of women. Other factors which are known to increase breast cancer risk (i.e. obesity, low physical activity, and the use of exogenous hormones) have become more common. In addition to these changes in risk factors, breast cancer screening has

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impacted disease incidence. Mammography artifactually increased breast cancer incidence in the short-term by advancing the lead time for prevalent disease and possibly in the long-term by identifying lesions with limited malignant potential. In general, greater lifetime exposure to

estrogen, influenced by endogenous and exogenous risk factors, increases risk of breast cancer. Although many exposures that increase risk are not readily modifiable, some behaviors can be adopted to decrease risk (Morrow and Jordan, 2003).

Screening for Breast Cancer The purpose of breast cancer screening is to separate women who are clearly normal from those with abnormalities, with the goal of intervening in the disease process after biologic onset but before symptoms or signs develop. Mammography, regular breast exams, and breast self- examination are the key components of early detection and surveillance. Additional radiologic modalities will be mentioned as The use of

adjuncts, but they are not basic screening tools.

mammography to screen asymptomatic women 40 year of age and over for early detection of breast cancer has been shown to reduce mortality rates by 20-30%. A standard screening mammogram includes two views of each breast. Additional views at different angles or increased

compression of the breast tissues may be included for better definition of the character of the breast tissue (Aziz and Wu, 2002).

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Treatment and Side effects Successfully treating breast cancer means getting rid of the cancer or getting it under control for an extended period of time. But because a breast cancer is made up of different kinds of cancer cells, getting rid of all those cells can require different types of treatments. Treatment plan may include a combination of the following treatments: surgery, radiation

therapy, chemotherapy, hormonal therapy (anti-estrogen therapy) and some targeted therapies (such as Herceptin, Tykerb and Avastin). Surgery is usually the first line of attack against breast cancer. Decisions about surgery depend on many factors. The patient and the doctor will determine the kind of surgery thats most appropriate for you based on the stage of the cancer, the personality of the cancer, and what is acceptable to the patient in terms of long-term peace of mind. Under certain circumstances, people with breast cancer have the opportunity to choose between total removal of a breast (mastectomy) and breastconserving surgery (lumpectomy) followed by radiation. Lumpectomy

followed by radiation is likely to be equally as effective as mastectomy for people with only one site of cancer in the breast and a tumor under 4 centimeters. Clear margins are also a requirement (no cancer cells in the tissue surrounding tumor). Another treatment option is the radiation therapy also called radiotherapy is a highly targeted, highly effective way to destroy cancer cells in the breast that stick around after surgery.

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Radiation can reduce the risk of breast cancer recurrence by about 70%. Despite what many people fear, radiation therapy is relatively easy to tolerate and its side effects are limited to the treated area. Radiation

treatments will be overseen by a radiation oncologist, a cancer doctor who specializes in radiation therapy (Miller, 2008).

Radiation therapy uses a special kind of high-energy beam to damage cancer cells. (Other types of energy beams include light and xrays). These high-energy beams, which are invisible to the human eye, damage a cells DNA, the material that cells use to divide. Over time, the radiation damages cells that are in the path of its beam normal cells as well as cancer cells. But radiation affects cancer cells more than normal cells. Cancer cells are very busy growing and multiplying 2 activities

that can be slowed or stopped by radiation damage. And because cancer cells are less organized than health cells, it is harder for them to repair the damage done by radiation. So cancer cells are more easily destroyed by radiation, while healthy, normal cells are better able to repair themselves and survive the treatment. Tissues to be treated might include the breast area, lymph nodes, or another part of the body (Hunt et al., 2007).

Among the treatments for breast cancer, chemotherapy is the most popular. Chemotherapy treatment uses medicine to weaken and destroy cancer cells in the body, including cells at the orginal cancer site and any

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cancer cells that may have spread to another part of the body. Chemotherapy, often shortened to just chemo, is a systemic therapy, which means it affects the whole body by going through the bloodstream. There are quite a few chemotherapy medicines. In many cases, a

combination of two or more medicines will be used as chemotherapy treatment for breast cancer. Chemotherapy is used to treat: early-stage invasive breast cancer to get rid of any cancer cells that may be left behind after surgery and to reduce the risk of the cancer coming back; advanced-stage breast cancer to destroy or damage the cancer cells as much as possible. In some cases, chemotherapy is given before surgery to shrink the cancer (Miller, 2008).

Psychosocial Status and Health-Related Quality in Breast Cancer Breast cancer is a stressful even that can perturb psychologic equilibrium and reduce health-related quality of life (HRQOL) in the shortterm; recent survivorship research has evaluated long-term sequelae. Early studies involved mainly small convenience samples (maximum, 61 survivors), descriptive designs, and interview-based measurements. Key results of these studies include observations that the majority of survivors are fairly to very satisfied with their lives 8 years after diagnosis despite thoughts of recurrence reported by 50%; that survivors have a positive perception of life and attach less importance to trivial stressors even though fear of recurrence is a major concern; and that the majority of

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survivors thrive despite experiencing problems related to breast cancer and its treatment. (Ganz and Horning, 2007)

Quality of Life The quality of life (QOL) assessment is an important aspect of the current care provided to cancer patients. Tradition medical evaluations of the outcomes of cancer treatments have included disease-free survival, tumor response, and overall survival (U.S. Department of Health and Human Services, 1990). However, clinicians and researchers have come to realize that these outcomes are not adequate in assessing the impact of cancer and its treatment on the patient and daily life, nor in identifying interventions to improve or maintain the patients quality of life. Quality of life measurements provide valuable information to all members of the health care team. Interest in QOL assessment has continued to increase in recent years. The World Health Organization (WHO) has a global

cancer control program based on knowledge currently available that, if appropriately implemented, can reduce cancer morbidity and mortality worldwide. This program includes a focus on palliative care and its impact on the QOL of cancer patients. Since many of the worlds cancer patients have no access to effective cancer therapy, only palliative care can be offered. Palliative care programs frequently focus on symptom

management and can greatly improve QOL (World Health Organization Official Website, 2011).

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Defining Quality of Life Quality of life (QOL) is an ill-defined term. The World Health

Organization (WHO, 1948) declares health to be a state of complete physical, mental and social well-being, and not merely the absence of disease. Many other definitions of both health and quality of life have been attempted, often liking the two and, for quality of life, frequently emphasizing components of happiness and satisfaction with life. In the absence of any universally accepted definition, some investigators argue that most people, in the Western world at least, are familiar with the expression quality of life and have an intuitive understanding of what it comprises. However, it is clear that quality of life means different things to different people, and takes on different meanings according to the area of application (Fayers, et al 2007).

Quality of life assessment is complicated by the fact that there is no universally accepted definition of quality of life. In the past, many

researchers measured only one dimension, such as physical function, economic concern, or sexual function. More recently, researchers have attempted to further define QOL. Spillker (1990) described QOL

assessment through three interrelated levels: (a) overall assessment of well-being; (b) broad domains such as physical, psychological, economic, and social; and (c) the components of each domain. While progress has

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been made in defining QOL, developing qualitative and quantitative methodologies to study QOL, and identifying QOL outcomes, many research issues persist, including conceptual and methodological issues (King et al., 2003)

Methodological Issues in Survivorship Research The Office of Cancer Survivorship of the National Cancer Institute (U.S) defines a survivor as follows: An individual is considered a cancer survivor from the time of cancer diagnosis, through the balance of his or her life. Family members, friends and caregivers are also impacted by the survivorship experience and are therefore included in this definition. This is a very broad definition, most survivorship research in breast cancer focuses on the experience of individuals with cancer after they have completed their primary therapy, usually while they are free of recurrent disease. Some studies have focused on women who are 1, 3, 5, or more years post diagnosis. In breast cancer, where long-term survival is

becoming increasingly common, this variable definition may account for some of the inconsistencies in the literature (Ganz and Horning, 2007).

Related Studies Hayes et. al. (2010) conducted a 12 month period study assessing the upper body function and correlating it with quality of life among Breast Cancer patients post-surgery. Clinical assessment of upper body function

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(UBF) were done for strength and endurance, handgrip strength, and flexibility in that order. On the other hand, Functional Assessment of

Cancer Therapy-Breast (FACT-B+) questionnaire was included in the self administered survey to provide a measure of quality of life (QOL). This longitudinal study shows evident declines in UBF and that it continues to occur for some women well beyond the treatment period and that optimal UBF in the and short- and longer time following breast cancer is important with respect to concurrent quality of life and subsequent quality of life. Consequently, these findings provide support for the integration of a rehabilitation program into the care of women with breast cancer, which not only targets minimizing declines and facilitating recovery during and following breast cancer treatment, but also assists women to optimize clinical function and come to terms with perceived changes that have occurred with respect to UBF.

In a similar study conducted by Beaulac et. al. (2007), he cited the association between arm function and quality of life in survivors of early stage of breast cancer. Arm function was assessed by measuring range of motion and handgrip strength. Three aspects of shoulder movement (flexion, abduction and rotation) were examined. Based on

recommendations of the Boston University Medical Center Physical Therapy Department, shoulder movement was measured, because limited shoulder range of motion is more common and more difficult to

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compensate for than limited elbow or wrist movement in patients. Results were recorded based on a scale from 1 to 6, with 1 representing almost no movement, and 6, representing almost no movement. Handgrip strength was measured using a hydraulic hand dynamometer. The average of

three grip strength measurements was recorded for each hand. Quality of life measurements was assessed through FACT-B+4 survey and were scored and interpreted in accordance with the standardized scoring protocol. Results showed that those with full range of motion had an

increased total FACT-B+4, whereas those with decreased ROM had a decreased range of motion recorded lower functional and physical wellbeing and total FACT-B+4 scores.

Kaya et al (2010) did a comparable research using the same WHAT assessment tool used by Beaulac et. al. that aimed to determine the prevalence of impairments relevant to upper extremity following breast cancer surgery and its impact on disability and health-related quality of life. Subjects were evaluated for impairments (arm edema, loss of

handgrip strength, limited shoulder joint range of motion, physical disability using the disabilities of the arm, shoulder and hand (DASH) questionnaire and for health-related quality of life by means of the functional assessment of cancer therapy-breast+4 (FACT-B+4). Results showed that the most common impairment observed was arm pain on motion. Arm pain on motion, anterior chest wall pain, loss of grip strength, and shoulder flexion

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were significant factors in different domains of quality of life according to the FACT-B+4 questionnaire. The effect of pain in the arm subgroup of the FACT-B+4 was more pronounced when compared with other dependent variables.

In a different study done by Daves, et. al. (2008), they identified the impact of lymphoedema or arm function and health-related quality of life in women following breast cancer surgery. The study aims to estimate the extent to which the impairments associated with lymphoedema are linked to arm dysfunction and suboptimal health-related quality of life. A cross sectional study, embedded within a pilot for an epidemiology study, was undertaken involving women who had undergone surgery for unilateral stage I or II breast cancer. Two questionnaires (a lymphoedema

screening questionnaire and the Disabilities of Arm, Shoulder and Hand questionnaire) and women with symptoms attended for further testing. Women with self reported symptoms of lymphoedema had a significantly higher score on the Disabilities of Arm, Shoulder and Hand questionnaire, indicating activity limitation, participation restriction and suboptimal healthrelated quality of life.

In relation to Daves study, Ahmed, et. al. (2008) reported the impact of lymphedema or related arm symptoms in health-related quality of life (HRQOL) in breast cancer survivors. Arm symptoms assessment

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basically included flexibility and muscle strength of the affected side; and was evaluated through goniometric techniques and manual muscle testing. In Daves study, they measure upper extremity function through the use of Disability of Arm, Shoulder and Hand (DASH) Outcome Measures. In assessing quality of life, Medical Outcome Study Short

Form-36 Version 2 was used instead of the WHOQOL-BREF to be used in this study. Though it measures the same domains, it used a different format questionnaire.

In this study of unilateral breast cancer survivors in Iowa, 45% had either diagnosed lymphedema or arm symptoms without diagnosed lymphedema consistent with other reports. HRQOL was significantly

lower in breast cancer survivors without lymphedema compared with survivors without lymphedema or arm symptoms. Although women with known lymphedema experienced more arm symptoms on average, women with arm symptoms without diagnosed lymphedema had altered HRQOL in more domains of physical and mental HRQOL. Perhaps not surprisingly, there was a significant dose-response relationship for decreasing SF-36 scores by number of arm symptoms.

More complicated study done by Caban, et. al. (2006) studied the relationship between depressive symptoms and shoulder mobility among older women a year after breast cancer diagnosis. Depressive symptoms

ANGELES UNIVERSITY GRADUATE SCHOOL were linked as poorer quality of life.

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Association between depressive

symptoms and shoulder range of motion at one year after breast cancer diagnosis were examined. Depressive symptoms, sociodemographic

characteristics and breast cancer treatment were measured at 2 months and shoulder range of motion at 12 months. The relationship among

variables were evaluation with bivariate chi-square statistics and logistic regression analysis. Results showed an increasing depressive symptoms at baseline were associated with lower arm mobility at 12 months following breast cancer diagnosis. Each unit increases in depressive symptoms at baseline was associated with an eight percent decreased of odds of having full range of motion of shoulder.

Nesvold, et. al. (2010) discussed the association between arm/shoulder problems in breast cancer survivors and reduced health and poorer physical quality of life. In this study, demography, lifestyle, quality of life (QOL) and somatic morbidity in breast cancer survivors with and without arm/shoulder problems were examined. Association of restricted shoulder abduction with quality of life were also compared. In usnivariate analysis, arm/shoulder problems were associated with not being employed, having had mastectomy, longer follow-up time, radiotherapy to axilla, poorer self-rated health and physical condition, minimal physical activity, increased body mass index, regularly intake of analgesics and poorer physical quality of life. Multivariate analysis showed that

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mastectomy, longer follow-up time, minimal physical activity and poorer physical quality of life were associated with belonging to arm/shoulder problems group. There was also significant association with having

impaired abduction of greater than or equal to 25 degree difference.

In another study by Smoot (2009), he determines the impact of impairments on arm function and quality of life (QOL). All participants attended a single evaluation session and both upper extremities were assessed. Testing was completed by one investigator. Strength for hand grip was assessed using hand held dynamometer. Strength scores were obtained for shoulder abduction, elbow flexion, and wrist flexion using the MicroFET2 dynamometer (Hoggan MicroFET2 Muscle Tester Model 7477, ProMed Products, Atlanta). A goniometer was used to measure ranges of motion (ROM) of the upper extremities. Shoulder flexion, shoulder

abduction, shoulder external rotation, elbow flexion and extension, wrist flexion and extension, and flexion of the proximal interphalangeal joint of digit two were measured following standardized procedures reported by Norkin. The Quality of Life Cancer Survivors Questionnaire (QOL-CS) was used to assess quality of life in cancer survivors. Four subscales are calculated and represent physical, psychological, social and spiritual domains.

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This study indicates that following breast cancer treatment, women with or without lymphedema presents with upper extremity impairments. Women with lymphedema more frequently report pain, demonstrate bilateral deficits in shoulder ROM and upper extremity strength compared to women without lymphedema, and is present with greater restrictions in activity. Reduced upper extremity strength is associated with poorer quality of life in the physical, psychological, and social subscales of the QOL-CS questionnaire.

In a study of Cantero-Villanueva et. al. (2011), they aimed to investigate the relationship between shoulder movement and quality of life in breast cancer survivors. Quality of life is only measured against its relationship to shoulder movements. Women completed the Breast

Cancer-Specific Quality of Life questionnaire, the Piper Fatigue Scale, in addition to the assessment of shoulder flexion range of motion. Results showed that fatigue was greater in those patients with reduced shoulder movement.

Sagen et. al. (2009) accomplished a 5 year follow-up study to describe changes in arm morbidities and health-related quality of life (HRQOL) and to find factors that predict HRQOL 5 years after the surgery. The subjects were examined for arm volumes, shoulder function, and HRQOL, prior to surgery, and 6 months and 5 years after surgery. Arm

ANGELES UNIVERSITY GRADUATE SCHOOL morbidities were seen to decrease over time.

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Several dimensions of

HRQOL temporarily declined after surgery, but significantly improved in the period from 6 months to 5 years after surgery.

CHAPTER III RESEARCH DESIGN AND PROCEDURE Research Method The descriptive correlational research method is used in this study. A descriptive correlational research method aims to describe relationships among variables, without seeking to establish causal connections (Loiselle

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et al, 2010). This study assesses the shoulder range of motion, muscle strength and grip strength of the affected upper extremity and also assesses the present quality of life of breast cancer survivors. Likewise, this research is classified as descriptive correlational since it seeks to recognize relationships between range of motion, muscle strength, handgrip strength and quality of life among breast cancer survivors

Research Locale The study will be conducted at Jose B. Lingad Memorial Regional Hospital(JBLMRH) Physical Therapy Unit where assessment will be done by only one trained physical therapist.

Respondents of the Study Women who have completed active breast cancer treatment at six(6) months previously, will be recruited. The women are required to be at least 25 years of age, and is able to read English. Women will excluded for bilateral breast cancer, current upper extremity infection, lympangitis, pre-existing lymphedema, pre-existing neuromuscular or musculoskeletal conditions that would affect local upper extremity testing, or current recurrence of breast cancer. Study participant will be recruited through the outpatient department of the Physical Therapy Unit of JBLMRH, existing support

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groups in Pampanga and willing participants of ALLTO clinical trial project at the St. Lukes Medical Center, Quezon City. Research Instruments This study will This study will utilize the following instruments: 1. WHOQOL-BREF assessment tool for measuring the quality of life of

breast cancer survivors. The assessment tool measures 6 domains of quality of life and each domain has facets incorporated in each domain. Facets in each domain of overall quality of life and general health are the following:

Table 2: WHOQOL-BREF Domains Domain 1. Physical Health Facets Incorporated within Domains Activities of daily living Dependence on medicinal substances and medical aids Energy and fatigue Mobility Pain and discomfort Sleep and rest Work capacity Bodily image and appearance Negative feelings Positive feelings Self-esteem Spirituality/religion/personal beliefs Thinking, learning, memory and concentration Personal relationships Social support Sexual activity Financial Resources

2. Psychological

3. Social Relationships 4. Environment

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Freedom, physical safety and security Health and social care: accessibility and quality Home environment Opportunities for acquiring new information and skills Participation in and opportunities for recreation/leisure activities Physical environment (pollution/noise/traffic/climate) Transport

Each respondent will be asked to rate each item. There are eight sets of tables of questions which has different rating systems. following rating system is adherent to the following: The

Table 3: Ratings of Quality of Life Ratings 1 2 3 4 5 Description Very Poor Poor Neither Poor nor Good Good Very Good

Table 4: Satisfaction with Health 1 2 3 4 5 Very dissatisfied Dissatisfied Neither satisfied Nor dissatisfied Satisfied Very Satisfied

Table 5 and 6: Quantity of Experiences in Certain Things

ANGELES UNIVERSITY GRADUATE SCHOOL 1 2 3 4 5 Not at all A little A moderate amount Very much An extreme amount

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Table 7: Quantity of Doing Certain Things 1 2 3 4 5 Not at all A little Moderately Mostly Completely

Table 8: Ability to Get Around 1 2 3 4 5 Very poor Poor Neither poor nor good Good Very Good

Table 9: Satisfaction Over Various Aspects of Life 1 2 3 4 5 Very dissatisfied Dissatisfied Neither satisfied nor dissatisfied Satisfied Very Satisfied

Table 10: Frequency of Experiencing Certain Things 1 2 3 4 5 Never Seldom Quite Often Very Often Always

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Musculoskeletal Assessment of the Upper extremity 2.1. Range of Motion Through the use of a standard goniometer, range of motion of each shoulder is assess and noted on a table format. Table 11: Assessment form for Shoulder Range of Motion Range of Motion Shoulder flexion Shoulder Abduction Shoulder Rotation Shoulder Rotation 2.2. Shoulder Muscle Strength Manual muscle testing (MMT) will be used to measure muscle strength of the shoulder. MMT uses a standard grading system and is as follows: External Internal Active (L) Passive (L) Active (R) Passive(R)

Grade 5 patient can hold the position against maximum resistance through complete range of motion Grade 4 patient can hold the position against strong to moderate resistance and has full range of motion.

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Grade 3 patient can tolerate no resistance but can perform the movement through the full range of motion Grade 2 patient has all or partial range of motion in the gravity eliminated position Grade 1 the muscle/muscles can be palpated while the patient is performing the action Grade 0 no contractile activity can be felt in the gravity eliminated position.

2.3.

Handgrip Strength Protocol

This protocol follows the standard procedures measuring handgrip strength using a dynamometer. Results are compared to the following normative value. Table 12: Normative Values in Hand Grip Strength Among Women Age Female Hand 20 25 30 35 40 45 50 21.5 kg 22 kg 21 kg 19.5 kg 18.5 kg 17.5 kg 17.75 kg 10 kg 20 kg 19 kg 18.75 kg 17.75 kg 16.75 kg 16.5 kg Dominant Female Non Dominant Hand

Statistical Treatment

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Statistical analyses will be performed using SPSS statistical sorftware (Version 17). Means and standard deviations for interval data will be obtained and unpaired t-tests for significance of differences will performed for normally distributed data. Mann-Whitney ranked sum

analysis will be used to measure the test of difference for non-formally distributed interval data. Another statistical method to be used is the

Spearman correlation that indicates the direction of association between X (the independent variable) and Y (the dependent variable). Regression analysis was used to evaluate the contribution of variables of theoretical interest to the outcome measure. Multiple linear regression will be

selected for normally distributed interval data. For hypothesis testing, pvalues less than 0.05 were considered significant. Research Procedures The following are the procedures which will be used in conducting of the study: 1. 2. 3. Recruitment of Participants Selection of Participants Assessment of Participants

Recruitment of Participants

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Willing participants are very important in this study since it is very difficult to look for participants that inspite of their illness, is still able to undergo and participate in research studies. Participants will be

recruited from the Jose B. Lingad Memorial Regional Hospital (JBLMRH) out-patient department, breast cancer support groups in Pampanga and subjects from the ALLTO Clinical Trial at the St. Lukes Medical Center. ALLTO Clinical Trial is an on-going study that involves breast cancer survivors.

Selection of Participants Those who are willing to participate in the study will be further assess if they meet the inclusion criteria of this research. Criteria for inclusion are the following: 1. Women who have completed active breast cancer treatment at six(6) months previously. 2. The women are required to be at least 25 years of age, and is able to read English. 3. Women with bilateral breast cancer will be excluded, current upper extremity infection, lympangitis, pre-existing lymphedema, pre-existing neuromuscular or musculoskeletal conditions that would affect local upper extremity testing, or current recurrence of breast cancer.

Assessment of Participants

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Participants will be assessed according to the research method mentioned above. Assessment tools will be used to measure variables of interest. Goniometry will be used in the assessing the shoulder range of motion, manual muscle testing will be employ to measure shoulder muscle strength and hand grip strength will be assessed using a standard dynamometer.

BIBLIOGRAPHY A. BOOKS Carlson, Karen J., et. al. (2004). The New Harvards Guide to Womens Health. U.S.A: Harvard University Press.

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Carvalho, Lucia Guiggio, et. al. (2009). The Everything Health Guide to Living with Breast Cancer: An Accessible and Comprehensive Resource for Women. U.S.A: Everything Books. Chabner, Bruce, et. al. (2007). Harrisons Manual of Oncology. U.S.A.: McGrawHill Professional. Dow, Karen Hassey (2006). Pocket Guide to Breast Cancer. London: Jones and Barlett Publishers International. Fayers, et al. (2007). Quality of Life: The Assessment, Analysis and Interpretation of Patient-Reported Outcomes. U.S.A.: John Wiley and Sons. Fronteza, Walter, et. al., (2008). Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorder, Pain and Rehabiliation. Philadelphia: Saunders Company Hamer, Victoria. (2010). Breast Cancer Nursing Care and Management. U.S.A: John Wiley and Sons. Hislop, Helen J. (2007). Daniels and Worthinghams Muscle Testing: Techniques of Manual Examination. U.S.A: Saunders/Elsevier. Hunt, et al. (2007). Breast Cancer. U.S.A: Springer. Kendall, Florence Peterson et. al. (1993). Muscles: Function, Fourth Edition. Baltimore: Williams and Wilkins. Testing and

King, Cynthia, et al. (2003). Quality of life. Canada: Jones and Barlett Publishers International King, Eunice M., et.al. (1981). Illustrated Manual of Nursing Techniques. U.S.A: Lippincott Company. McFarland, Edward G. and Tae Kyun Kim (2006). Examination of the Shoulder: The Complete Guide. New York: Thiemes Medical Publishers, Inc. Miller, Kenneth D. (2008). Choices in Breast Cancer Treatment: Medical Specialists and Cancer Survivors. U.S.A.: The John Hopkins University Press.

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Morrow, Monica, et al. (2003). Managing Breast Cancer Risk. U.S.A.: PMPH. Tan, Jackson C. (2006). Practical Manual of Physical Medicine and Rehabilitation. China: Elsevier-Mosby, Inc Voight, Michael L., et.al. (2007). Musculoskeletal Interventions: Techniques for Therapeutic Exercise. U.S.A: Mc-Graw Hill Companies, Inc. B. JOURNALS Ahmed, Rehana L., et. al. (December 10, 2008). Lymphedema and Quality of Life in Breast Cancer Survivors: The Iowa Womens Health Study. Journal of Clinical Oncology. Vol. 26. No. 25. Beaulac, Sarah M., et. al. (November 2002). Lymphedema and Quality of Life in Survivors of Early-Stage Breast Cancer. Archives of Surgery. Vol. 137, No. 11. Pp. 1253-1257. Cantero-Villanueva I., et. al. (March 17, 2011). Associations among m musculoskeletal impairments, depression, body image and fatigue breast cancer survivors within the first year after treatment. European Journal of Cancer Care. Dawes, Diana J. et. al. (2008). Impact of lymphedema on arm function and health-related quality of life in women following breast cancer surgery. Journal of Rehabilitation Medicine. Vol. 40. Pp. 51-58 Hayes, Sandra C., et. al. (2010). Upper-body morbidity following breast cancer treatmen is common, may persist longer-term and adversely influences quality of life. Health and Quality of Life Outcomes: Open Access Research. Vol. 8, Issue 92. Karasen, Sagen A., et. al. (2009). Changes in arm morbidities and Health-related quality of life after breast cancer surgery a fiveyear f follow up study. Acta Oncologica. Vol. 48. No. 8. Pp. 11111118. Nesvold IL, et. al. (April 2010). Arm/shoulder problems in breast cancer survivors are associated with reduced health and poorer physical quality of life. Acta Oncologica. Vol. 49. No. 3. Pp. 347-353.

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Smooth, Betty, et. al. (2010) Upper Extremity impairments in women with or without lymphedema following breast cancer treatment. Journal of Cancer Survivor. Vol. 4. Pp. 167-178.