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Evidence-Based Usefulness of Physiotherapy Techniques in Breast Cancer Patients
Almir José Sarri1 and Sonia Marta Moriguchi2
of Physiotherapy of Nuclear Medicine Barretos Cancer Hospital Brazil
Breast cancer is one of the most frequent causes of death among women, with high incidence in both developed and developing countries. When it is diagnosed at an advanced stage, including cases of metastatic lymph node invasion, the treatment becomes more aggressive and expensive (Johansson et al., 2002; Parkin & Fernandez, 2006), with the implication that the post-treatment complication rate will be greater (Kwan et al., 2002; Szuba et al., 2003; Goffman et al., 2004; King & Difalco, 2005). The complications may be short or long-term, and the commonest of them include hemorrhage, infection, seroma, axillary web syndrome (AWS), chronic pain, paresthesia, reduction of the range of motion, muscle weakness in the shoulder homolateral to the surgery and lymphedema (Fig. 1). Of these, lymphedema is the most important morbid condition (Lee et al., 2008; Paskett, 2008; Fourie & Robb, 2009; Stanton et al., 2009). Aggressive surgery, such as radical axillary dissection, may interrupt the main lymphatic drainage route in the arms, and this is the most important factor in edema formation (Bourgeois et al., 1998). Associated complementary radiotherapy induces fibrosis in lymphatic vessels in 20 to 30% of the cases, thus worsening the lymphatic flow (Paci et al., 1996; Bumpers et al., 2002; Carpentier, 2002; Kwan et al., 2002; Van Der Veen et al., 2004; Moseley et al., 2007). This modification to the lymphatic flow induces alteration of the homeostatic equilibrium of absorption and transportation of interstitial fluid, which triggers lymphedema. This is a progressive condition characterized by four pathological factors: excess protein in tissues, edema, chronic inflammation and fibrosis. When the arm remains untreated, its volume progressively increases, as does the frequency of complications relating to this condition (Weissleder & Weissleder, 1988; Carpentier, 2002; Didem et al., 2005; King, 2006). It is difficult to diagnose lymphedema, especially in its initial stages. Without a proper diagnosis, it always takes time to institute therapy. When the treatment is immediate, the improvement occurs quickly and progression of the condition is prevented (Szuba et al., 2003; Linnitt, 2007).
. 1994. Physiotherapeutic approaches Physiotherapeutic approaches for lymphedema can be divided into two parts: prophylactic and therapeutic approaches.. 2004. treated and controlled with daily preventive measures (Linnitt. and to improve patients’ quality of life. 1999.. Nevertheless.. 2004.. 2002. 1999). 2006). Lymphedema following axillary dissection. safe and less mutilating resection has become possible. The aim of physical rehabilitation is to prevent and minimize the sequelae caused by oncological treatment or by the disease itself. 2006). selective.. The desire to prevent lymphedema has led to intraoperative techniques that take a more conservative approach to the axillary chain.intechopen. such as investigating the sentinel lymph node. 1981. with the aim of preventing sequelae and improving the patient’s physical condition to face up to the treatment (Bergmann et al. this is limited to patients without evidence of lymph node macrometastases (Clodius et al... it can be avoided. in both its physical and its psychological aspects. 2. Rietman et al.com . with satisfactory results. with the aim of preventing sequelae and improving the patient’s physical condition to face up to the treatment (Bergmann et al. Through this.1 Prophylactic physiotherapeutic approaches It should be started preoperatively or in the immediate postoperative period. When lymphedema becomes established. Ronka et al. it is incurable. Didem et al. Bumpers et al. 1999). 2007). Sakorafas et al. Bourgeois et al. 2006). 2005). The pathogenesis of post-mastectomy lymphedema associated with axillary dissection is mainly attributed to greater numbers of dissected lymph nodes (Filippetti et al. However. 2.. www..752 Current Cancer Treatment – Novel Beyond Conventional Approaches Fig. Glass et al.. 1998. Goffman et al. The more extensive the axillary dissection is.. the greater the risk of complications will be (Glass et al. 1. Studies have demonstrated that surgical and drug treatments are unsuccessful (Roucout & Oliveira. 2004..
transcutaneous electrical nerve stimulation (TENS) can be applied. with guidance about positioning in bed (with the operated arm above the head). Andersen et al. Improvement of respiratory capacity through the use of apparatus to incentivize the respiratory flow or volume (incentive spirometry) is also indicated for diminishing general morbid conditions.. Bergmann et al. in addition to individualized attendance. when present (Bergmann et al. muscle weakness and pains (Lee et al.1 Preoperative physiotherapy Limitations on shoulder range of motion. Huit.com .2 Immediate postoperative intervention The second step of preventive intervention starts immediately after the surgical procedure. 2010).Evidence-Based Usefulness of Physiotherapy Techniques in Breast Cancer Patients 753 The focus of this evaluation aimed to identify risk factors for developing complications and morbid conditions relating to the axillary approach and to implementation of strategies for minimizing preexisting symptoms.. functional exercises on the limb homolateral to the surgery as shown in Fig. with prevention of trauma and lesions that might trigger inflammation and infection in the arm homolateral to the axillary dissection. with the aim of achieving better postoperative functional recovery (Paskett. it is also undertaken in collective groups. before the start of radiotherapy. 2005. and respiratory physiotherapy if necessary. 2006).. 3). Camargo & Marx. 2010). 2010).1. 2. Guidance regarding care for the limb that underwent manipulation. For patients with locoregional pain. 2. 2008.intechopen.1. 2008). limitations on shoulder range of motion. assisted active exercises. pain and diminished muscle strength are the main focuses of the assessment. Springer et al. such as subcutaneous fibrosis.. passive exercises.2 Postoperative follow-up A new physiotherapeutic reassessment is undertaken immediately after removal of the patient’s surgical stitches and suction drain. focusing on reorientation regarding preventive measures against lymphedema and assessment of the need for early physiotherapeutic intervention. active exercises of the scapular belt and neck relaxation exercises are indicated (Lauridsen et al. Physiotherapeutic treatment concomitant to radiotherapy is very important. 1999.. 2. 2000. before hospital discharge (Roucout & Oliveira. with exchanges of experiences.. In outpatient rehabilitation. 2006). 2. Additional guidance regarding early lymphatic self-massage should also be provided for patients after axillary dissection (Sarri et al. 2000. Springer et al. Patients should be advised to continue with the treatment at home. This has the benefit of promoting interaction among the patients. In the presence of limitations on shoulder range of motion and/or loss of muscle strength. Rezende et al. since these may lead to morbid conditions that relate directly to axillary manipulation. on the first day after the operation. thus making the session more agreeable and providing encouragement towards doing the exercises (Fig. avoidance of using clothes that restrict the superficial lymphatic circulation. because it minimizes the side effects... skin hydration and provision of kinesiotherapy limited to 90° of range of shoulder movement are administered to patients who undergo radial axillary dissection and sentinel lymph node biopsy.. Although preventive interventions have shown good results. 2006. www. 2000. the numbers of patients referred for preoperative assessments and preventive care are still very small.
Group of mastectomized patients. Fig. 2. In the following. we will describe the main physiotherapeutic interventions relating to specific symptoms of complications following surgical manipulation of the axillae. Postoperative functional exercises. 3. www.com .intechopen.754 Current Cancer Treatment – Novel Beyond Conventional Approaches Fig.
Andersen et al. which include increased contraction of the lymphatic vessels and increased protein reabsorption. Williams et al. Leal et al. www. We performed early homolateral inguinal and contralateral axillary lymph node stimulation for up to 60 days after the operation. Huit. 1998.. skincare and lymph myokinetic exercises (Bergmann et al. These routes deviate the lymph flow in a direction contrary to the usual flow. As a strategy for stimulating the lymphatic circulation in cases of obstruction of the normal lymphatic flow. Williams et al.1 Manual lymphatic drainage The treatment for lymphedema that has already become established is based on techniques that are well accepted and described in the worldwide literature. increasing the collateral lymphatic drainage among the lymphatic areas of the skin and improving the drainage capacity in order to direct the lymph away from the edematous area and towards lymph nodes in areas that are unaffected by lymphedema (Fritsch & Tomson. Recently.. The therapeutic phase aims to mobilize the accumulated proteinrich fluid and reduce the fibrosclerotic tissue. Rietman et al. 2002.. before stimulating the edematous areas... physiotherapy to treat lymphedema that has already become established and to prevent this and other comorbidities is of paramount importance for diminishing the surgical sequelae from breast cancer treatment. the collateral routes and anastomoses of the lymphatic capillaries should be taken to be the peripheral circulation. compressive bandaging. 2002). 2010). 1997. and used lymphoscintigraphy to identify the immediate improvement in lymphatic flow following the stimulation (Sarri et al. 2007). Camargo & Marx. Several lymphatic drainage techniques are used to stimulate the lymphatic flow and treat lymphedema.intechopen. 2009). thereby reducing the microlymphatic hypertension. 2002.. 2010). 3..com .. treatment also known as lymph therapy or complex physical treatment is the type most used. MLD can be carried out in regions with or without edema. such as skincare (Kwan et al. Prior knowledge of the normal lymphatic circulation and the changes that it undergoes in the presence of obstruction directs the techniques for physiotherapeutic stimulation. 2000. kinesiotherapy and self-massage (Glass et al... we studied 22 women with breast carcinoma who underwent surgical treatment and axillary lymph node dissection. depending on the aim at the time of treatment. 1999. 2009). Complete decongestive physiotherapy (CDP) is composed of four approaches: manual lymphatic drainage (MLD).. 2000. Sarri et al. Williams et al.. Lymphedema Early diagnosis and intervention. such as the techniques proposed by Vodder.Evidence-Based Usefulness of Physiotherapy Techniques in Breast Cancer Patients 755 3.. 1991. Lymph therapy is carried out in two phases. thereby simulating self-massage according to the Földi technique. 2000. Araujo et al. Leduc and Földi.. The first has therapeutic aims and the second consists of maintenance. through the lateral cephalic lymphatic bundle and continuing over the deltoid muscle. Moseley et al. The search for better quality of life has indicated that prevention of lymphedema is the best strategy among this group of patients. using MLD and compressive bandaging (Foldi. 2006.. 2002). 2009. The main objective of manual lymphatic drainage is to increase lymphokinetic activity in healthy areas. There are several physiological effects.. Leal et al. It is done in two stages: evacuation and uptake. may significantly reduce the incidence of complications (Williams et al. 2004). 2002. thereby bypassing the axillary lymph node chain and draining the lymph directly to the supra and infraclavicular lymph nodes (Stanton et al. In Brazil. Within this context.
Firstly. Sarri et al. 5) (Foldi et al.. Williams et al. Camargo & Marx. wavelike movements are made across the anterior region of the chest. as shown in Fig. 4. www.com . 4. d) wavelike maneuver directing the lymphatic flow towards the ipsilateral inguinal region.intechopen. After these areas have been stimulated. After completing the manual lymphatic drainage.756 Current Cancer Treatment – Novel Beyond Conventional Approaches The evacuation maneuvers begin with a series of gentle circular movements with the therapist’s palms in contact with the patient’s skin. Evacuation maneuvers on a patient who underwent radical right-side lymphadenectomy: a) axillary limph node chain stimulation. This is always performed from proximal to distal regions. 2002. thus stimulating first the contralateral quadrant until reaching the ipsilateral quadrant.. c) wavelike maneuver directing the lymphatic flow towards the contralateral axillary region. b) inguinal lymph node chain stimulation. the contralateral axillary lymph node chain is stimulated and then the inguinal region homolateral to the surgical manipulation. and it is very important to take into consideration the deviation in the region of the deltoid muscle (Stanton et al.. These movements can be carried out both in the anterior and in the posterior region of the trunk. 2005). towards areas adjacent to the axilla that underwent the operation. and then making the same movement going from the ipsilateral inguinal region to the axilla. 1985. the uptake process is started. until reaching the fingers (Fig. Linnitt. 2000.. with wavelike maneuvers in the upper arm region and then the forearm and hand. After finishing the evacuation phase. (a) (b) (c) (d) Fig. the arms should be hydrated using neutral cream so that compressive bandaging can be started. 2009. 2010). The direction of lymphatic drainage should respect the anatomy of the lymphatic system.
. such that the patient was able to make movements.com . b) forearm region. thereby avoiding recurrence of lymphatic fluid accumulation in the interstices (Foldi et al. Fig. www. It should always be functional. c) hand region. Elastic bandages increase the tissue pressure and counterbalance the elastic insufficiency. Compressive bandaging is an important technique. 5.2 Compressive bandaging One of the consequences of lymphedema is that the elastic fibers are destroyed. 6). because it boosts the effects achieved through the preceding lymph drainage. Evacuation of the lymphatic fluid by means of manual lymphatic drainage diminishes the pressure on the tissue and increases the effective ultrafiltration pressure. Functional compressive bandaging.Evidence-Based Usefulness of Physiotherapy Techniques in Breast Cancer Patients 757 (a) (b) (c) (d) Fig. Uptake maneuver on a patient who underwent radical right-side lymphadenectomy: wavelike maneuvers directing the lymphatic flow from the proximal to the distal region: a) upper-arm region. 1985). 3. 6.intechopen. thereby enabling all day-to-day movements and guided kinesiotherapy (Fig. d) finger region.
758 Current Cancer Treatment – Novel Beyond Conventional Approaches After hydration. c) protection with cotton gauze. 7.intechopen. i. starting with the fingers. b) placement of cotton gauze. (a) (b) (c) (d) (e) (f) (g) Fig. The pressure exerted by the bandaging is greater in the distal region and diminishes towards the root of the limb (Fig. e) bandaging.e. www. It is started on the fingers and then the forearm and the upper arm. The compressive bandaging is done using low-elasticity bandage rolls. It is also important to respect the trophic conditions of the skin.com . Functional compressive bandaging: a) hydration. f) bandaging on forearm. 7). g) bandaging on upper arm. with the aim of filling in any anatomical spaces. for two days. The compressive bandaging is kept in place until the next physiotherapy session. the skin and bone prominences should be protected using cotton gauze and foam.
we use compression garments in conjunction with self-massage and kinesiotherapy in cases of initial lymphedema.3 Compression garments The aim of using compression garments is to maintain and optimize the results obtained from the first phase of lymphedema treatment and avoid recurrences.. 3. Hampton. with the palms in the axilla. In our institution. 2009. 2000. and www. Camargo & Marx. with significant improvements achieved. Bergmann et al.. called the maintenance phase. 1985. skincare.. also known as simple manual lymphatic drainage. is a version of manual lymphatic drainage. 2003)..Evidence-Based Usefulness of Physiotherapy Techniques in Breast Cancer Patients 759 The second phase. 1999. Leal et al. 1985.. (Foldi et al. The patient should begin the self-massage with circular movements in the contralateral axillary region.. Sarri et al. through keeping the interstitial pressures in balance. 2000. 2005). has the aims of keeping the interstitial pressures in balance and optimizing the results obtained from the first phase of the treatment. The model of garment and the compression used depend on the patient’s needs (Fig. followed by gentle movements starting at a place distant from the congested area and moving towards the edematous limb (Foldi et al. lightly and gently moving the skin 30 times.4 Lymphatic self-massage Lymphatic self-massage. They should be used continuously and only be removed for personal hygiene.. It consists of using compression garments. Huit.. kinesiotherapy and manual self-massage (Foldi et al. 2010). 2002. Linnitt. The technique for this procedure is taught to the patient. the patient should also comply with the guidance previously given regarding limb care. 1985. 8). Camargo & Marx. 2000. Roucout & Oliveira. at home every day. 3. hydration. Williams et al.com . who can then perform this alone. Garments and gloves for elastic containment. Fig. 2000. Concomitantly with using the compression garments. Andersen et al. hydration and kinesiotherapy.intechopen. 2000. 8. Camargo & Marx. It involves a series of gentle circular movements that begin with stimulation of the contralateral axillary lymph node chains and the inguinal chains homolateral to the surgical manipulation.
9). Several studies have combined its use with other types of treatment for lymphedema. and high incidence of complications has been found. in the region above the surgery. or vascular strings (Johansson et al.. After the axillary and inguinal lymph node chains have been stimulated. There are basically two types of compression pumps: the segmental or sequential type and the dynamic type.. axillary strings (Lauridsen et al. Individual use of pneumatic compression has not shown satisfactory results. 2005). Leduc et al. 2000. Lymphatic self-massage on patient who underwent right axillary dissection: a) axillary lymph node chain stimulation. 2001).intechopen. 4. Leal et al.. is a sequela of breast cancer www.. 9.. b) inguinal lymph node chain stimulation. c) wavelike maneuver directing the lymphatic flow towards the contralateral axillary region.5 Pneumatic compression This consists of mechanical compression with air pumps. 2002. The movement in each region is repeated 30 times (Fig.. Szuba et al.. d) wavelike maneuver directing the lymphatic flow towards the ipsilateral inguinal region. on the edematous limb. 2002). hand movements are made with the aim of shifting the lymph from the operated axilla to the contralateral axilla. 3. The same movement is then made to shift the lymph from the manipulated axilla to the homolateral inguinal region. 1998. such as the use of lymph therapy (Dini et al. Axillary web syndrome Axillary web syndrome.760 Current Cancer Treatment – Novel Beyond Conventional Approaches then repeating this in the inguinal region homolateral to the axillary dissection. Camargo & Marx. 1998. also known as cording (Box et al. 2009). (a) (b) (c) (d) Fig.com .
2001.Evidence-Based Usefulness of Physiotherapy Techniques in Breast Cancer Patients 761 treatment (Fourie & Robb.. aseptic lymphangitis and lesions in the lymphatic ducts also seem to be involved (Johansson et al. 2009).com . 2003).. as tense and painful strings under the skin of the axilla.. Tilley et al. 10. as shown in Fig. 2003. Fourie & Robb. 2009). b) axillary region after the maneuver. In our service. We have also used active and passive kinesiotherapy on the limb and light stretching. 2005). b) axillary web syndrome maneuver.. Fig. without specific treatment (Moskovitz et al. Lauridsen et al. thereby enabling movements that had previously been limited (Fig. c) anterior region of the elbow before the maneuver. It is believed that interruption of the axillar lymphatic vessels has an important role in the development of this syndrome. stretching exercises and manual manipulation techniques (Moskovitz et al. thrombophlebitis. 2005).. It is developed between the first and fifth week after axillary dissection. 11. Leidenius et al. 11). Some papers have shown that this syndrome resolves within three months. 2001. It may extend as far as the cubital fossa or the medial face of the upper arm (Tilley et al. Moskovitz et al... while applying pressure from central to distal regions. 2009. d) anterior region of the elbow after the maneuver. The literature is deficient with regard to the approach to be taken in cases of AWS. 2001). 2001. Axillary Web Syndrome: a) axillary region before the maneuver. 10. without string.. 2009). The maneuver consists of stretching the string with the thumbs. Axillary Web Syndrome maneuver: a) string in anterior region of elbow. This maneuver triggers tolerable local pain that is relieved as soon as the maneuver ends.. (b) (c) (d) (a) Fig... It is always associated with pain and limitation of shoulder and elbow movement (Lauridsen et al. c) anterior region of forearm after maneuver. Its incidence and predisposing factors are not well defined in the worldwide literature (Moskovitz et al. Leidenius et al. we have used string stretching with very favorable results. www. Lymphovenous lesions with stasis.intechopen. 2001. Other studies have shown benefits from implementing active range-of-motion exercises.
Pascal. Curbelo. it is increasingly certain that early intervention significantly minimizes the emergence of lymphedema. the axilla or the medial face of the upper arm (Vecht et al. Int J Dermatol. Painful post-mastectomy syndrome Chronic pain secondary to surgical treatment for breast cancer is of neuropathic origin or results from muscle and ligament injuries. Hojris. Araujo. The symptoms generally diminish within three months. thus interfering with these patients’ quality of life (Kärki et al. The physiotherapeutic treatment consists of specific analgesia techniques. No. Caffo et al.intechopen. However.. F.. active exercises of the scapular belt. Beurskens et al. 2001. J. 2007. 2001.. Treatment of breast-cancerrelated lymphedema with or without manual lymphatic drainage.. 389-92. 39. Intercostal brachial neuralgia has been correlated most frequently in axillary treatments.. Passive exercises.. L. M. Vol. G. Such pain may be continuous or intermittent. May. Erlandsen. which is one of the complications following axillary lymph node dissection. taking care in manipulating the limb so as to avoid tissue or muscle injuries.. This musculoskeletal disorder of the shoulder results in considerable joint debility and pain. and their coworkers Thiago Buosi and Carla Laurienzo da Cunha Andrade. ISSN 0011-9059 (Linking) www. may occur because of tissue and nerve lesions.com . pp. L. A. Effective management of marked lymphedema of the leg. in which the nerve may become injured because of its proximity (Poleshuck et al. assisted active exercises. A. G. Vol. 9. 399-405. J.. Couceiro et al.. Acta Oncol. The treatment should be progressive. Vignale. Mayol. Beurskens et al. cryotherapy and kinesiotherapy. with varying intensity.. ISSN 0011-9059 (Print). A randomized study. Labreze et al. I. 3. (2000). 1989.. 5. Acknowledgements The authors thank Barretos Cancer Hospital. such as transcutaneous electrical nerve stimulation (TENS). 2006. Early physiotherapeutic treatment is effective for this disorder and promotes faster functional recovery (Kärki et al. R. No.. 7. Burckhardt & Jones. A..762 Current Cancer Treatment – Novel Beyond Conventional Approaches 5. 2007). but they may become chronic. J. 2005). and it can be located in the anterior wall of the chest. References Andersen. 2007). physiotherapeutic interventions on patients who have undergone axillary lymph node manipulation can be implemented at any postoperative stage. 8.. G. & Andersen. 36. 2005. 2009).. & Fleurquin. It can also be implemented in association with the use of analgesic medications. pp. neck relaxation and postural guidance should be undertaken. Limitation of shoulder movement Restriction of shoulder movement. (1997). 2003. Conclusion In conclusion. 6. with prevalence of 736%.. ISSN 0284-186X. Lauridsen et al.
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Thus. feel free to copy and paste the following: Almir José Sarri and Sonia Marta Moriguchi (2011). Shanghai. Oner Ozdemir (Ed. changing the face of adjuvant therapy for early breast cancer. Prof. China Phone: +86-21-62489820 Fax: +86-21-62489821 .). Hotel Equatorial Shanghai No. 2011 Currently there have been many armamentaria to be used in cancer treatment.Current Cancer Treatment . It seems this will take a long period of time to achieve. 2011 Published in print edition December. InTech. Evidence-Based Usefulness of Physiotherapy Techniques in Breast Cancer Patients. cancer treatment in general still seems to need new and more effective approaches. How to reference In order to correctly reference this scholarly work.com InTech China Unit 405. December. radiation treatment of skull and spine chordoma.intechopen. The book "Current Cancer Treatment . 200040. This indeed indicates that the final treatment has not yet been found.intechopen. new therapeutic approaches of old techniques: laser-driven radiation therapy. Available from: http://www. ISBN: 978-953-307-397-2. Croatia Phone: +385 (51) 770 447 Fax: +385 (51) 686 166 www. This book is a valuable contribution to this area mentioning various modalities in cancer treatment such as some rare classic treatment approaches: treatment of metastatic liver disease of colorectal origin.Novel Beyond Conventional Approaches. Office Block. 810 pages Publisher InTech Published online 09.Novel Beyond Conventional Approaches Edited by Prof. Current Cancer Treatment .65. consisting of 33 chapters. Yan An Road (West). new approaches targeting androgen receptor and many more emerging techniques. laser photo-chemotherapy. will help get us physicians as well as patients enlightened with new research and developments in this area.Novel Beyond Conventional Approaches". Oner Ozdemir ISBN 978-953-307-397-2 Hard cover.com/books/currentcancer-treatment-novel-beyond-conventional-approaches/evidence-based-usefulness-of-physiotherapytechniques-in-breast-cancer-patients InTech Europe University Campus STeP Ri Slavka Krautzeka 83/A 51000 Rijeka.
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