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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

manual muscle testing and dynamometer to measure hand grip strength. This research will be conducted in Jose B. hand grip strength and quality of life among breast cancer survivors in selected population. Bilateral breast cancer. shoulder muscle strength. Assessment tools and procedures conformed to the standard method used in clinical practice such as the use of goniometer. infection of the upper extremity. pre-existing lymphedema. 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). Lingad Memorial Regional Hospital (JBLMRH) Physical Therapy Unit were recruited subjects will be assessed by a trained physical therapist. and has a good comprehension of the English language. lymphangitis. history of neuromuscular or musculoskeletal condition that would affect local upper . 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. 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.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 6 4.

it refers to the assessment of shoulder range of motion. It is an evaluation of the condition based on the patients’ subjective report of the symptoms and course of illness or condition and the examiner’s objective findings. including data obtained through physical examination. marital status and job satisfaction which are not presented in this study. In this study. and information reported by family members and other health care teams (Mosby’s Medical Dictionary. the following terms are defined: Assessment.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 7 extremity testing or current recurrence will be excluded from the study. The study is limited to other factors that will affect quality of life such as current lifestyle. involvement in support groups. muscle strength and hand grip strength of the affected side of . muscle strength and hand grip strength as to their quality of life. 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. medical history. DEFINITION OF TERMS For better understanding of the study on hand. 2009). This study will be conducted from May 2011 to June 2012.

Breast Cancer Survivor. In this study. 2011). this refers to breast cancer patients who underwent surgery. Hand grip strength. 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). Manual Muscle Testing. 2008). Dynamometer. usually the ducts and lobules. A breast cancer survivors is someone who is “living with” or beyond cancer (Breast Friends Online. It is a procedure for the evaluation of the function and strength of individual muscles and muscle groups based of . online). It is commonly measured by the used of a hand-held dynamometer (Fronteza et al. as in mastectomy (removal of the entire breast) or lumpectomy (removal of the lump) and other treatments such as chemotherapy and radiation therapy. It is a type of cancer that forms in tissues of the breast. It occurs in both men and women.ANGELES UNIVERSITY GRADUATE SCHOOL breast cancer survivors. PAGE 8 Breast Cancer. although male breast cancer is rare (National Cancer Institute.

2000). It is a broad ranging concept affected in a complex way by the person’s physical health. social relationships. Range of Motion. standards and concerns. level of independence. personal beliefs and their relationship to salient features of their environment (World Health Organization. expectations. Quality of Life. Condition of an individual’s 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.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 9 effective performance of a movement in relation to the forces of gravity and manual resistance (Clarkson. 2010).. Range of motion is the maximum amount of movement that is possible in any particular joint (King et al. psychological state. 1981) .

Breast cancer cannot be prevented. a musculoskeletal assessment is also being done to evaluate parameters of function such as flexibility. Radiotherapy to breast tissue can cause tissue fibrosis. patients can pain. patients frequently require Following breast surgery. Aside from physical assessment. Newly diagnosed patients often treated with a combination of surgery. 2010). but early detection offers more treatment option and a greater chance of cure. radiotherapy. Chemotherapy and hormone therapy can lead to changes in menopausal status and general . and endurance (Hamer. chemotherapy and hormone treatments. strength. physiotherapy intervention. experience problems with As a result of this. Physical therapists may be involved in the treatment of breast cancer patients at any stage of their disease.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 10 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. limited shoulder movement and lymphedema. resulting in movement limitation and lymphedema.

The starting position for measuring all ROM. the 180. It is being measured in joint range of motion. except rotations in the transverse plane. PAGE 11 Physical therapists’ knowledge of anatomy and normal movement makes them ideally suited in treating this group of patients (Hamer. the upper and lower extremity joints are at 0 degrees for flexion-extension and abduction-adduction when the body is in anatomical position. the American Academy of Orthopedic Surgeons. First described by Silver in 1923. In the 0. and the 360-degree system. Range of Motion One aspect of musculoskeletal assessment is flexibility. Range of motion is the amount of motion that is available at a joint is called the range of motion (ROM). Three notation systems have been used to define ROM: the 0-to 180-degree system. 2010). its use have been supported by many authorities.ANGELES UNIVERSITY GRADUATE SCHOOL debility. Moore. 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. and the American Medical Association (Norkin.to 180-degree system of notion is widely used throughout the world. A ROM begins at 0 degrees and proceeds in an arc toward 180 degrees. . including Cave and Roberts.to 180-degree notion system.1995).to 0-degree system. This 0. is the anatomical position.

a therapist should first observe the client during a function activity. than males in the same age groups. When evaluating a client’s range of motion. 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. Beighton et al. This functional observation may be referred to as a screening because it is not a formal assessment. Numerous studies have been conducted to determine the effects of age on ROM of extremities and spine. gender. the therapist can avoid spending excessive time on measuring the range of motion of each . found that females across an age range of 21 to 69 years have less hip extension. found that females between 0 and 80 years of age were more mobile than their male counterparts (McFarland and Kim.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 12 Normal ROM varies among individuals and is influenced by factors such as age. Females in the age range of 1 to 29 years had less hip adduction and lateral rotation than males in the same age groups. and whether the motion is performed actively or passively. The effects of gender on the ROM of the extremities and spine also appear to be joint. Boone et al. 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.. in a study of an African population.and motion specific. If no deficits are noted during observation. 2006). but more hip flexion.

the therapist utilizes bony landmarks on the human body to place the goniometer.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 13 joint only to determine that all joints are functional or normal. The body is a full or semicircle with a center point called the axis or fulcrum. The goniometer is the most commonly used instrument to measure joint motion. Once a deficit joint or joints are noted. There are different planes (of glass) running through the body in different directions because the body moves in different directions. the axis or fulcrum is placed over the axis of motion being measured. The axis or fulcrum is the . this screening can be completed during another assessment such as activities of daily living (ADL). The planes are the surfaces along which movement occurs. goniometers have a body and two arms. The purpose of goniometry is to measure the arc of motion of joint. During the use of the goniometer.2000). They are imaginary sheets of glass that run through the body. Movement of the body generally occurs in an arc or circular motion. but is distal to the joint being measured and follows the arm of motion. shapes. In addition. In order to measure this arc of motion. the therapist will need to complete a goniometry assessment. Now that the goniometer placement has been determined. One arm is called the stationary arm and the other is the movable arm (Clarkson. it is important to understand the planes and axis of joint motion. The movable arm is also aligned with the plane of motion. There are many sizes and All Some goniometers are plastic while others are metal.

it must be perpendicular to that plane. and the axis is the location around which the movement occurs (Latella and Meriano. 2003). The function of an individual muscle or group of muscles is evaluated by placing the muscle at a . Each axis and plane that are perpendicular to each other create a partnership. PAGE 14 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).ANGELES UNIVERSITY GRADUATE SCHOOL center of this motion. The plane is the flat surface along which the movement occurs. Figure 1: Shoulder Range of Motion Muscle Strength Assessing the patient’s ability to flex or extend the extremities against resistance tests muscle strength. Because the axis runs through the plane.

It is commonly recognized that a number of factors affect strength. Clinicians use a 5-point scale to rate muscle strength. First to consider is the age. drift is seen as pronation of the palm. 2 indicates the ability to move but not to overcome the force of gravity or severe weakness. it is exceedingly difficult for the examiner to flex the knee. A 5 indicates full power of contraction against gravity and resistance or normal muscle strength. Muscle strength increases from .ANGELES UNIVERSITY GRADUATE SCHOOL disadvantage. Subtle differences in strength may be evaluated by testing for drift. is a powerful muscle responsible for straightening the leg. the right upper extremity is compared to the left upper extremity. weakness can be elicited. For example. and 0 indicates no movement (Hislop and Montgomery. The evaluation of muscle strength compares the sides of the body to each other. for example. For example. 1 indicates minimal contractile power (weak muscle contraction can be palpated but no movement is noted) or very severe weakness. 4 indicates fair but not full strength against gravity and a moderate amount of resistance or slight weakness. indicating a subtle weakness that may not have been detected on the resistance examination. 3 indicates just sufficient strength to overcome the force of gravity or moderate weakness. The therapist must consider these factors when assessing a patient’s strength. both arms are out in front of the patient with palms up. If the knee is flexed and the patient is asked to straighten the leg against resistance. PAGE 15 The quadriceps. Once the leg is straightened. 2007).

Following this maximum. thick muscle (Clarkson. the greater the strength of the muscle. a decrease in strength occurs with increasing age due to a deterioration in muscle mass. 2000). there are thirty five . and the respiratory capacity of the muscle decreases. Muscle size also play an important role in the intensity of muscle strength. Another point is that. The larger the cross-sectional area of a muscle. the therapist would expect less tension to be developed than if testing a large. men are generally stronger than women. Muscle fibers decrease in size and number. connective tissue and fat increase. When testing a muscle that is small. In the forearm and hand movement.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 16 birth to a maximum point between 20 and 30 years of age. Figure 2: Manual Muscle Testing of the Shoulder Hand Grip Strength Manual muscle testing evaluates only individual muscle or small muscle groups.

this reason. Normally. Hand function can be quickly assessed by performing a number of movements to test overall function of the wrist and hand. like ulnar drift of the fingers. 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. Excessive radial deviation. 2009). with many of these involved in gripping activities. can affect grip strength adversely. and finger joints have the ability to move through a relatively large ROM.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 17 For muscles involved. Although the wrist. hand. Figure 3: Testing Hand Grip Strength with a Dynamometer . Functional flexion at the metacarpophalangeal and proximal interphalangeal joints is approximately 60 degrees (Hoeger and Hoeger. 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. hand grip strength is difficult to assess by merely using the manual muscle testing. most functional daily tasks do not require full ROM.

Breast cancer develops as the result of malignant changes in the cells lining the ducts or the lobules. The breasts.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 18 The most common method of assessment for grip strength is the use of handheld dynamometer. Atypical hyperplasia does not cause lumps and cannot be . avoiding at the same time possible fatigue and stress lesions in the locomotory system. Biomechanical measurements allow sports coaches to appreciate the bioenergetics and efficiency of sports movements. Handheld grip strength dynamometry is used to measure the muscular force generated by flexor mechanisms of the hand and forearm (Hoeger and Hoeger. or mammary glands. This is a form of what is referred to as a biomechanical measurement. the condition is called atypical hyperplasia. consist of fat pads inside of which is a branching system of ducts. If these extra cells seem a bit odd-looking when examined under the microscope. 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. These ducts are designed to ferry milk from the milkproducing lobules to the nipples. 2009). Breast Cancer Flexibility and muscle strength are the primarily affected in breast cancer which is an uncontrolled growth of breast cells. traning can then aim to achieve a maximal energetic output with minimal expenditure of energy.

staging of cancer can be done and is classified in the table below.(Carvalho and Stewart. 2009). 2004). whether the cancer is invasive or noninvasive. in which the cells are breaking through to surrounding tissue and the tumor is 2 . but they can sometimes be detected by mammogram.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 19 detected by breast examination or by mammogram. Ductal carcinoma in situ and lobar carcinoma in situ by definition remain confined to the ducts or lobules. If the abnormal cells break away from these parts of the breast to infiltrate adjoining cells. in the course of biopsying a suspicious lump. When it is discovered in the ducts or lobules. whether lymph nodes are involved. 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. Once all of these factors are determined. If cells lining the ducts or lobules become odder still and start to clog them. and whether it has spread beyond the breast and nodes.. Stages of Breast Cancer The stage of cancer is based on: the size of the tumor. and in rare instances may produce a lump that can be felt. it is usually by accident. It is at this point that a discrete malignant lump starts to grow (Carlson et al. the condition is called carcinoma in situ. the condition is called invasive cancer.

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. IIA – describes invasive breast cancer in which no tumor is PAGE 20 found in the breast. or 3 IIIA - The tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes. or - Tumor measures 2 centimeters or less and has spread to the axillary lymph nodes.ANGELES UNIVERSITY GRADUATE SCHOOL centimeters or less in greatest dimension and no lymph 2 nodes are involved. No tumor is found in the breast. but cancer cells are found in the axillary lymph nodes (lymph nodes under the arm). 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 - The tumor is 5 centimeters or smaller and has spread to axillary lymph nodes that are clumped .

usually the lungs. bone.ANGELES UNIVERSITY GRADUATE SCHOOL together or sticking to other structures. Describes invasive breast cancer that has spread to other organs of the body. if there is a tumor. and 4 The cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone. IIIC There may be no sign of cancer in the breast or. or brain. or - PAGE 21 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 The cancer has spread to lymph nodes above or below the collarbone. it may be any size and may have spread to the chest wall and/or skin of the breast. It is also called metastatic breast cancer. . liver. 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.

Physician might mention the TNM classification. but many lumps are not cancerous. Node. any woman who notices a change in her breasts – such as a lump or thickening. however. They are the result of normal hormonal changes or trauma to the breast. TNM (Tumor. the younger a woman is. There is no sure way to distinguish a malignant from a benign lump by touch alone. 2007) Breast Cancer Symptoms The classic symptom of breast cancer is a lump in the breast. the more likely it is that her breast lump is benign..ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 22 TNM Staging System According to Harrison’s Manual of Oncology. but he is much more likely to use the numberical staging system. clear or . it is generally difficult to move under the skin and often feels rock-hard with irregular edges. only 6 percent of women with breast cancer have breast pain as a symptom. Sometimes clinical trials require TNM information from participants (Chabner et al. 2007. Pain in the breast is also highly unlikely to signal breast cancer. For this reason. Metastasis) is another staging system researchers use to provide more details about how the cancer looks and behaves. 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. If a lump is cancerous.

an estimated 207. redness. breast cancer incidence rates in the U. In 2010. From 1999 to 2006.S.. 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. al.). 2011).970 new cases of invasive breast cancer were expected to be diagnosed in men in 2010.2004).Org. dimpling of skin. One theory is that this decrease was partially due to the reduced used of hormone replacement . along with 54. About 1.090 new cases of invasive breast cancer were expected to be diagnosed in women in the United States(U. change in contours. or retracted nipple – should consult a clinician (Carlson et. Less than 1% of all new breast cancer cases occur in men. (BreastCancer. April 19. decreased by about 2% per year.010 new cases of non-invasive (in situ) breast cancer.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 23 bloody discharge.S.

and increased awareness.5 million breast cancer survivors in the U. In 2010.S. These decreases are thought to be the result of treatment advances. 2006). About 39.S. Hispanic. These results suggested a connection between HRT and increased breast cancer risk (Dow. besides lung cancer.S. white women are slightly more likely to develop breast cancer. breast cancer is the most commonly diagnosed cancer among U. women.S. daughter) who has been diagnosed with breast cancer. earlier detection through screening. were expected to die in 2010 from breast cancer. there were more than 2. although why this is the case is not known.840 women in the U.. breast cancer death rates are among higher than those for any other cancer.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 24 therapy (HRT) by women after results of a large study called the Women’s Health Initiative were published in 2002. Besides skin cancer. More than 1 in 4 cancers in women (about 28%) are breast cancer. Women of other ethnic backgrounds – Asian. and Native American – have a lower risk of developing and dying from breast cancer than white women and African American women. Compared to African American women. One possible reason is that African American women tend to have more aggressive tumors. About 20-30% of women diagnosed with breast cancer have a family history of breast cancer. sister. For women in the U. though the rates have been decreasing since 1990. but less likely to die of it. A woman’s risk of breast cancer approximately doubles if she has a first-degree relative (mother. About 5-10% of breast .

ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 25 cancer can be linked to gene mutations (abnormal changes)inherited from one’s mother or father. 2011). and the use of exogenous hormones) have become more common. An increased ovarian cancer risk is also associated with these genetic mutations. These occur due to genetic abnormalities that happen as a result of the aging process and life in general. The most significant risk factors for breast cancer are gender (being a woman) and age (growing older) (Breastcancer. Mutations of the BRCA1 and BRCA2 genes are the most common. 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. obesity. and they are more likely to be diagnosed at a younger age (before menopaue). In addition to these changes in risk factors. In men. Some of this change can be directly attributable to a reduction of protective factors (e. Other factors which are known to increase breast cancer risk (i. about 1 in 10 breast cancers are believed to be due to BRCA2 mutations and even fewer cases to BRCA1 mutations. rather than inherited mutations. breast cancer screening has . Women with these mutations have up to an 80% risk of developing breast cancer during their lifetime. low physical activity.org. increasing parity.e. early age at first birth) in a higher proportion of women. About 70-80% of breast cancers occur in women who have no family history of breast cancer.g.

2002). 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. but they are not basic screening tools. Screening for Breast Cancer The purpose of breast cancer screening is to separate women who are clearly normal from those with abnormalities.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 26 impacted disease incidence. 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%. and breast self. influenced by endogenous and exogenous risk factors. 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. some behaviors can be adopted to decrease risk (Morrow and Jordan. greater lifetime exposure to estrogen. Mammography. increases risk of breast cancer. Although many exposures that increase risk are not readily modifiable. In general. Additional radiologic modalities will be mentioned as The use of adjuncts. regular breast exams. with the goal of intervening in the disease process after biologic onset but before symptoms or signs develop. 2003).examination are the key components of early detection and surveillance. . A standard screening mammogram includes two views of each breast.

hormonal therapy (anti-estrogen therapy) and some targeted therapies (such as Herceptin. But because a breast cancer is made up of different kinds of cancer cells. . Under certain circumstances. The patient and the doctor will determine the kind of surgery that’s most appropriate for you based on the stage of the cancer. and what is acceptable to the patient in terms of long-term peace of mind. Tykerb and Avastin). 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. Decisions about surgery depend on many factors. Treatment plan may include a combination of the following treatments: surgery. getting rid of all those cells can require different types of treatments. Clear margins are also a requirement (no cancer cells in the tissue surrounding tumor).ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 27 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. people with breast cancer have the opportunity to choose between total removal of a breast (mastectomy) and breastconserving surgery (lumpectomy) followed by radiation. Surgery is usually the first line of attack against breast cancer. 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. chemotherapy. the “personality” of the cancer. radiation therapy.

.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 28 Radiation can reduce the risk of breast cancer recurrence by about 70%. Tissues to be treated might include the breast area. (Other types of energy beams include light and xrays). Radiation therapy uses a special kind of high-energy beam to damage cancer cells. Radiation treatments will be overseen by a radiation oncologist. So cancer cells are more easily destroyed by radiation. the radiation damages cells that are in the path of its beam – normal cells as well as cancer cells. Chemotherapy treatment uses medicine to weaken and destroy cancer cells in the body. But radiation affects cancer cells more than normal cells. And because cancer cells are less organized than health cells. normal cells are better able to repair themselves and survive the treatment. the material that cells use to divide. These high-energy beams. Despite what many people fear. lymph nodes. it is harder for them to repair the damage done by radiation. a cancer doctor who specializes in radiation therapy (Miller. while healthy. 2008). damage a cell’s DNA. radiation therapy is relatively easy to tolerate and its side effects are limited to the treated area. which are invisible to the human eye. Among the treatments for breast cancer. or another part of the body (Hunt et al. including cells at the orginal cancer site and any . Over time. 2007). chemotherapy is the most popular. Cancer cells are very busy growing and multiplying – 2 activities that can be slowed or stopped by radiation damage.

often shortened to just “chemo. advanced-stage breast cancer to destroy or damage the cancer cells as much as possible. 2008). 61 survivors). descriptive designs. In many cases. a combination of two or more medicines will be used as chemotherapy treatment for breast cancer. 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. which means it affects the whole body by going through the bloodstream. Chemotherapy. and interview-based measurements. chemotherapy is given before surgery to shrink the cancer (Miller. There are quite a few chemotherapy medicines. recent survivorship research has evaluated long-term sequelae. and that the majority of . Early studies involved mainly small convenience samples (maximum. In some cases. 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%.” is a systemic therapy.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 29 cancer cells that may have spread to another part of the body. that survivors have a positive perception of life and attach less importance to trivial stressors even though fear of recurrence is a major concern. 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.

Tradition medical evaluations of the outcomes of cancer treatments have included disease-free survival. 1990). This program includes a focus on palliative care and its impact on the QOL of cancer patients. Since many of the world’s cancer patients have no access to effective cancer therapy. 2011). 2007) Quality of Life The quality of life (QOL) assessment is an important aspect of the current care provided to cancer patients. can reduce cancer morbidity and mortality worldwide. Quality of life measurements provide valuable information to all members of the health care team. .S. (Ganz and Horning. if appropriately implemented. However. and overall survival (U. Department of Health and Human Services. Interest in QOL assessment has continued to increase in recent years. 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. tumor response. only palliative care can be offered. Palliative care programs frequently focus on symptom management and can greatly improve QOL (World Health Organization Official Website.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 30 survivors thrive despite experiencing problems related to breast cancer and its treatment. The World Health Organization (WHO) has a global cancer control program based on knowledge currently available that. nor in identifying interventions to improve or maintain the patient’s quality of life.

” Many other definitions of both “health” and “quality of life” have been attempted. researchers have attempted to further define QOL. psychological. In the past. The World Health Organization (WHO. mental and social well-being. While progress has . and social. economic concern. et al 2007). Spillker (1990) described QOL assessment through three interrelated levels: (a) overall assessment of well-being. (b) broad domains such as physical. many researchers measured only one dimension. Quality of life assessment is complicated by the fact that there is no universally accepted definition of quality of life. such as physical function. and (c) the components of each domain. economic. However. or sexual function. in the Western world at least.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 31 Defining Quality of Life Quality of life (QOL) is an ill-defined term. often liking the two and. some investigators argue that most people. In the absence of any universally accepted definition. and not merely the absence of disease. it is clear that “quality of life” means different things to different people. for quality of life. and takes on different meanings according to the area of application (Fayers. frequently emphasizing components of happiness and satisfaction with life. More recently. 1948) declares health to be “a state of complete physical. are familiar with the expression “quality of life” and have an intuitive understanding of what it comprises.

In breast cancer.S) defines a survivor as follows: “An individual is considered a cancer survivor from the time of cancer diagnosis. or more years post diagnosis. and identifying QOL outcomes. Some studies have focused on women who are 1. 5. usually while they are free of recurrent disease.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 32 been made in defining QOL. 2003) Methodological Issues in Survivorship Research The Office of Cancer Survivorship of the National Cancer Institute (U. through the balance of his or her life. Related Studies Hayes et. Family members. including conceptual and methodological issues (King et al. where long-term survival is becoming increasingly common. 3. 2007).. developing qualitative and quantitative methodologies to study QOL. al. Clinical assessment of upper body function . (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. friends and caregivers are also impacted by the survivorship experience and are therefore included in this definition.” This is a very broad definition. many research issues persist. this variable definition may account for some of the inconsistencies in the literature (Ganz and Horning. most survivorship research in breast cancer focuses on the experience of individuals with cancer after they have completed their primary therapy.

Three aspects of shoulder movement (flexion. al. On the other hand. 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. but also assists women to optimize clinical function and come to terms with perceived changes that have occurred with respect to UBF. and flexibility in that order. (2007). Based on recommendations of the Boston University Medical Center Physical Therapy Department. In a similar study conducted by Beaulac et. abduction and rotation) were examined. these findings provide support for the integration of a rehabilitation program into the care of women with breast cancer.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 33 (UBF) were done for strength and endurance. shoulder movement was measured. which not only targets minimizing declines and facilitating recovery during and following breast cancer treatment. 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). because limited shoulder range of motion is more common and more difficult to . handgrip strength. he cited the association between arm function and quality of life in survivors of early stage of breast cancer. Consequently. Arm function was assessed by measuring range of motion and handgrip strength.and longer time following breast cancer is important with respect to concurrent quality of life and subsequent quality of life.

Kaya et al (2010) did a comparable research using the same WHAT assessment tool used by Beaulac et. physical disability using the disabilities of the arm.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 34 compensate for than limited elbow or wrist movement in patients. representing almost no movement. Results showed that the most common impairment observed was arm pain on motion. Handgrip strength was measured using a hydraulic hand dynamometer. Quality of life measurements was assessed through FACT-B+4 survey and were scored and interpreted in accordance with the standardized scoring protocol. and 6. Arm pain on motion. limited shoulder joint range of motion. Results showed that those with full range of motion had an increased total FACT-B+4. with 1 representing almost no movement. loss of handgrip strength. loss of grip strength. Results were recorded based on a scale from 1 to 6. The average of three grip strength measurements was recorded for each hand. whereas those with decreased ROM had a decreased range of motion recorded lower functional and physical wellbeing and total FACT-B+4 scores. Subjects were evaluated for impairments (arm edema. 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). anterior chest wall pain. 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. and shoulder flexion .

ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 35 were significant factors in different domains of quality of life according to the FACT-B+4 questionnaire. (2008) reported the impact of lymphedema or related arm symptoms in health-related quality of life (HRQOL) in breast cancer survivors. embedded within a pilot for an epidemiology study. indicating activity limitation. In relation to Daves’ study. Ahmed. was undertaken involving women who had undergone surgery for unilateral stage I or II breast cancer. al. Arm symptoms assessment . (2008). Women with self reported symptoms of lymphoedema had a significantly higher score on the Disabilities of Arm. Two questionnaires (a lymphoedema screening questionnaire and the Disabilities of Arm. A cross sectional study. they identified the impact of lymphoedema or arm function and health-related quality of life in women following breast cancer surgery. et. Shoulder and Hand questionnaire. al. participation restriction and suboptimal healthrelated quality of life. et. In a different study done by Daves. The effect of pain in the arm subgroup of the FACT-B+4 was more pronounced when compared with other dependent variables. 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. Shoulder and Hand questionnaire) and women with symptoms attended for further testing.

In assessing quality of life. In Daves’ study. and was evaluated through goniometric techniques and manual muscle testing. Medical Outcome Study Short Form-36 Version 2 was used instead of the WHOQOL-BREF to be used in this study. it used a different format questionnaire. Although women with known lymphedema experienced more arm symptoms on average. HRQOL was significantly lower in breast cancer survivors without lymphedema compared with survivors without lymphedema or arm symptoms. et. al. they measure upper extremity function through the use of Disability of Arm. Shoulder and Hand (DASH) Outcome Measures. In this study of unilateral breast cancer survivors in Iowa. women with arm symptoms without diagnosed lymphedema had altered HRQOL in more domains of physical and mental HRQOL. More complicated study done by Caban.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 36 basically included flexibility and muscle strength of the affected side. Though it measures the same domains. Depressive symptoms . 45% had either diagnosed lymphedema or arm symptoms without diagnosed lymphedema consistent with other reports. (2006) studied the relationship between depressive symptoms and shoulder mobility among older women a year after breast cancer diagnosis. Perhaps not surprisingly. there was a significant dose-response relationship for decreasing SF-36 scores by number of arm symptoms.

arm/shoulder problems were associated with not being employed. regularly intake of analgesics and poorer physical quality of life. Nesvold. sociodemographic characteristics and breast cancer treatment were measured at 2 months and shoulder range of motion at 12 months. increased body mass index.ANGELES UNIVERSITY GRADUATE SCHOOL were linked as poorer quality of life. PAGE 37 Association between depressive symptoms and shoulder range of motion at one year after breast cancer diagnosis were examined. In this study. (2010) discussed the association between arm/shoulder problems in breast cancer survivors and reduced health and poorer physical quality of life. having had mastectomy. Multivariate analysis showed that . In usnivariate analysis. radiotherapy to axilla. lifestyle. Association of restricted shoulder abduction with quality of life were also compared. al. 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. poorer self-rated health and physical condition. Depressive symptoms. quality of life (QOL) and somatic morbidity in breast cancer survivors with and without arm/shoulder problems were examined. demography. minimal physical activity. longer follow-up time. Results showed an increasing depressive symptoms at baseline were associated with lower arm mobility at 12 months following breast cancer diagnosis. The relationship among variables were evaluation with bivariate chi-square statistics and logistic regression analysis. et.

Strength for hand grip was assessed using hand held dynamometer. Shoulder flexion. elbow flexion. minimal physical activity and poorer physical quality of life were associated with belonging to arm/shoulder problems group. A goniometer was used to measure ranges of motion (ROM) of the upper extremities. Four subscales are calculated and represent physical. Atlanta). In another study by Smoot (2009). psychological. Testing was completed by one investigator. shoulder abduction. longer follow-up time. social and spiritual domains. There was also significant association with having impaired abduction of greater than or equal to 25 degree difference. The Quality of Life Cancer Survivors Questionnaire (QOL-CS) was used to assess quality of life in cancer survivors. shoulder external rotation. . wrist flexion and extension. and wrist flexion using the MicroFET2 dynamometer (Hoggan MicroFET2 Muscle Tester Model 7477. he determines the impact of impairments on arm function and quality of life (QOL).ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 38 mastectomy. elbow flexion and extension. All participants attended a single evaluation session and both upper extremities were assessed. ProMed Products. and flexion of the proximal interphalangeal joint of digit two were measured following standardized procedures reported by Norkin. Strength scores were obtained for shoulder abduction.

demonstrate bilateral deficits in shoulder ROM and upper extremity strength compared to women without lymphedema. In a study of Cantero-Villanueva et. and is present with greater restrictions in activity. Reduced upper extremity strength is associated with poorer quality of life in the physical.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 39 This study indicates that following breast cancer treatment. Arm . Women with lymphedema more frequently report pain. and social subscales of the QOL-CS questionnaire. prior to surgery. they aimed to investigate the relationship between shoulder movement and quality of life in breast cancer survivors. the Piper Fatigue Scale. women with or without lymphedema presents with upper extremity impairments. al. and 6 months and 5 years after surgery. (2011). Quality of life is only measured against its relationship to shoulder movements. Results showed that fatigue was greater in those patients with reduced shoulder movement. psychological. in addition to the assessment of shoulder flexion range of motion. (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. and HRQOL. Sagen et. shoulder function. The subjects were examined for arm volumes. al. Women completed the Breast Cancer-Specific Quality of Life questionnaire.

ANGELES UNIVERSITY GRADUATE SCHOOL morbidities were seen to decrease over time. but significantly improved in the period from 6 months to 5 years after surgery. without seeking to establish causal connections (Loiselle . A descriptive correlational research method aims to describe relationships among variables. CHAPTER III RESEARCH DESIGN AND PROCEDURE Research Method The descriptive correlational research method is used in this study. PAGE 40 Several dimensions of HRQOL temporarily declined after surgery.

ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 41 et al. this research is classified as descriptive correlational since it seeks to recognize relationships between range of motion. Women will excluded for bilateral breast cancer. 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. muscle strength. current upper extremity infection. Likewise. lympangitis. or current recurrence of breast cancer. Respondents of the Study Women who have completed active breast cancer treatment at six(6) months previously. pre-existing neuromuscular or musculoskeletal conditions that would affect local upper extremity testing. handgrip strength and quality of life among breast cancer survivors Research Locale The study will be conducted at Jose B. pre-existing lymphedema. The women are required to be at least 25 years of age. and is able to read English. Study participant will be recruited through the outpatient department of the Physical Therapy Unit of JBLMRH. existing support . will be recruited. Lingad Memorial Regional Hospital(JBLMRH) Physical Therapy Unit where assessment will be done by only one trained physical therapist. 2010).

WHOQOL-BREF assessment tool for measuring the quality of life of breast cancer survivors. Lukes Medical Center. learning. Psychological 3.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 42 groups in Pampanga and willing participants of ALLTO clinical trial project at the St. Facets in each domain of overall quality of life and general health are the following: Table 2: WHOQOL-BREF Domains Domain 1. Social Relationships 4. memory and concentration Personal relationships Social support Sexual activity Financial Resources 2. 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. Environment . Research Instruments This study will This study will utilize the following instruments: 1. Quezon City. The assessment tool measures 6 domains of quality of life and each domain has facets incorporated in each domain.

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 . 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.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 43 Freedom.

ANGELES UNIVERSITY GRADUATE SCHOOL 1 2 3 4 5 Not at all A little A moderate amount Very much An extreme amount PAGE 44 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 .

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.1. Shoulder Muscle Strength Manual muscle testing (MMT) will be used to measure muscle strength of the shoulder. . Table 11: Assessment form for Shoulder Range of Motion Range of Motion Shoulder flexion Shoulder Abduction Shoulder Rotation Shoulder Rotation 2. range of motion of each shoulder is assess and noted on a table format.2.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 45 Musculoskeletal Assessment of the Upper extremity 2. Range of Motion Through the use of a standard goniometer.

Results are compared to the following normative value.5 kg – Dominant Female – Non Dominant Hand Statistical Treatment .75 kg 16.75 kg 17.5 kg 22 kg 21 kg 19. Table 12: Normative Values in Hand Grip Strength Among Women Age Female Hand 20 25 30 35 40 45 50 21.75 kg 10 kg 20 kg 19 kg 18.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 46 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.5 kg 17.5 kg 18.75 kg 16.5 kg 17. Handgrip Strength Protocol This protocol follows the standard procedures measuring handgrip strength using a dynamometer.3. 2.

Multiple linear regression will be selected for normally distributed interval data. Means and standard deviations for interval data will be obtained and unpaired t-tests for significance of differences will performed for normally distributed data.05 were considered significant. 3. pvalues less than 0. Research Procedures The following are the procedures which will be used in conducting of the study: 1. Regression analysis was used to evaluate the contribution of variables of theoretical interest to the outcome measure. 2.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 47 Statistical analyses will be performed using SPSS statistical sorftware (Version 17). Recruitment of Participants Selection of Participants Assessment of Participants Recruitment of Participants . 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). Mann-Whitney ranked sum analysis will be used to measure the test of difference for non-formally distributed interval data. For hypothesis testing.

Lingad Memorial Regional Hospital (JBLMRH) out-patient department.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 48 Willing participants are very important in this study since it is very difficult to look for participants that inspite of their illness. Lukes Medical Center. 2. The women are required to be at least 25 years of age. Criteria for inclusion are the following: 1. 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. Women who have completed active breast cancer treatment at six(6) months previously. lympangitis. ALLTO Clinical Trial is an on-going study that involves breast cancer survivors. Participants will be recruited from the Jose B. is still able to undergo and participate in research studies. 3. pre-existing neuromuscular or musculoskeletal conditions that would affect local upper extremity testing. and is able to read English. Women with bilateral breast cancer will be excluded. or current recurrence of breast cancer. current upper extremity infection. breast cancer support groups in Pampanga and subjects from the ALLTO Clinical Trial at the St. pre-existing lymphedema. Assessment of Participants .

BIBLIOGRAPHY A..S. et. Assessment tools will be used to measure variables of interest. Goniometry will be used in the assessing the shoulder range of motion. BOOKS Carlson. U.A: Harvard University Press.ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 49 Participants will be assessed according to the research method mentioned above. The New Harvard’s Guide to Women’s Health. al. . Karen J. manual muscle testing will be employ to measure shoulder muscle strength and hand grip strength will be assessed using a standard dynamometer. (2004).

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

ANGELES UNIVERSITY GRADUATE SCHOOL PAGE 52 Smooth. (2010) Upper Extremity impairments in women with or without lymphedema following breast cancer treatment. . al. Pp. et. Journal of Cancer Survivor. Vol. Betty. 4. 167-178.

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