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Rehabilitation of Post- Mastectomy Syndrome Eric Wisotzky, MD Director of Cancer Rehabilitation MedStar National Rehabilitation Network Assistant Professor of Rehabilitation Medicine Georgetown University School of Medicine Slide 2 Disclosures None Slide 3 Objectives Therapy techniques for post-mastectomy syndrome Rehabilitation precautions for post-mastectomy syndrome Medications for post-mastectomy syndrome Interventional procedures for post-mastectomy syndrome Prevention of post-mastectomy syndrome Slide 4 Therapy Techniques Effectiveness of Postoperative Physical Therapy for Upper-Limb Impairments After Breast Cancer Treatment: A Systematic Review De Groef, An et al. Archives of Physical Medicine and Rehabilitation 2015; 96:1140-53. Slide 5 Therapy Techniques: Passive Mobilization One study showed beneficial effects of passive mobilization on shoulder pain and ROM Followed patients for 8-24 months post-op Le Vu B, Dumortier A, Guillaume MV, Mouriesse H, Barreau-Pouhaer L. Efficacy of massage and mobilization of the upper limb after surgical treatment of breast cancer. Bulletin du Cancer 1997; 84:957-61. Slide 6 Therapy Techniques: Stretching One study investigating pectoral stretching program compared to a home exercise program consisting of ROM exercises Followed patients for 7 months No difference in pain or ROM Lee TS, Kilbreath SL, Refshauge KM, Pendlebury SC, Beith JM, Lee MJ. Pectoral stretching program for women undergoing radiotherapy for breast cancer. Breast Cancer Res Treat 2007;102:313-21. Slide 7 Therapy Techniques: Exercise Therapy Five studies investigated the effectiveness of exercise therapy (shoulder exercises) All found beneficial effect on shoulder ROM One found positive effect on pain Active physical therapy vs home exercise program Great variability in terms of type of exercises, frequency, intensity, and duration of programs De Groef, An, et al. Effectiveness of Postoperative Physical Therapy for Upper-Limb Impairments After Breast Cancer Treatment: A Systematic Review. Archives of physical medicine and rehabilitation (2015) Slide 8 Therapy Techniques: Multifactorial Two studies showed multifactorial therapy consisting of manual stretching and active exercises effectively treated impaired shoulder ROM at 6 months post-op De Groef, An, et al. Effectiveness of Postoperative Physical Therapy for Upper-Limb Impairments After Breast Cancer Treatment: A Systematic Review. Archives of physical medicine and rehabilitation (2015) Slide 9 Therapy Techniques: Timing of Therapy Three studies showed early start (POD#1) more beneficial for recovery of ROM Four studies showed greater incidence of seromas and wound drainage in group with early start vs those starting >7 days post-op De Groef, An, et al. Effectiveness of Postoperative Physical Therapy for Upper-Limb Impairments After Breast Cancer Treatment: A Systematic Review. Archives of physical medicine and rehabilitation (2015) Slide 10 Therapy Techniques: Authors Recommendations First week post-op: low-intensity program involving elbow/wrist 7-10 days post-op: gradually increase intensity Passive mobilization, manual stretching, active exercises No recommendations can be made on length of time, content, intensity De Groef, An, et al. Effectiveness of Postoperative Physical Therapy for Upper-Limb Impairments After Breast Cancer Treatment: A Systematic Review. Archives of physical medicine and rehabilitation (2015) Slide 11 Post-mastectomy Syndrome: Occupational Therapy Patients need help with ADLs Difficulty with household chores, dressing Thomas-MacLean, Roanne L., et al. "Arm morbidity and disability after breast cancer: new directions for care." Oncology nursing forum. Vol. 35. No. 1. 2008 Slide 12 Therapy Techniques for Specific Syndromes: Incisional pain Axillary Web Syndrome (cording) Shoulder dysfunction Post-Reconstruction Pain Syndrome Neuropathic syndromes Intercostobrachial neuralgia Phantom breast pain Slide 13 Therapy Techniques: Incisional Pain From local adherence of incision to chest wall Presents with incisional hypersensitivity Decreased mobility of incision Slide 14 Therapy Techniques: Incisional Pain Scar massage/mobilization Desensitization techniques Slide 15 Therapy Techniques: Axillary Web Syndrome (Cording) Often spontaneously resolve Soft tissue techniques Nerve glides ROM May have audible snap Slide 16 Shoulder Dysfunction: Impingement Protective posturing/radiation Shortening of pec muscles Decreased size of subacromial arch due to forward depressed shoulder girdle Rotator cuff dysfunction/impingement Slide 17 Shoulder Dysfunction: Range of Motion in Breast Cancer Decreased planes of motion: flexion abduction external rotation Levangie PK, Drouin J. Magnitude of late effects of breast cancer treatments on shoulder function: a systematic review. Breast Cancer Res Treat 2009;116(1):115 Slide 18 Shoulder Dysfunction: Scapular Mechanics Scapulothoracic motion altered in all planes Shamley, et al. Three-dimensional scapulothoracic motion following treatment for breast cancer. Breast Cancer Res Treat (2009) 118:315-322 Slide 19 Shoulder Dysfunction: Muscle Strength Multiple studies have shown weakness in: Abduction Flexion Extension External/internal rotation Scapular upward rotation/depression/adduction Slide 20 Based on above findings, a sensible PT rx might include: Pec stretching Scapular stabilization/mechanics exercises Strengthening in all planes Slide 21 Post-Reconstruction Pain Syndrome (PRPS) Neuromuscular symptoms including: paresthesias, dysesthesias, cramping, spasms, or other characteristically neuropathic discomfort in the chest wall, shoulder, upper arm, abdomen, and/or back following breast surgery with reconstruction for breast cancer. Slide 22 Therapy Techniques: PRPS Stretching of pectoralis and serratus Manual release of tissues around implant/tissue expander Slide 23 Intercostobrachial Neuralgia Slide 24 Intercostobrachial Nerve Cutaneous branch of 2nd intercostal nerve (T2) Supplies the posterior and medial upper arm, axilla, and lateral chest wall Much anatomic variation Increase risk of injury during ALND Slide 25 Therapy Techniques: Intercostobrachial Neuralgia Desensitization Slide 26 Therapy Techniques: Phantom Breast Pain Desensitization Mirror therapy Slide 27 Therapy Precautions Caution with manual therapy around tissue expander/implant Common sense lymphedema precautions Avoid aggressive deep tissue work to lymphedematous limb or limb at risk of lymphedema Slide 28 ABSOLUTE Precautions Avoid physical agents or e-stim directly over active tumor Avoid heat/ice in potentially ischemic or insensate areas Avoid heat in patients at high bleeding risk Avoid heat/ice, e-stim, TENS in areas at risk for fracture Avoid traction in area of malignancy Fracture risk Slide 29 Post-mastectomy Syndrome: Medications Slide 30 Post-mastectomy Syndrome: Oral Medications Anti-depressants Venlafaxine showed significant pain relief vs placebo Tasmuth, Tiina, Brita Hrtel, and Eija Kalso. Venlafaxine in neuropathic pain following treatment of breast cancer. European journal of pain 6.1 (2002): 17-24. Amitriptyline 25-100 mg daily resulted in >50% pain relief in 8/15 patients Randomized placebo controlled crossover study Tasmuth, Tiina. Amitriptyline effectively relieves neuropathic pain following treatment of breast cancer. Pain 64.2 (1996): 293-302. Slide 31 Post-mastectomy Syndrome: Topical Medications Capsaicin Randomized, placebo controlled trial 5/13 patients using capsaicin had >50% pain relief 1/10 in placebo group had >50% pain relief Watson, C. Peter N., and Ramon J. Evans. The postmastectomy pain syndrome and topical capsaicin: a randomized trial. Pain 51.3 (1992): 375- 379 Slide 32 Post-mastectomy Syndrome: Topical Medications Lidocaine patch 28 patients randomized to lidocaine patch vs placebo patch No difference in pain scores between the two groups Cheville, Andrea L., et al. Use of a lidocaine patch in the management of postsurgical neuropathic pain in patients with cancer: a phase III double- blind crossover study (N01CB). Supportive care in cancer 17.4 (2009): 451- 460. Slide 33 Post-mastectomy Syndrome: Other Medications Anti-inflammatories: topical or oral Nerve stabilizers: gabapentin, pregabalin Duloxetine Opioids Topical compounds Slide 34 Post-mastectomy Syndrome: Modalities TENS no better than placebo for post- mastectomy pain Robb, Karen A., Di J. Newham, and John E. Williams. "Transcutaneous electrical nerve stimulation vs. transcutaneous spinal electroanalgesia for chronic pain associated with breast cancer treatments." Journal of pain and symptom management 33.4 (2007): 410-419. Slide 35 Post-mastectomy Syndrome: Acupuncture Randomized controlled trial of acupuncture vs usual care showed decreased pain and improved ROM in the acute postoperative period after breast surgery He, J. P., et al. "Pain-relief and movement improvement by acupuncture after ablation and axillary lymphadenectomy in patients with mammary cancer." Clinical and experimental obstetrics & gynecology 26.2 (1998): 81-84. Slide 36 Injections in Post-mastectomy Syndrome Can they be performed? Slide 37 Injections in Post-mastectomy Syndrome Can they be performed? Yes for the most part Slide 38 Injections in Post-mastectomy Syndrome Can they be performed? Yes for the most part Precautions to consider: -Wounds -Skin issues during radiation -Blood counts during chemotherapy -Lymphedema/infection risk Slide 39 Injections in Post-mastectomy Syndrome: Musculoskeletal Rotator cuff impingement subacromial injection Adhesive capsulitis glenohumeral injection Myofascial pain trigger point injection Slide 40 Intercostobrachial Neuralgia Management Intercostobrachial nerve block Slide 41 Intercostobrachial Nerve Block Technique Slide 42 Slide 43 Case Series for Intercostobrachial Nerve Block PatientBaseline2 weeks4 weeks6 weeks3 months A6/104/10 B6/104/10 (2 nd inj)2/10 C10/100/10 Slide 44 Neuroma Injections 19 patients injected 93% had complete relief of pain after injection of T4 and/or T5 neuromas with bupivicaine and dexamethasone Tang CJ, Elder SE, Lee DJ, Rabow MW, Esserman LJ: 2013 San Antonio Breast Cancer Symposium Abstract P3-10-03. Presented December 12, 2013.Abstract P3-10-03. Presented December 12, 2013. http://cancer.ucsf.edu/videos/Esserman_v4.mp4 Slide 45 Neuroma Injections Slide 46 Neuropathic Chest Wall Pain Intercostal Nerve Block Paravertebral Nerve Block Intercostal Neurolysis Thoracic Nerve Pulse Radiofrequency Ablation Intrathecal Pump Gulati, Amitabh, et al. A retrospective review and treatment paradigm of interventional therapies for patients suffering from intractable thoracic chest wall pain in the oncologic population. Pain Medicine 16.4 (2015): 802-810. Slide 47 Botulinum Toxin for Post-Reconstruction Pain Syndrome Consider injecting pectoralis major, serratus anterior Dont pop the implant! Can use ultrasound Slide 48 Botulinum Toxin for Post-Reconstruction Pain Syndrome: Evidence 100 units botulinum toxin A in pec major resulting in 100% pain relief for 6 weeks 250 units of abobotulinumtoxin A into pec major resulting in 100% pain relief for 4 weeks O'Donnell, Casey J. Pectoral muscle spasms after mastectomy successfully treated with botulinum toxin injections. PM&R 3.8 (2011): 781-782. Slide 49 Botulinum Toxin for Radiation Fibrosis Syndrome 87% of patients reported self-reported benefits from the injections Stubblefield, Michael D., et al. "The role of botulinum toxin type A in the radiation fibrosis syndrome: a preliminary report." Archives of physical medicine and rehabilitation 89.3 (2008): 417-421. Slide 50 Post-mastectomy Syndrome: Prevention Regional anesthesia 40 patients assigned to general anesthesia vs general anesthesia plus paravertebral nerve block Patients in the nerve block group had significantly less chronic pain than general anesthesia alone 4-5 months post-op Ibarra, M. M., et al. Chronic postoperative pain after general anesthesia with or without a single-dose preincisional paravertebral nerve block in radical breast cancer surgery. Revista espanola de anestesiologia y reanimacion 58.5 (2011): 290-294. Slide 51 Post-mastectomy Syndrome: Prevention EMLA 46 patients randomized to chest wall EMLA cream vs placebo peri-operatively 5 min before surgery and then daily for 4 days post-op Placed on sternum, supraclavicular region, and axilla Pain intensity significantly less in EMLA group 3 months post-op Fassoulaki, Argyro, et al. EMLA reduces acute and chronic pain after breast surgery for cancer. Regional anesthesia and pain medicine 25.4 (2000): 350-355 Slide 52 Post-mastectomy Syndrome: Prevention Gabapentin peri-operatively Single dose of 600 mg gabapentin one hour pre- operatively Treatment group had less post-op pain and less opioid consumption in first day after surgery Grover, V. K., et al. A single dose of preoperative gabapentin for pain reduction and requirement of morphine after total mastectomy and axillary dissection: randomized placebo- controlled double-blind trial. Journal of postgraduate medicine 55.4 (2009): 257. Slide 53 Post-mastectomy Syndrome: Prevention Minimizing pre-op pain/ROM restrictions PREHAB!! Slide 54 Post-mastectomy Syndrome: Prevention Psychological Factors Depression Anxiety Catastrophizing Schreiber, K. L., et al. (2014). "Predicting, preventing and managing persistent pain after breast cancer surgery: the importance of psychosocial factors." Pain Manag 4(6): 445-459 Slide 55 Intercostobrachial Neuralgia Prevention Prevention: Nerve sparing surgery may or not help prevent this pain syndrome Meta-analysis showed that complaints when nerve is severed are typically numbness which may be less bothersome Warrier S, Hwang S, Koh CE, Shepherd H, Mak C, Carmalt H, Solomon M. Preservation or division of the intercostobrachial nerve in axillary dissection for breast cancer: Meta-analysis of Randomised Controlled Trials. Breast. 2014 Feb 24 Slide 56 Post-Reconstruction Pain Syndrome Prevention Botulinum toxin injected into pec major, serratus, rectus abdominus intra-operatively during mastectomy and tissue expander placement Botulinum toxin group had significantly less post-op pain and narcotic use than control group at initial and final tissue expansions Layeeque, Rakhshanda, et al. Botulinum toxin infiltration for pain control after mastectomy and expander reconstruction. Annals of surgery 240.4 (2004): 608. Slide 57 Summary Post-mastectomy syndrome rehabilitation often requires a multimodal approach Patient assessment should look for specific cause of symptoms which will dictate treatment options Much is still not known so many research possibilities Slide 58 Questions??? Eric.m.wisotzky@medstar.net