<LEAP> highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions—medication, surgery, education, nutrition, exercise—and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.1 Each article in this PTJ series summarizes a Cochrane review or other scientific evidence on a single topic and presents clinical scenarios based on real patients or programs to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on a woman with a diagnosis of breast cancer who underwent a modified radical mastectomy with a sentinel lymph node biopsy. She subsequently received chemotherapy and radiation therapy and required episodic physical therapy to decrease impairments and improve functional limitations. Could an exercise program for the upper limb delivered preoperatively and postoperatively and along the trajectory of adjuvant chemotherapy and radiation therapy help reduce shoulder and upper extremity impairments?
More than 2.6 million breast cancer survivors currently reside in the United States.2 Although improvements in the medical management of women diagnosed with breast cancer have resulted in a 5-year survival rate of 89%, curative treatments often are associated with adverse effects that affect physical function.3–5 Shoulder and arm morbidity (eg, loss of range of motion [ROM] and strength and pain due to axillary web syndrome and cording, in addition to lymphedema) is highly prevalent in patients undergoing breast cancer treatment.6–9 This condition may lead to difficulty with activities of daily living (ranging from overhead reaching and lifting and carrying objects to caring for family and returning to work).10,11 As a result of these impairments, women often attenuate their activities after treatment, which leads to poor activity tolerance and diminished quality of life.6,12–16
Early breast cancer typically is treated over a period of up to 1 year. During this time, women are exposed to various treatment modalities (eg, surgery, chemotherapy, radiation therapy, and reconstruction surgery) that may contribute to diminished arm function. Because of this protracted time frame and the unique nature of cancer treatment, some adverse effects contribute to early arm and shoulder impairments, and others occur months, or even years, after treatment is withdrawn.8,17–24 Regardless of the duration of breast cancer treatment, rehabilitation interventions throughout the trajectory of disease treatment are known to reduce arm and shoulder morbidity.7,24–26 Although studies have demonstrated that rehabilitation care reduces the incidence of breast cancer–related physical impairments,26–29 early intervention with physical therapy to restore and maintain arm and shoulder mobility after surgery is optimal to reduce overall morbidity.19,25,26,28,30–34 To determine the effectiveness of physical therapy intervention in the treatment of the upper extremity during breast cancer treatment, McNeely et al35 conducted a systematic review of randomized trials investigating the effectiveness of exercise to reduce shoulder and upper extremity morbidity throughout treatment.
A robust body of evidence supports the effectiveness of physical therapy intervention in reducing shoulder morbidity and restoring shoulder function during and after breast cancer treatment. The Cochrane review by McNeely et al35 collates the relevant research to inform physical therapy clinical practice regarding treatment intervention for breast cancer–related shoulder morbidity. The Table provides key points of this Cochrane review. It includes randomized controlled trials (RCTs) based upon the following outcomes: upper extremity ROM, muscular strength, lymphedema, and pain. Types of therapeutic exercises included active ROM (AROM) or active-assisted ROM (AAROM), passive range of motion (PROM)/manual stretching, stretching exercises, and strengthening or resistance exercises. Twenty-four studies involving 2,132 participants were included in the review. Ten of the 24 studies were considered to be of adequate methodological quality. Ten studies examined the effect of early (1–3 days) versus delayed implementation of postoperative exercise. Early exercise was more effective than delayed exercise in the short-term recovery of shoulder flexion ROM; however, early exercise also resulted in a statistically significant increase in wound drainage volume and duration. Fourteen studies examined the effect of structured exercise when compared with usual care (eg, informational pamphlet) or comparison interventions (eg, independent exercise). Of these, 6 were postoperative, 3 during adjuvant treatment, and 5 following cancer treatment. Structured exercise programs in the postoperative period significantly improved shoulder flexion ROM in the short term. Physical therapy treatment yielded additional benefit for shoulder function immediately after surgery and at the 6-month follow-up. There was no evidence of increased risk of lymphedema from exercise at any time point.35
The review supports the premise that targeted upper limb exercises result in significant and clinically meaningful improvements in shoulder ROM and aid in the recovery of upper limb movement following surgery. In the postoperative period, awareness of early implementation of exercise must be carefully weighed against increases in wound drainage volume. The evidence presented suggests that structured exercise programs are beneficial and safe for women during and after treatment.35 Further research is needed to explore exercise intensity factors and other persistent upper extremity dysfunction beyond 6 months.
Case #17: Exercise for Upper Limb Dysfunction
Can an exercise program assist this patient?
“Mrs Jamison” is a 42-year-old woman diagnosed with stage IIA cancer of the right breast. She currently exercises 3 to 4 times per week. Exercises include lifting weights, running, and swimming; recreational activities include golfing and hiking; and social activities include participation in book club and church activities and occasional work with her daughter's school. She is employed full time as a clinical research nurse, and her job duties do not require significant lifting, carrying, or physical exertion. She is right-handed and has no prior history of trauma or surgery to the shoulders, elbow, wrist or hand, or neck.
Mrs Jamison is seen for short-term interventions during the course of 6 months; she is examined by a physical therapist and receives episodic care through her surgery, chemotherapy, and radiation. It is important to establish exercise guidelines through the trajectory of treatment because Mrs Jamison is undergoing various interventions. Each point in her treatment may address varying degrees of upper limb impairment and needs proper titration given the systemic nature of adjuvant chemotherapy and radiation. This review contends that targeted upper limb exercise results in improvements in shoulder ROM and is helpful in recovering upper limb movement following surgery. Although other factors (eg, chemotherapy-related fatigue, cognitive decline, painful peripheral neuropathy, and radiation fibrosis) can occur during treatment for breast cancer, this article will focus on recovery of upper limb function and the impact of structured exercise.
How did the physical therapist apply the results of the Cochrane review to Mrs Jamison?
Both Mrs Jamison's oncologist and her physical therapist wanted to determine whether she would be a good candidate for an exercise program throughout her treatment for breast cancer. Using the PICO (Patient, Intervention, Comparison, Outcome) format, they asked: Will an exercise regimen (compared with no exercise regimen) be beneficial for improving upper extremity function in a 42-year-old woman following a modified radical mastectomy with a sentinel lymph node biopsy on the right side? They determined that the systematic review by McNeely et al35 provided relevant information that permitted them to answer their question. This Cochrane review included RCTs based upon upper extremity ROM, muscular strength, lymphedema, and pain. Types of therapeutic exercises included the following: AROM or AAROM; PROM/manual stretching; stretching exercises; and strengthening, or resistance, exercises. Early exercise was more effective than delayed exercise in the short-term recovery of shoulder flexion ROM; however, early exercise also resulted in a statistically significant increase in wound drainage volume and duration. Structured exercise programs in the postoperative period significantly improved shoulder flexion ROM in the short term. Physical therapy treatment yielded additional benefit for shoulder function postintervention and at 6-month follow-up.
Based on their assessment of the systematic review, Mrs Jamison's health care team recommended that she begin an exercise program postoperatively. The review by McNeely et al35 addresses the necessary time point for postoperative intervention and supports the efficacy of a targeted exercise program during this period. Specifically, upper limb ROM and stretching exercises have been shown to enable recovery of shoulder motion. The optimal gauge of recovery will be based on the assessment of the patient's relatively normal health state at baseline.
Mrs Jamison is seen for physical therapy on postoperative day 2 and has a Jackson-Pratt (JP) drain in place; it is putting out 100 cc of serosanguineous fluid per day. She notes her pain level is 4/10 at rest. She is hesitant to lift her arm and is fearful the movement will induce pain. She reports her pain is 6/10 when reaching at shoulder level and describes it as a “pulling in the chest wall.” Her Disabilities of the Arm, Shoulder and Hand (DASH) score is 61.4%. Scores range from 0 (no disability) to 100 (most severe disability), and Mrs Jamison has moderate disability. According to the review, the postoperative exercise program will enable improvement in shoulder ROM; however, there is evidence that early exercise may require her JP drain to stay in place longer as there may be greater drainage with early mobilization. Considering that the drain is putting out considerable fluid levels, the evidence suggests that withholding overhead ROM exercise at this early time point will not impair her ability to regain full shoulder motion and may help facilitate earlier removal of the drains.
The patient was provided upper extremity AROM exercises below 90 degrees of elevation and through all planes of motion at the elbow and wrist joints. Diaphragmatic breathing was encouraged for pain management along with use of mindfulness strategies36 to reduce anxiety associated with the postoperative course of events.37–39 Postural and scapular recruitment exercises were initiated to facilitate return of mobility without compromising healing of the tissue.
Mrs Jamison returns to an outpatient clinic 10 days postoperatively. The JP drain has been removed, and she is scheduled to begin chemotherapy in 2 weeks. She has been trying to move her arm and is attempting to undertake routine daily activities; however, she has pain with overhead reaching rated at 3/10. Examination reveals right upper arm ROM deficits at 130 degrees overhead. The DASH is administered again and demonstrates expected deficits based on her preoperative assessment (52.3%). Limb volume is measured, and no significant difference in volume change is noted based on her preoperative measurement and with consideration for her contralateral limb. Physical therapy intervention focuses on ROM and strength restoration, postural dynamics, and education for lymphedema prevention.
The Cochrane review suggests that a supervised exercise intervention is preferable to usual care (instructional packet or no structured exercise) following surgery; therefore, a plan of care including AAROM, PROM, soft tissue scar mobilization, and proprioceptive neuromuscular facilitation (PNF) exercises to ensure optimal scapulohumeral rhythm is initiated. Mrs Jamison's home exercise program includes AROM or AAROM stretching, PNF, and mild resistance exercises, in addition to isometric biceps and triceps muscle and scapular recruitment exercises. She is encouraged to resume her aerobic activity on the treadmill and a home walking program for general conditioning. She also is educated on lymphedema prevention and shoulder exercises consistent with her improved ROM. Energy conservation strategies are discussed to accommodate her work demands as a research clinical nurse during her course of chemotherapy.
Mrs Jamison returns for an outpatient reexamination 3 months postoperatively and has completed 5 of 6 cycles of adriamycin and cytoxan. She is able to continue her home exercise program and most activities of daily living, but still complains of shoulder pain with far overhead reaching rated at 2/10. She is concerned about having enough shoulder ROM to tolerate the overhead position for her upcoming radiation therapy. In addition, she is experiencing generalized cancer-related fatigue, rated at 6/10 on the visual analog scale. Examination reveals slight right arm ROM deficits with overhead motion at 170 degrees. Follow-up DASH shows improvement since her last visit (39.7%). Strength testing reveals deficits in scapular stability and recruitment. Limb volume changes are symmetrical bilaterally. Based on the evidence presented in the systematic review, Mrs Jamison's plan of care is to continue targeted upper extremity exercise, as this intervention is beneficial during adjuvant chemotherapy. The plan of care continues to include AROM or PROM, stretching, and soft tissue mobilization, as well as upper body resistive exercises using Thera-Band (Hygenic Corporation, Akron, Ohio), postural dynamics, and lymphedema prevention education. Her fatigue level is clinically significant and warrants intervention; therefore, a graded exercise program on the treadmill with vital sign monitoring is prescribed.
At 6 months, the patient returns for a physical therapist reexamination. She is in week 2 of 6 for radiation therapy. Mrs Jamison has been consistent with her home exercise program; however, she has not continued her aerobic conditioning program due to cancer-related fatigue, which she rates at 5/10. She complains of “tightness” in her right chest wall and restrictions with overhead activities and various yoga postures. Upon examination, right upper limb volume is stable, with no evidence of lymphedema and DASH score is 27.2%. The AROM of the right arm is 160 degrees overhead, and she reports right chest wall pain at 4/10, mostly with far overhead reaching. The Cochrane review supports continued upper limb exercises at this juncture. Generalized conditioning exercise during adjuvant treatment for breast cancer can be regarded as a supportive self-care intervention that results in improved physical fitness and thus the capacity for performing activities of daily living.
How well do the outcomes of the intervention provided to Mrs Jamison match those suggested by the systematic review?
Mrs Jamison completed 18 of 20 exercise sessions and was able to self-monitor when she experienced changes in upper extremity function and returned for physical therapy as planned at 3 and 6 months. According to the DASH, her disability improved from a score of 64% to a score of 27% (improvement of 37%). Given that a difference of 15 points on the DASH has been reported to be of clinical importance,40,41 her improvement was substantial. The patient was able to receive structured upper limb exercise as described in the review by McNeely et al35 during the various treatments for her breast cancer during the course of 6 months. Because structured exercise was superior to usual care in the Cochrane review, the physical therapist was able to maximize outcomes by applying the evidence to Mrs Jamison's case throughout the trajectory of treatment.
Can you apply the results of the systematic review to your patients?
The findings of this review apply to women breast cancer survivors during postoperative surgery, chemotherapy, and radiation. Types of therapeutic exercise included AROM or AAROM, PROM/manual stretching, stretching exercises, and resistance exercises. The results apply to patients in home-based and supervised exercise programs. However, the review does not provide clear evidence of pain management and quality of life as specific endpoints for women with breast cancer, and further research is needed beyond the 6-month period regarding shoulder impairment and function.
What can be advised based on the results of this systematic review?
The integral role of physical therapy to restore upper extremity function is highlighted in this patient case in the early weeks postoperatively. However, there is inconclusive evidence of benefit beyond this time frame. McNeely et al35 demonstrate the efficacy of targeted upper extremity limb exercise at various intervals along the continuum of disease treatment. Further research is needed beyond this time frame in order to determine sustainable benefits of early intervention in this population.
The unique nature of cancer treatment is profiled in this case study. Patients with breast cancer undergo a multimodal approach to disease management that extends across the time frame of at least 1 year. Evidence suggests that physical impairments and functional limitations are associated with every treatment modality introduced throughout that continuum.8,21,42–46 Therefore, this need for ongoing assessment and treatment when necessary warrants a prospective clinical approach that provides advice and guidance for return to full function and promotes early detection and intervention for other potential impairments known to be associated with cancer treatment.26,31 Findings of the meta-analyses suggest that patients with upper limb dysfunction due to breast cancer treatment benefit from a specific structured postoperative exercise program when compared with those given usual care (no exercise instruction or written instructions) in both short-term and long-term shoulder flexion and abduction. Upper limb exercises positively affected outcomes, including ROM, strength, and shoulder function. The review did not find adverse responses to exercise at these intervals specifically regarding lymphedema. The evidence supports structured exercise programs as beneficial and safe for women during and after treatment. Further research, however, is needed to explore exercise intensity factors, impact of exercise on persistent upper extremity dysfunction, and adherence to such a program.
The use of emerging research findings and contemporary models of care that target functional recovery after breast cancer treatment are important in survivorship care.47 This role falls squarely in the physical therapist's domain and serves as an entrée for the rehabilitation specialist throughout cancer survivorship. Integration of physical therapist examination and intervention from the point of diagnosis and through the steps of treatment for improved healthy survivorship are supported through the evidence presented in this Cochrane review, and further research is warranted. This approach enables early identification and management of acute and late effects of cancer treatment and promotes overall health and wellness to promote optimal recovery of function.
The views expressed in this article are solely those of the authors and are not necessarily reflective of the official policies or positions of the Department of Defense nor the US government.
- Received February 5, 2012.
- Accepted April 12, 2013.
- © 2013 American Physical Therapy Association