Early Education, Exercise and CDT Following Radiation Therapy for Breast Cancer By Linda Boyle, PT, DPT, CLT-LANA OUTLINE FOR CASE PRESENTATIONS I. Reason for presenting case Patients receiving external beam radiation therapy may not be seen by a lymphedema therapist until late effects of radiation are apparent. Physical changes following external beam radiation therapy for breast cancer may include osteoporosis/osteopenia, soft tissue fibrosis, muscular contraction, and cardiopulmonary compromise in the treatment area. 1,2 The effects of external beam radiation can lead to the following deficits in the affected lymphatic quadrant. 1 1. Pain 2. Range of motion restrictions 3. Muscular compromise 4. Exercise restrictions 5. Functional deficits 6. Decline in quality of life Early tissue changes following external beam radiation do not necessarily predict long-term effects. 2 Lymphedema therapists need to be familiar with the early and late effects of external beam radiation. Affected areas encompass the entrance and exit paths and all deep tissues and organs therein. Radiation history and treatment area will help direct the therapist in appropriate clinical intervention. 3 The clinical questions in this case. Would it be prudent to evaluate/assess patients prior their radiation therapy and provide education concerning possible side effects? Could we intervene to minimize long term morbidity in these individuals? II. Lymphedema Diagnosis Our patient is a 34 year old right dominant woman diagnosed with left sided breast cancer in June, 2005. Body Mass Index (BMI) 20. She undergoes post-operative chemotherapy and radiation therapy extending to the supraclavicular lymph nodes following a lumpectomy with axillary lymph node dissection and positive lymph nodes 5/12. Early persistent pain free left upper extremity edema is reported following surgery and with a negative venous doppler study. 4 Patient is scheduled to begin radiation therapy from September until December 2005. Onset of edema is noted by the patient on the dorsum of the left hand immediately post-operatively, but initially resolves with elevation. The referral is made to the lymphedema team due to gradually persistent left hand/wrist/forearm edema and the fact that radiation therapy would soon begin. Initial volume is 6% greater in the affected left upper extremity and increases to 8% following radiation therapy. 5 Tissue texture is slightly spongy in the left hand and wrist in September 2005. By December 2005 the left forearm also feels spongy. Stemmers sign is positive on the left.
The patient attends four sessions of outpatient physical therapy in September 2005 including manual lymphatic drainage and a home therapeutic exercise program to maintain flexibility and strength in the neck, thoracic spine, left shoulder, and scapula. A well fitting, compression class one ready to wear arm sleeve and glove are provided. She is instructed in measuring girth in both upper extremities. Education concerning fluctuations in body weight common during cancer therapies is provided. Garments are worn during the day and removed before bed. 3 At the end of the initial four sessions, volume difference in the upper extremities is 5%. III. Medical History/ Physical Examination Prior to diagnosis of breast cancer there is no pertinent past medical/surgical history. The review of systems is unremarkable. Patient is BRCA1 positive and diagnosed with stage 3 breast cancer. Cervical and thoracic range of motion is within normal limits and pain free at initial evaluation and follow-up assessments. Sensation to light touch is intact throughout except for the left breast incision, left axilla and proximal humerus due to surgical disruption of the intercostobrachial nerve. 6 Initially, palpation of the pectoralis major and minor, subscapularis, upper trapezius and levator scapulae is unremarkable, but moderate muscle tightness and tenderness are present following radiation therapy. September December Standing posture Normal Forward shoulder Scapular abduction/external rotation Pain 0/10 Anterior chest wall 5/10 Supine active range of motion shoulder Within normal limits - 5 degrees flexion & extension Manual muscle test shoulder and scapula 5/5 throughout 4+/5 Range of motion and strength deficits are noted following radiation therapy. 7 Special tests on left shoulder for scapular stability, muscle tendon pathology, impingement, and neurological pathology were negative. 8 II. Psychosocial Considerations The patient is an intelligent motivated and appropriately anxious 34 year old woman with breast cancer. 9 She lives with a roommate and has a supportive family that lives locally. Unfortunately, a quality of life questionnaire is not administered. The patient and her mother attend our first session and both had many questions concerning the disease of lymphedema. The patient travels by air frequently for her job as a video producer. 10 She is a triathlete before her diagnosis and has questions concerning exercise and lymphedema. 11 She also has a supportive boyfriend. IV. Functional Limitations Our patient reports no functional limitations but notes cancer related fatigue in December 2005 at 5/10 on analogue scale of 0 to 10 (0= absence of fatigue and 10 overwhelming fatigue). She reported 0/10 fatigue in September 2005. The disabilities of the arm, shoulder and hand (DASH) was 24/100 upon initial evaluation and 31/100 at the follow up visit in December 2005. 12
V. Degree of Impairment in ADL's The patient is unable to work or perform her regular aerobic and conditioning exercises during her radiation sessions due to fatigue. She continues to live in her apartment and is independent in all aspects of her activities of daily living. Pain is reported in the radiation field due to skin erythema and disruption. This irritation interferes with patient s ability to perform regular aerobic conditioning between October and December 2005. VI. VII. Summary of Pre-treatment goals a. Educate patient Concerning the disease of lymphedema with emphasis on signs and symptoms Concerning tissue changes from radiation In monitoring bilateral upper extremity volume with respect to body weight To perform daily home exercises for flexibility and strengthening of the trunk, scapulae, and upper extremity throughout her radiation intervention b. Fit patient with ready to wear garments compression class one (CCI) to wear during the day while physically active. Garments are removed at night. c. Assure that the patient and her family contacts the cancer counselors to receive psychosocial support throughout cancer intervention. d. Promote open communication and trust between the patient and the lymphedema team. The patient is encouraged to contact her medical team as questions arise concerning her care. Summary of Therapeutic Interventions, Goals and Outcomes Intervention Goal Outcome Manual lymphatic drainage -Facilitate lymphangioactivity prior to radiation therapy -Promote relaxation -Minimal change in volume -Positive communication with patient Patient education -Provide knowledge concerning lymphedema and tissue changes with radiation -Patient knowledge and home program allows her to partner in her care Garment fitting Therapeutic exercises -Minimize volume fluctuations in the left upper extremity while undergoing radiation therapy -Maintain range of motion in the neck, thoracic spine and left upper extremity -Maintain strength in the same -Some increase in volume left upper extremity addressed by the patient and the lymphedema therapist -Mild range of motion deficits -Mild strength deficits VIII. Results of modified intervention Patient feels that her need for information was addressed. She also feels supported by the lymphedema team throughout her cancer interventions. IX. Follow-up
The patient continues to consult the lymphedema team for monitoring of her musculoskeletal, integumentary and volumetric conditions at regular intervals. This patient is adherent with exercises and use of elastic compression garments. She replaces her compression garments at least every 6 months. X. Conclusions. What lesson/s can this case teach us? Objective examination findings are needed to support the use of complete decongestive therapy. It is our role as lymphedema therapists to remain current with medical evidence and apply it to our daily lymphedema practices. Specific documentation standards would be helpful to practicing lymphedema therapists. Some omissions from data in this case include absence of quality of life and cancer related fatigue functional tools. Functional tools are administered upon evaluation and at the time of discharge and must be valid and reliable within the diagnostic group. Including this information will provide outcome information concerning the efficacy of complete decongestive therapy. Discussion/Alternative Suggestions Early intervention for persons with lymphedema may be helpful towards preventing the progression of volume increases, tissue changes and musculoskeletal dysfunctions associated with breast cancer therapies. Perhaps early referral to a lymphedema therapist before radiation therapy begins would minimize psychological and physical morbidity following radiation therapy. Baseline data prior to surgery may be ideal. Further studies would be beneficial. 1 DeVita VT, et al. Cancer: Principles & Practice of Oncology,7th Edition. Philadelphia, Pa. Lippincott Williams & Wilkins, 2005 2 Pinar B, Radiation-induced DNA damage as a predictor of long-term toxicity in locally advanced breast cancer patients treated with high-dose hyperfractionated radical radiotherapy. Radiat Res. 2007Oct;168(4):41522. 3 Foldi M, Foldi E, Kubik S. Textbook of Lymphology, 5 th Edition. Munich, Germany. Urban and Fischer, 2003 4 Ascher E, Salles-Cunha S, Hingorani A. Morbidity and mortality associated with internal jugular vein thromboses. Vasc Endovascular Surg. 2005 Jul-Aug;39(4):335-9. 5 Armer J.Upper limb swelling following mastectomy: lymphedema or not Oncology (Williston Park). 2007 Apr; 21(4 Suppl):26-8. 6 Taylor KO. Morbidity associated with axillary surgery for breast cancer.
ANZ J Surg. 2004 May; 74(5):314-7. 7 Cheville AL, Tchou J. Barriers to Rehabilitation Following Surgery for Primary Breast Cancer. Journ Surg Oncol 2007; 95:409-418. 8 Magee DJ. Orthopedic Physical Assessment, 3 rd Edition. Philadelphia, Pennsylvania. W B Saunders Company, 1997 (Chapter 5) 9 Parker PA, Youssef A, Walker S, Basen-Engquist K, Cohen L, Gritz ER, Wei QX, Robb GL. Short-term and long-term psychosocial adjustment and quality of life in women undergoing different surgical procedures for breast cancer.ann Surg Oncol. 2007 Nov;14(11):3078-89. Epub 2007 Jun 16. 10 National Lymphedema Network, Consensus paper. Air Travel and Lymphedema, May 2006. http://www.lymphnet.org/lymphedemafaqs/positionpapers.htm 11 Holmes MD,et al. Physical activity and survival after breast cancer diagnosis.jama. 2005;293:2479-2486. 12 Hudak P, Amadio P, Bombardier C (1996) Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) American Journal of Industrial Medicine 29, 602-608.