Breast cancer rehabilitation

    According to the literature analysis, the incidence of postoperative functional disorder of the upper limb and shoulder joint at the surgical side of breast cancer is 48%. While the function of the shoulder joint accounts for 60% of the upper limb function, the loss and the weakening of the function in the shoulder joint and the upper limb of the side are very significant, bringing much inconvenience to patients' life. The main clinical manifestations dysfunction including, the range is much limited, outward extension, internal rotation and external rotation. Decreased ability in daily life including, difficulty in combing hair, tying hair, wearing underwear, besides more fatigue after exercise. As for psychological problems, patients often feel anxiety, insomnia, and more fear of tumor recurrence due to shoulder pain and limited activity, resulting in great psychological pressure. In addition, patients may have upper limb limitations due to pain, lymphedema, axillary web syndrome and other causes, which should be treated accordingly.

    A number of clinical randomized controlled trials have demonstrated that mild and active exercise or physical therapy in the early postoperative period after breast cancer surgery can improve shoulder mobility, relieve pain and prevent lymphedema without increasing the risk of lymphedema. Harris has given some suggestions on upper limb function rehabilitation: Bilateral upper limb functional assessment should be performed before surgery to provide a baseline value. Physical therapy begins on the first day after surgery. Patients are encouraged to exercise moderately in the first week after surgery. Active stretching can start in the first week after surgery and should continue for 6 to 8 weeks, or until the upper limbs can complete the full range of motion angles. Scar tissue can be massaged. Postoperative evaluation should be performed regularly. Progressive resistance training, which can start within 4 to 6 weeks after surgery. Multiple prospective clinical trials have demonstrated that exercise training can help improve shoulder mobility [3-5,7-11,13-20]. Results of one meta-analysis show that exercise  is significantly performed ,among women  with breast cancer, [1], but exercise intensity and duration should be carefully weighed to avoid the increase of wound drainage volume. A small sample of RCT suggested that acupuncture did not improve the motion of shoulder joint after breast cancer surgery [6], and a meta-analysis shows that acupuncture could improve shoulder arthritis pain caused by chemotherapy drugs and thereby improve the motion of the joint [2].

    Exercise training: moderate active exercise/progressive resistance exercise can be used for upper limb motor dysfunction after breast cancer surgery (level I recommendation, level A evidence)

Acupuncture :(level IIb recommendation, level C evidence)

Laser therapy, electrical stimulation, microwave and thermotherapy (level III recommendation, level C evidence)

Axillary web syndrome

    Axillary reticulum syndrome (AWS) is originally defined as an axillary pain radiating to the ipsilateral arm, limited shoulder joint activity, and armpit reticulum linear tissue inflammation. It’s the most evident in patients who try to extend the arm during physical examination, which still lacks the gold standard definition of AWS. According to the literature about AWS, the armpit skin is covered with one or more "rope" lines that feel like strings, bands, tendons, strings, or tight wires. These "lines" can radiate through the armpit and extend to the surface of the forearm and wrist. Typically, AWS appears within the first eight weeks after underarm surgery and disappears within 12 weeks of surgery. But some studies suggest that AWS appears or persists 12 to 2 years after surgery. The presence of AWS can affect shoulder abduction, and patients who receive radiation in the chest and/or armpit often fall short of the upper limb placement requirements. AWS epidemiology varied widely from 6% to 85.4%, with a median incidence of 36% to 37% in one meta-analysis [59]. Sixteen percent of the patients who had AWS on sentinel lymph node biopsy (SLNB) had limited shoulder joint activity, and 64 percent of the patients who had AWS on axillary dissection had limited shoulder joint activity [60]. Physical therapy: a single randomized controlled trial showed that PT combined with lymphatic drainage was effective [8], and some individual case reports described AWS management:active and passive shoulder movements, including gentle stretching [57,58].(IIa recommendation, b-evidence)

Breast cancer, upper limb lymphedema

    Lymphedema is a complication after treatment, which results in partial destruction or blockage of lymphatic pathways after breast cancer surgery or radiation treatment or some other damage to the lymphatic system. Accumulation in lymphatic fluid and the tissue, it will cause swelling. For breast cancer patients, lymphedema is most common in the upper extremities, sometimes in the chest and  chest wall. It can occur up to 30 years after treatment, with the highest incidence 3-5 years after surgery. The overall incidence of arm lymphedema after breast cancer ranges from 8% to 56% due to differences in diagnosis, patient characteristics, and inadequate follow-up. Compared to breast cancer survivors  without lymphedema, breast cancer survivors with arm lymphedema have a decreased quality of life. with upper limb lymphedema, some problems always happen, for example, shoulder  motion is limited,  patients are often painful because of upper limb dysfunction, and muscle strength is reduced.

    Treatment of lymphedema with detumescence, including manipulation of lymphatic drainage, compression bandage dressing, pressure clothing, intermittent pressure therapy, low energy laser, intramuscular tiling, acupuncture, resistance movement, etc.
1.Bandage compression bandage, manual lymph drainage technique, the pressure garments: multiple RCT compare the pros and cons of the three methods, the study confirms the bandage compression bandage degree of swelling, lower limb circumference effect is superior to the technique and pressure garment, lymphatic drainage technique in the early prevention and promote lymphatic circumfluence. But there is  no obvious effect on the degree of lower limb circumference,30,31,33,34,38,39,40 [24]. Three therapeutic combinations were used in the study. (level I recommendation, level A evidence)
2.Low-energy laser: multiple RCT, 1 meta-analysis [41], showing the effectiveness of low-energy laser in eliminating edema [42-46];
3.Intermittent air pressure in the treatment of intermittent pneumatic compression will: one meta-analysis [48] not shown effectiveness, multiple RCT shows effective detumescence action [49-53]. (IIa level recommendation, a-level evidence)
4.Intramuscular patch: a limited small sample of RCT[31], showing effectiveness. (class III recommendation, class C evidence)
5.Acupuncture and moxibustion: 1 randomized trial showed no effect of swelling, and 2 small sample RCT showed some effect. (class IIb recommendation, class B evidence)

6.Exercise: multiple RCT signs confirmed the efficacy of progressive resistance exercise without swelling treatment, but could improve the range of motion and quality of life[21,22,23,29,32,35,36]. (class III recommendation, class A evidence)

Assessment of lymphedema

    Evaluation of lymphedema: objective evaluation tools include water displacement method, arm circumference measurement method, Perometry, BIS for bioelectrical impedance measurement, tissue dielectric constant measurement, b-mode ultrasound, MRI, and lymphatic scintigraphy. Common clinical arm circumference measurements, including BIS, 3Dprinting, tissue permittivity, expert consensus [63,64,65]. (level I recommendation, level C evidence).

Pain/chemotherapy related peripheral neuropathy
    The incidence of pain in breast cancer patients ranges from 40% to 89%, which seriously affects the quality of life of patients [61]. The literature of chemotherapy-related peripheral neuropathy(CIPN) reported the occurrence of peripheral neuropathy in 30-40% of patients[62]. These problems can affect the hand function to a certain extent and should be dealt with clinically.
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