Document Type : Original Articles

Authors

1 Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

2 Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

3 Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

4 Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran

Abstract

Background: Upper extremity (UE) lymphedema, which negatively affects patients’ personal and social well-being, is the most common complication after breast cancer treatment. Previous studies have demonstrated the adverse effects
of surgical interventions for breast cancer on spinal postures and UE disability;however, no studies have examined the relationships between UE volume and postural changes and between UE volume and UE disability in patients with
lymphedema. Furthermore, some spinal postural changes in patients with forward head posture (FHP) remain unassessed in these patients. Therefore, the present study investigated the relationship between the volume of the affected UE with FHP, kyphosis, shoulder protraction, and UE disability in lymphedema patients.
Methods: The present cross-sectional study was carried out on 32 women with unilateral UE lymphedema. UE volume and kyphosis were measured by volumetry and a flexible ruler, respectively. Cervical angle was used to assess FHP. To measure shoulder protraction and FHP, data obtained from markers and photography was analyzed in ImageJ software. The disability of the affected UE was assessed by the Persian version of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Data analysis was performed using Pearson’s correlation test.
Results: Significant positive correlations were observed between UE volume and UE disability as well as kyphosis. Significant negative correlations between UE volume and shoulder as well as cervical angle were also seen. UE disability
had a significant negative correlation with shoulder angle but no significant relationship with kyphosis or cervical angle.
Conclusion: An increase in the affected UE volume due to lymphedema is related to an increase in UE disability, kyphosis angle, FHP, and shoulder protraction. In addition to treatments for UE volume reduction in lymphedema patients,
accurate posture evaluation is also recommended.

Keywords

  1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2021;71(3):209-49.
  2. Emiroğlu M, Inal A, Sert İ, İlhan E, Peker K, Gürçelik MA, et al. How do surgeons approach breast cancer surgery in Turkey? A national survey. 2015;22(4):421-6.
  3. Lang AE, Murphy M, Dickerson CR, Stavness I, Kim SY. Shoulder Dysfunction in Breast Cancer Survivors: Can Treatment Type or Musculoskeletal Factors Identify Those at Higher Risk? Rehabilitation Oncology. 2021;39(3):143-51.
  4. Kootstra JJ, Dijkstra PU, Rietman H, de Vries J, Baas P, Geertzen JH, et al. A longitudinal study of shoulder and arm morbidity in breast cancer survivors 7 years after sentinel lymph node biopsy or axillary lymph node dissection. Breast cancer research and treatment. 2013;139(1):125-34.
  5. Yang EJ, Park WB, Seo KS, Kim SW, Heo CY, Lim JY. Longitudinal change of treatment‐related upper limb dysfunction and its impact on late dysfunction in breast cancer survivors: a prospective cohort study. Journal of surgical oncology. 2010;101(1):84-91.
  6. Ebaugh D, Spinelli B, Schmitz KH. Shoulder impairments and their association with symptomatic rotator cuff disease in breast cancer survivors. Medical hypotheses. 2011;77(4):481-7.
  7. Lang AE, Milosavljevic S, Dickerson CR, Trask CM, Kim SY. Evidence of rotator cuff disease after breast cancer treatment: scapular kinematics of post-mastectomy and post-reconstruction breast cancer survivors. Annals of Medicine. 2022;54(1):1058-66.
  8. Miguel-Andrés I, García-González SB, de Jesús Mayagoitia-Vázquez J, Barrera-Beltrán K, Samayoa-Ochoa D, León-Rodríguez M, et al. Effect of the Unilateral Breast Cancer Surgery on the Shoulder Movement: Electromyographic and Motion. Mexican Journal of Biomedical Engineering. 2022;43(1):40-51.
  9. DiSipio T, Rye S, Newman B, Hayes SJTlo. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. 2013;14(6):500-15.
  10. Soyder A, Taştaban E, Özbaş S, Boylu Ş, Özgün HJTjobh. Frequency of early-stage lymphedema and risk factors in postoperative patients with breast cancer. 2014;10(2):92.
  11. Taghian NR, Miller CL, Jammallo LS, O’Toole J, Skolny MNJCrioh. Lymphedema following breast cancer treatment and impact on quality of life: a review. 2014;92(3):227-34.
  12. Hayes SC, Johansson K, Stout NL, Prosnitz R, Armer JM, Gabram S, et al. Upper‐body morbidity after breast cancer: incidence and evidence for evaluation, prevention, and management within a prospective surveillance model of care. 2012;118(S8):2237-49.
  13. Cheville AL, McGarvey CL, Petrek JA, Russo SA, Taylor ME, Thiadens SR, editors. Lymphedema management. Seminars in radiation oncology; 2003: Elsevier.
  14. Celenay ST, Ucurum SG, Kaya DO. Comparison of spinal alignment and mobility in women with and without post modified radical mastectomy unilateral lymphoedema. Clinical breast cancer. 2020;20(3):e295-e300.
  15. Smoot B, Wong J, Cooper B, Wanek L, Topp K, Byl N, et al. Upper extremity impairments in women with or without lymphedema following breast cancer treatment. Journal of cancer survivorship. 2010;4(2):167-78.
  16. Haddad CAS, Saad M, Perez MdCJ, Miranda Júnior F. Assessment of posture and joint movements of the upper limbs of patients after mastectomy and lymphadenectomy. Einstein (Sao Paulo). 2013;11:426-34.
  17. Mangone M, Bernetti A, Agostini F, Paoloni M, De Cicco FA, Capobianco SV, et al. Changes in spine alignment and postural balance after breast cancer surgery: a rehabilitative point of view. BioResearch open access. 2019;8(1):121-8.
  18. Serel S, Tuzlalı ZY, Akkaya Z, Uzun Ç, Kaya B, Bayar S. Physical effects of unilateral mastectomy on spine deformity. Clinical breast cancer. 2017;17(1):29-33.
  19. Shamley D, Srinaganathan R, Oskrochi R, Lascurain-Aguirrebeña I, Sugden E. Three-dimensional scapulothoracic motion following treatment for breast cancer. Breast cancer research and treatment. 2009;118(2):315-22.
  20. Galiano-Castillo N, Fernández-Lao C, Cantarero-Villanueva I, Fernández-de-Las-Peñas C, Menjón-Beltrán S, Arroyo-Morales M. Altered pattern of cervical muscle activation during performance of a functional upper limb task in breast cancer survivors. American journal of physical medicine & rehabilitation. 2011;90(5):349-55.
  21. Pinto M, Gimigliano F, Tatangelo F, Megna M, Izzo F, Gimigliano R, et al. Upper limb function and quality of life in breast cancer related lymphedema: a cross-sectional study. Eur J Phys Rehabil Med. 2013;49(5):665-73.
  22. Korucu TS, Ucurum SG, Tastaban E, Ozgun H, Kaya DO. Comparison of shoulder-arm complex pain, function, and scapular dyskinesia in women with and without unilateral lymphedema after breast cancer surgery. Clinical Breast Cancer. 2021;21(3):e285-e93.
  23. Zuther JE, Norton S. Lymphedema management: the comprehensive guide for practitioners: Thieme; 2017.
  24. Meijer RS, Rietman JS, Geertzen JH, Bosmans JC, Dijkstra PU. Validity and intra-and interobserver reliability of an indirect volume measurements in patients with upper extremity lymphedema. Lymphology. 2004;37(3):127-33.
  25. Sander AP, Hajer NM, Hemenway K, Miller AC. Upper-extremity volume measurements in women with lymphedema: a comparison of measurements obtained via water displacement with geometrically determined volume. Physical therapy. 2002;82(12):1201-12.
  26. Baran E, Yildiz Tİ, Gursen C, Üzelpasaci E, Özgül S, Düzgün İ, et al. The association of breast cancer-related lymphedema after unilateral mastectomy with shoulder girdle kinematics and upper extremity function. Journal of Biomechanics. 2021;121:110432.
  27. Nafisi S, Bagheri H, Arab Kheradmand A, Razavi F, Mousavi S. Comparive Effect of Complex Decongestive Physical Therapy Alone and Along with Intermittent Pneumatic Compression Pump on Shoulder Range of Motion, Heaviness, and Upper Extremity Circumfference in Patients with Secondary Upper Extremity Lymphedema Post Breast Cancer Tretments. The Scientific Journal of Rehabilitation Medicine. 2017;6(4):76-83.
  28. Mousavi SJ, Parnianpour M, Abedi M, Askary-Ashtiani A, Karimi A, Khorsandi A, et al. Cultural adaptation and validation of the Persian version of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure. Clinical rehabilitation. 2008;22(8):749-57.
  29. Mirbagheri S-S, Rahmani-Rasa A, Farmani F, Amini P, Nikoo M-R. Evaluating kyphosis and lordosis in students by using a flexible ruler and their relationship with severity and frequency of thoracic and lumbar pain. Asian spine journal. 2015;9(3):416.
  30. Ruivo RM, Pezarat-Correia P, Carita AI. Cervical and shoulder postural assessment of adolescents between 15 and 17 years old and association with upper quadrant pain. Brazilian journal of physical therapy. 2014;18:364-71.
  31. Silva AG, Punt TD, Sharples P, Vilas-Boas JP, Johnson MI. Head posture and neck pain of chronic nontraumatic origin: a comparison between patients and pain-free persons. Archives of physical medicine and rehabilitation. 2009;90(4):669-74.
  32. Lee JJ, You JH. Movement measurement validity and reliability of the image J program for kinematic analysis. Journal of Mechanics in Medicine and Biology. 2016;16(08):1640028.
  33. Angin S, Karadibak D, Yavuzşen T, Demirbüken İ. Unilateral upper extremity lymphedema deteriorates the postural stability in breast cancer survivors. Contemporary Oncology. 2014;18(4):279.
  34. Brach M, Cieza A, Stucki G, Fussl M, Cole A, Ellerin B, et al. ICF Core Sets for breast cancer. Journal of Rehabilitation Medicine. 2004;36(0):121-7.
  35. Bani HA, Fasching PA, Lux MM, Rauh C, Willner M, Eder I, et al. Lymphedema in breast cancer survivors: assessment and information provision in a specialized breast unit. Patient education and counseling. 2007;66(3):311-8.
  36. Dawes DJ, Meterissian S, Goldberg M, Mayo NE. Impact of lymphoedema on arm function and health-related quality of life in women following breast cancer surgery. Journal of rehabilitation Medicine. 2008;40(8):651-8.
  37. Surmeli M, Ozdemir OC. Examination of the relationship between upper limb function, posture and quality of life in patients with and without lymphedema after breast cancer surgery. Konuralp Medical Journal. 2019;11(3):432-9.
  38. Stubblefield MD, Custodio CM. Upper-extremity pain disorders in breast cancer. Archives of physical medicine and rehabilitation. 2006;87(3):96-9.
  39. Erickson VS, Pearson ML, Ganz PA, Adams J, Kahn KL. Arm edema in breast cancer patients. Journal of the National Cancer Institute. 2001;93(2):96-111.
  40. Armer JM, Ballman KV, McCall L, Armer NC, Sun Y, Udmuangpia T, et al. Lymphedema symptoms and limb measurement changes in breast cancer survivors treated with neoadjuvant chemotherapy and axillary dissection: results of American College of Surgeons Oncology Group (ACOSOG) Z1071 (Alliance) substudy. Supportive Care in Cancer. 2019;27(2):495-503.
  41. Collins LG, Nash R, Round T, Newman B. Perceptions of upper-body problems during recovery from breast cancer treatment. Supportive Care in Cancer. 2004;12(2):106-13.
  42. Jeong HJ, Sim Y-J, Hwang KH, Kim GC. Causes of shoulder pain in women with breast cancer-related lymphedema: a pilot study. Yonsei medical journal. 2011;52(4):661-7.
  43. Hayes S, Battistutta D, Newman B. Objective and subjective upper body function six months following diagnosis of breast cancer. Breast cancer research and treatment. 2005;94(1):1-10.
  44. Kisner C, Colby LA, Borstad J. Therapeutic exercise: foundations and techniques: Fa Davis; 2017.
  45. Crosbie J, Kilbreath SL, Dylke E, Refshauge KM, Nicholson LL, Beith JM, et al. Effects of mastectomy on shoulder and spinal kinematics during bilateral upper-limb movement. 2010;90(5):679-92.
  46. Shamley DR, Srinanaganathan R, Weatherall R, Oskrochi R, Watson M, Ostlere S, et al. Changes in shoulder muscle size and activity following treatment for breast cancer. Breast cancer research and treatment. 2007;106(1):19-27.
  47. Adriaenssens N, Van Parijs H, Miedema G, Reynders T, Versmessen H, De Ridder M, et al. Preliminary analysis of a randomized clinical trial comparing shoulder-arm morbidity between early breast cancer patients treated with short course image guided radiation therapy and conventional post surgery radiation therapy. Meme Sagligi Dergisi/Journal of Breast Health. 2012;8(2).
  48. Singla D, Veqar Z. Association between forward head, rounded shoulders, and increased thoracic kyphosis: a review of the literature. Journal of chiropractic medicine. 2017;16(3):220-9.
  49. Balzarini A, Lualdi P, Lucarini C, Ferla S, Galli M, Crivellini M, et al. Biomechanical evaluation of scapular girdle in patients with chronic arm lymphedema. Lymphology. 2006;39(3):132-40.