Transcript Post-Mastectomy Pain Syndrome: “An Anatomic Understanding”

Rehabilitation of PostMastectomy Syndrome
Eric Wisotzky, MD
Director of Cancer Rehabilitation
MedStar National Rehabilitation Network
Assistant Professor of Rehabilitation Medicine
Georgetown University School of Medicine
Disclosures
• None
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
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.
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.
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.
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)
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)
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)
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)
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
Therapy Techniques for Specific
Syndromes:
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Incisional pain
Axillary Web Syndrome (cording)
Shoulder dysfunction
Post-Reconstruction Pain Syndrome
Neuropathic syndromes
– Intercostobrachial neuralgia
– Phantom breast pain
Therapy Techniques: Incisional Pain
 From local adherence of incision to chest wall
 Presents with incisional hypersensitivity
 Decreased mobility of incision
Therapy Techniques: Incisional Pain
• Scar massage/mobilization
• Desensitization techniques
Therapy Techniques: Axillary Web
Syndrome (Cording)
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•
•
•
•
Often spontaneously resolve
Soft tissue techniques
Nerve glides
ROM
May have audible “snap”
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
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):1–15
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
Shoulder Dysfunction: Muscle Strength
• Multiple studies have shown weakness in:
–
–
–
–
–
Abduction
Flexion
Extension
External/internal rotation
Scapular upward rotation/depression/adduction
Based on above findings, a sensible PT
rx might include:
• Pec stretching
• Scapular stabilization/mechanics exercises
• Strengthening in all planes
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.
Therapy Techniques: PRPS
• Stretching of pectoralis and serratus
• Manual release of tissues around implant/tissue
expander
Intercostobrachial Neuralgia
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
Therapy Techniques: Intercostobrachial
Neuralgia
• Desensitization
Therapy Techniques: Phantom Breast
Pain
• Desensitization
• Mirror therapy
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
“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
Post-mastectomy Syndrome:
Medications
Post-mastectomy Syndrome: Oral
Medications
• Anti-depressants
– Venlafaxine showed significant pain relief vs placebo
Tasmuth, Tiina, Brita Härtel, 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.
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): 375379
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 doubleblind crossover study (N01CB). Supportive care in cancer 17.4 (2009): 451460.
Post-mastectomy Syndrome: Other
Medications
 Anti-inflammatories: topical or oral
 Nerve stabilizers: gabapentin, pregabalin
 Duloxetine
 Opioids
 Topical compounds
Post-mastectomy Syndrome:
Modalities
• TENS no better than placebo for postmastectomy 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.
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.
Injections in Post-mastectomy Syndrome
Can they be performed?
Injections in Post-mastectomy Syndrome
Can they be performed?
Yes for the most part…
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
Injections in Post-mastectomy
Syndrome: Musculoskeletal
• Rotator cuff impingement  subacromial
injection
• Adhesive capsulitis  glenohumeral injection
• Myofascial pain  trigger point injection
Intercostobrachial Neuralgia
Management
• Intercostobrachial nerve block
Intercostobrachial Nerve Block
Technique
Case Series for Intercostobrachial Nerve
Block
Patient
Baseline
A
6/10
B
6/10
C
10/10
2 weeks
4 weeks
6 weeks
3 months
4/10
4/10 (2nd inj)
2/10
0/10
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.
http://cancer.ucsf.edu/videos/Esserman_v4.mp4
Neuroma Injections
Neuropathic Chest Wall Pain
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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.
Botulinum Toxin for Post-Reconstruction
Pain Syndrome
• Consider injecting pectoralis major, serratus
anterior
• Don’t pop the implant!
– Can use ultrasound
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.
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.
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.
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
Post-mastectomy Syndrome:
Prevention
 Gabapentin peri-operatively
› Single dose of 600 mg gabapentin one hour preoperatively
› 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 placebocontrolled double-blind trial. Journal of postgraduate
medicine 55.4 (2009): 257.
Post-mastectomy Syndrome:
Prevention
 Minimizing pre-op pain/ROM restrictions
PREHAB!!
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
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
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.
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
Questions???
[email protected]