An De Groef

Effectiveness of Postoperative Physical Therapy for Upper-Limb Impairments After Breast Cancer Treatment: A Systematic Review

OBJECTIVE To systematically review the effectiveness of various postoperative physical therapy modalities and timing of physical therapy after treatment of breast cancer on pain and impaired range of motion (ROM) of the upper limb. DATA SOURCES We searched the following databases: PubMed/MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, Physiotherapy Evidence Database, and Cochrane. Articles published until October 2012 were included. STUDY SELECTION Only (pseudo) randomized controlled trials and nonrandomized experimental trials investigating the effectiveness of passive mobilization, manual stretching, myofascial therapy, and/or exercise therapy and timing of physical therapy after treatment for breast cancer are reviewed. Primary outcomes are pain of the upper limb and/or ROM of the shoulder. Secondary outcomes are decreased shoulder strength, arm lymphedema, limitations in activities of daily living, decreased quality of life, and wound drainage volume. Physical therapy modalities had to be started in the first 6 weeks after surgery. DATA EXTRACTION Articles were selected by 2 independent researchers in 3 phases and compared for consensus. First the titles were analyzed, and then the selected abstracts and finally the full texts were reviewed. DATA SYNTHESIS Eighteen randomized controlled trials were included in the review. Three studies investigated the effect of multifactorial therapy: 2 studies confirmed that the combination of general exercises and stretching is effective for the treatment of impaired ROM another study showed that passive mobilization combined with massage had no beneficial effects on pain and impaired ROM. Fifteen studies investigated the effectiveness of a single physical therapy modality. One study of poor quality found evidence supporting the beneficial effects of passive mobilization. The only study investigating the effect of stretching did not find any beneficial effects. No studies were found about the effectiveness of myofascial therapy in the postoperative phase. Five studies found that active exercises were more effective than no therapy or information on the treatment of impairments of the upper limb. Three studies supported the early start of exercises for recovery of shoulder ROM, whereas 4 studies supported the delay of exercises to avoid prolonged wound healing. CONCLUSIONS Multifactorial physical therapy (ie, stretching, exercises) and active exercises were effective to treat postoperative pain and impaired ROM after treatment for breast cancer. High-quality studies are necessary to determine the effectiveness of passive mobilization, stretching, and myofascial therapy as part of the multifactorial treatment. In addition, the appropriate timing and content of the exercise programs need to be further investigated.

Unraveling Patient-Preferred Health and Treatment Outcomes in Early Rheumatoid Arthritis: A Longitudinal Qualitative Study

To unravel the perspective of patients with rheumatoid arthritis (RA) on preferred health and treatment outcomes at 2 time points during the early stage of their disease and treatment.

Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL): Reliability and Validity

Background Patients may develop primary (congenital) or secondary (acquired) lymphedema, causing significant physical and psychosocial problems. To plan treatment for lymphedema and monitor a patients progress, swelling, and problems in functioning associated with lymphedema development should be assessed at baseline and follow-up. Objective The purpose of this study was to investigate the reliability (test-retest, internal consistency, and measurement variability) and validity (content and construct) of data obtained with the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL). Design This was a multicenter, cross-sectional study. Methods The Lymph-ICF-LL is a descriptive, evaluative tool containing 28 questions about impairments in function, activity limitations, and participation restrictions in patients with lower limb lymphedema. The questionnaire has 5 domains: physical function, mental function, general tasks/household activities, mobility activities, and life domains/social life. The reliability and validity of the Lymph-ICF-LL were examined in 30 participants with objective lower limb lymphedema. Results Intraclass correlation coefficients for test-retest reliability ranged from .69 to .94, and Cronbach alpha coefficients for internal consistency ranged from .82 to .97. Measurement variability was acceptable (standard error of measurement=5.9–12.6). Content validity was good because all questions were understandable for 93% of participants, the scoring system (visual analog scale) was clear, and the questionnaire was comprehensive for 90% of participants. Construct validity was good. All hypotheses for assessing convergent validity and divergent validity were accepted. Limitations The known-groups validity and responsiveness of the Dutch Lymph-ICF-LL and the cross-cultural validity of the English version of the Lymph-ICF-LL were not investigated. Conclusions The Lymph-ICF-LL is a Dutch questionnaire with evidence of reliability and validity for assessing impairments in function, activity limitations, and participation restrictions in people with primary or secondary lower limb lymphedema.

An evaluation tool for myofascial adhesions in patients after breast cancer (MAP-BC evaluation tool): Development and interrater reliability

Purpose To develop a tool to evaluate myofascial adhesions objectively in patients with breast cancer and to investigate its interrater reliability. Methods 1) Development of the evaluation tool. Literature was searched, experts in the field of myofascial therapy were consulted and pilot testing was performed. 2) Thirty patients (63% had a mastectomy, 37% breast-conserving surgery and 97% radiotherapy) with myofascial adhesions were evaluated using the developed tool by 2 independent raters. The Weighted Kappa (WK) and the intra-class correlation coefficient (ICC) were calculated. Results 1) The evaluation tool for Myofascial Adhesions in Patients with Breast Cancer (MAP-BC evaluation tool) consisted of the assessment of myofascial adhesions at 7 locations: axillary and breast region scars, musculi pectorales region, axilla, frontal chest wall, lateral chest wall and the inframammary fold. At each location the degree of the myofascial adhesion was scored at three levels (skin, superficial and deep) on a 4-points scale (between no adhesions and very stiff adhesions). Additionally, a total score (0–9) was calculated, i.e. the sum of the different levels of each location. 2) Interrater agreement of the different levels separately was moderate for the axillary and mastectomy scar (WK 0.62–0.73) and good for the scar on the breast (WK >0.75). Moderate agreement was reached for almost all levels of the non-scar locations. Interrater reliability of the total scores was the highest for the scars (ICC 0.82–0.99). At non-scar locations good interrater reliability was reached, except for the inframammary fold (ICC = 0.71). Conclusions The total scores of all locations of the MAP-BC evaluation tool had good to excellent interrater reliability, except for the inframammary fold which only reached moderate reliability.

Pain characteristics as important contributing factors to upper limb dysfunctions in breast cancer survivors at long term

PURPOSE The aim of this study was to explore the treatment, patient, and impairment-related risk factors associated with upper limb dysfunctions in breast cancer survivors. METHODS A cross-sectional study was performed in 274 women treated for breast cancer. The following risk factors were analysed by bivariable and multivariable analysis: 1) treatment-related variables (type of surgery, levels of lymph node dissected, radiotherapy, chemotherapy, hormone therapy and trastuzumab); 2) patients related variables (age and Body Mass Index); 3) and finally impairment-related variables such as pain (intensity, quality and pressure hypersensitivity, signs of central sensitisation, the degree of pain catastrophizing and vigilance and awareness to pain), active ROM and upper limb strength were investigated. The dependent variable was upper limb function measured with the Disability of Arm, Shoulder and Hand (DASH) questionnaire. Additionally, a stepwise regression was performed. RESULTS An impaired upper limb function was noted in 170 (62%) of patients. Mean time after surgery was 1.5 (1.6) years. From multivariable analysis, it appears that in particular certain pain characteristics such as pain intensity, pain quality, signs of central sensitisation and pain catastrophizing are contributing to upper limb dysfunctions after breast cancer treatment at long term. Additionally, higher age, shoulder ROM and handgrip strength are possible contributing factors. The stepwise regression analysis revealed that central sensitisation mechanisms alone can explain about 40% of the variance in upper limb function. CONCLUSIONS At long term, especially pain and central sensitisation mechanisms contribute to upper limb function in breast cancer survivors.

Progression and predictors of physical activity levels after radical prostatectomy

To investigate the progression of all aspects (total, occupational, sports, household) of physical activity (PA) over time after radical prostatectomy (RP) and to find predictive factors for a decrease in PA.

Physical activity levels after treatment for breast cancer: Two-year follow-up

OBJECTIVES Breast cancer treatment can have a considerable large and prolonged impact on activity levels of breast cancer survivors. Therefore, the aim of the present study was to investigate the change in total physical activity level and occupational, sport and household activity levels of breast cancer survivors from preoperatively up to 24 months after breast cancer surgery. Additionally, predictive factors for this change were investigated. METHODS Patients with primary breast cancer (n = 267) filled in the Flemish Physical Activity Computerized Questionnaire (FPACQ) before surgery and 1, 3, 6, 12 and 24 months after surgery. Patient-, disease- and treatment-related factors were analyzed as predictive factors for change in physical activity. RESULTS Two years after surgery, all activity levels (total, occupational, sport and household) were still significantly lower compared to preoperative values. After the first 12 months, no significant improvements were seen for none of the activity levels, except for the occupational activity. CONCLUSIONS Two years after breast cancer surgery, physical activity levels are still significantly lower compared to pre-operative values. Based on this limited recovery, it seems important to monitor physical activity levels in breast cancer patients and advice these patients to stay active after surgery and return to pre-operative activity levels in the long term as well. This study indicates the importance of long term monitoring and subsequently coaching of physical activity after breast cancer surgery.

Effect of myofascial techniques for treatment of persistent arm pain after breast cancer treatment: randomized controlled trial:

Objective: To investigate the effect of myofascial therapy in addition to a standard physical therapy program for treatment of persistent arm pain after finishing breast cancer treatment. Design: Double-blinded (patient and assessor) randomized controlled trial. Setting: University Hospitals Leuven, Belgium. Patients: A total of 50 patients with persistent arm pain and myofascial dysfunctions after breast cancer treatment. Intervention: Over three months, all patients received a standard physical therapy program. The intervention group received in addition 12 sessions of myofascial therapy, and the control group received 12 sessions of placebo therapy. Main measurements: Main outcome parameters were pain intensity (primary outcome) (maximum visual analogue scale (VAS) (0–100)), prevalence rate of arm pain, pressure hypersensitivity (pressure pain thresholds (kg/cm2) and pain quality (McGill Pain Questionnaire). Measures were taken before and after the intervention and at long term (6 and 12 months follow-up). Results: Patients in the intervention group had a significantly greater decrease in pain intensity compared to the control group (VAS −44/100 vs. −24/100, P = 0.046) with a mean difference in change after three months between groups of 20/100 (95% confidence interval, 0.4 to 39.7). After the intervention, 44% versus 64% of patients still experienced pain in the intervention and control group, respectively (P = 0.246). No significant differences were found for the other outcomes. Conclusion: Myofascial therapy is an effective physical therapy modality to decrease pain intensity at the arm in breast cancer survivors at three months, but no other benefits at that time were found. There were no long-term effects at 12 months either.

Myofascial techniques have no additional beneficial effects to a standard physical therapy programme for upper limb pain after breast cancer surgery: a randomized controlled trial

Objective: To investigate the effects of myofascial techniques, in addition to a standard physical therapy programme for upper limb pain shortly after breast cancer surgery. Design: Double-blinded (patient and assessor) randomized controlled trial with two groups. Setting: University Hospitals Leuven, Belgium Patients: A total of 147 patients with unilateral axillary clearance for breast cancer. Intervention: All participants received a standard physical therapy programme starting immediately after surgery for four months. The intervention group received additionally eight sessions of myofascial therapy from two up to four months after surgery. The control group received eight sessions of a placebo intervention, including static hand placements at the upper body region. Main measurements: The primary outcome was prevalence rate of upper limb pain. Additionally, pain intensity (Visual Analogue Scale (VAS, 0–100)), pressure hypersensitivity (pressure pain thresholds (PPTs; kg/cm2)) and pain quality (McGill Pain Questionnaire) were evaluated. All measurements were performed at 2 (=baseline), 4, 9 and 12 months post-surgery. Results: At 4, 9 and 12 months post-surgery, prevalence rates of pain, pain intensity and pain quality were comparable between the intervention and control group. PPT of the upper trapezius muscle was significantly higher in the intervention group at four months with a difference of −1.2 (−1.9 to −0.4) kg/cm2, P = 0.012). PPT of the supraspinatus muscle was significantly higher in the intervention group at four months (−0.7 (−1.4 to −0.1) kg/cm2, P = 0.021) and at nine months (−0.5 (−1.1 to 0.0), P = 0.040). Conclusion: Myofascial therapy has no added beneficial effect as standard physical therapy modality in the postoperative stage.

The efficacy of physiotherapy for the prevention and treatment of prenatal symptoms: a systematic review

Several studies have described the evidence of prenatal physiotherapy for one symptom, but none has made an overview. We provided a systematic review on the effectiveness of prenatal physiotherapy. A full search was conducted in three electronic databases (Embase, PubMed/MEDLINE and PEDro), selecting randomized controlled trials concerning prenatal physiotherapy. Methodological quality was assessed using the PEDro scale. We identified 1,249 studies and after exclusions 54 studies were included concerning the evidence of prenatal physiotherapy. The majority of studies indicated a preventative effect for low back pain/pelvic girdle pain, weight gain, incontinence, and perineal massage. For leg edema, fear, and prenatal depression, the efficacy was only based on one study per symptom. No preventative effect was found for gestational diabetes, while literature concerning gestational hypertensive disorders was inconclusive. Regarding the treatment of low back pain/pelvic girdle pain and weight gain, most therapies reduced pain and weight respectively. Evidence regarding exercises for diabetes was contradictory and only minimally researched for incontinence. Foot massage and stockings reduced leg edema and leg symptoms respectively. Concerning gestational hypertensive disorders, perineal pain, fear, and prenatal depression no treatment studies were performed. The majority of studies indicated that prenatal physiotherapy played a preventative role for low back pain/pelvic girdle pain, weight gain, incontinence, and pelvic pain. Evidence for the remaining symptoms was inclusive or only minimally investigated. Regarding treatment, most studies indicated a reduction of low back pain/pelvic girdle pain, weight gain, incontinence, and the symptoms of leg edema.