Mariana Maia Freire de Oliveira

Exercícios para membros superiores durante radioterapia para câncer de mama e qualidade de vida

PURPOSE To assess the influence of physiotherapy performed during radiotherapy (RT) on the quality of life (QL) of women under treatment for breast cancer. METHODS This was a randomized clinical trial conducted on 55 women under RT treatment, 28 of whom were assigned to a group submitted to physiotherapy (PG) and 27 to the control group receiving no PG (CG). The physiotherapy technique used for PG was kinesiotherapy for the upper limbs using 19 exercises actively performed, with a series of ten rhythmic repetitions or stretching movements involving flexion, extension, abduction, adduction, internal and external shoulder rotation, separate or combined. QL was evaluated using the Functional Assessment of Cancer Therapy-Breast (FACT-B), at the beginning and at the end of RT and six months after the end of RT. The physiotherapy sessions were started concomitantly with RT, 90 days after surgery, on average. RESULTS There was no difference between subgroups regarding the following subscales: physical well-being (p=0.8), social/family well-being (p=0.3), functional well-being (p=0.2) and breast subscale (p=0.2) at the three time points assessed. A comparison of the emotional subscale applied at the three evaluations demonstrated a better behavior of PG as compared to CG (p=0.01), with both groups presenting improvement on the breast subscale between the beginning and the end of RT (PG p=0.0004 and CG p=0.003). There was improvement in FACT-B scores at the end of RT in both groups (PG p=0.0006 and CG p=0.003). However, at the sixth month after RT, this improvement was maintained only in PG (p=0,005). QL assessed along time by the FACT B (p=0.004) and the Trial Outcome Index (TOI) (sums of the physical and functional well-being subscales and of the breast subscale) was better for PG (p=0.006). There was no evidence of negative effects associated with the exercises. CONCLUSIONS The execution of exercises for the upper limbs was beneficial for QL during and six months after RT.

Manual lymphatic drainage versus exercise in the early postoperative period for breast cancer

Abstract Objective: To compare the effect of active exercise and manual lymphatic drainage (MLD) on postoperative wound healing complications, shoulder range of motion (ROM) and upper limb (UL) perimetry in women undergoing radical mastectomy for breast cancer. Methods: Controlled non-randomized clinical trial with 89 women undergoing breast cancer surgery with axillary lymph node dissection (Brazilian Registry of Clinical Trials: 906). Women were matched for staging, age and body mass index, with 46 women allocated to the exercise group and 43 in the MLD group, receiving 2 weekly sessions during one month. Assessments were performed in the preoperative and 60 d after surgery, including inspection, palpation, goniometry and perimetry. Results: No significant difference existed between groups relative to individual and clinical surgical characteristics. The incidence of seroma, number of punctures performed, dehiscence and infection was similar in both groups. A comparison of shoulder ROM and UL perimetry between groups, obtained in the preoperative and postoperative period, did not show any significant difference. Conclusion: The performance of active exercise or MLD did not demonstrate difference in wound healing complications, shoulder ROM and UL perimetry at 60 d after surgery, suggesting that these techniques may be employed, according to the complaints or symptoms of each woman and physical therapist experience.

Complicações e condutas fisioterapêuticas após cirurgia por câncer de mama: estudo retrospectivo

After breast cancer surgery, women may develop some physical complications. Thus, the aims of this study were to investigate the outcome of these women, who participated in a rehabilitation program for one month, as well to identify along two years the most frequent complications and adopted physical therapy conducts. It was a descriptive and retrospective study with 707 medical records of women treated for breast cancer at the Womens Hospital Professor Doutor Jose Aristodemo Pinotti, Universidade Estadual de Campinas, between January 2006 and December 2007, admitted in the Division of Physical Therapy. Analysis was performed by means, standard deviation, absolute and relative frequencies. By the end of the program, 55% of women were discharged, 17% required additional treatment, and 26% did not join it. The most frequent complications were: pericicatricial adherence (26%), range of motion (ROM) restriction (24%), and scar dehiscence (17%). In the first year after surgery (n=460), the main complaints were: pain (28.5%), heaviness (21.5%), and restriction of shoulder range of motion (16.7%); in the second year (n=168), they were pain (48.2%), heaviness (42.8%), and lymphedema (23.2%). It was concluded that most women were discharged in the end of the program and, over the years, they presented reduction of shoulder range of motion frequency and lymphedema increase. Care of the arm, home exercises, and self-lymphatic drainage were the most adopted conducts.

Long term effects of manual lymphatic drainage and active exercises on physical morbidities, lymphoscintigraphy parameters and lymphedema formation in patients operated due to breast cancer: A clinical trial.

Purpose evaluate whether manual lymphatic drainage (MLD) or active exercise (AE) is associated with shoulder range of motion (ROM), wound complication and changes in the lymphatic parameters after breast cancer (BC) surgery and whether these parameters have an association with lymphedema formation in the long run. Methods Clinical trial with 106 women undergoing radical BC surgery, in the Women’s Integrated Healthcare Center—University of Campinas. Women were matched for staging, age and body mass index and were allocated to performed AE or MLD, 2 weekly sessions during one month after surgery. The wound was evaluated 2 months after surgery. ROM, upper limb circumference measurement and upper limb lymphoscintigraphy were performed before surgery, and 2 and 30 months after surgery. Results The incidence of seroma, dehiscence and infection did not differ between groups. Both groups showed ROM deficit of flexion and abduction in the second month postoperative and partial recovery after 30 months. Cumulative incidence of lymphedema was 23.8% and did not differ between groups (p = 0.29). Concerning the lymphoscintigraphy parameters, there was a significant convergent trend between baseline degree uptake (p = 0.003) and velocity visualization of axillary lymph nodes (p = 0.001) with lymphedema formation. A reduced marker uptake before or after surgery predicted lymphedema formation in the long run (>2 years). None of the lymphoscintigraphy parameters were shown to be associated with the study group. Age ≤39 years was the factor with the greatest association with lymphedema (p = 0.009). In women with age ≤39 years, BMI >24Kg/m2 was significantly associated with lymphedema (p = 0.017). In women over 39 years old, women treated with MLD were at a significantly higher risk of developing lymphedema (p = 0.011). Conclusion Lymphatic abnormalities precede lymphedema formation in BC patients. In younger women, obesity seems to be the major player in lymphedema development and, in older women, improving muscle strength through AE can prevent lymphedema. In essence, MLD is as safe and effective as AE in rehabilitation after breast cancer surgery.

Lymphatic compensation during the postoperative period after breast cancer treatment with axillary dissection

Lymphedema secondary to breast cancer causes physical and psychological morbidity and compromises quality of life. The objective of this literature review was to study lymphatic compensation after surgery for breast cancer and the factors that influence this process, with a view to understanding the etiopathogenesis of lymphedema. Articles indexed on Pubmed published from 1985 to 2012 were reviewed. According to the literature, lymphangiogenesis reduces damage to lymph vessels; there is little evidence that Vascular Endothelial Growth Factor is elevated in women with lymphedema; lymphovenous communications can be observed 60 days after surgery; women without lymphedema have acquired alternative mechanisms for removal of proteins from the interstitial space; and active exercise stimulates lymphatic and venous pumping. Health professionals should teach these patients about the risk factors for lymphedema. The effects of lymphangiogenesis, proteolysis and lymphovenous communications on development of lymphedema should be studied, since these events are intimately related.

Influencia del índice de masa corporal en la frecuencia de linfedema y otras complicaciones después de la cirugía para el cáncer de mama

Objective: this study assessed the influence of pre-operative body mass index (BMI) has upon lymphedema, scar tissue adhesion, pain, and heaviness in the upper limb at two years after surgery for breast cancer. Methods: retrospective analysis of 631 medical records of women who underwent surgery for breast cancer and were referred to the Physiotherapy Program at Prof. Dr. Jose Aristodemo Pinotti Womens Hospital of the Center for Integral Womens Health Care, CAISM/UNICAMP between January 2006 and December 2007. Results: mean age of women was 56.5 years (±13.7 years) and the most part (55%) were overweight or obese, surgical stages II and III were present in 63% of women studied. Radical mastectomy was the most frequent surgery (54.4%), followed by quadrantectomy (32.1%). In the first year after surgery, there was no significant association between BMI categories and incidence of scar tissue adhesion, pain, heaviness and lymphedema. In the second year, overweight and obese women had higher rates of heaviness in the upper limb and lymphedema. For lymphedema, there was a significant difference among BMI categories (p=0.0268). Obese women are 3.6 times more likely to develop lymphedema in the second year after surgery (odds ratio 3.61 95% CI 1.36 to 9.41). Conclusion: BMI ≥25kg/m2 prior to treatment for breast cancer can be considered a risk factor for developing lymphedema in the two years after surgery. There was no association between BMI and the development of other complications.Avaliou-se a influencia do indice de massa corporal (IMC) pre-operatoria na ocorrencia de linfedema, aderencia cicatricial, dor e peso no membro superior nos primeiros dois anos apos cirurgia para câncer de mama. O estudo e uma analise retrospectiva, secundaria de 631 prontuarios de mulheres submetidas a cirurgia para câncer de mama e encaminhadas ao Programa de Fisioterapia do Hospital Professor Dr. Jose Aristodemo Pinotti do Centro de Atencao Integral a Saude da Mulher, CAISM /UNICAMP, entre janeiro de 2006 e dezembro de 2007. Eram mulheres com idade media de 56,5 anos (±13,7 anos), a maioria (55%) com sobrepeso ou obesa. Os estadios clinicos II e III foram encontrados em 63% das mulheres. Mastectomia radical foi a cirurgia mais frequente (54,4%), seguida por quadrantectomia (32,1%). No primeiro ano apos a cirurgia nao houve associacao significativa entre as categorias do indice de massa corporal e incidencia de aderencia cicatricial, dor, peso e linfedema. No segundo ano, mulheres com sobrepeso e obesidade apresentaram maiores taxas de peso no membro superior e linfedema. Para linfedema houve diferenca significativa entre as categorias de indice de massa corporal (p=0,0268). Mulheres obesas tem 3,6 vezes mais chance de desenvolver linfedema no segundo ano apos a cirurgia (odds ratio 3,61 95% IC 1,36-9,41). Concluiu-se que IMC ≥25kg/m2 anterior ao tratamento para câncer de mama pode ser considerado fator de risco para desenvolvimento do linfedema dois anos apos a cirurgia. Nao houve associacao entre IMC e outras complicacoes.

Influência da massa corporal na frequência de linfedema e outras complicações depois de cirurgia para câncer de mama

Objective: this study assessed the influence of pre-operative body mass index (BMI) has upon lymphedema, scar tissue adhesion, pain, and heaviness in the upper limb at two years after surgery for breast cancer. Methods: retrospective analysis of 631 medical records of women who underwent surgery for breast cancer and were referred to the Physiotherapy Program at Prof. Dr. Jose Aristodemo Pinotti Womens Hospital of the Center for Integral Womens Health Care, CAISM/UNICAMP between January 2006 and December 2007. Results: mean age of women was 56.5 years (±13.7 years) and the most part (55%) were overweight or obese, surgical stages II and III were present in 63% of women studied. Radical mastectomy was the most frequent surgery (54.4%), followed by quadrantectomy (32.1%). In the first year after surgery, there was no significant association between BMI categories and incidence of scar tissue adhesion, pain, heaviness and lymphedema. In the second year, overweight and obese women had higher rates of heaviness in the upper limb and lymphedema. For lymphedema, there was a significant difference among BMI categories (p=0.0268). Obese women are 3.6 times more likely to develop lymphedema in the second year after surgery (odds ratio 3.61 95% CI 1.36 to 9.41). Conclusion: BMI ≥25kg/m2 prior to treatment for breast cancer can be considered a risk factor for developing lymphedema in the two years after surgery. There was no association between BMI and the development of other complications.Avaliou-se a influencia do indice de massa corporal (IMC) pre-operatoria na ocorrencia de linfedema, aderencia cicatricial, dor e peso no membro superior nos primeiros dois anos apos cirurgia para câncer de mama. O estudo e uma analise retrospectiva, secundaria de 631 prontuarios de mulheres submetidas a cirurgia para câncer de mama e encaminhadas ao Programa de Fisioterapia do Hospital Professor Dr. Jose Aristodemo Pinotti do Centro de Atencao Integral a Saude da Mulher, CAISM /UNICAMP, entre janeiro de 2006 e dezembro de 2007. Eram mulheres com idade media de 56,5 anos (±13,7 anos), a maioria (55%) com sobrepeso ou obesa. Os estadios clinicos II e III foram encontrados em 63% das mulheres. Mastectomia radical foi a cirurgia mais frequente (54,4%), seguida por quadrantectomia (32,1%). No primeiro ano apos a cirurgia nao houve associacao significativa entre as categorias do indice de massa corporal e incidencia de aderencia cicatricial, dor, peso e linfedema. No segundo ano, mulheres com sobrepeso e obesidade apresentaram maiores taxas de peso no membro superior e linfedema. Para linfedema houve diferenca significativa entre as categorias de indice de massa corporal (p=0,0268). Mulheres obesas tem 3,6 vezes mais chance de desenvolver linfedema no segundo ano apos a cirurgia (odds ratio 3,61 95% IC 1,36-9,41). Concluiu-se que IMC ≥25kg/m2 anterior ao tratamento para câncer de mama pode ser considerado fator de risco para desenvolvimento do linfedema dois anos apos a cirurgia. Nao houve associacao entre IMC e outras complicacoes.

Influence of body mass index on the frequency of lymphedema and other complications after surgery for breast cancer

Objective: this study assessed the influence of pre-operative body mass index (BMI) has upon lymphedema, scar tissue adhesion, pain, and heaviness in the upper limb at two years after surgery for breast cancer. Methods: retrospective analysis of 631 medical records of women who underwent surgery for breast cancer and were referred to the Physiotherapy Program at Prof. Dr. Jose Aristodemo Pinotti Womens Hospital of the Center for Integral Womens Health Care, CAISM/UNICAMP between January 2006 and December 2007. Results: mean age of women was 56.5 years (±13.7 years) and the most part (55%) were overweight or obese, surgical stages II and III were present in 63% of women studied. Radical mastectomy was the most frequent surgery (54.4%), followed by quadrantectomy (32.1%). In the first year after surgery, there was no significant association between BMI categories and incidence of scar tissue adhesion, pain, heaviness and lymphedema. In the second year, overweight and obese women had higher rates of heaviness in the upper limb and lymphedema. For lymphedema, there was a significant difference among BMI categories (p=0.0268). Obese women are 3.6 times more likely to develop lymphedema in the second year after surgery (odds ratio 3.61 95% CI 1.36 to 9.41). Conclusion: BMI ≥25kg/m2 prior to treatment for breast cancer can be considered a risk factor for developing lymphedema in the two years after surgery. There was no association between BMI and the development of other complications.Avaliou-se a influencia do indice de massa corporal (IMC) pre-operatoria na ocorrencia de linfedema, aderencia cicatricial, dor e peso no membro superior nos primeiros dois anos apos cirurgia para câncer de mama. O estudo e uma analise retrospectiva, secundaria de 631 prontuarios de mulheres submetidas a cirurgia para câncer de mama e encaminhadas ao Programa de Fisioterapia do Hospital Professor Dr. Jose Aristodemo Pinotti do Centro de Atencao Integral a Saude da Mulher, CAISM /UNICAMP, entre janeiro de 2006 e dezembro de 2007. Eram mulheres com idade media de 56,5 anos (±13,7 anos), a maioria (55%) com sobrepeso ou obesa. Os estadios clinicos II e III foram encontrados em 63% das mulheres. Mastectomia radical foi a cirurgia mais frequente (54,4%), seguida por quadrantectomia (32,1%). No primeiro ano apos a cirurgia nao houve associacao significativa entre as categorias do indice de massa corporal e incidencia de aderencia cicatricial, dor, peso e linfedema. No segundo ano, mulheres com sobrepeso e obesidade apresentaram maiores taxas de peso no membro superior e linfedema. Para linfedema houve diferenca significativa entre as categorias de indice de massa corporal (p=0,0268). Mulheres obesas tem 3,6 vezes mais chance de desenvolver linfedema no segundo ano apos a cirurgia (odds ratio 3,61 95% IC 1,36-9,41). Concluiu-se que IMC ≥25kg/m2 anterior ao tratamento para câncer de mama pode ser considerado fator de risco para desenvolvimento do linfedema dois anos apos a cirurgia. Nao houve associacao entre IMC e outras complicacoes.

Efficacy of physiotherapy performed during radiotherapy in the prevention of locoregional complications in women under treatment for breast cancer: a controlled clinical trial

A fisioterapia no pos-operatorio de câncer de mama visa a prevenir as complicacoes e promover a independencia funcional. Porem, nao ha dados na literatura sobre a influencia da fisioterapia realizada durante a radioterapia, bem como qual a melhor abordagem. Objetivo: Avaliar a eficacia da realizacao da fisioterapia durante a radioterapia na prevencao das seguintes complicacoes fisicas loco-regionais: limitacao da amplitude de movimento do ombro, aumento da circunferencia e incapacidade funcional do membro superior e aderencia cicatricial em mulheres em tratamento por câncer de mama. Sujeitos e Metodos: Ensaio clinico controlado randomizado, realizado no Servico de Fisioterapia do Centro de Atencao Integral a Saude da Mulher da Universidade Estadual de Campinas, com 66 mulheres em tratamento radioterapico apos cirurgia para câncer de mama e fisioterapia pos-operatoria. As mulheres foram alocadas no Grupo 1 (32 mulheres) que realizou fisioterapia durante a radioterapia e no Grupo 2 (34 mulheres), controle, sendo avaliadas no inicio e no final da radioterapia e 6 meses apos seu termino. A amplitude de movimento do ombro foi avaliada atraves da goniometria, a circunferencia do braco, pela cirtometria e a aderencia cicatricial, pela palpacao e friccao cicatricial. A capacidade funcional foi graduada atraves de escore de dificuldade para movimentar o ombro. Para calculos estatisticos foram utilizados MANOVA com estatisitca de Wilks ou Friedman e os testes de associacao qui-quadrado ou exato de Fisher, assumindo nivel de significância ? = 5%. Resultados: A idade media foi de 52,3 ± 10,6 anos no Grupo 1 e de 48,7 ± 10,8 anos no Grupo 2. Os valores medios de amplitude de movimento do ombro para abducao e flexao observados nas tres avaliacoes revelaram melhores resultados para Grupo1 em relacao ao Grupo 2 (p= 0,0244 e 0,0044, respectivamente). Os valores medios da circunferencia do braco obtidos nas avaliacoes nao se alteraram em ambos os grupos. Ha evidencias de que a fisioterapia realizada durante a radioterapia possa favorecer a melhora da capacidade funcional. Na avaliacao final, a frequencia de aderencia cicatricial no Grupo1 foi duas vezes menor que a observada no Grupo 2 (24% e 48%, p= 0,0477). Conclusao: A fisioterapia realizada durante a radioterapia para tratamento de câncer de mama previne a limitacao na amplitude de movimento do ombro e minimiza a incidencia de aderencia cicatricial. Os resultados sugerem tambem favorecer a melhora da capacidade funcional. No periodo estudado, nao foi encontrada associacao entre a realizacao da fisioterapia e alteracao na circunferencia do braco Abstract