Susannah Haarmann, PT, CLT, WCS is the author and instructor of Physical Therapy Treatment for the Breast Oncology Patient. Join her this September 24-25 in Stockton, CA to learn about the various diagnostic tests, medical and surgical interventions to provide appropriate and optimal therapeutic interventions for breast cancer patients.
I turned to the literature and found prominent articles discussing breast reconstruction and giving minimal consequence to shoulder function after resection of the latissimus dorsi muscle. As a physical therapist, this left me in a quandary, “Really? Harvesting a portion of the broadest muscle of the back then threading it through the axilla to recreate the breast mound won’t have an impact on shoulder function or back pain? Impressive!” However, this did not correlate with my clinical findings. Often, scapulohumeral rhythm was altered, range of motion restricted and activities limited due to pain and fatigue. Scrutinizing the literature, I found that those articles were mostly unsubstantiated. Here is a quick summary of two systematic reviews published in 2014 addressing what the research really found pertaining to shoulder function after ‘lat flap’ reconstruction:
- Reported incidence of overall functional impairment is 41%. 8
- Overhead activities, lifting and pushing objects and high-level activities such as sport and housework were the most cumbersome. 1,7
- Subjective deficits did not resolve based on length of follow-up. 1
- Greatest deficits are noted with reconstruction on the dominant side. 4
- Extension of the shoulder is the most common strength deficit followed by adduction then internal rotation. 8
- Objective strength deficits typically resolved within a year. 8,9
- Rehab should be ordered pro-actively. 4
Range of Motion:
- Active flexion is the most common restriction followed by abduction. 8
- Rarely were these restrictions severe. 5,6
- Restrictions were greatest post-operatively likely due to alterations in shoulder biomechanics, scar formation and post-operative pain.
- Discrepancies were found regarding resolution of range of motion without rehab. 5,8
- No clinically significant functional morbidity was found when therapy was provided from post-op day one. 2,3
Other reported complications that may impact function:
- Taratino, Banic and Fischer noted that capsular contracture was the most significant and recurrent complication in their study.10
- 50% reported post-operative numbness and tightness.1
- Scar tissue adhesions were associated with functional limitations.2,3
In conclusion, is it feasible to say that the latissimus dorsi muscle bears little consequence to function after reconstruction? I’m going to trust what the researchers performing the systematic reviews say:
- Physicians and researchers Lee and Mun state the following; “over 20 percent of the patients undergoing latissimus dorsi muscle transfer suffered from considerable disability…7% of patients changed their job postoperatively. These results suggest that considerable discomfort, even to the extent of limitation on daily activity, can be developed after latissimus dorsi muscle harvest, as opposed to the previous assumption that latissimus dorsi muscle harvest may not lead to serious disability” .8
- Smith does give merit to the fact that most strength deficits resolve within 6 to 12 months due to other muscles compensating for function, however, she states “standardization of physical therapy protocols is imperative as it appears to have a measurable positive impact.” Immediately after this statement she remarks that physical therapy is rarely included in the physician’s plan of care.9
I guess it is time we start talking to our surgical oncologists and plastic surgeons.
1. Adams, Jr., W., Lipschitz, A., Ansari, M., Kenkel, J., & Rohrich, R. J. (2004). Functional donor site morbidity following LD muscle flap transfer. Annals of Plastic Surgery, 53(1), 6–11.
2. de Oliveira, R., Nascimento, S., Derchain, S. & Sarian, L. (2013). Immediate breast reconstruction with a latissimus dorsi flap has no detrimental effects on shoulder motion or postsurgical complications up to 1 year after surgery. Plas¬tic and Reconstructive Surgery, 131(5), 673e–680e.
3. de Oliveira, R. R., Pinto e Silva, M. P., Costa Gurgel, M. S., Pas¬tori-Filho, L., & Sarian, L. O. (2010). Immediate breast re¬construction with transverse latissimus dorsi flap does not affect the short-term recovery of shoulder range of motion after mastectomy. Annals of Plastic Surgery, 64(4), 402– 408.
4. Forthomme, B., Heymans, O., Jacquemin, D., Klinkenberg, S., Hoff¬mann, S., Grandjean, F. X.,...Croisier, J. L. (2010). Shoulder function after latissimus dorsi transfer in breast reconstruc-tion. Clinical Physiology and Functional Imaging, 30, 406– 412.
5. Giordano, S., Kääriäinen, M., Alavaikko, J., Kaistila, T. & Kuok¬kanen, H. (2011). Latissimus dorsi free flap harvesting may affect the shoulder joint in long run. Scandinavian Journal of Surgery, 100, 202–207.
6. Hamdi, M., Decorte, T., Demuynck, M., Defrene, B., Fredricks, A., VanMaele, G.,...Monstrey, S. (2008). Shoulder func¬tion after harvesting a thoracodorsal artery perforator flap. Plastic and Reconstructive Surgery, 122(4), 1111–1117.
7. Koh, C. E., & Morrison, W. A. (2009). Functional impairment af¬ter latissimus dorsi flap. Australian Journal of Surgery, 79, 42–47. http://dx.doi.org/10.1111/j.1445-2197.2008.04797.x
8. Lee, K.T., Mun, G.H., (2014).A systematic review of functional donor-site morbidity after latissimus dorsi muscle transfer, Plast. Reconstr. Surg. 134: 303.
9. Smith, S., (2014). Functional morbidity following latissimus dorsi flap breast reconstruction. J Adv Pract Oncol, 5, 181–187.
10. Tarantino, I., Banic, A., & Fischer, T. (2006). Evaluation of late results in breast reconstruction by latissimus dorsi flap and prosthesis implantation. Plastic and Reconstructive Surgery, 117(5), 1387–1394.
Today we hear more from Susannah Haarmann, PT, WCS, CLT about how pelvic rehabilitation practitioners are suited to contribute to a breast oncology patient's medical team. Susannah will be sharing more insights and treatment tools at the Rehabilitation for the Breast Cancer Patient course taking place June 27-28 in Maywood, IL.
Most pelvic rehab practitioners are incredible problem solvers and independent thinkers. We understand that often our referrals from a physician occur after a battery of tests and ineffective medical interventions. We may agree to treat a patient only to find that the diagnosis is vague and the patient often feels lost and broken. So we take out our sleuth caps, ask as many subjective questions as it takes and see where our objective examination leads us. Afterwards we paint a picture of our findings, focus the patient on what is working, tell them where we are going to start and how we are going to build one brick at a time.
The same is true for rehabilitation and breast oncology. Most physicians don’t understand how our work as therapists can complement and alleviate the side effects of mainstream medical intervention, but when the pain medication no longer works, we are there. When the range of motion no longer exists to get the patient’s arm into a cradle for breast radiation, we are there. And when the patient walks in our door, we are there, quite often for a period of time that extends well beyond after treatments cease, because the potential side effects of breast cancer, if they occur, may take years or even decades to show up. The rehab practitioner understands how to prepare the patient, without fear, for what the road ahead may look like. The purpose of this education is to empower patients to serve as their own best advocates. Pelvic practitioners and breast oncology specialists are noted for their exceptional manual skills. We are also versed to pounding the pavement educating physicians, patients and other therapists alike about who we can serve and how we can be of service. We are definitely a unique breed of therapists.
The Rehabilitation for the Breast Cancer Patient course will add to the pelvic rehab practitioner's current knowledge allowing them to become a specialist. Consider the following:
A therapist understands the biomechanics of a shoulder joint and function, but do they understand how the effects of radiation, reconstruction procedures and impairments in the lymphatic system as a side effect of cancer treatment might prevent optimal upper extremity function?
A therapist may understand peripheral neuropathy and balance training or osteoporosis and aging, however, do they understand which chemotherapeutic and hormone therapies may cause these side effects and how the prognosis may differ depending upon which medical intervention was used?
A therapist may commonly treat back pain, but do they understand how a plan of care might be altered to accommodate for a patient who experienced a TRAM flap or latissimus dorsi reconstruction?
A therapist may be able to initiate a post-operative rotator cuff strengthening program for the upper extremity, but if the patient has a history of lymphedema, how do these parameters change?
A therapist may have advanced manual therapy skills, but how might one use these skills to identify and treat lymphatic cording or set safe parameters for working around radiated tissue to restore optimal function?
These are just a few of many examples of what constitutes a specialist in the field of breast oncology and each of these questions and more will be covered in detail in the course Rehabilitation for the Breast Cancer Patient.
Today we hear from Susannah Haarmann, the instructor for Rehabilitation for the Breast Cancer Patient. If you want to learn how to implement your pelvic rehab training with breast oncology patients, join Susannah in Maywood, IL on June 27th and 28th.
Effective pelvic rehab practitioners demonstrate many skills which are especially suitable to treat people with breast cancer, however, the first idea that comes to mind is that they understand what my friend refers to as, ‘the bikini principle.’ She remarked this week that I treat the ‘no no’ areas; the private places that we rarely share…with anyone. The reproductive regions of the pelvis and chest wall both consciously and subconsciously are associated with a plethora of personal psychological and social connotations. A pelvic health practitioner has a raised level of sensitivity to working with this patient population; there is no true protocol in this line of work, effective treatment will require a deeper level of listening and being present with the patient, and a person’s healing of the pelvic region is likely to go beyond the physiologic realm.
The biopsychosocial model of treatment is especially pertinent to the pelvic and breast oncology specialties. The breasts have great biological importance for sexual reproduction and nurturing offspring. Psychologically, breasts represent femininity for many women (and imagine how the story would change for a male with breast cancer.) Furthermore, different societies tend to create a host of rules and guidelines about what is ‘breast appropriate.’ The rehab practitioner understands that a person’s perceptions of their breasts are unlike any others and the same holds true for their cancer journey and goals with therapy.
The pelvic practitioner understands the importance of a straight face; if you have been in the field long enough something completely surprising is bound to occur, but in the day in the life of a pelvic rehab practitioner, no matter how shocking, we’ve seen it before, right? The breast oncology practitioner is going to visualize radiation burns that make their own chest wall hurt upon seeing it. Practitioners will encounter the most frustrating of severe functional deficits that could have been easily avoided had there been the opportunity for earlier intervention. The rehab practitioner providing breast oncologic care understands the story is complex, the road may be long, and although our role revolves around the body, the side effects of our treatment may have much greater reward beyond just physical function.