Dysfunctional upper limb or dysfunctional beliefs?
Difficulties in performing daily life upper limb activities is a frequently reported side effect of treatment for breast cancer. However, many different factors can contribute to these upper limb dysfunctions. Breast cancer treatments can affect the functioning of various musculoskeletal or lymphatic structures that in turn may cause a change in functioning of the upper limb (e.g. pain, lymphedema).1, 2 In addition, research in non-oncological populations showed that cognitive factors may also play an important role in persistent pain and upper limb function in the late stage following surgery (e.g. fear of movement).3 As the survival rate of women diagnosed with breast cancer rises, it is critical to gain a better understanding of the factors that are associated with the long-term effects of breast cancer treatment.4 Understanding the factors that contribute to these dysfunctions is vital for optimizing the prevention and treatment of these sequelae.
A recently published study explored these factors in a population of 41 women with pain and myofascial dysfunctions in the upper limb region that was treated for breast cancer.5 Participants had pain at the upper limb for a period longer than 3 months, with a pain intensity of more than 40 out of 100 over the past week. Upper limb function was evaluated with the Disabilities of Arm, Shoulder and Hand questionnaire; a 30-item questionnaire that looks at the ability to perform certain upper-limb activities (e.g. placing an object on a shelf above your head, washing your back). The study found that higher pain intensity, more pain-related catastrophizing (worrying and feeling helplessness about pain) and an increased attention towards pain (pain hypervigilance) were related to more upper limb dysfunctions. Relative excessive arm volume (measured with perimetry) and humerothoracic elevation and scapular lateral rotation (evaluated with kinematic analysis) were not significantly associated with upper limb functioning.
The findings of this exploratory study highlight the need of a biopsychosocial evaluation of pain in women presenting with pain and myofascial dysfunctions in the upper limb region in the late stage after breast cancer surgery. When such a patient presents in clinical practice, the focus of the clinical examination may be easily on biomedical information (e.g. condition of the scar, pectoral muscle or scapulothoracic movement) and less attention may be given to the psychosocial part of pain or upper limb dysfunction. However, taking the time to understand and discuss what pain or upper limb dysfunction mean for an individual patient, may play a crucial role in the success of the treatment in the long term.6
By Lore Dams
1. Lovelace DL, McDaniel LR, Golden D. Long-Term Effects of Breast Cancer Surgery, Treatment, and Survivor Care. J Midwifery Womens Health. 2019;64(6):713-24.
2. Dunne M, Keenan K. CE: Late and Long-Term Sequelae of Breast Cancer Treatment. Am J Nurs. 2016;116(6):36-45.
3. De Baets L, Matheve T, Meeus M, Struyf F, Timmermans A. The influence of cognitions, emotions and behavioral factors on treatment outcomes in musculoskeletal shoulder pain: a systematic review. Clin Rehabil. 2019;33(6):980-91.
4. 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 Cancer J Clin. 2021.
5. De Baets L, Devoogdt N, Haenen V, Evenepoel M, Dams L, Smeets A, et al. Cognitions and physical impairments in relation to upper limb function in women with pain and myofascial dysfunctions in the late stage after breast cancer surgery: an exploratory cross-sectional study. Disabil Rehabil. 2021:1-8.
6. Shala R, Roussel N, Lorimer Moseley G, Osinski T, Puentedura EJ. Can we just talk our patients out of pain? Should pain neuroscience education be our only tool? J Man Manip Ther. 2021;29(1):1-3.