Pain rehabilitation treatment for women with breast cancer

BACKGROUND AND OBJECTIVES : Breast cancer is a public health problem due to its high rates of incidence and mortality, and the presence of pain in the arm and breast is a very frequent symptom in these women. The objective of this study was to organize scientific evidence on rehabilitation treatments for women after breast cancer surgery. CONTENTS : The search was performed based on the Medline, LILACS, and Scielo database on articles published in the last 10 years, from January 2008 to January 2018. The survey was carried out with the following keywords: “Breast Cancer” and “Up-per Limb” and “Pain” and “Rehabilitation”. Randomized clinical trials, pilot study, and quasi-experimental study were included. The search totaled 92 articles, of which only seven articles were selected. The visual analog scale was used in most articles. CONCLUSION : Physiotherapy and physical exercise can benefit women with breast cancer, reducing pain, and increasing the upper limb’s functionality, as well as minimize the lymphedema.


INTRODUCTION
Breast cancer (BC) is a public health problem due to the high incidence and mortality rates.Among the types of cancer, breast cancer has the highest incidence among women 1,2 .In the world, the growth rate has reached 20% in the last decade, and the impact of cancer will correspond to 80% in the population between developed and developing countries 1 .BC surgery, axillary lymphadenectomy, and manipulation of the pectoral muscles bring a risk of tissue injury and complications in up to 70% of cases.Complications due to axillary alterations include chronic pain, shoulder movement limitations, and muscle atrophy 3 .Thus, the presence of moderate or severe pain is more frequent in patients undergoing axillary dissection compared to those who underwent sentinel node biopsy 4 .The occurrence of pain in the arm that is homolateral to the surgery is more related to the extension of the axillary surgical procedure and injuries to some structures such as the intercostobrachial nerve and the serratus anterior 4 .Arm and breast pain is the most frequent symptom in these women, corresponding to 51.6% [4][5][6] .In patients under 40 years old, the presence of lymphedema significantly increases the risk of post-mastectomy pain syndrome 7 , and the literature converges on sedentary behavior as a predictor of pain [8][9][10] .Thus, rehabilitation may be an acceptable non-pharmacological alternative to minimize pain in women with BC to promote an improvement in physical recovery.Thus, to minimize the pain caused by the treatment of BC, rehabilitation becomes essential and an integral part in the adjunctive treatment of these women.Given the above, this study aimed to organize the scientific evidence on pain rehabilitation treatments used with women after BC surgery.

CONTENTS
The systematic review was performed based on a retrospective consultation of the Scielo, Pubmed, and LILACS databases, in January 2018, and the search strategy was formulated by crossing descriptors (DeCS and MeSH).Only studies conducted with women diagnosed with BC and treated with pain rehabilitation techniques were included.In addition, the studies should be in Portuguese, English, or Spanish, published in the last 10 years (January 2008 to January 2018).Articles that did not present any intervention to treat pain were excluded.In the Scielo, LILACS (DeCS) and Medline databases, the following crosses were used: "Breast Cancer" AND "Upper Limb" AND "Pain and Rehabilitation".In the initial phase, titles and abstracts were independently identified and assessed by two reviewers to select those that met the eligibility criteria.Articles that did not meet the criteria described were excluded by title analysis, followed by exclusion by the abstract.Finally, potentially relevant studies were retained for further analysis of the full text.The prominent information was presented in a descriptive table, considering the following variables: authors, sample, assessed outcomes, methodological design, intervention, and effects found.In the initial search in the databases, 92 articles were found.After a first selection by title, 75 articles were excluded, staying 17 for analysis of the abstracts.Of these, eight articles were selected that met the inclusion criteria established.Figure 1 shows the selection process of the included articles, and table 1 shows the list of selected studies that used rehabilitation to treat pain in women with BC.Analyzing the results obtained by the search strategy, there was a higher concentration of studies in 2016, with a single publication in 2008.It is also evident that the study participants were volunteers of different age groups, but the average age of the analyzed samples corresponded to the middle-age population.Of the eight articles that were used in this study, four used  T1-T2 postoperative pain levels were lower in IG for ER, flexion, and abduction movements.T3-T4 IG improved ROM in ER and abduction movements; the same movements were decreased in CG.Pain levels were decreased in IG for flexion, abduction, and ER movements and increased incidence of pain in the same movements in CG.T5-T6 12 months after radiotherapy IG did not report pain in all movements except for ER.Recurrence of IG pain at 18 months after radiotherapy was present in all shoulder movements.In contrast, CG at 12 months after radiation reported pain in all movements and persisted at 18 months after radiotherapy in flexion and ER movements.

Descriptive and l o n g i t u d i n a l analytical study.
There were 20 physical therapy sessions, 3 times a week, lasting 60 minutes.The exercises were cervical stretching and active-free exercises of flexion, extension, abduction, adduction, IR, and ER.VAS pain decreased from 3.8±1.7 to 3.0±1.9when compared from the 1 st session to the 10 th session.From the 1 st session to the 20 th session, there was no decrease in pain (p=0.09), and from the 10 th session to the 20 th session (p=0.79).In the Br-MPQ scale from the 1 st session (p=0.0021) and the 10 th session (p=0.0159) and from the 1 st (p=0.0001)session to the 20 th (p=0.0003).ROM improved in all movements, and no association was found between ROM and pain intensity.

VAS to assess pain, two articles were assessed by the McGill pain scale, and one article was assessed by the Brief Pain Inventory Short (BPI)
. VAS is a one-dimensional measure for pain intensity assessment.Composed of a 10 BC line, with anchors at both ends, on one end of the line is marked "no pain" and the other "worst pain imaginable."The magnitude of pain is indicated by marking the line, and a ruler is used to quantify the measurement on a scale from zero to 100mm 11 .It is recognized worldwide and widely used in studies with BC patients.

DISCUSSION
BC is the most common among women, causing upper limb disability homolateral to surgery and chronic pain, being observed in the listed studies.Decreased upper limb functionality homolaterally to surgery may interfere with the quality of life of these women, and the prevalence of pain is high as a result of treatment.This study revealed effective outcomes regarding pain relief rehabilitation in women with BC.The interaction of psychological and social factors, surgery, upper limb muscle weakness homolateral to the surgery, decreased range of motion (ROM) and pain are determinant to cause reduced upper limb functionality.Impaired functionality negatively affects the QoL of these women.Studies by Ibrahim et al. 8 , Zengin Alpozgen et al. 9 and Keays et al. 10 reported that physical exercise was able to promote the improvement of clinical symptoms related to pain.In addition, physical exercise improves joint mobility, upper limb functionality, and increased muscle strength [8][9][10] .The duration of pain treatment in these women can be from 4 to 12 weeks.However, some authors suggest the need to treat this symptom for a longer period of time [8][9][10] .In the specific exercise program, Ibrahim et al. 8 were able to improve shoulder ROM three months after radiation compared to the control group, and it was found that increased ROM is associated with a reduction in the incidence of pain.Participants had pain in all shoulder movements at 12 months after radiation.However, there was a decrease in pain in the intervention group compared to the control group.On the other hand, shoulder movement pain remained in both groups at 18 months after radiation.
The Pilates method was used in rehabilitation in the studies by Zengin Alpozgen et al. 9 and Keays et al. 10 .The method has been shown to be adequate and capable of eliminating adverse effects of BC treatment, relieving or reversing the reduction of shoulder mobility, improving ROM, decreasing pain at movement and at rest, and consequently promoting the improvement of upper limb functionality.Robotic rehabilitation for eight weeks was used by House et al. 13 .The authors observed improvement in activities of daily living due to increased muscle strength and ROM.Also, the study's most notable finding was a significant improvement in depression.This finding facilitates the hypothesis that the ability to interact with virtual media may be beneficial to the mental health of this population.The upper trapezius muscle region has been described as one of the most sensitive areas in patients with BC.Pain caused by myofascial dysfunction may, in fact, manifest as increased pressure and hypersensitivity in the upper limb region 12 .Myofascial therapy, however, had no beneficial effects on the prevalence, quality, and intensity of postoperative pain after BC surgery 12 .It is noteworthy that lymphedema causes pressure on the vessels and peripheral nerves of the skin and muscles of the upper limb and trunk, causing pain.In this context, in studies by Cho et al. 14 and Angooti Oshnari et al. 15 , lymphatic drainage reduced muscle pain and lymphedema, which is a painful condition that limits upper limb functioning and leads to low QoL 14,15 .Kinesiotherapy improves the ROM of these women and reduces pain when performed at the beginning of treatment, even without showing a direct relationship between increased ROM and decreased pain 16 .Knowing the interference in daily life with the physical and social tasks that the pain can lead, it is extremely relevant and valid to think about this strategy within rehabilitation.Rehabilitation has been shown to be effective in improving pain in patients with BC.From this review, it was noted that several features such as manual therapy, stretching and muscle strengthening exercise, upper limb mobility, lymphatic drainage, and Pilates exercises bring notable benefits for women with BC [8][9][10][11][12][13][14][15][16] .All women improved shoulder flexion and ER, and 2 women improved abduction and RI. 3 women had zero pain score.3 women showed improved mood.
In the analysis of UL functionality, 2 women reported improvement, and only 1 woman kept UL functionality stable.
VAS = visual analog scale; QoL = quality of life; ER = external rotation; IR = internal rotation; Br-MPQ = McGill Pain Questionaire; BPI = Brief Pain Inventory Short; DASH = Disabilities of the Arm, Shoulder and Hand; ROM = range of motion; NRS = Numeric Rating Scale; FMA = Fugl-Meyer Assessment; CAHAI-9 = Chedoke arm and hand activity inventory; JHFT = Jebsen-Taylor Hand Function Test; UL = upper limb; BDI = Beck Depression Inventory; EORTC QLQ-C30; European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30; POMS = Profile of Mood States.

Table 1 .
Description of the selected studies that used rehabilitation to treat pain in women with breast cancer

Table 1 .
Description of the selected studies that used rehabilitation to treat pain in women with breast cancer -continuation

Table 1 .
Description of the selected studies that used rehabilitation to treat pain in women with breast cancer -continuation