Musculoskeletal, cardiorespiratory, anthropometric and sensorial changes following breast cancer surgery

Introduction: Breast cancer is the second most common malignant neoplasm in women. Surgical intervention is one of the recommended treatments, which can lead to significant physical and sensorial sequelae. Objective: To analyze the musculoskeletal, cardiorespiratory, anthropometric and sensorial functions of women who underwent breast cancer surgery. Methods: An observational, cross-sectional study with women who underwent surgical resection of breast tumors at Amaral Carvalho, a reference hospital in the countryside of the São Paulo State, Jaú/SP, Brazil. Three assessments were obtained: pre-surgery (Ass1), one day after the surgery (Ass2) and 15 days after surgery (Ass3). Sociodemographic and gynecological data were collected, and anthropometric, cardiovascular, dermal sensitivity, range of motion (ROM) of the upper limbs, peripheral oxygen saturation (SpO 2 ), inspiratory muscle strength (PImax), peak expiratory flow (PEF) and thoracoabdominal mobility assessments were performed. Data were evaluated by repeated measures ANOVA and Wilcoxon statistical test with a Bonferroni correction (p < 0.05). Results: Eighteen women, with a mean age of 57.44 ± 9.35 years, mainly with the left side affected (61.1%) and lymphadenectomy performed in 50% of the cases. Differences were found in systolic and diastolic blood pressure, PEF and SpO 2 , axillary ROM index (Ass1>Ass2), PImax (Ass3>Ass2), perimetry (Ass2>Ass3), ROM in all axes of shoulder motion and wrist flexion (Ass2<Ass1), and sensitivity alteration close to the surgical wound (Ass3>Ass2 and Ass1). Conclusion: The surgery for breast cancer excision resulted in hemodynamic and respiratory changes, especially on the first day after the procedure, returning to baseline values approximately 15 days later.

Another aspect of interest is that the greater the proximity of the surgery to the diaphragm, the greater the tendency for pulmonary alterations, consistent with those seen in restrictive breathing patterns, which may reach their peak 24 to 48 hours after the procedure. The variables usually subject to alterations are the forced expiratory volume, vital capacity, tidal volume, and respiratory rate. 7 In the experience of BC diagnosis and treatment, the assessment of body image is essential to understand the stress generated by changes arising from the disease itself and the entire therapeutic process. 8 Specifically, these changes are related to appearance, psychosocial problems, and physical limitations, causing clinical manifestations in the cardiovascular, respiratory, musculoskeletal, and lymphatic systems. 9 The perception of the impact of surgical procedures for removal of breast tumor must be individualized, and depends on various aspects, including the biological one. Therefore, it is assumed that the surgery causes musculoskeletal changes that persist after the at one of the assessment times were excluded. Figure 1 shows the sequence of the study stages and the number of women involved. The Shapiro-Wilk test was used to assess for normal distribution of quantitative variables.

Results
Eighteen women with a mean age of 57.44 ± 9.35 years participated in this study. The sociodemographic data indicated that the majority was Caucasian, with incomplete elementary school, married, and Catholicism was the predominant religion. Period: one day before or immediately after the surgery (pre-procedure). Technique: anamnesis, vital signs, ventilometry, fluxometry, respiratory effort and thoracoabdominal molibity.

ASS3
Period: 15 days after the surgery (post-procedure, stitch removal).   The measurements of the upper limbs circumference, as well as the identification of the filament by means of sensitivity in the surgical wound area are shown in Table 3.
The range of motion of the shoulder, elbow, and wrist segments are presented in Table 4. No statistical difference was found when comparing the ROM between the homo and contralateral shoulders after surgery. Also, the findings did not show pain and its relationships with activities and perceptions (Table 5).    Note: Ass1 = pre-surgery; Ass 2 = one day after surgery; Ass3 = 15 days after surgery; R = right; L = left; F = flexion; Ext = extension; Ab = abduction; Ad = adduction; Int R = internal rotation; Ext R = external rotation. *Comparison between Ass1 and Ass2; **Comparison between Ass1 and Ass3; †Comparison between Ass2 and Ass3.

Discussion
This study aimed to identify possible cardiorespiratory, sensorial, and musculoskeletal alterations in women who underwent excision of BC. An exploratory search of studies related to the our subject did not retrieve similarities in terms of techniques, studied variables, and sample profile, which indicate the originality of this study.
Thus, studies with certain similarities will be compared.
The sample had an anthropometric classification of overweight, which is associated with BC. which are similar to the values found in Ass3, but below the normal range. 32 The surgical intervention on the BC alters the ROM of these movements, and the restriction to movement occurs due to dermal adhesion and pain, especially in cases with greater impairment, resulting in functional reduction. 32 However, muscle dysfunction is present in patients with BC, mainly related to sarcopenia and the type of treatment used. The reduction in upper limb muscle strength may be reduced by up to 12-16%, without substantial difference in shoulder muscle strength, but flexibility appears reduced when the procedure was radical mastectomy. 33 This study presented some limitations, such as a reduced sample due to the clinical condition of the inpatients, and a limited access to the patients and to the procedures to be performed. The collection period was limited to the morning period, according to the department's availability and the unit's requirements.

Conclusion
This study aimed to analyze the musculoskeletal,