Efficacy of Shoulder wheel exercises and pain gone pen modality on the functional activity of shoulder joint post-mastectomy
Ahmed m. Abd al-kader
1, Said a. Mohamed
2, Lamyaa a. Fergany
3, Alaaeldin khaireldin
4, Dalia m. Mahmoud
5, Elsayed s. Mehrem
*61. Lecturer Department of physical Therapy for Integumentary, Faculty of physical therapy, Deraya University, Minia, Egypt.
2. Assistant professor of physical therapy, Woman health department, Faculty of physical therapy, Deraya University, Egypt.
3. Lecturer Department of physical therapy for neurological and neurosurgical disorders, Faculty of physical therapy, Deraya University, Minia, Egypt.
4. Lecturer of Physical Therapy, orthopedics & orthopedic surgery department, Faculty of physical therapy, Deraya University, Minia, Egypt.
5. Assistant-lecturer of Physical Therapy, orthopedics & orthopedic surgery department, Faculty of physical therapy, Al Ahram Canadian University, Cairo, Egypt.
6*. Lecturer of Physical Therapy, pediatrics & pediatric Surgery department, Faculty of physical therapy, Deraya University, Minia, Egypt. [email protected]
ABSTRACT
Background: After mastectomy and the accompanying excision or radiation of adjacent axillary lymph nodes, a patient is at risk of developing upper extremity lymphedema, shoulder pain and loss of shoulder motion which can be prevented or minimized by physical therapy modalities. Objective: to evaluate effectiveness of shoulder wheel range exercises and pain gone pen (PGP) modality on functional activity of shoulder joint post-mastectomy. Methods: Thirty adult women with shoulder pain following mastectomy were recruited from the National Cancer Institute in Cairo, Egypt. They were ranged in age from 40 to 55 years, split into two categories (control group A.) getting only conventional medical attention and (study group B.) who received physical therapy modalities plus the traditional medical treatment. We evaluated of the findings by used Visual analogue scale (VAS) and technical appraisal of the simple shoulder test (SST). Results: The results revealed a highly significant reduction in Visual Analogue Scale (VAS) (P<0.0001), and the mean value of the scores percentage of the functional assessment of the Simple Shoulder Test (SST), (P<0.0001) related to shoulder joint activities. Conclusion: Shoulder wheel range of motion exercises and pain gone pen PGP are useful in minimizing discomfort and enhancing the post-mastectomy functional operation of the shoulder joint.
Key words:Functional activity of shoulder joint, Post-mastectomy, Pain gone pen and Shoulder wheel exercises.
Introduction
Breast cancer is extremely rare before the age of 25 years. It reaches a high incidence in the decade from 40 to 50 and continuous to increase in the frequency into old age. Mastectomy is the traditional approach to remove the entire breast once the diagnosis is confirmed. The most common cancers being lung cancer in men and breast cancer in women, however despite the large numbers of people affected by cancer there is very little literature on role of physiotherapists in cancer care (Puled et al., 2004).
One of the most frequent musculoskeletal disorders in post-mastectomy patients is shoulder pain (Pérez-Palomares et al., 2017). It is associated with reduced well-being and is responsible for restrictions on behavior (Dudkiewicz et al., 2004).The dressing, basic grooming and overhead tasks of patients with shoulder pain are complicated (Rundquist &
Ludewig, 2004).
After mastectomy and the accompanying excision or radiation of adjacent axillary lymph nodes a patient is at risk of developing upper extremity lymphedema, shoulder pain and loss of shoulder motion. Physical therapists often become involved in the postoperative management of patients who have undergone a mastectomy. Therapeutic activity is an integral aspect of the postoperative treatment strategy of the patient to reduce or mitigate lymphedema, pain in the shoulder or lack of shoulder motion (Brennan & Garden, 2006).
Shoulder dysfunction is common complication following treatment of breast cancer, Shoulder motion is usually affected by the extent of axillary dissection. Flexion, external rotation, and abduction (the true articular shoulder movements) are the most likely to be affected and are often the most difficult to restore if lost. Shoulder pain is a significant clinical problem that requires treatment to improve comfort and function(Waston & Wall, 2009).
Early physical therapy intervention for the post-mastectomy patients will make a significant contribution to the return of patient’s functional level and ultimately her quality of life. Immediate postoperative mobilization of the injured arm was advised to prevent shoulder pain and restriction of R.O.M of the shoulder following mastectomy. Full range of motion of the shoulder is often needed in order to obtain necessary positioning for post-operative radiation therapy(Waston &
Wall, 2009).
The fact that the living organism has an intrinsic bioelectric mechanism that facilitates bone fracture recovery, soft tissue lesions and decreases pain severity is based on motor neurons. The external current can be used to imitate failed natural bioelectric currents in order to inhibit chronic complications. The pain gone pen has been stated to be a modern pain treatment system that is stronger than other higher amplitude current to boost cell physiology processes, the piezo- electronic crystal inserted in the pain gone pen device operates by generating a piezo resistive stimulus in the form of high impedance for a short moment, a low frequency wave, the production speed electrical signals to the human skin and then to the cell's mechanism for pain management by tapping on the sore area (Benedetti et al., 2011).
Subjects, Material and Methods:
Subjects
This study was administered for three months from September 2020 to November 2020. Thirty female patients with shoulder pain following mastectomy and they've been promoted from the National Cancer Institute, Cairo, Egypt.
Their ages were ranged from 40 to 55 years old. Before data collection, Informed consent was obtained from all participants. Their Socio-demographic parameters and Clinical characteristics of the study population are in table (1A)
& (1B).
The participants were examined to ensure that they met the following inclusion criteria, their aged were 40 to 55 years who underwent radical mastectomy and breast-conserving axillary lymph node dissection surgery (ALND),for breast cancer with intravenous analgesia and no regional anesthesia under general anesthesia; at least three months after surgery; routine follow-up at the breast treatment center; no breast cancer recurrence; patients who may have received pre / post adjunctive treatment.
The exclusion criteria were Conservatives another (without ALND), breast reconstruction surgery or cosmetic surgery;
local anesthesia as part of the management of the anesthetic (for examples, cancer return, latest breast cancer, other metastatic cancers, post-surgical infections, chronic pain induced by something other than post- mastectomy pain syndrome) and patients who have had inadequate medical records.
They were divided randomly into two groups, Group (A) "Control group": Fifteen patients who received only the traditional medical treatment.Group (B) "Study group": Fifteen patients who received shoulder wheel range of motion exercises and pain gone pen (PGP) stimulation, in addition to the traditional medical treatment.
Instrumentation:
- Shoulder wheel method for applying the spectrum of shoulder exercises in movement (15 minutes for three times per week /3 months)(Griffin & Clifft, 2011).
- pain gone pen (PGP), A modern pain management system is a product that has gained considerable attention. The piezo-electronic crystal placed in the product works by producing a high voltage, low frequency pulse for a brief period.
The production speed electrical signals to the dermis and then to the body's pathway for pain relief by tapping on the sore region. Pain gone pen unit as in figure (1) (it was assembled in the UK for medical-direct international Ltd. Unit17;
Ruddiington Lane, Nottingham, NG 11 7EP, Wilford industrial estate and business park, UK) with the following technical requirements: Stimulator, hand-held, pen-like, piezoelectric. Name of the device: Pain Gone. Classification:
Medical System Class Stage ii (CE0086). Length: length: 132 mm. Diameter: a diameter of 20mm. Specifications for electricity: No power supply is needed. Energy production: 2.6 MJ in 2000Ω. Operating life: 2-3 years under regular administration of 3 therapies a day of 30-40 clicking per procedure. Volt: 15.000 V high voltage. Amplitude: low 1-2 Hz frequency and 0.006 mA16 strength (Kloth, 2005).
Figure (1)pain gone pen (PGP)
Table 1 (A): Socio-demographic parameters of the study population
Age
Study G. (n=15) Control G. (n =15)
Numbers % Numbers %
40-45 years 9 60 7 46.6
45-50 years 4 26.6 4 26.6
50-55 years 2 13.3 4 26.6
Area of residence
Cairo region 8 53.3 10 66.6
Upper Egypt 6 40 5 33.3
Missing or unspecified 1 6.6 0 0
Level of education
Less than secondary 12 80 13 86.6
Secondary 2 13.3 1 6.6
Tertiary 1 6.6 1 6.6
Working status
Worker 5 33.3 4 26.6
House wives 8 53.3 9 60
self-employed 2 13.3 2 13.3
Marital status
Single 2 13.3 3 20
Married 13 86.6 12 80
Table 1 (B): -Clinical characteristics of the study population
Type of medical treatment
Study G. (n=15) Control G. (n =15)
Numbers % Numbers %
Radiotherapy 2 13.3 1 6.6
Chemotherapy 2 13.3 4 26.6
Both 11 73.3 10 66.6
Type of surgery
Radical mastectomy 12 80 11 73.3
Modified radical mastectomy 3 20 4 26.6
Tumor grade
I 1 6.6 2 13.3
II 1 6.6 3 20
III 13 86.6 10 66.6
Weight(kg.) 50-65 15 100 15 100
Height(cm.) 155-165 15 100 15 100
BMI(kg/m2) 22-25 15 100 15 100
Systolic and diastolic blood pressure
120/80 (mmHg) 15 100 15 100
Family history of breast cancer
Positive 14 93.3 13 86.6
Negative 1 6.6 2 13.3
Table (2): Comparison of the mean score, pre and post-treatment VAS values of both categories.
Table (2) Revealed the mean value of the visual analogue scale in degrees (VAS) before and after treatment for study group. These results revealed a highly significant reduction in VAS. But in the control group, the mean value of the visual analogue scale in degrees (VAS), before and after treatment revealed non-significant difference.
Before treatment After treatment
Mean Difference
T value P value Mean in
degrees
± SD Mean
in degrees
± SD
Study group 8.515 0.145 3.222 0.231 5.29300 75.16 < 0.0001
Control group 8.518 0.131 8.520 0.116 0.002000 0.04 0.965
Table (3): Comparison between the mean values of the percentage scores of the SST functional test before and after therapy of both categories:
Before treatment After treatment
Mean difference
T value P value Mean in
% scores
± SD Mean in
% scores
± SD
Study group 32.600 7.615 77.20 7.78 -44.6000 -15.87 < 0.0001
Control group 32.595 7.661 32.585 7.670 0.010000 0.00 0.997
Table (3): Revealed the mean value of the scores percentage of the functional assessment of the Simple Shoulder Test (SST) before and after treatment for study group which showed a very important improvement in the overall percentage value of the ratings of the functional assessment of (SST), (P<0.0001). While in the control group, the mean value of the scores percentage of the functional assessment of the Simple Shoulder Test (SST), before and after treatment
indicated a non-significant difference in the mean percentage.
Measurement equipment and tools
Visual Analogue Scale (VAS): Pain level was assessed by visual analogue scale. It is a line of ten cm held at either end of wards like no discomfort and the worst possible pain (Waston & Wall, 2009).
Functional Assessment of the Simple Shoulder Test (SST): (SST) is a scale of the shoulder feature composed of 12 things that question individuals about their ability to withstand or perform 12 everyday life tasks. The participant shows that she can do the activity or is not willing to do it. The SST scores differ from 0 to 100 and are recorded as the percentage of items to which the participant answers in the affirmation. SST was done before starting treatment (first record) and at the end of the total period of treatment after 3 months (second record) (Box et al., 2002).
Intervention
Patients in the two groups (A) and (B) received the same traditional medical treatment, same nursing care and described diet. Group (B) patients sit on a chair with back support and the PGP stimulation was applied (for a brief period) one (10 clicks) on the shoulder tip and the other (for a brief period) (10 clicks) on the centre of deltoid muscle (as in figure 1). PGP device was used in conjunction with the following parameters: high voltage of 15.000 V, amplitude (intensity) 0,006 mA, frequency 1-2 HZ. The frequency of this treatment protocol for each patient of this group was three sessions per week, day after day for three months, while the shoulder wheel range of motion exercises (15 minutes for three times weekly for 3 months) (Griffin & Clifft, 2011). and (Benedetti et al., 2011).
Data analysis:
Visual Analogue Scale (VAS) and Functional Assessment of the Simple Shoulder Test (SST) reports were assessed in all classes prior to therapy and following conclusion of the therapy program. Collected data were fed into computer for the statistical analysis; descriptive statistics as mean, standard deviation, minimum and maximum were calculated for each group. The t-test was done to compare the mean difference of the two groups before and after application and within each group. Alpha point of 0.05 was used as a level of significance (Hinton, 2004).
Results
In the present study, effects of the range of motion exercises and PGP electrical stimulation on functional activity of the shoulder joint post-mastectomy were investigated. As shown in table (2) and figure (2), the mean value of the visual analouge scale in degrees (VAS) before treatment was (8.515 ± 0.145) degrees in the study group, while after treatment was (3.222 ± 0.231) degrees. These results revealed a highly significant reduction in VAS, (P<0.0001). But in the control group, the mean value of the visual analouge scale in degrees (VAS), before treatment was (8.518 ± 0.131) degrees, while after treatment was (8.520 ± 0.116) degrees, these revealed non-significant difference in VAS, (P > o.
o5).
In the present study, effects of the shoulder wheel range of motion exercises and electrical stimulation on functional
the scores percentage of the functional assessment of the Simple Shoulder Test (SST) before treatment was (32.600 ± 7.715) in the study group, while after treatment was (77.20 ± 7.78). These findings showed a very important improvement in the overall percentage value of the ratings of the functional assessment of (SST), (P<0.0001). While in the control group, the mean value of the scores percentage of the functional assessment of the Simple Shoulder Test (SST), before treatment was (32.595 ± 7.661), and after treatment was (32.585 ± 7.670), These findings indicated a non- significant difference in the mean percentage value of the ratings of the functional assessment of (SST), (P > o. o5).
Discussion
Breast cancer is one of the most disturbing types of cancer that affects patients emotionally, culturally and mentally (Beyaz et al., 2016). Mastectomy contributes to weakness and discomfort in the arm, thereby reducing musculature intensity and restricting ROM (Skalsky & McDonald.2012).Such modifications prohibit patients with post-mastectomy from undertaking regular everyday life tasks. Initial studies have also indicated that most post mastectomy patients do not successfully perform ADL's due to discomfort and reduced shoulder ROM (Cheville & Tchou,2007).
Cancer of the breast is the most frequent cancer among the Egyptian females and constitutes 25.5% of all their cancers.
A ten years' report, from the National Cancer institute, Cairo, showed that breast cancer is the most frequent malignancy among females attending the institute, accounting for 34.7% of all female cancer cases and 14% of all cases of cancer registered (Abeloff & Lichter, 2009).
There are several aspects of conventional treatment of breast cancer that can lead to temporary shoulder and arm dysfunction. Decrease skin mobility of the chest wall and formation of fibrous adhesions resulting from surgical dissection, radiation fibrosis and axillary scarring can cause shoulder joint dysfunction, the shoulder joint dysfunction can cause pain, muscle spasms, immobility, and a functional loss of range of motion. The causes of restricted range of motion are immobility by dressing, instruction, pain, fear, or scarring (Bosompra et al., 2002).
In breast cancer patients, discomfort is a common complaint and may be of many forms, the normal history of the occurrence, how quickly it arises after treatment, its nature and severity also suggest its cause. Medical arm dysesthesia, for example, happens shortly following surgery which is the result of removing the medial brachial cutaneous nerve;
hand dysesthesia is probably referred to as carpal tunnel syndrome or cervical spine, sometimes secondary to arm edema and related to axillary dissection. Scar tightness and paresthesia in the propagation of the intercostal brachial nerve cause pain following breast surgery in a large proportion of patients. More extreme pain, which can be debilitating, is less frequent (4% to 6%) (Waston & Wall, 2009).
The use of exogenous electrical potentials, fields and currents in order to facilitate tissue healing or pain management is becoming a clinically accepted technique. An injury to a living system initiates a series of complex electrical currents at the site of injury, which are directly responsible for changes in both cell type and number (Akai & Hayashi, 2006).
Findings of the present study showed that there were a highly significant differences between both groups between pre and post treatment in relation to the means of the second record VAS and the scores of the functional assessment of the SST.
Findings of the present study showed that there were non-significant differences between both groups in pre-treatment in relation to the means of the second record VAS and the scores of the functional assessment of the SST.
Our results are consistent with those observed and recorded by Griffin &Clifft, and Benedetti et al. (Griffin & Clifft, 2011). and (Benedetti et al., 2011).
Conclusion
We concluded that shoulder wheel exercises and the electrical stimulation of pain gone pen (PGP) in addition to the traditional medical treatment had valuable effects on functional activity of the shoulder joint post-mastectomy as evidenced by the highly significant differences inVAS and the scores of the functional assessment of the SST.
Acknowledgments
The authors acknowledge all women who participated in this work for their co-operation, also all medical team in the National Cancer Institute, Cairo for their help.
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