Author: Davies, Claire C; Brockopp, Dorothy Y
Date published: July 1, 2010
Breast cancer is one of the most common cancers among American women, with approximately 192,370 newly diagnosed in 2009.1 Many of the more than 2.5 million breast cancer survivors1 experience the side effects of pain, scar tissue adherence, and decreased flexibility leading to limitations in function activity following treatment for their disease.
Tight scar tissue can develop following surgical treatment for breast cancer, leading to decreased flexibility and function in the involved upper quadrant. If mastectomy includes axillary dissection, further impairments due to fibrosis, soft tissue contracture, loss of shoulder mobility, and adhesions may be present.2 Effects of radiation therapy and other complications of breast cancer treatment include: lymphedema, adhesions, pain, psychological problems, and change in body image, resulting in decreased quality of life and function.2·3 Evidence suggests that functional limitations and surgery-related impairments are present in 15% to 50% of women treated for breast cancer.4-7 These common complications are often left untreated and can lead to activity limitations and restriction in participation for patients following treatment.2-8
The most obvious effect of adhesions and scar tissue is loss of shoulder range of motion. According to Leidenius et al,9 86% of patients had shoulder limitation following complete axillary dissection and 45% of patients after a sentinel node biopsy.2·9 This limitation in range of motion may cause additional complications if radiation is indicated, since the patient may be unable to obtain adequate shoulder flexion and abduction for optimal positioning during radiation.
Scar tissue may also become hypersensitive. This hypersensitivity frequently occurs at the drain site, a source of pain that is often over looked. This condition may restrict movement and can lead to further loss of function in the shoulder. In addition, women may be unable to wear a bra following surgery; a choice that can negatively impact body image as well as quality of life. Unfortunately, issues related to hypersensitivity of scars and clothing restrictions have not been addressed in the literature.
Early intervention and treatment of these complications can help minimize pain, swelling, and formation of scar tissue, therefore reducing limitations in activity, function, and participation.2 Current rehabilitation techniques for this population frequently focus on increasing range of motion through stretching and exercise. However, stretching and exercise may not change the presence or extent of scar tissue and limitations may still exist. There is little evidence in the literature to support specific scar tissue interventions postoperatively in the treatment of breast cancer.
ASTYM® treatment10 is a noninvasive soft tissue therapy in which a specific treatment process uses hand-held instrumentation to topically locate underlying dysfunctional soft tissue and then transfer pressure and appropriate shear forces to that tissue. ASTYM treatment has been developed and refined over the last 15 years. The research that resulted in ASTYM began with the review of friction massage, Gua Sha, and other manual therapies and how the addition of tools may assist in those approaches. As ASTYM research progressed, the focus turned to optimizing the underlying physiological response of the body to certain shear forces generated by topically applying instruments in a specific manner. Inducing the desired underlying physiological responses, which result in healing and regeneration, became the fundamental factor that guided the development of protocols and application of the ASTYM process. The goal of ASTYM treatment is to induce biological changes at a cellular level to promote the resorption of scar tissue, and to stimulate tissue turnover and regeneration of soft tissues. ASTYM treatment is applied in a consistent manner in accordance with its specific treatment guidelines. While anecdotal evidence is available to support the use of ASTYM to address scars such as around the mastectomy incision, reconstruction site, drain sites, and axillary scaring this use of ASTYM has not been researched.
The goal of ASTYM treatment in addressing scar tissue is to stimulate resorption of inappropriate fibrosis and regenerate healthy tissue in affected areas. This outcome is achieved through a systematic process of strokes that are performed throughout the involved area, using hand-held instruments with a specifically defined edge. Surgical or traumatic scars are also addressed. As the instruments glide over the dysfunctional areas, they 'catch' on the irregular tissue and the clinician and patient experience a sensation of roughness. The irregularities are believed to be fibrous adhesions. It is theorized that this process activates a healing response via induction of capillary leakage as well as from the mechanical stimulus of fibroblasts. Leakage from the capillaries results in the release of white and red blood cells into the area as well as growth factors from the serum, stimulating tissue turnover and a healing response. Histological studies have demonstrated that ASTYM treatment results in increased fibroblast recruitment and activation.11·12 There also appears to be a neurological component to the process as evidenced by immediate changes in pain perception and strength measures that often occur following treatment. In breast cancer patients, anecdotal evidence suggests ASTYM may have a desensitizing affect on touch and pressure on the involved tissue.
Following ASTYM stimulation, specific stretches, exercises, and activities are incorporated to identify dysfunctional areas. This process stretches and provides stress on the remodeling tissue along the desired lines of muscle fiber alignment for functional activities. Tissue stimulation is dosed with 2 days between sessions to allow adequate recovery. Patients and clinicians report a decreased sensation of roughness during subsequent treatments, as well as decreased pain and improved function. ASTYM has demonstrated effectiveness in treating scarring postoperatively following knee fracture and total knee replacement in case studies.1314 Given the dearth of information on ASTYM and its effectiveness with breast cancer patients following mastectomy, a pilot study was designed to provide initial data regarding its use.
The purpose of this study was to determine the effectiveness of ASTYM on upper extremity functioning among breast cancer patients following mastectomy. Specific aims were to assess:
1. range of motion (flexion) before and after treatment;
2. range of motion (abduction) before and after treatment;
3. patients perceptions of functional disability [Disabilities of the Arm, Shoulder, and Hand - (DASH) questionnaire];415 and
4. patient's perceptions of the 5 most difficult activities following surgery.
A retrospective, descriptive design was used to evaluate functioning before and after ASTYM following mastectomy.
Data was collected from charts on a convenience sample of 1 8 women diagnosed with breast cancer who had undergone either a single or bilateral mastectomy and had received ASTYM treatment as part of their rehabilitation. These women were referred for physical therapy to Central Baptist Hospital from August 2008 to August 2009.
An audit tool that included demographic data (age, date of surgery, type of surgery, number of physical therapy visits, and date of initial PT visit and discharge) and use of ASTYM or not, was designed by the investigator. This tool also recorded the functional ability of each individual including: active range of motion (AROM) and DASH score.
Active range of motion of shoulder flexion and abduction at initial evaluation and at discharge were retrieved from the charts. Initial physical therapy evaluation that included initial measurements of the range of motion occurred anywhere from 3 weeks to 3.75 years following the mastectomy surgery. These specific measurements were chosen based on the literature stating that axillary dissection, shoulder flexion, and abduction are most often limited following surgery.4·'619 Active range of motion was assessed in supine using a standard (12 in) plastic goniometer and measured in degrees. All measurements were made by the same clinician.
Functional limitation can affect any part of the upper quadrant following treatment for breast cancer, therefore the DASH questionnaire was chosen to assess functional limitations throughout the upper extremity. See Appendix 1 . The DASH is a 30-item, self- report questionnaire used to assess function and symptoms in upper extremity musculoskeletal conditions.4·" The DASH includes items relating to social functioning (eg, occupation and family), physical functioning (eg, home management, recreational activities, and ADLs/ self care) and psychological function (self image).415 Range of scores possible is 0 to 100% where 0 means no disability and 100% is severe disability.4·9
DASH items are scored from 1- 5 with 1 being no difficulty and 5 severe difficulty. Instructions for scoring the DASH are as follows: [total score = (sum of ? responses)/n -1) ? 25], ? is the number of completed responses.4·15 The DASH has demonstrated reliability and validity in previous studies on other populations with a test-retest intra-class coefficient (ICC) 0.92 to 0.96.4·20·21 The minimal detectable change in the DASH questionnaire is 10 points.2224 The DASH is an appropriate outcome measure for patients with breast cancer due to the many musculoskeletal issues that can occur in the upper extremity.4 In order to examine the appropriateness of the DASH for this population, each participant was also asked on initial evaluation, "What are the 5 active daily living activities that you have difficulty completing following your surgery?" and these responses were recorded. This information may help support the validity of questions addressed on the DASH and also respond to concerns regarding difficulties wearing a bra.
Following institutional review board approval, patient charts were identified and data retrieved.
The ASTYM protocol used in this pilot study was designed by a certified ASTYM physical therapist with extensive experience in treating patients with breast cancer. Certification in the ASTYM treatment includes successful completion of pre-reading and precourse written exams, 2 to 3 days of lab-intensive training, and successful completion of practical and written testing to ensure appropriate and effective treatment application. The same therapist performed the ASTYM treatment on all patients in the study. Treatment began with manual lymph drainage (MLD), a gentle massage, proximally to open up the appropriate lymph nodes and facilitate the flow of lymph fluid. This process was followed by the ASTYM treatment. The 3 resin composite hand held ASTYM instruments are applied to the scar tissue area individually with pressure adjusted for the patient's comfort. The 3 instruments are of varying size and design in order to produce appropriate forces to the tissue with minimal stress on the clinician's hands. Using the ASTYM instruments, gentle gliding strokes were made across the pectoral muscle to the axilla. More specific strokes were used to address the mastectomy incision adhesions and also the axillary scar, if present. Additional strokes were also made around the drain site, which is frequently a source of discomfort. The direction of treatment followed the lymph fluid flow to regional lymph nodes. Strokes were repeated 3 to 4 times with each appropriate ASTYM instrument depending on the individual's tolerance and quality of tissue. Treatment with the ASTYM instruments was followed by manual lymph drainage on the same area towards the axilla as appropriate to continue to encourage lymph flow and decrease some of the tenderness associated with the treatment. Active or active assistive range of motion exercises into flexion and abduction in supine, postural exercises of blade squeezes in sitting, and stretching and strengthening techniques were also included. Each patient was given ASTYM home instructions including stretching exercises and activity guidelines. See Appendix 2. Treatment was administered twice a week with at least 2 days between treatments to allow the scar tissue time to reabsorb. Patients were given flexion and abduction exercises to complete in supine initially but their ability to participate in further exercises was dependent on their pain and functional limitations.
It may seem contradictory to use the ASTYM instruments over areas with mild lymphedema since manual lymph drainage incorporates extremely light pressure to facilitate the lymphatic system. However, the ASTYM treatment applies instrument guided pressure (that may appear 'heavier than MLD') to the tissue as determined by patient tolerance and promotes scar tissue resorption allowing the tissue to be more flexible. Therapists certified in MLD techniques as well as ASTYM feel the ASTYM treatment frees up and 'uncorks' restrictions and adhesions that are inhibiting normal lymph drainage. In women being treated for breast cancer, the lymph system is often already compromised due to node resection. Coordinating treatments of ASTYM with manual lymph drainage sessions seems to optimize the effects of the MLD.
Descriptive and inferential statistics were used to analyze chart data. Means, standard deviations, percentages, and t tests were calculated on the variables of interest.
Twenty-four charts were reviewed, 1 8 met the inclusion criteria of mastectomy surgery and over 18 years old. Age range was 26 to 74 years old; mean age 53 (SD = 13). Sixty-one percent of patients in the study had a bilateral mastectomy and 39% had a single mastectomy. Dates of surgery ranged from 2005 to 2009. Treatment time following surgery ranged from 3 weeks to 3.75 years with a mean of 8.8 months (SD =12) between surgery and when PT began. The total number of physical therapy ASTYM treatments ranged from 3 to 15 visits with a mean of 8.5 visits (SD = 3.3). Treatment was completed over a period of 2 to 32 weeks with a mean of 9.27 (SD = 7.13) weeks.
Shoulder Active Range of Motion
There were significant differences in flexion range of motion before and after ASTYM (t = -5.012, ? < .000), abduction (t = -3.949, ? < .000), and DASH scores (t = 6.088, ? < .000). Mean improvement was as follows: flexion 13°, abduction 16°; and DASH scores 29 points. Table 1 describes findings related to measures of functioning.
Chart data collected at initial evaluation included the ability to wear a bra and 5 functional activities that cause difficulties for patients. The ability to wear a bra was also noted at discharge. Fifty-six percent of women in this study complained of inability to wear a bra at the initial evaluation due to sensitive skin. At discharge, all women (100%) were able to wear a bra.
The literature shows that impaired shoulder mobility is a problem following both mastectomy and radiation with flexion and abduction being the most serious problems.2·25"27 ASTYM was effective in this study in demonstrating improvement in flexion, abduction, and perception of physical disability among patients with breast cancer following mastectomy. ASTYM treatment can assist in enabling patients to attain optimal positioning for radiation treatment. In addition to completing the DASH at initial evaluation, all participants were asked to list the 5 activities that were the most difficult for them since surgery (Table 2). Many of these activities were already included in the DASH questionnaire, such as opening a jar, blow drying hair, and gardening. Reaching is an example of an activity that participants identified among their 5 most difficult activities that is also included in the DASH questionnaire as a functional activity, ie, being able to change a light bulb overhead or the ability to place an object on a shelf above their head. The 3 items that patients complained about that did not appear in the DASH items were turning over in bed (1/18 participants), walking a dog on a leash (2/18 participants), and wearing a bra (6/18 participants).
One area not adequately captured by the DASH is the hypersensitivity of the scar tissue following a mastectomy. While this sensitivity may impair function, it also has a significant effect on a woman's tolerance to being touched and to wearing a bra. ASTYM can be instrumental in addressing this sensitivity. The gliding strokes of the instruments allow a gentle touch sensation to be applied to the area, often before the patient can tolerate any manual treatment by the physical therapist. ASTYM empowers the patient to touch the mastectomy scar, a precursor to being able to wear a prosthesis and bra. From the initial evaluation, 56% of women were unable to wear a bra due to tender or hypersensitive scars whereas at discharge 100% of women reported the ability to wear a bra. This effect should be researched further since there is no evidence regarding clothing restriction in the literature. In this study, the notion that these women do not wear bras because of discomfort was supported. Anecdotal evidence suggests that being unable to wear a bra diminishes body image and thus quality of life.
Whenever there are multiple interventions in a study, it is difficult to assess how much each component affected the outcome. It would be inappropriate to use ASTYM independent of exercise in this population since exercises are a necessary component following the ASTYM treatment. Manual lymph drainage is not part of ASTYM but a very beneficial adjunct therapy that can improve lymph fluid movement to compliment ASTYM treatment. This initial investigation was performed to evaluate whether patients receiving ASTYM achieved documentable functional changes. Future studies need to compare patients that received ASTYM in addition to the standard treatment of MLD and exercise to a group that received the standard treatment but did not receive ASTYM.
The lack of control of the type of exercise is a limitation of this pilot study. Initially patients had flexion and abduction active or active-assisted range of motion modified by (1) the patient's tolerance and (2) time since surgery. IfAROM was not limited, they were progressed to strengthening exercises that were appropriate to their functional level. Varying functional levels of individual patients required individualized exercise programs. Controlling for degree and type of exercise is an important area to address in future studies.
The number of ASTYM treatment sessions varied depending on the individuals' progress ranging from 3 to 15 visits over a period of 2 to 32 weeks. Treatment sessions are spaced so that there are 2 days of 'healing' in between each treatment. Over time, treatment can be decreased to once per week or once per month and still demonstrate an effect. Future studies will need to address the number of sessions per week of treatment in a more controlled manner.
Another limitation of this study was that the same clinician completed the AROM measurements as well as performed the ASTYM treatment on the patients. Future studies should have the data assessed by blinded independent raters and could use multiple treatment sites and multiple clinicians. Development of a new outcome measurement tool that incorporates specific functional activities, which are difficult for patients with breast cancer, would be beneficial. This should include hypersensitivity of the tissue, which is not currently captured when using the DASH outcome measure.
Thickened scar tissue and soft tissue adhesions may develop following treatment for breast cancer. These difficulties are often left untreated, leaving many women with tight scars, poor flexibility, swelling, decreased range of motion, and pain. Results of this study show that early incorporation of the ASTYM treatment may help increase AROM of flexion and abduction that may help prevent functional limitations. ASTYM may also help reduce hypersensitivity of postoperative scar tissue through women subjectively reporting having less clothing restrictions posttreatment.
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Claire C. Davies, PT, DPT1
Dorothy Y. Brockopp, RN, PhD2
1 Physical Therapist, Central Baptist Hospital, Lexington, KY
2 Evidence-based Practice Consultant, Central Baptist Hospital, Lexington, KY