Physical Therapy Implications for Complications of Breast Cancer Treatment
Megan Schilter, SPT
Background & Purpose
The topic of my capstone was inspired by personal interest, following my mom’s diagnosis of breast cancer last year. Immersed in physical therapy coursework and a constant clinical mindset, my immediate thought upon hearing this news was, “What functional impairments might she encounter in light of this diagnosis?”
I began to independently research the physical and functional deficits that might accompany typical course of treatment in a breast cancer patient. In turn, this opened the door to many more subjects in the realm of breast cancer management: myocutaneous reconstruction, shoulder dysfunction, axillary web syndrome, and lymphedema. While there is a wealth of evidence supporting physical therapy intervention on reducing and managing these pathologies, it seemed that patients and even our fellow clinicians are not fully aware of PT’s beneficial role in this field. Discussion with practicing physical therapists and a Certified Lymphedema Therapist confirmed this notion that perhaps the general patient population and fellow medical professionals (i.e. oncologists, vascular surgeons, and plastic surgeons) are under-informed on physical therapy management for breast cancer.
Thus, this capstone presentation was developed to better inform physical therapists and other clinicians about the beneficial role of physical therapy in reducing breast-cancer related impairments. In addition, a patient education pamphlet was created to provide brief overview of these potential side-effects of treatment and to inform this patient population on physical therapy intervention during and after breast cancer treatment.
Relevant Coursework & Gathering Evidence
In a 52 yo F with breast cancer, is regular physical exercise beneficial in decreasing severity of the negative side-effects (i.e. fatigue, nausea, loss of appetite, chronic pain, and myalgia) of chemotherapy and radiation treatment, versus traditional symptom management (i.e. medication, rest, “usual care”)?
- The P.I.C.O. question above guided my review of the current and best evidence in Evidence Based Practice II. Current literature supports use of both aerobic and resisted exercise for reducing chemo-induced fatigue in the breast cancer patient population. However, quality of literature varied widely, with statistical results that ranged from very thorough to almost non-existent. Further discussion can be read in my Critically Appraised Topic, linked below.
- Our Advanced Orthopedics Elective presented the opportunity to further explore breast-cancer related impairments from a musculoskeletal standpoint. I assessed musculoskeletal complications stemming from breast cancer treatment and surgery, as well as the osteoporotic changes that accompany chemo and hormonal treatments of breast cancer.
- The aforementioned learning experiences in past coursework prompted my desire to gain more in-person clinical experience with this patient population. Specifically, I wanted to improve my understanding of lymphedema management, a common complication of lymph node biopsy or dissection. I spent several sessions throughout this past semester independently observing a Certified Lymphedema Therapist in an outpatient setting who practices Manual Lymphatic Drainage and its accompanying wrapping techniques.
Critically Appraised Topic Breast Cancer Schilter
Advanced Orthopedics Breast Cancer MSK Schilter
Products
I intended to educate physical therapists and other medical professionals on the benefits of physical therapy intervention for improving a variety of breast cancer-related symptoms. As such, I created a Powerpoint presentation and audiovisual presentation that could be more easily dispersed to other professionals through electronic communication.
PT Interventions for Breast Cancer and Lymphedema Management
I also hoped to inform current breast cancer patients about physical therapy management and created an educational brochure for this purpose. The paper pamphlet is meant to provide a “snapshot” of potential complications from treatment and to simultaneously inform the patient of PT’s role in managing those very complications.
Schilter_Patient Education Brochure
Evaluation & Self-Assessment
Evaluation of material was initially assessed independently after viewing the capstone course’s voicethread about patient health literacy. After personal review of my initial rough drafts, I realized that there was a wealth of evidence and citations in my material, but all that information had not been synthesized in an easily-understood many. In short, the educational material was much too dense. Both the presentation and patient brochure were tailored to be more easily understood and less “bogged down” with statistics. Furthermore, I found that language in the patient brochure was too clinical and perhaps even a bit dry. I edited the patient brochure to be understood and more easily-read by the general public, keeping in mind that the average American has a 4th-6th grade level of literacy.
I then had the privilege of presenting this material to a group of outpatient physical therapists, of which two specialize in women’s health. I utilized a feedback form, attached below, which asked for their response on various categories in the presentation. Discussion with my committee members and face-to-face conversation with the PTs to whom I presented resulted in further revisions to the presentation, including more streamlined information and more pictures illustrating concepts. Feedback from the presentation is summarized in the link below.
This led to production of my final product, which will be used once again at the Portsmouth Naval Medical Hospital as part of an educational in-service for clinicians during my final rotation.
Response Form and Feedback Summary
Acknowledgements
I would like to thank Rebecca Neal, PTA, CLT for her guidance throughout this process. Not only did she provide incredibly helpful feedback throughout development of the capstone, but she also provided me with an invaluable opportunity to observe and learn through first-hand experience about lymphedema management. Furthermore, her insights regarding physician referrals and patient education were very helpful in creating a product that other medical professionals could utilize.
I would also like to thank Molly Fostek, MSPT, CMTPT for prompting great discussion about this patient population from an outpatient clinical standpoint. Her clinical expertise and personal experience with this patient population guided my final product toward one that is more easily understood and highly relevant to any practicing physical therapist.
I must also thank Karen McCulloch, PT, PhD, NCS for her assistance in shaping this capstone. Kmac, you have been so helpful in providing feedback on my various ideas and the eventual final product. Thank you for your enthusiasm and patience in my development of this idea.
A special thank you to the physical therapists at Tidewater Physical Therapy in Chesapeake, VA, who provided their time and feedback during presentation of my materials. Not only was their insight very helpful, but their words of support and advice were greatly valued and taken to heart. Furthermore, they have been role models to me in these past seven months of working as an aide at their clinic. I am so grateful for all their assistance.
Finally, I am incredibly thankful for my friends and classmates who have been a source of fellowship, inspiration, and learning throughout these past three years. I cannot think of a better group of future clinicians.
5 Responses to “Physical Therapy Intervention for Complications of Breast Cancer Treatment”
Debbie Thorpe
Megan
Fantastic job on this capstone!! I was “educated” while viewing your ppt presentation. You work is very professional and supported by evidence. I also enjoyed reading your paper for Advanced Ortho. As clinicians, we all find a specialty area that “tugs at our hearts”. I know you Mom is so very proud of you and I am sure your intensive research into breast cancer treatment has provided her with valuable information as well:) Thank you for great work and all your contributions to the Division of PT at UNC. Another outstanding graduate is on the way!!
Best
Debbie
Megan Schilter
Thank you for the responses, everyone!
Elizabeth, to address your questions:
I found information regarding the great benefits of physical activity and lymphedema reduction at this source: http://www.oncolink.org/blogs/2010/12/physical-activity-lymphedema-pal-trial/ There is also a pubmed link here: https://www.ncbi.nlm.nih.gov/pubmed/19171204
It was a resource that one of my committee members actually recommended based on the great professional implications it had for demonstrating the importance of exercise in the lymphedema population.
As far as my learning experience goes, I highly enjoyed it and absolutely recommend observing and working with this population, if given the opportunity. I do not know if I’ll be going on to become a CLT, but I certainly have newfound appreciation for the benefits of lymphedema wrapping, not only in clinical outcomes but also in patients’ happiness and quality of life.
Hannah, thanks for the comment!
You are absolutely more than welcome to share this information with your sister-in-law! My intention with the project was to educate clinicians and patients alike, and I am thrilled to know it might help her too 🙂
Thank you for bringing up the outcome measures–I agree that there are less outcome measures specific to breast cancer quality of life. I actually do address the FACT-B in my presentation as a good measure for QoL assessment, so I’m glad you also found it and recognize the importance of assessing quality of life in addition to solely physical outcomes.
Hi, Kmac-
Thanks very much for the response and kind words. I’ve really enjoyed this capstone process and can’t wait to present my project again during this upcoming rotation!
KMac
Nice job Megan – I’m glad that you “followed this trail” where it took you and were flexible in figuring how to modify it for a receptive audience. Sometimes these things happen – hope that your Mom’s treatment is wrapped up and she is doing well. There are a lot of “us” out there who are finding our way after this diagnosis. Your efforts to educate PTs on what to expect and where to refer helps a better match of therapy to need. Congrats!!!
kmac
Hannah Leshin
Megan,
Nice work. As you and I have discussed, my future sister-in-law underwent a prophylactic double mastectomy due to her positive BRCA gene test. Unfortunately, her tissue from this surgery was cancerous, resulting in a lymphadenectomy and chemotherapy. In speaking with her, I have learned that there is very little literature or patient education about physical therapy options. After surgery, she was given a sheet of arm exercises from the MD, with no PT consult. Given this experience, I agree with you that there is a definite need for patient education materials, in addition to clinician education. Would you mind if I share your patient education pamphlet with my future sister-in-law? I think she may benefit from your information about exercises after surgery.
In your powerpoint, I appreciated your inclusion of musculoskeletal complications associated with different types of reconstructive surgery. While we may associate this patient population with lymphedema management, it is critical to assess secondary MSK concerns and protect the patients from injury. I was also happy to see that you included outcome measures to utilize with this patient population. Although you do include some tools that are specific to breast cancer patients, neither of these assessments included the body structure/function category of the ICF model. For example, I downloaded the FACT-B tool from the website FACIT.org (http://www.facit.org/facitorg/questionnaires). This measure appears more focused on activity/participation/quality of life. Despite the strong validity of the DASH for this patient population, I would be curious to know if there are any breast cancer-specific outcome measures for body structure and function. Do you think there is a need for this type of outcome measure?
Congratulations on an informative and useful capstone project! I am sure that your mom is proud of you for pursuing this topic for your capstone.
Best,
Hannah
Elizabeth Lynch
Megan,
I absolutely loved reviewing your capstone project. You have a quality about your writing and communication that is so inviting, and this skill has led to the development of fantastic materials that will truly be useful for patients and clinicians alike. Specifically, I think that your patient brochure is exceptionally well done. It offers a great balance of text and images that immediately draws readers to the most important points of physical therapy care in relation to breast cancer. I remember from reviewing the health literacy resources that it is permissible to eliminate references from patient brochures for the sake of space and formatting. Would you mind sharing with me some of the articles you used to create this document? I would specifically love to have access to the research showing that functional strength training reduces the likelihood of developing lymphedema symptoms after breast cancer by 70%. Any of the best resources you found related to manual therapy and exercise would be appreciated as well. Lastly, I think it was a great idea to participate in observation experiences with a Certified Lymphedema Therapist in order to enhance your knowledge of this topic. My CI for my first clinical rotation was a CLT, and I learned so much from her and really developed an appreciation for lymphedema therapy. However, she worked almost solely with patients who have lower extremity lymphedema, so I did not have the opportunity to see any patients who presented with this condition secondary to breast cancer. Do you have any specific words of wisdom or a favorite story to share from this learning experience? Thanks again for all your hard work to create a wonderful final product. I know your mom must be really proud!
Congratulations!
Elizabeth