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Freezing The Pain

Written by  Tina Joyce

Improving patients’ quality of life, increasing their range of motion, and striving to help their days be pain-free following a surgical procedure are goals of all healthcare professionals.

Receiving proactive care in the days and weeks following a lumpectomy or mastectomy may greatly reduce both acute and chronic pain as well as minimize a patient’s long-term limitations.

Diane Short, a patient who underwent a successful lumpectomy 18 months ago, found herself experiencing symptoms of adhesive capsulitis, or “frozen shoulder.” However, she had no previous knowledge that this condition existed and was treatable. This complication is not uncommon, but it can be misdiagnosed or ignored if a patient is not persistent with his or her post-surgery care provider. Often, a patient may feel that the pain or discomfort is normal following a lumpectomy and wait to disclose the severity or details of the symptoms, resulting in unneeded suffering for months or years.

Diane explains, “No one ever called my symptoms ‘frozen shoulder,’ but my pectoral muscle was very sore, and I was unable to raise or straighten my right arm above my head. When I tried to raise it, I would have a sharp pain in my shoulder. I had a hard time reaching up in the cabinets or hanging or getting down items in a closet. I would shift my body and use my other arm or get a stepstool to get to what I needed. It seemed like I had no strength to lift or carry items. I finally asked my surgeon about physical therapy options a few months later. He set me up with a physical therapist.”

It is important for patients to continually ask their doctors clarifying questions and communicate with them both before and after a procedure. Patients may have to be their own advocates and ask for options to alleviate their pain or improve their mobility.

Adhesive capsulitis is a pattern of restriction of the shoulder joint due to pain caused by an injury or surgery.1 A patient who experiences this, like Diane, will refrain from moving their arm and shoulder in order to avoid additional pain and discomfort. The joint then becomes “frozen” or stiff from lack of use and inflammation.

It is fairly common for patients to experience pain, joint restriction, and functional limitations after surgeries related to breast cancer, although it is also not uncommon after a stroke, rotator cuff injury, or other arm injuries. Muscle weakness, swelling, numbness, and a feeling of tingling may also persist. Typically, these symptoms are more prevalent after a mastectomy than a lumpectomy because more tissue is removed. Also, the complications may be more intense depending on whether or not any lymph nodes are removed.

“Many women, however, don't develop a true adhesive capsulitis, but instead have limited shoulder motion that comes from tightness from the scar tissue in the chest wall and shoulder area and sometimes from the swelling, or lymphedema, that can occur after mastectomy. Treatment of true adhesive capsulitis involves stretching the muscles of the shoulder as well as joint mobilization, a type of Manual Therapy. Shoulder stiffness after mastectomy might indeed include joint mobilization, but will also include mobilization of the scar tissue to make it more flexible and amenable to stretching of the shoulder joint muscles, management of any lymphedema (swelling in the arm after mastectomy) and, ultimately, strengthening exercises,” explains Audrey Ward, PT, the Clinic Manager of Professional Therapies, Inc.’s Daleville location.

 

When a patient suffers from “frozen shoulder,” the shoulder capsule thickens and becomes tight. Stiff bands of tissue called adhesions develop. In many cases, there is less synovial fluid in the joint.

The primary symptom of this condition is being unable to move your shoulder, either on your own or with the help of someone else. It develops in three stages:

  1. Freezing: In the "freezing" stage, you slowly experience more and more pain. As the pain worsens, your shoulder loses range of motion. The freezing stage typically lasts from six weeks to nine months.
  2. Frozen: The condition’s painful symptoms may actually improve during this stage, but the stiffness remains. During the four to six months of the "frozen" stage, performing normal daily activities may become very difficult.
  3. Thawing: Shoulder motion slowly improves during the "thawing" stage. A complete return to normal or close to normal strength and motion typically takes anywhere from six months to two years.

Prompt, proactive care can greatly reduce the symptoms of “frozen shoulder.” Typically, a patient can begin physical therapy as early as two days post-surgery. According to Audrey Ward, PT, the Clinic Manager at the Professional Therapies, Inc.’s Daleville office, “Studies have shown that women who participate in physical therapy starting the second day after mastectomy have better shoulder joint mobility and function a year after surgery than those who don't participate in physical therapy.”

Therapists agree that early physical therapy significantly improves the patient’s joint mobility and overall recovery time and ultimately decreases the cost of healthcare associated with post-operative limitations. As the American Cancer Society explains, “It’s important to complete exercises [after breast cancer surgery] to get the arm and shoulder moving again. Exercises help to decrease side effects of surgery and help patients get back to usual activities.”

A thorough evaluation needs to be completed at a physical therapist’s office in order to discuss the patient’s medical history and assess their posture, range of motion, strength, balance, and functional level; this will allow the physical therapist to determine the best plan of care. During the following appointments, the focus shifts to teaching exercises and performing hands-on treatments targeting the joint as well as strength deficits that were found during the initial evaluation.

Therapists also integrate functional training to develop the use of the painful area in order to improve the patient’s daily living or working activities. Additionally, manual therapy improves soft tissue, scar or joint restriction, while some therapists use modalities such as electrical stimulation to increase circulation and decrease pain.

A physical therapist can teach patients range-of-motion exercises to assist them in recovering their mobility. However, the degree to which patients are willing and able to commit to consistently performing the exercises, both in the office and at home, will affect their results.

Diane reveals that she is doing much better today, 18 months after she had the procedure and 10 months after she began physical therapy, but she must continue to perform the exercises she learned. “If I do too much,” she explains, “I will feel [pain] in the shoulder, especially if I haven't kept up with what I should be doing. The pectoral muscle is still sore, and it might be a while before that pain is no longer there.”

Ward expands, “Patients should also listen to their bodies so that they don't overdo on the stretches and exercises. It's crucial for them to communicate with the physical therapist about how they are tolerating treatment.”

“Continue to inform your doctors how you are feeling or ask if there is a treatment that would help with any pain,” Diane advocates. “It's important that you continue to ask questions until you are satisfied.”

“Patients can learn about physical therapy treatments by calling a local PT office, talking to their physician, or getting in touch with the American Physical Therapy Association,” shares Ward. “Another great source of information is other women who have undergone breast cancer surgeries or breast cancer support groups in the area.”

Physical therapy offers patients who are recovering from breast cancer surgeries an option to proactively enhance their speed and quality of recovery. Patients and providers who are looking to eliminate or minimize post-surgery “frozen shoulder” symptoms may begin treatment shortly after surgery, once a proper evaluation can be completed.

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Sources:
1. The Mayo Clinic. http://www.mayoclinic.org
2. Frozen Shoulder. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=a00071
3. American Cancer Society. http://www.cancer.org
4. Professional Therapies, Inc. Daleville Office. http://www.professionaltherapies.org

 

SWVA