Impact of Physical Therapy in Patients Undergoing Modified Radical Mastectomy: A Case Report

This work was carried out in collaboration among all authors. Authors SL, SD and TB made best contribution for the concept, assessment and evaluation, data acquisition and analysis and interpretation of the data. All authors read and approved the final manuscript. Therapeutic Intervention and Outcomes: Physical therapy intervention involves a variety of range of motion exercises, strengthening exercises, resistance conditioning, breathing exercises, lymphoedema treatment and scar management. Conclusion: This intensive outpatient program is a successful way to enhance the mobility of the shoulder and ROM during the initial 6-week treatment cycle after surgery.


INTRODUCTION
The most commonly reported cancer for women is breast cancer [1]. A dynamic multi-step mechanism involving the spread of cancer cells from the breast to other parts of the body is metastatic breast cancer [2]. In the world, 1.38 million women with breast cancer are diagnosed every year [3]. It is the leading cause of cancer mortality in most countries [1]. Breast Cancer is responsible for 2.09 million cases and 6,27,000 deaths worldwide, as per WHO [4]. In India, women have the most common cancer, accounting for 14 per cent of all female cancers [4]. Numerous risk factors are present, such as ethnicity, aging, hormones, family medical history, genetic abnormalities, and unhygienic lifestyles [5]. Early menarche is a significant risk factor for breast cancer [6]. About 5-10 percent of all cases of breast cancer are Heritage [7]. The need for the hour is therefore the comprehension of breast cancer, breast sensitivity and self-breast testing [8]. The majority of people diagnosed with breast cancer had breast and axillary surgery [9]. A modified radical mastectomy (MRM) is an operation that extracts the whole breast by surgery [10]. 79% of those exposed to MRM and 83% treated with lumpectomy have one or more late signs, 1-4 years after surgery [11]. Muscles, nerves and lymphatic channels throughout the shoulder and upper body can be impaired by such procedures [9]. This may lead to complications with the Musculo skeleton such as reduced mobility capacity, fatigue, constant discomfort, distorted stimuli, and lymphoedema [9]. Late signs include discomfort in the scar and/or surgical area, pain in the neck, and reduced mobility in the arm or shoulder [11]. Secondary lymphedema is the most significant chronic complication after axillary lymph node dissection [12]. Disfigurement, physical pain, and functional disability may be caused (12). Anxiety, depression, and emotional disturbance are more common in patients with or without it (12). Side effects of cancer treatment may be alleviated by exercise interventions [9]. Several systematic literature reviews suggest they may be clinically efficient [9].The purpose of this study is therefore to gain insight into the effectiveness of physiotherapy with ALND (Axillary Lymph Node Dissection) after breast cancer [13]. Key measurements involved joint mobility, movement of the shoulder and arm, and pain, with quality of life also being assessed [14].

CASE DESCRIPTION
Patient is a 60-year-old widow with a right-hand dominance; she was evidently well until she noticed a lump in her right breast that was painful on touch. With this complaint, she met a nearby doctor who had referred her for further care because she had not obtained adequate relief. Then Patient came to multispecialty hospital on 27 October 2020 with the similar complaint. There, after following a few investigations, Infiltrative Ductal Carcinoma of the Right Breast has been diagnosed. The diagnosed lump was 4x4cm present in the Right Upper Quadrant, insidious at onset and progressive in nature with no aggravating or relieving causes. As soon as the diagnosis was made, the patient attended 4 chemo treatments. Now the woman has pain in the lump for the last 2 months, along with Tingling Numbness in her right hand for 4 months. Patient presents a history of early menarche at the age of 11 years along with dysmenorrhoea in puberty and a history of miscarriage (G2P1L1A1).On 25 January 2021, Patient was admitted as advised for MRM (Modified Radical Mastectomy) of Right Breast. At present, the patient complains about Tingling Numbness and restricted movements of the shoulder along with the swelling of Right-hand Post Surgery. While conducting shoulder motions, the character of the pain was described as cramping, dull aching along with tingling numbness across the right hand (Pain on Visual Analogue Scale: 7/10).On examination and palpation, the non-tender lymph oedema pitting form was present in the right hand, which limited the movement of the shoulder, the elliptical incision mark and the excisional biopsy scar were present in the right breast region, which created a restriction in her breathing pattern.    Volumetric Estimations: The volume of the arm was determined by the movement of water. The arm was placed on a water-filled tank and the flowing water was measured. Both arms were measured and the discrepancy was determined between the flowing water of the two arms. The sum of the swollen limb was 10% more than that of the unaffected limb.

Measure of the Circumference:
The oedema of the arm was determined by circumference calculation. A standard one-inch, movable, fiberglass tape measure was used to measure the diameter. The measurements were taken from 10, 15, 20 cm above and below the olecranon process, to the wrist and to the metacarpophalangeal joints. The circumference of the swelling arm was higher than that of the unaffected arm.

Chest Expansion:
At repetitions, two to three times a day.  Wall Climbing-Five to ten repetitions, two to three times a day.  Side wall stretch  Incremental resistance training was introduced for the shoulder and elbow with 1⁄2 kg to 1 kg of weight cuffs, 10 repetitions 2 times a day and progress in resistance as well as repetitions. Static stretching of the shoulder flexors and successful range of motion is performed. Functional taskoriented exercise has begun to reduce the complexity of everyday tasks.  Scar Massage-Once healing of the scar was done massage was started to prevent Contractures and tightness. Ringing, Rolling, and Kneading was done. Massage once a day for 5-10 minutes.

OUTCOME MEASURES
A) DASH: Arm, Shoulder and Hand Disabilities (DASH) checklist is a 30-item questionnaire that measures the patient's capacity to perform certain upper extremity tasks. This checklist is a self-report questionnaire that helps patients to rate everyday life challenges and intervention on a 5-point Likert scale.
Prescore-moderate difficulty Post score-mild difficulty B) FIM: Functional Independence Measure (FIM) is an 18-item measuring instrument that investigates the physical, psychological and social role of a person.
Pre score-2 maximal assistance Post score-7 complete independence

DISCUSSION
Many studies have suggested the complication post-MRM where physiotherapy can be helpful in improving shoulder ROM, post-operative pain, and chest expansion [14]. There is statistically significant improvement in ROM, chest expansion, and reduction in pain with physiotherapy postmastectomy [14]. There is a reduction in chest expansion because of incisional pain and decrease shoulder girdle movement [14]. In modified radical mastectomy, as there was preservation of pectoral muscle, they are muscle of respiration [14]. The pain reduces gradually as well as the tightness of pectoral muscles reduces with exercises which help in improving chest expansion [14]. There is a significant difference in pre-and post-shoulder ROM value [14]. Impaired ROM of shoulder joint is due to incisional pain that causes the muscle guarding and tenderness of shoulder joint [14]. Fibrosis of soft tissues in the axillary region in which adherence between muscles, subcutaneous [14]. The attachment between the muscles, the subcutaneous tissue, and the skin in the axillary and pectoral regions mechanically prevents the rotation of the shoulder, and the adjuvant chemotherapy and radiation therapy contribute to the firm fibrous link between the structures [14]. The fascia overlying the main pectoral muscle is separated as part of the breast ablation [14]. The subcutaneous tissue on the skin flaps expands to the raw muscle and adheres closely to prevent the rotation of the shoulder [14]. In addition, there is a reduction in the use of the hand and arm for everyday experiments [14].   The use of physiotherapy during the first postoperative week is necessary in order to ensure patients that they are able to use the arm [15]. Immediate postoperative sequelae, though, hinders the entire spectrum of workouts and, throughout the first postoperative months, the adverse effects of radiation therapy and axillary strings reduce recovery [15]. They accept movement limits and attempt to compensate by using the other arm or by modifying work procedures [15]. The utilization of supplementary physiotherapy before or immediately after radiotherapy allows patients to take full-scale use of the shoulder [15]. Extension of scar tissue and muscles decreases the firm connection of the skin to the underlying tissue and reduces muscle shortening [15]. Therefore, the mobility of the shoulder is enhanced [15]. Few of the related studies on carcinoma breast [16] and associated physiotherapy interventions [17][18][19] were reviewed. Beneficial effects of Ghrelin in cancer cachexia were reflected through a series of studies [20][21][22].
Strengths: Strength, in this case was that the patient had a strong family support and she performed all the given interventions perfectly in the given amount of time [23][24][25][26].

CONCLUSION
The case study concluded that there is a significant effect of the given therapeutic intervention on the muscle strength, shoulder range of motion, reducing pain, improving chest expansion and ADLs of the patient after 8 weeks of intensive physiotherapeutic intervention.

CONSENT AND ETHICAL APPROVAL
As per international standard or university standard guideline patients consent and ethical approval has been collected and preserved by the authors.