© Borgis - Postępy Nauk Medycznych 7/2015, s. 509-514
*Aleksandra Kołodziejczyk1, Wojciech Zegarski1, 2, Maciej Kopeć2
Ocena postawy ciała i sprawności kończyny górnej u kobiet po zabiegu chirurgicznym w obrębie gruczołu piersiowego
Evaluation of body posture and upper limb efficiency in women after surgery within the mammary gland
1Department of Surgical Oncology, prof. Franciszek Łukaszczyk Oncology Center, Bydgoszcz
Head of Department: prof. Wojciech Zegarski, MD, PhD
2Ludwig Rydygier Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń
Head of Collegium: prof. Jan Styczyński, MD, PhD
Streszczenie
Wstęp. Rak piersi jest najczęściej diagnozowanym nowotworem złośliwym u polskich kobiet. Stanowi tym samym około 23% ogółu zachorowań na nowotwory wśród populacji żeńskiej w Polsce. Według Krajowego Rejestru Nowotworów liczba zachorowań na złośliwe nowotwory gruczołu piersiowego przekracza wartość 16 500 przypadków na rok.
Cel pracy. Celem przeprowadzonych badań była ocena postawy ciała oraz sprawności kończyny górnej strony operowanej po wykonanym zabiegu w obrębie gruczołu piersiowego z uwzględnieniem różnych metod leczenia.
Materiał i metody. W badaniach uczestniczyło 30 kobiet po chirurgicznej interwencji na gruczole piersiowym. Do ewaluacji zakresu ruchu w stawach kończyny górnej, siły mięśniowej kończyny górnej oraz wad postawy wynikających z operacji posłużono się testem Kułakowskiego i Miki, a także oceną według Kasperczyka.
Wyniki. Nie wykazano istotnych statystycznie zależności pomiędzy rodzajem stosowanych metod leczenia a postawą ciała i sprawnością górnej kończyny pacjentek. Zanotowano jednak pewną tendencję, z której wynika, że sprawność kończyny górnej po stronie operowanej (oceniana na podstawie testu Kułakowskiego i Miki) była najwyższa u pacjentek leczonych za pomocą tumorektomii, najniższa zaś u badanych leczonych metodą Pateya. Jednocześnie, potwierdzono istotną statystycznie zależność pomiędzy wiekiem pacjentek a siłą mięśniową oraz obrzękiem w obrębie górnej kończyny po wykonanym zabiegu.
Wnioski. Nie istnieją istotne statystycznie różnice pomiędzy wpływem poszczególnych metod leczenia a postawą ciała oraz sprawnością kończyny górnej po zabiegu w obrębie gruczołu piersiowego. Pacjentki starsze, u których wykonano zabieg, odznaczają się istotnie większą siłą mięśniową, ale jednocześnie większym obrzękiem w obrębie kończyny górnej, niż pacjentki młodsze.
Summary
Introduction. Breast cancer is the most commonly diagnosed cancer in Polish women. Therefore constitutes approximately 23% of all cancers of the female population in Poland. According to the National Cancer Registry incidence of malignant mammary gland cancer exceeds 16500 cases per year.
Aim. The aim of this study was to evaluate body posture and efficiency of upper limb of operated side after the surgery within the mammary gland, taking into account the different treatments.
Material and methods. In the study involved 30 women after surgical intervention on the mammary gland. To evaluate the range of motion in the joints of the upper limb, the upper limb muscle strength and posture problems resulting from operation, was used Kułakowski and Mika test, and Kasperczyk evaluation.
Results. There was no statistically significant evidence for relation between the type of methods of treatment and the body posture and the efficiency upper limbs of patients. However, some trends were noted, which shows that the efficiency of the upper limb on the operated side (assessed on the basis of the Kułakowski and Mika test) was highest in patients treated with tumorectomy, while the lowest – in patients treated with Patey method. At the same time, there was confirmed a statistically significant relation between age of patients, muscle strength and edema in the upper limbs after the surgery.
Conclusions. There are not significant statistically differences between the effects of different treatments and the body posture and the efficiency of the upper limb after surgery within the mammary gland. Older patients, who underwent surgery characterized by significantly higher muscle strength, but also a bigger edema of the upper limb than younger patients.
Introduction
Breast cancer is the most commonly diagnosed cancer in Polish women. Therefore constitutes approximately 23% of all cancers of the female population in Poland (1). According to the National Cancer Registry incidence of malignant mammary gland cancer exceeds 16 500 cases per year (1). Moreover, in recent years there has been an increase in morbidity, which relates especially breast cancers occur in postmenopausal women. This upward trend resulting mainly due to changes in lifestyle of Polish women (especially those aspects that directly affect the hormonal metabolism), and also from an increase in exposure to carcinogens (1).
Nowadays, the most commonly performed surgical procedures aimed at treatment of breast cancer include: surgical removal of the tumor with a margin of surrounding tissues (tumorectomy), surgical removal of breast quadrant within which the tumor is located, and axillary lymph nodes (quadrantectomy), surgical removal of whole breast (mastectomy), sentinel lymph node excision and removal of the entire axillary lymphatic system (lymph node dissection) (1-3).
Each type of surgery performed within the mammary gland may result in disturbances and irregularities within the patient’s body posture occurring after the operation, as well as a reduction in the efficiency of the upper limb on the operated side (2-6). At the same time, the assessment of the efficiency of the upper limb and body posture after the breast surgery allows the prediction and control of the appropriate course of improvement in patient (2, 5, 6).
Aim
The aim of this study was estimation of the parameters for the evaluation of body posture and efficiency of upper limb of surgery women. The study included mainly the impact of the various methods of surgical treatment of breast cancer to the test parameters associated with the efficiency of patients.
Material and methods
The test group
Test group consisted of 30 women who had undergone surgical treatment of breast cancer. The study did not include a control group, but only patients who had undergone mentioned surgery. The average age of the women was about 50 years old, the youngest patient was 18 years old and the oldest 77 years. Therefore, the median age was 54.5 years. In female patients, the majority (63.3%) had operated the right breast. The remaining 36.7% of the women the cancerous process took the left breast, and therefore, in their case, the procedure was carried out on this side. To the patients included in the study used the following surgical methods of treatment: removal of the sentinel lymph node, lymph node dissection, quadrantectomy, tumorectomy, modified radical mastectomy – Patey method (removal of the entire breast along with the pectoralis major muscle fascia, axilla lymph nodes and smaller pectoral muscle) and removal of cancerous changes by harpoon method (removal of the lesion after designation it with a hook – harpoon, under the control of mammography). When using the latter method also used the lymphoscintigraphy treatment (introduction of the radioactive tracer to determine the location of any tumor lesions in the lymph nodes).
The most commonly used surgical procedure was quadrantectomy, which was performed in 36.7% of the patients. A slightly smaller group of their patients (26.7%) were underwent mastectomy by Patey method. Other women underwent sentinel lymph node removal (10% of patients), treatment with harpoon and lymphoscintigraphy method (10%), lymph node dissection (10%) and tumorectomy (6.7%).
Area and organization of the study
The study was conducted in the prof. Franciszek Łukaszczyk Oncology Center in Bydgoszcz, in the Department of Surgical Oncology, the Section of Breast Diseases. Conducting the tests was approved by the Head of the Department and the Director of the Center of Oncology. The participants of the study – the patients – were informed about the purpose of the study, which they joined voluntarily. They were also assured that the study is anonymous.
To assess body posture and upper limb efficiency of the patients who underwent the surgery within the mammary gland used research tools discussed below.
The method of scoring by Kasperczyk
According to this method, in the patients made direct observation of selected elements of body construction and posture (7). Subject of the study was the following elements: in the sagittal plane: head, shoulders, scapulas, chest, abdomen, back; in the coronal plane (with front setting): shoulders, chest, knees; in the coronal plane (with back setting): shoulders, scapulas, spine (7). For each element attributed the appropriate number of points. The point scale as follows: 0 points – the correct system of elements assessed, 1 point – slight deviation from normal, 2 to 3 points – a significant deviation from normal, 4 to 5 points – the distortion of the high-grade, structural changes (7). The maximum number of points that could be given the patient was 28. This would be the worst possible to assess the subject’s body posture – providing a very significant distortion of figure. According to the method of posture scoring by Kasperczyk – the lower the value reached by the patient, the more correct is her posture, and vice versa – poor posture resulting in higher values of the test (7).
Kułakowski and Mika test
As pointed out by Kułakowski and Mika test in the evaluation of upper limb efficiency are included three basic categories: range of motion in the shoulder joint in different planes and directions, muscle strength (squeezing the hand) and the severity of possible edema (8).
By measuring the range of active motion in the shoulder joint were taken into account the range of three movements, which have the greatest limitation after the breast surgery, namely: abduction, external rotation, and straighten in the horizontal plane. Range of motion was measured by goniometer, and then set the percentage reduction compared to normal, assuming that they should be: 180° – for the abduction, 90° – for the external rotation 120° – for the straighten in the horizontal plane (8).
Upper limb muscle strength on the operated side measured with manually dynamometer (squeezing the hand in a sitting position). This parameter was measured in both upper limbs, and then defined the percentage reduction in muscle strength in the limb of operated side compared to the values obtained from the healthy limb study (8).
In order to assess of patients’ lymphedema, were evaluated two factors: the circumference of the upper limb on the operated side and the consistency of the edema. Measure made using a centimeter tape in three locations: 10 cm above the lateral epicondyle of the humerus, 10 cm below the lateral epicondyle of the humerus, and in the mid-metacarpal excluding the thumb. Then calculated the difference between the values obtained after the measurement of the healthy limb and the limb circuit board on the operated side. The consistency of the lymphatic edema was evaluated by the method proposed by Singh et al. (9). According to this method, granted 5 points in the case of a patient with a soft consistency of edema, and 10 points for the diagnosis of a hard edema. Score was then included to the overall summary, which allowed to assess in numerical scale the health status of the patient’s upper limb (9).
In statistical analysis of the results used parametric and non-parametric tests. Selection of tests for this group was dependent on compliance with the relevant conditions of normality and homogeneity of distributions, which was verified by the Shapiro-Wilk test and Levenen test. The level of statistical significance was set at p < 0.05.
Results
The posture of the patients
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Piśmiennictwo
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2. Bąk M: Hand grip strength rating of women after mastectomy participating in motion rehabilitation. Medycyna Sportowa 2010; 26: 25-32.
3. Haddad CAS, Saad M, Perez MDCJ, Miranda Júnior F: Assessment of posture and joint movements of the upper limbs of patients after mastectomy and lymphadenectomy. Einstein 2013; 11(4): 426-434.
4. Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furnival CM: Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema. Breast cancer research and treatment 2002; 75(1): 51-64.
5. Bąk M: Limitations in shoulder joint mobility as a result of mastectomy. Annales Universitatis Mariae Curie-Skłodowska 2005; 21: 88-92.
6. Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furnival CM: Shoulder movement after breast cancer surgery: results of a randomised controlled study of postoperative physiotherapy. Breast cancer research and treatment 2002; 75(1): 35-50.
7. Kasperczyk T: Body posture defects – diagnosis and treatment. IV ed., Kasper, Kraków 2001.
8. Kułakowski A, Mika K: Usefulness of the objective determining the efficiency of the upper limb for the evaluation of the rehabilitation results after mastectomy. Cancers 1983; 33(4): 341-346.
9. Singh C, De Vera M, Campbell KL: The Effect of Prospective Monitoring and Early Physiotherapy Intervention on Arm Morbidity Following Surgery for Breast Cancer: A Pilot Study. Physiotherapy Canada 2013; 65(2): 183-191.
10. Bąk M, Cieśla S: Evaluation of woman’s postural disorders after radical amputation with simultaneous breast reconstruction. Physiotherapy 2009; 17(1): 30-37.
11. Malicka I, Barczyk K: The posture of women after breast cancer treatment. Orthopaedics Traumatology Rehabilitation 2010; 12(4): 353-361.
12. Bąk M: The Woman’s body posture in the sagittal plane after mastectomy actively participating in rehabilitation. Physiotherapy 2008; 16(4): 35-43.
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