Fernandez-Lao, C., Cantarero-Villanueva, I., Fernandez-de-Las-Penas, C., del Moral-Avila, R., Castro-Sanchez, A.M., & Arroyo-Morales, M. (2012). Effectiveness of a multidimensional physical therapy program on pain, pressure hypersensitivity, and trigger points in breast cancer survivors: A randomized controlled clinical trial. Clinical Journal of Pain, 28, 113–121.

To evaluate the effects of an eight-week multidimensional physical therapy program, including strengthening exercises and recovery massage, on neck and shoulder pain, pressure hypersensitivity, and the presence of active trigger points (TrPs) in breast cancer survivors

Forty-four breast cancer survivors were randomly assigned to one of two groups: the CUIDATE group, which received a multidimensional physical therapy program, or the control group, which received usual care treatment for breast cancer. The CUIDATE program consisted of 24 hours of individual physical training (aerobic, mobility, stretching, and strengthening exercises) and 12 hours of physical therapy recovery interventions (stretching, massage) three times per week for 90 minutes. The program was supervised by two physical therapists with clinical experience in the management of patients with different cancer conditions. Each group had approximately six to eight patients. Outcomes were assessed at baseline and after the eight-week program by a blinded assessor. Control group patients followed usual care recommended by the oncologist in relation to a healthy lifestyle. They received a printable dossier from the oncologist that outlined recommendations related to nutrition, lifestyle behaviors, and exercise.

• The study reported on 44 breast cancer survivors.
• Mean patient age was 49 years in the CUIDATE group and 47 years in the control group (p = 0.482).
• The sample was 100% female.
• Patients were eligible if they had a diagnosis of breast cancer (stage I–IIIA); had received a simple mastectomy or quadrantectomy, including those with breast reconstruction at the time of initial surgery or subsequent breast reconstruction; were between the ages of 25 and 65; had completed coadjuvant treatment except for hormone therapy; did not have active cancer; and had neck and shoulder pain that began after their breast cancer surgery.
• All patients underwent axillary lymph node dissection during their surgery. The mean time from breast surgery was 10 months (SD = 2 months).
• Patients were excluded if they were receiving chemotherapy or radiotherapy at the time of the study, suffered from chronic or orthopedic diseases that would not allow them to participate in physical therapy, had uncontrolled hypertension with diastolic blood pressures greater than 95 mmHg, had lymphedema, had recurrent cancer, or had previous diagnosis of fibromyalgia syndrome.

• Breast oncology unit of the Virgen de las Nieves Hospital
• Outpatient setting
• Granada, Spain

• Patients were undergoing the survivorship phase of care.
• The study has clinical applicability for late effects and survivorship.

The study was a randomized, controlled, clinical trial.

• Visual analog scale (0–100) to measure neck and shoulder pain: pressure pain thresholds over the C5–C6 zygaphophyseal joints, deltoid muscles, and second metacarpal and tibialis anterior muscles, and the presence of active TrPs in shoulder muscles
• Minnesota Leisure Time Physical Activity Questionnaire

The CUIDATE group demonstrated an estimated improvement for neck pain of –56 mm [95% confidence interval (CI), –71 –40, p < 0.001; effect size 2.72, 1.94–3.44] and for shoulder/axillary pain of –56 mm [95% CI, –74 –38, p < 0.001; effect size 2.45, 1.66–3.23]. Improvements also were noted for pressure pain thresholds levels: Patients within the CUIDATE program showed a greater reduction of active muscle TrPs compared with the control group (p < 0.01).

An eight-week supervised multidimensional program including strengthening and endurance exercises, relaxation, and massage as major components was effective for improving neck and shoulder pain and reducing widespread pressure hyperalgesia in breast cancer survivors compared with usual care treatment.

• The study had a small sample size, with less than 100 participants.
• Investigators only assessed the short-term effects of the CUIDATE program.
• Program adherence was not evaluated.
• Control group patients were also allowed to freely exercise, but no information on their use of exercise was provided.
• Physical therapy sessions were done in small groups, but no appropriate attentional control was used.

Almost all cancer survivors experience one or more cancer-related symptoms that impact their quality of life. Among these symptoms, localized pain is the most frequent impairment after breast cancer treatment (20%–65%). There is evidence that breast cancer survivors may present with changes in nociceptive pain from damage to the small nerve fibers during surgery.

There is also evidence showing that physical therapy, including exercise and massage interventions, may be beneficial for improving physical function in breast cancer survivors. Nurses can provide patient education regarding the use of a multidimensional physical therapy program to activate exercise-induced hypoalgesia in breast cancer survivors. Physical therapy interventions may be clinically useful in minimizing pain and persistent hypersensitivity after medical treatment in this cancer population.