Flor Thesis

8/6/2019 Flor Thesis

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ANGELES UNIVERSITY GRADUATE SCHOOL PAGE1

AN ASSESSMENT OF SHOULDER RANGE OF MOTION, MUSCLESTRENGTH, AND HAND GRIP STRENGTH IN RELATION TOQUALITY OF LIFE AMONG BREAST CANCER SURVIVORS

_________________________

A Thesis Proposal

Presented to the

Faculty of the Graduate School

_________________________

In Partial Fulfillment of the

Requirements for the Degree

Master in Public Health

_________________________

By:

Floriza P. de Leon

May 2011


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CHAPTER I

THE PROBLEM AND ITS BACKGROUND

INTRODUCTION

Breast cancer is so far the most frequent type of cancer among

women worldwide, resulting in over one million new cases each year and

is the leading cause of female cancer-related deaths. In Asia, the

Philippines has the highest incidence rate of breast cancer with a survival

rate that is much lower than the world average (GlaxoSmithKline

Philippines, 2007).

Treatment for breast cancer, such as surgery, radiation therapy,

and chemotherapy, have the potential to cause upper extremity

impairment on the affected side such as limited range of motion, poor

muscle strength and hand grip strength. This is where the role of physical

therapy takes place. Under Physical Rehabilitation, these problems are

addressed through the application of therapeutic intervention. In

Philippine setting, post-surgical breast cancer patients are not usually

referred to a physical rehabilitation institute for the reason that patients are

given time to recuperate from the limitations brought about by the

operation. Four to six weeks after operation, patients are then referred for


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further treatment such as chemotherapy and radiation therapy. Very rare,

these patients are referred to undergo musculo-skeletal assessment.

Arm morbidity being one of the most troublesome complications of

breast cancer treatment has a significant impact on the daily lives of

breast cancer survivors. The most common impairments reported after

breast cancer surgery include reduced range of motion of the shoulder;

numbness of the axilla or lateral chest wall; reduced grip strength; and

arm edema with a high degree of functional impairment and pain. With

advances in the medical treatment of persons with cancer, including the

combined use of surgical intervention, radiation therapy, and

chemotherapy, cancer survival rates (defined as a relative combined 5-

year statistic) are now above fifty percent (50%). As survival rates and

survival time have increased, so have public attitudes and the willingness

to discuss cancer care is not simply on survival, but on cancer

rehabilitation which aims to improve functional status and quality of life

(Veronika-Fialka, et al, 2003).

The concept of health-related quality of life (HRQOL) and its

determinants have evolved since the 1980s to encompass those aspects

of overall quality of life that can be clearly shown to affect health either

physical or mental. On the individual level, this includes physical and


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mental health perceptions and their correlates including health risks and

conditions, functional status, social support, and socioeconomic status.

HRQOL questions about perceived physical and mental health and

function have become an important component of health surveillance and

are generally considered valid indicators of service needs and intervention

outcomes. Self-assessed health status also proved to be more powerful

predictor of mortality and morbidity than many objective measure of health

(Center for Disease Control and Prevention Online, 2011).

In this light, the researcher assesses the shoulder range of motion,

muscle strength, and hand grip strength of breast cancer survivors in

relation to quality of life. The objective of the study is also the intention of

this study to assess quality of life in terms of physical health,

psychological, social relationships and the environment. It aims to

recognize the relationship between the shoulder range of motion, shoulder

muscle strength and hand grip strength and levels of quality of life of

breast cancer survivors. And lastly, its purpose is to know the implication

of the results of the study for public health education. It is the hope of this

study that the results could contribute for the eclectic approach in the total

rehabilitation of breast cancer survivors. Rehabilitation doctors and

physical therapists can work hand in hand in the integration of new

component of therapeutic intervention in the field of cancer rehabilitation.

It will be anticipated also that with this study, physical rehabilitation will be


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of help to Physical Therapist on how they should conduct therapeutic

intervention and that will result to breast cancer survivors recuperate in a

shorter period of time and with a better quality of life.

STATEMENT OF THE PROBLEM

This study assesses the shoulder range of motion, muscle strength,

and hand grip strength of breast cancer survivors in relation to quality of

life. Specifically, it seeks to answer the following questions:

1. How are breast cancer survivors be assessed in terms of:

1.1 shoulder range of motion (all planes)

1.2 shoulder muscle strength

1.3 hand grip strength

2. How may the breast cancer survivors be assessed in terms of their

quality of life?

2.1 Physical Health

2.2 Psychological

2.3 Social relationships

2.4 Environment

3. Is there significant relationship between the following and levels of

quality of life of breast cancer survivors:

3.1 shoulder range of motion (all planes)

3.2 shoulder muscle strength

3.3 hand grip strength


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4. What are the implications of the results of the study for public health

education?

SCOPE AND DELIMITATION OF THE STUDY

This study will be focused on the assessment of shoulder range of

motion, shoulder muscle strength, hand grip strength and quality of life

among breast cancer survivors in selected population. Assessment tools

and procedures conformed to the standard method used in clinical

practice such as the use of goniometer, manual muscle testing and

dynamometer to measure hand grip strength. WHOQOL-BREF will be the

assessment tool to be used to evaluate quality of life. This is an

assessment tool formulated by the World Health Organization (WHO).

This research will be conducted in Jose B. Lingad Memorial

Regional Hospital (JBLMRH) Physical Therapy Unit were recruited

subjects will be assessed by a trained physical therapist. Only one

physical therapist will assessed the participants to preserve validity and

reliability of the results. Subjects who will be recruited to participate

should have completed active breast cancer treatment at six(6) months

previously and should be at least 25 years of age, and has a good

comprehension of the English language. Bilateral breast cancer, infection

of the upper extremity, lymphangitis, pre-existing lymphedema, history of

neuromuscular or musculoskeletal condition that would affect local upper


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extremity testing or current recurrence will be excluded from the study.

Mann-Whitney ranked sum analysis and regression analysis are the

statistical tool to be used for hypothesis testing of this study.

The focus of the study is to find relationship between shoulder

range of motion, muscle strength and hand grip strength as to their quality

of life. The study is limited to other factors that will affect quality of life

such as current lifestyle, involvement in support groups, marital status and

job satisfaction which are not presented in this study. This study will be

conducted from May 2011 to June 2012.

DEFINITION OF TERMS

For better understanding of the study on hand, the following terms

are defined:

Assessment. It is an evaluation of the condition based on the

patients subjective report of the symptoms and course of illness or

condition and the examiners objective findings, including data obtained

through physical examination, medical history, and information reported by

family members and other health care teams (Mosbys Medical Dictionary,

2009).

In this study, it refers to the assessment of shoulder range of

motion, muscle strength and hand grip strength of the affected side of


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effective performance of a movement in relation to the forces of gravity

and manual resistance (Clarkson, 2000).

Quality of Life. Condition of an individuals perception of his

position in life in the context of the culture and value systems in which he

lives and in relation to his goals, expectations, standards and concerns. It

is a broad ranging concept affected in a complex way by the persons

physical health, psychological state, level of independence, social

relationships, personal beliefs and their relationship to salient features of

their environment (World Health Organization, 2010).

Range of Motion. Range of motion is the maximum amount of

movement that is possible in any particular joint (King et al., 1981)


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CHAPTER II

REVIEW OF RELATED LITERATURES AND STUDIES

Related Literature

Physical Assessment

Physical assessment of the breast and axillae is part of periodic

health maintenance examination for women of all ages. Breast cancer

cannot be prevented, but early detection offers more treatment option and

a greater chance of cure. Aside from physical assessment, a

musculoskeletal assessment is also being done to evaluate parameters of

function such as flexibility, strength, and endurance (Hamer, 2010).

Physical therapists may be involved in the treatment of breast

cancer patients at any stage of their disease. Newly diagnosed patients

often treated with a combination of surgery, radiotherapy, chemotherapy

and hormone treatments. As a result of this, patients frequently require

physiotherapy intervention. Following breast surgery, patients can

experience problems with pain, limited shoulder movement and

lymphedema. Radiotherapy to breast tissue can cause tissue fibrosis,

resulting in movement limitation and lymphedema. Chemotherapy and

hormone therapy can lead to changes in menopausal status and general


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debility. Physical therapists knowledge of anatomy and normal

movement makes them ideally suited in treating this group of patients

(Hamer, 2010).

Range of Motion

One aspect of musculoskeletal assessment is flexibility. It is being

measured in joint range of motion. Range of motion is the amount of

motion that is available at a joint is called the range of motion (ROM). The

starting position for measuring all ROM, except rotations in the transverse

plane, is the anatomical position. Three notation systems have been used

to define ROM: the 0-to 180-degree system, the 180- to 0-degree system,

and the 360-degree system. In the 0- to 180-degree notion system, the

upper and lower extremity joints are at 0 degrees for flexion-extension and

abduction-adduction when the body is in anatomical position. A body

position in which the extremity joints are halfway between medial (internal)

and lateral (external) rotation is 0 degrees for the ROM in rotation. A

ROM begins at 0 degrees and proceeds in an arc toward 180 degrees.

This 0- to 180-degree system of notion is widely used throughout the

world. First described by Silver in 1923, its use have been supported by

many authorities, including Cave and Roberts, Moore, the American

Academy of Orthopedic Surgeons, and the American Medical Association

(Norkin,1995).


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Normal ROM varies among individuals and is influenced by factors

such as age, gender, and whether the motion is performed actively or

passively. Numerous studies have been conducted to determine the

effects of age on ROM of extremities and spine. Most investigators who

have studied a wide range of age groups have found that older adult

groups have somewhat less ROM of the extremities than younger adult

group. The effects of gender on the ROM of the extremities and spine

also appear to be joint- and motion specific. Boone et al. found that

females across an age range of 21 to 69 years have less hip extension,

but more hip flexion, than males in the same age groups. Females in the

age range of 1 to 29 years had less hip adduction and lateral rotation than

males in the same age groups. Beighton et al., in a study of an African

population, found that females between 0 and 80 years of age were more

mobile than their male counterparts (McFarland and Kim, 2006).

When evaluating a clients range of motion, a therapist should first

observe the client during a function activity. This functional observation

may be referred to as a screening because it is not a formal assessment,

but a method to allow the therapist to determine quickly which joints need

further assessment. By demonstrating proficient observation skills a

therapist will be able to save time in the fast-paced health care

environment. If no deficits are noted during observation, the therapist can

avoid spending excessive time on measuring the range of motion of each


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joint only to determine that all joints are functional or normal. In addition,

this screening can be completed during another assessment such as

activities of daily living (ADL). Once a deficit joint or joints are noted, the

therapist will need to complete a goniometry assessment. The purpose of

goniometry is to measure the arc of motion of joint. In order to measure

this arc of motion, the therapist utilizes bony landmarks on the human

body to place the goniometer. The goniometer is the most commonly

used instrument to measure joint motion. There are many sizes and

shapes. Some goniometers are plastic while others are metal. All

goniometers have a body and two arms. The body is a full or semicircle

with a center point called the axis or fulcrum. One arm is called the

stationary arm and the other is the movable arm (Clarkson,2000).

During the use of the goniometer, the axis or fulcrum is placed over

the axis of motion being measured. The movable arm is also aligned with

the plane of motion, but is distal to the joint being measured and follows

the arm of motion. Now that the goniometer placement has been

determined, it is important to understand the planes and axis of joint

motion. The planes are the surfaces along which movement occurs.

They are imaginary sheets of glass that run through the body. There are

different planes (of glass) running through the body in different directions

because the body moves in different directions. Movement of the body

generally occurs in an arc or circular motion. The axis or fulcrum is the


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disadvantage. The quadriceps, for example, is a powerful muscle

responsible for straightening the leg. Once the leg is straightened, it is

exceedingly difficult for the examiner to flex the knee. If the knee is flexed

and the patient is asked to straighten the leg against resistance, weakness

can be elicited. The evaluation of muscle strength compares the sides of

the body to each other. For example, the right upper extremity is

compared to the left upper extremity. Subtle differences in strength may

be evaluated by testing for drift. For example, both arms are out in front of

the patient with palms up; drift is seen as pronation of the palm, indicating

a subtle weakness that may not have been detected on the resistance

examination. Clinicians use a 5-point scale to rate muscle strength. A 5

indicates full power of contraction against gravity and resistance or normal

muscle strength; 4 indicates fair but not full strength against gravity and a

moderate amount of resistance or slight weakness; 3 indicates just

sufficient strength to overcome the force of gravity or moderate weakness;

2 indicates the ability to move but not to overcome the force of gravity or

severe weakness; 1 indicates minimal contractile power (weak muscle

contraction can be palpated but no movement is noted) or very severe

weakness; and 0 indicates no movement (Hislop and Montgomery, 2007).

It is commonly recognized that a number of factors affect strength.

The therapist must consider these factors when assessing a patients

strength. First to consider is the age. Muscle strength increases from


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birth to a maximum point between 20 and 30 years of age. Following this

maximum, a decrease in strength occurs with increasing age due to a

deterioration in muscle mass. Muscle fibers decrease in size and number,

connective tissue and fat increase, and the respiratory capacity of the

muscle decreases. Another point is that, men are generally stronger than

women. Muscle size also play an important role in the intensity of muscle

strength. The larger the cross-sectional area of a muscle, the greater the

strength of the muscle. When testing a muscle that is small, the therapist

would expect less tension to be developed than if testing a large, thick

muscle (Clarkson, 2000).

Figure 2: Manual Muscle Testing of the Shoulder

Hand Grip Strength

Manual muscle testing evaluates only individual muscle or small

muscle groups. In the forearm and hand movement, there are thirty five


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The most common method of assessment for grip strength is the

use of handheld dynamometer. This is a form of what is referred to as a

biomechanical measurement. Biomechanical measurements allow sports

coaches to appreciate the bioenergetics and efficiency of sports

movements; traning can then aim to achieve a maximal energetic output

with minimal expenditure of energy, avoiding at the same time possible

fatigue and stress lesions in the locomotory system. Handheld grip

strength dynamometry is used to measure the muscular force generated

by flexor mechanisms of the hand and forearm (Hoeger and Hoeger,

2009).

Breast Cancer

Flexibility and muscle strength are the primarily affected in breast

cancer which is an uncontrolled growth of breast cells. The breasts, or

mammary glands, consist of fat pads inside of which is a branching

system of ducts. These ducts are designed to ferry milk from the milk-

producing lobules to the nipples. Breast cancer develops as the result of

malignant changes in the cells lining the ducts or the lobules. The first

abnormalities that occur are not themselves cancer but are simply an

overgrowth of normal cells in the ducts or lobules. These conditions are

called intraductal hyperplasia. If these extra cells seem a bit odd-looking

when examined under the microscope, the condition is called atypical

hyperplasia. Atypical hyperplasia does not cause lumps and cannot be


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detected by breast examination or by mammogram. When it is discovered

in the ducts or lobules, it is usually by accident, in the course of biopsying

a suspicious lump. If cells lining the ducts or lobules become odder still

and start to clog them, the condition is called carcinoma in situ. Ductal

carcinoma in situ and lobar carcinoma in situ by definition remain confined

to the ducts or lobules, but they can sometimes be detected by

mammogram, and in rare instances may produce a lump that can be felt.

If the abnormal cells break away from these parts of the breast to infiltrate

adjoining cells, the condition is called invasive cancer. It is at this point

that a discrete malignant lump starts to grow (Carlson et al., 2004).

Stages of Breast Cancer

The stage of cancer is based on: the size of the tumor, whether the

cancer is invasive or noninvasive, whether lymph nodes are involved, and

whether it has spread beyond the breast and nodes.(Carvalho and

Stewart, 2009). Once all of these factors are determined, staging of

cancer can be done and is classified in the table below.

Table 1: Stages of Breast Cancer

Stages Characteristics

0 Means that there is no invasion of the cancer cells

surrounding tissue

1 Describes invasive breast cancer, in which the cells are

breaking through to surrounding tissue and the tumor is 2


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centimeters or less in greatest dimension and no lymph

nodes are involved.

2 IIA

describes invasive breast cancer in which no tumor is

found in the breast, but cancer cells are found in the axillary

lymph nodes (lymph nodes under the arm), or

- Tumor measures 2 centimeters or less and has

spread to the axillary lymph nodes, or

- The tumor is larger than 2 centimeters but less than

5 centimeters and has not spread to the axillary

lymph nodes

IIB

- Tumor is larger than 2 but less than 5 centimeters

and has spread to the axillary lymph nodes, or

- The tumor is larger than 5 centimeters but has not

spread to the axillary lymph nodes.

3 IIIA

- No tumor is found in the breast. Cancer is found in

the axillary lymph nodes that are clumped together

or sticking to other structures or the cancer has

spread to the axillar nodes near the breastbone, or

- The tumor is 5 centimeters or smaller and has

spread to axillary lymph nodes that are clumped


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together or sticking to other structures, or

- Tumor is larger than 5 centimeters and has spread to

axillary lymph nodes that are clumped together or

sticking to other structures

IIIB

- Tumor may be any size and has spread to the chest

wall and/or skin of the breast, and

- Tumor may have spread to axillary lymph nodes that

are clumped together or sticking to other structures

or cancer may have spread to lymph nodes near the

breastbone.

IIIC

- There may be no sign of cancer in the breast or, if

there is a tumor, it may be any size and may have

spread to the chest wall and/or skin of the breast,

and

- The cancer has spread to lymph nodes above or

below the collarbone, and

- The cancer may have spread to axillary lymph nodes

or to lymph nodes near the breastbone.

4 Describes invasive breast cancer that has spread to other

organs of the body, usually the lungs, liver, bone, or brain.

It is also called metastatic breast cancer.


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TNM Staging System

According to Harrisons Manual of Oncology, 2007, TNM (Tumor,

Node, Metastasis) is another staging system researchers use to provide

more details about how the cancer looks and behaves. Physician might

mention the TNM classification, but he is much more likely to use the

numberical staging system. Sometimes clinical trials require TNM

information from participants (Chabner et al., 2007)

Breast Cancer Symptoms

The classic symptom of breast cancer is a lump in the breast, but

many lumps are not cancerous. They are the result of normal hormonal

changes or trauma to the breast. Although half of all breast lumps in

postmenopausal women (and three-quarters of all breast lumps in women

over the age of 70) are malignant, the younger a woman is, the more likely

it is that her breast lump is benign. Pain in the breast is also highly

unlikely to signal breast cancer; only 6 percent of women with breast

cancer have breast pain as a symptom. If a lump is cancerous, it is

generally difficult to move under the skin and often feels rock-hard with

irregular edges. There is no sure way to distinguish a malignant from a

benign lump by touch alone, however. For this reason, any woman who

notices a change in her breasts such as a lump or thickening, clear or


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bloody discharge, change in contours, dimpling of skin, redness, or

retracted nipple should consult a clinician (Carlson et. al.,2004).

Figure 4: Breast Cancer Symptoms

Breast Cancer Statistics

About 1 in 8 women in the United States (12%) will develop

invasive breast cancer over the course of her lifetime. (BreastCancer.Org,

April 19, 2011). In 2010, an estimated 207,090 new cases of invasive

breast cancer were expected to be diagnosed in women in the United

States(U.S.), along with 54,010 new cases of non-invasive (in situ) breast

cancer. About 1,970 new cases of invasive breast cancer were expected

to be diagnosed in men in 2010. Less than 1% of all new breast cancer

cases occur in men. From 1999 to 2006, breast cancer incidence rates in

the U.S. decreased by about 2% per year. One theory is that this

decrease was partially due to the reduced used of hormone replacement


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therapy (HRT) by women after results of a large study called the Womens

Health Initiative were published in 2002. These results suggested a

connection between HRT and increased breast cancer risk (Dow, 2006).

About 39,840 women in the U.S. were expected to die in 2010 from

breast cancer, though the rates have been decreasing since 1990. These

decreases are thought to be the result of treatment advances, earlier

detection through screening, and increased awareness. For women in the

U.S., breast cancer death rates are among higher than those for any other

cancer, besides lung cancer. Besides skin cancer, breast cancer is the

most commonly diagnosed cancer among U.S. women. More than 1 in 4

cancers in women (about 28%) are breast cancer. Compared to African

American women, white women are slightly more likely to develop breast

cancer, but less likely to die of it. One possible reason is that African

American women tend to have more aggressive tumors, although why this

is the case is not known. Women of other ethnic backgrounds Asian,

Hispanic, and Native American have a lower risk of developing and

dying from breast cancer than white women and African American women.

In 2010, there were more than 2.5 million breast cancer survivors in the

U.S. A womans risk of breast cancer approximately doubles if she has a

first-degree relative (mother, sister, daughter) who has been diagnosed

with breast cancer. About 20-30% of women diagnosed with breast

cancer have a family history of breast cancer. About 5-10% of breast


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cancer can be linked to gene mutations (abnormal changes)inherited from

ones mother or father. Mutations of the BRCA1 and BRCA2 genes are

the most common. Women with these mutations have up to an 80% risk

of developing breast cancer during their lifetime, and they are more likely

to be diagnosed at a younger age (before menopaue). An increased

ovarian cancer risk is also associated with these genetic mutations. In

men, about 1 in 10 breast cancers are believed to be due to BRCA2

mutations and even fewer cases to BRCA1 mutations. About 70-80% of

breast cancers occur in women who have no family history of breast

cancer. These occur due to genetic abnormalities that happen as a result

of the aging process and life in general, rather than inherited mutations.

The most significant risk factors for breast cancer are gender (being a

woman) and age (growing older) (Breastcancer.org, 2011).

Breast Cancer Risk Factors

The rapidly increasing and high incidence of breast cancer over the past

few decades supports the hypothesis that factors determining breast

cancer risk have changed. Some of this change can be directly

attributable to a reduction of protective factors (e.g. increasing parity, early

age at first birth) in a higher proportion of women. Other factors which are

known to increase breast cancer risk (i.e. obesity, low physical activity,

and the use of exogenous hormones) have become more common. In

addition to these changes in risk factors, breast cancer screening has


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impacted disease incidence. Mammography artifactually increased breast

cancer incidence in the short-term by advancing the lead time for

prevalent disease and possibly in the long-term by identifying lesions with

limited malignant potential. In general, greater lifetime exposure to

estrogen, influenced by endogenous and exogenous risk factors,

increases risk of breast cancer. Although many exposures that increase

risk are not readily modifiable, some behaviors can be adopted to

decrease risk (Morrow and Jordan, 2003).

Screening for Breast Cancer

The purpose of breast cancer screening is to separate women who

are clearly normal from those with abnormalities, with the goal of

intervening in the disease process after biologic onset but before

symptoms or signs develop. Mammography, regular breast exams, and

breast self- examination are the key components of early detection and

surveillance. Additional radiologic modalities will be mentioned as

adjuncts, but they are not basic screening tools. The use of

mammography to screen asymptomatic women 40 year of age and over

for early detection of breast cancer has been shown to reduce mortality

rates by 20-30%. A standard screening mammogram includes two views

of each breast. Additional views at different angles or increased

compression of the breast tissues may be included for better definition of

the character of the breast tissue (Aziz and Wu, 2002).


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Treatment and Side effects

Successfully treating breast cancer means getting rid of the cancer

or getting it under control for an extended period of time. But because a

breast cancer is made up of different kinds of cancer cells, getting rid of all

those cells can require different types of treatments. Treatment plan may

include a combination of the following treatments: surgery, radiation

therapy, chemotherapy, hormonal therapy (anti-estrogen therapy) and

some targeted therapies (such as Herceptin, Tykerb and Avastin).

Surgery is usually the first line of attack against breast cancer. Decisions

about surgery depend on many factors. The patient and the doctor will

determine the kind of surgery thats most appropriate for you based on the

stage of the cancer, the personality of the cancer, and what is

acceptable to the patient in terms of long-term peace of mind. Under

certain circumstances, people with breast cancer have the opportunity to

choose between total removal of a breast (mastectomy) and breast-

conserving surgery (lumpectomy) followed by radiation. Lumpectomy

followed by radiation is likely to be equally as effective as mastectomy for

people with only one site of cancer in the breast and a tumor under 4

centimeters. Clear margins are also a requirement (no cancer cells in the

tissue surrounding tumor). Another treatment option is the radiation

therapy also called radiotherapy is a highly targeted, highly effective

way to destroy cancer cells in the breast that stick around after surgery.


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Radiation can reduce the risk of breast cancer recurrence by about 70%.

Despite what many people fear, radiation therapy is relatively easy to

tolerate and its side effects are limited to the treated area. Radiation

treatments will be overseen by a radiation oncologist, a cancer doctor who

specializes in radiation therapy (Miller, 2008).

Radiation therapy uses a special kind of high-energy beam to

damage cancer cells. (Other types of energy beams include light and x-

rays). These high-energy beams, which are invisible to the human eye,

damage a cells DNA, the material that cells use to divide. Over time, the

radiation damages cells that are in the path of its beam normal cells as

well as cancer cells. But radiation affects cancer cells more than normal

cells. Cancer cells are very busy growing and multiplying 2 activities

that can be slowed or stopped by radiation damage. And because cancer

cells are less organized than health cells, it is harder for them to repair the

damage done by radiation. So cancer cells are more easily destroyed by

radiation, while healthy, normal cells are better able to repair themselves

and survive the treatment. Tissues to be treated might include the breast

area, lymph nodes, or another part of the body (Hunt et al., 2007).

Among the treatments for breast cancer, chemotherapy is the most

popular. Chemotherapy treatment uses medicine to weaken and destroy

cancer cells in the body, including cells at the orginal cancer site and any


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cancer cells that may have spread to another part of the body.

Chemotherapy, often shortened to just chemo, is a systemic therapy,

which means it affects the whole body by going through the bloodstream.

There are quite a few chemotherapy medicines. In many cases, a

combination of two or more medicines will be used as chemotherapy

treatment for breast cancer. Chemotherapy is used to treat: early-stage

invasive breast cancer to get rid of any cancer cells that may be left

behind after surgery and to reduce the risk of the cancer coming back;

advanced-stage breast cancer to destroy or damage the cancer cells as

much as possible. In some cases, chemotherapy is given before surgery

to shrink the cancer (Miller, 2008).

Psychosocial Status and Health-Related Quality in Breast Cancer

Breast cancer is a stressful even that can perturb psychologic

equilibrium and reduce health-related quality of life (HRQOL) in the short-

term; recent survivorship research has evaluated long-term sequelae.

Early studies involved mainly small convenience samples (maximum, 61

survivors), descriptive designs, and interview-based measurements. Key

results of these studies include observations that the majority of survivors

are fairly to very satisfied with their lives 8 years after diagnosis despite

thoughts of recurrence reported by 50%; that survivors have a positive

perception of life and attach less importance to trivial stressors even

though fear of recurrence is a major concern; and that the majority of


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survivors thrive despite experiencing problems related to breast cancer

and its treatment. (Ganz and Horning, 2007)

Quality of Life

The quality of life (QOL) assessment is an important aspect of the

current care provided to cancer patients. Tradition medical evaluations of

the outcomes of cancer treatments have included disease-free survival,

tumor response, and overall survival (U.S. Department of Health and

Human Services, 1990). However, clinicians and researchers have come

to realize that these outcomes are not adequate in assessing the impact of

cancer and its treatment on the patient and daily life, nor in identifying

interventions to improve or maintain the patients quality of life. Quality of

life measurements provide valuable information to all members of the

health care team. Interest in QOL assessment has continued to increase

in recent years. The World Health Organization (WHO) has a global

cancer control program based on knowledge currently available that, if

appropriately implemented, can reduce cancer morbidity and mortality

worldwide. This program includes a focus on palliative care and its impact

on the QOL of cancer patients. Since many of the worlds cancer patients

have no access to effective cancer therapy, only palliative care can be

offered. Palliative care programs frequently focus on symptom

management and can greatly improve QOL (World Health Organization

Official Website, 2011).


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Defining Quality of Life

Quality of life (QOL) is an ill-defined term. The World Health

Organization (WHO, 1948) declares health to be a state of complete

physical, mental and social well-being, and not merely the absence of

disease. Many other definitions of both health and quality of life have

been attempted, often liking the two and, for quality of life, frequently

emphasizing components of happiness and satisfaction with life. In the

absence of any universally accepted definition, some investigators argue

that most people, in the Western world at least, are familiar with the

expression quality of life and have an intuitive understanding of what it

comprises. However, it is clear that quality of life means different things

to different people, and takes on different meanings according to the area

of application (Fayers, et al 2007).

Quality of life assessment is complicated by the fact that there is no

universally accepted definition of quality of life. In the past, many

researchers measured only one dimension, such as physical function,

economic concern, or sexual function. More recently, researchers have

attempted to further define QOL. Spillker (1990) described QOL

assessment through three interrelated levels: (a) overall assessment of

well-being; (b) broad domains such as physical, psychological, economic,

and social; and (c) the components of each domain. While progress has


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been made in defining QOL, developing qualitative and quantitative

methodologies to study QOL, and identifying QOL outcomes, many

research issues persist, including conceptual and methodological issues

(King et al., 2003)

Methodological Issues in Survivorship Research

The Office of Cancer Survivorship of the National Cancer Institute

(U.S) defines a survivor as follows: An individual is considered a cancer

survivor from the time of cancer diagnosis, through the balance of his or

her life. Family members, friends and caregivers are also impacted by the

survivorship experience and are therefore included in this definition. This

is a very broad definition, most survivorship research in breast cancer

focuses on the experience of individuals with cancer after they have

completed their primary therapy, usually while they are free of recurrent

disease. Some studies have focused on women who are 1, 3, 5, or more

years post diagnosis. In breast cancer, where long-term survival is

becoming increasingly common, this variable definition may account for

some of the inconsistencies in the literature (Ganz and Horning, 2007).

Related Studies

Hayes et. al. (2010) conducted a 12 month period study assessing

the upper body function and correlating it with quality of life among Breast

Cancer patients post-surgery. Clinical assessment of upper body function


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compensate for than limited elbow or wrist movement in patients. Results

were recorded based on a scale from 1 to 6, with 1 representing almost no

movement, and 6, representing almost no movement. Handgrip strength

was measured using a hydraulic hand dynamometer. The average of

three grip strength measurements was recorded for each hand. Quality of

life measurements was assessed through FACT-B+4 survey and were

scored and interpreted in accordance with the standardized scoring

protocol. Results showed that those with full range of motion had an

increased total FACT-B+4, whereas those with decreased ROM had a

decreased range of motion recorded lower functional and physical well-

being and total FACT-B+4 scores.

Kaya et al (2010) did a comparable research using the same

WHAT assessment tool used by Beaulac et. al. that aimed to determine

the prevalence of impairments relevant to upper extremity following breast

cancer surgery and its impact on disability and health-related quality of

life. Subjects were evaluated for impairments (arm edema, loss of

handgrip strength, limited shoulder joint range of motion, physical disability

using the disabilities of the arm, shoulder and hand (DASH) questionnaire

and for health-related quality of life by means of the functional assessment

of cancer therapy-breast+4 (FACT-B+4). Results showed that the most

common impairment observed was arm pain on motion. Arm pain on

motion, anterior chest wall pain, loss of grip strength, and shoulder flexion


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were significant factors in different domains of quality of life according to

the FACT-B+4 questionnaire. The effect of pain in the arm subgroup of

the FACT-B+4 was more pronounced when compared with other

dependent variables.

In a different study done by Daves, et. al. (2008), they identified the

impact of lymphoedema or arm function and health-related quality of life in

women following breast cancer surgery. The study aims to estimate the

extent to which the impairments associated with lymphoedema are linked

to arm dysfunction and suboptimal health-related quality of life. A cross

sectional study, embedded within a pilot for an epidemiology study, was

undertaken involving women who had undergone surgery for unilateral

stage I or II breast cancer. Two questionnaires (a lymphoedema

screening questionnaire and the Disabilities of Arm, Shoulder and Hand

questionnaire) and women with symptoms attended for further testing.

Women with self reported symptoms of lymphoedema had a significantly

higher score on the Disabilities of Arm, Shoulder and Hand questionnaire,

indicating activity limitation, participation restriction and suboptimal health-

related quality of life.

In relation to Daves study, Ahmed, et. al. (2008) reported the

impact of lymphedema or related arm symptoms in health-related quality

of life (HRQOL) in breast cancer survivors. Arm symptoms assessment


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basically included flexibility and muscle strength of the affected side; and

was evaluated through goniometric techniques and manual muscle

testing. In Daves study, they measure upper extremity function through

the use of Disability of Arm, Shoulder and Hand (DASH) Outcome

Measures. In assessing quality of life, Medical Outcome Study Short

Form-36 Version 2 was used instead of the WHOQOL-BREF to be used in

this study. Though it measures the same domains, it used a different

format questionnaire.

In this study of unilateral breast cancer survivors in Iowa, 45% had

either diagnosed lymphedema or arm symptoms without diagnosed

lymphedema consistent with other reports. HRQOL was significantly

lower in breast cancer survivors without lymphedema compared with

survivors without lymphedema or arm symptoms. Although women with

known lymphedema experienced more arm symptoms on average,

women with arm symptoms without diagnosed lymphedema had altered

HRQOL in more domains of physical and mental HRQOL. Perhaps not

surprisingly, there was a significant dose-response relationship for

decreasing SF-36 scores by number of arm symptoms.

More complicated study done by Caban, et. al. (2006) studied the

relationship between depressive symptoms and shoulder mobility among

older women a year after breast cancer diagnosis. Depressive symptoms


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were linked as poorer quality of life. Association between depressive

symptoms and shoulder range of motion at one year after breast cancer

diagnosis were examined. Depressive symptoms, sociodemographic

characteristics and breast cancer treatment were measured at 2 months

and shoulder range of motion at 12 months. The relationship among

variables were evaluation with bivariate chi-square statistics and logistic

regression analysis. Results showed an increasing depressive symptoms

at baseline were associated with lower arm mobility at 12 months following

breast cancer diagnosis. Each unit increases in depressive symptoms at

baseline was associated with an eight percent decreased of odds of

having full range of motion of shoulder.

Nesvold, et. al. (2010) discussed the association between

arm/shoulder problems in breast cancer survivors and reduced health and

poorer physical quality of life. In this study, demography, lifestyle, quality

of life (QOL) and somatic morbidity in breast cancer survivors with and

without arm/shoulder problems were examined. Association of restricted

shoulder abduction with quality of life were also compared. In usnivariate

analysis, arm/shoulder problems were associated with not being

employed, having had mastectomy, longer follow-up time, radiotherapy to

axilla, poorer self-rated health and physical condition, minimal physical

activity, increased body mass index, regularly intake of analgesics and

poorer physical quality of life. Multivariate analysis showed that


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mastectomy, longer follow-up time, minimal physical activity and poorer

physical quality of life were associated with belonging to arm/shoulder

problems group. There was also significant association with having

impaired abduction of greater than or equal to 25 degree difference.

In another study by Smoot (2009), he determines the impact of

impairments on arm function and quality of life (QOL). All participants

attended a single evaluation session and both upper extremities were

assessed. Testing was completed by one investigator. Strength for hand

grip was assessed using hand held dynamometer. Strength scores were

obtained for shoulder abduction, elbow flexion, and wrist flexion using the

MicroFET2 dynamometer (Hoggan MicroFET2 Muscle Tester Model 7477,

ProMed Products, Atlanta). A goniometer was used to measure ranges of

motion (ROM) of the upper extremities. Shoulder flexion, shoulder

abduction, shoulder external rotation, elbow flexion and extension, wrist

flexion and extension, and flexion of the proximal interphalangeal joint of

digit two were measured following standardized procedures reported by

Norkin. The Quality of Life Cancer Survivors Questionnaire (QOL-CS)

was used to assess quality of life in cancer survivors. Four subscales are

calculated and represent physical, psychological, social and spiritual

domains.


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This study indicates that following breast cancer treatment, women

with or without lymphedema presents with upper extremity impairments.

Women with lymphedema more frequently report pain, demonstrate

bilateral deficits in shoulder ROM and upper extremity strength compared

to women without lymphedema, and is present with greater restrictions in

activity. Reduced upper extremity strength is associated with poorer

quality of life in the physical, psychological, and social subscales of the

QOL-CS questionnaire.

In a study of Cantero-Villanueva et. al. (2011), they aimed to

investigate the relationship between shoulder movement and quality of life

in breast cancer survivors. Quality of life is only measured against its

relationship to shoulder movements. Women completed the Breast

Cancer-Specific Quality of Life questionnaire, the Piper Fatigue Scale, in

addition to the assessment of shoulder flexion range of motion. Results

showed that fatigue was greater in those patients with reduced shoulder

movement.

Sagen et. al. (2009) accomplished a 5 year follow-up study to

describe changes in arm morbidities and health-related quality of life

(HRQOL) and to find factors that predict HRQOL 5 years after the surgery.

The subjects were examined for arm volumes, shoulder function, and

HRQOL, prior to surgery, and 6 months and 5 years after surgery. Arm


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morbidities were seen to decrease over time. Several dimensions of

HRQOL temporarily declined after surgery, but significantly improved in

the period from 6 months to 5 years after surgery.

CHAPTER III

RESEARCH DESIGN AND PROCEDURE

Research Method

The descriptive correlational research method is used in this study.

A descriptive correlational research method aims to describe relationships

among variables, without seeking to establish causal connections (Loiselle


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et al, 2010). This study assesses the shoulder range of motion, muscle

strength and grip strength of the affected upper extremity and also

assesses the present quality of life of breast cancer survivors. Likewise,

this research is classified as descriptive correlational since it seeks to

recognize relationships between range of motion, muscle strength,

handgrip strength and quality of life among breast cancer survivors

Research Locale

The study will be conducted at Jose B. Lingad Memorial Regional

Hospital(JBLMRH) Physical Therapy Unit where assessment will be done

by only one trained physical therapist.

Respondents of the Study

Women who have completed active breast cancer treatment at

six(6) months previously, will be recruited. The women are required to be

at least 25 years of age, and is able to read English. Women will excluded

for bilateral breast cancer, current upper extremity infection, lympangitis,

pre-existing lymphedema, pre-existing neuromuscular or musculoskeletal

conditions that would affect local upper extremity testing, or current

recurrence of breast cancer.

Study participant will be recruited through the outpatient

department of the Physical Therapy Unit of JBLMRH, existing support


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groups in Pampanga and willing participants of ALLTO clinical trial project

at the St. Lukes Medical Center, Quezon City.

Research Instruments

This study will

This study will utilize the following instruments:

1. WHOQOL-BREF assessment tool for measuring the quality of life of

breast cancer survivors. The assessment tool measures 6 domains of

quality of life and each domain has facets incorporated in each domain.

Facets in each domain of overall quality of life and general health are the

following:

Table 2: WHOQOL-BREF Domains

Domain Facets Incorporated within Domains

1. Physical Health Activities of daily livingDependence on medicinal substancesand medical aidsEnergy and fatigueMobilityPain and discomfortSleep and restWork capacity

2. Psychological Bodily image and appearanceNegative feelingsPositive feelings

Self-esteemSpirituality/religion/personal beliefsThinking, learning, memory andconcentration

3. Social Relationships Personal relationshipsSocial supportSexual activity

4. Environment Financial Resources


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Freedom, physical safety and securityHealth and social care: accessibilityand qualityHome environment

Opportunities for acquiring newinformation and skillsParticipation in and opportunities forrecreation/leisure activitiesPhysical environment(pollution/noise/traffic/climate)Transport

Each respondent will be asked to rate each item. There are eight

sets of tables of questions which has different rating systems. The

following rating system is adherent to the following:

Table 3: Ratings of Quality of Life

Ratings Description

1 Very Poor 2 Poor

3 Neither Poor nor Good

4 Good

5 Very Good

Table 4: Satisfaction with Health

1 Very dissatisfied

2 Dissatisfied

3 Neither satisfied Nor dissatisfied

4 Satisfied

5 Very Satisfied

Table 5 and 6: Quantity of Experiences in Certain Things


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1 Not at all

2 A little

3 A moderate amount

4 Very much

5 An extreme amount

Table 7: Quantity of Doing Certain Things

1 Not at all

2 A little

3 Moderately

4 Mostly

5 Completely

Table 8: Ability to Get Around

1 Very poor

2 Poor

3 Neither poor nor good

4 Good

5 Very Good

Table 9: Satisfaction Over Various Aspects of Life

1 Very dissatisfied

2 Dissatisfied

3 Neither satisfied nor dissatisfied

4 Satisfied

5 Very Satisfied

Table 10: Frequency of Experiencing Certain Things

1 Never

2 Seldom

3 Quite Often

4 Very Often

5 Always


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Musculoskeletal Assessment of the Upper extremity

2.1. Range of Motion

Through the use of a standard goniometer, range of

motion of each shoulder is assess and noted on a table

format.

Table 11: Assessment form for Shoulder Range of Motion

Range of Motion Active (L) Passive (L) Active (R) Passive(R)

Shoulder flexionShoulder Abduction

Shoulder ExternalRotation

Shoulder Internal

Rotation

2.2. Shoulder Muscle Strength

Manual muscle testing (MMT) will be used to measure

muscle strength of the shoulder. MMT uses a standard

grading system and is as follows:

Grade 5 patient can hold the position against maximum

resistance through complete range of motion

Grade 4 patient can hold the position against strong to

moderate resistance and has full range of motion.


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Grade 3 patient can tolerate no resistance but can

perform the movement through the full range of motion

Grade 2 patient has all or partial range of motion in the

gravity eliminated position

Grade 1 the muscle/muscles can be palpated while the

patient is performing the action

Grade 0 no contractile activity can be felt in the gravity

eliminated position.

2.3. Handgrip Strength Protocol

This protocol follows the standard procedures measuring

handgrip strength using a dynamometer. Results are compared

to the following normative value.

Table 12: Normative Values in Hand Grip Strength Among Women

Age Female Dominant

Hand

Female Non Dominant Hand

20 21.5 kg 10 kg

25 22 kg 20 kg

30 21 kg 19 kg

35 19.5 kg 18.75 kg

40 18.5 kg 17.75 kg

45 17.5 kg 16.75 kg

50 17.75 kg 16.5 kg

Statistical Treatment


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Statistical analyses will be performed using SPSS statistical

sorftware (Version 17). Means and standard deviations for interval data

will be obtained and unpaired t-tests for significance of differences will

performed for normally distributed data. Mann-Whitney ranked sum

analysis will be used to measure the test of difference for non-formally

distributed interval data. Another statistical method to be used is the

Spearman correlation that indicates the direction of association betweenX

(the independent variable) and Y (the dependent variable). Regression

analysis was used to evaluate the contribution of variables of theoretical

interest to the outcome measure. Multiple linear regression will be

selected for normally distributed interval data. For hypothesis testing, p-

values less than 0.05 were considered significant.

Research Procedures

The following are the procedures which will be used in

conducting of the study:

1. Recruitment of Participants

2. Selection of Participants

3. Assessment of Participants

Recruitment of Participants


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Participants will be assessed according to the research method

mentioned above. Assessment tools will be used to measure variables

of interest. Goniometry will be used in the assessing the shoulder range

of motion, manual muscle testing will be employ to measure shoulder

muscle strength and hand grip strength will be assessed using a

standard dynamometer.

BIBLIOGRAPHY

A. BOOKS

Carlson, Karen J., et. al. (2004). The New Harvards Guide toWomens Health. U.S.A: Harvard University Press.


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Carvalho, Lucia Guiggio, et. al. (2009). The Everything Health Guide toLiving with Breast Cancer: An Accessible and ComprehensiveResource for Women. U.S.A: Everything Books.

Chabner, Bruce, et. al. (2007). Harrisons Manual of Oncology. U.S.A.:McGrawHill Professional.

Dow, Karen Hassey (2006). Pocket Guide to Breast Cancer. London:Jones and Barlett Publishers International.

Fayers, et al. (2007). Quality of Life: The Assessment, Analysis andInterpretation of Patient-Reported Outcomes. U.S.A.: John Wileyand Sons.

Fronteza, Walter, et. al., (2008). Essentials of Physical Medicine and

Rehabilitation: Musculoskeletal Disorder, Pain and Rehabiliation.Philadelphia: Saunders Company

Hamer, Victoria. (2010). Breast Cancer Nursing Care and Management.U.S.A: John Wiley and Sons.

Hislop, Helen J. (2007). Daniels and Worthinghams Muscle Testing:Techniques of Manual Examination. U.S.A: Saunders/Elsevier.

Hunt, et al. (2007). Breast Cancer. U.S.A: Springer.

Kendall, Florence Peterson et. al. (1993). Muscles: Testing andFunction,Fourth Edition. Baltimore: Williams and Wilkins.

King, Cynthia, et al. (2003). Quality of life. Canada: Jones and BarlettPublishers International

King, Eunice M., et.al. (1981). Illustrated Manual of Nursing Techniques.U.S.A: Lippincott Company.

McFarland, Edward G. and Tae Kyun Kim (2006). Examination of theShoulder: The Complete Guide. New York: Thiemes MedicalPublishers, Inc.

Miller, Kenneth D. (2008). Choices in Breast Cancer Treatment: MedicalSpecialists and Cancer Survivors. U.S.A.: The John HopkinsUniversity Press.


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Morrow, Monica, et al. (2003). Managing Breast Cancer Risk. U.S.A.:PMPH.

Tan, Jackson C. (2006). Practical Manual of Physical Medicine and

Rehabilitation. China: Elsevier-Mosby, Inc

Voight, Michael L., et.al. (2007). Musculoskeletal Interventions:Techniques for Therapeutic Exercise. U.S.A: Mc-Graw HillCompanies, Inc.

B. JOURNALS

Ahmed, Rehana L., et. al. (December 10, 2008). Lymphedema andQuality of Life in Breast Cancer Survivors: The Iowa Womens

Health Study. Journal of Clinical Oncology. Vol. 26. No. 25.

Beaulac, Sarah M., et. al. (November 2002). Lymphedema and Quality ofLife in Survivors of Early-Stage Breast Cancer. Archives ofSurgery. Vol. 137, No. 11. Pp. 1253-1257.

Cantero-Villanueva I., et. al. (March 17, 2011). Associations among mmusculoskeletal impairments, depression, body image and fatiguebreast cancer survivors within the first year after treatment.European Journal of Cancer Care.

Dawes, Diana J. et. al. (2008). Impact of lymphedema on arm functionand health-related quality of life in women following breast cancersurgery. Journal of Rehabilitation Medicine. Vol. 40. Pp. 51-58

Hayes, Sandra C., et. al. (2010). Upper-body morbidity following breastcancer treatmen is common, may persist longer-term and adverselyinfluences quality of life. Health and Quality of Life Outcomes:Open Access Research. Vol. 8, Issue 92.

Karasen, Sagen A., et. al. (2009). Changes in arm morbidities andHealth-related quality of life after breast cancer surgery a five-year f follow up study. Acta Oncologica. Vol. 48. No. 8. Pp. 1111-1118.

Nesvold IL, et. al. (April 2010). Arm/shoulder problems in breast cancersurvivors are associated with reduced health and poorer physicalquality of life. Acta Oncologica. Vol. 49. No. 3. Pp. 347-353.


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Smooth, Betty, et. al. (2010) Upper Extremity impairments in women withor without lymphedema following breast cancer treatment. Journalof Cancer Survivor. Vol. 4. Pp. 167-178.

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