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Immediate versus delayed shoulder exercises after axillary lymph node dissection
Immediate versus Delayed Shoulder Exercises After Axillary Lymph Node Dissection Ruud F.M. Jansen, MD, Albert N. van Geel, MD, PhO, Rotterdam.The Netherlands, Hans G.W. de Groot, MD, The Hague, The Netherlands,Atto B. Rottier, MD, Gerard A.A. Olthuis, MD, PhD, Wim t . J . van Putten, MSc, Rotterdam,The Netherlands
A total of 144 evaluable patients with breast cancer were enrolled in a muhicenter, randomized, prospective study to establish the role of delayed shoulder exercises on wound drainage and shoulder function after axillary lymph node dissection. Patients in group 1 (n = 78) started active shoulder exercises 1 day postoperatively. Patients in group 2 (n = 6 6 ) started on the eighth postoperative day, following 1 week of immobilization of the arm. Patients in group 2 had I 4 % less wound drainage volume than those in group 1 ( 6 0 0 4- 4 3 6 mL versus 701 4- 398 m L ) ; this difference, however, was not significant. Also, no differences could be established between the two groups when duration and volume of wound drainage, number and volume of seroma aspirations, wound complication rates, and shoulder function were compared 6 months after surgery.
reast cancer is the most common malignancy in women, occurring in 9% of the female population. About 85,000 women in the United States and 4,500 women in The Netherlands undergo primary surgical resection of breast cancer annually (modified radical mastectomy or lumpectomy and axillary node dissection). Complication rates up to 63.6% are reported and include hemorrhage (1.3% to 4.3%), nerve injury (0.7% to 4.1%), infection (5.6% to 14.2%), skin necrosis (3% to 61%; full-thickness losses up to 8.2%), seroma (up to 35% but reported to be the most frequent postoperative complication), lymphoedema (6.7% to 62.5%), and shoulder dysfunction [I]. To date, no consensus exists on postoperative care with respect to these complications.
B
From the Departments of Surgical Oncology (RFMJ, ANvG) and Statistics (WLJvP), Dr Daniel den Hoed Cancer Center, Rotterdam; the Departments of Surgery, Zuiderziekenhuis Rotterdam (ANvG, GAAO) and Leyenburg Ziekenhuis, The Hague (HGWdG); and Haven Ziekenhuis (ABR), Rotterdam, The Netherlands. Requests for reprints should be addressed to Albert N. van Geel, MD, PhD, Department of Surgical Oncology, The Dr Daniel den Hoed Cancer Center, P.O. Box 5201, 3008 AE Rotterdam, The Netherlands. Manuscript submitted January 10, 1990, and accepted March 30, 1990.
Many surgeons advise immediate postoperative shoulder exercises to avoid impaired shoulder function [2]. It is questionable, however, whether such a recommendation is justified. There are indications that delaying shoulder exercises until a few days after the operation leads to a reduction in the suction drainage time without loss of shoulder function [3,4]. However, these studies were carried out on women undergoing radical mastectomy. Van der Horst et al [5], in a prospective study of 59 women in whom axillary lymph node dissections were performed, and Dawson et al [6], who prospectively studyed a group of 100 women undergoing modified radical mastectomies, compared immediate supervised exercises with exercises started after 1 week of immobilization. There was a tendency (no significant differences) to smaller volumes and shorter duration of wound drainage in the immobilized group. Shoulder function and complication rates were equivalent in both groups. In our opinion, the results of both studies are inconclusive, because of the small number of patients in one study [5] and the incomplete statistical analysis in the other study [6]. We performed a prospective, randomized study with a large number of patients, in whom immediate and delayed shoulder exercises were compared with respect to (1) wound drainage and (2) shoulder function. PATIENTS AND M E T H O D S Patients: All women undergoing primary surgical treatment of breast carcinoma in our four institutions between March 1987 and April 1988 were admitted to the trial after giving informed consent. Exclusion criteria were as follows: grade 3 or 4 of World Health Organization Performance Status Scale; previous diseases or operations influencing ipsilateral shoulder movements; previous ipsilateral axillary operations or radiotherapy; and immediate postoperative iridium implantation and simultaneous bilateral axillary lymph node dissection. Surgical procedures: Breast-conserving surgical treatment, consisting of wide lumpectomy and axillary lymph node dissection, was performed whenever possible. A modified radical mastectomy according to Madden [7], in which both pectoral muscles were saved, was performed when the primary tumor was not suitable for breast-conserving treatment or when the patient preferred mastectomy. In a few patients, axillary lymph node dissection was performed without simultaneous lumpectomy because the primary tumor has been removed previously for histologic confirmation of malignancy. In both surgical procedures, axillary lymph node dissection was performed in a uniform way. After incision of the skin in the lower axillary hairline, all tissues in the
THE AMERICAN JOURNAL OF SURGERY
VOLUME 160 NOVEMBER 1990 481
JANSEN ET AL
area with the following margins were removed: cranially, the axillary vein; laterally, the anterior edge of the latissimus dorsi muscle; medially, the anterior serratus muscle; dorsally, the subscapular muscle; and anteriorly, the skin flaps that were formed. The pectoralis major and minor muscles, as well as the long thoracic nerve and the thoracodorsal artery, vein, and nerve in clinically node-negative cancer were spared. Wound closure was not standardized. Suction drainage with a suction force of more than 100 cm Hg (132 kPa) was performed with one drain in the region of the axillary node dissection, and a second drain in the breast region in patients with modified radical mastectomies. Wound drainage production from both drains was noted daily. Drains were removed when drain production was less than 30 m L / 2 4 hours on 2 consecutive days, without signs of drain obstruction. On the 14th postoperative day, all drains were removed irrespective of their production. Aspiration of axillary seromas after drain removal was performed only when there were serious complaints clearly related to seroma accumulation. Study design: After giving informed consent, all patients were randomized preoperatively in one center (DdHCC). The exercise scheme for group 1 prescribed active shoulder exercises 1 day after the operation. The exercise scheme for group 2 prescribed shoulder exercises starting at the eighth postoperative day. In the latter group, the arm was immobilized for the first 7 days. A Collar 'n Cuff sling was used when the patient was out of bed, with the arm relaxed and the elbow flexed 90 ~ . When the patient was in bed, the arm was rested on a pillow. Hand and wrist movements were allowed. Physiotherapy: In group 1 at day 1 and in group 2 at day 8, movements of the shoulder were performed actively once a day under the supervision of a physiotherapist. All movements, especially anteflexion, abduction, horizontal abduction, and exo-rotation, were carried out until the pain barrier was reached. All spontaneous movements and use of the arm during the remaining part of the day were allowed, provided pain did not occur. Physiothera-
TABLE
peutic supervision was discontinued when shoulder function had returned to its preoperative level or when the patient was discharged. Physiotherapy at home was prescribed when anteflexion was restricted more than 20 ~ or exo-rotation was restricted more than 10 ~ Shoulder function measurement: Shoulder function (abduction, anteflexion, horizontal abduction, exo-rotation with the humerus in a neutral position, and exorotation with the humerus in abduction) was measured by one or two physiotherapists at each center. Measurements were performed before surgery, on the first day of shoulder movements, at discharge, and at 1 and 6 months after operation; the first and last measurements were done with the contralateral shoulder as well, so that each patient had a "normal" standard. Statistical methods: While data were being collected, it was discovered that the techniques of measuring shoulder function differed significantly between the four hospitals. This resulted in large differences in measured shoulder functions. In order to evaluate the difference between the two groups with respect to shoulder function, the difference between the treated and contralateral shoulders at 6 months was used as the main point. Since the functions of both shoulders were measured by the same physiotherapist at the same time, this end point was more appropriate than a comparison with the preoperative value. For a graphical description, the means of the measurements at all time points were used, but these values were not used for testing purposes. The Wilcoxon signed rank test was used to assess differences between both groups in the total volume of seroma and in the 6-month measurements of shoulder function. RESULTS In 13 months, 168 patients were randomized at our 4 institutions. Of these, 24 patients could not be evaluated for the following reasons: ineligible (10 patients), no measurements obtained (8 patients), and refusal to participate after randomization (6 patients, all of whom had been randomly assigned to the immobilization group).
I
Immediate (Group 1) Versus Delayed ( G r o u p 2 ) Shoulder Exercises After Axillary Lymph Node DissecUon
Axiilary drainage time (days 4- S.D.) Axiliary drainage volume (mL 4- S.D.) Aspirations (n 4- S.D.) Volume of aspirations (mL 4- S.D.) Serious shoulder restriction (%)t Wound complications (%) Lymphedema (%) Physiotherapy during admission (days 4- S.D.) Physiotherapy after discharge (days 4- S.D.)
Group (n = 78)
Group 2 (n = 66)
p Value*
9.1 4- 2.9 701.4 4- 397.7 0.4 4- 0.8 60.4 4- 157.9 18.2 15.6 2.6 8.5 4- 4.6 2.2 4- 8.6
8.5 4- 3.2 600.1 4- 435.6 0.6 4- 1.8 66.1 4- 197.0 21.5 13.8 3.1 4.7 4- 3.6 1.4 4- 3.7
NS 0.07 NS NS NS NS NS 0.0001' NS
*NS=p>0.10 1-Serious shoulder restriction was definedas a reduction of abduction, anteflexion, horizontal abduction, exo-rotation with the humerus in a neutral position or exo-rotation with the humerus in 90 ~ abduction by 20~ or more at 6 months, when compared with contralateral shoulder function at 6 months. * As a direct result of the study design.
482
THE AMERICAN JOURNAL OFSURGERY
VOLUME 160 NOVEMBER 1990
SHOULDER EXERCISES AFTER AXILLARY NODE DISSECTION
Therefore, 144 patients were evaluable. Of these, 78 were in group 1 (immediate exercises) and 66 were in group 2 (7 days of immobilization). The three types of operations [modified radical mastectomy, (101 patients), and axillary lymph node dissection with (38 patients) or without lumpectomy (5 patients)] were equally divided among the two groups. Patient data (age, left- or right-sided operation, dominancy of the involved arm, and preoperative shoulder function) were comparable between the two groups. Mean age was 59.2 years (range: 28 to 81 years). Seroma: When comparing the two groups, only the number of days of physiotherapeutic supervision during admission was significantly higher in group 1 (Table I). Patients in group 2 had 14% less wound drainage volume (600 4- 436 mL versus 701 4. 398 mL) than patients in group 1, but this difference was not statistically significant. All other variables (axillary drainage time, number and volume of seroma aspirations, percentage of patients with serious shoulder restrictions, wound complications,
.oI ,
and lymphedema, and number of days of physiotherapy at home) were equal. Shoulder function" A distinctive pattern could be seen in the measurements of all shoulder functions over time (Figure 1): preoperative values of abduction, anteversion, horizontal abduction exo-rotation with the humerus in a neutral position, and exo-rotation with the humerus in 90 ~ abduction were those of normal, unaffected shoulders; ipsilateral and contralateral shoulder functions were equal. On the first day of exercise, there was a sharp decrease in all shoulder function measurements, which disappeared almost completely during the first 6 postoperative months. All shoulder functions were slightly reduced 6 months after operation. Abduction was reduced by 7.7 4- 1.4 ~ and anteflexion by 7.7 4- 1.1 o. Horizontal abduction, exorotation with the humerus in a neutral position, and exorotation with an abducted humerus were all reduced by less than 2* when compared with those of the contralateral shoulder.
160
1.1,:oi 100
80 I~
60
L
PrI. . . . . operative
Lx. . . . . . day
Ois~mi. . . . .
_ _
Immediale exercise
.....
Irnmobdisation
fter I1 . . . . . .
80 l ' -
60
fter 16 . . . . . .
110
80
106
74
~02
6a
98
62
94
~
I
1st exercise day
Dismissal
I r cise lsl exe
Dis /m ' issal
I
After 1 mont
lmmobilisatlon
h
After 8 Imonths
day
tmmediate exercise
: ! mm~db:I ts~fi~ . . . . .
..... 50
After 6 monlhs
After 1 month
Immediate exercise
.....
56
.....
I
90 Preoperative
r eoperative
_ _
I Preoperative
I 1st exercise day
I Dismissal
/
Immobilisation I
After 1 month
After 6 months
\\
_
_
.....
Pr~
1st exercise
operative
day
Immediate
exercise
Immobilisation
I
i
I
Dismissal
After 1 month
After 8 months
Figure 1. Results of shoulder function in group 1 (immediate exercises) and group 2 (immobilization). Top left, abduction; top right, anteflexion; middle left, horizontal abduction; middle right, exo-rotation; bottom left, exo-rotation with humerus in 90 ~ abduction.
T H E A M E R I C A N J O U R N A L OF S U R G E R Y
V O L U M E 160
N O V E M B E R 1990
483
,JANSEN ET AL
In this pattern and especially in the final outcome of shoulder functions after 6 months, no differences could be seen between the two exercise scheme groups (Figure 1). A total of 28 patients [19.4%, equally divided among the exercise scheme groups (Table I)] experienced a reduction of either shoulder movement of more than 200; in 13 patients (9% of all patients), the reduction was more than 30 ~ . Patient age appeared to play a small role in some variables. Older patients needed longer physiotherapeutic supervision: 1 day for every 11 extra years of age. The volume of axillary drainage increased slightly with age: 6 m L for every year. Axillary drains were removed 1 day later for every 14 years of age. Preoperative shoulder functions were slightly less in older patients (a mean decrease of 3.4 ~ abduction and 3.8 ~ in anteflexion per 10 years), but older patients did not have a bigger reduction of shoulder function after the operation than younger patients did. COMMENTS In this study, we compared two different exercise schemes after axillary lymph node dissection. Only one difference in final outcome appeared to exist: a slightly higher axillary drainage volume in the group who exercised on the first postoperative day (701 4- 398 versus 600 4- 436; p = 0.07). The difference in physiotherapeutic supervision during admission (8.5 4- 4.6 days versus 4.7 43.6; p = 0.001) is a direct result of the difference in exercise schedules between the two groups. These results are equivalent to those of Van der Horst et al [5] and Dawson et al [6] in smaller series. The relatively high percentage of women with a serious restriction of shoulder movement (19.4%) is of concern. To our knowledge, no figures on this complication of modified radical mastectomy or axillary lymph node dissection exist in the recent literature. Further studies on causes and prevention of this loss of shoulder function are required. In our series, the influence of postoperative radiotherapy was not considered, although it is known that irradiation of the supraclavicular fossa and/or axilla reduces shoulder mobility [8]. Because this phenomenon seems to be important after a long period, this problem was not expected in our study since measurements were taken at the most 6 months after the operation.
484
THE AMERICAN JOURNAL OFSURGERY
CONCLUSIONS Since no difference has been found in shoulder function after immediate and delayed shoulder exercises and since a decrease of seroma production of about 14% was seen after immobilization, we prefer a period of rest after operation before starting exercises. The high percentage of women with serious restrictions in shoulder function (19.4%) requires further studies. On the basis of these results, we decided to change our postoperative instructions to our patients. During the first week, patients may use the affected arm and shoulder as much as desired. In our experience, patients do so until they feel some pain or discomfort. After 1 week, measurements are made, and physiotherapy is requested when a marked reduction in function is found.
This manuscript represents a careful evaluation of a common management problem for patients having axillary lymph node dissection and shows no difference between delayed versus immediate shoulder exercises.
REFERENCES 1. Aitken DR, Minton JP. Complicationsassociated with mastectomy. Surg Clin North Am 1983; 63: 1331-52. 2. Pollard R, Callum KG, Celtman DG, Bates T. Shoulder movement following mastectomy. Clin Oncol 1976; 2: 343-9. 3. Flew TJ, Wound drainage following radical mastectomy: the effect of restriction of shoulder movement.Br J Surg 1979; 66: 3025. 4. Lotze MT, Duncan MA, Gerber LH, Woltering EA, Rosenberg SA. Early versus delayed shoulder motion followingaxillary dissection: a randomizedprospectivestudy. Ann Surg 1981; 193: 288-95. 5. Van der Horst ChMAM, Kenter JAL, De Jong MT, Keeman JN. Shoulder function following early mobilization of the shoulder after mastectomy and axillary dissection. Neth J Surg 1985; 37: 105-8. 6. Dawson I, Stan L, Heslinga JM, Kalsbeek HL. Effect of shoulder immobilization on wound seroma and shoulder dysfunction following modified radical mastectomy; a randomized prospective clinical trial. Br J Surg 1989; 76: 311-2. 7. Madden JL. Modified radical mastectomy. Surg GynecolObstet 1965; 121: 1221-30. 8. Aitken R J, Gare MN, Rodger A, Chetty U, Forrest APM. Arm morbidity within a trial of mastectomy and either nodal sample with selective radiotherapy or axillary clearance. Br J Surg 1989; 76: 568-71.
VOLUME 160 NOVEMBER1990
A total of 144 evaluable patients with breast cancer were enrolled in a muhicenter, randomized, prospective study to establish the role of delayed shoulder exercises on wound drainage and shoulder function after axillary lymph node dissection. Patients in group 1 (n = 78) started active shoulder exercises 1 day postoperatively. Patients in group 2 (n = 6 6 ) started on the eighth postoperative day, following 1 week of immobilization of the arm. Patients in group 2 had I 4 % less wound drainage volume than those in group 1 ( 6 0 0 4- 4 3 6 mL versus 701 4- 398 m L ) ; this difference, however, was not significant. Also, no differences could be established between the two groups when duration and volume of wound drainage, number and volume of seroma aspirations, wound complication rates, and shoulder function were compared 6 months after surgery.
reast cancer is the most common malignancy in women, occurring in 9% of the female population. About 85,000 women in the United States and 4,500 women in The Netherlands undergo primary surgical resection of breast cancer annually (modified radical mastectomy or lumpectomy and axillary node dissection). Complication rates up to 63.6% are reported and include hemorrhage (1.3% to 4.3%), nerve injury (0.7% to 4.1%), infection (5.6% to 14.2%), skin necrosis (3% to 61%; full-thickness losses up to 8.2%), seroma (up to 35% but reported to be the most frequent postoperative complication), lymphoedema (6.7% to 62.5%), and shoulder dysfunction [I]. To date, no consensus exists on postoperative care with respect to these complications.
B
From the Departments of Surgical Oncology (RFMJ, ANvG) and Statistics (WLJvP), Dr Daniel den Hoed Cancer Center, Rotterdam; the Departments of Surgery, Zuiderziekenhuis Rotterdam (ANvG, GAAO) and Leyenburg Ziekenhuis, The Hague (HGWdG); and Haven Ziekenhuis (ABR), Rotterdam, The Netherlands. Requests for reprints should be addressed to Albert N. van Geel, MD, PhD, Department of Surgical Oncology, The Dr Daniel den Hoed Cancer Center, P.O. Box 5201, 3008 AE Rotterdam, The Netherlands. Manuscript submitted January 10, 1990, and accepted March 30, 1990.
Many surgeons advise immediate postoperative shoulder exercises to avoid impaired shoulder function [2]. It is questionable, however, whether such a recommendation is justified. There are indications that delaying shoulder exercises until a few days after the operation leads to a reduction in the suction drainage time without loss of shoulder function [3,4]. However, these studies were carried out on women undergoing radical mastectomy. Van der Horst et al [5], in a prospective study of 59 women in whom axillary lymph node dissections were performed, and Dawson et al [6], who prospectively studyed a group of 100 women undergoing modified radical mastectomies, compared immediate supervised exercises with exercises started after 1 week of immobilization. There was a tendency (no significant differences) to smaller volumes and shorter duration of wound drainage in the immobilized group. Shoulder function and complication rates were equivalent in both groups. In our opinion, the results of both studies are inconclusive, because of the small number of patients in one study [5] and the incomplete statistical analysis in the other study [6]. We performed a prospective, randomized study with a large number of patients, in whom immediate and delayed shoulder exercises were compared with respect to (1) wound drainage and (2) shoulder function. PATIENTS AND M E T H O D S Patients: All women undergoing primary surgical treatment of breast carcinoma in our four institutions between March 1987 and April 1988 were admitted to the trial after giving informed consent. Exclusion criteria were as follows: grade 3 or 4 of World Health Organization Performance Status Scale; previous diseases or operations influencing ipsilateral shoulder movements; previous ipsilateral axillary operations or radiotherapy; and immediate postoperative iridium implantation and simultaneous bilateral axillary lymph node dissection. Surgical procedures: Breast-conserving surgical treatment, consisting of wide lumpectomy and axillary lymph node dissection, was performed whenever possible. A modified radical mastectomy according to Madden [7], in which both pectoral muscles were saved, was performed when the primary tumor was not suitable for breast-conserving treatment or when the patient preferred mastectomy. In a few patients, axillary lymph node dissection was performed without simultaneous lumpectomy because the primary tumor has been removed previously for histologic confirmation of malignancy. In both surgical procedures, axillary lymph node dissection was performed in a uniform way. After incision of the skin in the lower axillary hairline, all tissues in the
THE AMERICAN JOURNAL OF SURGERY
VOLUME 160 NOVEMBER 1990 481
JANSEN ET AL
area with the following margins were removed: cranially, the axillary vein; laterally, the anterior edge of the latissimus dorsi muscle; medially, the anterior serratus muscle; dorsally, the subscapular muscle; and anteriorly, the skin flaps that were formed. The pectoralis major and minor muscles, as well as the long thoracic nerve and the thoracodorsal artery, vein, and nerve in clinically node-negative cancer were spared. Wound closure was not standardized. Suction drainage with a suction force of more than 100 cm Hg (132 kPa) was performed with one drain in the region of the axillary node dissection, and a second drain in the breast region in patients with modified radical mastectomies. Wound drainage production from both drains was noted daily. Drains were removed when drain production was less than 30 m L / 2 4 hours on 2 consecutive days, without signs of drain obstruction. On the 14th postoperative day, all drains were removed irrespective of their production. Aspiration of axillary seromas after drain removal was performed only when there were serious complaints clearly related to seroma accumulation. Study design: After giving informed consent, all patients were randomized preoperatively in one center (DdHCC). The exercise scheme for group 1 prescribed active shoulder exercises 1 day after the operation. The exercise scheme for group 2 prescribed shoulder exercises starting at the eighth postoperative day. In the latter group, the arm was immobilized for the first 7 days. A Collar 'n Cuff sling was used when the patient was out of bed, with the arm relaxed and the elbow flexed 90 ~ . When the patient was in bed, the arm was rested on a pillow. Hand and wrist movements were allowed. Physiotherapy: In group 1 at day 1 and in group 2 at day 8, movements of the shoulder were performed actively once a day under the supervision of a physiotherapist. All movements, especially anteflexion, abduction, horizontal abduction, and exo-rotation, were carried out until the pain barrier was reached. All spontaneous movements and use of the arm during the remaining part of the day were allowed, provided pain did not occur. Physiothera-
TABLE
peutic supervision was discontinued when shoulder function had returned to its preoperative level or when the patient was discharged. Physiotherapy at home was prescribed when anteflexion was restricted more than 20 ~ or exo-rotation was restricted more than 10 ~ Shoulder function measurement: Shoulder function (abduction, anteflexion, horizontal abduction, exo-rotation with the humerus in a neutral position, and exorotation with the humerus in abduction) was measured by one or two physiotherapists at each center. Measurements were performed before surgery, on the first day of shoulder movements, at discharge, and at 1 and 6 months after operation; the first and last measurements were done with the contralateral shoulder as well, so that each patient had a "normal" standard. Statistical methods: While data were being collected, it was discovered that the techniques of measuring shoulder function differed significantly between the four hospitals. This resulted in large differences in measured shoulder functions. In order to evaluate the difference between the two groups with respect to shoulder function, the difference between the treated and contralateral shoulders at 6 months was used as the main point. Since the functions of both shoulders were measured by the same physiotherapist at the same time, this end point was more appropriate than a comparison with the preoperative value. For a graphical description, the means of the measurements at all time points were used, but these values were not used for testing purposes. The Wilcoxon signed rank test was used to assess differences between both groups in the total volume of seroma and in the 6-month measurements of shoulder function. RESULTS In 13 months, 168 patients were randomized at our 4 institutions. Of these, 24 patients could not be evaluated for the following reasons: ineligible (10 patients), no measurements obtained (8 patients), and refusal to participate after randomization (6 patients, all of whom had been randomly assigned to the immobilization group).
I
Immediate (Group 1) Versus Delayed ( G r o u p 2 ) Shoulder Exercises After Axillary Lymph Node DissecUon
Axiilary drainage time (days 4- S.D.) Axiliary drainage volume (mL 4- S.D.) Aspirations (n 4- S.D.) Volume of aspirations (mL 4- S.D.) Serious shoulder restriction (%)t Wound complications (%) Lymphedema (%) Physiotherapy during admission (days 4- S.D.) Physiotherapy after discharge (days 4- S.D.)
Group (n = 78)
Group 2 (n = 66)
p Value*
9.1 4- 2.9 701.4 4- 397.7 0.4 4- 0.8 60.4 4- 157.9 18.2 15.6 2.6 8.5 4- 4.6 2.2 4- 8.6
8.5 4- 3.2 600.1 4- 435.6 0.6 4- 1.8 66.1 4- 197.0 21.5 13.8 3.1 4.7 4- 3.6 1.4 4- 3.7
NS 0.07 NS NS NS NS NS 0.0001' NS
*NS=p>0.10 1-Serious shoulder restriction was definedas a reduction of abduction, anteflexion, horizontal abduction, exo-rotation with the humerus in a neutral position or exo-rotation with the humerus in 90 ~ abduction by 20~ or more at 6 months, when compared with contralateral shoulder function at 6 months. * As a direct result of the study design.
482
THE AMERICAN JOURNAL OFSURGERY
VOLUME 160 NOVEMBER 1990
SHOULDER EXERCISES AFTER AXILLARY NODE DISSECTION
Therefore, 144 patients were evaluable. Of these, 78 were in group 1 (immediate exercises) and 66 were in group 2 (7 days of immobilization). The three types of operations [modified radical mastectomy, (101 patients), and axillary lymph node dissection with (38 patients) or without lumpectomy (5 patients)] were equally divided among the two groups. Patient data (age, left- or right-sided operation, dominancy of the involved arm, and preoperative shoulder function) were comparable between the two groups. Mean age was 59.2 years (range: 28 to 81 years). Seroma: When comparing the two groups, only the number of days of physiotherapeutic supervision during admission was significantly higher in group 1 (Table I). Patients in group 2 had 14% less wound drainage volume (600 4- 436 mL versus 701 4. 398 mL) than patients in group 1, but this difference was not statistically significant. All other variables (axillary drainage time, number and volume of seroma aspirations, percentage of patients with serious shoulder restrictions, wound complications,
.oI ,
and lymphedema, and number of days of physiotherapy at home) were equal. Shoulder function" A distinctive pattern could be seen in the measurements of all shoulder functions over time (Figure 1): preoperative values of abduction, anteversion, horizontal abduction exo-rotation with the humerus in a neutral position, and exo-rotation with the humerus in 90 ~ abduction were those of normal, unaffected shoulders; ipsilateral and contralateral shoulder functions were equal. On the first day of exercise, there was a sharp decrease in all shoulder function measurements, which disappeared almost completely during the first 6 postoperative months. All shoulder functions were slightly reduced 6 months after operation. Abduction was reduced by 7.7 4- 1.4 ~ and anteflexion by 7.7 4- 1.1 o. Horizontal abduction, exorotation with the humerus in a neutral position, and exorotation with an abducted humerus were all reduced by less than 2* when compared with those of the contralateral shoulder.
160
1.1,:oi 100
80 I~
60
L
PrI. . . . . operative
Lx. . . . . . day
Ois~mi. . . . .
_ _
Immediale exercise
.....
Irnmobdisation
fter I1 . . . . . .
80 l ' -
60
fter 16 . . . . . .
110
80
106
74
~02
6a
98
62
94
~
I
1st exercise day
Dismissal
I r cise lsl exe
Dis /m ' issal
I
After 1 mont
lmmobilisatlon
h
After 8 Imonths
day
tmmediate exercise
: ! mm~db:I ts~fi~ . . . . .
..... 50
After 6 monlhs
After 1 month
Immediate exercise
.....
56
.....
I
90 Preoperative
r eoperative
_ _
I Preoperative
I 1st exercise day
I Dismissal
/
Immobilisation I
After 1 month
After 6 months
\\
_
_
.....
Pr~
1st exercise
operative
day
Immediate
exercise
Immobilisation
I
i
I
Dismissal
After 1 month
After 8 months
Figure 1. Results of shoulder function in group 1 (immediate exercises) and group 2 (immobilization). Top left, abduction; top right, anteflexion; middle left, horizontal abduction; middle right, exo-rotation; bottom left, exo-rotation with humerus in 90 ~ abduction.
T H E A M E R I C A N J O U R N A L OF S U R G E R Y
V O L U M E 160
N O V E M B E R 1990
483
,JANSEN ET AL
In this pattern and especially in the final outcome of shoulder functions after 6 months, no differences could be seen between the two exercise scheme groups (Figure 1). A total of 28 patients [19.4%, equally divided among the exercise scheme groups (Table I)] experienced a reduction of either shoulder movement of more than 200; in 13 patients (9% of all patients), the reduction was more than 30 ~ . Patient age appeared to play a small role in some variables. Older patients needed longer physiotherapeutic supervision: 1 day for every 11 extra years of age. The volume of axillary drainage increased slightly with age: 6 m L for every year. Axillary drains were removed 1 day later for every 14 years of age. Preoperative shoulder functions were slightly less in older patients (a mean decrease of 3.4 ~ abduction and 3.8 ~ in anteflexion per 10 years), but older patients did not have a bigger reduction of shoulder function after the operation than younger patients did. COMMENTS In this study, we compared two different exercise schemes after axillary lymph node dissection. Only one difference in final outcome appeared to exist: a slightly higher axillary drainage volume in the group who exercised on the first postoperative day (701 4- 398 versus 600 4- 436; p = 0.07). The difference in physiotherapeutic supervision during admission (8.5 4- 4.6 days versus 4.7 43.6; p = 0.001) is a direct result of the difference in exercise schedules between the two groups. These results are equivalent to those of Van der Horst et al [5] and Dawson et al [6] in smaller series. The relatively high percentage of women with a serious restriction of shoulder movement (19.4%) is of concern. To our knowledge, no figures on this complication of modified radical mastectomy or axillary lymph node dissection exist in the recent literature. Further studies on causes and prevention of this loss of shoulder function are required. In our series, the influence of postoperative radiotherapy was not considered, although it is known that irradiation of the supraclavicular fossa and/or axilla reduces shoulder mobility [8]. Because this phenomenon seems to be important after a long period, this problem was not expected in our study since measurements were taken at the most 6 months after the operation.
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CONCLUSIONS Since no difference has been found in shoulder function after immediate and delayed shoulder exercises and since a decrease of seroma production of about 14% was seen after immobilization, we prefer a period of rest after operation before starting exercises. The high percentage of women with serious restrictions in shoulder function (19.4%) requires further studies. On the basis of these results, we decided to change our postoperative instructions to our patients. During the first week, patients may use the affected arm and shoulder as much as desired. In our experience, patients do so until they feel some pain or discomfort. After 1 week, measurements are made, and physiotherapy is requested when a marked reduction in function is found.
This manuscript represents a careful evaluation of a common management problem for patients having axillary lymph node dissection and shows no difference between delayed versus immediate shoulder exercises.
REFERENCES 1. Aitken DR, Minton JP. Complicationsassociated with mastectomy. Surg Clin North Am 1983; 63: 1331-52. 2. Pollard R, Callum KG, Celtman DG, Bates T. Shoulder movement following mastectomy. Clin Oncol 1976; 2: 343-9. 3. Flew TJ, Wound drainage following radical mastectomy: the effect of restriction of shoulder movement.Br J Surg 1979; 66: 3025. 4. Lotze MT, Duncan MA, Gerber LH, Woltering EA, Rosenberg SA. Early versus delayed shoulder motion followingaxillary dissection: a randomizedprospectivestudy. Ann Surg 1981; 193: 288-95. 5. Van der Horst ChMAM, Kenter JAL, De Jong MT, Keeman JN. Shoulder function following early mobilization of the shoulder after mastectomy and axillary dissection. Neth J Surg 1985; 37: 105-8. 6. Dawson I, Stan L, Heslinga JM, Kalsbeek HL. Effect of shoulder immobilization on wound seroma and shoulder dysfunction following modified radical mastectomy; a randomized prospective clinical trial. Br J Surg 1989; 76: 311-2. 7. Madden JL. Modified radical mastectomy. Surg GynecolObstet 1965; 121: 1221-30. 8. Aitken R J, Gare MN, Rodger A, Chetty U, Forrest APM. Arm morbidity within a trial of mastectomy and either nodal sample with selective radiotherapy or axillary clearance. Br J Surg 1989; 76: 568-71.
VOLUME 160 NOVEMBER1990