Introduction

Breast cancer is the most common cancer affecting females. Important survival rates have been achieved in recent decades, due to advances in treatment, but side-effects of these treatments are frequent. In women who were treated by mastectomy, a common side-effect is the occurrence of adhesive capsulitis or frozen shoulder. In primary (also called idiopathic) frozen shoulder, exercise therapy is the gold standard treatment. Much less is known about the conservative treatment options for post-mastectomy frozen shoulder, which is an acquired form of adhesive capsulitis. In this light, this study aimed to broaden our knowledge about the effectiveness of post-mastectomy frozen shoulder exercises.

Methods

In this randomized controlled trial, females with a post-mastectomy frozen shoulder on one side were included. They were all between 40 and 60 years of age. Their frozen shoulder was in the second (frozen) phase. Their shoulder pain was ongoing for at least 3 months, and the stiffness led to restrictions in shoulder range of motion for flexion, abduction, and internal and external rotation of at least 50% compared to the healthy shoulder.

The included women received post-mastectomy frozen shoulder exercises. They were randomized to either conventional physiotherapy or the experimental intervention consisting of Thera-band exercises, scapular stabilization exercises, and the conventional program. The control group only performed the conventional physiotherapy program. The authors described this conventional physiotherapy to include the following:

Conventional Physiotherapy Program:

• Frequency: 30-40 minutes, 5 days per week for 8 weeks.
• Components:
  • Hot Packs: Applied for 5-10 minutes.
  • Passive Mobilization Exercises:
    • Glenohumeral (GH) Joint Mobilizations:
      • Posterior gliding to increase flexion and internal rotation.
      • Caudal glide to increase abduction.
      • Anterior gliding to increase external rotation.
    • Scapulothoracic Mobilization: To improve scapular movements (protraction/retraction, elevation/depression, and rotation).
  • Active Range of Motion (ROM) Exercises:
    • Pendular Exercises: Leaning forward with the unaffected hand on a table, swaying the arm back and forth, side to side, and in circular movements (10 reps, 5 times per day).
    • Wall Climb Exercises: Climbing the wall with the hand, holding for 15-30 seconds at the peak (10 reps, 5 times daily).
  • Capsular Stretching Exercises: Stretching the anterior, posterior, and inferior shoulder capsule, holding for 15-30 seconds (5 reps, 5 times per day).

The intervention group participated in a combination of graded Thera-Band exercises and scapular stabilization exercises, in addition to the same conventional physiotherapy program.

Graded Thera-Band Exercises:

• Frequency: 60 minutes, 5 days per week for 8 weeks.
• Progression: Started with the yellow band, then progressed to red, and finally green as they could complete three sets of 10-15 reps of 25 seconds easily.
• Exercises: shoulder flexion, abduction, internal rotation, external rotation

Scapular Stabilization Exercises:

• Frequency: 30 minutes, 10 reps each.
• Exercises:
  • Scapular Clock Exercises: Arm placed on a wall, moving fingers to 12, 3, 6, and 9 o’clock positions to improve scapular elevation, protraction, depression, and retraction.
  • Towel Slide Exercises: Hand on a towel on the wall, moving in a 12-inch (30.5 cm) backward and forward motion.
  • Ball Stabilization Exercises: Hand on a ball against the wall, keeping the ball stable while disturbances are applied.
  • Lawnmower Exercises: Pulling a weight with lower extremity extension and trunk rotation.
  • Serratus Anterior Punch: Performing alternative punches while holding the Thera-Band for resistance.

These post-mastectomy frozen shoulder exercises aimed to improve shoulder range of motion (ROM), muscle strength, and overall quality of life (QoL).

Outcome measures:

The outcome measures were assessed before and after the 8-week intervention period and included:

• Shoulder physical function was measured by the Disability of the Arm, Shoulder and Hand Questionnaire (DASH)
• Pain measured by the Visual Analogue Scale (VAS),
• Quality of life is measured by the Short-Form 36 (SF-36).
• Range of motion was assessed using a digital goniometer
• Muscle strength was objectively measured using a handheld dynamometer

No subdivision between primary and secondary outcome measures was specified.

Results

Seventy participants were included in the trial. At baseline, the groups were comparable.

The analysis indicated a significant interaction of the intervention and time (F18,51=139.81, p=0.001,=0.98). Both the effect of time (F18,51=1181.78, p=0.001,=0.99), and intervention (F18,51=35.59, p=0.001,=0.92) was significant.

The between-group comparisons showed that pain, DASH score, range of motion (in all directions), and quality of life were significantly more improved in the intervention group.

All directions of range of motion were significantly improved in both groups. However, the mean difference showed significantly better improvements in the intervention group for all directions of range of motion.

All dimensions of quality of life, measured using the SF-36 were significantly improved in both groups, but also here, the mean between-group difference indicated that the intervention group improved to a greater extent.

Questions and thoughts

Why did the intervention group improve to a larger extent? I assume that the reason behind it was twofold. On the one hand, the intervention group participated in double the amount of physiotherapy compared to the control group. The intervention group had sessions of at least 90-100 minutes duration, while the control group only participated in 30-40 minutes of training. On the other hand, the conventional physiotherapy program is merely a passive and active-passive intervention, while the experimental intervention group also had to perform challenging strengthening and stabilization exercises. The effectiveness of strengthening in primary frozen shoulder has already been established in a trial by Kumar et al. (2017). Taken together, I understand that a more challenging exercise program of significantly longer duration would add up to increased effectiveness, as demonstrated in the intervention group.

Physiotherapists can incorporate graded Thera-Band exercises and scapular stabilization exercises into rehabilitation programs for post-mastectomy AC patients to enhance shoulder function and QoL. The trial did not encounter any adverse event, and thus these exercises are safe to add to the conventional therapy approach.

The findings can be generalized to similar populations undergoing mastectomy and experiencing frozen shoulder, as the exercises used are widely applicable. However, no details about the status of the cancer treatment were given, so we can not say if these women were still undergoing treatment or not. This limits the generalizability.

Talk nerdy to me

The study’s methodology, including randomization and comprehensive outcome measures, ensures robust results. However, the absence of blinding during treatment and lack of long-term follow-up are limitations.

The scapular stability exercises aimed to improve the scapular alignment and movement. Unfortunately, this was not measured. So was it because the scapula moved better, or the muscles surrounding the scapula got stronger?

An important limitation was the lack of a defined primary outcome. In the registered protocol, the authors indicated that the primary outcome measures were shoulder range of motion, physical functioning measured using the DASH, and health-related quality of life measured by the SF-36. The other outcomes muscle strength and pain were considered secondary outcome measures. A Bonferroni correction that set the p-value lower was used to be able to make different comparisons.

Take home messages

This randomized trial compared conventional physiotherapy to an experimental intervention consisting of Thera-band exercises and scapular stabilization exercises added to conventional physiotherapy. Both groups showed significant improvements in shoulder ROM, muscle strength, pain reduction, and QoL. However, the intervention group demonstrated significantly greater improvements compared to the control group.

The intervention group had lower VAS scores and DASH (Disability of the Arm, Shoulder, and Hand) scores post-treatment, indicating less pain and better shoulder function.Significant increases in shoulder flexion, abduction, internal and external rotation, and muscle strength were observed in the intervention group.All aspects of QoL, including physical functioning, role functioning, bodily pain, general health, vitality, social health, emotional health, and mental health, improved significantly more in the intervention group.

Combining Thera-Band strengthening and scapular stabilization exercises significantly benefits shoulder function and quality of life in post-mastectomy frozen shoulder patients, making it a valuable addition to conventional physical therapy programs.

Reference

Aboelnour NH, Kamel FH, Basha MA, Azab AR, Hewidy IM, Ezzat M, Kamel NM. Combined effect of graded Thera-Band and scapular stabilization exercises on shoulder adhesive capsulitis post-mastectomy. Support Care Cancer. 2023 Mar 16;31(4):215. doi: 10.1007/s00520-023-07641-6. PMID: 36922413; PMCID: PMC10017571.