Effectiveness of PNF Training for Improving for Muscle Strength, Function, and Pain After Axillary Lymph Node Dissection
Condition: Breast Cancer; Muscle Strength
Study type: Interventional

Summary: 
      Breast cancer is the most common type of cancer affecting women of all ages worldwide.
      Advanced and comprehensive treatment options have increased survival rate and life
      expectancy, necessitating a focus on the complications of breast cancer treatment. Although
      axillary lymph node dissection (ALND) causes high morbidity, it is an integral part of
      surgical treatment in patients with invasive breast cancer and axillary lymph node
      metastasis. Axillary lymph node dissection and radiotherapy are associated with pain,
      physical symptoms, and decreased functional abilities in the upper extremity. This study
      aimed to compare the potential effects of proprioceptive neuromuscular facilitation (PNF)
      technique on muscle strength, pain and functionality in this patient group with progressive
      resistance exercise (PRT).
    

Detailed description: 
      Breast cancer is the most common type of cancer affecting women of all ages worldwide. An
      increase in the incidence of breast cancer is observed with the effect of widespread
      screening programs today. Improved and comprehensive treatment options (surgery,
      radiotherapy, systemic adjuvant and neoadjuvant therapy, hormonal therapy) have increased the
      survival rate and life expectancy. This has necessitated a focus on the short, medium and
      long term complications of breast cancer treatment and their management.

      Although axillary lymph node dissection (ALND) causes high morbidity, it is an integral part
      of surgical treatment in patients with invasive breast cancer and axillary lymph node
      metastasis (2). Radiotherapy is routinely used to reduce the local recurrence rate after
      ALND. 73% of the patients who received these treatments reported that they had at least 1
      complaint of limitation of shoulder joint range of motion, loss of strength in the operated
      arm, pain, lymphedema numbness, fibrosis, fatigue, and inability in activities of daily
      living in the postoperative period.

      It is known that the muscle strength of the operated side arm is less than the strength of
      the contralateral extremity and the strength of healthy women due to many reasons such as
      deterioration of the soft tissue integrity of the chest wall with surgery, inactivity
      tendencies of the patients due to protecting the operated arm, adhesions that may occur with
      radiotherapy, and fibrosis formations making movement difficult. In addition, one-third of
      women with breast cancer treated with surgery experience permanent loss of strength in their
      upper extremity muscles for more than 1 year after treatment. According to the results of a
      study investigating the causes of persistent pain after breast cancer treatment, ALND and
      radiotherapy administration are the two main risk factors for persistent pain, and 21% of
      women who have ALND experience persistent shoulder/arm pain throughout their lives. Adequate
      muscle strength and no pain during movement are of great importance for the quality of
      movement and for the smooth performance of daily life activities. In a study on patients'
      evaluation of their own upper extremity functionality, women receiving breast cancer
      treatment stated that they were more functionally limited than their healthy peers and had
      difficulties in activities of daily living. In a study of large populations, it was reported
      that the prevalence of functional limitations in women receiving breast cancer treatment
      ranged from 18% to 54%. Functional limitations complicate the situation and bring the need
      for additional treatments to improve daily living activities, as well as the application of
      treatments related to the current disease to the patient.

      Exercise is one of the most commonly used modalities in the rehabilitation of patients
      receiving breast cancer treatment. The main goals of exercise in these patients are to
      increase muscle strength, reduce pain, increase limited range of motion and contribute to the
      ability to continue activities of daily living. Resistance exercises are the most commonly
      used method to provide strength gain and restoration, and there are many studies in the
      literature on their positive effects on strength enhancement in the affected extremity.

      The proprioceptive neuromuscular facilitation (PNF) technique applied for the treatment of
      the operated shoulder/arm may play a role in regaining strength, power and endurance by
      increasing the response of neuromuscular mechanisms by stimulating the proprioceptors. At the
      same time, there are studies showing that this treatment modality provides a significant
      reduction in shoulder-arm pain and provides painless quality movement. With this technique,
      functional restoration is provided thanks to the movement patterns applied in the diagonal
      direction. These gains reveal the importance of using the PNF technique more frequently in
      breast cancer patient groups where it is applicable.

      The PNF technique is emerging as a therapeutic option to increase muscle strength, reduce
      pain, and improve functionality in patients treated for breast cancer with ALND. The aim of
      this study is to compare the efficacy of resistance exercise and PNF technique, the
      effectiveness of which was defined on the patient, on the aforementioned subjects.Patients
      who applied to Istanbul Medipol University General Surgery Department for routine control
      after breast cancer treatment were determined. Individuals who were willing to participate
      and met the inclusion criteria were divided into 3 groups (PNF, progressive resistant ex.,
      control) using the website www.randomizer.org.

      Exercise was applied to both Proprioceptive Neuromuscular Facilitation (PNF) and Progressive
      Resistance Exercise (PRE) groups, 2 days a week for 8 weeks. Each session lasted an average
      of 1 hour. Exercise sessions; It was carried out under the supervision of the same
      physiotherapist with experience in the field and individually with each patient. At the
      beginning and at the end of the treatment, warm-up-cooling exercises including mild
      stretching exercises to increase the range of motion were performed for 5-10 minutes. In both
      groups, exercises were performed only for the affected extremity.
    

Intervention name(s): Proprioceptive Neuromuscular Rehabilitation group; Progressive Resistance Exercise Group; Control Group
Intervention type(s): Other; Other; Other
Intervention description(s): The PNF technique was performed in the supine position with the hip joints of the patients in 30° flexion and the lower extremities in semi-flexion. The application was performed in 2 different diagonal and 4 different patterns (flexion-abduction-external rotation/extension-abduction-internal rotation, and flexion-adduction-external rotation/extension-abduction-internal rotation) of the upper extremity. When starting the exercise, the muscles were first brought to their longest position and the patient was asked to move in the direction of the pattern with resistance (concentric contraction) and to maintain this position for 6 seconds at the end of the pattern (isometric contraction). Then, while the therapist was taking the patient's arm to the starting position, the patient was asked to prevent movement (eccentric contraction). All of these moves counted as one repetition. 3 sets of 8-12 repetitions were performed for each pattern.; Strengthening exercises targeting the upper extremity main muscles were applied to the PRE group with progressive resistance. Dumbbells and sandbags were used as resistance equipment. resistance intensity; 50-80% of a repetition maximum (RM) was determined according to the patient's tolerance. The exercises were applied as 8-12 repetitions and 3 sets. A rest period of 60-90 seconds was allowed between each set. After the 4th week of the training, 1 RM was measured again and the resistance density was updated. The 8 strengthening exercises to be applied were created by taking examples from the literature and in accordance with the "Guidelines for implementing exercise programs exercise programs for cancer patients". These exercises are: "dumbbell fly", "triceps extension", "biceps curl up", "one-arm bent over row", "dumbbell sides rise", "lifting the arm forward", "wrist curl" and side lying shoulder internal -external rotation".; The patients in the control group were instructed to continue their usual daily lives (not changing their physical activity levels, diet, drug use, etc.) until the date of re-evaluation after the initial evaluation. Information was given about the upper extremity normal range of motion exercises that they could apply at home, and a brochure was given.
Other intervention name(s): PNF; PRE
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Proprioceptive Neuromuscular Facilitation; Pain; Axillary Disease