It is important to have early detection and effective treatment options that can allow us to improve the outlook for breast cancer and this should be the goal of all health care practices. What we do know to be true for people with cancer is that it’s still a huge ordeal to live through and it’s not without its complications. In fact, lymphedema is one of the most frequent side effects of breast cancer, with most cases arising 18-24 months after treatment [1]. Dissection of the axillary lymph nodes and radiation are considered to be factors contributing to this outcome. Is lymphedema just swelling though? Far from it! It is also associated with other symptoms such as pain, bloating, pressure, fatigue, limited joint movement, and subsequent reduction in use of affected limbs.
A reality for those who have gone through treatment is that postoperative pain can be a common side effect. In fact, it occurs in at least half of women who have undergone surgery, and it tends to hit between 6 and15 months after operation [1]. Does this mean that people suffering from breast cancer ignore the advice of their oncology team? Absolutely not! This is life-saving or life prolonging advice. But as this case reports show, that doesn’t mean you can’t consult your chiropractor for subluxation-based care in the aftermath.
In a recent case report published in the Journal of the International Academy of Neuromusculoskeletal Medicine, a 67-year-old female presented with the main complaint of radiating numbness and swelling in both of her hands [2]. She had been diagnosed with stage 2 breast cancer and had undergone a radical mastectomy. The patient reported she had been receiving chiropractic care previously which involved spinal adjustments and provided minimal relief. She was also receiving physical therapy which required her to wear compression bandages to prevent post-surgical lymphadenopathy. She reported this was causing her significant discomfort and further reducing her ability to go about activities in her daily life.
All shoulder range of motion was reduced and pain was experienced when performing the wall angel functional assessment. She was unable to place her arms into the 90-degree position, indicating external rotator cuff and pectoralis minor issues bilaterally. Multiple over-the-counter non-steroidal anti-inflammatory medications were being taken by the patient, but with no improvement in symptoms. At the time of presentation her condition was impacting her ability to perform daily activities and her job performance.
The chiropractor noted decreased sensation along the C6 and C7 dermatomes on both sides. Her blood pressure was 135/70 with a heart rate of 65 bpm. Active range of motion of the shoulders were confirmed to be decreased by a positive O’Donoghue test. The chiropractor determined the pain in the shoulders was of a muscular cause, as passive range of motion elicited no pain while resisted range of motion did. Hypertonicity in both the infraspinatus and pectoralis minor muscles on both sides were also identified.
The Chiropractic Care Plan
As she commenced a new care plan with a new chiropractor, Myofascial release technique was performed to relax the hypertonic infraspinatus and pectoralis minor muscles. A prone diversified chiropractic adjustment was performed on the cervicothoracic junction at C7-T1. The patient demonstrated an immediate increase in shoulder range of motion and reported feeling tension relieved throughout her upper body.
The chiropractor recommended home stretches to be performed 5 times per day for 30 second holds. She received one chiropractic session a week for 6 weeks, following which a re-evaluation was performed. She reported experiencing her symptoms less frequently over the first 2 weeks of treatment, and by her re-evaluation reported no symptoms.
The authors suggest this case opens the door for future research into the potential benefits of chiropractic care in relieving symptoms caused by serious illness such as double mastectomy and postsurgical lymphedema.
Let’s talk about what it all means
It is important we draw attention to the lack of honest discussion about the implications and limitations of this study included in its published report. A large part of the value of case reports is found in the tying in of other pieces of literature. The context of a case report in broader research (and quality documentation) is what brings meaning to the story. The current case also lacks any objective, quantifiable, or detailed data regarding its outcomes, however, let us not be too hasty in throwing it out altogether. When positioned against the background of the following reviews and controlled trials, its value deepens.
A systematic review and meta-analysis has been conducted reviewing studies of myofascial techniques with female participants who had completed breast cancer treatment at least 2 months prior and had upper limb or neck pain [1]. This study was the first of its kind. In this study, pain and shoulder functionality were the two primary measures. The secondary measures were shoulder mobility, mood state, quality of life.
Although there was no statistical significance beyond range of motion in abduction, all of the studies individually reported a clinically relevant improvement in favour of the experimental group with myofascial intervention. The effectiveness of the therapy, by this review, remains unclear because the subgroup analyses were hampered by the small number of studies that include the same outcome measures and long term follow ups. Limited by a small number of published trials to date [1].
An earlier systematic review and meta-analysis reviewed 5 papers relevant to chronic musculoskeletal pain in female breast cancer survivors and manual therapy. Again, myofascial techniques featured heavily in the review [3]. The evidence reviewed suggests manual therapy is considered effective for treating chronic musculoskeletal pain in the upper limbs and thorax of female breast cancer survivors (and chiropractic care is considered a manual therapy modality). However, this review found no significant difference in quality of life after the intervention compared to the control.
A randomised controlled trial featuring 21 breast cancer survivors also revealed improvement in range of motion in affected upper limb nerves following a single session of myofascial induction. It demonstrated significant change in mechanosensitivity, particularly with regard to the ulnar nerve [4].
Yet another study assessed blood flow after manual lymphatic drainage in women who had received surgery for breast cancer and had post-axillary lymphadenectomy lymphedema [5].
One group received manual lymphatic drainage without upper limb elevation and the other received it with 30 degree elevation. Significant increase in blood flow velocity was noted immediately after the procedure with upper limb elevation – that is, a higher velocity of venous blood flow post treatment, which after 30 minutes, returned to baseline values.
In 2020, a paper appeared in the Journal of the Canadian Chiropractic Association discussing the important question of whether there was a role for chiropractic care in cancer care (as distinct from post cancer care) [6]. While the latter question is perhaps more easily answered in that a body that has been through such an ordeal deserves the gentle, considered care of a chiropractor who can nurture the nervous system back to adaptability, the former question remains difficult. Some notable comments from the 23-expert panel feeding into the paper included the following [6]:
“The reasons that a patient with cancer will visit a chiropractor were not considered to be different from those of any other patient namely: musculoskeletal pain/conditions. One panellist reported that “cancer patients seek chiropractic care for neurological complications affecting eyesight, balance, dizziness, autonomic nervous system complications and weakness”.
“Most patients seek chiropractic treatment after the cancer was diagnosed” and “the aim should be the improvement of the function of the patient and that multidisciplinary patient centred approach could benefit patients with cancer”.
Three of the panellists stated that chiropractors should not treat the cancer but address the neuro-musculoskeletal problems of the patient and help them by improving their function.
A further panellist stated: “patients with cancer may benefit from chiropractors and a vitalistic approach as long as it is as part of multidisciplinary management. Contraindications must be considered and weeded out very carefully. Specific chiropractic spinal manipulation guidelines must be determined, and all of the healthcare providers must work together in a patient-centred manner”.
There are many opportunities for chiropractic to enter the conversation with respect to supporting people who are being managed with cancer and how they can have enhanced health outcomes, and potentially a more positive health trajectory. Naturally, there is significant research that needs to be done into the benefits of chiropractic which is exactly what this report is highlighting – that people do seek chiropractic care for both musculoskeletal and other reasons for their care during their cancer diagnosis.
The value of this report highlights the need for further investigation into why a person would seek chiropractic care during their cancer journey, the benefits of seeking that care, and the outcomes of a patient undergoing cancer treatment with or without chiropractic care and the impacts on quality of life. Through the use of our thorough examination, history, orthopaedic and neurological testing in chiropractic practice provides an opportunity to not only identify the areas that might benefit from chiropractic or multidisciplinary care, it might also flag appropriate referral for early diagnosis for this portion of the population.
It is important in the matter of cancer that chiropractors know and understand the symptoms, understand when and how to refer (particularly if they see a red flag), and be comfortable being part of a multidisciplinary team for the management of these patients. We can support nervous system and musculoskeletal health while simultaneously pressing forward for greater research to evidence the impact chiropractic can have in such situations. Until this research is done, the focus needs to remain on working within these multidisciplinary teams and letting the researchers blaze the trails.
References:
- Lara-Palomo IC, Castro-Sánchez AM, Córdoba-Peláez MM, Albornoz-Cabello M, Ortiz-Comino L. Effect of Myofascial Therapy on Pain and Functionality of the Upper Extremities in Breast Cancer Survivors: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2021. 18(9):4420.
- J Hodges, N Beck. Chiropractic care and rehabilitation combined with myofascial release technique after double mastectomy: A case report. J Int Acad Neuromusculoskel Med. 2022. 19(1): 35-40.
- Pinheiro da Silva F, Moreira GM, Zomkowski K, Amaral de Noronha M, Flores Sperandio F. Manual Therapy as Treatment for Chronic Musculoskeletal Pain in Female Breast Cancer Survivors: A Systematic Review and Meta-Analysis. J Manipulative Physiol Ther. 2019. 42(7):503–13.
- Castro-Martín E, Galiano-Castillo N, Ortiz-Comino L, Cantarero-Villanueva I, Lozano-Lozano M, Arroyo-Morales M, et al. Effects of a Single Myofascial Induction Session on Neural Mechanosensitivity in Breast Cancer Survivors: A Secondary Analysis of a Crossover Study. J Manipulative Physiol Ther. 2020. 43(4):394–404.
- Guerero RM, das Neves LMS, Guirro RR de J, Guirro EC de O. Manual Lymphatic Drainage in Blood Circulation of Upper Limb With Lymphedema After Breast Cancer Surgery. J Manipulative Physiol Ther. 2017. 40(4):246–9.
- Laoudikou, M. T., & McCarthy, P. W. (2020). Patients with cancer. Is there a role for chiropractic?. The Journal of the Canadian Chiropractic Association, 64(1), 32–42.
