Timing of physical therapy to optimize shoulder range of motion among patients receiving breast radiotherapy

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Specht, Eric C Liao, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3325900/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Establishing optimal timing of physical therapy (PT) during multimodal breast cancer treatment can be challenging. We hypothesized patients initiating PT post-surgery and pre-radiation therapy (RT) would experience greater gains in functionality compared to PT initiated during/after RT. Methods A retrospective review was performed for patients receiving multimodality breast cancer treatment and PT between 1/2015-8/2021. Three cohorts were established: patients who received no RT, PT initiated before RT (pre-RT), and PT during/after RT (d/a-RT). The primary endpoint was percent change in ipsilateral shoulder ROM between first and last PT visits. Associations between range of motion (ROM) across groups and baseline characteristics were evaluated with analysis of variance testing. Results Thirty-seven patients were identified, median age of 47 years. The no-RT cohort exhibited the greatest mean percent improvement in ROM with PT (74%) versus pre-RT (59%) and d/a-RT (20%). The no RT and pre-RT groups demonstrated greater improvements in ROM compared to patients receiving PT d/a-RT (no RT 74% vs d/a-RT 20%, p = 0.006; pre-RT 59% vs d/a-RT 20%, p = 0.045). There was no difference in ROM gains between the no-RT and pre-RT groups (p = 0.528). Lower baseline ROM was associated with smaller improvements in ROM after PT (p = 0.008). When adjusting for baseline ROM, the no-RT cohort remained associated with ROM improvement compared to the d/a-RT group (p = 0.024). There was no difference in ROM change between no-RT and pre-RT cohorts. Conclusion PT improves shoulder ROM in patients undergoing multimodality breast cancer treatment; however, early initiation of PT before starting RT may maximize ROM gains. Breast cancer breast cancer rehabilitation physical therapy timing upper extremity range of motion Figures Figure 1 Figure 2 Introduction Upper limb disability and functional limitations are frequent concerns after breast cancer treatment [ 1 ]. Women undergoing surgery, including reconstructive surgery, axillary lymph node dissection, and radiation often experience a host of musculoskeletal sequelae such as reduced shoulder range of motion (ROM), pain, axillary cording, diminished strength, paresthesias, lymphedema and fatigue [ 2 ]. These impairments can lead to the inability to raise one’s arms overhead or behind the scapular plane, which is critical for activities of daily living (ADL) and instrumental ADLs [ 3 ]. This can cause a decline in quality of life and generate lasting discomfort that can extend for years after completion of cancer therapy [ 2 ]. Known predictors of long-term shoulder disability include the presence of positive lymph nodes at diagnosis for breast cancer, older age at diagnosis and elevated body mass index (BMI) [ 4 ]. Physical therapy (PT) has been shown to be an effective tool for reducing pain and improving ROM for breast cancer patients to reduce long-term impairment [ 5 ]. With limited studies examining early surveillance of ROM deficits after multimodality breast cancer therapy, there is a paucity of data surrounding when physical therapy should be initiated to optimally prevent and reduce upper limb disability following breast cancer interventions [ 1 , 6 ]. In order to optimize cancer rehabilitation, we performed a retrospective review of patients referred to PT following breast cancer treatment, with a specific focus on the timing of initiating PT and the relationship of improvements in function. We hypothesized that patients who initiated early referral for physical therapy after surgery and before radiation therapy experienced greater gains in functionality over time. Methods Study Population A retrospective chart review was performed on all patients referred to outpatient oncology PT receiving multimodal treatment for breast cancer at Massachusetts General Hospital from January 2015 to August 2021. For the purposes of this study, we included only PT referrals associated with treatment for breast cancer, including diagnoses related to decreased shoulder ROM, cording, lymphedema, and upper quarter pain. Clinical and treatment characteristics related to cancer and physical therapy were captured, including patient age, BMI, tumor staging, cancer-directed treatment (type of surgery including axillary surgery, reconstruction type, systemic therapy, radiation therapy), and details of the patients’ physical therapy interventions. While the nature and frequency of physical therapy performed were at the discretion of the individual provider, relevant details were captured. Interventions performed include therapeutic exercise, self-care/home management and manual therapy with a focus on range of motion, scar massage, lymphatic drainage and myofascial release. Specifically, shoulder ROM was collected at the first and last PT visits. If ROM measurements were not available at the final PT visit, the most recent documented measurements were captured. When within normal limits (WNL) was encountered in the chart for documented shoulder ROM, shoulder ROM flexion and abduction was assumed to be 160 degrees and shoulder external rotation to be 60 degrees based on normative data [ 7 ]. A standing institutional review board through Massachusetts General Hospital approved this study protocol. Study endpoints Descriptive statistics were used to report cancer and PT treatment characteristics. The primary endpoint in this study was the percent change of total ROM measurements of the ipsilateral shoulder before and after PT. Secondary endpoints included the absolute change in degrees of total ROM of the ipsilateral shoulder before and after PT. Range of motion changes by percent and absolute degrees of freedom were captured for individual measures of flexion, abduction, and external rotation. Total ROM was defined as a composite score of overall ROM change, calculated by summing vector changes for each movement. In addition, the timing of PT initiation was calculated from the date of index surgery until the first PT appointment across three identified cohorts: patients receiving no radiation therapy (no-RT), patients who initiated PT before radiation therapy (pre-RT), and patients who initiated PT during/after radiation therapy (d/a RT). The timing of patients who received no RT was compared to patients who initiated PT pre-RT and during/after RT in separate analyses. Statistical analysis Baseline clinical characteristics were summarized using medians and interquartile range (IQR) for continuous variables or as numbers and percentages for categorical variables. Associations between range of motion measures across RT groups (no-RT vs pre-RT and no-RT vs d/a-RT) and baseline characteristics were evaluated with analysis of variance (ANOVA) testing. Characteristics significantly associated with ROM were included in the multivariable analysis for ROM measures between groups using multiple ANOVA testing. Statistical analyses were performed with Stata, Version 17.0 (College Station, TX, USA). P values < 0.05 were considered statistically significant. Results Patient Characteristics A total of 37 patients were referred to PT during multimodal breast cancer treatment and had both baseline and follow-up ROM measurements. Nine (24%) patients received PT after index breast surgery without subsequent RT, 15 (41%) initiated PT before RT, and 13 (35%) began PT during/after the course of radiation. The median age of patients referred to therapy was 46 years for the no-RT group, 46 years for the pre-RT group, and 50 years for the PT during/after RT group. Most patients had unilateral breast cancer (n = 36, 97%), underwent mastectomy with breast reconstruction (n = 34, 92%), had nodal surgery (n = 34, 92%), and received chemotherapy (n = 24, 65%). Higher tumor stage and axillary lymph node dissection were associated with the receipt of RT (p = 0.023 and p = 0.003, respectively) [Table 1 ]. Table 1 Patient characteristics No RT Pre-RT During/After RT P-value Number of patients 9 15 13 Patient Age 0.169 Median (mean) 46 (46.3) 46 (42.7) 50 (53.0) IQR 39–52 35.5–48.5 45–65 Range 32–60 28–58 36–76 BMI (kg/m 2 ) Median (mean) 21.3 (24.0) 24.1 (24.5) 28.5 (28.7) 0.055 IQR 20.5–24.8 23.0-26.7 24.5–32.1 Tumor Stage 0.023 T0 2 (22.2) 0 1 (7.7) T1 6 (66.7) 5 (33.3) 3 (23.1) T2 0 8 (53.3) 2 (15.4) T3 1 (11.1) 1 (6.7) 7 (53.9) T4 0 1 (6.7) 0 Lymph Nodes 0.434 N0 5 (55.6) 3 (20.0) 5 (38.5) N1 3 (33.3) 10 (66.7) 7 (53.9) N2 0 1 (6.7) 1 (7.7) N3 1 (11.1) 1 (6.7) 0 Laterality of Cancer 0.315 Unilateral 8 (88.9) 15 (100) 13 (100) Left 6 (66.7) 6 (40.0) 9 (69.2) Right 2 (22.2) 9 (60.0) 4 (30.8) Bilateral 1 (11.1) 0 0 Surgery 0.905 Unilateral 3 (33.3) 6 (40.0) 5 (38.5) Bilateral 6 (66.7) 9 (60.0) 8 (61.5) Mastectomy 9 (100) 15 (100) 14 (100) Lumpectomy 2 (22.2) 5 (33.3) 4 (30.8) Axillary Surgery 0.003 SLNB 5 (55.6) 3 (20.0) 7 (53.9) ALND 1 (11.1) 12 (80.0) 6 (46.2) No axillary surgery 3 (33.3) 0 0 Breast Reconstruction 9 (100.0) 15 (100.0) 13 (100.0) 0.183 Direct-to-implant (DTI) 7 (77.8) 15 (100.0) 11 (84.6) Tissue expander (TE) 2 (22.2) 0 2 (15.4) Chemotherapy 0.484 Neoadjuvant only 0 5 (33.3) 3 (23.1) Adjuvant 4 (44.4) 6 (40.0) 6 (46.2) None 5 (55.6) 4 (26.7) 4 (30.8) Timing and Duration of Physical Therapy The interval from index surgery to the first PT visit was a median of 43 days (interquartile range 32–115) in the no-RT cohort and 42 days in the pre-RT cohort (IQR 32.5–52.5). The cohort that initiated PT during/after RT had a median of 179 days (IQR 152–290) from index surgery to the start of PT and a median of 97 days (IQR 8-212) between radiation and the start of PT. Following index surgery, the median timing from PT to the start of radiation in the pre-RT group was 25 days (IQR 14-57.5). The timing, in days, between the first and last PT visit for the three cohorts were as follows: the no RT cohort had a median of 113 days (IQR 49–254). The pre-RT group’s median was 82 days (IQR 29–244) and the during/after RT had a median of 106 days (IQR 86–193) (p = 0.1237). Patients who initiated PT before RT completed a greater mean number of PT visits at 16.5 (median = 12, IQR 2–18) compared to patients who initiated PT during/after RT completed a mean of 8.2 visits (median = 5, IQR 3–13) and patients who received no RT completed a mean of 9.4 visits (median = 5, IQR 3–10) (p = 0.742). Range of Motion Outcomes Nearly all (34/37, 92%) patients across the three cohorts demonstrated improvements in overall ROM from baseline to the last PT visit. Three patients did not experience ROM gains. Of these, two experienced a decline in overall ROM and ceased PT intervention: one patient developed unexplained thoracic pain limiting participation in therapy, and the other patient experienced a decrease in ROM due to the development of breast cancer-related lymphedema in the arm causing poor PT adherence. The third patient only had one PT encounter following mastectomy and did not return for follow-up. This patient returned to PT 15 months following breast cancer treatment with continued shoulder ROM limitation. Overall, the no-RT group demonstrated the greatest mean percent improvement in ROM (74%), compared to the pre-RT and PT during/after RT cohorts, which demonstrated a 59% and 20% improvement, respectively [Figure 1 and Fig. 2 ]. In pairwise comparisons, patients who initiated PT before RT experienced greater total percent change in ROM compared to patients receiving PT during/after RT (59% vs 20%, p = 0.045) and greater absolute gains in degrees of ROM (56% vs 21%, p = 0.036). Although patients in the no-RT cohort demonstrated the greatest gain in mean percent ROM improvement, this change was only statistically significant when compared to the PT during/after RT group (74% vs 20%, p = 0.006). There was no difference in percent change in ROM or absolute change in degrees of ROM between the no-RT and pre-RT groups (percent ROM 59% vs 74% p = 0.528; absolute ROM 59.9 vs 55.8 p = 0.829) [Table 2 and Table S1 ]. Table 2 Percent improvement in degrees of active range of motion by timing of PT ROM Measure No RT Pre-RT PT d/a- RT P-value (No RT vs pre-RT) P-value (No RT vs during/after RT) P-value (pre-RT vs during/after RT) Overall ROM 74 59 20 0.528 0.006* 0.045* Flexion 30 18 6 0.360 0.089 0.074 Abduction 33 38 13 0.752 0.114 0.643 External Rotation 28 21 6 0.781 0.284 0.036* *P < 0.05 On univariate analysis, characteristics associated with percent change in improved ROM were higher N stage (p = 0.045) and worse baseline ROM (p = 0.007). On multivariate analysis, when adjusting for N stage and baseline ROM, baseline ROM continued to be associated greater improvement in ROM between patients who did not receive RT and those who received PT during or after RT (p = 0.024). On multivariate analysis, there was no difference in ROM between patients who received PT pre-RT compared to those who did not receive RT (p = 0.829). Discussion In this study, we found that patients who underwent PT prior to RT demonstrated greater improvements in ROM than those who initiated PT during or after RT. Notably, patients who received PT pre-RT demonstrated no statistical difference in ROM improvements compared to patients who did not receive RT. In contrast, patients who started PT after initiating RT demonstrated statistically worse ROM improvements compared to patients who received no RT. These results suggest that earlier intervention may maximize ROM gains and mitigate treatment-related effects of RT. To our knowledge, this is the first study that has quantified the relationship between the degree of ROM improvement with timing of PT intervention. Several systematic reviews have found that physical therapy is a helpful intervention to improve shoulder function for individuals with breast cancer [ 8 , 9 ]. Physical therapy is imperative to address shoulder range of motion limitations, as these limitations can often persist for months to years after breast surgery, ultimately contributing to pain and decreased function [ 6 , 10 ]. Additionally, there is level I evidence that suggests that breast and axillary radiotherapy are risk factors for reduced shoulder ROM in flexion, abduction and external rotation [ 9 ]. One study found that shoulder ROM deficits persisted up to 2 months after receiving RT for breast cancer [ 11 ], while another study found that shoulder flexion ROM deficits persisted 6 months post-operatively, relative to women who did not receive radiation (p = 0.01) [ 5 ] Hwang et al. found statistically significant improvements in mean shoulder ROM after RT with a guided exercise intervention [ 12 ]. Contrastingly, Klein et al. failed to identify an improvement in shoulder ROM after lumpectomy, axillary surgery, and radiation though this study was limited to written and verbal instructions to guide patient-directed exercises, in lieu of formal PT evaluation and therapist-directed interventions [ 5 ]. In our study, nearly all patients demonstrated improvements in shoulder ROM, regardless of surgical type or timing of PT to RT, when receiving formal in-person PT evaluation and intervention [ 13 ]. Of equal importance, however, is determining when to initiate PT for patients undergoing breast cancer therapy. To date, there has been a paucity of data on the optimal timing for performing PT during breast cancer rehabilitation to maximize both short and long-term ROM gains. Some studies have found that initiating exercise within the first week after surgery led to a faster recovery in ROM when compared to later intervention [ 14 – 16 ]. Conversely, other studies have shown an increase in adverse effects including wound dehiscence and seroma in the early intervention group, when compared to the group starting PT > 7 days after surgery [ 17 – 19 ]. For this reason, many providers delay early referral to PT after surgery, particularly in the case of breast reconstruction and/or axillary dissection, out of concern that it may lead to greater adverse effects [ 20 – 22 ]. In our study, the median time to initiate PT was 42 days postoperatively for the pre-RT group and 43 days for the surgery-only (no RT) group, which is consistent with prior studies that initiated exercise interventions within 45–70 days of surgery [ 23 – 26 ]. In the patients who initiated PT during or after RT, there was a median of 179 days between surgery and PT. One potential way to address ROM limitations early without increasing the risk of post-operative complications could be to begin gentle PT one to three weeks postoperatively, after initial wound healing is complete, with oversight by a physical therapist and input and support from members of the multidisciplinary breast oncology team [ 27 ]. These gentle PT interventions could include passive and active mobilization, stretching, resistance training, and scar tissue massage to enhance tissue extensibility, improve circulation, and assist with restoring normal movement patterns, with the degree of intensity of PT determined based on wound healing [ 27 – 29 ]. Interestingly, in our study the pre-RT group underwent more frequent PT visits, as reflected by an increase in the mean number of PT visits of 16.6 compared to the no-RT group’s 9.4 visits. The pre-RT group also had the greatest proportion of patients receiving ALND. Previous studies have shown that patients who receive ALND typically demonstrate a greater loss of ROM, which may be one reason why the pre-RT group required a greater number of PT visits [ 4 , 30 – 32 ]. However, despite this, the overall duration of PT was similar across groups, suggesting that the timing of initiation may be more important than the overall duration of therapy. Limitations There are several limitations to this study including its retrospective design and modest sample size. Physical therapy was at the discretion of the treating clinician, so therapy interventions were individualized and not necessarily standardized across patients. Additionally, only patients referred to physical therapy were included in the study sample. As a result, patients in our study may have experienced greater ROM deficits than the general population. Conclusion Physical therapy appears helpful in improving shoulder ROM among women who underwent multimodality breast cancer treatment. Starting PT before radiation therapy may help maximize long-term range of motion gains in women who undergo breast cancer therapy with surgery and RT. Future prospective studies and additional RCTs that include assessments at multiple time points during breast cancer interventions are needed to further elucidate the extent of ROM improvement with early intervention. Declarations Funding The authors declare no competing interests. This research did not receive any funding from public, commercial, or non-profit sectors. Competing Interests All authors declare that they have no potential conflicts of interest to disclose. Author Contributions CB, AS, MS, EL, and RBJ contributed to the study conception and design. Data collection was performed by BH and analysis led by BH, AS, CB, and RBJ. The first draft of the manuscript was written by CB, BH, AS, and RBJ and all authors commented on subsequent versions of the manuscript. All authors read and approved the final manuscript. Data Availability The datasets generated during and/or analyzed during the current study are not publicly available due to the small sample size and patient privacy, but are available from the corresponding author on reasonable request. Ethics approval A standing institutional review board through Massachusetts General Hospital approved this study protocol. This is a retrospective study; ethics accordance was not required for this study as this was a retrospective review. References Hayes SC, Johansson K, Stout NL. et al., Upper body morbidity after breast cancer: incidence and evidence for evaluation, prevention and management within a prospective surveillance model of care. Cancer. 2012;118:2237-49. Rietman, JS, Dijkstra, PU, Debreczeni R; Geertzen, et al., Impairments, disabilities and health related quality of life after treatment for breast cancer: A follow-up study 2.7 years after surgery. Disabil. Rehabil. 2004; 26:78–84. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3325900","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":233144528,"identity":"22b41801-9f72-4bbe-9874-1037352093c0","order_by":0,"name":"Carolyn Baek","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Carolyn","middleName":"","lastName":"Baek","suffix":""},{"id":233144529,"identity":"31ce8bf4-657b-4d1a-be60-0b713936b6ee","order_by":1,"name":"Anurag Saraf","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Anurag","middleName":"","lastName":"Saraf","suffix":""},{"id":233144530,"identity":"7d47ca10-5273-4bb4-a956-0046934418b7","order_by":2,"name":"Bonnie Hu","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bonnie","middleName":"","lastName":"Hu","suffix":""},{"id":233144531,"identity":"b228f10e-a0f1-44e7-9fa3-079173cfbcdc","order_by":3,"name":"Michelle C. Specht","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"C.","lastName":"Specht","suffix":""},{"id":233144532,"identity":"a54edfdd-8ae3-4426-acfe-6300b863d9cc","order_by":4,"name":"Eric C Liao","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eric","middleName":"C","lastName":"Liao","suffix":""},{"id":233144533,"identity":"ed45e625-7c6e-455b-98c7-e16d31cd3441","order_by":5,"name":"Rachel B. Jimenez","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYDACCYaEA2AGewPJWnhAVAJxWmCMBCK1mM9ueHjoRsUdOfmZbw9+rvxxR868/wDj44pfuLXI3DmQcDjnzDNjxtl5yZJnEp4Zy9xIYDY824fHXRIJCYdz2w4nNkvnGEg2JBxOnCHBwCbZ2ENIy7/D9W2SZ4x/ArXUz+A/QIyWhsMJPBI8ZiBbEoBByCbZ8AOPFhmQX44dNpzBk5dm2ZAGZEgkNhs2NuDRIt2T/Dmn5rC8fPvZwzcbbA7LS/AfPviw4Q9uLcAoTIAxYCKMDQyMbfi0sB9A1wICeG0ZBaNgFIyCEQYAWJ9XO9u49B4AAAAASUVORK5CYII=","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Rachel","middleName":"B.","lastName":"Jimenez","suffix":""}],"badges":[],"createdAt":"2023-09-05 02:14:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3325900/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3325900/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":43363844,"identity":"5ec8d32f-bd2d-4f2d-82dc-dbdaa8ee1fc5","added_by":"auto","created_at":"2023-09-19 13:46:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30228,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePercent change in range of motion by the timing of physical therapy in relation to radiation therapy\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3325900/v1/915b660b5c58f9ba44db7953.png"},{"id":43363843,"identity":"52497d9a-2a34-440d-b4b4-ffb96f517041","added_by":"auto","created_at":"2023-09-19 13:46:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":17435,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMean percent improvement in active range of motion by timing of PT in relation to RT\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3325900/v1/44cf8a2906d6e821449cf395.png"},{"id":61362356,"identity":"1afbe84a-f632-4e79-95a4-2bd646ebd0b2","added_by":"auto","created_at":"2024-07-29 23:46:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":647435,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3325900/v1/5d3c9c96-3d43-49e4-a08d-6591595d9005.pdf"},{"id":43363845,"identity":"764ae2c8-468d-4559-8870-2e26971c0194","added_by":"auto","created_at":"2023-09-19 13:46:47","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14004,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable9423.docx","url":"https://assets-eu.researchsquare.com/files/rs-3325900/v1/1ea0c48e7ec23b3802d6b4b5.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Timing of physical therapy to optimize shoulder range of motion among patients receiving breast radiotherapy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUpper limb disability and functional limitations are frequent concerns after breast cancer treatment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Women undergoing surgery, including reconstructive surgery, axillary lymph node dissection, and radiation often experience a host of musculoskeletal sequelae such as reduced shoulder range of motion (ROM), pain, axillary cording, diminished strength, paresthesias, lymphedema and fatigue [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These impairments can lead to the inability to raise one\u0026rsquo;s arms overhead or behind the scapular plane, which is critical for activities of daily living (ADL) and instrumental ADLs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This can cause a decline in quality of life and generate lasting discomfort that can extend for years after completion of cancer therapy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Known predictors of long-term shoulder disability include the presence of positive lymph nodes at diagnosis for breast cancer, older age at diagnosis and elevated body mass index (BMI) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePhysical therapy (PT) has been shown to be an effective tool for reducing pain and improving ROM for breast cancer patients to reduce long-term impairment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. With limited studies examining early surveillance of ROM deficits after multimodality breast cancer therapy, there is a paucity of data surrounding \u003cem\u003ewhen\u003c/em\u003e physical therapy should be initiated to optimally prevent and reduce upper limb disability following breast cancer interventions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e In order to optimize cancer rehabilitation, we performed a retrospective review of patients referred to PT following breast cancer treatment, with a specific focus on the timing of initiating PT and the relationship of improvements in function. We hypothesized that patients who initiated early referral for physical therapy after surgery and before radiation therapy experienced greater gains in functionality over time.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003e A retrospective chart review was performed on all patients referred to outpatient oncology PT receiving multimodal treatment for breast cancer at Massachusetts General Hospital from January 2015 to August 2021. For the purposes of this study, we included only PT referrals associated with treatment for breast cancer, including diagnoses related to decreased shoulder ROM, cording, lymphedema, and upper quarter pain. Clinical and treatment characteristics related to cancer and physical therapy were captured, including patient age, BMI, tumor staging, cancer-directed treatment (type of surgery including axillary surgery, reconstruction type, systemic therapy, radiation therapy), and details of the patients\u0026rsquo; physical therapy interventions. While the nature and frequency of physical therapy performed were at the discretion of the individual provider, relevant details were captured. Interventions performed include therapeutic exercise, self-care/home management and manual therapy with a focus on range of motion, scar massage, lymphatic drainage and myofascial release. Specifically, shoulder ROM was collected at the first and last PT visits. If ROM measurements were not available at the final PT visit, the most recent documented measurements were captured. When within normal limits (WNL) was encountered in the chart for documented shoulder ROM, shoulder ROM flexion and abduction was assumed to be 160 degrees and shoulder external rotation to be 60 degrees based on normative data [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A standing institutional review board through Massachusetts General Hospital approved this study protocol.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy endpoints\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to report cancer and PT treatment characteristics. The primary endpoint in this study was the percent change of total ROM measurements of the ipsilateral shoulder before and after PT. Secondary endpoints included the absolute change in degrees of total ROM of the ipsilateral shoulder before and after PT. Range of motion changes by percent and absolute degrees of freedom were captured for individual measures of flexion, abduction, and external rotation. Total ROM was defined as a composite score of overall ROM change, calculated by summing vector changes for each movement. In addition, the timing of PT initiation was calculated from the date of index surgery until the first PT appointment across three identified cohorts: patients receiving no radiation therapy (no-RT), patients who initiated PT before radiation therapy (pre-RT), and patients who initiated PT during/after radiation therapy (d/a RT). The timing of patients who received no RT was compared to patients who initiated PT pre-RT and during/after RT in separate analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eBaseline clinical characteristics were summarized using medians and interquartile range (IQR) for continuous variables or as numbers and percentages for categorical variables. Associations between range of motion measures across RT groups (no-RT vs pre-RT and no-RT vs d/a-RT) and baseline characteristics were evaluated with analysis of variance (ANOVA) testing. Characteristics significantly associated with ROM were included in the multivariable analysis for ROM measures between groups using multiple ANOVA testing. Statistical analyses were performed with Stata, Version 17.0 (College Station, TX, USA). P values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient Characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 37 patients were referred to PT during multimodal breast cancer treatment and had both baseline and follow-up ROM measurements. Nine (24%) patients received PT after index breast surgery without subsequent RT, 15 (41%) initiated PT before RT, and 13 (35%) began PT during/after the course of radiation. The median age of patients referred to therapy was 46 years for the no-RT group, 46 years for the pre-RT group, and 50 years for the PT during/after RT group. Most patients had unilateral breast cancer (n\u0026thinsp;=\u0026thinsp;36, 97%), underwent mastectomy with breast reconstruction (n\u0026thinsp;=\u0026thinsp;34, 92%), had nodal surgery (n\u0026thinsp;=\u0026thinsp;34, 92%), and received chemotherapy (n\u0026thinsp;=\u0026thinsp;24, 65%). Higher tumor stage and axillary lymph node dissection were associated with the receipt of RT (p\u0026thinsp;=\u0026thinsp;0.023 and p\u0026thinsp;=\u0026thinsp;0.003, respectively) [Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e].\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePatient characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo RT\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePre-RT\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDuring/After RT\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient Age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.169\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (42.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (53.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u0026ndash;52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.5\u0026ndash;48.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u0026ndash;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28\u0026ndash;58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u0026ndash;76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.3 (24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.1 (24.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.5 (28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.5\u0026ndash;24.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.0-26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.5\u0026ndash;32.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor Stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (53.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLymph Nodes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.434\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (53.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLaterality of Cancer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (88.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.905\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMastectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLumpectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAxillary Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSLNB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (53.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo axillary surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreast Reconstruction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.183\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDirect-to-implant (DTI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTissue expander (TE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.484\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeoadjuvant only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdjuvant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eTiming and Duration of Physical Therapy\u003c/h2\u003e\n \u003cp\u003eThe interval from index surgery to the first PT visit was a median of 43 days (interquartile range 32\u0026ndash;115) in the no-RT cohort and 42 days in the pre-RT cohort (IQR 32.5\u0026ndash;52.5). The cohort that initiated PT during/after RT had a median of 179 days (IQR 152\u0026ndash;290) from index surgery to the start of PT and a median of 97 days (IQR 8-212) between radiation and the start of PT. Following index surgery, the median timing from PT to the start of radiation in the pre-RT group was 25 days (IQR 14-57.5).\u003c/p\u003e\n \u003cp\u003eThe timing, in days, between the first and last PT visit for the three cohorts were as follows: the no RT cohort had a median of 113 days (IQR 49\u0026ndash;254). The pre-RT group\u0026rsquo;s median was 82 days (IQR 29\u0026ndash;244) and the during/after RT had a median of 106 days (IQR 86\u0026ndash;193) (p\u0026thinsp;=\u0026thinsp;0.1237). Patients who initiated PT before RT completed a greater mean number of PT visits at 16.5 (median\u0026thinsp;=\u0026thinsp;12, IQR 2\u0026ndash;18) compared to patients who initiated PT during/after RT completed a mean of 8.2 visits (median\u0026thinsp;=\u0026thinsp;5, IQR 3\u0026ndash;13) and patients who received no RT completed a mean of 9.4 visits (median\u0026thinsp;=\u0026thinsp;5, IQR 3\u0026ndash;10) (p\u0026thinsp;=\u0026thinsp;0.742).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eRange of Motion Outcomes\u003c/h2\u003e\n \u003cp\u003eNearly all (34/37, 92%) patients across the three cohorts demonstrated improvements in overall ROM from baseline to the last PT visit. Three patients did not experience ROM gains. Of these, two experienced a decline in overall ROM and ceased PT intervention: one patient developed unexplained thoracic pain limiting participation in therapy, and the other patient experienced a decrease in ROM due to the development of breast cancer-related lymphedema in the arm causing poor PT adherence. The third patient only had one PT encounter following mastectomy and did not return for follow-up. This patient returned to PT 15 months following breast cancer treatment with continued shoulder ROM limitation.\u003c/p\u003e\n \u003cp\u003eOverall, the no-RT group demonstrated the greatest mean percent improvement in ROM (74%), compared to the pre-RT and PT during/after RT cohorts, which demonstrated a 59% and 20% improvement, respectively [Figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eIn pairwise comparisons, patients who initiated PT before RT experienced greater total percent change in ROM compared to patients receiving PT during/after RT (59% vs 20%, p\u0026thinsp;=\u0026thinsp;0.045) and greater absolute gains in degrees of ROM (56% vs 21%, p\u0026thinsp;=\u0026thinsp;0.036). Although patients in the no-RT cohort demonstrated the greatest gain in mean percent ROM improvement, this change was only statistically significant when compared to the PT during/after RT group (74% vs 20%, p\u0026thinsp;=\u0026thinsp;0.006). There was no difference in percent change in ROM or absolute change in degrees of ROM between the no-RT and pre-RT groups (percent ROM 59% vs 74% p\u0026thinsp;=\u0026thinsp;0.528; absolute ROM 59.9 vs 55.8 p\u0026thinsp;=\u0026thinsp;0.829) [Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and Table \u003cspan class=\"InternalRef\"\u003eS1\u003c/span\u003e].\u003c/p\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePercent improvement in degrees of active range of motion by timing of PT\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eROM Measure\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo RT\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePre-RT\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePT d/a- RT\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003cp\u003e(No RT vs pre-RT)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003cp\u003e(No RT vs during/after RT)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003cp\u003e(pre-RT vs during/after RT)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall ROM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.528\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFlexion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbduction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.752\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.643\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExternal Rotation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.781\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.036*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003ch2\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/h2\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003cp\u003eOn univariate analysis, characteristics associated with percent change in improved ROM were higher N stage (p\u0026thinsp;=\u0026thinsp;0.045) and worse baseline ROM (p\u0026thinsp;=\u0026thinsp;0.007). On multivariate analysis, when adjusting for N stage and baseline ROM, baseline ROM continued to be associated greater improvement in ROM between patients who did not receive RT and those who received PT during or after RT (p\u0026thinsp;=\u0026thinsp;0.024). On multivariate analysis, there was no difference in ROM between patients who received PT pre-RT compared to those who did not receive RT (p\u0026thinsp;=\u0026thinsp;0.829).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we found that patients who underwent PT prior to RT demonstrated greater improvements in ROM than those who initiated PT during or after RT. Notably, patients who received PT pre-RT demonstrated no statistical difference in ROM improvements compared to patients who did not receive RT. In contrast, patients who started PT after initiating RT demonstrated statistically worse ROM improvements compared to patients who received no RT. These results suggest that earlier intervention may maximize ROM gains and mitigate treatment-related effects of RT. To our knowledge, this is the first study that has quantified the relationship between the degree of ROM improvement with timing of PT intervention.\u003c/p\u003e \u003cp\u003eSeveral systematic reviews have found that physical therapy is a helpful intervention to improve shoulder function for individuals with breast cancer [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Physical therapy is imperative to address shoulder range of motion limitations, as these limitations can often persist for months to years after breast surgery, ultimately contributing to pain and decreased function [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Additionally, there is level I evidence that suggests that breast and axillary radiotherapy are risk factors for reduced shoulder ROM in flexion, abduction and external rotation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. One study found that shoulder ROM deficits persisted up to 2 months after receiving RT for breast cancer [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], while another study found that shoulder flexion ROM deficits persisted 6 months post-operatively, relative to women who did not receive radiation (p\u0026thinsp;=\u0026thinsp;0.01) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHwang et al. found statistically significant improvements in mean shoulder ROM after RT with a guided exercise intervention [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Contrastingly, Klein et al. failed to identify an improvement in shoulder ROM after lumpectomy, axillary surgery, and radiation though this study was limited to written and verbal instructions to guide patient-directed exercises, in lieu of formal PT evaluation and therapist-directed interventions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In our study, nearly all patients demonstrated improvements in shoulder ROM, regardless of surgical type or timing of PT to RT, when receiving formal in-person PT evaluation and intervention [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOf equal importance, however, is determining \u003cem\u003ewhen\u003c/em\u003e to initiate PT for patients undergoing breast cancer therapy. To date, there has been a paucity of data on the optimal timing for performing PT during breast cancer rehabilitation to maximize both short and long-term ROM gains. Some studies have found that initiating exercise within the first week after surgery led to a faster recovery in ROM when compared to later intervention [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Conversely, other studies have shown an increase in adverse effects including wound dehiscence and seroma in the early intervention group, when compared to the group starting PT\u0026thinsp;\u0026gt;\u0026thinsp;7 days after surgery [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. For this reason, many providers delay early referral to PT after surgery, particularly in the case of breast reconstruction and/or axillary dissection, out of concern that it may lead to greater adverse effects [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, the median time to initiate PT was 42 days postoperatively for the pre-RT group and 43 days for the surgery-only (no RT) group, which is consistent with prior studies that initiated exercise interventions within 45\u0026ndash;70 days of surgery [\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In the patients who initiated PT during or after RT, there was a median of 179 days between surgery and PT. One potential way to address ROM limitations early without increasing the risk of post-operative complications could be to begin gentle PT one to three weeks postoperatively, after initial wound healing is complete, with oversight by a physical therapist and input and support from members of the multidisciplinary breast oncology team [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These gentle PT interventions could include passive and active mobilization, stretching, resistance training, and scar tissue massage to enhance tissue extensibility, improve circulation, and assist with restoring normal movement patterns, with the degree of intensity of PT determined based on wound healing [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterestingly, in our study the pre-RT group underwent more frequent PT visits, as reflected by an increase in the mean number of PT visits of 16.6 compared to the no-RT group\u0026rsquo;s 9.4 visits. The pre-RT group also had the greatest proportion of patients receiving ALND. Previous studies have shown that patients who receive ALND typically demonstrate a greater loss of ROM, which may be one reason why the pre-RT group required a greater number of PT visits [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. However, despite this, the overall duration of PT was similar across groups, suggesting that the timing of initiation may be more important than the overall duration of therapy.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThere are several limitations to this study including its retrospective design and modest sample size. Physical therapy was at the discretion of the treating clinician, so therapy interventions were individualized and not necessarily standardized across patients. Additionally, only patients referred to physical therapy were included in the study sample. As a result, patients in our study may have experienced greater ROM deficits than the general population.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePhysical therapy appears helpful in improving shoulder ROM among women who underwent multimodality breast cancer treatment. Starting PT before radiation therapy may help maximize long-term range of motion gains in women who undergo breast cancer therapy with surgery and RT. Future prospective studies and additional RCTs that include assessments at multiple time points during breast cancer interventions are needed to further elucidate the extent of ROM improvement with early intervention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests. This research did not receive any funding from public, commercial, or non-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no potential conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCB, AS, MS, EL, and RBJ contributed to the study conception and design. Data collection was performed by BH and analysis led by BH, AS, CB, and RBJ. The first draft of the manuscript was written by CB, BH, AS, and RBJ and all authors commented on subsequent versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are not publicly available due to the small sample size and patient privacy, but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA standing institutional review board through Massachusetts General Hospital approved this study protocol. This is a retrospective study; ethics accordance was not required for this study as this was a retrospective review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHayes SC, Johansson K, Stout NL. et al., Upper body morbidity after breast cancer: incidence and evidence for evaluation, prevention and management within a prospective surveillance model of care. \u003cem\u003eCancer.\u003c/em\u003e 2012;118:2237-49.\u003c/li\u003e\n \u003cli\u003eRietman, JS, Dijkstra, PU, Debreczeni R; Geertzen, et al., Impairments, disabilities and health related quality of life after treatment for breast cancer: A follow-up study 2.7 years after surgery. \u003cem\u003eDisabil. Rehabil.\u003c/em\u003e 2004; 26:78\u0026ndash;84.\u003c/li\u003e\n \u003cli\u003eShamley D, Lascurain-Aguirrebe\u0026ntilde;a I, Oskrochi R, Srinaganathan R. Shoulder morbidity after treatment for breast cancer is bilateral and greater after mastectomy. 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Delayed shoulder exercises in reducing seroma frequency after modified radical mastectomy: a prospective randomized study. \u003cem\u003eAnn Surg Oncol.\u003c/em\u003e 1997; 4:293-7.\u003c/li\u003e\n \u003cli\u003eTood J, Scally A, Dodwell D, et al., A randomized controlled trial of two programs of shoulder exercise following axillary node dissection for invasive breast cancer. \u003cem\u003ePhysiotherapy\u003c/em\u003e 2008; 94:265-73.\u003c/li\u003e\n \u003cli\u003eChen SC, Chen MF. Timing of shoulder exercise after modified radical mastectomy: a prospective study: \u003cem\u003eChanggeng Yi Xue Za Zhi\u003c/em\u003e 1999; 22: 37-43.\u003c/li\u003e\n \u003cli\u003eShamley D, Barker K, Simonite V, et al., Delayed versus immediate exercises following surgery for breast cancer: a systematic review. \u003cem\u003eBreast Cancer Res Treat\u0026nbsp;\u003c/em\u003e2005; 90(30):263-71.\u003c/li\u003e\n \u003cli\u003eStuiver MM, Ten MR, Agasi-Idenburg CS, et al., Conservative interventions for preventing clinically detectable upper-limb lymphedema in patients who are at risk of developing lymphedema after breast cancer therapy. Cochrane Database Syst Rev 2015; 2015(20): CD009765. https://doi.org/10.1002/14651858.CD009765.pub2.\u003c/li\u003e\n \u003cli\u003eKoehler LA, Hunger DW, Blaes AH, et al., Function, shoulder motion, pain, and lymphedema in breast cancer with and without axillary web syndrome: an 18-month follow up. \u003cem\u003ePhys Ther.\u003c/em\u003e 2018; 98(6):518-27.\u003c/li\u003e\n \u003cli\u003eSteindort K, Schmidt ME, Klassen O, et al., Randomized controlled trial of resistance training in breast cancer patients receiving adjuvant radiotherapy: results on cancer-related fatigue and quality of life. \u003cem\u003eAnn Oncol.\u003c/em\u003e 2014; 25(11):2237-2243.\u003c/li\u003e\n \u003cli\u003eWiskemann J, Schmidt ME, Klassen O, et al., Effects of 12 week resistance training during radiotherapy in breast cancer patients. \u003cem\u003eScand J Med Sci Sports.\u003c/em\u003e 2016; 27:1500-1510.\u003c/li\u003e\n \u003cli\u003eSchmidt ME, Meynkohn A, Habermann N, et al.,Resistance exercise and inflammation in breast cancer patients undergoing adjuvant radiation therapy: mediation analysis from a randomized controlled intervention trial. \u003cem\u003eInt J Radiat Oncol Biol Phys.\u0026nbsp;\u003c/em\u003e2016; 94(2): 329-337.\u003c/li\u003e\n \u003cli\u003ePotthoff K, Schmidt ME, Wiskemann J, et al., Randomized controlled trial to evaluate the effects of progressive resistance training compared to progressive muscle relaxation in breast cancer patients undergoing adjuvant radiotherapy: the BEST study. \u003cem\u003eBMC Cancer\u003c/em\u003e. 2013;13: 162.\u003c/li\u003e\n \u003cli\u003eHarris, S.R., Schmitz, K.H., Campbell, K.L. and McNeely, M.L. (2012), Clinical practice guidelines for breast cancer rehabilitation. Cancer, 118: 2312-2324. https://doi.org/10.1002/cncr.27461\u003c/li\u003e\n \u003cli\u003eHarris SR, Hugi MR, Olivotto IA, et al., Upper extremity rehabilitation in women with breast cancer after axillary dissection: clinical practice guidelines. \u003cem\u003eCrit Rev Phys Rehabil Med\u003c/em\u003e 2001; 13:91-103.\u003c/li\u003e\n \u003cli\u003eStout, NL, Binkley JM, Schmitz, KH, et al., A prospective surveillance model for rehabilitation for women with breast cancer. \u003cem\u003eCancer\u003c/em\u003e. (2012) 118: 2191-2200. https://doi.org/10.1002/cncr.27476\u003c/li\u003e\n \u003cli\u003eVoogd AC, Ververs JM, Vingerhoets AJ. et al., Lymphoedema and reduced shoulder function as indicators of quality of life after axillary lymph node dissection for invasive breast cancer. \u003cem\u003eBr J Surg.\u0026nbsp;\u003c/em\u003eJan 2003 90:76-81.\u003c/li\u003e\n \u003cli\u003eSmoot B, Paul SM, Aouizerat BE, et al., Predictors of altered upper extremity function during the first year after breast cancer treatment. \u003cem\u003eAm J Phys Med Rehabil.\u003c/em\u003e 2016 Sept; 95(9): 639-655.\u003c/li\u003e\n \u003cli\u003eSagen A, Kaaresen R, Sandvik L, et al., Upper limb physical function and adverse effects after breast cancer surgery: A prospective 2.5 year follow up study and preoperative measures. \u003cem\u003eArchives of physical medicine and rehabilitation.\u0026nbsp;\u003c/em\u003e2014; 95: 875-81.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breast cancer, breast cancer rehabilitation, physical therapy, timing, upper extremity range of motion","lastPublishedDoi":"10.21203/rs.3.rs-3325900/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3325900/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eEstablishing optimal timing of physical therapy (PT) during multimodal breast cancer treatment can be challenging. We hypothesized patients initiating PT post-surgery and pre-radiation therapy (RT) would experience greater gains in functionality compared to PT initiated during/after RT.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective review was performed for patients receiving multimodality breast cancer treatment and PT between 1/2015-8/2021. Three cohorts were established: patients who received no RT, PT initiated before RT (pre-RT), and PT during/after RT (d/a-RT). The primary endpoint was percent change in ipsilateral shoulder ROM between first and last PT visits. Associations between range of motion (ROM) across groups and baseline characteristics were evaluated with analysis of variance testing.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThirty-seven patients were identified, median age of 47 years. The no-RT cohort exhibited the greatest mean percent improvement in ROM with PT (74%) versus pre-RT (59%) and d/a-RT (20%). The no RT and pre-RT groups demonstrated greater improvements in ROM compared to patients receiving PT d/a-RT (no RT 74% vs d/a-RT 20%, p\u0026thinsp;=\u0026thinsp;0.006; pre-RT 59% vs d/a-RT 20%, p\u0026thinsp;=\u0026thinsp;0.045). There was no difference in ROM gains between the no-RT and pre-RT groups (p\u0026thinsp;=\u0026thinsp;0.528). Lower baseline ROM was associated with smaller improvements in ROM after PT (p\u0026thinsp;=\u0026thinsp;0.008). When adjusting for baseline ROM, the no-RT cohort remained associated with ROM improvement compared to the d/a-RT group (p\u0026thinsp;=\u0026thinsp;0.024). There was no difference in ROM change between no-RT and pre-RT cohorts.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePT improves shoulder ROM in patients undergoing multimodality breast cancer treatment; however, early initiation of PT before starting RT may maximize ROM gains.\u003c/p\u003e","manuscriptTitle":"Timing of physical therapy to optimize shoulder range of motion among patients receiving breast radiotherapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-19 13:46:43","doi":"10.21203/rs.3.rs-3325900/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"09a77784-80d1-49a9-9a62-12d89e0f75f9","owner":[],"postedDate":"September 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-29T23:38:25+00:00","versionOfRecord":[],"versionCreatedAt":"2023-09-19 13:46:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3325900","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3325900","identity":"rs-3325900","version":["v1"]},"buildId":"iFTdqyg4nuje_uAy1AHro","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}