|Year : 2022 | Volume
| Issue : 4 | Page : 265-270
Ebbing axillary web syndrome the physical therapy way: A narrative review
Renu B Pattanshetty, Brinda R Patel
Department of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India
|Date of Submission||06-Aug-2021|
|Date of Decision||06-Sep-2021|
|Date of Acceptance||01-Jan-2022|
|Date of Web Publication||17-Mar-2023|
Dr. Renu B Pattanshetty
Professor and Head, Department of Oncology Physiotherapy, KAHER Institute of Physiotherapy, Nehru Nagar, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Axillary web syndrome (AWS) or cording is a clinical entity characterized by a palpable cord tissue or band generally extending from axilla to antecubital fossa with restricted shoulder mobility commonly occurring in both axillary surgical cases and nonaxillary surgeries. Exercises in the form of active and passive exercises, joint mobilizations, manual therapies in the form of massage therapy, myofascial release, manual lymphatic drainage, thermal therapy, and low level LASER therapy are found to be effective in patients with AWS. There is dearth in literature for manual therapy techniques used for AWS in breast cancer patients. Future research is recommended to conduct clinical trials using advanced manual therapy techniques like cupping, jade stone mobilization and matrix in addition to the exercise protocols in larger population for breast cancer survivors with axillary web syndrome.
Keywords: Axillary web syndrome, electrotherapy modalities, manual therapy, physical therapy exercises
|How to cite this article:|
Pattanshetty RB, Patel BR. Ebbing axillary web syndrome the physical therapy way: A narrative review. J NTR Univ Health Sci 2022;11:265-70
| Introduction|| |
National Cancer Institute defines cancer as “the aberrant proliferation of normal cells in the body with the potential to spread to other regions of the body. Cancers of the breast (female), lung, prostate, nonmelanoma of the skin, and gastrointestinal cancers are the most common cancers globally. The global cancer statistics 2020 reveals that 11.7% of females were diagnosed and 6.9% died of breast cancer. According to the expected incidence of cancer data in India for 2020, a total of 13,92,179 cases have been documented with breast and cervix cancer being the leading cancers among women. It is alarming to note that in India, every 29th woman is diagnosed with breast cancer. However, the number of survivors has risen recently, due to improved medical treatment of untreated breast cancer patients, which has resulted in an 89% 5-year survival rate.
The rise in number of breast cancer cases globally has reinforced and advanced the treatment options with review of patient's condition at regular intervals by health care professionals at various levels apart from the routine check-ups by well-trained oncologists and breast surgeons. Axillary web syndrome (AWS) is one of the most common side effects of cancer treatment but lacks evidences in treatment options in field of health science. Hence, there is a need for the patients to be well acquainted and educated with such consequences due to cancer and its related treatment.
| Axillary Web Syndrome|| |
AWS is a clinical condition involving palpable fibrotic bands or cords in the axilla region of patients who have undergone axillary lymph node dissection or axillary surgeries commonly performed in breast cancer patients. It is also called as axillary or lymphatic cording/webbing/superficial lymphatic thrombosis/aseptic lymphangitis/lymph vessel fibrosis. The term “AWS” was first coined by Moskovitz and colleagues in 2001. AWS, a clinical syndrome, characterized by palpable cords of tissue like a taut wire/violin string/band/tendon, may become painful in the affected arm region, which may or may not radiate to the ipsilateral arm, causing restricted range of motion in the affected shoulder. These fibrous bands generally extend from axilla to the antecubital fossa and further to volar surface of the forearm and wrist usually occurring within the first 8 weeks of axillary surgeries with symptoms generally resolving within first 12 weeks of surgery. However, it may remain or appear after 12 weeks to 2 years postsurgery.
| Pathophysiology of AWS|| |
AWS has shown to highlight some differences in surgical as compared to nonsurgical cases of breast cancer. In the patients who have undergone surgical procedure for breast cancer, the cord or web formation occurs due to disturbance in the venous flow causing hypercoagulation, blood clot formation in large superficial veins of arm, leading to inflammation and transformation of fibrous veins and lymphatic tissues into palpable fibrous bands. The pattern of cord formation has shown to follow a specific course along the lymphatic vessels after surgical procedures of venous clipping and lymph node resection due to the venous stasis in superficial large veins of affected extremity. The adhesion formed in the cords and the surrounding tissues is said to contribute to impaired shoulder mobility.
In the nonsurgical cases of breast cancer, AWS presents with linear skin changes along with band-like fibrous structure on palpation. Sporotrichoid lymphangitis, acute lymphangitis, linear morphea, eosinophilic fascitis (Shulman syndrome), and superficial thrombo-phlebitis are the nonlymphatic conditions that can lead to similar symptoms of AWS occurring postbreast cancer surgery.
[TAG:2]Clinical Presentation and Assessment,,,[/TAG:2]
The patients with AWS usually present with the following symptoms:
- One or more solid linear bands, referred to as “cords,” are generally palpated or visible in the axilla under the skin, extending along the medial arm, occasionally may cross the cubital fossa, and even extend to the wrist or base of the thumb. These cords or webs generally emerge in the first few weeks following surgery although they can appear later [Figure 1].
- Patient may also complain of dull pain with a tugging sensation that is felt along the affected arm with decreased mobility of the affected shoulder joint.
- Palpable nodules may also be felt in the axillary or arm region demonstrating formation of cords or webs generally appearing in the first few weeks following surgery or may appear even later.
Patricia and colleagues have initiated a protocol for patient assessment in supine lying position with the shoulder abducted, extended, and laterally rotated with elbow extended and supinated with wrist and fingers extended [Figure 2]a and [Figure 2]b. The upper limb position may seem restricted depending upon patient's pain tolerance. The restricted motion and the position may exhibit cord visibility that may be counted along with thickness measurement of bands, their number and location. A slight skin traction is then applied over affected extremity and chest region to determine and palpate the location of the cords and its characteristics. The objective evaluation of AWS is done by assessing the following features: the site, length, width, depth, and the number of palpable cords.,,
| Physical Therapy for AWS|| |
Nonsteroidal antiinflammatory drugs and opioids aid to reduce pain and improve mobility enhancing adherence to the physiotherapy treatment provided. Aescuven Forte with a dosage of 300 mg two times a day for one week in adjunct to physiotherapy has proven to ameliorate pain and adherence for rehabilitation. The invasive procedure introduced for AWS is percutaneous needle cord disruption with autologous fat grafting, which is found to be effective in improving tissue mobility due to fat grafting and disruption of the scarred tissue. Injecting Xiaflex directly into the maximal area of palpable cord with a 27 gauge needle is said to reduce scarring and enhance tissue mobility. Such techniques are found to be more effective when administered prior to physical therapy treatment.
Administration of various physiotherapeutic treatment modalities include therapeutic exercises, manual therapies, therapeutic massage, myofascial release techniques, manual lymphatic drainage therapies, thermal therapy, and low level laser therapy over an average period for 3 weeks to 6 months is found to be effective in releasing the taut fibrous cord, improving the shoulder range of motion and tissue mobility.
Therapeutic exercises are widely used as tailor-made exercises for postural correction, enhancing joint mobility, restoring muscular imbalance, and finitude of life. They are advised for different diseases and for individuals with different age groups for speedy recovery from illness.
Exercises used for therapeutic purposes are often classified under different categories as follows: Active exercises include movements that are performed or controlled by the voluntary action of muscles working in opposition to external force. The resisted or strengthening exercises are the exercises performed in opposition to the forces applied to the action of the working muscle, which is progressively increased to enhance power and endurance of the involved muscle. The resistance applied to the working muscle is calculated using one repetition maximum and ten repetition maximum for strength and endurance training, respectively. The relaxation exercises are found effective to reduce tension in the muscle due to stress and pain. Pumping exercises involve alternate contraction and relaxation of muscles facilitate the venous outflow through venous pumping effect, while stretching exercises are the maneuvers designed to improve the flexibility and extensibility of the shortened and hypomobile structures. The combination of the active shoulder range of motion exercises with strengthening, stretching, relaxation, and pumping exercises of upper extremity are found to increase mobility of the skin and reduce tautness of the cord in individuals with AWS.,,
Pulley is a grooved wheel, which rotates about a fixed axis by a rope which passes around it. The axis is supported by a frame work or block. Exercises performed using this pulley device are termed as pulley exercises. These exercises when focused on shoulder and elbow strengthening with a frequency of 10 repetitions are proven beneficial for symptom reduction in individuals with AWS.
Mobilization is a manual therapy technique which is defined as “passive skilled manual therapy techniques applied at joint and related soft tissues at varying speed and amplitudes using accessory motions for therapeutic purposes.” Luca and colleagues designed an MAP treatment protocol for AWS that included mobilization of shoulder and scapulothoracic joint in combination with breathing exercises for two times/week for a period of 45 min over 2 months, which has proved beneficial in axillary web syndrome. In addition to mobilization techniques, manual release given transversely around scar has shown to significantly reduce AWS symptoms.
Massage is a soft tissue technique, which aids for relaxation, stress and pain reduction, improves blood circulation, and maintains blood pressure. Stroking, kneading, rubbing, and tapping are the different techniques used in massage therapy. Modified massage techniques are applied longitudinally, transversely, and rotationally performed at different ranges available for the tissue movement. Now, this is widely used to treat cancer pain, fatigue, and depression.
While delivering the massage therapy techniques, the therapist's hand and the patient's tissue move together as a unit to avoid hand-on-skin sliding and friction. For gliding the skin and superficial fascia, modified effleurage techniques in different directions are used. Gentle circular movements and tissue wringing are performed with full hand contact following a longitudinal tissue stretch to release the deep fascia and myofascial interfaces in the region where tissue tightness is identified. To decrease the tightness over the deep muscles and the myofascia on the bone interfaces, modified skin rolling techniques have proved better at inner, mid, and outer range of available tissue movement. Scar tissue massage and release is also used aiding in breaking the adhesions in the cords, thus helping in improving shoulder joint mobility [Figure 3].
Dynamic angular petrissage is the technique that involves passive movement in relaxed state performed dynamically in a particular angle to reduce restrictions over the affected area. The dynamic technique is modified in three different dimensions to break the adhesions while maintaining the patients' available range of motion and comfort zone. For this reason, one hand is used for petrissage over the soft tissue while using the other to passively contract and relax the involved muscle causing to increase and decrease in the tension on the targeted tissue by changing position of the limb and its angle (i.e., while the limb serving as a lever). Change in the angle of the lever mimics natural movement of the muscle. This technique is generally applied segmentally along the targeted tissue length in stretching and relaxation phase of the involved area. This helps in stretching the tissue with minimum risk of eliciting stretch reflex. Dynamic angular petrissage has proved to be beneficial in alleviating pain and improving mobility in postbreast cancer surgeries.
Myofascial release technique
Myofascial release technique (MFR) is a soft tissue technique that enhances mechanical, neurological, and psychophysiological adaption of superficial and deep structures. It is a goal-oriented approach for tissue-based restrictions and their two-way interactions with movement and posture. MFR causes elongation of the sarcomere in the muscle fiber due to the gradual pressure on the motor trigger point (MTrP) until the therapist feels the release of tension. Release in MTrPs was found to be successful in decreasing pressure pain sensitivity. Different myofascial release techniques are applied over the affected area to release the restrictions in soft tissues of the body. The technique is performed for 90–120 s alternate days in a week for a frequency of one month and found to have optimistic effect on pain relief commonly seen in AWS. Gentle passive range of motion exercises are usually performed before initiation with release technique by holding the point of restriction for few seconds.
An audible click is a sign (due to the release of adhesions/disruption of weak connective tissue during the process of lymphogenesis) suggesting reduction in pain severity after the release of the tight structure, which is beneficial in improving range of motion on the affected side.
The soft tissue manipulation when performed with use of specially designed stainless steel tools available in different sizes and shapes for different parts of body with edges neatly shaped is called as instrument-assisted soft tissue manipulation (IASTM). It is known to facilitate proliferation of the extracellular matrix of fibroblasts, break adhesions, and mobilize the scar tissue, improving alignment of the tissues in the affected area. These tools/instruments may be used to stroke in different directions maintaining an angle of 30°C to 60°C. While performing these techniques in AWS, it is generally delivered above the palpated axillary web with the arm abducted passively for 5 min while performing the manipulation from distal to proximal direction. These techniques are often delivered in combination with other physiotherapeutic modalities including range of motion, stretching and strengthening exercises proving beneficial in patients with AWS.
Manual lymphatic drainage
Manual Lymphatic Drainag (MLD) is a superficial tissue massage involving circular, pumping, scooping, and rotatory movements with different pressure thresholds using hands or palms performed by a certified lymphedema therapist. It is usually carried out for 30 min, 5 times/week for one month. Self-administered manual lymphatic drainage is also a useful technique that may be taught to the patient as home exercise program.This maneuver when performed in combination with shoulder pulley strengthening exercises for a frequency of ten times × 3 sets, stretching exercises with mobility of the tight cord and scapular mobilization is useful in improvising shoulder mobility and quality of life in patients with AWS.
Thermal therapy is a term that includes physical agents producing superficial heat to reduce soft tissue adherence, pain severity, enhance blood circulation and healing to the affected area. This occurs due to vasodilatation reducing alpha motor neuron firing rate thus enhancing pain tolerance level and oxygen supply to the affected area.
Prior to the commencement of the physiotherapeutic treatment protocol and sensory testing, additional padding is done followed by 10 min of hot moist pack to the affected area with risk control methods. A better alternative to applying local heat on the affected area is taking a warm shower prior to the treatment that may aid in reducing pain and inflammation, improving collagen production and range of motion.
Low level LASER therapy
LASER is an acronym for “Light Amplification by Stimulated Emission of Radiation.” Therapeutic Laser is also known as cold laser/photo therapy/light therapy/photobiomodulation. LASER therapy is known to have radiation of different wavelengths thus producing radiation at different frequencies. Depending on the wavelength of light, laser is further classified into high and low level laser. Low level laser therapy (LLLT) does not cause heating during and post treatment and hence is called as a cold laser therapy. LLLT treatment delivered after 4–5 weeks of mastectomy for duration of 24–45 min in combination with traditional physical therapy program is useful to decrease pain and improve shoulder mobility demonstrating a significant effect in reducing the web in the axillary region.
| Conclusion|| |
AWS is a clinical condition that often goes unnoticed due to lack of knowledge of both patients as well as health care professionals. Physiotherapeutic techniques and modalities are proven to be more effective to reduce the symptoms of AWS and improve the shoulder mobility and quality of life in breast cancer survivors. However, there are limited clinical trials in this aspect especially with regard to the usage of various manual therapies for AWS. Hence, authors recommend early identification of AWS and intervention in the form of physiotherapy for the same.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]