Background. A recent study in our laboratory found signifi cant differences in scapular kinematics between the affected and unaffected sides of women reporting shoulder pain following treatment for breast cancer. An earlier smaller study from our laboratory found reduced muscle activity from four key muscles and an association with greater shoulder pain and disability. The aims of this study were to: correlate altered muscle activity from a larger sample with observed movement deviations; compare within subject movement and muscle deviations in survivors with healthy variation; explore the impact of a mastectomy vs. a wide local excision (WLE) on the observed deviations. Method. Cross-sectional study. One hundred and fi fty-fi ve women treated for unilateral carcinoma of the breast and 21 age-matched healthy women were included in the study. All patients fi lled out the Shoulder Pain and Disability Index (SPADI). Three-dimensional (3D)-kinematic data and EMG muscle activity were recorded during scaption on the affected and unaffected side. The association between kinematic data, EMG data, SPADI and covariates was determined using a two stage, random effects mixed multiple regression technique. Results. All scapula kinematic and muscle EMG parameters in both arms were altered in breast cancer survivors when compared to healthy participants. Altered movement patterns were different for left vs. right side affected. Mastectomy patients demonstrated greater movement deviations and reported signifi cantly higher levels of pain than WLE patients. Conclusion. Shoulder morbidity is bilateral, greater in patients having a mastectomy and is present for up to six years post-surgery. This study and others now provide ample evidence to support prospective surveillance programmes that can be integrated into Survivorship Programmes.

Varying levels of shoulder morbidity following treatment for breast cancer have been reported. Patients report pain, weakness, tightness and reduced functional capacity. Normal painfree motion of the arm and shoulder requires mobility in the scapulothoracic, glenohumeral, acromioclavicular and sternoclavicular joints. Under healthy conditions elevation of the arm is accompanied by scapula retraction, lateral rotation and posterior tilt. However, when scapulothoracic motion is disproportionate to glenohumeral motion, the potential exists for microtrauma and long term pain. A number of studies on women treated for breast cancer have shown limitations in glenohumeral range of movement and a recent report from our laboratory has shown decreased muscle activity in four key muscles acting on the scapula. However, no study has measured the effect of treatment on three-dimensional (3-D) scapulothoracic motion in relation to glenohumeral motion. 152 women treated for unilateral carcinoma of the breast were included in the study. All patients filled out the Shoulder Pain and Disability Index (SPADI). 3-D-kinematic data for the humerus and scapula was recorded during scaption on the affected and unaffected side. The association between kinematic data, SPADI and covariates was determined using random effects multiple regression techniques. All scapula kinematic parameters were significantly altered on the side of the carcinoma in breast cancer survivors. Both reported levels of pain and dysfunction were associated with altered kinematics. High levels of pain and disability were reported for up to 6 years post surgery. Patients with the left side affected reported higher levels of pain and demonstrated more significant scapulathoracic dysfunction independent of dominance. Altered movement patterns were different for left versus right side affected. Left side affected patients need to be considered as a group of patients at risk of experiencing higher levels of pain and showing greater shoulder dysfunction. Whether cause or effect, pain reports are accompanied by 3-dimensional scapula dysfunction which mimics that of many other shoulder conditions.

3.

Physiotherapy is considered an important component of the perioperative period of lung resection surgery. A systematic review was conducted to assess evidence for the effectiveness of different physiotherapy interventions in patients undergoing lung cancer resection surgery. Online literature databases [Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, SCOPUS, PEDro and CINAHL] were searched up until June 2013. Studies were included if they were randomized controlled trials, compared 2 or more perioperative physiotherapy interventions or compared one intervention with no intervention, included only patients undergoing pulmonary resection for lung cancer and assessed at least 2 or more of the following variables: functional capacity parameters, postoperative pulmonary complications or length of hospital stay. Reviews and meta-analyses were excluded. Eight studies were selected for inclusion in this review. They included a total of 599 patients. Seven of the studies were identified as having a low risk of bias. Two studies assessed preoperative interventions, 4 postoperative interventions and the remaining 2 investigated the efficacy of interventions that were started preoperatively and then continued after surgery. The substantial heterogeneity in the interventions across the studies meant that it was not possible to conduct a meta-analysis. The most important finding of this systematic review is that presurgical interventions based on moderate-intense aerobic exercise in patients undergoing lung resection for lung cancer improve functional capacity and reduce postoperative morbidity, whereas interventions performed only during the postoperative period do not seem to reduce postoperative pulmonary complications or length of hospital stay. Nevertheless, no firm conclusions can be drawn because of the heterogeneity of the studies included. Further research into the efficacy and effectiveness of perioperative respiratory physiotherapy in this patient population is needed.

Objective Specific neck exercises targeting deep cervical flexors and extensors are commonly used for the treatment of nonspecific neck pain (NSNP). However, whether specific neck exercises are more effective than alternative exercise interventions remains unclear. Furthermore, it has been postulated that specific neck exercises may be most effective when they are tailored and targeted to patients with evidence of motor control dysfunction, yet this notion also remains unproven. The objectives of this study were to compare the effectiveness of specific neck exercises with that of alternative exercise interventions for reducing pain and disability in people with NSNP and to assess whether the effectiveness of specific neck exercises is increased when the exercises are tailored and provided to patients with evidence of motor control dysfunction. Methods For this systematic review with meta-analysis, Medline, Web of Science, Scopus, and Physiotherapy Evidence Database were searched. Eligibility criteria included randomized controlled trials evaluating the effectiveness of specific neck exercises against that of alternative exercise interventions in people with NSNP. Meta-analysis included subgroup analyses to determine the effect of exercise tailoring and participant selection criteria on the effectiveness of specific neck exercises. Results Twelve studies were included. Meta-analysis revealed greater effectiveness of specific neck exercises in the short to medium term for reducing pain (pooled standardized mean difference [SMD] = −0.41; 95% CI = −0.76 to −0.06; P = .02) and disability (pooled SMD = −0.41; 95% CI = −0.78 to −0.04; P = .03) but no differences in the long term for pain (pooled SMD = −1.30; 95% CI = −3.35 to 0.75; P = .21) and disability (pooled SMD = −1.81; 95% CI = −4.29 to 0.67; P = .15), although evidence was limited for the latter. The effectiveness of specific neck exercises was not superior in studies that included only participants with motor control dysfunction or when exercises were tailored to each participant. Overall, the studies were of low quality. Grading of Recommendations Assessment, Development and Evaluation revealed low certainty, serious risk of bias, and inconsistency of findings for short- to medium-term effects and very low certainty, serious risk of bias, and very serious inconsistency for long-term effects. Conclusion The preferential use of specific neck exercises may be recommended to achieve better short- to medium-term outcomes, although the low quality of evidence affects the certainty of these findings. Currently used strategies for selecting patients and tailoring specific neck exercises are not supported by the evidence and therefore cannot be recommended for clinical practice. Impact Specific neck exercises are more effective than alternative exercise interventions for reducing pain and disability in patients with nonspecific neck pain in the short to medium term, but overall evidence is of low quality, affecting the certainty of the findings. Tests of muscle dysfunction (mostly the craniocervical flexion test) currently used in studies to select patients and tailor specific neck exercises do not result in greater effectiveness of these exercises. Lay Summary Evidence suggests specific neck exercises are more effective than other forms of exercise, although evidence is overall of low quality. Use of the craniocervical flexion test in isolation to select participants and/or tailor specific neck exercises can not be recommended.

Normal painfree movement of the upper limb requires movement at the glenohumeral joint and movement of the scapula on the thorax. Co-ordinated movement of these joints is known as the scapulohumeral rhythm and is required during elevation of the arm. Coordinated movement is further achieved by timing of the many muscles acting across the joints. A pilot study from our laboratory has shown significant alterations to this scapulohumeral rhythm and its muscle control following treatment for breast cancer. The aims of this study were to: (1) correlate altered muscle activity from a larger sample with observed movement deviations; (2) compare movement and muscle deviations in survivors with a healthy population and (3) explore the impact of a mastectomy versus a wide local excision (WLE) on the observed deviations. Cross-sectional study. 155 women treated for unilateral carcinoma of the breast and 21 age-matched healthy women were included in the study. All patients filled out the Shoulder Pain and Disability Index (SPADI). Three-dimensional kinematic data and EMG muscle activity were recorded during scaption on the affected and unaffected side. Patients demonstrated a different movement dysfunction depending on whether the left or the right shoulder was affected. Left affected shoulders demonstrated the greatest degree of internal rotation of all shoulders studied. Compared to healthy shoulders patients following a mastectomy demonstrated increased activity in both the left and right affected shoulders in all the measured muscles. In patients having a WLE, such increases were not observed in serratus anterior and pectoralis major activity on the right affected shoulder, where a decrease was noted. Muscle dysfunction was also observed in the unaffected side of patients. Having received chemotherapy contributed significantly to the difference seen between the affected and unaffected shoulders in patients. Differences in scapular tilt between affected and unaffected shoulders in patients were significantly associated with pain and disability, and changes in serratus anterior activity. Patterns of movement deviation resemble those seen in known shoulder conditions. Anatomical and biomechanical evidence supports the need for integrated rehabilitation and surveillance systems for the shoulder in oncology units.

Objective Evidence suggests altered pronociceptive and antinociceptive mechanisms in many chronic pain conditions. Knowledge about these mechanisms in nonspecific chronic neck pain (NSNP) would improve understanding of the causes and the design of more effective treatments. Pressure pain threshold (PPT) is often used to assess presence of altered nociceptive processing in NSNP; however, its usefulness to detect this is yet to be established. The purpose of this study was to determine the functional status of temporal summation of second pain (TSSP) and conditioned pain modulation (CPM) in NSNP and to characterize the association of both measures with PPT and clinical features of NSNP. Methods Thirty-two participants with NSNP (mean [SD] age = 44 [11] y; 27 female) and 32 age and sex matched healthy controls were recruited. TSSP was assessed using an electrical stimulus at the dorsum of the hand, and CPM was evaluated with the Cold Pressor Test. PPT was assessed bilaterally at the neck and tibialis anterior muscles. Results Participants with NSNP showed greater TSPP (mean difference = 0.23; 95% CI = 0.46-0.01; Cohen d = 0.51) and lower CPM (mean difference = 19.44; 95% CI = 10.42-28.46; Cohen d = 1.09). Pooled data from all participants showed lower PPTs at the neck than the tibialis anterior. However, PPT measures did not differ between groups at either location. PPT measures were not correlated with CPM and TSP. Conclusion NSNP is associated with enhanced pronociceptive and impaired antinociceptive mechanisms, which may explain long-lasting pain and failure of some treatments to resolve symptoms. However, due to the observational nature of this study, a clear cause-effect relationship cannot be established. Normal PPT values in the clinic should not be interpreted as absence of altered nociceptive processing. Impact This study fills in some gaps in knowledge. Changes in central nociceptive processing may explain persistent and recurrent symptoms in NSNP and failure of treatments to obtain long-lasting relief. Further research is required to ascertain if TSSP and CPM assessment in the clinic may help predict physical therapy treatment outcome. Whether symptomatic relief with physical therapy is mediated by an improvement in TSSP and CPM should also be explored. PPTs were unaltered in participants with NSNP despite evidence of impairment in the central pain modulatory systems. Normal PPTs should not be interpreted as evidence of unaltered central pain-related processing.

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