Case Study

by Reena Pathak, DC, CSMLS(MLT), ASCP(MT)
Aug 1, 2017      0 Comments

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Treatment of Post-Surgical Mobility Restriction due to Post-Surgical Scarring and Pain Post-Mastectomy with Graston Technique®

Objective: Instrument-assisted Soft Tissue Mobilization (IASTM) and scar mobilization treatment using Graston Technique® of a 62-year-old female patient who was diagnosed with carcinoma in situ (breast cancer). She had two surgeries over the right breast. As a result of two surgeries and radiation treatment, she had restricted right shoulder range of motion and pain with activity. The surgical areas had developed scar tissue and pain due to the restricted range of motion. She could feel the skin around the scar pulling into the scar. The goal of treatment was to reduce the pain and increase range of motion so that she could return to all activities of daily living.

Background: At the age of 61, the patient went to her yearly mammogram. Following the mammogram, she received a phone call that the mammogram was not normal. She had a second mammogram to obtain better, more detailed imaging. Following the second mammogram, she was scheduled for biopsy. An excisional biopsy was performed twice (on two separate occasions), and confirmed carcinoma in situ of right breast.

The first excisional biopsy was to remove an area of the breast that was suspected to have the cancer as found on the mammogram; that biopsy was successful in removing calcifications and some of the abnormal tissue. However, the margins were not clear. As a result, more surgery was needed to ensure all of the cancer is removed along with "clear margins". This meant that a border of healthy tissue around the cancer is also removed. For the second surgery/biopsy, a metal wire marker was placed into the breast to mark the center of the lesion as a guide for the surgery and to get clear margins surrounding the cancer.

After surgery, tattooed ink marks were placed by the surgeon. The purpose of that tattooed ink marks was to assist with the alignment of the for the target area to which radiation treatment would occur. The patient had radiation sessions 5 days a week for a total of 18 sessions (October 21 - November 23, 2012)

According to BreastCancer.org:
Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. Ductal means that the cancer starts inside the milk ducts, carcinoma refers to any cancer that begins in the skin or other tissues (including breast tissue) that cover or line the internal organs, and in situ means 'in its original place.' DCIS is called 'non-invasive' because it hasn't spread beyond the milk duct into any normal surrounding breast tissue. DCIS isn't life-threatening, but having DCIS can increase the risk of developing an invasive breast cancer later on.

Prior to treatment at the office, the patient has received approval for soft tissue treatment from her doctors for Graston Technique® or instrument assisted soft tissue mobilization over the area. Treatment was started nearly 6 months post last radiation treatment. She had spoken to the oncologist about the pain and restriction in motion, and was told that is just the nature of surgery and treatment. The patient had been researching techniques and learned about the Graston Technique® and scheduled appointment with my office.

Graston Technique® is a form of instrument-assisted soft-tissue mobilization designed to break down scar tissue and fascial restrictions. According to the company's official website, http://www.grastontechnique.com/, the technique can decrease overall time of treatment, foster a faster recovery, and resolve chronic conditions thought to be permanent. In 1997, Craig et ali found, through research conducted on rat tendons, that morphologic and functional changes resulting from instrument-assisted soft-tissue massage suggest that the controlled microtrauma induced through the GT protocol may promote healing by increased fibroblast recruitment.

That being said, with any kind of soft-tissue trauma to tissue, such as surgery, an immobilization occurs in the connective tissue. There are many effects of immobilization. These include ii iii iv v vi vii:

  • Permanent loss of glycosaminoglycans (GAGs) and water.
  • No net collagen loss unless immobilized longer than 9 weeks, then collagen breakdown exceeds synthesis with a net loss of collagen.
  • Loss of "critical inter-fiber distance," since GAGs serve to maintain inter-fiber distance.
  • Macroscopic and microscopic formation of collagen, inter-fiber cross-links.
  • Irregular lying down of collagen.
  • Macroscopic fibro-fatty infiltrates serve as cross-links.
  • Ligaments eventually weaken (9 weeks).
  • Insertion sites of ligaments, tendons and joint capsules to bone demonstrate declining soft tissue and bone junctional strength.
  • With time the tissue essentially down-regulates (Davis' Law), weakens, and loses elasticity which translates to loss of motion.

Post-surgery and post-radiation, the patient in this case report had restricted range of motion due to the changes that occur due to immobilization of soft tissue, and pain over the scar. She was active, and worked out and felt that she could not do as much as she wanted to at the gym (as prior to radiation and surgeries) due to tightness and pain over the right shoulder and pulling she felt from the tissue surrounding the right breast.

Intervention and outcome: Postoperative care included three weeks of treatment. During this time, the patient was seen two times a week. The treatments consisted of a functional chiropractic rehabilitation program (warm up, Graston Technique®, and then high-repetition, low-load exercise and then stretching) along with KinesioTaping (as needed), followed by 3 weeks at one visit per week.

Following treatment, the patient recorded a 0/10 on the Numeric Pain Scale. There was also recorded improvement on the Patient Specific Functional and Pain Scale and on the QuickDASH Disability/Symptom Score. She also reported that she had returned to all her activities of daily living (ADLs) with no complications. This improvement included complete restoration of range of motion to a full range. The scar has also become less visible.

The pictures accompanied in this case study are taken pre-treatment on random visit dates at the office, as the patient wanted to document the course of treatment for herself. The pictures were provided by the patient with permission. She also wanted to show her oncologist and surgeon the changes she had made and that things were not 'normal' to have restricted range of motion and post-surgery and post-radiation. That being said, the pictures were recently provided with permission from the patient to submit in this case report. At 1- and 2-year follow-up, the patient reported no pain and was fully functional.

In regards to the treatment with Graston Technique® using GT 3, 6 and scar-rolling technique for a total of 2 minutes over scar, and then surrounding musculature for an additional 3 minutes, followed by stretching of the associate muscles, and then high-repetition, low-load exercise of associated muscles. The muscles were treated bilaterally. The muscles treated were as follow: trapezius muscles, levator scapulae muscles, supraspinatus muscles, rhomboid muscles, pectoralis major and minor muscles, latissimus dorsi muscles. The stretching and exercises that were performed were also performed with the associated muscles that were treated.

Conclusion: A combination of conservative chiropractic rehabilitation strategies may be used by chiropractors to treat range-of-motion restrictions and to aid in the restrictions in mobility due to scarring post-surgery and post-radiation. This treatment has allowed the patient to return to all activities of daily living (ADLs) pain-free. Graston Technique® was invaluable in removing and reducing adhesions that interfered with the gliding of the soft-tissue planes of the involved, as well as the neighbouring structures. GT should be considered in all cases where post-surgical restriction range of motion and scarring is involved.

Figure 1 - 6/26/13 Figure 2 - 7/1/13 Figure 3 - 7/5/13 Figure 4 - 7/9/13 Figure 5 - 7/16/13 Figure 6 - 8/5/13 Figure 7 - 8/8/13 Figure 8 - 7/23/15

References:
i Craig JD, Ganion LR, Gehlsen GM, et al. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Med Sci Sports Exer 1997:313-9.

ii Akeson W, Amiel D, LaViolette D. The connective tissue response to immobility: a study of the chrondroitin 4 and 6 sulfate and derma tan sulfate changes in periarticular connective tissue of control and immobilized knees of dogs. Clinical Orthopaedics and Related Research, 67(51): 183 197.

iii Akeson, Amiel, LaViolette, Secrist: The connective tissue response to immobility: an accelerated aging process. Exp. Gerontol, 68(3): 289 301.

iv Akeson, Woo, et al. The connective response to immobility: biochemical changes in periarticular connective tissue of the immobilized rabbit knee. Clinical Orthopaedics and Related Research, 73(93): 356 362.

v Basmajian JV, Nyberg R. Rational manual therapies. Williams & Wilkens, Baltimore, MD, 1993; 199 221.

vi Cantu R, Grodin A. Myofascial manipulation: Publishers, Gaithersburg, Maryland, 1992.

vii Morgan D. Principles of soft tissue treatment. J Manual & Manipulative Therapy, 1994, 2(2): 63 65.

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