Supervised physical therapy in women treated with radiotherapy for breast cancer1
Identifieur interne : 004621 ( Pmc/Corpus ); précédent : 004620; suivant : 004622Supervised physical therapy in women treated with radiotherapy for breast cancer1
Auteurs : Nara Fernanda Braz Da Silva Leal ; Harley Francisco De Oliveira ; Hélio Humberto Angotti CarraraSource :
- Revista Latino-Americana de Enfermagem [ 0104-1169 ] ; 2016.
Abstract
to evaluate the effect of physical therapy on the range of motion of the shoulders and perimetry of the upper limbs in women treated with radiotherapy for breast cancer.
a total of 35 participants were randomized into two groups, with 18 in the control group (CG) and 17 in the study group (SG). Both of the groups underwent three evaluations to assess the range of motion of the shoulders and perimetry of the upper limbs, and the study group underwent supervised physical therapy for the upper limbs.
the CG had deficits in external rotation in evaluations 1, 2, and 3, whereas the SG had deficits in flexion, abduction, and external rotation in evaluation 1. The deficit in abduction was recovered in evaluation 2, whereas the deficits in all movements were recovered in evaluation 3. No significant differences in perimetry were observed between the groups.
the applied supervised physical therapy was effective in recovering the deficit in abduction after radiotherapy, and the deficits in flexion and external rotation were recovered within two months after the end of radiotherapy. Registration number of the clinical trial: NCT02198118.
Url:
DOI: 10.1590/1518-8345.0702.2755
PubMed: 27533265
PubMed Central: 4996084
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PMC:4996084Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Supervised physical therapy in women treated with radiotherapy for breast cancer<xref ref-type="fn" rid="fn1"><bold><sup>1</sup></bold></xref></title><author><name sortKey="Leal, Nara Fernanda Braz Da Silva" sort="Leal, Nara Fernanda Braz Da Silva" uniqKey="Leal N" first="Nara Fernanda Braz Da Silva" last="Leal">Nara Fernanda Braz Da Silva Leal</name><affiliation><nlm:aff id="aff2">MSc, Physical Therapist, Centro de Fisioterapia Maria Izabel Garnica Roberto, Pontal, SP, Brazil.</nlm:aff></affiliation></author><author><name sortKey="De Oliveira, Harley Francisco" sort="De Oliveira, Harley Francisco" uniqKey="De Oliveira H" first="Harley Francisco" last="De Oliveira">Harley Francisco De Oliveira</name><affiliation><nlm:aff id="aff3">PhD, Professor, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Carrara, Helio Humberto Angotti" sort="Carrara, Helio Humberto Angotti" uniqKey="Carrara H" first="Hélio Humberto Angotti" last="Carrara">Hélio Humberto Angotti Carrara</name><affiliation><nlm:aff id="aff3">PhD, Professor, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27533265</idno><idno type="pmc">4996084</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4996084</idno><idno type="RBID">PMC:4996084</idno><idno type="doi">10.1590/1518-8345.0702.2755</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">004621</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">004621</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Supervised physical therapy in women treated with radiotherapy for breast cancer<xref ref-type="fn" rid="fn1"><bold><sup>1</sup></bold></xref></title><author><name sortKey="Leal, Nara Fernanda Braz Da Silva" sort="Leal, Nara Fernanda Braz Da Silva" uniqKey="Leal N" first="Nara Fernanda Braz Da Silva" last="Leal">Nara Fernanda Braz Da Silva Leal</name><affiliation><nlm:aff id="aff2">MSc, Physical Therapist, Centro de Fisioterapia Maria Izabel Garnica Roberto, Pontal, SP, Brazil.</nlm:aff></affiliation></author><author><name sortKey="De Oliveira, Harley Francisco" sort="De Oliveira, Harley Francisco" uniqKey="De Oliveira H" first="Harley Francisco" last="De Oliveira">Harley Francisco De Oliveira</name><affiliation><nlm:aff id="aff3">PhD, Professor, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Carrara, Helio Humberto Angotti" sort="Carrara, Helio Humberto Angotti" uniqKey="Carrara H" first="Hélio Humberto Angotti" last="Carrara">Hélio Humberto Angotti Carrara</name><affiliation><nlm:aff id="aff3">PhD, Professor, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.</nlm:aff></affiliation></author></analytic><series><title level="j">Revista Latino-Americana de Enfermagem</title><idno type="ISSN">0104-1169</idno><idno type="eISSN">1518-8345</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>ABSTRACT</title><sec><title>Objective:</title><p> to evaluate the effect of physical therapy on the range of motion of the
shoulders and perimetry of the upper limbs in women treated with radiotherapy for
breast cancer.</p></sec><sec><title>Methods:</title><p> a total of 35 participants were randomized into two groups, with 18 in the
control group (CG) and 17 in the study group (SG). Both of the groups underwent
three evaluations to assess the range of motion of the shoulders and perimetry of
the upper limbs, and the study group underwent supervised physical therapy for the
upper limbs. </p></sec><sec><title>Results:</title><p> the CG had deficits in external rotation in evaluations 1, 2, and 3, whereas the
SG had deficits in flexion, abduction, and external rotation in evaluation 1. The
deficit in abduction was recovered in evaluation 2, whereas the deficits in all
movements were recovered in evaluation 3. No significant differences in perimetry
were observed between the groups. </p></sec><sec><title>Conclusion:</title><p> the applied supervised physical therapy was effective in recovering the deficit
in abduction after radiotherapy, and the deficits in flexion and external rotation
were recovered within two months after the end of radiotherapy. Registration
number of the clinical trial: NCT02198118.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Lazzeroni, M" uniqKey="Lazzeroni M">M Lazzeroni</name></author><author><name sortKey="Decensi, A" uniqKey="Decensi A">A DeCensi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Senkus, E" uniqKey="Senkus E">E Senkus</name></author><author><name sortKey="Kyriakides, S" uniqKey="Kyriakides S">S Kyriakides</name></author><author><name sortKey="Penault Llorca, F" uniqKey="Penault Llorca F">F Penault-Llorca</name></author><author><name sortKey="Poortmans, P" uniqKey="Poortmans P">P Poortmans</name></author><author><name sortKey="Thompson, A" uniqKey="Thompson A">A Thompson</name></author><author><name sortKey="Zackrisson, S" uniqKey="Zackrisson S">S Zackrisson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sedlmayer, F" uniqKey="Sedlmayer F">F 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Rev Lat Am Enfermagem</journal-id><journal-id journal-id-type="iso-abbrev">Rev Lat Am Enfermagem</journal-id><journal-id journal-id-type="publisher-id">rlae</journal-id><journal-title-group><journal-title>Revista Latino-Americana de Enfermagem</journal-title></journal-title-group><issn pub-type="ppub">0104-1169</issn><issn pub-type="epub">1518-8345</issn><publisher><publisher-name>Escola de Enfermagem de Ribeirão Preto / Universidade de São
Paulo</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27533265</article-id><article-id pub-id-type="pmc">4996084</article-id><article-id pub-id-type="doi">10.1590/1518-8345.0702.2755</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Articles</subject></subj-group></article-categories><title-group><article-title>Supervised physical therapy in women treated with radiotherapy for breast cancer<xref ref-type="fn" rid="fn1"><bold><sup>1</sup></bold></xref></article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Leal</surname><given-names>Nara Fernanda Braz da Silva</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>de Oliveira</surname><given-names>Harley Francisco</given-names></name><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Carrara</surname><given-names>Hélio Humberto Angotti</given-names></name><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib></contrib-group><aff id="aff2"><label>2</label>MSc, Physical Therapist, Centro de Fisioterapia Maria Izabel Garnica Roberto, Pontal, SP, Brazil.</aff><aff id="aff3"><label>3</label>PhD, Professor, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.</aff><author-notes><corresp id="c1">Corresponding Author: Nara Fernanda Braz da Silva Leal Universidade de
São Paulo Faculdade de Medicina de Ribeirão Preto Av. dos Bandeirantes, 3900 Monte
Alegre - Campus Universitário CEP: 14.040-902, Ribeirão Preto, SP, Brasil E-mail:
<email>nanda.taz@bol.com.br</email></corresp></author-notes><pub-date pub-type="epub"><day>15</day><month>8</month><year>2016</year></pub-date><pub-date pub-type="collection"><year>2016</year></pub-date><volume>24</volume><elocation-id>e2755</elocation-id><history><date date-type="received"><day>13</day><month>2</month><year>2015</year></date><date date-type="accepted"><day>19</day><month>1</month><year>2016</year></date></history><permissions><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/4.0"><license-p>This is an open-access article distributed under the terms of the Creative
Commons Attribution License</license-p></license></permissions><abstract><title>ABSTRACT</title><sec><title>Objective:</title><p> to evaluate the effect of physical therapy on the range of motion of the
shoulders and perimetry of the upper limbs in women treated with radiotherapy for
breast cancer.</p></sec><sec><title>Methods:</title><p> a total of 35 participants were randomized into two groups, with 18 in the
control group (CG) and 17 in the study group (SG). Both of the groups underwent
three evaluations to assess the range of motion of the shoulders and perimetry of
the upper limbs, and the study group underwent supervised physical therapy for the
upper limbs. </p></sec><sec><title>Results:</title><p> the CG had deficits in external rotation in evaluations 1, 2, and 3, whereas the
SG had deficits in flexion, abduction, and external rotation in evaluation 1. The
deficit in abduction was recovered in evaluation 2, whereas the deficits in all
movements were recovered in evaluation 3. No significant differences in perimetry
were observed between the groups. </p></sec><sec><title>Conclusion:</title><p> the applied supervised physical therapy was effective in recovering the deficit
in abduction after radiotherapy, and the deficits in flexion and external rotation
were recovered within two months after the end of radiotherapy. Registration
number of the clinical trial: NCT02198118.</p></sec></abstract><kwd-group><title>Descriptors:</title><kwd>Breast Neoplasms</kwd><kwd>Radiotherapy</kwd><kwd>Physical Therapy Specialty</kwd></kwd-group><counts><fig-count count="3"></fig-count><table-count count="9"></table-count><equation-count count="0"></equation-count><ref-count count="25"></ref-count><page-count count="1"></page-count></counts></article-meta></front><body><sec sec-type="intro"><title>Introduction</title><p>Cancer is a chronic disease characterized by uncontrolled cell growth due to changes in
the genetic code. Breast cancer is the second most common type of cancer worldwide and
is the most common type of cancer among women. Gynecologic variables, anthropometric
variables, history of breastfeeding and alcohol consumption, body composition, and
physical activity levels are potential risk factors for this disease<xref rid="B1" ref-type="bibr"><sup>1</sup></xref><sup>-</sup><xref rid="B3" ref-type="bibr"><sup>3</sup></xref>.</p><p>Early diagnosis is one of the primary prognostic factors, and the therapeutic choice
depends on the clinical stage, anatomopathological characteristics of the disease, and
the clinical status of the patient. Local treatment consists of surgery and radiotherapy
(RT), whereas systemic treatment consists of chemotherapy (CT), hormone therapy (HT),
and biological therapy<xref rid="B3" ref-type="bibr"><sup>3</sup></xref><sup>-</sup><xref rid="B4" ref-type="bibr"><sup>4</sup></xref>.</p><p>Postoperative RT may be associated with complications that affect the quality of life of
patients<xref rid="B5" ref-type="bibr"><sup>5</sup></xref>. This treatment destroys cancer cells but also affects healthy tissues around
the irradiated area and causes vascular lesions. These lesions can evolve to fibrosis
and adhesion between the skin and muscles of the chest wall, shoulder, and
supraclavicular and axillary cavities<xref rid="B6" ref-type="bibr"><sup>6</sup></xref>. In addition, RT can cause lymphedema, impaired motion of the shoulder, pain,
stiffness, and fatigue<xref rid="B7" ref-type="bibr"><sup>7</sup></xref><sup>-</sup><xref rid="B9" ref-type="bibr"><sup>9</sup></xref>.</p><p>Few studies have evaluated the effectiveness of physical therapy during RT. A previous
study found that physical therapy intervention applied during RT prevented the
limitation of the range of motion (ROM) of the shoulder, reduced the incidence of scar
tissue adhesion, and improved the quality of life<xref rid="B10" ref-type="bibr"><sup>10</sup></xref><sup>-</sup><xref rid="B11" ref-type="bibr"><sup>11</sup></xref>. Another study reported that physical activity during RT increased shoulder ROM,
improved the quality of life and decreased fatigue<xref rid="B5" ref-type="bibr"><sup>5</sup></xref>.</p><p>Considering the severity of the possible consequences of RT and the limited number of
studies on this topic, the objective of the present analysis was to evaluate the effect
of physical therapy intervention during the RT period on the ROM of the shoulder and
perimetry of the upper limbs in women treated with radiotherapy for breast cancer.</p></sec><sec sec-type="methods"><title>Methods</title><p>This study was approved by the Research Ethics Committee of the Clinical Hospital of the
Ribeirão Preto Medical School, University of São Paulo (Hospital das Clínicas da
Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo-HCFMRP-USP) under
Protocol No. 11678/2009.</p><p>This clinical, prospective, non-blinded, randomized, controlled study was conducted in
the Mastology Clinic and Radiotherapy Service of HCFMRP-USP between November 2009 and
March 2012. </p><sec><title>Sample characteristics</title><p>The study population consisted of women treated at the Mastology Clinic and
Radiotherapy Service who met the following inclusion criteria: (i) diagnosis of
unilateral breast cancer; and (ii) undergoing surgery and RT for breast cancer,
conducted according to the therapeutic protocol of the center. The exclusion criteria
were patients with orthopedic and/or neurological disorders that limited the movement
of the upper limbs, bilateral breast cancer, prior thoracic RT, and the presence of
distant metastasis. </p><p>All of the participants were invited to participate in the study by telephone and
were successively treated at the Radiotherapy Service with an indication for RT as
part of their treatment. Those who met the inclusion criteria and agreed to
participate were included in the study and signed an informed consent form. A total
of 35 participants were selected. The study group comprised homemakers or women who
were out of work because of breast cancer treatment. The participants did not
practice physical exercise and were therefore considered sedentary. </p></sec><sec><title>Evaluation protocol and physical therapy intervention</title><p>The participants were evaluated at three different time points: pre-RT (evaluation
1), post-RT (evaluation 2), and two months after the end of RT (evaluation 3). The
variables evaluated were the ROM of the shoulder joint and perimetry of the upper
limbs. Shoulder ROM was evaluated by assessing flexion, extension, abduction,
adduction, and internal and external rotation, which were actively performed by the
participants. These measurements were made using a Carci(r) goniometer, and
positioning was performed according to the protocol proposed by Marques<xref rid="B12" ref-type="bibr"><sup>12</sup></xref>. Perimetry involved the performance of measurements at six different points:
point A - in the metacarpophalangeal joints of the second, third, fourth, and fifth
fingers; point B - an imaginary line pointing in the direction of the
metacarpophalangeal joint of the first finger; point C - 10 cm below the olecranon;
point D - 6 cm below the olecranon; point E - 6 cm above the olecranon; and point F -
10 cm above the olecranon<xref rid="B13" ref-type="bibr"><sup>13</sup></xref>. The subjects remained in a sitting position with the arm resting on the
thigh and the forearm supinated. The measurements were bilateral.</p><p>The selected participants were randomly divided into two groups: one group was
subjected to the evaluations described in the paragraph above and was designated the
control group (CG). Another group was subjected to supervised kinesiotherapy of the
upper limbs and was designated the study group (SG). The randomization plan was
generated using computer software that distributed the participants into the two
groups, following the sample size obtained in the sample calculation. The
participants were distributed into each group during evaluation 1. The distribution
was random but non-blinded. </p><p><xref ref-type="fig" rid="f1">Figure 1</xref> shows the plans for inclusion,
allocation, monitoring, and analysis.</p><p><fig id="f1" orientation="portrait" position="float"><label>Figure 1</label><caption><title>CONSORT diagram: inclusion, allocation, monitoring, and analysis</title></caption><graphic xlink:href="0104-1169-rlae-24-02755-gf1"></graphic></fig></p><p>Kinesiotherapy was performed during the RT period on an individual basis and was
performed in both limbs and twice a week. The exercise protocol<xref rid="B14" ref-type="bibr"><sup>14</sup></xref> was performed under the supervision of a physical therapist. Kinesiotherapy
consisted of 14 free active exercises for the cervical spine and upper limbs, with a
series of 15 repetitions, and was performed in a sitting position. The exercises
involved cervical tilt and rotation; elevation, flexion, extension, abduction,
adduction, and rotation of the shoulder; and flexion and extension of the elbow and
wrist.</p></sec><sec><title>Statistical analysis</title><p>Considering an α of 0.05, a test power of 80%, differences in the mean perimetry
values of 3.0 cm before and after RT, and a standard deviation of 4.5, a required
sample size of 16 was calculated using Power and Sample Size Calculation version
software 2.1.31<xref rid="B15" ref-type="bibr"><sup>15</sup></xref> .</p><p>The analysis involved the assessment of the intention to treat (ITT) and included all
participants in the study group who were originally allocated by randomization,
irrespective of the period of initiation of treatment, discontinuation of therapy,
nonadherence to the protocol received, or the use of treatment protocols that
differed from the original<xref rid="B16" ref-type="bibr"><sup>16</sup></xref>. </p><p>For the intragroup analysis, an unpaired t-test was used to compare the goniometry
results between the ipsilateral and contralateral limbs within the same evaluation.
One-way analysis of variance (ANOVA) was used to assess differences in perimetry
among the three evaluations. For intergroup analysis, unpaired t-tests were used to
evaluate the goniometry results in the ipsilateral limb and differences in perimetry.
P-values lower than 5% were considered statistically significant.</p></sec></sec><sec sec-type="results"><title>Results</title><p><xref ref-type="table" rid="t1">Table 1</xref> shows the characteristics of the
participants with respect to age, body weight, type and duration of surgery, and disease
staging. </p><p><table-wrap id="t1" orientation="portrait" position="float"><label>Table 1</label><caption><title>The characteristics of the study participants. Ribeirão Preto, São Paulo,
Brazil, 2012.</title></caption><table frame="hsides" rules="groups"><colgroup span="1"><col span="2"></col><col span="1"></col><col span="1"></col></colgroup><tbody><tr><td align="center" colspan="2" rowspan="1">Characteristic </td><td align="center" rowspan="1" colspan="1">Control group (n = 18)</td><td align="center" rowspan="1" colspan="1">Study group (n = 17)</td></tr><tr><td align="left" colspan="2" rowspan="1">Age (years)* </td><td align="center" rowspan="1" colspan="1"><italic>54.8</italic> ±11.86</td><td align="center" rowspan="1" colspan="1">55.2 ± 7.14</td></tr><tr><td align="left" colspan="2" rowspan="1">Body weight (kg)* </td><td align="center" rowspan="1" colspan="1">70.75 ± 18.24</td><td align="center" rowspan="1" colspan="1">69.58 ± 8.44</td></tr><tr><td align="left" colspan="2" rowspan="1">Type of surgery<sup>†</sup></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Conservative</td><td align="center" rowspan="1" colspan="1">13</td><td align="center" rowspan="1" colspan="1">13</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Radical</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">4</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Axillary lymphadenectomy</td><td align="center" rowspan="1" colspan="1">11</td><td align="center" rowspan="1" colspan="1">11</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Sentinel lymph node biopsy</td><td align="center" rowspan="1" colspan="1"><italic>7</italic></td><td align="center" rowspan="1" colspan="1">4</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Plastic surgery</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">-</td></tr><tr><td align="left" colspan="2" rowspan="1">Duration of surgery (months)* </td><td align="center" rowspan="1" colspan="1">5.81</td><td align="center" rowspan="1" colspan="1">4.52</td></tr><tr><td align="left" colspan="2" rowspan="1">Chemotherapy<sup>†</sup></td><td align="center" rowspan="1" colspan="1">15</td><td align="center" rowspan="1" colspan="1">12</td></tr><tr><td align="left" colspan="2" rowspan="1">Hormone therapy<sup>†</sup></td><td align="center" rowspan="1" colspan="1">13</td><td align="center" rowspan="1" colspan="1">11</td></tr><tr><td align="left" colspan="2" rowspan="1">Disease staging<sup>†</sup></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">3</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">I</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">2</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">IIA</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">6</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">IIB</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">2</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">IIIA</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">3</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">IIIB</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">2</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">IIIC</td><td align="center" rowspan="1" colspan="1">-</td><td align="center" rowspan="1" colspan="1">-</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">IV</td><td align="center" rowspan="1" colspan="1">-</td><td align="center" rowspan="1" colspan="1">-</td></tr></tbody></table><table-wrap-foot><fn id="TFN1"><p>*Mean and standard deviation (SD)</p></fn><fn id="TFN2"><label>†</label><p>Number of participants</p></fn></table-wrap-foot></table-wrap></p><p>Considering the RT period, an average of 11 supervised physiotherapy sessions should
have been conducted in the SG, but only 8 (72.72%) were conducted. </p><p>Radiotherapy was performed according to the protocol in force in the service, in which
the irradiated regions were the breast or chest plastron in all 35 participants and the
supraclavicular fossa (SCF) in 7 participants from the two study groups. The
participants were treated with conformational RT (3DRT) in the residual breast or chest
plastron and the SCF, when indicated, for lymphatic drainage regions. Fractionation was
1.8 and 2.0 Gy/fraction (one fraction per day, 5 days per week) using total doses
between 45.0 and 50.4 Gy in 25 fractions in the first treatment stage. During tumor bed
boost, the prescribed dose was 9-10 Gy in 5 fractions or 1.8-2.0 Gy per fraction (one
fraction per day, 5 days per week) and involved only the target volume or quadrant that
was previously affected by the tumor. Therefore, the RT duration in both groups was five
weeks. The duration of RT was six weeks in cases where tumor bed boost was
indicated.</p><p>The CG exhibited ROM deficits in external rotation in evaluations 1, 2, and 3, whereas
the SG exhibited ROM deficits for flexion, abduction, and external rotation in
evaluation 1. The deficit in the abduction was recovered in evaluation 2 in the SG, and
the deficits in all movements were recovered in evaluation 3. The intergroup analysis
indicated no significant difference in the ipsilateral goniometry results. The
goniometry data are shown in <xref ref-type="table" rid="t2">Table 2</xref>.</p><p><table-wrap id="t2" orientation="portrait" position="float"><label>Table 2</label><caption><title>Goniometry of ipsilateral and contralateral limbs: evaluation 1 (T1),
evaluation 2 (T2), and evaluation 3 (T3) (mean ± SD). Ribeirão Preto, São
Paulo, Brazil, 2012</title></caption><table frame="hsides" rules="groups"><colgroup span="1"><col span="1"></col><col span="3"></col><col span="1"></col><col span="3"></col><col span="1"></col><col span="1"></col></colgroup><tbody><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" colspan="3" rowspan="1">Study group (GE) </td><td align="left" rowspan="1" colspan="1"></td><td align="center" colspan="3" rowspan="1">Control group (CG) </td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">IL* SG vs. CG</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">IL*</td><td align="center" rowspan="1" colspan="1">CL<sup>†</sup></td><td align="center" rowspan="1" colspan="1">p</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">IL*</td><td align="center" rowspan="1" colspan="1">CL<sup>†</sup></td><td align="center" rowspan="1" colspan="1">p</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">P </td></tr><tr><td align="justify" rowspan="1" colspan="1">Flex<sup>‡</sup>_T1<sup>‡‡</sup></td><td align="center" rowspan="1" colspan="1">135.80° ± 17.48</td><td align="center" rowspan="1" colspan="1">147.40° ± 9.44</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">134.0 ± 26.2</td><td align="center" rowspan="1" colspan="1">148.3 ± 14.6</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.82</td></tr><tr><td align="justify" rowspan="1" colspan="1">Flex<sup>‡</sup>_T2<sup>§§</sup></td><td align="center" rowspan="1" colspan="1">140.40° ± 10.41</td><td align="center" rowspan="1" colspan="1">148.60° ± 7.41</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">139.1 ± 18.1</td><td align="center" rowspan="1" colspan="1">150.8 ± 14.1</td><td align="center" rowspan="1" colspan="1"><0.01</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.82</td></tr><tr><td align="justify" rowspan="1" colspan="1">Flex<sup>‡</sup>_T3<sup>||</sup></td><td align="center" rowspan="1" colspan="1">143.40° ± 9.76</td><td align="center" rowspan="1" colspan="1">148.00° ± 5.38</td><td align="center" rowspan="1" colspan="1">0.22</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">139.4 ± 15.6</td><td align="center" rowspan="1" colspan="1">149.2 ± 13.3</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.46</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="justify" rowspan="1" colspan="1">Ext<sup>§</sup>_T1<sup>‡‡</sup></td><td align="center" rowspan="1" colspan="1">39.53° ± 7.18</td><td align="center" rowspan="1" colspan="1">44.41° ± 8.02</td><td align="center" rowspan="1" colspan="1">0.07</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">41.78 ± 9.1</td><td align="center" rowspan="1" colspan="1">43.3 ± 9.0</td><td align="center" rowspan="1" colspan="1">0.302</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.42</td></tr><tr><td align="justify" rowspan="1" colspan="1">Ext<sup>§</sup>_T2<sup>§§</sup></td><td align="center" rowspan="1" colspan="1">41.46° ± 5.92</td><td align="center" rowspan="1" colspan="1">43.88° ± 5.52</td><td align="center" rowspan="1" colspan="1">0.40</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">37.9 ± 41.8</td><td align="center" rowspan="1" colspan="1">41.8 ± 8.0</td><td align="center" rowspan="1" colspan="1"><0.01</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.22</td></tr><tr><td align="justify" rowspan="1" colspan="1">Ext<sup>§</sup>_T3<sup>||</sup></td><td align="center" rowspan="1" colspan="1">40.25° ± 5.89</td><td align="center" rowspan="1" colspan="1">43.17° ± 4.32</td><td align="center" rowspan="1" colspan="1">0.18</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">39.3 ± 8.1</td><td align="center" rowspan="1" colspan="1">40.3 ± 7.0</td><td align="center" rowspan="1" colspan="1">0.524</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.73</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="justify" rowspan="1" colspan="1">Abd<sup>|</sup>_T1<sup>‡‡</sup></td><td align="center" rowspan="1" colspan="1">133.20° ± 22.70</td><td align="center" rowspan="1" colspan="1">147.20° ± 14.08</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">127.9 ± 31.0</td><td align="center" rowspan="1" colspan="1">146.1 ± 22.8</td><td align="center" rowspan="1" colspan="1"><0.01</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.57</td></tr><tr><td align="justify" rowspan="1" colspan="1">Abd<sup>|</sup>_T2<sup>§§</sup></td><td align="center" rowspan="1" colspan="1">140.80° ± 16.61</td><td align="center" rowspan="1" colspan="1">149.10° ± 3.13</td><td align="center" rowspan="1" colspan="1">0.17</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">132.9 ± 21.8</td><td align="center" rowspan="1" colspan="1">146.6 ± 20.3</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.29</td></tr><tr><td align="justify" rowspan="1" colspan="1">Abd<sup>|</sup>_T3<sup>||</sup></td><td align="center" rowspan="1" colspan="1">139.70° ± 14:53</td><td align="center" rowspan="1" colspan="1">147.30° ± 14.75</td><td align="center" rowspan="1" colspan="1">0.22</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">133.0 ± 20.5</td><td align="center" rowspan="1" colspan="1">149.1 ± 17.9</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.37</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="justify" rowspan="1" colspan="1">Ad<sup>¶</sup>_T1<sup>‡‡</sup></td><td align="center" rowspan="1" colspan="1">28.71° ± 7.88</td><td align="center" rowspan="1" colspan="1">31.53° ± 8.25</td><td align="center" rowspan="1" colspan="1">0.32</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">29.4 ± 13.9</td><td align="center" rowspan="1" colspan="1">32.8 ± 7.6</td><td align="center" rowspan="1" colspan="1">0.291</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.85</td></tr><tr><td align="justify" rowspan="1" colspan="1">Ad<sup>¶</sup>_T2<sup>§§</sup></td><td align="center" rowspan="1" colspan="1">29.38° ± 7:34</td><td align="center" rowspan="1" colspan="1">30.31° ± 30.06</td><td align="center" rowspan="1" colspan="1">0.74</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">25.81 ± 9.4</td><td align="center" rowspan="1" colspan="1">31.3 ± 8.6</td><td align="center" rowspan="1" colspan="1">0.062</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.27</td></tr><tr><td align="justify" rowspan="1" colspan="1">Ad<sup>¶</sup>_T3<sup>||</sup></td><td align="center" rowspan="1" colspan="1">28.42° ± 7:33</td><td align="center" rowspan="1" colspan="1">31.25° ± 9:58</td><td align="center" rowspan="1" colspan="1">0.42</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">28.8 ± 8.5</td><td align="center" rowspan="1" colspan="1">33.3 ± 10.0</td><td align="center" rowspan="1" colspan="1">0.070</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.92</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="justify" rowspan="1" colspan="1">ER<sup>**</sup>_T1<sup>‡‡</sup></td><td align="center" rowspan="1" colspan="1">74.88° ± 15.10</td><td align="center" rowspan="1" colspan="1">83.76° ± 4.70</td><td align="center" rowspan="1" colspan="1"><0.01</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">73.0 ± 14.4</td><td align="center" rowspan="1" colspan="1">81.1 ± 7.4</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.66</td></tr><tr><td align="justify" rowspan="1" colspan="1">ER<sup>**</sup>_T2<sup>§§</sup></td><td align="center" rowspan="1" colspan="1">75.46° ± 10:45</td><td align="center" rowspan="1" colspan="1">83.15° ± 6.18</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">72.9 ± 13.0</td><td align="center" rowspan="1" colspan="1">82.1 ± 9.3</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.57</td></tr><tr><td align="justify" rowspan="1" colspan="1">ER<sup>**</sup>_T3<sup>||</sup></td><td align="center" rowspan="1" colspan="1">78.33° ± 9.76</td><td align="center" rowspan="1" colspan="1">82.50° ± 5:38</td><td align="center" rowspan="1" colspan="1">0.21</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">70.8 ± 15.4</td><td align="center" rowspan="1" colspan="1">83.4 ± 9.2</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.17</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="justify" rowspan="1" colspan="1">IR<sup>††</sup>_T1<sup>‡‡</sup></td><td align="center" rowspan="1" colspan="1">74.18° ± 14:33</td><td align="center" rowspan="1" colspan="1">77.94° ± 09.05</td><td align="center" rowspan="1" colspan="1">0.37</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">74.3 ± 12.1</td><td align="center" rowspan="1" colspan="1">72.9 ± 12.2</td><td align="center" rowspan="1" colspan="1">0.510</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.97</td></tr><tr><td align="justify" rowspan="1" colspan="1">IR<sup>††</sup>_T2<sup>§§</sup></td><td align="center" rowspan="1" colspan="1">73.62° ± 12.02</td><td align="center" rowspan="1" colspan="1">76.23° ± 7:53</td><td align="center" rowspan="1" colspan="1">0.51</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">77.1 ± 9.1</td><td align="center" rowspan="1" colspan="1">75.1 ± 9.4</td><td align="center" rowspan="1" colspan="1">0.382</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.39</td></tr><tr><td align="justify" rowspan="1" colspan="1">IR<sup>††</sup>_ T3<sup>||</sup></td><td align="center" rowspan="1" colspan="1">76.08° ± 9:46</td><td align="center" rowspan="1" colspan="1">76.92° ± 7.66</td><td align="center" rowspan="1" colspan="1">0.81</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">75.9 ± 7.4</td><td align="center" rowspan="1" colspan="1">76.3 ± 8.4</td><td align="center" rowspan="1" colspan="1">0.827</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.96</td></tr></tbody></table><table-wrap-foot><fn id="TFN3"><p>* IL: ipsilateral limb; † CL: contralateral limb; ‡ Flex: flexion; §Ext:
extension; |Abd: abduction; ¶Ad adduction; **ER: external rotation; †† IR:
internal rotation; ‡‡ T1: evaluation 1; §§T2: evaluation 2; ||T3: evaluation
3.</p></fn></table-wrap-foot></table-wrap></p><p>The intragroup point-by-point analysis of perimetry indicated no significant differences
in perimetry. However, the intergroup analysis indicated a significant difference in
point F in evaluation 3. These results are shown in <xref ref-type="table" rid="t3">Table 3</xref>.</p><p><table-wrap id="t3" orientation="portrait" position="float"><label>Table 3</label><caption><title>Difference in perimetry between ipsilateral and contralateral limbs in
evaluation 1 (T1), evaluation 2 (T2), and evaluation 3 (T3) (mean ± SD).
Ribeirão Preto, São Paulo, Brazil, 2012</title></caption><table frame="hsides" rules="groups"><colgroup span="1"><col span="1"></col><col span="1"></col><col span="1"></col><col span="1"></col><col span="1"></col><col span="1"></col><col span="1"></col></colgroup><tbody><tr><td align="left" colspan="2" rowspan="1"></td><td align="center" rowspan="1" colspan="1">T1</td><td align="center" rowspan="1" colspan="1">T2</td><td align="center" rowspan="1" colspan="1">T3</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">P-value*</td></tr><tr><td align="center" rowspan="3" colspan="1">Point A</td><td align="center" rowspan="1" colspan="1"> Study group</td><td align="center" rowspan="1" colspan="1">0.04 ± 0.46</td><td align="center" rowspan="1" colspan="1">12.12 ± 0.87</td><td align="center" rowspan="1" colspan="1">12.17 ± 0.81</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.90</td></tr><tr><td align="center" rowspan="1" colspan="1"> Control group</td><td align="center" rowspan="1" colspan="1">0.03 ± 0.65</td><td align="center" rowspan="1" colspan="1">0.20 ± 0.75</td><td align="center" rowspan="1" colspan="1">0.29 ± 0.62</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.67</td></tr><tr><td align="center" rowspan="1" colspan="1">p-value†</td><td align="center" rowspan="1" colspan="1">0.89</td><td align="center" rowspan="1" colspan="1">0.78</td><td align="center" rowspan="1" colspan="1">0.67</td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="center" rowspan="3" colspan="1">Point B</td><td align="center" rowspan="1" colspan="1">Study group</td><td align="center" rowspan="1" colspan="1">0.14 ± 0.63</td><td align="center" rowspan="1" colspan="1">0.15 ± 0.85</td><td align="center" rowspan="1" colspan="1">0.67 ± 1.15</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.26</td></tr><tr><td align="center" rowspan="1" colspan="1">Control group</td><td align="center" rowspan="1" colspan="1">-0.19 ± 0.84</td><td align="center" rowspan="1" colspan="1">0.10 ± 0.63</td><td align="center" rowspan="1" colspan="1">0.29 ± 0.75</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.38</td></tr><tr><td align="center" rowspan="1" colspan="1">p-value†</td><td align="center" rowspan="1" colspan="1">0.32</td><td align="center" rowspan="1" colspan="1">0.85</td><td align="center" rowspan="1" colspan="1">0.36</td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="center" rowspan="3" colspan="1">Point C</td><td align="center" rowspan="1" colspan="1">Study group</td><td align="center" rowspan="1" colspan="1">0.25 ± 0.98</td><td align="center" rowspan="1" colspan="1">0.38 ± 1.21</td><td align="center" rowspan="1" colspan="1">0.75 ± 1.05</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.50</td></tr><tr><td align="center" rowspan="1" colspan="1">Control group</td><td align="center" rowspan="1" colspan="1">-0.17 ± 0.94</td><td align="center" rowspan="1" colspan="1">-0.03 ± 1.38</td><td align="center" rowspan="1" colspan="1">0.25 ± 1.27</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.50</td></tr><tr><td align="center" rowspan="1" colspan="1">p-value†</td><td align="center" rowspan="1" colspan="1">0.25</td><td align="center" rowspan="1" colspan="1">0.40</td><td align="center" rowspan="1" colspan="1">0.30</td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="center" rowspan="3" colspan="1">Point D</td><td align="center" rowspan="1" colspan="1">Study group</td><td align="center" rowspan="1" colspan="1">0.29 ± 0.95</td><td align="center" rowspan="1" colspan="1">0.42 ± 1.37</td><td align="center" rowspan="1" colspan="1">0.50 ± 1.22</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.87</td></tr><tr><td align="center" rowspan="1" colspan="1">Control group</td><td align="center" rowspan="1" colspan="1">-0.03 ± 0.88</td><td align="center" rowspan="1" colspan="1">-0.03 ± 1.04</td><td align="center" rowspan="1" colspan="1">0.17 ± 1.09</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1"> 0.89</td></tr><tr><td align="center" rowspan="1" colspan="1">p-value†</td><td align="center" rowspan="1" colspan="1">0.47</td><td align="center" rowspan="1" colspan="1">0.33</td><td align="center" rowspan="1" colspan="1">0.47</td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="center" rowspan="3" colspan="1">Point E</td><td align="center" rowspan="1" colspan="1">Study group</td><td align="center" rowspan="1" colspan="1">0.43 ± 1.31</td><td align="center" rowspan="1" colspan="1">0.46 ± 1.68</td><td align="center" rowspan="1" colspan="1">0.96 ± 1.42</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.61</td></tr><tr><td align="center" rowspan="1" colspan="1">Control group</td><td align="center" rowspan="1" colspan="1">0.36 ± 1.03</td><td align="center" rowspan="1" colspan="1">0.13 ± 1.23</td><td align="center" rowspan="1" colspan="1">0.08 ± 1.29</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.98</td></tr><tr><td align="center" rowspan="1" colspan="1">p-value†</td><td align="center" rowspan="1" colspan="1">0.89</td><td align="center" rowspan="1" colspan="1">0.56</td><td align="center" rowspan="1" colspan="1">0.13</td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr><tr><td align="center" rowspan="3" colspan="1">Point F</td><td align="center" rowspan="1" colspan="1">Study group</td><td align="center" rowspan="1" colspan="1">0.32 ± 1.28</td><td align="center" rowspan="1" colspan="1">0.54 ± 1.64</td><td align="center" rowspan="1" colspan="1">0.87 ± 0.98</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.58</td></tr><tr><td align="center" rowspan="1" colspan="1">Control group</td><td align="center" rowspan="1" colspan="1">0.17 ± 1.40</td><td align="center" rowspan="1" colspan="1">0.20 ± 1.31</td><td align="center" rowspan="1" colspan="1">-0.21 ± 1.17</td><td align="left" rowspan="1" colspan="1"></td><td align="center" rowspan="1" colspan="1">0.64</td></tr><tr><td align="center" rowspan="1" colspan="1">p-value†</td><td align="center" rowspan="1" colspan="1">0.88</td><td align="center" rowspan="1" colspan="1">0.55</td><td align="center" rowspan="1" colspan="1"><0.05</td><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1"></td></tr></tbody></table><table-wrap-foot><fn id="TFN4"><p>*Intragroup comparison</p></fn><fn id="TFN5"><p>†Intergroup comparison</p></fn></table-wrap-foot></table-wrap></p></sec><sec sec-type="discussion"><title>Discussion</title><p>Physical therapy can help reduce pain, fatigue, and lymphedema, and improve muscle
strength, shoulder ROM, functional status, and the quality of life of women undergoing
treatment for breast cancer<xref rid="B17" ref-type="bibr"><sup>17</sup></xref><sup>-</sup><xref rid="B20" ref-type="bibr"><sup>20</sup></xref>. </p><p>The occurrence of postoperative complications depends on the surgical extension,
axillary approach, and application of CT and RT. RT is associated with increased loss of
the ROM and muscle strength, lymphedema, fibrosis in the chest wall, and impaired
neoformation of lymphatic vessels. Fibrosis and lymphedema are more frequent during SCF
irradiation and tumor bed boost. The upper limbs are less impaired when RT excludes the
axilla<xref rid="B6" ref-type="bibr"><sup>6</sup></xref><sup>,</sup><xref rid="B9" ref-type="bibr"><sup>9</sup></xref><sup>,</sup><xref rid="B21" ref-type="bibr"><sup>21</sup></xref><sup>-</sup><xref rid="B22" ref-type="bibr"><sup>22</sup></xref>.</p><p>The deficit in the ROM observed in the CG and SG in evaluation 1 can be attributed to
surgery because ROM restrictions and functional problems in the shoulder may still be
present at six months or more after surgery<xref rid="B20" ref-type="bibr"><sup>20</sup></xref><sup>,</sup><xref rid="B23" ref-type="bibr"><sup>23</sup></xref>.</p><p>The CG maintained the deficit for external rotation throughout the study period. In the
SG, the deficit in the abduction movement was recovered in evaluation 2, and the
deficits in flexion and external rotation were recovered in evaluation 3, demonstrating
the importance of conducting supervised physical therapy in women undergoing RT for
breast cancer.</p><p>A study that evaluated the ROM in the shoulder of women before and after RT indicated an
increase in the deficit of flexion and abduction in the control group and a decrease in
the group subjected to physical therapy<xref rid="B10" ref-type="bibr"><sup>10</sup></xref>. Moreover, the ROM in women who underwent physical therapy improved during the
RT period and worsened in women who did not undergo physical therapy<xref rid="B5" ref-type="bibr"><sup>5</sup></xref>. Physical therapy results in a gain in shoulder ROM when applied during RT; this
effect can be observed immediately after the end of RT<xref rid="B5" ref-type="bibr"><sup>5</sup></xref> and persists for up to six months after RT<xref rid="B10" ref-type="bibr"><sup>10</sup></xref>. Our results are consistent with those of previous studies.</p><p>Muscles should be at their natural length and have a sufficient ability to glide under
adjacent soft tissues (i.e., skin and subcutaneous tissue) to ensure adequate mobility
of the joints. Full range of flexion and abduction requires proper functioning of the
major and minor pectoral, latissimus dorsi, teres major, subscapularis, and rhomboid
muscles. Adequate functioning of the serratus anterior muscle is also required for the
upward rotation of the scapula. For external rotation, the pectoralis major, latissimus
dorsi, teres major, and subscapularis muscles must be at their natural length and be
able to glide<xref rid="B21" ref-type="bibr"><sup>21</sup></xref>.</p><p>Because of their origin and insertion, the pectoral and serratus anterior muscles are
approached and can be damaged during surgery for breast cancer. Furthermore, these
muscles are located in the areas indicated for RT<xref rid="B6" ref-type="bibr"><sup>6</sup></xref>. Therefore, the movements used to recruit these muscles may be adversely
affected by the adhesion and fibrosis caused by RT<xref rid="B5" ref-type="bibr"><sup>5</sup></xref><sup>,</sup><xref rid="B10" ref-type="bibr"><sup>10</sup></xref><sup>,</sup><xref rid="B19" ref-type="bibr"><sup>19</sup></xref><sup>,</sup><xref rid="B24" ref-type="bibr"><sup>24</sup></xref>. </p><p>The analysis of the mean difference in the upper limb perimetry at each study point
indicated no significant differences in the intragroup comparison. Although intergroup
analysis indicated a significant difference in point F in evaluation 3, this result
indicates intergroup differences but not the presence of lymphedema, as shown in <xref ref-type="table" rid="t3">Table 3</xref>. The analysis of mean perimetry values
indicated that the participants did not present with lymphedema after surgery and did
not develop this complication during RT or two months after its completion. The same
result was found in another study, wherein lymphedema was not observed even six months
after the completion of RT<xref rid="B10" ref-type="bibr"><sup>10</sup></xref>.</p><p>The risk of the onset of lymphedema is associated with several factors, including
radical surgery, extent of axillary dissection, and application of RT. However,
pre-existing lymphatic insufficiency of genetic and traumatic origin may also be
responsible for the emergence of lymphedema. After axillary lymphadenectomy , the body
adjusts to compensate for the removal of lymph nodes to allow for the transport of
lymph, thereby preventing the development of lymphedema<xref rid="B9" ref-type="bibr"><sup>9</sup></xref><sup>,</sup><xref rid="B24" ref-type="bibr"><sup>24</sup></xref><sup>-</sup><xref rid="B25" ref-type="bibr"><sup>25</sup></xref>.</p><p>The exercises used in this study were free active exercises consisting of a series of 15
repetitions and were performed twice a week during the RT period. These exercises were
intended to maintain the movement of joints and soft tissues, minimize the loss of
flexibility and the formation of contractures and ensure early rehabilitation<xref rid="B19" ref-type="bibr"><sup>19</sup></xref>. The supervised kinesiotherapy helped recover the deficit in the shoulder ROM
between the ipsilateral and contralateral limbs.</p><p>The limitations of the present study include the non-blinded nature of the study, the
performance of all stages of research (i.e., patient selection and enrollment,
randomization of the study groups, evaluation and implementation of interventions) by
the same researcher, difficulty in recruitment and protocol adherence of the sample
study, and the fragile emotional state of the participants, leading to the
discontinuation of therapy before the completion of the study.</p><p>Notwithstanding these limitations, the results of this study contribute to the practice
of evidence-based physical therapy. Supervised physical therapy is beneficial to
patients treated with RT for breast cancer, which was demonstrated by recovery of the
shoulder ROM. Therefore, supervised physical therapy should be encouraged and applied in
the RT period to prevent and treat possible complications of the upper limbs. </p></sec><sec sec-type="conclusions"><title>Conclusion</title><p>Supervised physical therapy that targets the ROM of shoulders of women treated with RT
for unilateral breast cancer helps increase the ROM of flexion, abduction, and external
rotation. The deficit in the abduction was recovered after RT, and the deficits in
flexion and external rotation were recovered two months after the end of RT. The
physical therapy protocol applied did not change the upper limb perimetry, a result that
is consistent with the fact that the participants did not have lymphedema and did not
develop this condition during the study period. These results indicate the need to
perform this type of physical therapy in patients treated with RT for breast cancer.</p></sec></body><back><fn-group><fn fn-type="other" id="fn1"><label>1</label><p>Paper extrated from Master's Thesis "Avaliação e intervenção fisioterapêuticas em
mulheres submetidas à radioterapia para o câncer de mama", presented to Faculdade de
Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP,
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