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  • 8/6/2019 Flor Thesis





    A Thesis Proposal

    Presented to the

    Faculty of the Graduate School


    In Partial Fulfillment of the

    Requirements for the Degree

    Master in Public Health



    Floriza P. de Leon

    May 2011

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    Breast cancer is so far the most frequent type of cancer among

    women worldwide, resulting in over one million new cases each year and

    is the leading cause of female cancer-related deaths. In Asia, the

    Philippines has the highest incidence rate of breast cancer with a survival

    rate that is much lower than the world average (GlaxoSmithKline

    Philippines, 2007).

    Treatment for breast cancer, such as surgery, radiation therapy,

    and chemotherapy, have the potential to cause upper extremity

    impairment on the affected side such as limited range of motion, poor

    muscle strength and hand grip strength. This is where the role of physical

    therapy takes place. Under Physical Rehabilitation, these problems are

    addressed through the application of therapeutic intervention. In

    Philippine setting, post-surgical breast cancer patients are not usually

    referred to a physical rehabilitation institute for the reason that patients are

    given time to recuperate from the limitations brought about by the

    operation. Four to six weeks after operation, patients are then referred for

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    further treatment such as chemotherapy and radiation therapy. Very rare,

    these patients are referred to undergo musculo-skeletal assessment.

    Arm morbidity being one of the most troublesome complications of

    breast cancer treatment has a significant impact on the daily lives of

    breast cancer survivors. The most common impairments reported after

    breast cancer surgery include reduced range of motion of the shoulder;

    numbness of the axilla or lateral chest wall; reduced grip strength; and

    arm edema with a high degree of functional impairment and pain. With

    advances in the medical treatment of persons with cancer, including the

    combined use of surgical intervention, radiation therapy, and

    chemotherapy, cancer survival rates (defined as a relative combined 5-

    year statistic) are now above fifty percent (50%). As survival rates and

    survival time have increased, so have public attitudes and the willingness

    to discuss cancer care is not simply on survival, but on cancer

    rehabilitation which aims to improve functional status and quality of life

    (Veronika-Fialka, et al, 2003).

    The concept of health-related quality of life (HRQOL) and its

    determinants have evolved since the 1980s to encompass those aspects

    of overall quality of life that can be clearly shown to affect health either

    physical or mental. On the individual level, this includes physical and

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    mental health perceptions and their correlates including health risks and

    conditions, functional status, social support, and socioeconomic status.

    HRQOL questions about perceived physical and mental health and

    function have become an important component of health surveillance and

    are generally considered valid indicators of service needs and intervention

    outcomes. Self-assessed health status also proved to be more powerful

    predictor of mortality and morbidity than many objective measure of health

    (Center for Disease Control and Prevention Online, 2011).

    In this light, the researcher assesses the shoulder range of motion,

    muscle strength, and hand grip strength of breast cancer survivors in

    relation to quality of life. The objective of the study is also the intention of

    this study to assess quality of life in terms of physical health,

    psychological, social relationships and the environment. It aims to

    recognize the relationship between the shoulder range of motion, shoulder

    muscle strength and hand grip strength and levels of quality of life of

    breast cancer survivors. And lastly, its purpose is to know the implication

    of the results of the study for public health education. It is the hope of this

    study that the results could contribute for the eclectic approach in the total

    rehabilitation of breast cancer survivors. Rehabilitation doctors and

    physical therapists can work hand in hand in the integration of new

    component of therapeutic intervention in the field of cancer rehabilitation.

    It will be anticipated also that with this study, physical rehabilitation will be

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    of help to Physical Therapist on how they should conduct therapeutic

    intervention and that will result to breast cancer survivors recuperate in a

    shorter period of time and with a better quality of life.


    This study assesses the shoulder range of motion, muscle strength,

    and hand grip strength of breast cancer survivors in relation to quality of

    life. Specifically, it seeks to answer the following questions:

    1. How are breast cancer survivors be assessed in terms of:

    1.1 shoulder range of motion (all planes)

    1.2 shoulder muscle strength

    1.3 hand grip strength

    2. How may the breast cancer survivors be assessed in terms of their

    quality of life?

    2.1 Physical Health

    2.2 Psychological

    2.3 Social relationships

    2.4 Environment

    3. Is there significant relationship between the following and levels of

    quality of life of breast cancer survivors:

    3.1 shoulder range of motion (all planes)

    3.2 shoulder muscle strength

    3.3 hand grip strength

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    4. What are the implications of the results of the study for public health



    This study will be focused on the assessment of shoulder range of

    motion, shoulder muscle strength, hand grip strength and quality of life

    among breast cancer survivors in selected population. Assessment tools

    and procedures conformed to the standard method used in clinical

    practice such as the use of goniometer, manual muscle testing and

    dynamometer to measure hand grip strength. WHOQOL-BREF will be the

    assessment tool to be used to evaluate quality of life. This is an

    assessment tool formulated by the World Health Organization (WHO).

    This research will be conducted in Jose B. Lingad Memorial

    Regional Hospital (JBLMRH) Physical Therapy Unit were recruited

    subjects will be assessed by a trained physical therapist. Only one

    physical therapist will assessed the participants to preserve validity and

    reliability of the results. Subjects who will be recruited to participate

    should have completed active breast cancer treatment at six(6) months

    previously and should be at least 25 years of age, and has a good

    comprehension of the English language. Bilateral breast cancer, infection

    of the upper extremity, lymphangitis, pre-existing lymphedema, history of

    neuromuscular or musculoskeletal condition that would affect local upper

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    extremity testing or current recurrence will be excluded from the study.

    Mann-Whitney ranked sum analysis and regression analysis are the

    statistical tool to be used for hypothesis testing of this study.

    The focus of the study is to find relationship between shoulder

    range of motion, muscle strength and hand grip strength as to their quality

    of life. The study is limited to other factors that will affect quality of life

    such as current lifestyle, involvement in support groups, marital status and

    job satisfaction which are not presented in this study. This study will be

    conducted from May 2011 to June 2012.


    For better understanding of the study on hand, the following terms

    are defined:

    Assessment. It is an evaluation of the condition based on the

    patients subjective report of the symptoms and course of illness or

    condition and the examiners objective findings, including data obtained

    through physical examination, medical history, and information reported by

    family members and other health care teams (Mosbys Medical Dictionary,


    In this study, it refers to the assessment of shoulder range of

    motion, muscle strength and hand grip strength of the affected side of

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    effective performance of a movement in relation to the forces of gravity

    and manual resistance (Clarkson, 2000).

    Quality of Life. Condition of an individuals perception of his

    position in life in the context of the culture and value systems in which he

    lives and in relation to his goals, expectations, standards and concerns. It

    is a broad ranging concept affected in a complex way by the persons

    physical health, psychological state, level of independence, social

    relationships, personal beliefs and their relationship to salient features of

    their environment (World Health Organization, 2010).

    Range of Motion. Range of motion is the maximum amount of

    movement that is possible in any particular joint (King et al., 1981)

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    Related Literature

    Physical Assessment

    Physical assessment of the breast and axillae is part of periodic

    health maintenance examination for women of all ages. Breast cancer

    cannot be prevented, but early detection offers more treatment option and

    a greater chance of cure. Aside from physical assessment, a

    musculoskeletal assessment is also being done to evaluate parameters of

    function such as flexibility, strength, and endurance (Hamer, 2010).

    Physical therapists may be involved in the treatment of breast

    cancer patients at any stage of their disease. Newly diagnosed patients

    often treated with a combination of surgery, radiotherapy, chemotherapy

    and hormone treatments. As a result of this, patients frequently require

    physiotherapy intervention. Following breast surgery, patients can

    experience problems with pain, limited shoulder movement and

    lymphedema. Radiotherapy to breast tissue can cause tissue fibrosis,

    resulting in movement limitation and lymphedema. Chemotherapy and

    hormone therapy can lead to changes in menopausal status and general

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    debility. Physical therapists knowledge of anatomy and normal

    movement makes them ideally suited in treating this group of patients

    (Hamer, 2010).

    Range of Motion

    One aspect of musculoskeletal assessment is flexibility. It is being

    measured in joint range of motion. Range of motion is the amount of

    motion that is available at a joint is called the range of motion (ROM). The

    starting position for measuring all ROM, except rotations in the transverse

    plane, is the anatomical position. Three notation systems have been used

    to define ROM: the 0-to 180-degree system, the 180- to 0-degree system,

    and the 360-degree system. In the 0- to 180-degree notion system, the

    upper and lower extremity joints are at 0 degrees for flexion-extension and

    abduction-adduction when the body is in anatomical position. A body

    position in which the extremity joints are halfway between medial (internal)

    and lateral (external) rotation is 0 degrees for the ROM in rotation. A

    ROM begins at 0 degrees and proceeds in an arc toward 180 degrees.

    This 0- to 180-degree system of notion is widely used throughout the

    world. First described by Silver in 1923, its use have been supported by

    many authorities, including Cave and Roberts, Moore, the American

    Academy of Orthopedic Surgeons, and the American Medical Association


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    Normal ROM varies among individuals and is influenced by factors

    such as age, gender, and whether the motion is performed actively or

    passively. Numerous studies have been conducted to determine the

    effects of age on ROM of extremities and spine. Most investigators who

    have studied a wide range of age groups have found that older adult

    groups have somewhat less ROM of the extremities than younger adult

    group. The effects of gender on the ROM of the extremities and spine

    also appear to be joint- and motion specific. Boone et al. found that

    females across an age range of 21 to 69 years have less hip extension,

    but more hip flexion, than males in the same age groups. Females in the

    age range of 1 to 29 years had less hip adduction and lateral rotation than

    males in the same age groups. Beighton et al., in a study of an African

    population, found that females between 0 and 80 years of age were more

    mobile than their male counterparts (McFarland and Kim, 2006).

    When evaluating a clients range of motion, a therapist should first

    observe the client during a function activity. This functional observation

    may be referred to as a screening because it is not a formal assessment,

    but a method to allow the therapist to determine quickly which joints need

    further assessment. By demonstrating proficient observation skills a

    therapist will be able to save time in the fast-paced health care

    environment. If no deficits are noted during observation, the therapist can

    avoid spending excessive time on measuring the range of motion of each

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    joint only to determine that all joints are functional or normal. In addition,

    this screening can be completed during another assessment such as

    activities of daily living (ADL). Once a deficit joint or joints are noted, the

    therapist will need to complete a goniometry assessment. The purpose of

    goniometry is to measure the arc of motion of joint. In order to measure

    this arc of motion, the therapist utilizes bony landmarks on the human

    body to place the goniometer. The goniometer is the most commonly

    used instrument to measure joint motion. There are many sizes and

    shapes. Some goniometers are plastic while others are metal. All

    goniometers have a body and two arms. The body is a full or semicircle

    with a center point called the axis or fulcrum. One arm is called the

    stationary arm and the other is the movable arm (Clarkson,2000).

    During the use of the goniometer, the axis or fulcrum is placed over

    the axis of motion being measured. The movable arm is also aligned with

    the plane of motion, but is distal to the joint being measured and follows

    the arm of motion. Now that the goniometer placement has been

    determined, it is important to understand the planes and axis of joint

    motion. The planes are the surfaces along which movement occurs.

    They are imaginary sheets of glass that run through the body. There are

    different planes (of glass) running through the body in different directions

    because the body moves in different directions. Movement of the body

    generally occurs in an arc or circular motion. The axis or fulcrum is the

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    disadvantage. The quadriceps, for example, is a powerful muscle

    responsible for straightening the leg. Once the leg is straightened, it is

    exceedingly difficult for the examiner to flex the knee. If the knee is flexed

    and the patient is asked to straighten the leg against resistance, weakness

    can be elicited. The evaluation of muscle strength compares the sides of

    the body to each other. For example, the right upper extremity is

    compared to the left upper extremity. Subtle differences in strength may

    be evaluated by testing for drift. For example, both arms are out in front of

    the patient with palms up; drift is seen as pronation of the palm, indicating

    a subtle weakness that may not have been detected on the resistance

    examination. Clinicians use a 5-point scale to rate muscle strength. A 5

    indicates full power of contraction against gravity and resistance or normal

    muscle strength; 4 indicates fair but not full strength against gravity and a

    moderate amount of resistance or slight weakness; 3 indicates just

    sufficient strength to overcome the force of gravity or moderate weakness;

    2 indicates the ability to move but not to overcome the force of gravity or

    severe weakness; 1 indicates minimal contractile power (weak muscle

    contraction can be palpated but no movement is noted) or very severe

    weakness; and 0 indicates no movement (Hislop and Montgomery, 2007).

    It is commonly recognized that a number of factors affect strength.

    The therapist must consider these factors when assessing a patients

    strength. First to consider is the age. Muscle strength increases from

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    birth to a maximum point between 20 and 30 years of age. Following this

    maximum, a decrease in strength occurs with increasing age due to a

    deterioration in muscle mass. Muscle fibers decrease in size and number,

    connective tissue and fat increase, and the respiratory capacity of the

    muscle decreases. Another point is that, men are generally stronger than

    women. Muscle size also play an important role in the intensity of muscle

    strength. The larger the cross-sectional area of a muscle, the greater the

    strength of the muscle. When testing a muscle that is small, the therapist

    would expect less tension to be developed than if testing a large, thick

    muscle (Clarkson, 2000).

    Figure 2: Manual Muscle Testing of the Shoulder

    Hand Grip Strength

    Manual muscle testing evaluates only individual muscle or small

    muscle groups. In the forearm and hand movement, there are thirty five

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    The most common method of assessment for grip strength is the

    use of handheld dynamometer. This is a form of what is referred to as a

    biomechanical measurement. Biomechanical measurements allow sports

    coaches to appreciate the bioenergetics and efficiency of sports

    movements; traning can then aim to achieve a maximal energetic output

    with minimal expenditure of energy, avoiding at the same time possible

    fatigue and stress lesions in the locomotory system. Handheld grip

    strength dynamometry is used to measure the muscular force generated

    by flexor mechanisms of the hand and forearm (Hoeger and Hoeger,


    Breast Cancer

    Flexibility and muscle strength are the primarily affected in breast

    cancer which is an uncontrolled growth of breast cells. The breasts, or

    mammary glands, consist of fat pads inside of which is a branching

    system of ducts. These ducts are designed to ferry milk from the milk-

    producing lobules to the nipples. Breast cancer develops as the result of

    malignant changes in the cells lining the ducts or the lobules. The first

    abnormalities that occur are not themselves cancer but are simply an

    overgrowth of normal cells in the ducts or lobules. These conditions are

    called intraductal hyperplasia. If these extra cells seem a bit odd-looking

    when examined under the microscope, the condition is called atypical

    hyperplasia. Atypical hyperplasia does not cause lumps and cannot be

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    detected by breast examination or by mammogram. When it is discovered

    in the ducts or lobules, it is usually by accident, in the course of biopsying

    a suspicious lump. If cells lining the ducts or lobules become odder still

    and start to clog them, the condition is called carcinoma in situ. Ductal

    carcinoma in situ and lobar carcinoma in situ by definition remain confined

    to the ducts or lobules, but they can sometimes be detected by

    mammogram, and in rare instances may produce a lump that can be felt.

    If the abnormal cells break away from these parts of the breast to infiltrate

    adjoining cells, the condition is called invasive cancer. It is at this point

    that a discrete malignant lump starts to grow (Carlson et al., 2004).

    Stages of Breast Cancer

    The stage of cancer is based on: the size of the tumor, whether the

    cancer is invasive or noninvasive, whether lymph nodes are involved, and

    whether it has spread beyond the breast and nodes.(Carvalho and

    Stewart, 2009). Once all of these factors are determined, staging of

    cancer can be done and is classified in the table below.

    Table 1: Stages of Breast Cancer

    Stages Characteristics

    0 Means that there is no invasion of the cancer cells

    surrounding tissue

    1 Describes invasive breast cancer, in which the cells are

    breaking through to surrounding tissue and the tumor is 2

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    centimeters or less in greatest dimension and no lymph

    nodes are involved.

    2 IIA

    describes invasive breast cancer in which no tumor is

    found in the breast, but cancer cells are found in the axillary

    lymph nodes (lymph nodes under the arm), or

    - Tumor measures 2 centimeters or less and has

    spread to the axillary lymph nodes, or

    - The tumor is larger than 2 centimeters but less than

    5 centimeters and has not spread to the axillary

    lymph nodes


    - Tumor is larger than 2 but less than 5 centimeters

    and has spread to the axillary lymph nodes, or

    - The tumor is larger than 5 centimeters but has not

    spread to the axillary lymph nodes.

    3 IIIA

    - No tumor is found in the breast. Cancer is found in

    the axillary lymph nodes that are clumped together

    or sticking to other structures or the cancer has

    spread to the axillar nodes near the breastbone, or

    - The tumor is 5 centimeters or smaller and has

    spread to axillary lymph nodes that are clumped

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    together or sticking to other structures, or

    - Tumor is larger than 5 centimeters and has spread to

    axillary lymph nodes that are clumped together or

    sticking to other structures


    - Tumor may be any size and has spread to the chest

    wall and/or skin of the breast, and

    - Tumor may have spread to axillary lymph nodes that

    are clumped together or sticking to other structures

    or cancer may have spread to lymph nodes near the



    - There may be no sign of cancer in the breast or, if

    there is a tumor, it may be any size and may have

    spread to the chest wall and/or skin of the breast,


    - The cancer has spread to lymph nodes above or

    below the collarbone, and

    - The cancer may have spread to axillary lymph nodes

    or to lymph nodes near the breastbone.

    4 Describes invasive breast cancer that has spread to other

    organs of the body, usually the lungs, liver, bone, or brain.

    It is also called metastatic breast cancer.

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    TNM Staging System

    According to Harrisons Manual of Oncology, 2007, TNM (Tumor,

    Node, Metastasis) is another staging system researchers use to provide

    more details about how the cancer looks and behaves. Physician might

    mention the TNM classification, but he is much more likely to use the

    numberical staging system. Sometimes clinical trials require TNM

    information from participants (Chabner et al., 2007)

    Breast Cancer Symptoms

    The classic symptom of breast cancer is a lump in the breast, but

    many lumps are not cancerous. They are the result of normal hormonal

    changes or trauma to the breast. Although half of all breast lumps in

    postmenopausal women (and three-quarters of all breast lumps in women

    over the age of 70) are malignant, the younger a woman is, the more likely

    it is that her breast lump is benign. Pain in the breast is also highly

    unlikely to signal breast cancer; only 6 percent of women with breast

    cancer have breast pain as a symptom. If a lump is cancerous, it is

    generally difficult to move under the skin and often feels rock-hard with

    irregular edges. There is no sure way to distinguish a malignant from a

    benign lump by touch alone, however. For this reason, any woman who

    notices a change in her breasts such as a lump or thickening, clear or

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    bloody discharge, change in contours, dimpling of skin, redness, or

    retracted nipple should consult a clinician (Carlson et. al.,2004).

    Figure 4: Breast Cancer Symptoms

    Breast Cancer Statistics

    About 1 in 8 women in the United States (12%) will develop

    invasive breast cancer over the course of her lifetime. (BreastCancer.Org,

    April 19, 2011). In 2010, an estimated 207,090 new cases of invasive

    breast cancer were expected to be diagnosed in women in the United

    States(U.S.), along with 54,010 new cases of non-invasive (in situ) breast

    cancer. About 1,970 new cases of invasive breast cancer were expected

    to be diagnosed in men in 2010. Less than 1% of all new breast cancer

    cases occur in men. From 1999 to 2006, breast cancer incidence rates in

    the U.S. decreased by about 2% per year. One theory is that this

    decrease was partially due to the reduced used of hormone replacement

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    therapy (HRT) by women after results of a large study called the Womens

    Health Initiative were published in 2002. These results suggested a

    connection between HRT and increased breast cancer risk (Dow, 2006).

    About 39,840 women in the U.S. were expected to die in 2010 from

    breast cancer, though the rates have been decreasing since 1990. These

    decreases are thought to be the result of treatment advances, earlier

    detection through screening, and increased awareness. For women in the

    U.S., breast cancer death rates are among higher than those for any other

    cancer, besides lung cancer. Besides skin cancer, breast cancer is the

    most commonly diagnosed cancer among U.S. women. More than 1 in 4

    cancers in women (about 28%) are breast cancer. Compared to African

    American women, white women are slightly more likely to develop breast

    cancer, but less likely to die of it. One possible reason is that African

    American women tend to have more aggressive tumors, although why this

    is the case is not known. Women of other ethnic backgrounds Asian,

    Hispanic, and Native American have a lower risk of developing and

    dying from breast cancer than white women and African American women.

    In 2010, there were more than 2.5 million breast cancer survivors in the

    U.S. A womans risk of breast cancer approximately doubles if she has a

    first-degree relative (mother, sister, daughter) who has been diagnosed

    with breast cancer. About 20-30% of women diagnosed with breast

    cancer have a family history of breast cancer. About 5-10% of breast

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    cancer can be linked to gene mutations (abnormal changes)inherited from

    ones mother or father. Mutations of the BRCA1 and BRCA2 genes are

    the most common. Women with these mutations have up to an 80% risk

    of developing breast cancer during their lifetime, and they are more likely

    to be diagnosed at a younger age (before menopaue). An increased

    ovarian cancer risk is also associated with these genetic mutations. In

    men, about 1 in 10 breast cancers are believed to be due to BRCA2

    mutations and even fewer cases to BRCA1 mutations. About 70-80% of

    breast cancers occur in women who have no family history of breast

    cancer. These occur due to genetic abnormalities that happen as a result

    of the aging process and life in general, rather than inherited mutations.

    The most significant risk factors for breast cancer are gender (being a

    woman) and age (growing older) (Breastcancer.org, 2011).

    Breast Cancer Risk Factors

    The rapidly increasing and high incidence of breast cancer over the past

    few decades supports the hypothesis that factors determining breast

    cancer risk have changed. Some of this change can be directly

    attributable to a reduction of protective factors (e.g. increasing parity, early

    age at first birth) in a higher proportion of women. Other factors which are

    known to increase breast cancer risk (i.e. obesity, low physical activity,

    and the use of exogenous hormones) have become more common. In

    addition to these changes in risk factors, breast cancer screening has

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    impacted disease incidence. Mammography artifactually increased breast

    cancer incidence in the short-term by advancing the lead time for

    prevalent disease and possibly in the long-term by identifying lesions with

    limited malignant potential. In general, greater lifetime exposure to

    estrogen, influenced by endogenous and exogenous risk factors,

    increases risk of breast cancer. Although many exposures that increase

    risk are not readily modifiable, some behaviors can be adopted to

    decrease risk (Morrow and Jordan, 2003).

    Screening for Breast Cancer

    The purpose of breast cancer screening is to separate women who

    are clearly normal from those with abnormalities, with the goal of

    intervening in the disease process after biologic onset but before

    symptoms or signs develop. Mammography, regular breast exams, and

    breast self- examination are the key components of early detection and

    surveillance. Additional radiologic modalities will be mentioned as

    adjuncts, but they are not basic screening tools. The use of

    mammography to screen asymptomatic women 40 year of age and over

    for early detection of breast cancer has been shown to reduce mortality

    rates by 20-30%. A standard screening mammogram includes two views

    of each breast. Additional views at different angles or increased

    compression of the breast tissues may be included for better definition of

    the character of the breast tissue (Aziz and Wu, 2002).

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    Treatment and Side effects

    Successfully treating breast cancer means getting rid of the cancer

    or getting it under control for an extended period of time. But because a

    breast cancer is made up of different kinds of cancer cells, getting rid of all

    those cells can require different types of treatments. Treatment plan may

    include a combination of the following treatments: surgery, radiation

    therapy, chemotherapy, hormonal therapy (anti-estrogen therapy) and

    some targeted therapies (such as Herceptin, Tykerb and Avastin).

    Surgery is usually the first line of attack against breast cancer. Decisions

    about surgery depend on many factors. The patient and the doctor will

    determine the kind of surgery thats most appropriate for you based on the

    stage of the cancer, the personality of the cancer, and what is

    acceptable to the patient in terms of long-term peace of mind. Under

    certain circumstances, people with breast cancer have the opportunity to

    choose between total removal of a breast (mastectomy) and breast-

    conserving surgery (lumpectomy) followed by radiation. Lumpectomy

    followed by radiation is likely to be equally as effective as mastectomy for

    people with only one site of cancer in the breast and a tumor under 4

    centimeters. Clear margins are also a requirement (no cancer cells in the

    tissue surrounding tumor). Another treatment option is the radiation

    therapy also called radiotherapy is a highly targeted, highly effective

    way to destroy cancer cells in the breast that stick around after surgery.

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    Radiation can reduce the risk of breast cancer recurrence by about 70%.

    Despite what many people fear, radiation therapy is relatively easy to

    tolerate and its side effects are limited to the treated area. Radiation

    treatments will be overseen by a radiation oncologist, a cancer doctor who

    specializes in radiation therapy (Miller, 2008).

    Radiation therapy uses a special kind of high-energy beam to

    damage cancer cells. (Other types of energy beams include light and x-

    rays). These high-energy beams, which are invisible to the human eye,

    damage a cells DNA, the material that cells use to divide. Over time, the

    radiation damages cells that are in the path of its beam normal cells as

    well as cancer cells. But radiation affects cancer cells more than normal

    cells. Cancer cells are very busy growing and multiplying 2 activities

    that can be slowed or stopped by radiation damage. And because cancer

    cells are less organized than health cells, it is harder for them to repair the

    damage done by radiation. So cancer cells are more easily destroyed by

    radiation, while healthy, normal cells are better able to repair themselves

    and survive the treatment. Tissues to be treated might include the breast

    area, lymph nodes, or another part of the body (Hunt et al., 2007).

    Among the treatments for breast cancer, chemotherapy is the most

    popular. Chemotherapy treatment uses medicine to weaken and destroy

    cancer cells in the body, including cells at the orginal cancer site and any

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    cancer cells that may have spread to another part of the body.

    Chemotherapy, often shortened to just chemo, is a systemic therapy,

    which means it affects the whole body by going through the bloodstream.

    There are quite a few chemotherapy medicines. In many cases, a

    combination of two or more medicines will be used as chemotherapy

    treatment for breast cancer. Chemotherapy is used to treat: early-stage

    invasive breast cancer to get rid of any cancer cells that may be left

    behind after surgery and to reduce the risk of the cancer coming back;

    advanced-stage breast cancer to destroy or damage the cancer cells as

    much as possible. In some cases, chemotherapy is given before surgery

    to shrink the cancer (Miller, 2008).

    Psychosocial Status and Health-Related Quality in Breast Cancer

    Breast cancer is a stressful even that can perturb psychologic

    equilibrium and reduce health-related quality of life (HRQOL) in the short-

    term; recent survivorship research has evaluated long-term sequelae.

    Early studies involved mainly small convenience samples (maximum, 61

    survivors), descriptive designs, and interview-based measurements. Key

    results of these studies include observations that the majority of survivors

    are fairly to very satisfied with their lives 8 years after diagnosis despite

    thoughts of recurrence reported by 50%; that survivors have a positive

    perception of life and attach less importance to trivial stressors even

    though fear of recurrence is a major concern; and that the majority of

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    survivors thrive despite experiencing problems related to breast cancer

    and its treatment. (Ganz and Horning, 2007)

    Quality of Life

    The quality of life (QOL) assessment is an important aspect of the

    current care provided to cancer patients. Tradition medical evaluations of

    the outcomes of cancer treatments have included disease-free survival,

    tumor response, and overall survival (U.S. Department of Health and

    Human Services, 1990). However, clinicians and researchers have come

    to realize that these outcomes are not adequate in assessing the impact of

    cancer and its treatment on the patient and daily life, nor in identifying

    interventions to improve or maintain the patients quality of life. Quality of

    life measurements provide valuable information to all members of the

    health care team. Interest in QOL assessment has continued to increase

    in recent years. The World Health Organization (WHO) has a global

    cancer control program based on knowledge currently available that, if

    appropriately implemented, can reduce cancer morbidity and mortality

    worldwide. This program includes a focus on palliative care and its impact

    on the QOL of cancer patients. Since many of the worlds cancer patients

    have no access to effective cancer therapy, only palliative care can be

    offered. Palliative care programs frequently focus on symptom

    management and can greatly improve QOL (World Health Organization

    Official Website, 2011).

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    Defining Quality of Life

    Quality of life (QOL) is an ill-defined term. The World Health

    Organization (WHO, 1948) declares health to be a state of complete

    physical, mental and social well-being, and not merely the absence of

    disease. Many other definitions of both health and quality of life have

    been attempted, often liking the two and, for quality of life, frequently

    emphasizing components of happiness and satisfaction with life. In the

    absence of any universally accepted definition, some investigators argue

    that most people, in the Western world at least, are familiar with the

    expression quality of life and have an intuitive understanding of what it

    comprises. However, it is clear that quality of life means different things

    to different people, and takes on different meanings according to the area

    of application (Fayers, et al 2007).

    Quality of life assessment is complicated by the fact that there is no

    universally accepted definition of quality of life. In the past, many

    researchers measured only one dimension, such as physical function,

    economic concern, or sexual function. More recently, researchers have

    attempted to further define QOL. Spillker (1990) described QOL

    assessment through three interrelated levels: (a) overall assessment of

    well-being; (b) broad domains such as physical, psychological, economic,

    and social; and (c) the components of each domain. While progress has

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    been made in defining QOL, developing qualitative and quantitative

    methodologies to study QOL, and identifying QOL outcomes, many

    research issues persist, including conceptual and methodological issues

    (King et al., 2003)

    Methodological Issues in Survivorship Research

    The Office of Cancer Survivorship of the National Cancer Institute

    (U.S) defines a survivor as follows: An individual is considered a cancer

    survivor from the time of cancer diagnosis, through the balance of his or

    her life. Family members, friends and caregivers are also impacted by the

    survivorship experience and are therefore included in this definition. This

    is a very broad definition, most survivorship research in breast cancer

    focuses on the experience of individuals with cancer after they have

    completed their primary therapy, usually while they are free of recurrent

    disease. Some studies have focused on women who are 1, 3, 5, or more

    years post diagnosis. In breast cancer, where long-term survival is

    becoming increasingly common, this variable definition may account for

    some of the inconsistencies in the literature (Ganz and Horning, 2007).

    Related Studies

    Hayes et. al. (2010) conducted a 12 month period study assessing

    the upper body function and correlating it with quality of life among Breast

    Cancer patients post-surgery. Clinical assessment of upper body function

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    compensate for than limited elbow or wrist movement in patients. Results

    were recorded based on a scale from 1 to 6, with 1 representing almost no

    movement, and 6, representing almost no movement. Handgrip strength

    was measured using a hydraulic hand dynamometer. The average of

    three grip strength measurements was recorded for each hand. Quality of

    life measurements was assessed through FACT-B+4 survey and were

    scored and interpreted in accordance with the standardized scoring

    protocol. Results showed that those with full range of motion had an

    increased total FACT-B+4, whereas those with decreased ROM had a

    decreased range of motion recorded lower functional and physical well-

    being and total FACT-B+4 scores.

    Kaya et al (2010) did a comparable research using the same

    WHAT assessment tool used by Beaulac et. al. that aimed to determine

    the prevalence of impairments relevant to upper extremity following breast

    cancer surgery and its impact on disability and health-related quality of

    life. Subjects were evaluated for impairments (arm edema, loss of

    handgrip strength, limited shoulder joint range of motion, physical disability

    using the disabilities of the arm, shoulder and hand (DASH) questionnaire

    and for health-related quality of life by means of the functional assessment

    of cancer therapy-breast+4 (FACT-B+4). Results showed that the most

    common impairment observed was arm pain on motion. Arm pain on

    motion, anterior chest wall pain, loss of grip strength, and shoulder flexion

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    were significant factors in different domains of quality of life according to

    the FACT-B+4 questionnaire. The effect of pain in the arm subgroup of

    the FACT-B+4 was more pronounced when compared with other

    dependent variables.

    In a different study done by Daves, et. al. (2008), they identified the

    impact of lymphoedema or arm function and health-related quality of life in

    women following breast cancer surgery. The study aims to estimate the

    extent to which the impairments associated with lymphoedema are linked

    to arm dysfunction and suboptimal health-related quality of life. A cross

    sectional study, embedded within a pilot for an epidemiology study, was

    undertaken involving women who had undergone surgery for unilateral

    stage I or II breast cancer. Two questionnaires (a lymphoedema

    screening questionnaire and the Disabilities of Arm, Shoulder and Hand

    questionnaire) and women with symptoms attended for further testing.

    Women with self reported symptoms of lymphoedema had a significantly

    higher score on the Disabilities of Arm, Shoulder and Hand questionnaire,

    indicating activity limitation, participation restriction and suboptimal health-

    related quality of life.

    In relation to Daves study, Ahmed, et. al. (2008) reported the

    impact of lymphedema or related arm symptoms in health-related quality

    of life (HRQOL) in breast cancer survivors. Arm symptoms assessment

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    basically included flexibility and muscle strength of the affected side; and

    was evaluated through goniometric techniques and manual muscle

    testing. In Daves study, they measure upper extremity function through

    the use of Disability of Arm, Shoulder and Hand (DASH) Outcome

    Measures. In assessing quality of life, Medical Outcome Study Short

    Form-36 Version 2 was used instead of the WHOQOL-BREF to be used in

    this study. Though it measures the same domains, it used a different

    format questionnaire.

    In this study of unilateral breast cancer survivors in Iowa, 45% had

    either diagnosed lymphedema or arm symptoms without diagnosed

    lymphedema consistent with other reports. HRQOL was significantly

    lower in breast cancer survivors without lymphedema compared with

    survivors without lymphedema or arm symptoms. Although women with

    known lymphedema experienced more arm symptoms on average,

    women with arm symptoms without diagnosed lymphedema had altered

    HRQOL in more domains of physical and mental HRQOL. Perhaps not

    surprisingly, there was a significant dose-response relationship for

    decreasing SF-36 scores by number of arm symptoms.

    More complicated study done by Caban, et. al. (2006) studied the

    relationship between depressive symptoms and shoulder mobility among

    older women a year after breast cancer diagnosis. Depressive symptoms

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    were linked as poorer quality of life. Association between depressive

    symptoms and shoulder range of motion at one year after breast cancer

    diagnosis were examined. Depressive symptoms, sociodemographic

    characteristics and breast cancer treatment were measured at 2 months

    and shoulder range of motion at 12 months. The relationship among

    variables were evaluation with bivariate chi-square statistics and logistic

    regression analysis. Results showed an increasing depressive symptoms

    at baseline were associated with lower arm mobility at 12 months following

    breast cancer diagnosis. Each unit increases in depressive symptoms at

    baseline was associated with an eight percent decreased of odds of

    having full range of motion of shoulder.

    Nesvold, et. al. (2010) discussed the association between

    arm/shoulder problems in breast cancer survivors and reduced health and

    poorer physical quality of life. In this study, demography, lifestyle, quality

    of life (QOL) and somatic morbidity in breast cancer survivors with and

    without arm/shoulder problems were examined. Association of restricted

    shoulder abduction with quality of life were also compared. In usnivariate

    analysis, arm/shoulder problems were associated with not being

    employed, having had mastectomy, longer follow-up time, radiotherapy to

    axilla, poorer self-rated health and physical condition, minimal physical

    activity, increased body mass index, regularly intake of analgesics and

    poorer physical quality of life. Multivariate analysis showed that

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    mastectomy, longer follow-up time, minimal physical activity and poorer

    physical quality of life were associated with belonging to arm/shoulder

    problems group. There was also significant association with having

    impaired abduction of greater than or equal to 25 degree difference.

    In another study by Smoot (2009), he determines the impact of

    impairments on arm function and quality of life (QOL). All participants

    attended a single evaluation session and both upper extremities were

    assessed. Testing was completed by one investigator. Strength for hand

    grip was assessed using hand held dynamometer. Strength scores were

    obtained for shoulder abduction, elbow flexion, and wrist flexion using the

    MicroFET2 dynamometer (Hoggan MicroFET2 Muscle Tester Model 7477,

    ProMed Products, Atlanta). A goniometer was used to measure ranges of

    motion (ROM) of the upper extremities. Shoulder flexion, shoulder

    abduction, shoulder external rotation, elbow flexion and extension, wrist

    flexion and extension, and flexion of the proximal interphalangeal joint of

    digit two were measured following standardized procedures reported by

    Norkin. The Quality of Life Cancer Survivors Questionnaire (QOL-CS)

    was used to assess quality of life in cancer survivors. Four subscales are

    calculated and represent physical, psychological, social and spiritual


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    This study indicates that following breast cancer treatment, women

    with or without lymphedema presents with upper extremity impairments.

    Women with lymphedema more frequently report pain, demonstrate

    bilateral deficits in shoulder ROM and upper extremity strength compared

    to women without lymphedema, and is present with greater restrictions in

    activity. Reduced upper extremity strength is associated with poorer

    quality of life in the physical, psychological, and social subscales of the

    QOL-CS questionnaire.

    In a study of Cantero-Villanueva et. al. (2011), they aimed to

    investigate the relationship between shoulder movement and quality of life

    in breast cancer survivors. Quality of life is only measured against its

    relationship to shoulder movements. Women completed the Breast

    Cancer-Specific Quality of Life questionnaire, the Piper Fatigue Scale, in

    addition to the assessment of shoulder flexion range of motion. Results

    showed that fatigue was greater in those patients with reduced shoulder


    Sagen et. al. (2009) accomplished a 5 year follow-up study to

    describe changes in arm morbidities and health-related quality of life

    (HRQOL) and to find factors that predict HRQOL 5 years after the surgery.

    The subjects were examined for arm volumes, shoulder function, and

    HRQOL, prior to surgery, and 6 months and 5 years after surgery. Arm

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    morbidities were seen to decrease over time. Several dimensions of

    HRQOL temporarily declined after surgery, but significantly improved in

    the period from 6 months to 5 years after surgery.



    Research Method

    The descriptive correlational research method is used in this study.

    A descriptive correlational research method aims to describe relationships

    among variables, without seeking to establish causal connections (Loiselle

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    et al, 2010). This study assesses the shoulder range of motion, muscle

    strength and grip strength of the affected upper extremity and also

    assesses the present quality of life of breast cancer survivors. Likewise,

    this research is classified as descriptive correlational since it seeks to

    recognize relationships between range of motion, muscle strength,

    handgrip strength and quality of life among breast cancer survivors

    Research Locale

    The study will be conducted at Jose B. Lingad Memorial Regional

    Hospital(JBLMRH) Physical Therapy Unit where assessment will be done

    by only one trained physical therapist.

    Respondents of the Study

    Women who have completed active breast cancer treatment at

    six(6) months previously, will be recruited. The women are required to be

    at least 25 years of age, and is able to read English. Women will excluded

    for bilateral breast cancer, current upper extremity infection, lympangitis,

    pre-existing lymphedema, pre-existing neuromuscular or musculoskeletal

    conditions that would affect local upper extremity testing, or current

    recurrence of breast cancer.

    Study participant will be recruited through the outpatient

    department of the Physical Therapy Unit of JBLMRH, existing support

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    groups in Pampanga and willing participants of ALLTO clinical trial project

    at the St. Lukes Medical Center, Quezon City.

    Research Instruments

    This study will

    This study will utilize the following instruments:

    1. WHOQOL-BREF assessment tool for measuring the quality of life of

    breast cancer survivors. The assessment tool measures 6 domains of

    quality of life and each domain has facets incorporated in each domain.

    Facets in each domain of overall quality of life and general health are the


    Table 2: WHOQOL-BREF Domains

    Domain Facets Incorporated within Domains

    1. Physical Health Activities of daily livingDependence on medicinal substancesand medical aidsEnergy and fatigueMobilityPain and discomfortSleep and restWork capacity

    2. Psychological Bodily image and appearanceNegative feelingsPositive feelings

    Self-esteemSpirituality/religion/personal beliefsThinking, learning, memory andconcentration

    3. Social Relationships Personal relationshipsSocial supportSexual activity

    4. Environment Financial Resources

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    Freedom, physical safety and securityHealth and social care: accessibilityand qualityHome environment

    Opportunities for acquiring newinformation and skillsParticipation in and opportunities forrecreation/leisure activitiesPhysical environment(pollution/noise/traffic/climate)Transport

    Each respondent will be asked to rate each item. There are eight

    sets of tables of questions which has different rating systems. The

    following rating system is adherent to the following:

    Table 3: Ratings of Quality of Life

    Ratings Description

    1 Very Poor 2 Poor

    3 Neither Poor nor Good

    4 Good

    5 Very Good

    Table 4: Satisfaction with Health

    1 Very dissatisfied

    2 Dissatisfied

    3 Neither satisfied Nor dissatisfied

    4 Satisfied

    5 Very Satisfied

    Table 5 and 6: Quantity of Experiences in Certain Things

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    1 Not at all

    2 A little

    3 A moderate amount

    4 Very much

    5 An extreme amount

    Table 7: Quantity of Doing Certain Things

    1 Not at all

    2 A little

    3 Moderately

    4 Mostly

    5 Completely

    Table 8: Ability to Get Around

    1 Very poor

    2 Poor

    3 Neither poor nor good

    4 Good

    5 Very Good

    Table 9: Satisfaction Over Various Aspects of Life

    1 Very dissatisfied

    2 Dissatisfied

    3 Neither satisfied nor dissatisfied

    4 Satisfied

    5 Very Satisfied

    Table 10: Frequency of Experiencing Certain Things

    1 Never

    2 Seldom

    3 Quite Often

    4 Very Often

    5 Always

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    Musculoskeletal Assessment of the Upper extremity

    2.1. Range of Motion

    Through the use of a standard goniometer, range of

    motion of each shoulder is assess and noted on a table


    Table 11: Assessment form for Shoulder Range of Motion

    Range of Motion Active (L) Passive (L) Active (R) Passive(R)

    Shoulder flexionShoulder Abduction

    Shoulder ExternalRotation

    Shoulder Internal


    2.2. Shoulder Muscle Strength

    Manual muscle testing (MMT) will be used to measure

    muscle strength of the shoulder. MMT uses a standard

    grading system and is as follows:

    Grade 5 patient can hold the position against maximum

    resistance through complete range of motion

    Grade 4 patient can hold the position against strong to

    moderate resistance and has full range of motion.

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    Grade 3 patient can tolerate no resistance but can

    perform the movement through the full range of motion

    Grade 2 patient has all or partial range of motion in the

    gravity eliminated position

    Grade 1 the muscle/muscles can be palpated while the

    patient is performing the action

    Grade 0 no contractile activity can be felt in the gravity

    eliminated position.

    2.3. Handgrip Strength Protocol

    This protocol follows the standard procedures measuring

    handgrip strength using a dynamometer. Results are compared

    to the following normative value.

    Table 12: Normative Values in Hand Grip Strength Among Women

    Age Female Dominant


    Female Non Dominant Hand

    20 21.5 kg 10 kg

    25 22 kg 20 kg

    30 21 kg 19 kg

    35 19.5 kg 18.75 kg

    40 18.5 kg 17.75 kg

    45 17.5 kg 16.75 kg

    50 17.75 kg 16.5 kg

    Statistical Treatment

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    Statistical analyses will be performed using SPSS statistical

    sorftware (Version 17). Means and standard deviations for interval data

    will be obtained and unpaired t-tests for significance of differences will

    performed for normally distributed data. Mann-Whitney ranked sum

    analysis will be used to measure the test of difference for non-formally

    distributed interval data. Another statistical method to be used is the

    Spearman correlation that indicates the direction of association betweenX

    (the independent variable) and Y (the dependent variable). Regression

    analysis was used to evaluate the contribution of variables of theoretical

    interest to the outcome measure. Multiple linear regression will be

    selected for normally distributed interval data. For hypothesis testing, p-

    values less than 0.05 were considered significant.

    Research Procedures

    The following are the procedures which will be used in

    conducting of the study:

    1. Recruitment of Participants

    2. Selection of Participants

    3. Assessment of Participants

    Recruitment of Participants

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    Participants will be assessed according to the research method

    mentioned above. Assessment tools will be used to measure variables

    of interest. Goniometry will be used in the assessing the shoulder range

    of motion, manual muscle testing will be employ to measure shoulder

    muscle strength and hand grip strength will be assessed using a

    standard dynamometer.


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    Miller, Kenneth D. (2008). Choices in Breast Cancer Treatment: MedicalSpecialists and Cancer Survivors. U.S.A.: The John HopkinsUniversity Press.

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    Ahmed, Rehana L., et. al. (December 10, 2008). Lymphedema andQuality of Life in Breast Cancer Survivors: The Iowa Womens

    Health Study. Journal of Clinical Oncology. Vol. 26. No. 25.

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    Cantero-Villanueva I., et. al. (March 17, 2011). Associations among mmusculoskeletal impairments, depression, body image and fatiguebreast cancer survivors within the first year after treatment.European Journal of Cancer Care.

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    Hayes, Sandra C., et. al. (2010). Upper-body morbidity following breastcancer treatmen is common, may persist longer-term and adverselyinfluences quality of life. Health and Quality of Life Outcomes:Open Access Research. Vol. 8, Issue 92.

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    Smooth, Betty, et. al. (2010) Upper Extremity impairments in women withor without lymphedema following breast cancer treatment. Journalof Cancer Survivor. Vol. 4. Pp. 167-178.