Introduction

Breast cancer (BC) is the second most common cancer among the women. In the year 2020 has estimated about 1.3 million new cases of cancer, with 850,000 related cancer deaths reported. However, the incidence of BC is about 13.5%, being the major cause of death in India [1, 2]. Being one of the most common malignancies affecting women worldwide, its treatment often involves a surgical procedure such as axillary lymph node dissection (ALND), which is effective in disease control [3]. Axillary lymph node dissection leads to significant post-operative musculoskeletal complications and neuromuscular impairment, in particular affecting shoulder mobility, contributing to altered scapular kinematics and leading to scapular dyskinesia (SD) [4–6]. Often, scapular winging is one of the most undiagnosed and missed components during assessment, which might be the cause of shoulder mobility impairments. Scapular dyskinesia is the abnormal change in the kinematic motion of the scapula coupled with the scapulohumeral rhythm [6, 7]. The scapula plays a vital role in the stability and mobility of the shoulder, and its dysfunction can lead to pain and limited range of motion. In an ALND procedure, damage to key motor nerves, in particular the long thoracic nerve, impairs the function of the serratus anterior and the trapezius muscles, resulting biomechanical alteration of the scapular movements [8–10].

The literature shows a moderate to strong correlation between ALND and scapular dyskinesia, often exhibiting scapular winging, reduction in upward rotation, with reduced posterior tilt during functional movements [5, 11]. These biomechanical alterations result in pain and decreased upper limb mobility, impairing quality of life (QoL). Considering the functional importance of the mechanical component of the scapula, early detection, assessment, and rehabilitation for SD in post-ALND patients are essential.

Physical therapy is the conservative management for scapular winging to restore the muscle balance and strength for proper execution of movement and scapular positioning [12]. Scapular stabilisation exercises have also gained greater attention among the clinicians for being effective in improving the shoulder range as it aims in restore the position, muscle control, and function. The post-surgery rehabilitation focuses on these components to address the muscular imbalance.

However, quantitative diagnostic tools like Kinovea 2D motion analysis software provide feasible, reliable, and assessable ways to measure scapular motion by identifying compensatory movements during the functional pattern [13]. Exploring the impact of ALND over scapular position may address the development of an enhanced rehabilitation program to restore mobility and functional aspects, thereby improving the QoL and improving the long-term recovery.

Material and methods

This was a pilot study conducted on 25 post- operative female BC survivors who had undergone ALND and were screened for scapular dyskinesia. The study was conducted at the Oncology Department of a private hospital. All participants were provided with information and explanations regarding the study, and consent was obtained. The purpose, treatment protocol, and potential benefits were explained, and consent was obtained prior to the study, which was conducted in accordance with the Declaration of Helsinki (revised 2000).

Inclusion and exclusion criteria

Female subjects between the ages of 50 and 75 years, post-operative BC survivors, who had undergone ALND, and with positive SD on assessment were included.

The diagnosis of SD was based on observation and clinical examination done by a qualified physiotherapist with experience of clinical exposure in musculoskeletal rehabilitation and oncology care, which ensured diagnostic accuracy and consistency. The therapist performed a standardised clinical assessment test, such as the scapular dyskinesis test, lateral scapular slide test, manual muscle test of the scapular stabilisers, and palpation for symmetry of the scapula and winging to diagnose SD. The position of scapula was analysed using Kinovea software from a posterior view photograph. Participants stood in relaxed posture with arms by the side. The spinous process of T3 and the medial border of the scapula were identified and marked. A vertical reference line was drawn through T3 to represent the spinal midline. The horizontal distance from the midline to the medical border of the scapula at the level of the inferior angle was measured using the Kinovea line tool software. A distance of more than 7 cm from the spinal midline was considered altered scapular positioning and included in the study. The diagnostic indicators assessed included the prominence of the scapula’s inferior angle and weakness of the serratus anterior and the trapezius muscle. Subjects with psychiatric issues, cognitive impairment, neurological conditions, and cardiopulmonary conditions were excluded.

Study procedure

A total of 51 post-operative female BC survivors were screened using the Kinovea software for SD, and 25 were recruited based in the inclusion and exclusion criteria. Demographic details were collected. Prior to the intervention, all the subjects underwent a pre-intervention assessment for position of the scapular using Kinovea software for motion analysis to establish the baseline measurements. Subjects underwent a six-week shoulder bracing exercise program, with six sessions per week. Post-test measurements were taken to assess changes in scapular biomechanics and kinematics. Figure 1 illustrates the study flow, the enrolment process, and the intervention timeline.

Intervention

A structured rehabilitation regime was designed to improve the mobility and strength of the scapula muscles using resistance bands (Thera-Band). Subjects attended sessions six days per week for six weeks, with each session lasting for 30 minutes. These sessions focused on mild–moderate-intensity training exercises.

Chest opener

Performed in a standing position with feet shoulder-width apart and arms extended forward. Subjects were instructed to pull the band laterally to retract the scapulae, maintaining the position for 5 seconds and then returning to the starting position (Figure 2) [14].

Standing rows

The Thera-Band was anchored at chest height. Subjects stood 3–4 feet away. They were instructed to pull the band towards the body with elbows flexed to facilitate scapular retraction, promoting controlled scapular kinematics (Figure 3) [15].

Wall slides

With the Thera-Band looped around the wrists, maintaining shoulder-width distance while sliding the arms upward along the wall, sustaining the band tension to engage scapular stabilisers. They were asked to hold the position for 5 seconds and return to the starting position (Figure 4) [16].

These exercises targeted the scapular retractors, pectoralis major and minor, serratus anterior, and the latissimus dorsi muscles. Progression of the exercises was achieved by increasing the resistance band tension (from yellow to red and then green) and the repetitions based on the subjects performance and tolerance over the six-week duration.

Outcome measures

Kinovea software was used to assess the scapular biomechanics and its movements relative to the chest for SD in subjects who had undergone ALND. Sequential and step-by-step video analysis captured angles, movement patterns, and kinematic abnormalities, and objectively analysed the effectiveness of shoulder bracing exercise using resistance band. The software measured the scapular symmetry and postural deviations, assisting in framing the rehabilitation protocol to improve shoulder mobility and stability [17–19].

Statistical analysis

The data collected from the study were analysed using SPSS software version 30. Within-group data for scapular position was interpreted using the paired Student t-test. This statistical method was used to assess the difference between the pre- and post-intervention measurements, demonstrating the effectiveness of scapular kinematics following the intervention among the subjects.

Results

The comprehensive analysis of data from 25 individuals demonstrated a substantial change between baseline measurements and those obtained six weeks after intervention. The demographic characteristics of 25 subjects aged 50–75 years (mean age 61.6) were studied (Table 1).

After 6 weeks of intervention and statistical analysis, the scapular position using Kinovea software for interpretating the pre- and post-test mean values demonstrated a significant improvement (p ≤ 0.001) on the scapular kinematics following the intervention, indicating that the shoulder bracing exercises were effective in improving the scapular kinematics among post-operative BC survivors (Table 2, Figure 5).

The effect size (Cohen’s d = 2.20) indicates a very large effect, underscoring the clinical importance of the intervention, not just its statistical significance.

Discussion

This study had a positive impact on improving the scapular biomechanics and strength in ALND patients with scapular dyskinesia. The specific tailored shoulder bracing exercises provided a complete package of rehabilitation, addressing even the neglected issues associated with patients who had undergone ALND. Individuals with improved function and strength engaged in their day-to-day activities with ease, fostering a feeling of independence and minimising reliance.

The literature has described the incidence of scapular winging due to surgical procedures for BC and stated ALND is the most complex surgical technique with a greater risk of injuring the axillary structures, in particular the serratus anterior muscle. The study also observed that patients with ALND had greater risk of winged scapula and emphasised that shoulder bracing exercises with resistance were effective at addressing multiple components of strength and endurance [20]. The findings from this study suggest that incorporating Thera-Band-based shoulder bracing exercises for post-operative ALND patients’ rehabilitation programs significantly improve scapular control and shoulder function. By promoting proper scapular motion, these exercises help mitigate compensatory and reduce the risk of secondary complications such as rotator cuff tendinopathy and impingement syndrome.

Our results also align with a study highlighting the importance of early post-operative rehabilitation to address chronic movement dysfunction, which emphasised a shoulder-focused exercise protocol not only to improve joint range but also to reduce the occurrence of scapular malposition and compensatory movement patterns [21]. Few studies have advocated progressive rehabilitation strategies that focus on activation of muscle patterns, in particular serratus anterior muscle activation and lower trapezius strengthening [12]. Meanwhile a similar study reported that a shoulder rehabilitation protocol led to significant improvement in scapular movements and reduced disability scores in BC survivors [19].

Therapeutic shoulder bracing exercises using Thera-Band resistance bands have shown promising results in addressing shoulder and scapular dysfunctions. These exercises target the key stabiliser muscles of the scapula and help in restoring neuromuscular control by improving the scapulothoracic rhythm [20, 21]. Moreover, resistance training with the Thera-Band provides a progressive and adaptable approach to rehabilitation as the elasticity of the bands allows for controlled resistance, which can be modified based on the patient’s strength and recovery stage. This progressive resistance ensures continuous muscle activation, promoting neuromuscular re-education and functional recovery. The exercises also enhance proprioception and kinaesthetic awareness, leading to improved scapular positioning during daily activities. It also showed a positive impact on pain reduction, and it improved joint mobility and overall upper limb mobility after consistent practice of these exercises. Improved muscle endurance and strength facilitated by resistance exercises contributes to better postural stability and reduced fatigue, which are crucial for daily functional tasks and long-term recovery. Resistance band exercises initiate muscle activation in a controlled and progressive manner, which is vital for ALND patients with residual shoulder muscle weakness or a high risk of developing secondary lymphedema post-operatively.

Additionally, incorporating Kinovea 2D motion analysis software helped in precisely identifying subtle scapular deviations and tracking improvements over time. This biofeedback approach enhances motor relearning by educating patients about shoulder mechanics and correcting faulty movements in real time [18, 19].

The exercise program incorporated in this study was tailored to individual performance, gradually progressed, and was incorporated with functional activities to improve their overall QoL [22]. This patient-specific approach had a positive impact on the outcomes, which was in par with the study recommendation that supported patient-specific and goalspecific rehabilitation for cancer survivors [21, 22].

However, our study had some limitations that must be acknowledged. While the outcomes were promising, the long-term follow-up was not recorded to assess whether the results were sustained. Additionally, surgical extent variations, radiation therapy, and the baseline shoulder function would have influenced individual responses to rehabilitation.

The results of this study offer strong evidence that individuals with BC benefit significantly from pain, shoulder function, and overall upper limb functional performance. These scapular exercises with the Thera-Band have been demonstrated to promote shoulder function, reduce pain, and improve upper limb functional performance.

The larger effect size (Cohen’s d = 2.20) observed in the study highlights the meaningful impact of the intervention on scapular kinematics in subjects with post-ALND. While statistical significance confirms a difference, the magnitude of the change evidenced by the effect size suggests that the intervention has substantial clinical relevance, which supports incorporating targeted shoulder rehabilitation as an effective component for SD in post-ALND survivors.

Conclusions

The findings of the study suggest a potential positive effect of shoulder bracing exercise to improve the scapular kinematics and the biomechanics for SD in subjects who have undergone ALND. Due to the lack of a control group, causality cannot be established, and the improvements observed cannot be definitively attributed to the intervention.

Hence, further research such as randomised controlled trails with larger sample sizes is essential to confirm these preliminary observations and understand the efficacy and the long-term benefits of such intervention.

Disclosures

1. Institutional review board statement: This study was approved by the Institutional Scientific Research Board of the University prior to the recruitment of participants and was approved with ISRB (approval decision no. 04/029/2023/ISRB/SR/SCPT, dated: 29.04.2023).

2. Assistance with the article: None. 3. Financial support and sponsorship: None.

4. Conflicts of interest: None.

References