Deep Friction Massage in Treatment of Radiation-induced Fibrosis: Rehabilitative Care for Breast Cancer Survivors

Abstract

Treatment for invasive breast cancer usually involves some combination of surgery, radiation therapy, chemotherapy, hormone therapy, and/or targeted therapy. For approximately 50% of patients, radiation therapy is a component of the therapies used. As a result, radiation-induced fibrosis is becoming a common and crippling side effect, leading to muscle imbalance with a lessened range of motion as well as pain and dysfunction of the vascular and lymphatic systems. No good estimates are available for how many patients experience complications from radiation. Radiation-induced fibrosis can affect the underlying fascia, muscles, organs, and bones within the primary target field and the larger secondary field that is caused by the scatter effect of radioactive elements. For breast cancer patients, the total radiation field may include the neck, shoulder, axillary, and thoracic muscles and the ribs for both the ipsilateral (cancer-affected) and contralateral sides. This case study indicates that therapy using deep friction massage can affect radiation-induced fibrosis beneficially, particularly in the thoracic muscles and the intercostals (ie, the muscles between the ribs). When delivered in intensive sessions using deep friction techniques, massage has the potential to break down fibrotic tissues, releasing the inflammation and free radicals that are caused by radiation therapy. In the course of the massage, painful and debilitating spasms resulting from fibrosis can be relieved and the progressive nature of the radiation-induced fibrosis interrupted.

Approximately one-half of all cancer patients have received radiation therapy at some point during their treatment.1 In breast cancer, radiation therapy is administered to the axillary (underarm) area, chest, and/or neck. This radiation results in a combination of direct damage to nerve cells from ionizing radiation and more progressive damage from radiation-induced fibrosis, and the development of scar tissue in and around the nerves combined with damage to adjacent vessels that supply these nerves. Radiation of nerve tissue also causes the nerve cells to shrink, resulting in a decrease in the elasticity of the nerve fibers.2 After radiation therapy, radiation-induced fibrosis evolves rapidly and aggressively in some patients, whereas it develops gradually, even years later, in others due to complex, poorly understood mechanisms.3 No good estimates are available regarding how many patients will develop the clinical manifestations of radiation-induced fibrosis, how quickly the fibrosis will progress, or what its severity will be. It is common to see patients with very similar treatment histories develop divergent complications.2–4

Symptoms may include (1) paresthesia—tingling, pricking, or numbness; (2) dysesthesia—an abnormal sensation, such as burning, itching, a feeling like an electric current, pins and needles, or pain; (3) decreased sensitivity of the skin to touch; (4) partial loss of movement—muscle weakness and difficulty performing simple tasks, such as opening jars or holding objects; (5) complete paralysis of the arm; (6) muscular atrophy; (7) impaired mobility; and (8) partial dislocation of the shoulder joint.5,6

Muscle spasms and tenderness that are very similar to those associated with myofascial trigger points are common side effects of radiation fibrosis syndrome and tend to occur in similar anatomic regions, such as the cervical paraspinal, middle trapezius, and rhomboid muscles.2 At the onset of radiation-induced fibrosis, the spasm is not always obvious and may be perceived by the patient as a vague stiffness or tightness. However, as fibrosis progresses, sustained muscle contractions in the thoracic muscles and intercostals (ie, the muscles between the ribs) can become quite severe and last for several minutes, with a tightening that makes it difficult for the patient to take a breath.

In radiation-induced fibrosis, a key issue is prevention, with the primary approach being use of proper doses of radiation therapy and techniques that minimize the radiation exposure for normal tissue.7 For patients with established radiation-induced fibrosis, treatment is primarily symptomatic with management options including 4 general approaches, using (1) pharmaceuticals, (2) hyperbaric oxygen, (3) physiotherapy, and (4) microcurrent stimulation. Each of these approaches has shown varying degrees of benefits, with additional trials and studies needed.4 Among the therapies discussed within the physiotherapeutic approach are (1) physical exercise protocols to maintain recovery, (2) movement of the impaired shoulder(s) following breast cancer surgery and radiation therapy, and (3) lymphedema management to assist those patients suffering from posttreatment edema.

Massage therapy, as an additional manual therapy, should be investigated for those suffering from neuromuscular and musculoskeletal complications of radiation-induced fibrosis. A special type of massage, developed by LPG Systems (Valence, France), has already been shown to reduce skin fibrosis after radiotherapy for breast cancer.8 The case study discussed in the current article shows how the application of another type of massage technique, deep friction, can reach below the skin, deep into the affected area or region(s) of the thoracic muscles and intercostals; help eliminate painful muscle spasms; and prevent symptoms from returning.

Client’s Profile

The author’s client was a Caucasian female, 57 years of age, who did not drink or smoke and who was in good physical condition, with a moderate- to high-activity level. She worked as a certified massage therapist. Prior to her development of breast cancer, her medical history included 2 pregnancies, with 2 live births; a partial hysterectomy at age 26; hypothyroidism, treated with a Synthroid prescription; vertiginous migraines with tinnitus caused by left inner-ear damage; and osteopenia that she treated with herbal supplements.

On June 1, 2012, the client was diagnosed with stage IIA, invasive ductal carcinoma of the left breast, with a positive ER/PR and a negative HER-2/neu. On June 21, her medical practitioner performed a lumpectomy and a sentinel-node biopsy, showing that 3 of 6 lymph nodes were involved. She received external beam, adjuvant radiation therapy, starting on July 30 and ending on September 6. She had a total dose of 5040 cGy in 28 fractions of whole-breast radiation treatment, with the inclusion of the level-1 lymph nodes on the ipsilateral (left) side only. The client was given no additional radiation boost to the tumor cavity, chemotherapy, or hormone treatment.

As an acute, immediate side effect that occurred during radiation therapy, the client experienced a reddening of the skin and discomfort in the left breast, but she had no blistering or peeling in the course of the therapy. Thoracic muscle pain, an internal burning sensation, began toward the end of the second week of radiation therapy and became continuous during the last 10 sessions. During the last 2-week period, this pain intensifyied during radiation therapy sessions. The treating radiologist advised that this pain resulted from an inflammation to the intercostals because the rib muscles and bones were in the radiation field. The internal burning sensation resolved within 2 weeks of completion of the radiation therapy.

Three months or more following completion of radiation therapy, the client experienced chronic, late-onset side effects. On December 11, 2012, 3 months after completion of the therapy, the client’s medical practitioner performed a core biopsy of the left breast that showed reactive fibrosis; fat necrosis; foreign-body, chronic granulomatous inflammation; and foci of calcification. Eosinophilic degenerative material was present as well as degeneration focally of some skeletal muscle. No carcinoma was identified. The overall histologic features suggested some issues related to the biopsy cavity wall.

The axillary web syndrome (AWS) became apparent in February 2013, 5 months after radiation therapy, with chords that extended from the left axillary scar distally toward the antecubital space. In AWS, an interruption in the lymphovenous channels causes a thrombosis and stagnation of the lymphovenous fluid, resulting in inflammation, fibrosis, and shortening of the tissue. A visible chord can become taut with shoulder abduction, causing tightness and discomfort. In cases where biopsies have been performed on a chord, results indicated dilated lymphatics, a fibrin clot in the lymphatics, and venous thrombosis.6 In 2009, Torres Lacomba et al9 reported that AWS was found in 48.3% of women who were breast cancer survivors that the researchers’ study investigated.

Lymphatic system impairment also became apparent. For incisional scars and myofascial adhesions, the client resolved visible, taut chords from AWS through self-massage techniques. The client’s medical practitioner classified her status under the International Society of Lymphology (ISL) stage 0, a subclinical state in which swelling is not evident despite impaired lymphatic transport. This state may exist for months or years before edema becomes evident.6

Muscle spasms began in December 2012, 3 months after radiation therapy. The client first experienced them as a continuous 1- to 2-minute spasm of the left (ipsilateral) breast and axillary. From December 2012 through June 2013, spasms began occurring more frequently with greater intensity and area involvement. The final muscle spasm experienced prior to creation of the author’s proposed treatment plan occurred on June 27, 2013, and lasted 10 minutes. Originating in the posterior, midthoracic muscles of both the ipsilateral and contralateral sides, the spasm moved through the left thoracic muscles and intercostals from posterior to anterior. Tightening and pain were felt in the left torso from the upper trapezius to the iliocostal insertions for the iliac crest. By this time, spasms were occurring at a frequency of 1 to 2 per week. During a spasm, breathing and moving became difficult. Stretching neither prevented nor helped to remedy the spasm once it began its initial tightening. Spasms occurred during periods of rest rather than during physical exertion. The latent side effect of continuing, progressive spasms in the thoracic muscles and intercostals was the targeted symptom for the proposed treatment plan.

Treatment Techniques and Plan

In massage, friction is any type of technique that focuses on the connective tissues, such as tendons, ligaments, and fascia. If the technique is cross-fiber friction, then it usually is intended for releasing adhesions in the fascial layers between the muscle fibers or the ligaments and tendons at the joints. Cross-fiber is usually considered as deep friction and is performed by using the fingers, thumbs, and palm or heel of the hand and making short repeated movements that go transversely or across the fibers of the tissues being targeted for therapy.10

With the application of deep friction and compression in a place affected by pathology or injury, 4 major processes are triggered in the massaged tissues: (1) pain relief; (2) peripheral arterial vasodilation, with increasing venous and lymph drainage; (3) microtraumatization of soft tissues; and (4) cellular stimulation.11 Through these processes, newly synthesized procollagen molecules leave fibroblasts and form collagen deposits at the site of injury. Mechanical stimuli applied to the same area can then produce a chain of electrophysiological events that speed up the process of depositing collagen and orient the collagen fibrils correctly, restoring the normal anatomical structure in the place of original injury.11

Radiation-induced fibrosis is not confined to a specific, well-defined site of injury or pathology. It is a chronic, progressive side effect reaching deep into the fascia, muscles, organs, and bones of multiple areas or regions that are caught within the primary and larger secondary radiation fields. The author’s treatment plan was established to determine if deep friction massage could be applied intensely enough throughout expansive, regional areas of pathology to break up the established scar tissue or fibrosis and allow for more normalized neuromuscular activity.

Beginning on July 1, 2013, massage sessions began with a 4-week (28-d) interval between each session. The total number of sessions, with a minimum of 4, was to be determined depending on continued measurable results. Positive results were to be shown by a decrease in the frequency and intensity of thoracic muscle spasms. As previously mentioned, the last thoracic muscle spasm prior to beginning treatment was on June 27, 2013.

A certified massage therapist (CMT) delivered each session at a massage clinic in Nashville, Indiana. Each session provided 60 minutes of focused, deep friction massage to the anterior, lateral, and posterior thoracic muscles and intercostals for both the ipsilateral (cancer-treated) and contralateral sides. After a warm-up phase using effleurage and lengthening strokes, the deep friction massage was implemented. Strokes were performed at a moderate to fast pace and required a generous application of lubricant to provide a smooth, back-and-forth, gliding motion across the muscle fibers, without presenting a risk of tearing the surface skin. The strokes used within the deep friction technique included (1) cross-fiber thumb rolling, (2) cross-fiber fingertip raking, (3) circular friction, (4) myofascial spreading, and (5) myofascial mobilization.

Cross-fiber Thumb Rolling

This technique uses the broad side of the thumb all the way from its tip to the thenar eminence on the palm. The length of the thumb lies parallel to the direction that the muscle fibers run. As the hand glides back and forth across the muscle, the thumb rolls over the muscle fibers.

Cross-fiber Fingertip Raking

In this technique, the fingertip pads roll across the muscle at a 90° angle to the direction of the fibers and run in a continuous, back-and-forth motion along the length of the muscle.

Circular Friction

In this technique, the perpendicular motion of the thumb, fingers, or palm, lying across the muscles, occurs in a circular or rotary fashion.

Myofascial Spreading

This technique combines an up-and-down stroke (ie, one that is parallel to the muscle fibers) with side-to-side stroke (ie, one that is perpendicular to the muscle fibers) to create a criss-cross pattern in the same section of the muscle to palpate aberrations and trigger points more effectively.

Myofascial Mobilization

In this technique, the fingers roll muscles against the bones, helping them to slide freely. For example, in mobilization of tissues over the ribs, the fingertips are used to slide the tissues up and down over each rib.10

Targeted thoracic muscles should include the pectoralis major, pectoralis minor, serratus anterior, external obliques, latissimus dorsi, teres major, teres minor, serratus posterior, trapezius, rhomboid major, rhomboid minor, iliocostalis, erector spinae group, and intercostals. Deeper muscles cannot be palpated directly. Their fibers are felt through the layers of muscles above them. The following sequences are suggested for moving through the client’s chest, back and spine, and shoulder areas.

For deep friction chest massage, the sequence for massaging areas should be (1) the pectoralis major—attachments and belly; (2) the subclavius; (3) the intercostal muscles, from both the supine and side positions; (4) the diaphragm; and (5) the back muscles—the serratus posterior superior and inferior. For deep friction back massage, the sequence for massaging areas should be (1) the erector spinae group; (2) the deep paraspinal muscles; (3) the iliac crest; (4) the sacral ligaments; and (5) the intercostals. For deep friction shoulder massage, the sequence for massaging areas should be (1) the trapezius—upper, middle, and lower; (2) the levator scapula—the attachment; (3) the rhomboids; (4) the subscapularis; (5) the pectoralis minor; (6) the serratus anterior; and (7) the deltoids.

In the current case study, the treatment plan was very specific regarding the sites for the massage and the strokes used. However, it did not give details about the pace, depth, or number of repetitions of each stroke. These factors were variable depending on the receptivity of the client’s tissues and the client’s attitude toward the work. Clients, even the same client at different times, will require varying degrees of pressure on different muscle groups depending on their conditions, particularly clients who have undergone surgeries and follow-up therapy such as radiation therapy.

General contraindications for deep friction massage to targeted muscles include the following, which should be discussed with client’s physician: (1) inflammation, (2) sunburn, (3) rashes, (4) severe bruises, (5) broken bones, (6) tuberculosis, (7) recent surgery, (8) high fever, (9) severe illness, (10) recent trauma, (11) acute injury, (12) severe hypertension, and (13) bursitis.10

In addition to the contraindications listed earlier, the following special situations should be considered with cancer patients: (1) coagulation disorders, complicated by bruising and internal hemorrhage; (2) low platelet count; (3) medications—Coumadin (warfarin sodium), acetylsalicylic acid, or heparin; (4) metastases to the bone, complicated by fracture; and (5) open wounds or radiation dermatitis, complicated by pain and infection.12

Results

After treatment session 1 on July 1, 2013, the client had no neuromuscular or musculoskeletal indications (ie, no muscle spasms) during the following 28-day period. She experienced an anomaly or peculiarity from day 8 through day 21 (ie, lasting a total of 14 d) in which she had a return of the acute side effect, inflammation, that had occurred as a result of the radiation therapy (ie, an internal burning sensation throughout both ipsilateral and contralateral thoracic muscles and intercostals). She had no change in the outward appearance of the tissue.

After treatment session 2 on July 29, 2013, she had a spasm that occurred on day 21 after the second treatment, on August 18, 2013. The spasm was limited to the ipsilateral subscapular and axillary muscles, with a duration of 2 minutes. The muscle spasm occurred during her sleep and did not impede her ability to breathe or move. She experienced a reoccurrence of the same anomaly as had occurred after the first session: the internal burning sensation, but this time it occurred from day 8 through day 14, lasting a total of 7 days. Again, she had no change in the outward appearance of the tissue.

After treatment session 3 on August 26, 2013, she had no muscle spasms during the following 28 days. The anomaly, the internal burning sensation, reoccurred from day 7 through day 8, lasting a total of 2 days. This time she experienced it only in the ipsilateral thoracic muscles and intercostals. She had no change in the outward appearance of the tissue.

After treatment sessions 4, 5, 6, and 7 on September 23, October 21, November 18, and December 16, 2013, respectively, she had no muscle spasms during the following 28 days and no reoccurrence of the anomaly. Even though there were no longer any measurable results with session 4, the occurrence of the anomaly led the author to consider additional sessions. With consent of the client, sessions 5, 6, and 7 were completed to (1) determine the long-term resolution of the targeted muscle spasms, and (2) monitor for return of the anomaly, the internal burning sensation.

Discussion

Painful and worsening muscle spasms caused by radiation-induced fibrosis had been experienced by the client from 3 months after radiation therapy (ie, from December 2012) through 10 months after radiation therapy (ie, through June 2013). Immediately prior to implementation of the author’s treatment plan, the frequency of spasms had reached 1 to 2 per week, lasting up to 10 minutes in duration, with debilitation during the length of spasm.

On July 1, 2013, the treatment plan was initiated, and 7 sessions were carried out using deep friction massage, with special intensity and focus on the thoracic muscles and intercostals.

From the start of the treatment plan through its conclusion on December 16, 2013, the client experienced only 1 muscle spasm. This spasm occurred on August 18, 2013, which was 21 days after the second treatment session. Being more limited in the scope of the involved area and shorter in duration, this spasm was rated as only 25% as painful or severe as the last spasm experienced prior to implementation of the treatment plan on June 27, 2013. The treatment plan had not only been successful in eliminating this painful and debilitating symptom of established radiation-induced fibrosis but also in preventing its return.

Treatment Precautions and Considerations

Technique Intensity and Depth of Cross-fiber Stroke

The client in the current case study was acclimated to receiving deep muscle massage on a regular basis, both before and after breast cancer treatment. The intensity and specific focus of the treatment plan was based on this acclimation. A client who has not received such massage therapy can be expected to experience normal muscular soreness immediately following deep muscle massage of this nature (ie, within 24–48 h). The treatment plan for unacclimated clients will need to be prefaced with deep friction sessions of lesser intensity or focus until the client acclimates to the effects of deep tissue massage.

Presence and ISL Staging of Lymphedema

The client in the current case study was in ISL stage 0 lymphedema. The greater the impairment of or compromise to the lymphatic transport system, such as through surgery or radiation therapy, the greater the risk of overburdening the superficial lymphatic system of the body. ISL stage I identifies patients with an early onset of the condition where accumulation of tissue fluid occurs but subsides with limb elevation. ISL stage II is present when limb elevation alone rarely reduces the swelling. This stage is a point that is critical in postcancer treatment and therapy, at which lymphedema management techniques should be incorporated to help the client reduce the edema and maintain physical condition.6

Each client should be reviewed thoroughly prior to beginning a treatment plan such as the one used in the current case study. The therapist initiating the treatment plan for a client with ISL stage I lymphedema or higher should be trained in lymphedema management techniques and principles.

Unexpected Finding

Also noted in the results was the observation of an anomaly or peculiarity in the course of the treatment plan. It is apparent that this anomaly occurred because of the more intense and focused deep friction massage techniques. The burning sensation had been an acute side effect of the period of active radiation therapy and had not occurred since the conclusion of therapy in September 2012. This anomaly should not be confused with what would have been a normal, local inflammatory process that starts after the end of massage treatment and continues for 24 to 48 hours. All instances of the anomaly occurred at least 7 days following the time of the massage treatment. Whether this burning sensation was caused by mechanical effects on the fibrous tissue, changes in the local biochemical reactions following deep tissue massage, modification of the centrally mediated pain or spasm response, or other factors is not known. Exploring this anomaly may help researchers to understand the mechanism that initiates fibrosis and fuels its progressive nature, causing it to occur even years after the end of radiation therapy.

Conclusion

Radiation-induced fibrosis is a common, complex, and often painful or debilitating problem that patients treated with radiation therapy may face. Unfortunately, because radiation-induced fibrosis evolves quickly in some patients but gradually in others, symptom development may occur years after the radiation therapy. In the latter case, radiation therapy may go unrecognized as a causal factor and its symptoms misinterpreted by its sufferers and their health care providers. This issue causes underreporting of the condition. Fortunately, this case study suggests that symptoms of even established radiation-induced fibrosis may be partially reversed and that their reoccurrence may be reduced.

The management approach of manual therapy should be expanded to include further investigation into applying deep friction massage to the more expansive, deeper areas of radiation-induced fibrosis. In this instance, such an application was able to affect the fibrous tissue in the thoracic muscles and intercostals and, thereby, improve the function of the neuromuscular systems.