Exacerbating factors
Limiting factors
62 %: arm overuse
51 %: medications
59 %: vigorous arm massage
49 %: rest
42 %: pulling on the arm
46 %: local heat
38 %: sudden arm movements
22 %: physical exercise
16 %: local cold
19 %: arm massage, support sleeves, lying supine
14 %: dressing, stress, sweating
13 %: coughing
11 %: immobility, pressure on the arm, standing upright for long periods
A very recent study, collecting psychosocial and demographic informations via phone interview and examining sensory processing in the breast regions through quantitative sensory testing (QST), showed that surgical and disease-related variables did not differ significantly between painful and non painful patients after surgery [24]. Treatment with radiation, chemotherapy, or hormone therapy was not more common among those with pain. In contrast, women with PMPS exhibited high levels of distress-related psychosocial factors, such as anxiety, depression, catastrophizing, or somatization following operation. Moreover, QST in non surgical areas revealed increased sensitivity to mechanical stimulation in painful patients, while thermal pain responses were not different between painful and non painful patients. These findings suggest that individual psychophysical and psychosocial profile are more strongly related to PMPS than surgical and associated treatments.
Diagnosis
The diagnosis of PMPS is made on the basis of clinical examination. The classical criteria were described in 1989 by Watson [25], and are still in use:
lack of recurrent local disease, after eliminating other causes of post-mastectomy pain
presence of spontaneous pain such as dysaesthesias ipsilateral to the mastectomy, localised to the thoracic and/or axillary region and/or the superior and anteromedial part of the arm
persistence for 3 months at least
allodynia and/or hyperaesthesia and/or paraesthesias associated with spontaneous pain.
The pain begins immediately or some time after surgery and persists. Features of neuropathic pain are generally found:
spontaneous permanent pain in the anterior chest, the axillary crease and the ipsilateral upper limb, often described as burning
spontaneous paroxysmal pains, similar to lightning flashes, electric shocks or pinpricks
provoked pain in the form of mechanical or thermal allodynia centred on the axillary crease (one or more areas of allodynia may be found at the axillary crease or in the anterolateral chest wall)
sensory deficits, often in the form of anaesthesia or hypoaesthesia in the triceps region (possibly combined with hyperaesthesia to pressure over the ipsilateral second intercostal space).
Signs and Symptoms
During a French study of psychological and social factors predicting the development of chronic pain after breast cancer surgery (coordinator: F. Lakdja, Institut Bergonié—Centre Régional de Lutte contre le Cancer, Bordeaux, 2005), 154 women were followed up with breast cancer over a period of 9 months. Analysis of the signs and symptoms of PMPS identified in patients at 14 months revealed various clinical pictures, mosaics of signs and symptoms described in Tables 13.2, 13.3, 13.4 and corresponding to Watson’s criteria.
Table 13.2
Frequency of various characteristics of PMPS
Gripping sensation | 19.3 % |
Tingling | 17.9 % |
Numbness | 17.9 % |
Pins and needles | 13.6 % |
Electric shocks | 10.7 % |
Burning | 10.0 % |
Stretching | 8.6 % |
Heaviness | 8.6 % |
Tightness | 7.9 % |
Pinprick | 7.1 % |
Compression | 5.7 % |
Heat | 5 % |
Table 13.3
Localisation of pain symptoms in PMPS
Axillary crease | 66.67 % |
Breast (upper inner quadrant) | 18.12 % |
Arm (anteromedial side) | 10.87 % |
Scar | 5.07 % |
Table 13.4
Frequency of neurological signs in cases of PMPS
Anaesthetic | 6.4 % |
Hypoaesthesia to friction | 47.1 % |
Hypoaesthesia to pressure | 40 % |
Hyperaesthesia | 10 % |
Allodynia to friction | 29.3 % |
Allodynia to pressure | 27.9 % |
Trigger zone | 15.0 % |
This study also highlighted the importance of psychological factors in the occurrence of PMPS. Whether it was due to their historical personality (expressing sadness) or the strategies used to cope with postsurgical pain (dramatisation), women with pain expressed both physical and psychological suffering. This situation was seen in the comorbidity between anxiety or depression and PMPS, and confirms the interaction between dispositional difficulties with emotional regulation and chronic postsurgical pain.
Assessment
The assessment process should be global and systematic [26]. The document entitled “Standard Options Recommandations Douleur” (FR: standard options, recommendations on pain), updated in 2003 for those patients who have been in contact for more than 6 years, states that in the case of neuropathic pain the assessment process should include (as agreed by experts):
“open” questioning
“semi-directive” questioning centering on assessment of the components of pain and the symptoms that are experienced
exhaustive list of the different types of pain described
separate characterisation of each of the symptoms of pain, by intensity, site and type (a patient-assessed scale should be used to characterise the intensity of the pain for each symptom)
the time-course of each pain (reported occurrence of pain)
analysis of the psycho-affective components associated with the pain
a list of the treatments received, the route of administration, unwanted effects and efficacy.
Although the NPS scale can be used, other validated questionnaires for diagnosis and assessment of neuropathic pain are very useful, particularly the DN4 [27–29]. Referral to a pain specialist is recommended if the analysis is complex or where chronic pain is resistant to the standard treatment [26].
Phantom Breast Pain
Prevalence and Definition
Initially described in 1956 by Bressler et al. [30], phantom breast syndrome is a surgical complication which is non-painful in most but not all cases. It is primarily an abnormal, unpleasant and sometimes painful sensation which is felt in the cortical region representing the breast and may become distressing for some patients. This “hallucinosis” mainly affects the areola much more often than the whole breast [31]. The syndrome occurs an average of 3 months after a mastectomy and according to case series it occurs in 15–25 % of cases and up to 48 months after surgery. Kroner et al. [32] found that this syndrome had an overall prevalence of 11.8 % at 6 years after mastectomy.
Related posts:
Psychosocial Factors Involved in the Occurrence of Chronic Postsurgical Pain
The Role of Coxibs in the Management of Postoperative Pain
Antiepileptics and Perioperative Anti-hyperalgesia: A Survey
Risk Factors for Chronic Postsurgical Pain
Perioperative Strategy for Prevention of Chronic Postsurgical Pain: General Foundations
Scar Neuromas
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