Electromyographic study of shoulder and acromioclavicular joint muscles in women who underwent unilateral breast surgery of the types mastectomy and quadrantectomy

doi:10.4236/health.2013.511251

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Vol.5, No.11, 1866-1871 (2013) Health

http://dx.doi.org/10.4236/health.2013.511251

Electromyographic study of shoulder and

acromioclavicular joint muscles in women who

underwent unilateral breast surgery of the types

mastectomy and quadrantectomy

Antonia Dalla Pria Bankoff1,2, Sonia Regina Jurado2

1Postural Assessment Laboratory, FEF-Unicamp, Campinas, Brazil; [email protected]

2Federal University of Mato Grosso do Sul-Campus de Três Lagoas, Três Lagoas, Brazil

Received 10 September 2013; revised 15 October 2013; accepted 26 October 2013

Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original

work is properly cited.

ABSTRACT

We studied 20 women with m ea n ag e 5 7.7 years,

being 9 w ith unilateral quadra ntectomy surger y,

1 with surgery type bilateral quadrantectomy

and 10 with unilateral mastectomy surgery. The

average operative time was 9.8 (nine years and

eight months). We studied using surface elec-

tromyography the mean deltoid, upper trape-

zius and latissimus dorsi muscles in order to

check the action potentials of these muscles

when performing a sequence of movements of

these joints. It was used for the study, an Ac-

quisition Data System ADS1000 containing 12

channels. The electromyography (EMG) results

expressed in RMS (Root Mean Square) were

analyzed and compared between the surgical

and nonsurgical side, among the three repeti-

tions of the sequence of movements and be-

tween mastectomy and quadrantectom y for e ac h

muscle. For statistical analysis we used analy-

sis of variance (ANOVA) with a double repetition

factor (p < 0.05) for the EMG results. The results

showed a significant difference (p < 0.05) between

the surgical and non-surgical sides to the mus-

cles studied. There was no significant differ-

ence betw een the three repetitions of sequential

movement s in electromyographic analy sis to the

muscles studied. There was no significant dif-

ference between the types of surgery (mastec-

tomy and quadrantectomy) for the muscles stu-

died.

Keywords: Electromyography; Skeletal Muscle;

Breast Surgery; Quadrantectomy; Mastectomy

1. INTRODUCTION

The breasts are glands and their main function is to

produce milk. They are composed of lobes that divide

into smaller portions; the lobules and ducts that carry

milk produced outwards through the nipple. Like all

other organs of the human body, they are also found in

breast blood vessels that supply blood to the breast, and

lymphatic vessels through which lymph flows. Lymph

is a clear liquid that has a function similar to the blood

to carry nutrients to various parts of the body and col-

lect undesirable substances. The lymphatic vessels are

grouped in what is called lymph nodes, or swollen

lymph nodes. The lymphatic vessels drain into the breast

glands in the armpits (lower arms) in the neck and chest

[1].

Breast cancer occurs when cells of the body begin to

divide and reproduce very quickly and haphazardly.

Most breast cancer affects the cells of the ducts of the

breasts. Therefore, the most common breast cancer is

called ductal carcinoma. It can be in situ, when there is

nothing of the first cell layers of duct or attacker, when

invading the surrounding tissue. Cancers that begin in the

breast lobules are called lobular carcinoma and are less

common than the first. This type of cancer most often

affects both breasts. Carcinoma Inflammatory breast

cancer is rarer and usually presents itself aggressively,

compromising the entire breast, leaving it red, swollen

and hot [1].

As a result of breast cancer treatment, several compli-

cations have been reported, among them, including those

resulted from surgery. The surgical techniques can be

A. D. P. Bankoff, S. R. Jurado / Health 5 (2013) 1866-1871 1867

used for the mastectomy or conservative surgery, which

may be associated with axillary lymphadenectomy (AL)

or sentinel lymph node biopsy [2]. Among the surgical

complications of AL, it is the long thoracic nerve injury [3].

Most injuries of this nerve are partial and transient (neu-

ropraxia), which gradually recover with conservative

treatment [2]. However, when this regression does not

occur in the first six months, the lesion can be considered

complete, with few chances of rehabilitation [4].

The long thoracic nerve injury results in decreased

strength or paralysis of the serratus anterior muscle,

leading to destabilization of the shoulder girdle on the

prominence of the medial border of the scapu la and infe-

rior angle of rotation of the middle line, featuring a

winged scapula [5]. In addition to the specific lesion of

the long thoracic nerve, muscle changes are also seen as

morbidity related to the muscles in the sho ulder joint and

scapular stabilization and, we can cite, in addition to the

serratus anterior muscle, others such as the upper trape-

zius and deltoid medium [6].

After the AL in the treatment of breast cancer, the

prevalence of scapular winging has varied 1.5% - 12.6%

[7] and the incidence of 8% to 30% [8]. In a cross-sec-

tional study conducted in Rio de Janeiro, the prevalence

of 6.3% in women with seven to 287 months elapsed

after the AL was observed. In an incidence study with

599 women who underwent AL, we observed the pres-

ence of winged scapula in 69.5% of patients evaluated in

the immediate postoperative period [9].

The efficacy of physiotherapists, as well as the recov-

ery of normal movement in cases of neuropraxia may be

accompanied by physical examination. However, it is

believed that the use of objective methods such as sur-

face electromyography, for example, will provide more

reliable results on the evolution of the clinical status of

patients [10]. The EMG is defined as a non-invasive ex-

perimental technique, which consists of the development,

registration and analysis of myoelectric signals [11]. The

myoelectric activity through the electromyographic sig-

nal, based on the action potential of the plasma mem-

brane of muscle fibers, results from the process of de-

polarization and repolarization [4]. The root mean square

electromyographic signal (RMS) is one of the parameters

used to measure muscle electrical activity and indicates

changes in firing frequency and range of muscle activity,

so that the higher the value—and, consequently, the

range is greater—the greater the muscle electrical activ-

ity [12].

Decreased Range of Shoulder Motion

Range of motion (ROM) is the complete movement

possible of a segment being maintained by periodic

mov eme n t o f the me mbe r [ 1 3]. S ome fa ct o rs may le ad to

impairment of ROM. Among them we emphasize the

surgical aggression and inactivity or immobilization of

the limb. In case of realization of the radical mastectomy,

the pectoralis major and minor are removed, resulting in

a decrease in strength and upper limb function involved.

The same occurs when the nerve of Bell is temporarily

traumatized during axillary dissection, resulting in weak-

ness of the serratus anterior muscle, disrupting the move-

ment of the scapula and shoulder abduction on the af-

fected side [14,15]. Re-education of upper limb girdle

is a basic need in the patient undergoing surgery for

breast cancer, whatever the surgical technique is. Its

main objective is to restore limb functio n as soon as pos-

sible [16].

2. MATERIALS AND METHODS

We studied the middle deltoid, upper trapezius and

latissimus dorsi by surface electromyography in order to

check the action potentials of these muscles in women

affected by breast surgeries types unilateral mastectomy

and quadrantectomy

3. POPULATION

We studied 20 women with a mean age 57.7 years;

being 9 with unilateral quadrantectomy surgery, 1 with

bilateral quadrantectomy surgery and 10 with unilateral

radical mastectomy surgery. The average operative time

was 9.8 (nine years and eight months). The electromy-

ographic study was conducted with women who under-

went this surgery in a period longer than six months of

surgeries and that performed all sessions of physical

therapy after the surgery recommended by the physician

and the SUS after surgery being a total of 12 sessions.

4. Method

4.1. Instruments

It was used in the study, a data acquisition system

ADS1000 12-channel of analog input for simple signs,

50 × gain, 1 - 1000 Hz band (1), 12 differential analog

input channels, gains 1×, 100×, 300× and 600× select-

able in factory, 0 - 1000 Hz band (2), high-pass filter

with cutoff frequencies selectable in software options: 1

Hz, 2 Hz, 5 Hz, 10 Hz, 20 Hz, 50 Hz or without filter;

Low Pass Filter with upper cutoff frequencies selectable

software for the options: 100 Hz, 200 Hz, 300 Hz, 500

Hz, 1000 Hz or without filter; Filters “Notch” operated

by software in the options: 60 Hz, 120 Hz, 180 Hz and

240 Hz and 2 optically isolated digital inputs, 2 digital

outputs optically isolated acquired by FAPESP Process

No. 2010/08923-2.

4.2. Procedures and Data Acquisition

All research subjects; dressed on ly a brassiere, in itially,

A. D. P. Bankoff, S. R. Jurado / Health 5 (2013) 1866-1871

1868

it was performed the posterior superior asepsis of the

thorax and upper arm, thus preparing the sites for elec-

trode placement, avoiding any interference in the acqui-

sition of electromyographic signals.

Surface electrodes with electric-conductive gel were

fixed on the skin in the respectiv e muscles. For the latis-

simus dorsi muscle in the lower back and side of the

chest, deltoid medium in the ventral portion of the upper

trapezius. We analyzed the muscle action potentials bi-

laterally, regardless of the side where the surgery took

place (right or left). Each research subject underwent 3

proposed sequences of moves.

The study was conducted at the Laboratory of Elec-

tromyography and Biomechanics of Posture, School of

Physical Education—Unicamp. For each procedure be-

fore starting data acquisition, the subject was asked three

times to conduct the activities of sequential movements

of the shoulder joint, thus avoiding some sort of error

during execution.

All subjects in the study signed an informed consent

for participation in the research. The project was ap-

proved by the Ethics Committee of Unicamp under No.

984/2010.

5. MOVEMENTS REVIEWED

Hyper-flexion and extension of the arm, arm abduc-

tion and adduction, extension and flexion of the arm

horizontal, internal and external rotation of the arm, lift-

ing and lowering the shoulder.

6. RESULTS

In our work we studied the electrical potential of mus-

cle cells in skeletal muscles acting on the shoulder joint

of women who underwent breast surgeries due to breast

cancer. When women perform these types of surgeries

(mastectomy and quandrantectomia) are removed com-

pletely or partially muscles around th e shoulder joint, for

example muscles pectoralis major and minor and other

muscles. Then, using electromyography to measure the

action potentials of the latissimus dorsi, upper trapezius

and middle deltoid in women who have these types of

surgeries. What is electromyography? When we speak of

electromyography signals, we talk about “Generation of

Action Potential”. Therefore, an action potential is an

electrical control type all or nothing produced by the cell

in response to the impulse received. The signals are

action potentials generated b y an electric control between

neurons and muscle fibers. This means both neurons as

muscle fibers can generate action potentials, in other

words, the impulses received by the neuron, which are

the basis for the generation of the action potential. In this

sense, it is much easier to understand the relationsh ip be-

tween the action potential and electromy ography signals.

The trapezius muscle shown in Figure 1 had the low-

est average RMS values of EMG signals on the type of

mastectomy surgery, although the figures presented by

the type quadrantectomy hand surgery were not as im-

pressive. When we look at this graph the surgical side

considering both types of surgery, we found that the val-

ues are lower. With the results, it is quite evident that

both types of surgery compromise the kinesiology of the

trapezius muscle in relation to the joints studied. One of

the complaints of women is the difficulty of raising the

shoulder of the hand surgery to perform daily tasks and

also complain that the non-surgical side does not offer

force necessary to accomplish necessary task on a daily

basis.

Figure 2 shows the results of latissimus dorsi muscle.

One can check, on th e latter, that the lowest RMS values

through the acquisition of electromyography signals are

ANOVA-Analysis of Varian ce

SM SM NSQ SQ NS S

Avera

e 26.8 18.96 29.7 24.23 27.85 21.3

Variance 11.75 2.03 18.46 16.32 19.24 14.31

Figure 1. Income statement in RMS (Root Mean Square) on

the electromyography evaluation in women mastectomized and

quadrantectomized on the Trapezius muscle. Non-Surgical Mas-

tectomy (NSM), Sur gical Maste ctomy (SM), Non-Sur gical Qua-

drantectomy (NSQ), Surgical Quadrantectomy (SQ), Non-Sur-

gical (NS) and Surgical (S).

ANOVA- A nalys is of Var ia nce

SM SM NSQ SQ NS S

Avera

e 55.66 37.43 55.43 41.53 55.48 36.81

Variance 13.26 18.32 28.18 17.01 34.99 17.1

Figure 2. Income statement in RMS (Root Mean Square) for

electromyography evaluation in women mastectomized and

quadrantectomized on the latissimus dorsi muscle. Non-Surgi-

cal Mastectomy (NSM), Surgical Mastectomy (SM), Non-Sur-

gical Quadrantectomy (NSQ), Surgical Quadrantectomy (SQ),

Non-Surgical (NS)and Surgical (S).

A. D. P. Bankoff, S. R. Jurado / Health 5 (2013) 1866-1871 1869

scored on the type of surgery and hand surgery Mastec-

tomy both types of surgery. The results presented aimed

to be a muscle that suffer the consequences in their kine-

siology types of breast surgeries. It seemed to us to be

more engaged in radical mastectomy surgery, but in the

quadrantectomy surgery was also weakened in relation to

the achievement of the sequence of movements for the

shoulder joint. In the adduction movement women dem-

onstrated great difficulty in approaching the body side

arm with surgery. It is the primary motor adduction, ex-

tension and hyperextension of the shoulder joint, helping

also in the horizontal extens ion and internal rotation . It is

a muscle that works in many movements of the shoulder

joint and also interferes with the body posture tak ing into

account its origin from the ilium, through the lumbar,

thoracic, and its insertion to the humerus at the back. As

a result, it may change the biomechanical relationship

between shoulder and pelvis, causing misalignment be-

tween the sacrum and the ilium bones bilaterally, asym-

metrically tilting the pelvis, or pulling your shoulders

down causing drooping shoulders. For women with mas-

tectomy and quadrantectomy surgery the inability can

cause postural problems [17].

Figure 3 shows the results of the Middle Deltoid mus-

cle, which showed low values in RMS through the ac-

quisition of electromyography signals. Considering its

kinesiology as a whole performs the abduction of the arm,

specifically the middle portion. Part clavicular and ac-

romial portions of adjacent flex the arm, the spinal and

adjacent parts of the acromial portions extend arm. The

ventral portion rotates the arm medially and laterally

dorsal portio n.

Considering the kinesics trapezius muscle rotates the

scapula, raising the acromial extremity in abduction and

full flexion of the arm. The top acting alone elevates the

ANOVA-Ana lysis of Variance

SM SM NSQ SQ NS S

Avera

e 36.23 27.73 38.16 30.2 35.86 29.76

Variance 31.08 7.16 16.83 2.00 28.49 11.91

Figure 3. St atement of the results in RMS (Root Mean Square)

on the electromyography evaluation in women mastectomized

and quadrantectomized on the Middle Deltoid muscle. Non-

Surgical Mastectomy (NSM), Surgical Mastectomy (SM), Non-

Surgical Quadrantectomy (NSQ), Surgical Quadrantectomy (SQ),

Non-Surgical (NS)and Surgical (S).

scapula cranially, elevating the shoulder, then it has an

important participation from the shoulder joint. It is im-

portant to note that when all portions of the trapezius

contract simultaneously, they act more on the upper por-

tion than on the lower por tion of the scapu la. It should be

noted the effect of posture, the action of the trapezius

muscle. When the shoulder is the most high, or when a

weight is supported on the shoulders, with the individual

standing, the second portion is contracted vigorously and,

third, little or nothing [17].

One of the difficulties of women with breast surgeries

types of mastectomy and quadrantectomy is the realize-

tion of abduction movement of the arm because the mus-

cles that control the movements of the shoulder joint to

be affected by surgery. It showed electromyographic

signal after 45 degrees of abduction of the arm, stopping

soon after, because most could not reach the 90 degrees

of amplitude. If we look in depth at Figure 3 we see that

the values shown for the mastectomy surgery side, quad-

rantectomy surgery side and surgical side with both types

of surgery, the difference found between the values is

very small. This leads us to believe that the middle del-

toid muscle kinesiology suffer consequences with both

types of surg ery.

7. STATISTICAL RESULTS ABSTRACT

For statistical analysis we used analysis of variance

(ANOVA) with a double repetition factor (p < 0.05) for

the EMG results. The results showed significant differ-

ence (p < 0.05) between the surgical and nonsurgical

sides for all muscles studied. There was no significant

variation between the three sets of repetitions for all

muscles studied. There was no significant difference be-

tween the types of surgery (mastectomy and quadran-

tectomy) for the trapezius, latissimus dorsi and Middle

Deltoid.

8. DISCUSSION

When I discussed the project and drafted the literature

impressing me, the placements of some authors say that

the recovery was long overdue. The long thoracic nerve i n-

jury results in decreased strength or paralysis of the ser-

ratus anterior muscle, leading to destabilization of the

shoulder girdle on the prominence of the medial border

of the scapula and inferior angle of rotation of the middle

line, featuring a winged scapula [5]. [6] describes that in

addition to the specific lesion of the long thoracic nerve,

muscle changes are also seen as morbidity related to the

muscles in the shoulder joint and scapular stabilization

and can cite, in addition to the serratus anterior muscle,

others such as the upper trapeziu s and middle deltoid [4 ].

Reports that when this regression does not occur in the

first six months, the lesion can be considered complete,

A. D. P. Bankoff, S. R. Jurado / Health 5 (2013) 1866-1871

1870

with few chances of rehabilitation.

Considering the kinesiology of the muscles studied in

relation to the shoulder joint and acromioclavicular

which act in many of the movements of these joints, it

was evident that the types of mastectomy and quadran-

tectomy surgeries impair the quality of surgical hand

movements specifically, however, the non-surgical side

also suffers from some kind of commitment in the per-

formance of movements and also in relation to body

posture due to overload [1,18].

In our results electromyographic and Middle Deltoid

muscle Trapezius had lower RMS values representing

the action potentials of muscles in the sequence of move-

ments performed, specifically the surgical side confirm-

ing the findings of [6]. An observation, however, not

assessed by this project is that these types of surgeries

and more the problem of the disease also affect the next

non-surgical, body posture, body balance, muscle stre ng th

and more emotional, mainly because they feel fear and

pain on movement. They complain much of the limita-

tions on range of motion of these joints, especially for

performing everyday tasks.

9. CONCLUSIONS

Based on the results we believe we can draw the fol-

lowing conclusions regarding the three parts of our ex-

perimental work:

• There was a sign ifican t d iffere nce be tween su rgic al an d

nonsurgical sides (p < 0.05) for the muscles studied;

• There was no significant difference between the three

replicates during analysis of electromyography to the

muscles studied;

• There was no significant difference between the types

of surgery (mastectomy and quadrantectomy) (p <

0.05) for the muscles studied.

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