A new treatment approach that might explain stiff neck symptoms after breast cancer

Most people I see in the first year, or longer, after breast cancer treatments will experience increased neck stiffness. Looking over their shoulder gets increasingly harder to do; rolling the head down becomes a physical impossibility; the bones in the neck just won’t bend individually anymore. There's a new approach that can be trialled in a single session, to see if neck stiffness can be relieved through a gentle artery release method at the collar bone area.


Let me explain.


I used to think that radiotherapy was the reason behind chronic neck pain and neck stiffness following breast cancer. I thought the radiotherapy directly altered the neck muscles, making them stiff or fibrosed. This made sense, as some people remembered the burned skin at the side of their neck in the last weeks of the radiotherapy, which took 4-5 weeks to settle.


But not everyone had radiotherapy burns at their neck. Some would say they remembered the redness definitely at the chest and extending up to the collarbone. On some people who had more colour in their skin, you could actually see where the radiotherapy was received, so it was obvious in the years after where radiotherapy was delivered.


Some people would experience broken blood vessels on the skin of their chest or some may even have had heart changes detected. Each of these symptoms is known as chronic and late side effects of radiotherapy and may even be diagnosed as radiotherapy fibrosis.


Yes, I can hear a virtual sigh or a groan:

not another side effect!
.... just another new medical term: radiotherapy fibrosis.

Let’s unpack “radiotherapy fibrosis” because I think it means more than a diagnosis, it may offer a new approach to managing side effects that just won’t go away, after breast cancer treatments.


Fibrosis is a term that refers to stiffness and occurs in tissues where significant radiotherapy energy passed through. Fibrosis is actually scarring tissue and it forms because of inflammation within tissues, and the inflammation in this instance is the result of receiving radiotherapy.


What’s becoming clear now, because of better imaging technology, is that radiotherapy fibrosis not only can affect the heart, if the person receives radiotherapy on the left chest, but it affects the local skin, the local muscles, and now we can see even the local nerves and the blood vessels become fibrosed!



At this point, don’t get mad about not being told about this. I am sure the radio oncologist didn’t mention the risk of radiotherapy fibrosis to each of these tissues, as they were probably hoping that in time, things would settle down.

If you have noticed your neck getting stiffer, read on; there may be a new way to manage fibrosis that’s causing neck stiffness.



Kieran Schumaker, a Structural Integrator in the USA, has inspired me to think differently about neck stiffness after breast cancer. She’s studied the tiny and not so tiny blood vessels and nerves in the body and has examined how they can get pinched, squished or even protected by tight muscles. Kieran’s work has led to her developing very gentle methods of release for tight blood vessels. The method is gentle because these structures are so much finer than muscles. And she is reporting that the result of releasing tensioned arteries and nerves can be immediate: a reduction in persistently tight local muscles and more local movement.


Kieran is so confident of the link between neck stiffness and blood vessel stiffness that she’s running online training for health and exercise professionals; and that’s how I came upon her work. Because of COVID, Kieran has developed her practices so that she can share some techniques in an online format; whereas prior to COVID, therapists had to travel to USA for face to face training.


The amazing thing about online training is that I can be in Australia, thinking and working in my breast cancer rehab bubble, and then “ kazammmm”, another new insight that helps me unfold or demystify the side effects people are experiencing after breast cancer.


Kieran’s single session online training Heart to Hands, at Anatomy Trains website, offers training on how the large and small blood vessels in the neck can become tight and simple steps to gain release. She talks about a well-known site under the pec minor muscle, where these vessels get compressed and stressed. I've had this area on my radar for many years, but had only thought about the downstream consequences into the arm and chest.


Kieran expains that tightness in the blood vessels at this location can lead to tightness upwards, into the head: tension in the large and small neck blood vessels and then secondary tension at the major neck muscles; leading to stiffness in neck movement. I’m abbreviating her training- as there is so much more!


This is what I’m thinking for breast cancer-related neck stiffness: the same mechanism is happening! The pec minor muscle, which is deep in the upper front chest, gets tighter and tighter over time and this tightness compresses the local blood vessels running underneath, and because the vessels get pinned, the blood vessels back to the neck stiffen up and the muscles stiffen up around the vessels.


Ýes, it might be a catch 22, or chicken and egg question- which one is first?


It doesn’t matter, as the outcome may be the same: neck stiffness that just won’t go away.


What does this mean for people who are experiencing a stiff neck after breast cancer?


If this hypothesis is applicable, then trying two approaches can verify this potential link. One approach is to have local manual treatment at the pec minor to gain some release of the tightness within the muscle. The second approach, from Kieran Schumaker, is to release the tightness within the blood vessels between the neck and the pec minor insertion. Or maybe it’s a combo of both.


How do you check if your pec minor is tight?


Firstly, if you've had radiotherapy to the chest, then your pec minor is going to be tight; that’s the fibrosis to the muscle and arteries working beyond the radiotherapy treatment.


Next, if you've had nodes removed from your axilla area, then the surgery is at the base of pec minor, so it’s likely that pec minor muscle is caught up in the scar tissue that formed when the wound healed. If the muscle is caught in the scar tissue then we know that the muscle becomes less elastic.


If pec minor muscle is less elastic then you’ll find that you can’t reach your arm up to touch the side of your head, let alone reach further back: where your upper arm can stretch back behind your head. Your arm may feel heavier when reaching up and out to the side and it might not go as far as the arm on the non-surgery side.


If the pec minor is less elastic then pressing into the muscle will feel painful. If you feel just under the collar bone, about halfway along the bone, then this is where the muscle inserts onto the shoulder blade which protrudes somewhat to the front of the body. When muscles are tight they develop hypersensitivity to touch.


Ready to do a few more checks?


Check if there could be tension in the blood vessels between the neck and under the collar bone:


Head bend: If your neck feels like a giraffe's neck- stays straight and bending happens from the top of the back- it's not bending!


Head and neck tilting: If your ear to shoulder neck tilt is stiff, when you tilt your ear to the shoulder on the non-surgical side.


Head and neck turning: You might have less head turn to look over your shoulder on the side of the surgery.


Also on the other side of the collarbone:

If you find that you experience pins and needles down your arm to the fingers, when your arm is raised for a while; pec minor tension can be compressing the nerves to the arm.



Radiotherapy tension within the blood vessel system is now known.


Tension in the blood vessels has been identified in research and has been named as fibrosis and a long term side effect of radiotherapy. Vallerio and co-authors ( 2016) found tension changes in a group of people who were 15 years after radiotherapy. They claimed, “local arterial stiffening (on the same side as radiotherapy) because of radiation (that) can be involved in increased cardiovascular risk in breast cancer–treated patients”.



Image: Photo by Caique Silva on Unsplash



My breast cancer rehab focused brain asks:


Do we need to wait 15 years to find artery stiffness or signs of cardiovascular disease?


Can we apply the gentle artery release methods developed by Kieran Schumaker to mitigate some of the radiation changes to artery tension?


Can we apply the gentle artery release methods developed by Kieran Schumaker to mitigate some of the tension at pec minor after axilla node surgery?


The answer to these questions is unknown by research, as attention has not yet extended to non-medical interventions for artery tension in breast cancer survivors.


However, this does not stop people from trialling at least one therapy session to investigate the presence of artery tension at the neck and then trial simple and gentle release methods.


If people do this one session trial and find some freedom of movement at the neck, then maybe these gentle artery stretches can be added to their home self-care stretch program. We can be happy with short term outcomes of reducing and managing neck stiffness.


If you have neck stiffness and have ticked a few boxes in the checks above, then you might be ready to consider taking action on radiotherapy or breast cancer surgery fibriosis.

Connect if you are ready to purchase one session to test for artery tension: a 45 min session. I am available for face to face appointments in Brisbane or connect to book an online session.


Image: Radiotherapy changes the colour of skin for people with brown or dark skin colouring, and so the location of radiotherapy is obvious years later.















Reference:

Vallerio P, Sarno L, Stucchi M, Musca F, Casadei F, Maloberti A, Lestuzzi C, Mancia G, Moreo A, Palazzi M, Giannattasio C. Long-Term Effects of Radiotherapy on Arterial Stiffness in Breast Cancer Women. Am J Cardiol. 2016 Sep 1;118(5):771-6. doi: 10.1016/j.amjcard.2016.06.001. Epub 2016 Jun 14. PMID: 27392510.

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