Post-mastectomy pain syndrome (PMPS) is a common and severe neuropathic pain syndrome arising after breast surgery. Since few effective allopathic treatments exist for PMPS, many patients may seek assistance from complementary and alternative medicine. Here, we report a case of a woman with severe and persistent PMPS who was successfully treated with acupuncture.
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While a previous survey study found that some women use acupuncture for post-mastectomy pain syndrome (PMPS),1 to date there has been no clinical trial documenting the efficacy of acupuncture for this condition. Here, we report a successful case of acupuncture treatment for PMPS.
Our patient was a 47-year-old woman who was diagnosed as having multifocal oestrogen receptor and progesterone receptor positive breast cancer in late 2010. She underwent a bilateral mastectomy with tissue expander placement. Immediately after surgery, she developed a severe pain across her chest. She described the pain as shooting, stabbing, burning and aching with a sensation of a tight band around the chest wall. Activity and movement exacerbated the pain. Her pain was so severe that she initially required hospitalisation with intravenous analgesic administration. She was given oral morphine upon discharge, but required transition to hydromorphone shortly thereafter due to unrelenting pain. She also tried courses of lidocaine patches, non-steroidal anti-inflammatory drugs, acetaminophen and topical creams without improvement. Given her persistent symptoms, gabapentin was added to her treatment regimen for 18 months. Although gabapentin offered some relief, our patient did not tolerate it due to somnolence. Our patient took part in a clinical trial of exercise for breast cancer survivors, but was unable to participate effectively due to pain. She reported that her pain was preventing her from doing basic daily activities. Simple activities such as writing and doing laundry exacerbated her pain. The pain had a substantial and detrimental effect on her quality of life. In addition, our patient chose to delay the tamoxifen treatment her oncologist recommended for 1 year to focus on her pain management. After 27 months of symptoms without improvement, she was referred to our clinic in April 2013 for consideration of acupuncture.
In our clinic, she was educated about the history, theory and currently available evidence supporting acupuncture for pain management. She consented to undergo acupuncture. The acupuncturist was a doctor with expertise in palliative care in addition to being a licensed acupuncturist with 10 years of experience of acupuncture practice, mostly in a cancer care setting. We based the acupuncture point selection on traditional Chinese medicine (TCM) theory and clinical experience working with patients with breast cancer. In our clinic, each patient receives individualised acupuncture treatments that are focused on the symptoms they are experiencing. In this case, we used a combination of local points and distal points to address localised PMPS symptoms and constitutional problems (fatigue, depressed mood). The local points used can be seen in figure 1. After cleaning the area with alcohol, the needles (30 and 0.25 mm gauge, Seirin-America Inc., Weymouth, Massachusetts, USA) were inserted at an oblique angle with little to no stimulation because the chest area was highly sensitive for our patient. The insertion was superficial to avoid potential penetration of breast tissue expanders. In addition, we also placed needles at the following distal points: GV20, and LI4, SP6 and BL60 bilaterally, with needling manipulation until de qi sensation was achieved.2 The light was turned off and our patient was allowed to rest for 20–30 min. The needles were removed and minor bleeding was wiped with sterile gauze. Our patient returned weekly for eight treatment sessions. She was asked to rate her pain at each visit on a 0–10 numerical rating scale, with 10 being the worst pain imaginable. Our patient experienced no complications.
At the time of presentation in April 2013, she reported pain of 5/10 on average at rest and 10/10 with any prolonged activities using her arms and shoulder. After a single treatment, our patient reported a mild improvement in her pain, rating average pain as 4/10. Our patient reported that the pain was much improved after three treatments, with the disappearance of 10/10 incidental pain associated with use of her arms. After six treatments, she reported her pain was 1/10 at its worst and she was able to perform most daily activities. After eight treatments, she reported resolution of her pain, with minimal residual sensitivity on her chest. She was able to perform household tasks and hobbies. Our patient expressed interest in a repeated trial of physical therapy, so that she could resume actively exercising. As of October 2013, our patient remains pain free and on no pain medications.
To the best of our knowledge, this is the first case report documenting treatment effect of acupuncture for PMPS. A prior survey study found that some women had used acupuncture for treatment of PMPS, but did not explore effectiveness.1 Acupuncture has shown promise in treating other conditions involving neuropathic pain and lymphatic injury.3–5
PMPS is a debilitating condition that occurs in 10% to 65% of patients who undergo breast surgery, and can persist for years.1 ,6–8 Despite its name, PMPS can occur with any type of breast surgery.7 PMPS represents a significant health problem, given that there are expected to be over 200 000 new diagnoses of breast cancer in 2013 in the US alone and that most of these patients will undergo surgery.9 Symptoms of PMPS include altered skin sensations, burning or electric pains, pressure sensations, numbness, aching, and tightening in the breast and axilla.1 ,6 ,8 ,10 ,11 PMPS usually immediately follows surgery, but can present more than 6 months postoperatively.6 It is more common in younger women and those with a higher body mass index, and has a significant negative effect on quality of life.1
While the aetiology of PMPS is unknown, some studies have associated its incidence with damage to nervous or lymphatic structures.6 ,7 ,12 PMPS is usually treated with non-steroidal anti-inflammatory drugs, benzodiazepines and antidepressants but these drugs are unfortunately not very effective. As a result, many patients turn to complementary and alternative medicine.1
Acupuncture is a treatment modality that uses fine needles along ‘meridians’ throughout the body. These specific points are believed to modulate the flow of ‘qi’ and restore balance to the body, according to Traditional Chinese Medicine. Acupuncture has been shown to be safe and minimally invasive.13–15 Serious adverse effects resulting from acupuncture are very rare,14 with the most common side effect being bruising and needling pain. The efficacy of acupuncture for treating PMPS is unknown, as no clinical trial has been conducted in this area.
Here, we report the first case to our knowledge of successfully treating PMPS with acupuncture. Following eight treatments, our patient reported resolution of her pain as measured by a 0–10 numerical pain rating scale. Our patient no longer needed pain medications. She reported that her quality of life had been greatly improved following acupuncture. In addition, her newly controlled pain allowed her to begin tamoxifen administration, which has been shown to prolong survival in this population. Further, she remained pain free for at least 3 months after her last treatment.
Our case report has a few limitations. First, there is the possibility that our patient's PMPS underwent spontaneous remission unrelated to the intervention. This is unlikely given the prior persistence of her symptoms, which is consistent with existing knowledge about PMPS.7 Next, there is the possibility of a placebo effect that can explain her symptom improvement. However, this would have to be a unique placebo effect only associated with acupuncture as our patient had tried many prior medications, physical therapy and had seen multiple doctors. A case report by its very nature describes the clinical experience of only a single patient, but it can help generate a testable hypothesis. Thus, we cannot conclude that acupuncture is effective in treating PMPS. PMPS remains a common and debilitating problem with few effective interventions. Therefore, the potential for a safe and effective treatment certainly warrants further investigation of the effect of acupuncture for PMPS in a randomised controlled trial setting.
PMPS is a debilitating condition with few effective treatments. In the present report, acupuncture was successfully used to treat a woman with severe and persistent PMPS, which warrants evaluation in a randomised controlled trial to determine the efficacy of acupuncture for PMPS.
Contributors All authors contributed equally to the design and execution of this manuscript.
Competing interests JJM is a recipient of the National Institutes of Health NCCAM K23 AT004112 award.
Provenance and peer review Not commissioned; internally peer reviewed.
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