INTRODUCTION

Breast cancer is a high-impact disease worldwide that affects women around the world in a 1:2 ratio. In Colombia, the most recent data show that about 7 000 new cases are diagnosed and that around 4 500 women survive per year. ^1,2 Currently, the country has guidelines and management protocols for this disease, which include rehabilitation through relevant interventions such as occupational therapy in order to increase the impact on the persons and their health. ^1,3

In general, some of the health and occupation alterations caused by cancer, especially breast cancer, are related to physical, emotional and cognitive impairments. ⁴ Regarding daily life, women who suffer and survive this disease present alterations in the activities of daily living, work, education, leisure, etc., resulting in restrictions that involve everything from body structures and functions to emotionality. ^5-10

Occupational therapy positively impacts the rehabilitation process of a person with cancer ^5,6,8,10-14, covering important aspects including initial diagnosis, survival phase or final stage of life ⁴, even in subjects who relapse in intensive care units. ¹⁵ The activities performed by an occupational therapist in breast cancer rehabilitation involve those related to prevention of alterations and occupational restrictions and the improvement and enhancement of skills ^{4,6,8,13,14,16} through activities and strategies such as motor rehabilitation, enhancement of the execution of activities of daily living, prevention of cognitive dysfunctions, teaching techniques, using splints, the psychosocial approach, among others. ^{4-8,11,13,14,17}

The importance of the following case lies in the comprehensive epistemological stance from occupational therapy. Said stance arises from knowledge based on the dynamic interaction of the personal areas (public, private, "the me") and the medical, social and environmental areas, grounded on reflection by the subjects involved through their participation and change process. ¹⁸

CASE PRESENTATION

64-year-old woman, living in Bogotá D.C., referred to the occupational therapy service 9 months after modified radical mastectomy surgery and neoadjuvant therapy with radiotherapy by the Physical Medicine and Rehabilitation Service of the Instituto Nacional de Cancerología Empresa Social del Estado (National Institute of Cancerology Social Enterprise of the State - INC) with diagnosis of infiltrating ductal carcinoma of the left breast. During consultation, restrictions in participation and occupational performance were observed, which in part were caused by the diagnosis and subsequent complete breast tissue removal surgery (including the nipple, the areola and the secondary and sentinel lymph nodes). The surgery took place in January 2016, with subsequent development of lymphedema in the upper left limb.

Assessment

A comprehensive assessment process was initiated by occupational therapy through occupational history, observation of movements, execution of activities and application of tests by areas. During the process, the woman manifested difficulties to develop activities of daily living and socio-emotional distress related to the surgery and treatment. Regarding her general background, she stated being the head of the family, living with five children and close relatives, being a housewife and having only elementary school education. She also said that she was self-employed in the sale of food, and that her hobbies included weaving, dancing and local music activities. She manifested that her family or close network accompanied her occasionally in rehabilitation.

In relation to executive skills, she responded positively to sensory, auditory, visual and vestibular stimuli, but with difficulties in affected areas such as the upper limbs, trunk and chest. The proprioceptive and tactile sensory systems were found to be affected at a deep, superficial and thermal hypoesthesia level. In a later study, she was diagnosed with severe carpal tunnel syndrome caused by bilateral median nerve entrapment.

Regarding motor skills, limitations in the upper left limb were observed such as mobility, strength and functional, integral and grip motor skills (Table 1), related, among others, to lymphedema.

Table 1 Specifications of the biomechanical assessment. 

Source: Own elaboration.

The motor evaluation, by measuring the limb circumference and in accordance with the guidelines of the Consensus Document of the International Society of Lymphology, ¹⁹ showed a stage 3 lymphedema in the upper left limb, characterized by visible edema, enlargement of the affected area, hardening, difference between limbs of around 3-5 cm and thickening of the skin.

Regarding the cognitive-perceptual level, processing skills, time-place-person orientation, basic cognitive functions, basic learning devices and executive functions were functional and appropriate. The social-emotional aspect showed affectations referred and related directly to the loss of body image and self-awareness due to the removal of the mammary gland and the lymphedema. The person said that this was her main concern and the main reason for the alterations and difficulties in her activities of daily living and her health.

Regarding occupation, alterations were found in all the activities of daily living as the person mentioned that they were "difficult", slow and sometimes painful to perform. Sections of the Occupational Therapy Practice Framework were used for this item. ²⁰ In relation to food, the person manifested difficulties for using cutlery, eating normally, preparing meals, reaching tools and implements located in elevated areas of the kitchen, general cleaning of food sites, among others, always in relation to bimanual activities.

Concerning with personal hygiene, she showed difficulties in activities such as showering, combing and putting on makeup as she needed to use the affected limb. When getting dressed, more relevant difficulties were mentioned due to the need to use the affected limb globally; in this regard, the person manifests pain when putting on underwear, blouses or coats, pants or skirts and shoes, and the need to make more efforts and put to test the resistance of her body. Additionally, she expressed discomfort and night pain due to the lymphedema, and that she did not know how to position it to be able to rest.

When asking her about her thoughts on the disease and her way of coping with it, in relation to her daily life, she mentioned two main ideas: one related to the her body image and her routine to shape her breast using pads and cottons in order to wear bras (body getting dressed) and another related to her emotional and physical distress, which she must set aside to carry out her daily activities, specifically, mobility restrictions when doing housework (psychosocial participation). Regarding her family role and networks, she says that her relationships with others and her body image have been altered, especially her participation at home. Finally, with respect to family accompaniment, her children and the people close to her occasionally accompany her during the intervention process; however, it is clear that the process is mostly individual.

Intervention

The person underwent occupational therapy intervention in the Rehabilitation Unit of the INC in April-May 2017, with a total of 10 sessions of 30 minutes each for 4 weeks. The sessions were distributed as follows: first week, two sessions; second week, two sessions; third week, three sessions; and fourth week, three sessions. The purpose of the intervention addressed the reason for referral, her priorities and the greatest amount of information about her condition and how to develop different activities of daily living. To this end, the activities focused on addressing self-perception, self-care, participation and performance in activities of daily living through socio-emotional and biomechanical intervention using the educational approach.

Intervention activities

To fulfill the proposed objectives, and taking the person as the center of the intervention, mainstreaming care through a project executed by and for the person was decided, including tasks and specifications that met the occupational therapy objectives.

The sessions were structured in: A) introductory activity, B) education activity and C) central activity. Table 2 lists the activities and strategies used.

Table 2 Introductory, educational and central activity strategies. 

Source: Own elaboration.

In particular, the central strategy combines performance skills (motor and socio-emotional), occupation areas and occupational history, building the ideal link between likes and interests and the latent needs of the person.

The occupational project included a series of requirements that allowed the person to relate to motor, sensory, socio-emotional and relational demands. The occupational therapists also used the therapeutic relationship as an opportunity to engage in and allow for a social-emotional intervention. For this, the central activity was based on using skills that would help the person to make a breast prosthesis.

Creating a breast prosthesis is as an alternative strategy to breast reconstruction and surgery for vulnerable women with low incomes or those who do not have the possibility of benefitting from this surgery. The activity begins with the identification of the need and the voluntary involvement of the person for its elaboration. It is important to start socializing the final result, as shown in Figure 1, and invite the person to build her own prosthesis following a rehabilitation plan whose focus is occupational therapy.

Source: Document obtained during the study

Figure 1 Final result and person 

Results

Favorable results in the performance of the skills and effective responses -remarkably faster with respect to sensory stimuli, especially at the tactile level-, were achieved during the intervention and after the scheduled sessions, which also correlates with management and self-care of the lymphedema by the person. At a biomechanical level, a goniometric evaluation was carried out, showing mobility and plane degrees close to the normal ranges: flexion reached 170°; extension, 38°; adduction, 35°; and elbow flexion, 135°. Regarding strength, both members stabilized at an average rating of 29.

Regarding functional and motor skills, greater progress was observed in the actions that involve activities of daily living, games and education. It was evident that the person can now perform all functional and motor skills correctly, completely and slowly, with specific adaptations.

Regarding the cognitive-perceptual component, no time-space-person alterations were found; her responses and attention were adequate to environmental stimuli, managing to initiate, execute and finalize activities; in consequence, the final assessment was preserved, according to age and schooling.

At the psychosocial level, the woman responded to the requirements for social interaction and emotional regulation by combining rehabilitation tools and experiences considering her current situation. This was evident in her attitude and willingness to develop the activities and to attend to all sessions, handing in homework, and the improvement of her body schema, among others.

In this sense, the breast prosthesis activity included an approach based on functional skills, occupation areas and her personal background. Figure 2 shows the previous correlations with the requirements of the activity.

Source: Own elaboration.

Figure 2 Intervention and activity correlations 

The different tasks and requirements needed accessible and comprehensive-real language with the person, which was complemented with introductory and education activities. For example, strategies such as postural feedback, passive and active motion in different ranges, and work planes and tasks ranging from gross to fine motor skills were used to strengthen a comprehensive therapeutic process that would allow designing, molding, sewing or filling her own prosthesis.

This project and the central occupational activity began with an explanatory task as shown in Figure 3. From that moment, the activity began, allowing the person to lead her own project, and developing and integrating it with her routine. It is worth noting that the progress was >80% in each of the tasks in some sessions, yielding favorable responses to the requirements. In other occasions, sessions focused more on introductory activities, clearly related to biomechanics due to its high correlation with the performance of activities of daily living.

Source: Document obtained during the study.

Figure 3 Explanatory task. 

Throughout the sessions, an increase in the amplitude of the range of motion expressed by the person in relation to her activities of daily living was observed in activities such as reaching objects located at the top of the cupboard and in the decrease of pain when putting cloths on her upper body or when bathing, which she was now able to do in shorter times. Another result achieved with education strategies was the considerable reduction of the lymphedema, in collaboration with physiotherapy, stabilizing in stage 2.

Manual activity was relevant to integrate fine motor requirements, becoming a space for emotional expression, and integrating many of the rehabilitation strategies as shown in Figure 4. At the end of the sessions, the tasks were carried out in shorter times and the elements were distributed in a work plane as required by the person herself for better performance. As these tasks were related to her likes and interests, manipulation, coordination and efficiency were evident in each sensorimotor process performed.

Source: Document obtained during the study.

Figure 4 Manual task. 

In terms of adherence and tolerance to treatment, the person adhered to the plan and the proposed sessions. It was necessary to perform constant feedback after completing each therapeutic activity and make sure that the results were evident at home. Likewise, she was able to adapt information about her diagnosis, risks and prevention at home, tasks and modified daily activities during the final sessions.

DISCUSSION

In Colombia, breast cancer figures continue to increase and its survival rate is approximately 64%. ² This condition requires massive rehabilitation intervention efforts that focus on the person and not on the health system. ^1,3,5,6,13 To this end, interdisciplinary teams, including physicians, physiotherapists, speech therapists, psychologists and occupational therapists, have evolved and consolidated as an essential transforming link for rehabilitation, proposing new forms of intervention where biomedical parameters can interact with psychosocial parameters. ^{5,10,11,14,17} An example of this situation is the intervention proposed here, where care components were intertwined with all functional skills and areas of occupation.

This case report is an alternative to purely biomedical interventions and includes biopsychosocial perspectives, taking into account the different dimensions of the human being. It is worth pointing that this work does not use the word "patient" because of its connotation, and that it intends to show that the objectives of rehabilitation and treatment can focus on the person, bearing in mind expressions, actions and therapeutic relationships, without neglecting the diagnostic reality. ^5,10,11,14

Said diagnostic reality implies an alternative management of rehabilitation procedures; for this, an occupational assessment was used to know the perspectives of the person, understanding that the central activity was focused on socio-emotional management and that biomechanical, sensory and daily life concepts could mix with it. The activity consisted of movements in planes that favored not only the motor component, but her performance in activities of daily living such as taking down a container from the cupboard or putting on cloths, which are used to face the tasks of a normal day and have a real impact on health. ¹⁰

Occupational therapy intervention, in this case, comprised the needs that arise after surviving breast cancer, surgeries and reality, considering a group of structures, functions, actions, procedures and experiences that involve this population. It is worth mentioning that the role of occupational therapists is involved with the process of consolidation thanks to the transmission of knowledge, techniques and strategies through experience.

CONCLUSIONS

It is clear that a comprehensive intervention, focused on the person and responding to a biopsychosocial model, can be a valid rehabilitation strategy that addresses and solves the needs of the person in constant relation with the medical or traditional intervention. In the case of occupational therapy, a meaningful activity in combination with motor, sensory, cognitive and socio-emotional requirements serves and is ratified as a means of differential and potential intervention by a rehabilitation team.

In this case, focused rehabilitation divided into steps to respond to the needs of the person and her health was established as a benefit additional to traditional health intervention, directly impacting her physical health, functionality and psychosocial well-being. To that extent, the activities and global interventions of occupational therapy in the biosocial or clinical field should be informed in case reports that allow replicating successful intervention models and that understand and dialogue with the person, their culture and their work.