Multimodal physiotherapy versus scapular and conventional exercise for persistent pain following breast cancer treatment: a randomized controlled trial

OBJECTIVE: To evaluate the effectiveness of a multimodal physiotherapy program compared with exercise programs on pain, disability, quality of life, and shoulder muscle activation in women with persistent pain following breast cancer treatment (PPBCT). DESIGN: Randomized, assessor-blinded, three-arm parallel-group clinical trial. SETTING: Physiotherapy in Women's Health Research Unit at the University of Alcalá, Madrid, Spain. SUBJECTS: Ninety women with PPBCT were recruited between April 2016 and April 2022. INTERVENTIONS: Participants were randomized into three groups (n = 30 each). All groups received six individual physiotherapy sessions over 6 weeks and the same pain education. Participants were allocated to (i) multimodal physiotherapy (MP) including scapular exercises, deep dry needling, and neurodynamic techniques, (ii) scapular exercises (SE), or (iii) conventional shoulder exercises (CSE). OUTCOME MEASURES: The primary outcome was shoulder pain intensity (VAS). Secondary outcomes included perceived shoulder pain and disability assessed with the Shoulder Pain and Disability Index (SPADI), health-related quality of life measured with the Functional Assessment of Cancer Therapy-Breast version 4 (FACT-Bv4), shoulder muscle activation assessed using surface electromyography, and myofascial pain syndrome evaluated according to Travell and Simons' criteria. RESULTS: Ninety women were randomized and completed all follow-up assessments. All three groups showed improvements over time in most outcomes. Overall, the pattern of results favored MP, followed by SE and then CSE, with consistent superiority of MP across most outcomes and several time points. For the primary outcome, MP showed greater reductions in pain intensity than SE at all assessment points, with large between-group effects post-intervention and at 3 months, and a reduced effect at 6 months. Both MP and SE showed greater pain reductions than CSE at all assessment points, with large between-group effects, and changes exceeded the minimal clinically important difference only in the MP and SE groups. CONCLUSIONS: A multimodal physiotherapy program combining scapular exercises, deep dry needling, and neurodynamic techniques was more effective than exercise programs alone in women with PPBCT. Scapular exercise-based rehabilitation appears to play a key role in long-term recovery, while the addition of other physiotherapy techniques may primarily contribute to earlier symptom reduction. These findings support the use of a multimodal approach to address the complex mechanisms underlying persistent pain in breast cancer survivors, with potential implications for clinical decision-making in survivorship care. IMPLICATIONS FOR CANCER SURVIVORS: A multimodal physiotherapy approach integrating scapular exercises, pain education, deep dry needling, and neurodynamic techniques may provide clinically meaningful benefits for breast cancer survivors with persistent pain, improving function, quality of life, and long-term engagement in self-management strategies.