Received: 17 June 2017 | Accepted: 21 July 2017

DOI: 10.1002/jso.24800

RESEARCH ARTICLE

Changes in shoulder muscle activity pattern on surface

electromyography after breast cancer surgery

Eun Joo Yang MD, PhD1 | YoungOk Kwon PhD2

1 Department of Rehabilitation Medicine,

Seoul National University Bundang Hospital, Background and Objectives: Alterations in muscle activation and restricted shoulder
Seoul National University College of
mobility, which are common in breast cancer patients, have been found to affect
Medicine, Seongnam, Korea
2 Division
of Business Administration, upper limb function. The purpose of this study was to determine muscle activity
Sookmyung Women’s University, Seoul, Korea patterns, and to compare the prevalence of abnormal patterns among the type of

Correspondence
YoungOk Kwon, Associate Professor, Division
of Business Administration, Sookmyung
Women’s University, Address: Cheongpa-ro
47-gil 100, Yongsan-gu, Seoul, Korea.
Email: yokwon@sm.ac.kr
Funding information
National Research Foundation of Korea,
Grant number: 2014R1A1A2055384
breast surgery.
Methods: In total, 274 breast cancer patients were recruited after surgery. Type of
breast surgery was divided into mastectomy without reconstruction (Mastectomy),
reconstruction with tissue expander/implant (TEI), latissimus dorsi (LD) flap, or
transverse rectus abdominis flap (TRAM). Activities of shoulder muscles were
measured using surface electromyography. Experimental analysis was conducted
using a Gaussian filter smoothing method with regression.
Results: Patients demonstrated different patterns of muscle activation, such as normal,
lower muscle electrical activity, and tightness. After adjusting for BMI and breast
surgery, the odds of lower muscle electrical activity and tightness in the TRAM are
40.2% and 38.4% less than in the Mastectomy only group. The prevalence of abnormal
patterns was significantly greater in the ALND than SLNB in all except TRAM.
Conclusions: Alterations in muscle activity patterns differed by breast surgery and
reconstruction type. For breast cancer patients with ALND, TRAM may be the best
choice for maintaining upper limb function.

KEYWORDS
breast cancer, reconstruction, shoulder muscle, surface electromyography

1 | INTRODUCTION achieve a smooth scapulohumeral rhythm. The contributions made by

The possibility of shoulder morbidity following treatment for breast
cancer is well known. Patient reports of arm morbidity include pain,
1
weakness, tightness, and reduced functional capacity. Evaluations of
altered shoulder movements in breast cancer patients have taken the
form of clinical observations and goniometric measures of the
glenohumeral range of movement2,3 or assessments of shoulder
4,5
kinematics and muscle function. Elevation of the arm is a function of
both glenohumeral movement and scapulothoracic movement and
timed interaction between these two groups of muscle is essential to
various muscles to shoulder motion have been studied using various
approaches, including assessment of muscle activation by electromy-
ography (EMG) during arm motion.6 However, shoulder muscle
activation in breast cancer patients depends on both clinical and
patient variables, such as the use of chemotherapy, type of breast
surgery, time since surgery, and current physiotherapy, exercise, and
pain statuses.7 To date, shoulder morbidity has been described
according to knowledge of how muscle activation and force
production contribute to shoulder kinematics in patients with breast
cancer.

116 | © 2017 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/jso J Surg Oncol. 2018;117:116–123.

YANG AND KWON
Pectoralis tightness, the most common form of upper limb
8
dysfunction at up to 6 months after breast surgery, can alter scapular
kinematics.9 The scapula provides a foundational base of support for
coordinated, functional shoulder movements.10 Alterations in scapular
muscle activation, which are common in breast cancer patients, may
affect upper limb function differently according to treatment and
patient factors. Previous research demonstrated an association
between dysfunction and more aggressive mastectomy procedures.11
There are strong associations between shoulder movement deviations,
muscle control, patient-reported pain, chemotherapy, and radiother-
apy.12,13 In one study, fear of lymphedema and disuse of the affected
arm contributed significantly to a difference in muscle strength
between the affected and unaffected shoulders of patients.14 Pain
7
serves to increase muscle activation and is likely to limit movement.
Along with the key clinical variables of age, affected side, dominant
hand, degree of arm elevation, treatment protocol, time since surgery,
chemotherapy status, and degree of shoulder pain, the extent of
pectoralis tightness should also be considered.
Changes in force transfer of part of the pectoralis major (PM)
muscle after breast reconstruction could reduce the contribution
to overall force and movement. Fear of lymphedema may further
weaken the affected arm due to reduced muscle activity. Previous
studies have reported the prevalence rates of impaired range of
motion (ROM; 2-51%) and decreased strength (17-33%) after
breast cancer surgery.3,8 Factors that contribute to muscle
weakness and tightness, such as the type of breast cancer
treatment, should be identified. With so many treatment options
available, both the type of breast surgery, such as breast
conservation and mastectomy, and the type of reconstruction,
such as implant-based procedures and flap-based techniques,
should be considered. Weighing the relative risks and benefits of
each type of operation can prove challenging.
In this study, we compared the shoulder kinematics and spatial
pattern of muscle activation associated with various breast cancer
treatments. The hypothesis of our study was that alterations in the
normal motion of the shoulder may be associated with scapular
positioning, as well as movement-related pain and lower muscle
electrical activity. The purpose of this study was to compare shoulder
muscle activity in the affected and unaffected shoulder, and to explore
the impact of type of breast and lymph node surgery, and shoulder
contracture, on the observed deviation.
2 | M ATERIA LS AN D METH ODS
2.1 | Subjects
Between July 2013 and March 2016, 274 women with breast cancer
underwent breast surgery at the authors’ institution. Patients who had
bilateral or recurrent breast cancer, a history of previous cancer, or
who needed palliative surgery or a contralateral breast operation for
benign disease were excluded. Patients who complained of pain on
shoulder movement, or had a previous history of upper limb
dysfunction, were also excluded.
| 117
The study protocol was approved by the institutional review board
of the authors’ institution. All participants provided written informed
consent. The trial was conducted in accordance with the Declaration of
Helsinki.15
2.2 | Surface electromyography (SEMG)
SEMG signals were acquired using a four-channel EMG Nicolet EDX
instrument (Natus Medical, Inc, San Carlos, CA). SEMG recordings
were done for each muscle using small disposable electrodes (Ag/AgCl
discs, 10 mm in diameter; CareFusion, San Diego, CA) in a bipolar
configuration. The sites of electrode placement were prepared by
abrading the skin with fine sandpaper and cleansing the area with 70%
isopropyl alcohol. Excess hair was shaved off as necessary. Bipolar
surface electrodes were placed on the skin overlying the scapular and
shoulder muscles, and reference electrodes were placed on the
ipsilateral clavicle of the test extremity. The anatomic placement of
electrodes was parallel to the fiber direction of each muscle, as follows:
upper trapezius (UT) electrodes were placed at half the distance
between the spine (C7 vertebra) and acromion process over the muscle
belly. Deltoid (D) electrodes were placed over the most prominent
portion of the middle D. Pectoralis (P) electrodes were placed below
the clavicle and above the breast and nipple. Bilateral EMG measure-
ments of the shoulder muscles were taken for each patient. The
activity of each muscle was recorded in microvolts (μV) for 1 ms during
arm abduction. At each time point, four EMG measures were obtained
(one for each of the four muscles), to allow for the possibility of
multiple correlations. The incremental data obtained at different time
points in each muscle can also be regarded as “repeated measures.” In
summary, four responses (one each for each shoulder and each
movement) were generated and correlated.
2.3 | Shoulder range of motion
Shoulder ROM was measured in abduction in the affected upper limb
using a goniometer, based on our clinical experience with patients in
a seated position.8 Movement-related pain was assessed using an
11-point numerical rating scale (NRS).16,17 Clinically meaningful
restriction in ROM was >10°, according to the definition of Thomas-
Maclean et al.18
In the absence of definitive diagnostic criteria, to rule out
pectoralis tightness or establish the degree of limitation in movement
after breast cancer surgery, pectoralis tightness was defined as the
presence of a limitation in forward flexion >10°, with no limitation in
external rotation, and a limitation in horizontal abduction of >10°,
based on our clinical experience.19
Clinical variables included the affected side, degree of arm
elevation, type of surgery, type of reconstruction, time since surgery
(3, 6, and 24 months), age (years), and body mass index (BMI). The
breast surgery group included patients who receive mastectomy
without reconstruction (Mastectomy group) and patients who
received underwent breast reconstruction using a transverse rectus
abdominis (TRAM) flap (TRAM group)20 and latissimus dorsi (LD) flap
118 | YANG
(LD group),21,22 and subpectoral prosthetic reconstruction with a
23
tissue expander/implant (TEI group).
2.4 | Pattern analysis of EMG data
Analysis was conducted after Gaussian filter smoothing to eliminate
noise. Linear regression modeling was done to analyze trends. First,
using data from the EMG analysis, we constructed a polynomial
regression model that fitted the data. Second, we converted negative
values to positive values to make the model fit better. Finally, we
applied a Gaussian filter to remove outliers. As shown in Supplemen-
tary Online Resource S1, the difference between the left and right
sides was analyzed by computing the ratio (%) between the area under
the curve (AUC; red) and the AUC (black) of the unaffected side.
Significant outliers (above 120%; 64 of 1041 data points) were
identified and removed. Then, the averages of the ratios were
compared between the different conditions, that is, surgery type,
muscle, activity, and time since surgery. The lowest quintile of each
muscle ratio was classified as lower muscle electrical activity.
According to the combination of lower muscle electrical activity
patterns, shoulder muscle activation patterns were reclassified into
normal (no D or UT lower muscle electrical activity), lower muscle
electrical activity (D and/or UT lower electrical activity, and P lower
muscle electrical activity without pectoralis tightness [as defined by
the ROM]), and tightness groups (D and/or UT lower muscle electrical
activity with normal P, and pectoralis tightness [as defined by the
ROM]).
2.5 | Statistical analysis
We used a mixed multinominal logistic regression model to test for
associations between the factors and muscle activity pattern (normal,
lower muscle electrical activity, tightness): The factors were as follows:
(1) follow-up characteristics: follow-up time; (2) personal factors: age,
dominant hand, BMI; (3) treatment characteristics: breast surgery such
as Mastectomy, TRAM, LD, TEI group, and axillary surgery such as
axillary lymph node dissection (ALND) and sentinel lymph node biopsy
(SLNB); and (4) functional factors: pain limited ROM. Before the
analyses, normalized EMG data were evaluated for outliers and
sphericity using the Kolmogorov-Smirnov test.
The velocities of the trajectories were computed by numerical
differentiation after smoothing (bidirectional second-order Butter-
worth low-pass filter at 8 Hz). When a significant effect was observed,
Bonferroni adjustment was performed for pair-wise comparisons. In all
tests, P values <0.05 were considered to indicate statistical
significance.
3 | RE SULTS
Data from 274 patients were included in the analysis. The
reconstructions included 38 implant procedures (13.8%), 18 LD flaps
(6.5%), and 18 TRAM flaps (6.5%). In total, 200 patients did not
AND KWON
undergo reconstruction procedures. The average age of the cohort
was 50.6 ± 0.31 years and the average BMI was 23.3 ± 0.12 kg/m2.
Clinical characteristics of breast cancer patients are summarized in
Table 1.
At months 3, 6, and 24 (M3, M6, and M24, respectively), 11.6%,
5.8%, and 17.2% of the patients showed reported normal patterns of
muscle activation. Lower muscle electrical activity patterns were seen
in 9.1% of patients at M3, 3.3% at M6, and 12.9% at M24. Tightness
patterns were seen in 12.0%, 10.1%, and 17.8% of the patients at M3,
M6, and M24, respectively (see Figure 1). Comparisons of the
prevalence of the different muscle activation patterns such as normal,
tightness, and lower muscle electrical activity between the breast
surgeries and between the axillary surgeries are illustrated at all time
points in Figure 2. The prevalence of lower muscle electrical activity
were significantly greater in the ALND group compared with the SLNB
group at 3 months after surgery in patients without reconstruction
(41.0% vs 6.3% at 3 months, P < 0.001), but by 6 months, no significant
difference was observed between groups. In the patients with LD flap,
the prevalence of lower muscle electrical activity were significantly
greater in the ALND group at 6 months (50.0% vs 0% at 6 months,
P < 0.001). The prevalence of tightness was significantly greater in the
ALND group in compared with the SLNB group in patients without
reconstruction (58.3% vs 30.0% at 6 months, P < 0.001), patients with
TEI (50.0% vs 37.5% at 3 months, P < 0.001), and LD flap (66.6% vs
33.3% at 3 months, P < 0.001; 100% vs 62.5% at 6 months, P < 0.001).
No significant difference was observed between the ALND and SLNB
group in TRAM flap group.
Table 2 shows the results of univariate and multivariate analyses
of shoulder activation patterns (normal, lower muscle electrical
activity, tightness). In univariate analyses, lower muscle electrical
activity (vs normal) was positively associated with BMI (odds ratio
[OR] = 1.115, 95% confidence interval [CI] = 1.061-1.172; P < 0.001)
and negatively associated with axillary surgery (sentinel lymph node
biopsy [SLNB] vs axillary lymph node dissection [ALND], OR = 0.676,
95%CI = 0.466-0.980; P = 0.039) and reconstruction surgery (TRAM vs
no reconstruction, OR = 0.346, 95%CI = 0.160-0.751; P = 0.007).
Variables with a P value >0.05 were removed from multivariate
stepwise regression analyses (forward selection), whereas those with a
P value >0.1 were eliminated. Results of the multivariate multinomial
logistic regression for the lower muscle electrical activity muscle
activation pattern (vs normal) showed that after adjusting for BMI and
breast surgery, the odds of lower muscle electrical activity in the TRAM
group are 47.3% less than in the Mastectomy group (TRAM vs no
reconstruction, OR = 0.475, 95% CI = 0.161-0.624; P = 0.017).
Tightness was analyzed in a similar way and results also revealed
negative association with TRAM flap reconstruction. In univariate
analyses, tightness (vs normal) was positively associated with time
since surgery (M6 vs M3, OR = 1.696, 95%CI = 1.079-2.667;
P = 0.022), side of operation (left vs right, OR = 1.414,
95%CI = 1.028-1.945; P = 0.033), and negatively associated with
reconstruction surgery (TRAM vs no reconstruction, OR = 0.402,
95%CI = 0.210-0.768; P = 0.006). Results of the multivariable multi-
nomial regression for the tightness muscle activation pattern (vs
YANG AND KWON | 119

TABLE 1 Clinical characteristics of breast cancer patients

Without reconstruction (n = 200) TEI (n = 38) LD flap (n = 18) TRAM flap (n = 18)
Age (y) 52.07 ± 0.36 47.68 ± 0.60 45.27 ± 0.94 46.56 ± 1.12
(51.35-52.78) (46.50-46.85) (43.42-47.14) (44.37-48.74)
BMI 23.60 ± 0.26 22.75 ± 0.51 23.10 ± 1.19 21.99 ± 0.56
(23.08-24.12) (21.75-23.75) (21.05-25.16) (20.88-23.09)
Side
Rt 105 14 9 15
Lt 95 24 9 3
Time after surgery
3 months 56 12 12 9
6 months 35 9 4 5
24 months 109 17 2 4
Axillary surgery
ALND 141 7 6 9
SLNB 59 31 12 8
EMG ratio 21.79 ± 1.03 23.31 ± 2.79 28.87 ± 6.28 27.64 ± 6.40
(19.76-23.83) (17.81-28.81) (16.50-41.25) (15.04-40.24)
Shoulder muscle activation pattern
Normal 64 14 7 10
Weakness 56 7 3 3
Tightness 80 17 8 5

BMI, body mass index; Rt, right; Lt, left; ALND, axillary lymph node dissection; SLNB, sentinel lymph node biopsy; EMG, electromyography TEI, tissue
expander/implant; LD, latissimus dorsi; TRAM, transverse rectus abdominis.
Data are means ± standard error (95%CI).

FIGURE 1 Comparison of muscle activation pattern according to type of breast surgery and time since surgery. Type of breast surgery are
mastectomy without reconstruction (Mastectomy) and with reconstruction by tissue expander/implant (TEI), latissimus dorsi flap (LD), or
transverse rectus abdominis flap (TRAM). SLNB, sentinel lymph node biopsy; ALND, axillary lymph node dissection; P, pectoralis; UT, upper
trapezius; D, deltoid
120 | YANG
FIGURE 2 Comparison of muscle activation pattern according to type of breast surgery, type of axillary surgery, and time since surgery.
TEI, tissue expander/implant; LD, latissimus dorsi; TRAM, transverse rectus abdominis; SLNB, sentinel lymph node biopsy; ALND, axillary
lymph node dissection
normal) showed that after adjusting for time since surgery and side of
operation, the odds of tightness in the TRAM group are 38.4% less
than in the Mastectomy group with the true population effect
between 75.5% and 19.5%. (TRAM vs no reconstruction, OR = 0.384,
95%CI = 0.195-0.755; P = 0.006).
4 | DISCUSSION
Our findings showed that shoulder muscle activation depends on
clinical and treatment variables, and the prevalence of the abnormal
activation patterns, such as lower muscle electrical activity or
tightness, varied depending on the type of breast surgery and type
of reconstruction. Tightness was common after tissue expander/
implant (TEI), but lower muscle electrical activity was more prevalent
after an LD flap. Different axillary surgeries, such as ALND and SLNB,
done within the same breast surgery or reconstruction, may affect the
prevalence of abnormal muscle activation patterns, but there was less
of an association with TRAM flaps.
It has been shown that survival and recurrence rates after breast-
conserving surgery are almost identical to those of patients undergoing
total mastectomies and radiation therapy, and that the choice of
treatment should be made only after the patient has been fully
informed by the surgeon of the risks and benefits of each procedure.
With respect to clinical factors, previous work has demonstrated that
surgical breast cancer treatment can result in shoulder morbidity,12
which is an important factor in quality of life. Previous studies reported
on the impact of shoulder morbidity according to differences in PM
activity associated with different types of breast surgery, such as
mastectomy and wide local excision, 13
or by comparing isokinetic
muscle strength test results among the different reconstruction
types. 24
However, the complexity of shoulder morbidity should be
AND KWON
considered, because there are differences in muscle adaptation
according to the type of movement performed and type of surgery
received.
Some types of reconstruction, such as the LD flap, cause
decreased muscle strength compared with controls,25 while other
types of reconstruction, such as those using implants or a mastectomy,
can cause pectoralis tightness.8,26,27 In a systematic review by Hidding
et al28 done in 2014, patients who underwent immediate breast
reconstruction showed less impairment of upper extremity function
compared with those who underwent only a mastectomy. However,
variables such as the method of reconstruction or mastectomy, and
ALND and radiotherapy status, were not included in the analysis. In our
study, we compared different muscle activation patterns, such as
lower muscle electrical activity without tightness or tightness. Results
were also found to be different according to the reconstruction type.
Tightness was common after TEI, but the lower muscle electrical
activity pattern was more prevalent after an LD flap. Moreover, the
type of axillary surgery was significantly associated with the
prevalence of upper limb dysfunction.
Upper limb dysfunction has been assessed previously by using the
disabilities of the arm, shoulder, and hand (DASH) question-
naire.25,29,30 Forthomme et al24 found decreased muscle strength
after an LD flap in a comparison of the isokinetic test results for
different shoulder muscles. Oskrochi et al7 investigated shoulder
muscle activities by SEMG to analyze shoulder complexity in breast
cancer patients. In our study, shoulder complexity after breast cancer
was assessed by both SEMG and measurement of the ROM.
Pectoralis tightness, which is a clinically important complication
that causes pain and limits the ROM,9 is one of the most common types
of upper limb dysfunction.8,26,27 Scar tissue formation and anterior
chest wall tightness31 changed muscle activation patterns more clearly
 YANG
AND
KWON

TABLE 2 Factors associated with shoulder muscle activation pattern (normal, weakness, tightness): univariate and multivariate logistic regression
Univariate analysis Multivariate analysis

Normal vs weakness Normal vs tightness Normal vs weakness Normal vs tightness

OR 95%CI P OR 95%CI P OR 95%CI P OR 95%CI P

Age 0.995 0.974-1.016 0.653 1.012 0.993-1.030 0.192
BMI 1.115 1.061-1.172 <0.001 1.024 0.977-1.073 0.317 1.103 1.049-1.161 <0.001
Month (M)
M3 1 1 1
M6 0.721 0.411-1.261 0.25 1.696 1.079-2.667 0.022 1.562 0.980-2.490 0.061
M 24 0.964 0.651-1.428 0.857 1.003 0.698-1.443 0.983 0.656 0.415-1.035 0.071
Side
Rt 1 1 1 1
Lt 1.351 0.943- 1.933 0.1 1.414 1.028-1.945 0.033 1.296 0.898-1.871 0.166 1.341 1.114-1.883 0.045
Axillary surgery
ALND 1 1 1
SLNB 0.676 0.466-0.980 0.039 1.007 0.728-1.393 0.964 0.820 0.576-1.169 0.274
Reconstruction
No recon 1 1 1 1
TEI 0.577 0.328-1.014 0.056 0.976 0.622-1.531 0.918 0.667 0.362-1.228 0.194 0.904 0.551-1.481 0.689
LD 0.495 0.220-1.111 0.088 0.919 0.496-1.700 0.788 0.536 0.232-1.235 0.144 0.863 0.448-1.662 0.660
TRAM 0.346 0.160-0.751 0.007 0.402 0.210-0.768 0.006 0.473 0.161-0.624 0.017 0.384 0.195-0.755 0.006

CI, confidence interval; BMI, body mass index; Rt, right; Lt, left, ALND, axillary lymph node dissection; SLNB, sentinel lymph node biopsy; TEI, tissue expander/implant; LD, latissimus dorsi; TRAM, transverse rectus
abdominis.
|
121
122 | YANG
at the extremes of ROM, due to a pain due to stretching or tearing of
32
tight or damaged tissues. In our study, the kinematics of the shoulder
joint and spatial activity of the UT and pectoralis were assessed during
shoulder exercises with and without pectoralis tightness. Postsurgical
pain related to skin defects and contractures, as well as depression of
the shoulder girdle due to shortening of the PM and minor muscles, can
lead to a protective posture in patients undergoing mastectomy
without immediate breast reconstruction. In this study, TRAM and LD
flap reconstructions were associated with an improved prognosis, with
regard to tightened pectoralis muscles, versus mastectomy alone.
Even with normal pain-free motion of the arm and shoulder, in the
scapulothoracic, glenohumeral, acromioclavicular, and sternoclavicular
joints,33 patients may encounter another issue, namely muscle lower
muscle electrical activity. Some studies suggest that humeral elevation
of the arm, upward movement on the affected side, and left shoulder
movement will increase the electrical activity of all four muscles
regardless of which side is affected, while treatment with wide local
excision and chemotherapy is associated with generally decreased
electrical activities.7 In our study, implant-based and TRAM flap
reconstruction did not affect shoulder muscle strength. However, the
LD flap, which involves detachment of both the origin and insertion
point of the LD muscle, reduced shoulder strength. This is important
information for patients and surgeons when choosing the most
appropriate surgical option for breast cancer. The impact of surgery on
upper limb dysfunction could influence treatment decisions, so
understanding these factors will help practitioners to improve patient
education, and thus aid them in guiding patients through the decision-
making process.34
The results of the present study showed that immediate breast
reconstruction with a free TRAM flap had positive effects on
postoperative shoulder function and recovery compared with
mastectomy alone or LD flap reconstruction, especially when ALND
is necessary. The prevalence of shoulder morbidities, such as tightness
or lower muscle electrical activity, was associated with all reconstruc-
tion types except the TRAM flap. TRAM surgery had no apparent
effect on the shoulder muscles. If the internal mammary artery and
vein are used as recipient vessels, a small muscular window is created
on the side of the sternal origin, but most of the muscle is left
undisturbed. The most common reasons cited by patients for not
undergoing reconstructive surgery are to avoid additional surgery or
additional dysfunction.24 In our study, we found that the TRAM flap
significantly improved recovery from abnormal patterns shoulder
muscle activation in mastectomy patients relative to
reconstruction.
This study had some limitations. First, it used a retrospective
design. Second, the breast cancer patients did not all undergo surface
dynamic EMG and were grouped by muscle activity pattern. However,
we excluded patients with a previous history of upper limb
dysfunction, such as rotator cuff disease or adhesive capsulitis, to
assess only the effects of treatment factors on muscle activity
patterns. Despite these limitations, we are confident that our study
provides important clinical implications for the impact of the type of
breast cancer treatment on upper limb dysfunction.
AND KWON
5 | CONCL US IO NS
Alterations in muscle activity patterns differed by breast surgery and
reconstruction type. For breast cancer patients with ALND, TRAM may
be the best choice for maintaining upper limb function.
ACKNOWLEDGMENTS
The authors thank Jiho Park and Kiyoung Jang, PhD students at the
Department of Computer Science, Yonsei University, Seoul, Korea, for
their assistance with data collection. This research was supported by
Basic Science Research Program through the National Research
Foundation of Korea (NRF) funded by the Ministry of Education (grant
number 2014R1A1A2055384).
ORCID
YoungOk Kwon PhD http://orcid.org/0000-0001-9231-0492
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How to cite this article: Yang EJ, Kwon Y. Changes in
shoulder muscle activity pattern on surface
electromyography after breast cancer surgery. J Surg Oncol.
2018;117:116–123. https://doi.org/10.1002/jso.24800