Journal of Hand Therapy 27 (2014) 12e13
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Clinical Commentary
Clinical commentary in response to: Mechanosensitivity in the upper extremity following Breast Cancer treatment Jack Hurov PT, CHT * Hand & Upper Extremity Therapy at UF & Shands Orthopaedic & Sports Medicine Institute, Gainesville, FL, USA
Comfort zone: a behavioral state in which a person operates in an anxiety-neutral condition. A person who has established a comfort zone tends to stay within that zone (Wikipedia). What question did this article answer? Breast cancer (BCA) treatment including surgery, radiation, and chemotherapy, places a patient’s nervous system at risk, contributing to upper extremity (UE) mechanosensitivity, or, decreased tolerance to physical stress imposed during movement. The authors of this study addressed the question, ‘in what manner is UE motion affected post-BCA treatment?’ Covariates of interest included lymphedema and self-reported pain. How did the study design and methods address this question? This cross-sectional, retrospective study was based on a sample of 145 patients who completed BCA treatment a minimum of six months previously. Patients were recruited from local, regional, and national databases, fulfilled specific criteria for inclusion, and provided informed consent to participate. Participants completed demographic, Karnofsky Performance Status (assesses levels of assistance required to complete self-care and instrumental activities of daily living status-post chemotherapy), and Norman Questionnaires (UE lymphedema monitor). Additional data used to evaluate pain and paresthesia were collected via the Lymphedema and Breast Cancer and Breast Symptoms Questionnaires. Goniometric measurements were obtained on participants’ shoulders and elbows, UE volumes were calculated and used as indices of lymphedema, and ‘neural tolerance’ was evaluated by ‘tensioning’ the UE in a specific pattern termed, ‘upper extremity neurodynamic test 1’ (ULNT1). ULNT1 provided data on the overall tolerance of subjects to increasing UE strain affecting neural pathways from the brachial plexus to distal peripheral nerves. The measurement of interest in this study was elbow extension, the final motion in the ULNT1 strain progression. For each of the aforementioned variables, subjects served as their own controls, * Corresponding author. E-mail address: [email protected].
meaning the un-operated limb was regarded as the independent variable, and the operated limb the dependent variable. Participants were assigned to one of four groups, based on self-reported UE pain and objective measures of UE volume; 1) pain þ lymphedema, 2) pain e lymphedema, 3) pain-free þ lymphedema, and 4) pain-free e lymphedema. Statistical analyses focused on between group comparisons, controlling for within group variance, and although unspecified, all tests were presumably one-tailed. When comparing operated with un-operated UEs, significant differences existed in shoulder abduction and elbow extension with maximum mean differences in group 1. ULNT1 provoked pain symptoms with distal radiation affecting operated and un-operated UEs. Perhaps unsurprisingly, elbow extension was diminished in operated UEs, as a function of ULNT1. However, the authors also revealed reductions in elbow motion affecting un-operated UEs, in response to ULNT1. When considered separately, UE pain or lymphedema appeared to influence elbow motion of operated UEs about equally. Even in the absence of UE pain or lymphedema, subjects lacked, on average, about 20 degrees of end-range elbow extension, in response to ULNT1. The frequency of axillary lymph node dissection and number of excised nodes were significantly different among groups; those subjects demonstrating lymphedema had volume differences between un-operated and operated UEs of up to 325 ml. How could I use this information in my clinical practice? This commentary began with a ‘definition’ of comfort zone. In those clinics where patient treatment status-post BCA and upper limb neurodiagnostic testing are routine, the present results may be unsurprising. In clinics unaccustomed to this patient population, and ULNT testing, the present study is an invitation for UE therapists to step outside their comfort zones and perhaps experiment with new techniques and experience the responses that occur. At a minimum, current research results should prompt clinicians to; 1) document shoulder and elbow motion and 2) evaluate motion ‘quality’ of both UEs in patients reporting a history of BCA. Impaired quality of overhead motion may inform about injury to the long thoracic (serratus anterior) and thoracodorsal (latissimus dorsi) nerves as dynamic testing or tests against moderate resistance will evince characteristic postural faults, for example, scapular winging (relative internal rotation of the glenoid fossa) or tipping (inferior
0894-1130/$ e see front matter Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jht.2013.10.003
J. Hurov / Journal of Hand Therapy 27 (2014) 12e13
angle elevation). Moreover, standard sensory tests may reveal injury to the intercostobrachial as well as other peripheral nerves. Future considerations for research This study provides support for pre- and postoperative assessment of mechanosensitivity in patients diagnosed with BCA.1 Could tests of mechanosensitivity be used as an adjunct screening tool for BCA, particularly in patients with a documented family history?2 Finally, given the multivariate nature of signs and symptoms associated with pre- and postoperative presentation of patients diagnosed with BCA, some type of multivariate analysis, or perhaps analysis of covariance may be warranted.
13
Whatever the underlying causes of limited UE motion in patients diagnosed with BCA; 1) neural, 2) alterations in fluid mechanics, 3) and/or soft tissue fibrosis and scarring, the authors should be commended on their research, which offers an opportunity for their colleagues to step outside their comfort zones and ask novel questions while applying new manual skills. The responses will certainly be enlightening. References 1. Kelly S, Jull G. Breast surgery and neural tissue mechanosensitivity. Aust J Physiother. 1998;44:31e37. 2. Goodman C. Screening for medical problems in patients with upper extremity signs and symptoms. J Hand Ther. 2010;23:105e126.
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Clinical Commentary
Clinical commentary in response to: Mechanosensitivity in the upper extremity following Breast Cancer treatment Jack Hurov PT, CHT * Hand & Upper Extremity Therapy at UF & Shands Orthopaedic & Sports Medicine Institute, Gainesville, FL, USA
Comfort zone: a behavioral state in which a person operates in an anxiety-neutral condition. A person who has established a comfort zone tends to stay within that zone (Wikipedia). What question did this article answer? Breast cancer (BCA) treatment including surgery, radiation, and chemotherapy, places a patient’s nervous system at risk, contributing to upper extremity (UE) mechanosensitivity, or, decreased tolerance to physical stress imposed during movement. The authors of this study addressed the question, ‘in what manner is UE motion affected post-BCA treatment?’ Covariates of interest included lymphedema and self-reported pain. How did the study design and methods address this question? This cross-sectional, retrospective study was based on a sample of 145 patients who completed BCA treatment a minimum of six months previously. Patients were recruited from local, regional, and national databases, fulfilled specific criteria for inclusion, and provided informed consent to participate. Participants completed demographic, Karnofsky Performance Status (assesses levels of assistance required to complete self-care and instrumental activities of daily living status-post chemotherapy), and Norman Questionnaires (UE lymphedema monitor). Additional data used to evaluate pain and paresthesia were collected via the Lymphedema and Breast Cancer and Breast Symptoms Questionnaires. Goniometric measurements were obtained on participants’ shoulders and elbows, UE volumes were calculated and used as indices of lymphedema, and ‘neural tolerance’ was evaluated by ‘tensioning’ the UE in a specific pattern termed, ‘upper extremity neurodynamic test 1’ (ULNT1). ULNT1 provided data on the overall tolerance of subjects to increasing UE strain affecting neural pathways from the brachial plexus to distal peripheral nerves. The measurement of interest in this study was elbow extension, the final motion in the ULNT1 strain progression. For each of the aforementioned variables, subjects served as their own controls, * Corresponding author. E-mail address: [email protected].
meaning the un-operated limb was regarded as the independent variable, and the operated limb the dependent variable. Participants were assigned to one of four groups, based on self-reported UE pain and objective measures of UE volume; 1) pain þ lymphedema, 2) pain e lymphedema, 3) pain-free þ lymphedema, and 4) pain-free e lymphedema. Statistical analyses focused on between group comparisons, controlling for within group variance, and although unspecified, all tests were presumably one-tailed. When comparing operated with un-operated UEs, significant differences existed in shoulder abduction and elbow extension with maximum mean differences in group 1. ULNT1 provoked pain symptoms with distal radiation affecting operated and un-operated UEs. Perhaps unsurprisingly, elbow extension was diminished in operated UEs, as a function of ULNT1. However, the authors also revealed reductions in elbow motion affecting un-operated UEs, in response to ULNT1. When considered separately, UE pain or lymphedema appeared to influence elbow motion of operated UEs about equally. Even in the absence of UE pain or lymphedema, subjects lacked, on average, about 20 degrees of end-range elbow extension, in response to ULNT1. The frequency of axillary lymph node dissection and number of excised nodes were significantly different among groups; those subjects demonstrating lymphedema had volume differences between un-operated and operated UEs of up to 325 ml. How could I use this information in my clinical practice? This commentary began with a ‘definition’ of comfort zone. In those clinics where patient treatment status-post BCA and upper limb neurodiagnostic testing are routine, the present results may be unsurprising. In clinics unaccustomed to this patient population, and ULNT testing, the present study is an invitation for UE therapists to step outside their comfort zones and perhaps experiment with new techniques and experience the responses that occur. At a minimum, current research results should prompt clinicians to; 1) document shoulder and elbow motion and 2) evaluate motion ‘quality’ of both UEs in patients reporting a history of BCA. Impaired quality of overhead motion may inform about injury to the long thoracic (serratus anterior) and thoracodorsal (latissimus dorsi) nerves as dynamic testing or tests against moderate resistance will evince characteristic postural faults, for example, scapular winging (relative internal rotation of the glenoid fossa) or tipping (inferior
0894-1130/$ e see front matter Ó 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jht.2013.10.003
J. Hurov / Journal of Hand Therapy 27 (2014) 12e13
angle elevation). Moreover, standard sensory tests may reveal injury to the intercostobrachial as well as other peripheral nerves. Future considerations for research This study provides support for pre- and postoperative assessment of mechanosensitivity in patients diagnosed with BCA.1 Could tests of mechanosensitivity be used as an adjunct screening tool for BCA, particularly in patients with a documented family history?2 Finally, given the multivariate nature of signs and symptoms associated with pre- and postoperative presentation of patients diagnosed with BCA, some type of multivariate analysis, or perhaps analysis of covariance may be warranted.
13
Whatever the underlying causes of limited UE motion in patients diagnosed with BCA; 1) neural, 2) alterations in fluid mechanics, 3) and/or soft tissue fibrosis and scarring, the authors should be commended on their research, which offers an opportunity for their colleagues to step outside their comfort zones and ask novel questions while applying new manual skills. The responses will certainly be enlightening. References 1. Kelly S, Jull G. Breast surgery and neural tissue mechanosensitivity. Aust J Physiother. 1998;44:31e37. 2. Goodman C. Screening for medical problems in patients with upper extremity signs and symptoms. J Hand Ther. 2010;23:105e126.
