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 patients nervous system at risk, contrib-
uting 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 fromlocal, regional, and
national databases, fullled specic criteria for inclusion, and pro-
vided 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 chemo-
therapy), and Norman Questionnaires (UE lymphedema monitor).
Additional data usedtoevaluate painandparesthesiawerecollected
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 specic pattern termed, upper extremity
neurodynamic test 1 (ULNT1). ULNT1 provided data on the overall
tolerance of subjects to increasing UE strain affecting neural path-
ways from the brachial plexus to distal peripheral nerves. The
measurement of interest in this study was elbow extension, the
nal motion in the ULNT1 strain progression. For each of the
aforementioned variables, subjects served as their own controls,
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) painlymphedema, 2) painelymphedema, 3) pain-free lymph-
edema, and 4) pain-free e lymphedema. Statistical analyses focused
onbetweengroupcomparisons, controllingfor withingroupvariance,
and although unspecied, all tests were presumably one-tailed.
When comparing operated with un-operated UEs, signicant
differences existed in shoulder abduction and elbowextensionwith
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 lym-
phedema appeared to inuence 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 signicantly
different among groups; those subjects demonstrating lymphe-
dema 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 denition 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 thera-
pists 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
* Corresponding author.
E-mail address: jackhurov@gmail.com.
Contents lists available at ScienceDirect
Journal of Hand Therapy
j ournal homepage: www. j handt herapy. org
0894-1130/$ e see front matter 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jht.2013.10.003
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 assess-
ment 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.
Whatever the underlying causes of limited UE motion inpatients
diagnosed with BCA; 1) neural, 2) alterations in uid mechanics,
3) and/or soft tissue brosis 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.
J. Hurov / Journal of Hand Therapy 27 (2014) 12e13 13