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Case Reports |
JE Donachy, PT, PhD, is Assistant Professor, Department of Physical Therapy, PO Box 271, Alabama State University, Montgomery, AL 36101 (USA) (jdonachy{at}asunet.alasu.edu). Address all correspondence to Dr Donachy
EL Christian, PT, PhD, is Associate Professor, Department of Physical Therapy, Alabama State University
Submitted January 30, 2001;
Accepted March 24, 2002
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Key Words: Carpal tunnel syndrome • Lymphedema • Physical therapy • Postmastectomy • Surgery
| Introduction |
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The highest incidence of postmastectomy lymphedema has been associated with axillary dissection in conjunction with radiation therapy.5,6 Although the lymphatic vessels appear to be somewhat resistant to radiation effects, studies have shown that radiation delays the normal growth of lymphatics into regenerating tissues after surgery and inhibits the lymphatic proliferative response to inflammatory stimuli.7,8 The narrowing of lymphatic vessels that has been observed after radiation therapy is thought to result from fibrosis of surrounding tissues.7,8 Lymph nodes also are sensitive to radiation and will fibrose following exposure.9 These radiation-induced effects on lymphatic vessels and nodes may compromise the function of the lymphatic system by reducing transport capacity, thereby resulting in the development of lymphedema.
One consequence of postmastectomy lymphedema may be the development of nerve entrapments. Median nerve entrapment in the carpal canal, or carpal tunnel syndrome (CTS), is one example.10,11 In a study of 90 women who underwent mastectomy for breast cancer, the majority of whom had lymphedema, 23 had CTS and 24 had brachial plexus entrapment.10 The authors10 concluded that brachial plexus entrapment and CTS are potential complications following mastectomy, with lymphedema playing a role in their development.
Severe CTS usually requires surgical release,12,13 which can present a problem for patients with upper-limb lymphedema. The surgical procedure stimulates a localized inflammatory response, thereby increasing the load on an already compromised lymphatic system.14 Furthermore, the sluggish flow of lymph through lymphedematous tissues increases susceptibility to percutaneous introduction of bacteria by iatrogenic or other mechanisms, which can result in infection, further lymphatic overload, and lymphatic blockage.15–17 Consequently, patients who are at risk for or who have lymphedema are instructed to follow certain precautions, including the avoidance of blood pressure readings, venipunctures, injections, and elective surgeries in the involved limb that might result in the development or exacerbation of lymphedema.18–20 Although the list of proscribed activities is long, it is not evidence based. Until research determines that these activities are safe, Runowicz21 recommended advising patients of the potential risks associated with them. Brennan and Weitz19 supported the importance of the precautions with a case study of an individual who developed lymphedema 30 years after surgical and radiation management of breast cancer, which they believed was the result of physician-prescribed finger sticks used to monitor blood glucose levels.
Few studies22,23 have addressed the effects of elective hand surgery in patients who, in management of their breast cancer, had a modified radical mastectomy with axillary dissection, with or without accompanying lymphedema. Smith and Giddins22 reported a case of a woman with a history of breast cancer treated with a radical mastectomy and axillary dissection without radiation therapy, who developed lymphedema in the involved upper limb following a carpal tunnel decompression complicated by a superficial wound infection. In a retrospective study of 15 women, 7 of whom had some postaxillary dissection lymphedema, Dawson et al23 found that none with a previous axillary dissection developed a postoperative infection or had any worsening of pre-existing lymphedema or onset of new upper-limb swelling after carpal tunnel release in the involved hand. None of these women had the combination of modified radical mastectomy, axillary dissection, and radiation therapy, and no reports describe patients with the combined treatments who subsequently developed lymphedema. Individuals who are at risk for developing or exacerbating lymphedema may choose to delay or forgo operative procedures for conditions affecting the involved limb.
In this case report, we present an individual with postsurgical carpal tunnel release. This individual had a history of upper-limb lymphedema secondary to right modified radical mastectomy, axillary dissection, radiation, and chemotherapy for treatment of breast cancer. The focus of this case report is the physical therapy examination, intervention, and outcomes.
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The patient developed chronic, moderate lymphedema in her right arm within 1 month of the surgery, with no apparent lymphedema in her forearm. At that time, she was measured for a custom-fitted Jobst compression sleeve and glove.* As reported by the patient, she wore these garments as needed for about 6 months, until the lymphedema seemed to stabilize. Approximately 6 years after surgery, moderate lymphedema developed in the patient' s right forearm as well. The increase in girth of the forearm was accompanied by localized pain, erythema, increased firmness, and elevated temperature. The lymphedema was moderate, based on the classification of Markowski et al,24 who described moderate lymphedema as a circumferential measure of 3.0 to 5.0 cm greater in the involved limb as compared with the uninvolved limb. At that time, the patient underwent a 1-month antibiotic regimen, used a Jobst compression pump daily for 3 hours, and wore an over-the-counter compression sleeve the remainder of the day. After 3 months, when the patient became unable to reduce limb swelling with this regimen of compression, she underwent a daily treatment regimen that consisted of manual lymphatic drainage for 45 minutes, application of a sequential compression pump
for 1 hour, and wrapping with short-stretch bandages (Comprilan*) for the remainder of the day. After 4 days, the patient' s forearm girth and texture were similar to her uninvolved forearm' s girth and texture. During the next 3 years, the patient experienced periodic episodes of worsening of her symptoms. Ultimately, the patient found that she was best able to control her lymphedema with the use of Comprilan bandages, as needed. Nine years after the mastectomy, the patient began experiencing signs and symptoms of CTS. At that time, she was taking Synthroid
for thyroid hormone replacement and cyproheptadine for allergies daily. She had no other medical problems and there were no relevant findings for social history.
Initial Interview
During the initial interview with her physician and physical therapist (JED), the patient described her symptoms as pain and paresthesia "that split the fourth finger" and weakness in her right hand. Using a numerical pain rating scale, with 0 equal to no pain and 10 equal to the worst pain imaginable, she rated her pain as 9 during the most severe episodes. She reported symptoms that were more severe at night than during the day and that were exacerbated by repetitive activities involving her right upper limb. The patient experienced some relief when wearing over-the-counter wrist splints. She expressed concern about decreased strength in her right hand, which was limiting her activities of daily living and participation in recreational activities. The pain and paresthesia continued to worsen, and the patient sought medical intervention 2 years after the first symptoms of CTS.
Physical Examination
The patient' s physician performed the initial physical examination. The patient had a positive Tinel' s sign on the right side over the median nerve at the distal volar wrist crease. She reported tingling of the thumb, the second and third digits, and the lateral half of the fourth digit. No visible thenar atrophy or sensory deficit (pinprick, light touch, 2-point discrimination) of the palmar aspect of the 3
radial digits were noted. Nerve conduction velocity tests conducted by a physician revealed a motor nerve latency of 6.1 milliseconds across the wrist and a sensory nerve latency of 4.5 milliseconds. These values were consistent with the diagnosis of moderately severe CTS following the criteria used by the facility conducting the tests. At that time, the patient was referred to a hand surgeon for a discussion about surgical release of her right carpal tunnel. The patient was reluctant to pursue a surgical intervention given her history of lymphedema. Sixteen months later, when the patient stated that she could no longer tolerate the pain, a surgical consultation was requested and surgery was scheduled.
All grip strength and circumferential measurements reported were taken by the first author (JED). Preoperative grip strength of both hands was tested with a Jamar dynamometer
using the third handle position. This position was chosen because it yielded the highest grip strength readings. The subject was seated with her elbow flexed 90 degrees, following the protocol recommended by the American Society of Hand Therapists (ASHT).25 Three trials were recorded, and the mean and standard deviation were calculated (Tab. 1). The Jamar dynamometer has been demonstrated to be both a reliable and valid indicator of grip strength using the ASHT protocol. Mathiowetz et al,26 using the Pearson product moment correlation coefficient, reported an interrater correlation coefficient of .97 and test-retest correlation coefficients of .80 or above in tests of grip strength of 27 female subjects. Measurements obtained with the standard Jamar dynamometer were reported to be within ±3% of a reference weight. In a similar study investigating test-retest reliability of measurements obtained with the Jamar dynamometer, Hamilton et al27 reported intraclass correlation coefficients (ICCs) of .90 and above for 33 subjects aged 20 to 55 years. In both of these studies, the highest correlation was found when the mean of 3 trials was used. MacDermid et al,28 who tested 38 people with cumulative trauma disorders, including people with CTS, found high interrater reliability coefficients (ICC>.87) for all dynamometer measurements. Although we did not assess the reliability of our measurements, we used the standard ASHT protocol25 and a device for which reliability has been established. Right-hand preoperative grip strength in this patient was less than her left-hand grip strength (Tab. 1). The patient complained of pain and tingling in her right hand with grip strength testing.
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Interventions
Surgical procedure.
Under general anesthesia, with direct visualization using the open surgical procedure, the patient' s palmar fascia was cleared off the transverse carpal ligament, which was then incised longitudinally along the ulnar aspect of the median nerve. The volar antebrachial fascia was released in the distal forearm. In addition, the median nerve had an area of slight flattening in the middle portion of the carpal tunnel. The total tourniquet time was 8 minutes.
Physical therapy intervention.
The patient was seen for 4 physical therapy treatment and education sessions over the course of 6 weeks, in accordance with guidelines established by the surgeon, and an additional 3 times for assessment of limb circumference, grip strength, or both. We developed an exercise and lymphedema management regimen to minimize upper-limb swelling, maintain range of motion (ROM), and increase strength of the wrist and hand. Because of her history, the patient was familiar with the general methods used to minimize lymphedema. Although elevation, exercise, and compression are discussed frequently as treatment options for managing lymphedema,1,18,38 the specific type, amount, and combination of these interventions continue to be debated because of a lack of controlled studies evaluating their efficacy. In this case, the treatment regimen was tailored to the individual patient based on her activity level, goals, and tolerance for the prescribed exercises. Immediately postoperatively, the patient' s right forearm was wrapped in a short-stretch compression bandage from distal to proximal beginning at the distal volar crease and ending just distal to the cubital fossa, with even pressure that did not compromise circulation to the extent of causing swelling in the hand. In addition, the limb was elevated approximately 30 degrees using pillows. The patient was instructed in the proper application of the compression bandage and was able to demonstrate good technique in wrapping her forearm. The compression bandage was rewrapped every 2 to 3 hours and was worn continuously for 3 weeks except when bathing and sleeping. The patient was instructed to sleep with the limb elevated on a pillow and to keep the limb elevated at approximately 30 degrees above horizontal whenever possible throughout the day unless she was using it for specific activities.18
Prior to discharge, the patient was provided with a written home exercise program for isometric contractions of all major muscle groups in the involved upper limb (flexors and extensors of the digits, wrist, and elbow, in that order) for the purpose of facilitating muscle pumping of interstitial fluid from the limb. Each exercise was demonstrated to the patient, who then was asked to perform it in her therapist' s presence using the appropriate technique and her uninvolved limb to provide resistance. Isometric contractions were chosen because of the postoperative limitations of wrist ROM. Each exercise consisted of holding a contraction for 3 seconds and resting for 10 seconds. These exercises were done in sets of 3, with 6 repetitions each, a minimum of 3 times per day. Exercise protocols were established based on the tolerance of the patient at this time. The patient was instructed to stop exercising and contact her therapist immediately if she experienced any pain, increase in involved limb size, or loss of mobility in the involved limb.
The patient' s stitches were removed 10 days after surgery. At this time, following the recommendation of the surgeon, the patient was instructed to massage the incision using vitamin E oil to soften the scar and to minimize scar tissue adhesion. Wrist active ROM exercises were added to her home program as well. The goal was to maintain physiological elasticity and contractility of the muscles around the wrist joint. These exercises involved moving the wrist in all planes possible to the point of soft tissue resistance but not pain. The patient was instructed to carry out each motion through the available range in a slow, steady fashion 10 times in each direction, a minimum of 3 times each day. Decisions about exercise repetitions and frequency were based on the patient' s endurance and pain threshold. The patient was reminded to continue wearing her compression bandage. Involved upper-limb circumference measurements were taken 2 weeks after surgery using the techniques described earlier.
Three weeks following her surgery, the physician cleared the patient for resistance exercises. The patient was instructed in the use of Thera-Bands|| for wrist extension, flexion, ulnar deviation, and radial deviation exercises to increase strength and endurance. Based on the patient' s tolerance, one exercise session consisted of 3 sets of 10 repetitions in each plane. These were to be done 2 times each day. The patient was given yellow, green, and blue Thera-Bands and instructed to progress to higher resistance as she felt able, taking care not to cause pain. At this time, the patient was instructed to decrease the wearing of her compression bandage to two 3-hour sessions per day unless she thought her arm was increasing in size.
Six weeks after surgery, the patient was given clearance from her physician to resume normal activities, provided that they did not cause pain. At this time, exercise to increase grip strength was begun because a strong grip was essential to the patient' s participation in her chosen recreational activities. This exercise consisted of squeezing a rubber ball that fit easily into the patient' s palm. Based on the patient' s fatigability and pain threshold, initial exercise sessions consisted of squeezing the ball for 3 seconds and relaxing for 10 seconds in 3 sets of 10 repetitions, repeated 3 times per day as tolerated by the patient. Care was taken not to exercise to the point of causing pain at the surgical site. Within 5 days, the patient progressed to sets consisting of squeezes for 10 seconds with 10 seconds of rest. The patient continued her Thera-Band program and the use of compression bandaging. Four months after surgery, the patient' s grip strength was tested as described previously. Six months after surgery, her grip strength and upper-limb circumference were evaluated as described previously. At this time, the patient was using compression bandaging 2 to 3 hours per day as needed, which was similar to her maintenance regimen prior to surgery. The patient stated that she adhered to her exercise program and the use of the compression bandage.
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| Discussion |
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This case report describes the surgical and physical therapy management of CTS in an individual who had chronic lymphedema resulting from breast cancer treatment. Few reports exist in the literature concerning the outcomes of elective hand surgery in women who have a history of or are at risk for lymphedema as the result of breast cancer management, and none involve an individual who has chronic lymphedema resulting from breast cancer management that included a modified radical mastectomy, extensive axillary dissection, radiation therapy, and chemotherapy. Because restrictions of blood flow to and from a lymphedematous limb and iatrogenic or other punctures are among the factors that have been reported to aggravate lymphedema,18,19 2 surgical precautions were taken. First, general anesthesia was chosen over the use of a local nerve block. A similar general anesthetic precaution was reported for some, but not all, of the individuals with lymphedema in a retrospective study of elective hand surgery in patients with breast cancer.23 Second, the upper-limb tourniquet was in place for only 8 minutes compared with a mean time of 41 minutes reported by Dawson et al.23 This reduced the time that blood flow within the limb was restricted and the time that soft tissues at the tourniquet site were compressed.
No known cure exists for lymphedema, and it is unresponsive to most therapeutic interventions. The combination of positioning, exercises, and use of pressure bandages or garments has been shown to promote collateral drainage and facilitate maintenance of limb circumference in the management of patients who develop lymphedema.40–42 Mortimer40 suggested that minimum care includes the use of compression bandages, with exercise as a complementary treatment. Most patients permanently require compression bandaging for part of each day.30 Markowski et al24 suggested that early recognition, the implementation of an early treatment program, close patient follow-up care, and patient education may be of primary importance in preventing and managing lymphedema. With the use of compression garments and self-administered massage therapy, Brennan and Weitz19 reported a marked reduction in lymphedema that developed following physician-prescribed finger sticks for glucose monitoring in a patient who had previously undergone a radical mastectomy, axillary dissection, and radiation therapy. They suggested that this success was related to early identification and immediate treatment of the lymphedema. Smith and Giddins22 reported the case of a person with a history of breast cancer treated with a radical mastectomy and axillary dissection who developed gross lymphedema following a carpal tunnel release under local anesthesia that was complicated by a superficial infection. Ten weeks postoperatively, the patient had severe lymphedema that subsequently failed to resolve with the use of intermittent positive pressure pumping or graduated pressure garments. In this case, no immediate postoperative antibiotic therapy was used to address the superficial infection, and physical therapy intervention was not begun until the lymphedema had reached the severe stage.
Our patient stated that she felt no increase in her right upper-limb lymphedema and that she was satisfied with the lymphedema management program. Circumferential measurements showed a 1.5- to 2-cm increase in the arm and a 1- to 1.5-cm decrease in the forearm. Considering the history of regular fluctuations in upper-limb girth and tissue plasticity reported by this patient, these outcomes were not surprising. A 1.5- to 2-cm increase in girth is considered to be clinically significant by some authors2,35 but not by others.43 This relatively small increase in arm circumference did not result in impaired ROM or function of the upper limb of this individual.
Following surgery and physical therapy, the patient had complete relief of pain and paresthesia in her involved hand, and her grip strength increased. A mean difference of 2.38 kg has been reported for grip strength between dominant and nondominant hands in women.27 Our patient' s right-hand mean grip strength prior to carpal tunnel release was 2.83 kg less than that of her nondominant left hand. Examination 4 months after surgery showed equal grip strength, and by 6 months, her right-hand mean grip strength was 3.0 kg greater than her left-hand grip strength. This was 113% of her preoperative grip strength and is comparable to the measurements taken at 6 months by Gellman et al44 that showed grip strength to be 116% of preoperative values in their study of people who had undergone carpal tunnel release.
This case supports the option of elective hand surgery for CTS in women with breast cancer-related upper-limb lymphedema. Although this case suggests that positive outcomes can occur, research is needed to demonstrate the safety and effectiveness of elective hand surgeries in people who have or are at risk for lymphedema.
| Footnotes |
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* BSN-Jobst Inc, 5825 Carnegie Blvd, Charlotte, NC 28209. 
LymphaPress, Mego Afek, Kibbutz Afek, Israel.
Abbott Laboratories, 1401 Sheridan Rd, North Chicago, IL 60064.
Sammons Preston, 4 Sammons Ct, Bolingbrook, IL 60440.
|| The Hygenic Corporation, 1245 Home Ave, Akron, OH 44310.
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