[Rehabilitation in lymphedema surgery]. / Tratamiento rehabilitador en la cirugía del linfedema.

Conservative treatment of lymphedema usually includes complex decongestive therapy in order to reduce the volume of the lymphedema, and compression garments in the maintenance phase. Follow-up is carried out in the Rehabilitation Services. Surgical treatment of lymphedema is a therapeutic option, the interest of which has increased in recent years, although there is no current evidence that it can cure lymphedema and it is always accompanied by conservative treatment. Most studies focus on results according to the type of surgery and there is no standardized protocol for conservative treatment before or after surgery. The objective of this work is to prepare a compendium about the most frequent lymphedema surgeries and their indications, focusing on the rehabilitation treatment for each surgery.

Risk factors for lymphedema after breast surgery: A prospective cohort study in the era of sentinel lymph node biopsy.

INTRODUCTION: The Objective was to investigate the incidence of lymphedema after breast cancer treatment and to analyze the risk factors involved in a tertiary level hospital. METHODS: Prospective longitudinal observational study over 3 years post-breast surgery. 232 patients undergoing surgery for breast cancer at our institution between September 2013 and February 2018. Sentinel lymph node biopsy (SLNB) or axillary lymphadenectomy (ALND) were mandatory in this cohort. In total, 201 patients met the inclusion criteria and had a median follow-up of 31 months (range, 1-54 months). Lymphedema was diagnosed by circumferential measurements and truncated cone calculations. Patients and tumor characteristics, shoulder range of motion limitation and local and systemic therapies were analyzed as possible risk factors for lymphedema. RESULTS: Most cases of lymphedema appeared in the first 2 years. 13.9% of patients developed lymphedema: 31% after ALND and 4.6% after SLNB (p < 0.01), and 46.7% after mastectomy and 11.3% after breast-conserving surgery (p < 0.01). The lymphedema rate increased when axillary radiotherapy (RT) was added to radical surgery: 4.3% for SLNB alone, 6.7% for SLNB + RT, 17.6% for ALND alone, and 35.2% for ALND + RT (p < 0.01). In the multivariate analysis, the only risk factors associated with the development of lymphedema were ALND and mastectomy, which had hazard ratios (95% confidence intervals) of 7.28 (2.92-18.16) and 3.9 (1.60-9.49) respectively. CONCLUSIONS: The main risk factors for lymphedema were the more radical surgeries (ALND and mastectomy). The risk associated with these procedures appeared to be worsened by the addition of axillary radiotherapy. A follow-up protocol in patients with ALND lasting at least two years, in which special attention is paid to these risk factors, is necessary to guarantee a comprehensive control of lymphedema that provides early detection and treatment.

Iatrogenic spinal cord injury: an observational study.

STUDY DESIGN: Retrospective descriptive observational study. OBJECTIVE: The primary objective of this study was to quantify the incidence of iatrogenic spinal cord injury (SCI) at our SCI unit (SCIU). The secondary objective was to discover the surgical and medical procedures that cause iatrogenic SCI and to estimate the incidence with each procedure. SUBJECTS: Patients admitted to or seen at outpatient services of the SCIU at a university hospital. METHODS: Histories were compiled from 1 July 2005 to 30 June 2009. We included patients with SCI caused by any medical or surgical procedure. We collected age, sex, diagnosis leading to medical intervention, predominant clinical manifestations, medical-surgical procedure and level and grade of injury upon admission and discharge. RESULTS: Out of 250 patients admitted to the SCIU, 32 (14.7%) patients presented iatrogenic SCI. Average age was 56.2 (s.d. 17.3), ranging from 0 to 82 years old. The most frequent clinical manifestation was pain. The most common diagnosis was channel stenosis. Lumbar level grade C of American Spine Injury Association (ASIA) was the most frequently observed. CONCLUSION: The rise in the population's life expectancy entails an increase in elderly patients with vascular risk factors, who underwent invasive interventions leading to spinal cord iatrogenia.

Transdermal nitroglycerine treatment of shoulder tendinopathies in patients with spinal cord injuries.

STUDY DESIGN: A clinical blind study was conducted to determine the efficacy of transdermal nitroglycerine treatment on the awareness of shoulder pain. OBJECTIVE: This study aims to determine the effects of transdermal nitroglycerine on shoulder pain and on functional shoulder movement in patients with spinal cord injuries and shoulder tendinopathies. A second aim is to establish the side effects of the treatment. SETTING: Hospital "La Fe" in Valencia, Spain. METHODS: A total of 45 spinal cord injury patients, all of whom are wheelchair users with shoulder tendinopathy, were randomly divided into two groups: placebo (n=12) and experimental (n=33). The experimental group (EG) received transdermal treatment for 6 months in the form of a 1.25 mg nitroglycerine (NT) patch on the greater tubercle. A placebo patch was used with the placebo subjects. Functional shoulder movements were assessed by articular range of motion and pain, using a visual analogical scale. RESULTS: NT treatment reduced the awareness of shoulder pain and increased the functional movement and range of articular motion in the shoulders of the EG members (P<0.05). CONCLUSIONS: We conclude that transdermal NT is an efficient method for treating shoulder tendinopathies in wheelchair users with spinal cord injuries.

Scapular winging in surgical treatment of breast cancer, prospective study to optimize the follow-up protocol.

INTRODUCTION: One of the most common complications of the surgical treatment of breast cancer is limited range-of-motion in the shoulder. Scapular winging is one of the most underdiagnosed shoulder mobility impairments. OBJECTIVE: The main objective of this study was to determine the incidence of scapular winging in patients who underwent breast cancer surgery as the basis for expanding the protocol to patients who have had a sentinel lymph node biopsy. The secondary objective was to determine the risk factors that lead to the development of a winged scapula presented after breast cancer treatment in our sample. METHODS: This was a prospective, observational, and multidisciplinary study. Between 2013 and 2018, 214 consecutive patients who had been diagnosed with breast cancer and treated for it surgically were followed by Rehabilitation Department for 3 years. The patients were evaluated in the 1st, 6th, 12th, 18th, 24th and 36th months following surgery. Scapular winging was evaluated at each visit by means of static and dynamic tests. RESULTS: The cumulative incidence of scapular winging was 3.6% and seven cases of winged scapula were diagnosed. All the cases were diagnosed at the first visit, 1 month after the intervention. In the univariate analysis, the axillary lymph node dissection technique was a more significant risk factor for a winged scapula than sentinel lymph node biopsy. CONCLUSIONS: The axillary lymph node dissection technique is a risk factor for developing a winged scapula. No evidence was found for any other significant risk factor.

Tratamiento rehabilitador en la cirugía del linfedema / Rehabilitation in lymphedema surgery

El tratamiento conservador de los pacientes con linfedema habitualmente comprende la terapia descongestiva compleja con objetivo de reducir el volumen y las prendas de compresión en fase de mantenimiento, realizando un seguimiento en los servicios de Rehabilitación. El tratamiento quirúrgico del linfedema es una opción terapéutica cuyo interés ha aumentado en los últimos años, aunque no existe evidencia actual de que pueda curar el linfedema y siempre se acompaña de tratamiento conservador. La mayoría de los estudios se centran en los resultados según el tipo de cirugía y no existe un protocolo estandarizado sobre el tratamiento conservador antes o después de la cirugía. Con este trabajo se pretende realizar un compendio sobre las cirugías de linfedema más frecuentes y sus indicaciones, centrándose en el tratamiento rehabilitador que implica cada cirugía.(AU)

Conservative treatment of lymphedema usually includes complex decongestive therapy in order to reduce the volume of the lymphedema, and compression garments in the maintenance phase. Follow-up is carried out in the Rehabilitation Services. Surgical treatment of lymphedema is a therapeutic option, the interest of which has increased in recent years, although there is no current evidence that it can cure lymphedema and it is always accompanied by conservative treatment. Most studies focus on results according to the type of surgery and there is no standardized protocol for conservative treatment before or after surgery. The objective of this work is to prepare a compendium about the most frequent lymphedema surgeries and their indications, focusing on the rehabilitation treatment for each surgery.(AU)

Efectividad de la fisioterapia multimodal acuática mediante ejercicio terapéutico, autodrenaje manual y medidas de autocuidado en el linfedema de miembro superior en mujeres supervivientes de cáncer de mama. Ensayo clínico aleatorizado / Effectiveness of aquatic multimodal physiotherapy through therapeutic exercise, manual self-drainage and self-care measures in upper limb lymphedema in female breast cancer survivors. Randomized clinical trial

Introducción El linfedema secundario al cáncer de mama es una patología crónica. La fisioterapia descongestiva compleja (FDC) es el tratamiento conservador de elección, consta de una fase intensiva para disminuir el volumen de la extremidad, y una fase de mantenimiento para fomentar el autocontrol de la patología. El objetivo es evaluar si la fisioterapia multimodal acuática (FMA) compuesta por ejercicio terapéutico, auto drenaje manual y medidas de autocuidado de miembro superior mantiene o reduce el volumen del linfedema en fase de mantenimiento y si esta es más efectiva que la fisioterapia multimodal de miembro superior en sala. Metodología Se ha realizado un ensayo clínico aleatorizado comparando dos grupos, experimental n:43 que realizó una pauta de ejercicios en el medio acuático y control n:47 que realizó la misma pauta de ejercicios en sala. Ambos grupos efectuaron 20 sesiones de 45 min, dos o tres días por semana. Se evaluaron como variables principales los cambios en el volumen del linfedema, mediante circometría y la calidad de vida de las participantes, mediante la escala FACT-B + 4. Resultados No se encontraron diferencias estadísticamente significativas entre las intervenciones realizadas, ambas mejoran el volumen a las 20 sesiones (p = 0,7855), pero si entre la frecuencia del tratamiento y el tiempo postintervención (p<0,01). Se encontraron mejoras en las variables de calidad de vida; «estado físico general del paciente», «ambiente familiar y social», «estado emocional», «capacidad de funcionamiento personal» y «preocupaciones de las pacientes» (p < 0,01). Conclusión La FMA de miembro superior parece mejorar la calidad de vida de las mujeres supervivientes con linfedema de miembro superior en fase de mantenimiento. La FMA no muestra un beneficio añadido a la fisioterapia multimodal en sala (AU)

Introduction Lymphedema secondary to breast cancer is a chronic pathology. Complex decongestive physiotherapy is the conservative treatment of choice, it consists of an intensive phase to minimize the volume of the limb, and a maintenance phase to promote self-control of the pathology. The objective is to evaluate if aquatic multimodal physiotherapy (AMP) composed of therapeutic exercise, manual self-drainage and upper limb self-care measures maintains or reduces the volume of lymphedema in the maintenance phase and if it is more effective than upper limb multimodal physiotherapy in-room. Methodology A randomized clinical trial has been carried out comparing two groups, experimental N:43 that performed a pattern of exercises in an aquatic environment and control N:47 that performed the same pattern of exercises in-room. Both groups carried out 20 sessions of 45min, 2 or 3 days per week. The main variables were the changes in the volume of the lymphedema, by means of circometry, and the quality of life of the participants, by means of the FACT-B + 4 scale. Results No statistically significant differences were found between the interventions carried out, both improve the volume at 20 sessions (p = 0.7855), the interaction between the frequency of treatment and the time after intervention was (p-value: < 0.01). Improvements were found in quality of life variables; «general physical state of the patient», «family and social environment», «emotional state», «personal functioning capacity» and «patient concerns» (p-value: < 0.01). Conclusion Upper limb AMP seems to improve the quality of life of surviving women with upper limb lymphedema in the maintenance phase. AMP does not show an added benefit to room multimodal physiotherapy (AU)

Scapular winging in surgical treatment of breast cancer, prospective study to optimize the follow-up protocol

Introduction One of the most common complications of the surgical treatment of breast cancer is limited range-of-motion in the shoulder. Scapular winging is one of the most underdiagnosed shoulder mobility impairments. Objective The main objective of this study was to determine the incidence of scapular winging in patients who underwent breast cancer surgery as the basis for expanding the protocol to patients who have had a sentinel lymph node biopsy. The secondary objective was to determine the risk factors that lead to the development of a winged scapula presented after breast cancer treatment in our sample. Methods This was a prospective, observational, and multidisciplinary study. Between 2013 and 2018, 214 consecutive patients who had been diagnosed with breast cancer and treated for it surgically were followed by Rehabilitation Department for 3 years. The patients were evaluated in the 1st, 6th, 12th, 18th, 24th and 36th months following surgery. Scapular winging was evaluated at each visit by means of static and dynamic tests. Results The cumulative incidence of scapular winging was 3.6% and seven cases of winged scapula were diagnosed. All the cases were diagnosed at the first visit, 1 month after the intervention. In the univariate analysis, the axillary lymph node dissection technique was a more significant risk factor for a winged scapula than sentinel lymph node biopsy. Conclusions The axillary lymph node dissection technique is a risk factor for developing a winged scapula. No evidence was found for any other significant risk factor (AU)

Linfedema de parénquima de mama. A propósito de 2 casos clínicos / Breast lymphoedema. A propos of 2 cases

El linfedema de mama (LM) secundario a cirugía tras un proceso neoplásico se manifiesta con edema o rubefacción en la zona de la mama. Presentamos 2 casos de pacientes intervenidas de cáncer de mama izquierda, hemimastectomía y linfadedectomía, que recibieron quimioterapia (QT) y radioterapia (RT) adyuvante. Fueron remitidas al Servicio de Rehabilitación (RHB) por aumento de volumen y sensación de dureza en extremidad superior izquierda (ESI) y mama. Tras objetivar el edema en la mama, tratamos el LM con taping linfático. Se las citó para revisión a la semana, y refirieron mejoría en la sensación de dureza e hinchazón en mama en la escala visual analógica (EVA). El LM es una dolencia infradiagnosticada aunque relativamente frecuente, de difícil cuantificación, y no hay descrito en la literatura un tratamiento específico. El taping linfático es una opción de tratamiento para el LM, ya que mejora la sensación subjetiva de dureza e hinchazón así como la clínica de induración y edema (AU)

Breast lymphoedema after oncological surgery is characterized by ipsilateral chest swelling and/or redness. We report the cases of 2 patients who underwent surgery for left breast cancer. Hemimastectomy and lymphadenectomy were performed, and postoperative therapy included adjuvant chemotherapy and radiotherapy. After discharge the patients were sent to our Rehabilitation Department complaining of swelling and heaviness in the left upper extremity and breast. The patients underwent a physical examination of the breast, and the lymphoedema of the upper extremity was measured. Lymphatic taping was applied to treat the breast lymphedema. One week later, both patients reported improvement in heaviness and swelling quantified by the visual analog scale (VAS). Breast lymphoedema is a relatively common but underdiagnosed condition and is difficult to quantify. There is no reported standard treatment for this entity in the literature. Lymphatic taping is an optional treatment for breast lymphoedema as it improves the subjective feeling of heaviness and swelling, as well as induration and oedema (AU)

Lesión medular de origen iatrogénico ¿un diagnóstico a tener en cuenta? / Iatrogenic spinal cord injury. Should this diagnosis be considered?

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