[Designing a therapeutic education program for patients with lymphedema: live with lymphedema]. / Conception d'un programme d'éducation thérapeutique pour les patients porteurs de lymphœdème: « vivre avec un lymphœdème ¼

BACKGROUND: Lymphedema is a chronic condition considered to be rare in its primary form and potentially frequent in women after breast surgery for cancer: 27,000 new cases annually. Therapeutic management is a serious challenge. In France, the health authorities (Haute Autorité de santé [HAS]) have recently proposed that appropriate management practices for lymphedema include "patient education". The HAS and the National institute for health care prevention and education also published a methodology guide devoted to structuring a therapeutic education program for patients with chronic disease. Current hospital regulations state that this education program is part of the care to be delivered to patients with chronic disease and that it must comply with the national directives. The purpose of our present work was to present the concept and the contents of a patient education program entitled "Live with lymphedema" designed for patients with lymphedema and developed within the inpatient-outpatient network GRANTED in Sud-Isère. METHODS: A standard detailed educative approach was applied. It was designed after the educational program for patients with lower limb arterial occlusive disease authorized by the Rhône-Alpes regional health agency. It was adapted to the specific problematic of patients with lymphedema, including medical management, rehabilitation, dermatology and nutritional aspects. It was developed in cooperation with patients and favors local associative actions. RESULTS: The specifically structured program included three therapeutic education consultations and five workshops. Less than one year after its institution, more than 30 patients have participated in the program. DISCUSSION: We report a structured patient education program designed for patients with lymphedema. This program was authorized by the Rhône-Alpes regional health agency in March 2011 and is in compliance with the national directives and HAS guidelines.

New rehabilitation program for intermittent claudication: Interval training with active recovery: pilot study.

BACKGROUND: Peripheral arterial disease (PAD) is one of the complications of atherosclerosis. Intermittent claudication is the second stage of PAD. In controlled studies on patients with Stage II PAD, intensive rehabilitation training has proved effective for improving the walking distance in this population. The objective of this prospective study was to determine the effects of treadmill interval training followed by active recovery (low-intensity exercise). METHODS AND RESULTS: Eleven patients with Stage II peripheral arterial disease were included in a rehabilitation program (mean age 68.3±10.3 years) for five days a week during two weeks including global exercises, exercises below and above the level of injury. The interval training program consisted of treadmill training for 30minutes twice a day (morning and evening) with a progressively increased intensity: the first week speed was increased and the second week slope was increased. Each session included five six-minute cycles. Each cycle was made of three minutes of active workout followed by three minutes of active recovery. RESULTS: All patients improved their walking distance, from a mean of 610 m (120-1930) at the beginning of the program to a mean of 1252 m (320-2870) at the end (P=0.003). All patients were very motivated by the rehabilitation training program No adverse event was reported. CONCLUSION: This study showed that an interval training program with active recovery was effective and safe for patients with Stage II peripheral arterial disease, the patients' motivation was high. This study must now be validated by a clinical trial.

Actuación fisioterapéutica en patología linfática / Lymphoedema physical treatment

El tratamiento de los linfedemas de las extremidades está dirigido por la fisioterapia. La descongestión del edema se consigue asociando drenaje linfático manual, vendajes funcionales no adhesivos y presoterapia neumática intermitente. La prevalencia del resultado se mantiene gracias a las de medidas de contención y al respeto de ciertas normas de vida

Physiotherapy dominates the treatment of limb lymphoedema. Its decongestion is mainly carried out by combination of manual lymphatic drainage, pneumatic drainage and bandages with or without an increased muscular pump effect. The decongestive result is maintained by two complementary elements: the wearing of elasto-rigid socks and the respect of certain rules of living

[Manual fragmentation of deep vein thrombosis]. / La fragmentation manuelle des thromboses veineuses profondes.

To preserve the venous function after deep vein thrombosis, physical treatment combines elastic stockings, active exercises, lower limbs elevation, ventilatory exercises and manual lymph drainage. When this traditional treatment is not sufficient, we use a new technique. It aims at fragmenting thrombus by compressing it between the physiotherapist's fingers and the patient's bone. In order to define the fragmentation sites we use the Triplex ultrasonography. This technique has been tested on ten patients with serious thrombosis, whom the thromboembolic risk was first controlled. The evaluation was performed by the clinical examination, echography and occlusive impedance plethysmography rheography. The improvement of the subjective and objective signs leads to use our technique. It has to be validated on a larger scale to extend its use.

Does medical treatment of lymphedema act by increasing lymph flow?

The lymphatic origin of chronic edema of the lower limbs was identified by lymphoscintigraphic exploration. Patients underwent therapy involving 8 days of manual lymph drainage combined with elevation of the limbs during rest periods and double compression bandaging. Manual drainage increased lymph flow in 16 limbs, implying that the edema resulted from a functional lymphatic anomaly. In contrast, manual drainage did not increase lymph flow in 9 limbs, suggesting a structural anomaly of the lymphatics. Hence, the same clinical picture corresponded to two different lymphatic anomalies, distinguished by lymphoscintigraphy. However, the therapeutic results were independent of the lymphoscintigraphic results. Increased lymph flow is therefore not the only explanation for the decrease in edema during therapy.

[Treatment of intermittent claudication by physical training. Techniques and place of reeducation (author's transl)]. / Traitement de la claudication intermittente par l'entrainement physique. Techniques et place de la rééducation.

The treatment of intermittent claudication by physical training includes walk and more specific exercises stopped before ischemia. Progresses are followed each week by the measurement of walking distance, and recognised by the majority of the authors. Physical training has thus far proved to be one of the best non surgical treatment of intermittent claudication.

[Programmed physical training in physiotherapy for obliterative arteriopathies of the lower limbs at the stage of claudication (author's transl)]. / L'entrainement physique programmé dans la rééducation des artériopathies des membres inférieurs au stade de la claudication.

Rehabilitation of lower limb arteriopathies at the stage of claudication is carried out during a stay of 30 to 45 days in a rehabilitation center. The daily program comprises general gymnastics, a specifical exercise training, and sport. The training is performed differently following the proximal, medial or distal level of arterial insufficiency. It includes sets or rythmical contractions up to about 70% of maximal capacity determined by a weekly test exercise.

[Objective evaluation of arterial intermittent claudication by the walking tolerance test. Comparative study of physiological walking and walking on a conveyor belt (author's transl)]. / Evaluation objective de la claudication intermittente artérielle par l'épreuve de marche. Etude comparative de la marche physiologique et sur tapis roulant.

Two methods are used to evaluate the walking distance: physiological walking along a standard path (0% - 6 mk/h) and walking on a tread mill (10% - 3 km/h). In both tests, four data are checked: -- initial trouble distance, -- cramp or walking-distance, -- localisation of pain, -- recovery time. These tests are dependable for the diagnosis of arterial claudication, reproducible and well tolerated. Their results have been compared: there is no correlation between the initial trouble distance and the cramp distance. However there is a correlation between the cramp distance by physiological walking and on treadmill. Recovery time, if long, is a criteria of gravity. Interests of both methods are discussed.