Venous thoracic outlet syndrome (vTOS) is a unilateral (rarely bilateral) form of thoracic outlet syndrome (approximately 4%), due to an extrinsic compression of the subclavian vein which can be divided into thrombotic and non thrombotic clinical entities.
In this study, the author underlines the usefulness of Echo-Color-Doppler diagnostic to evidence an intermittent subclavian vein compression, without intraluminal thrombus, in patients who had undergone breast surgery, with axillary lymphadenectomy, who refer homolateral positional  heaviness onset, fatigue, turgidity of the dorsal veins of the hand and cyanosis during the elevation of the homolateral arm (venous claudicatio) while performing work activities that can be resolved by resting the limb.
In this study, the subclavian venous obstacle discharge was due to impaired posture and predisposing morphotype (weak muscular support of the shoulder girdle): it was completely resolved through personalised physical therapy programme, in order to take pressure off the vein in the thoracic outlet, with complete disappearance of symptoms and consequent improvement in the performance of work activities and quality of life.
Furthermore, the resolution of non thrombotic venous thoracic outlet, through physical therapy, avoids the possibility of deep vein thrombosis onset due to the intermittent narrowing of the subclavian vein.

Aims                                                                                                                                                                                                  
The authors confirm the usefulness of Echo-colour-doppler diagnostics, in patients affected with upper and lower limb lymphoedema.

Description of initiative
The diagnosis of lymphoedema is essentially clinical, however, we must not ignore the usefulness of Echo-colour-Doppler diagnostics, non-invasive and repeatable diagnostic approach, using adequate high linear frequency probe, in lymphological field. The instrument available is provided with the “Siescape panoramic reconstruction” function, a system option allowing the acquisition of bi-dimensional ultrasound images with an extended visualisation field.

Outcome
Echo-Colour-Doppler diagnostics allows us to reach differentiated diagnoses to determine the origin of the upper and lower limbs oedema (deep venous thrombosis, post-thrombotic syndrome, Backer cist with popliteal vein compression, etc.).
It provides important indications on morphological characteristics-vascularisation of lympho-nodes, presence of vascularised neo-formations in oncological patients, subclavian-venous obstacle discharge after oncological surgery, etc.). Furthermore, it allows us to analyse the structural characteristics of oedematous tissue (thickness, echogenicity).
It is also interesting to note how it is possible to observe an increase of the calibre-flow of the superficial and deep veins in the lymphoedematous limb, proof of the venous-lymphatic twinning useful in the case of lymphatic system insufficiency.

Evaluation
Echo-Colour-Doppler diagnostics provides important data which lead to an improvement in lymphoedema management, helping the lymphologist and physiotherapist in the choice of precise strategies and, therefore, the setting up of personalised therapeutic programmes, with subsequent therapeutic optimisation. It also useful for therapeutic monitoring to verify the validity of treatment effectuated and in follow-up.

M.Cestari

O.U. Territorial Rehabilitation NHS Umbria - Terni,  Italy

Aims

Chronic oedema in the elderly may require a clinician’s skill to identify the persistent swelling (limbs, trunk, genitalia, head, neck) that has been present for more than 3 months, and to understand the different causes in order to apply the proper management with patient compliance and/or eventual caregiver’s collaboration.

Description

In the clinical assessment of chronic oedema in the elderly, a patients’s medical history, a general and local physical examination, the laboratory evaluation is required, and the ongoing drug therapy because some drugs may cause oedema.

The clinician has to consider that the swelling may be caused by coexisting or non-systemic diseases including heart failure, hepatic cirrhosis, kidney insufficiency, hypothyroidism, obesity as well as local conditions such as venous hypertension, primary/secondary lymphoedema, advanced cancer, dependency oedema (neurological problems, inactivity/muscle weakness, respiratory insufficiency).

During the physical examination signs of venous and arterial involvement may be investigated, and when present, they lead to a diagnostic instrumental evaluation to better determine the management.

Outcome

Careful clinical assessment is fundamental in order to identify chronic oedema in the elderly as well as the causes, due to often coexisting diseases, in order to schedule a prompt appropriate management, and to avoid local complications.

 

Evaluation of impact

An appropriate clinical assessment, with holistic approach considering patient and/or caregiver protagonists in the therapeutic process, is fundamental to avoid complications and to improve patient’s quality of life, considering that this condition has an impact on the physical, psychological and social aspects.

M.Cestari, S.Amati, F.Appetecchi, L.Curti, M.De Marchi, De Rebotti, C.Tomassi
O.U. Territorial Rehabilitation Domus Gratiae Center - NHS Umbria2 - Terni, Italy

INTRODUTION
Four years ago, in the authors’ laboratory of lymphology, it was decided to focus the attention on patients without clinical evidence of oedema, at risk of developing lymphoedema in the homolateral arm after breast cancer treatment.
The authors planned a preventive protocol that highlighted the importance of primary prevention in order to avoid lymphoedema onset.

MATERIALS AND METHODS
After join lymphologist and physiotherapist assessment consisting of clinical evaluation, a centimetrical/volumetrical measurement of compared arms, a lymphoscintigraphy request, a shoulder functionality evaluation, through Constant-Murley Shoulder Score, and BMI evaluation, patients were included in five different groups after the start-up of a rehabilitative project:


-Informative Group, which includes all patients , whose end-point is the information on lymphoedema and the preventive behavioural rules.                                          -Individual Rehabilitation Treatment which includes patients with limited shoulder functionality who undergo specific treatment after physiatrician and physiotherapist assessment. After improvement the patient is included in the Physical Activity Group.
-Individual Lymphological Section which includes patients with positive lymphoscintigraphy exam (slower radiotracer flow with initial dermal back-flow) and which consists of the review of preventive behavioural rules and a prescription of standard flat sleeve for housework. After this Section the patient is included in the Physical Activity Group.
-Individual post-surgery problems treatment (breast oedema, scar with or without oedema, ecc.). After the treatment the patient is included in the Physical Activity Group.
-Physical Activity Group which includes a physiotherapist and patients without limited shoulder functionality as well as all patients from individual treatments. This Physical Activity Group consists of gymnastics, breathing exercises, ecc.; furthermore, the physiotherapist highlights the importance of physical activity, based upon the patients predisposition and problems, and patients confront their problems with physiotherapist and/or each other.
In cases of slower radiotracer flow, a follow-up of 6 months was required instead of 12 months in cases of normal lymphoscintigraphy.

RESULTS
The preventive protocol has highlighted its usefulness in order to prevent lymphedema onset (9% of patients after 3 years of follow-up) and the physical-psychological well-being achieved through the early and holistic care.

CONCLUSIONS
In the authors’ laboratory of lymphology a protocol of lymphoedema prevention after breast cancer was planned, useful, in their opinion to prevent lymphoedema onset through the compliance of the patients, who must cooperate actively, and a rehabilitative team with early and holistic approach.

INTRODUTION

Four years ago, in the authors’ laboratory of lymphology, it was decided to focus the attention on patients without clinical evidence of oedema, at risk of developing lymphoedema in the homolateral arm after breast cancer treatment.
The authors planned a preventive protocol that highlighted the importance of primary prevention in order to avoid lymphoedema onset.

MATERIALS AND METHODS

After join lymphologist and physiotherapist assessment consisting of clinical evaluation, a centimetrical/volumetrical measurement of compared arms, a lymphoscintigraphy request, a shoulder functionality evaluation, through Constant-Murley Shoulder Score, and BMI evaluation, patients were included in five different groups after the start-up of a rehabilitative project:

-Informative Group, which includes all patients (20 patients at a time), whose end-point is the information on lymphoedema and the preventive behavioural rules;

-Individual Rehabilitation Treatment which includes patients with limited shoulder functionality (Costant-Murley Shoulder Score: range of motion equal or less to 28 out of 40 points) who undergo specific treatment after physiatrician and physiotherapist assessment. After improvement the patient is included in the Physical Activity Group.

-Individual Lymphological Section which includes patients with positive lymphoscintigraphy exam (slower radiotracer flow with initial dermal back-flow) and which consists of the review of preventive behavioural rules and a prescription of standard flat sleeve for housework. After this Section the patient is included in the Physical Activity Group.

-Individual post-surgery problems treatment (breast oedema, scar with or without oedema, axillary web syndrome, mobilization of prosthesis). After the treatment the patient is included in the Physical Activity Group.

-Physical Activity Group (10 patients at a time), which includes a physiotherapist, and patients without limited shoulder functionality or with a range more than or equal to 30 out of 40 points as well as all patients from individual treatments. This Physical Activity Group consists of gymnastics, with mobilisation of all physical districts, breathing exercises, relaxation technique, with music-therapy, and stretching exercises; furthermore, the physiotherapist highlights the importance of physical activity, based upon the patients predisposition and problems, and patients confront their problems with physiotherapist and/or each other.

In cases of slower radiotracer flow, a follow-up of 6 months was required instead of 12 months in cases of normal lymphoscintigraphy.

 

RESULTS

The preventive protocol has highlighted its usefulness in order to prevent lymphedema onset (9% of patients after 3 years of follow-up) and the physical-psychological well-being achieved through the early and holistic care.

 

CONCLUSIONS

In the authors’ laboratory of lymphology a protocol of lymphoedema prevention after breast cancer was planned, useful, in their opinion to prevent lymphoedema onset through the compliance of the patients, who must cooperate actively, and a rehabilitative team with early and holistic approach.

 

 

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