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Ultrasonography is a diagnosis imaging technique based on the application of ultrasound. Traditionally, it had been used in lymphoedema patients to discriminate lymphatic vessels and veins. Nowadays, there is scientific evidence to demonstrate the correlation between the ultrasound cross-sectional area of median nerve and EMG results, so a cross-sectional area higher than 10,8 mm2 can cause a CTS. Ultrasound can also prove pathologic changes inside median nerve 4-11.
The aim of this study is to prove the efficacy of ultrasound results in patients with breast cancer related lymphoedema and CTS.
METHOD
This was a prospective, analytical and observational study. When 2 cm of perimeter difference in two consecutive levels were achieved, the treatment was indicated. This treatment included 20 daily sessions, from Monday to Friday, of Manual Lymphatic Drainage (MLD), pressotherapy (20min of intermittent pneumatic compression) and multilayer bandage (with 3 layer). The principal investigator measured every patient with an ultrasound machine, and the valuation of the measurement of median nerve before treatment and after treatment. The day of the evaluation, patients did not use the sleeve after the measurement.
All participants were recruited from the Lymphoedema’s monographic consultation of Rehabilitation Service of the Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas de Gran Canaria, Spain, from March 2015 and January 2016. This unit serves approximately 350 lymphoedema’s patients per year. The aim and methology of the study was explained to all recruited women and voluntary participation was requested.
The inclusion criteria included: women; lymphoedema after breast cancer surgery; the need for physical therapy treatment; and literacy, including the ability to understand the study. The exclusion criteria included: bilateral oedema; primary lymphoedema; infection signs; tumour recurrence and metastasis diagnose.
The principal investigator involved in the intervention and data collection was a Rehabilitation and Physical Medicine specialist. Secondary investigators are Physiotherapists specialised in lymphatic drainage techniques for more than ten years. All of them used the same specific techniques of MLD, Vodder and Leduc methods. Both methods were used in all patients; especially Vodder method was used in fibrosis areas. Later, they had a session of pressotherapy, and finally, the multilayer bandage was placed.
A portable ultrasound machine with a lineal transducer (12MHz) was used by the principal investigator to measure cross-sectional median nerve area. The wrist was in neutral position and transducer was positioned on distal crease palmar wrist, in axial plane to take the measurement.
The principal investigator also collected clinical findings like paraesthesia, dysesthesia, Tinnel and Phalen signs, and an analogical visual scale (AVS).
Statistical study was used with SPSS program. The measurement and clinical findings results were compared to evidence the statistical signification after and before treatment. T-student and U Mann-Withney were used with quantitative variables. Chi-Square test was used to compare qualitative variables. It was considered significant statistical levels with p value<0.05.
RESUL TS
A total of 21 women with lymphoedema were recruited, with an average age of 62,45 (SD 9,615). The average value of the key variables is presented in Table 1. After treatment, there had been an improvement of 1.07 in AVS and 0.02mm2 in cross-sectional area if median nerve. Two of the ultrasound images of median nerve are presented in Figure 1 and 2.
Before treatment, all of them present clinical findings of CTS in lymphoedema’s arm, like paraesthesia, dysesthesia, Tinnel sign positive or Phalen sign positive. 9 of them (42,86%) suffered from the same symptoms in the healthy arm.
Table 1 - Results of AVS and cross-sectional area before and after treatment (BT and AT).
Fig. 1 - Ultrasound image of Median Nerve at the wrist of lymphoe- dema patient (transversal section).
Fig. 2 - Ultrasound image of Median Nerve at the wrist of lymphoe- dema patient (longitudinal section).
AVS BT
AVS AT
Cross-sectional median area BT
Cross-sectional median area AT
Cross-sectional median nerve healthy arm
Average
6.56
5.49
0.17 mm2
0.15 mm2
0.11 mm2
(SD)
(1.39)
(1.42)
(0.13)
(0.15)
(0.21)
THE EUROPEAN JOURNAL OF LYMPHOLOGY - Vol. XXIX - Nr. 75 - 2017
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