BACKGROUND AND CURRENT STATUS OF THE STUDY TOPIC.Breast Cancer is the most common tumor in women around the world, and is one of the
leading causes of death among women in developed countries.
It is an important Public Health problem, since according to the World Health
Organization more than a million new cases are diagnosed annually, becoming almost a
quarter of malignant tumors in females. In the West, it has been shown that one in nine
to twelve women will suffer from the disease in her lifetime.
Most cases occur in postmenopausal women, and the main age at diagnosis is around 60
years.
After the diagnosis of breast cancer, the patient undergoes surgical and / or cancer
treatment. Chemotherapy, radiotherapy and hormonal therapy are some of the treatment
alternatives, which currently are precisely adapted to the type of tumor seeking a better
response and survival.
Postmastectomy lymphedema is one of the best-known postsurgical and post-actinic sequelae
after breast cancer, with a prevalence of around 20% of mastectomized women.
The conservative treatment of this health problem is based on Decongestive Physical
Therapy and Kinesitherapy. Pneumatic Multicompartmental Pressotherapy helps reduce the
feeling of heaviness and stiffness of edema.
In addition to postmastectomy lymphedema, the patient undergoing surgery for breast
cancer may present Axillary Web Syndrome (AWS) or superficial lymphatic thrombosis. As
described by W.M. Yeung et al. In their systematic review, it can appear in the first
eight weeks after the operation and usually resolves spontaneously within three months of
its appearance.
The lymphatic thrombus is clinically manifested as a cord that frequently occurs in the
armpit, although it can also appear along the upper limb, elbow crease even reaching the
first finger. Regarding the diagnosis through imaging tests, nuclear magnetic resonance
does not manage to clearly identify the axillary network syndrome, being ultrasound the
most reliable method, due to the dynamism that can be applied to the patient's arm while
the diagnostic test is being carried out.
The axillary network syndrome produces pain when abducting and flexing the shoulder, with
the respective loss of functionality and limitation of mobility of the affected upper
limb.
According to the American Cancer Society, radiation therapy is applied 3-8 weeks after
the operation if chemotherapy is not required. If chemotherapy is used, it is applied 3-4
weeks after completion. It is usually applied 5 days a week from Monday to Friday.
The limitation of mobility often leads to a delay in the application of this useful tool
in the oncological therapeutic arsenal to prevent recurrences. Hence, the need and
importance of this study, where the investigator intend to demonstrate that the evolution
times of the lymphatic thrombus can be reduced with assisted passive kinesitherapy and
stretching.
At present, there are some publications that show possible alternatives of physiotherapy
treatment for lymphatic thromb. Many are interventions with a very small sample (even on
a caseby-case basis). Others are observational studies or even studies older than five
years. There are some studies that combine manual lymphatic drainage (Vodder method) with
physical therapy (strengthening, stretching, soft tissue work) with good results.
There is ambiguity in the relationship-association between the appearance of lymphatic
thrombosis and lymphedema of the ipsilateral limb. Patients who have developed AWS are
44% more likely to develop postmastectomy lymphedema. There are other studies that do not
find a relationship between the two.
The frequency of the AWS is not clear from the current posts. It depends on the type of
surgical intervention, age, BMI, the appearance of the postoperative seroma, and even
breast reconstruction. Thus being the frequency 30% of the operated patients.
After reviewing the relevant literature, it should be noted that there are very few
studies and therefore little evidence on the treatment of AWS. It is not possible to
prescript of a clear treatment in a clinical practice guide for this postsurgical
sequela. Most publications highlight the importance and need for more research to
determine the etiopathogenesis and useful treatment for this health issue.
OBJECTIVES GENERAL OBJECTIVES.I. Determine a preliminary exploration of the magnitude of the effect of a kinesitherapy
and stretching intervention for the functional recovery of the upper limb, the recovery
of the surgical scar and the improvement of the quality of life in women who have
suffered from breast cancer.
- II. Create a scale to objectively classify the axillary
thrombus (based on its clinical manifestations).
SPECIFIC OBJECTIVES for general objective I:
- - Check the intervention of assisted passive kinesitherapy and stretching for the
improvement of the range of joint mobility of the affected limb in the shortest
possible time.
- - Analyze the reduction of pain and increase of the degree of
functionality of the ipsilateral upper limb in patients with AWS after the
intervention.
- - Determine the impact of the physiotherapeutic intervention on the quality of life of
a mastectomized woman with lymphatic thrombus.
- - Analyse the physiotherapeutic intervention reduction of the time on the evolution of
the Superficial Lymphatic Thrombus and the application of Radiotherapy within the
terms established in the oncological protocols.
SPECIFIC OBJECTIVES for general objective II:
- - Create a scale to objectively classify the axillary thrombus (based on its clinical
manifestations).
METHODOLOGY TYPE OF STUDY.Quasi-experimental, prospective study.
STUDY POPULATION.The study sample is made up of patients undergoing surgery for Breast Cancer who attend
the Lymphedema Unit of the A.G.S. Campo de Gibraltar Oeste presenting Lymphatic Thrombus
after the operation, the recruitment period being from December 2021 to December 2023.
DESCRIPTION OF THE INTERVENTION.15 sessions of Assisted Passive Kinesitherapy are carried out by the physiotherapist.
Five days a week, for three weeks. If it is previously referred, the treatment will be
finished earlier (the patient must achieve the same ranges of motion and strength as the
contralateral limb, together with the remission of pain).
The stretches applied during the sessions will be gentle and maintained, never exceeding
a pain grade 5 VAS (moderate pain), once the tension of the cord is reached between 20-30
seconds. A special effort will be made to recover flexion and abduction of the shoulder,
bringing the cord to a tolerable tension on the part of the patient.
Friction will be made on the axillary scar to dislodge underlying planes and the
subcutaneous tissue of the muscle fascia.
The patient will be trained in active kinesitherapy to prevent lymphedema and activate
lymphatic circulation. Also with hygienic-postural measures for the same purpose.
CONTROL GROUP.All the variables and data for each patients are recorded in their clinical history.
Goniometric study will be performed of the affected upper limb (shoulder, elbow, wrist).
Constant scale, Quick-Dash, the Visual Analog Pain Scale and the International Scale of
Physical Activity will also be performed. This assessment will be carried out the patient
arrives at our unit and on day 30, 60, 90.
These patients will be instructed in hygienic-postural care and active assisted
autokinesitherapy to perform daily for 30 minutes. It will be assessed every 30 days.
These exercises are explained to the patient to be executed at home.
INTERVENTION GROUP.As well as the control group, all the variables and data for each patient will be
collected in their medical history. Goniometric study of the affected upper limb will be
performed too (shouderelbow-wrist). Constan scale, Quick- DASH, Visual Scale will also be
completed together with Analogue of Pain and the International Scale of Physical
Activity. This exploration will also take place during the first session and on the 30th,
60th and 90th day.
These users will arrive at the first diagnosis of the thrombus in our unit,in order to
receive manual therapy by the physical therapist. (see therapy pictures).
They will receive 15 sessions of manual therapy the physiotherapist, 5 days a week ,each
session being approximately 40 minutes long.
The session will begin with pendulum exercises of the shoulder to warm up the joint and
give proprioceptive stimulation to the joint capsule.
The physiotherapist will perform passive stretches looking to tensioning the lymphatic
cord, never exceeding grade 6 VAS pain chart. Mainly the affected shoulder will be
treated and if the cord reaches the crease of the elbow or thumb, the extension (frase
sin sentido general hay que volverla a escribir).
Scar massage will be done in the area where the lymphatic cord originates at the proximal
level while maintaining the tolerable tension of the lymphatic cord (during the massage
also pain grade 6VAS will be exceeded).
Patients with developed lymphedema will receive Decongestive Physical Therapy (PDT) on
the treated limb once the 15 day treatment described for the study is finished.
Therefore, PDT does not influence on obtained contaminated results. Those patients who do
not suffer from lymphedema do not receive PDT.
