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, De Rebotti, C.Tomassi

O.U. Territorial Rehabilitation Domus Gratiae Center - NHS Umbria2 - Terni, Italy

INTRODUTION
The author has decided to focus the attention on patients who underwent oncological breast surgery, without clinical evidence of oedema, and 5 years ago planned a preventive protocol which has highlighted during patients’ follow-up the importance of primary prevention in order to avoid lymphoedema onset.

MATERIALS AND METHODS
After lymphologist and physiotherapist join assessment consisted of clinical evaluation, a centimetrical measurement of compared arms, a clinical examination, a lymphoscintigraphy request and a shoulder functionality evaluation through Constant-Murley Shoulder Score, patient is included in different groups after the start up of a rehabilitative project:

Leggi tutto: Protocols of prevention of arm lymphoedema following breast cancer

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.

M.CESTARI

Il linfedema è una patologia cronica, con andamento evolutivo e disabilitante, ed il fine della prevenzione primaria è proprio quello di impedirne la comparsa, sia sui consanguinei di pazienti affetti da linfedema primario, che nello stadio pre-clinico a rischio evolutivo, dopo intervento chirurgico per patologia oncologica con asportazione dei linfonodi regionali.
La prevenzione primaria prevede la valutazione clinica, la misurazione centimetrico-volumetrica e funzionale degli arti a confronto, il calcolo dell’BMI e l’analisi dello stato psicologico del paziente. Alla valutazione linfologica, segue la richiesta dell’esame linfoscintigrafico, che permette una valutazione anatomo-funzionale del sistema linfatico con la possibilità di identificare i pazienti a rischio di insorgenza dell’edema, quelli che presentano un rallentamento del flusso del radiotracciante, che possono così essere sottoposti ad un trattamento fisioterapico precoce.

Leggi tutto: Prevenzione primaria e secondaria