One
dance step at a time for Colbert
By Diane Chiddister
Since being
diagnosed with an aggressive breast cancer nine months ago, Shelley Colbert has
endured chemotherapy, major surgery and radiation treatment. Along
with the resulting pain,
fatigue and anxiety of those treatments, Colbert has grappled with another challenge as well —
accepting
help from the community where she grew up, raised her children, and cared for
the
children of others.
“It’s very hard to ask for help,”
Colbert said in an interview last week. “I’m tremendously
grateful
to all who have stepped forward with help or good wishes.”
While asking for
help is a struggle for Colbert, who prides herself on her independence, she’s
reluctantly allowing her friends to ask for her. Specifically,
friends have organized a benefit
concert this Saturday, Jan. 16,
from 5 p.m. to midnight at the Emporium with a variety of local
musicians. The music is organized by Steve McColaugh.
Carl
Schumacher and Friends will play from about 5 p.m. to 7, Dawn Cooksey and Route
68
South at 8 p.m. and McColaugh’s band, the Undercovered, will
play from 9:30 p.m. on.
Colbert vetoed charging admission for the event,
according to her longtime friend and event
organizer Peggy
Koebernick, so there is no charge, but donations are welcome. The purpose of
the event is to help cover Colbert’s living expenses since she has been unable to work since last
March and will remain unable for the
foreseeable future. While most of Colbert’s medical
treatment is
currently covered by a special short-term form of Medicaid, and a benefit fun
run/walk last May raised enough money to pay Colbert’s living
expenses until now, those funds
are running out.
“I was thinking
about what it would be like to be in her shoes,” Koebernick said, regarding her
decision to organize the event. “I wanted to tap into the energy of
the community.”
The community’s energy so far has been extraordinary,
according to Colbert, who describes
herself as astonished at
people’s generosity, both in donating to a special fund at US Bank, and
offering goods and services. Those who can’t attend the fundraiser but
would like to make a
donation may do so at the Shelley Colbert Fund
at US Bank.
Colbert, one of a family of five children raised by her parents Chuck and Rita, grew up in Yellow
Springs. She left town to go to
college, and returned after earning a degree in early childhood
education. When her sons, Ben and Spencer Beggs, were small, Colbert
started her childcare
business at her Miami Drive home, where for
23 years she cared for village children until she
received her
diagnosis of Stage III breast cancer. At that time, doctors told her she would
no
longer be able to lift children after her treatment, Colbert
said, adding with a smile that they also
advised her to give up
chopping wood and hauling water from the well.
After chemotherapy ended in
August, Colbert, who is 60, had a mastectomy in September. And
cancer doesn’t deal out any favors. The night before her surgery, her
father, who had suffered a
stroke several weeks earlier, died at
Friends Care Community. It was rough, she said, with the
saving
grace that at least all her family had already come home for her surgery and
were here
when her father died.
The chemotherapy Colbert
initially received worked remarkably well, eradicating all traces of
tumors
on her scans. Her doctors were amazed, as a complete response is relatively
rare.
However, because her cancer had been so aggressive, they urged
her to “play her hand all in”
and to accept equally aggressive
treatments in surgery and radiation.
The decision to go ahead with seven
weeks of radiation — which ends this week — has been the
hardest of
all for Colbert. Her instincts told her that so much radiation can’t be good
for her body.
Radiation often causes significant damage to the
heart, lungs and thyroid, and her doctors couldn’
t guarantee those
side effects wouldn’t happen to her.
And Colbert knows something about side
effects. The tumors themselves caused lymphedema,
leading to pain
and swelling in her right arm and shoulder area. The condition is chronic, and
Colbert is working on finding ways to manage it. She thinks
swimming could be a good antidote,
as soon as she’s allowed back
into her beloved swimming pools.
As with each step of the nine-month ordeal
so far, Colbert has struggled with making decisions
that often seem
overwhelming. Mountains of information are available on the Internet, but the
amount seems impossible to sort through, although a good friend,
Mary Miller, has volunteered
her skills to analyze research
results. But the process often makes her feel crazy, ever focused
on
cancer, cancer, cancer.
The radiation left her in pain, with skin burns, and
Colbert still worries whether she made the
right choice, or
whether, even if the radiation does buy her time, it will be in a life that
feels not
worth living. But in the end, she pursued the aggressive
treatment that her doctors urged.
“I want people to know I’m doing
everything I have to do to stay alive,” she said.
There are people who say
that cancer has taught them how to live, or helped them to live better.
So far, Shelley Colbert is not one of those people, but she hasn’t
ruled out the possibility.
“I’m hoping maybe the silver lining will reveal
itself to me soon,” she said. And the silver lining
so far has been
that cancer helped her know who her friends are, and that she has far more
friends than she ever imagined.
“I don’t know how to thank people
for all they’ve done for me,” she said. “You don’t know how
many
people care about you, but they do. It’s been heartening and humbling. This is
a fantastic
community.”
And there’s a bright spot on the horizon.
That puppy that Colbert has been longing for is the first
thing on
her list after follow-up treatment begins and the weather warms up.
“I can’t
wait to get my puppy,” she said.
While Colbert loves to dance and would like
nothing better than to dance until midnight on Jan.
16, she’s
expecting that fatigue from the radiation treatments may prevent her from doing
so. But
she’ll do her best to show up, with her new sleek and short
hair. And if she has to go home early,
well, she’ll spend a cold
winter evening warmed by the thought of her many friends, new and old,
dancing the night away.
Contact:
[email protected]
http://www.ysnews.com/stories/2010/01/011410_colbert.html
My
Bra? Color Me Furious
The bra-color meme that's sweeping Facebook and
allegedly raising awareness of breast cancer
got a nice one-two
punch from my colleague Frances Tobin.
Get the new
PD
toolbar!
Allow me to pile on.
Not for myself, but for friends
I've watched face this beast. Many of them aren't wearing bras of
any color because their breasts are long gone. Instead they might be
wearing a lymphedema
sleeve on their arms, in some cases for the
rest of their lives.
As a member of the all-too-exclusive club of
long-term ovarian cancer survivors, let me first say I
used to
resent the enormous amount of attention breast cancer got over other cancers.
Breast
Cancer Awareness Month (also known as "pink nausea" by
certain folks) seemed to begin in
late July and end in late
November, totally eclipsing the far more lethal (per capita) cancers of
ovarian and pancreatic.
Where's all the teal in September? I
realize fountains are not so good for awareness, since
they're
always teal. But where are the endless rows of candy bars and other products
sporting
teal?
Where's all the purple in November? If you're
a playwright and you want your main character to
die, you choose
ovarian if it's a woman and pancreatic if it's a guy. So where's the love for
pancreatic cancer patients?
Cancer envy – wishing you could
trade in your bad-stat cancer for a more benign variety – is
known
only to those with personal experience with this dreadful disease.
Like
it was yesterday, I remember lunch with my friend Sherri. One year after my
diagnosis with
ovarian cancer, she'd been diagnosed with breast
cancer. She gazed out the window and said,
"This is going to kill
me."
"How can you say that," I replied. "I'd give anything to trade my
statistics for yours."
"Don't ask me how I know," she said. "I just
know."
Sherri was earlier stage than me. She was younger than me. I
thought about that when, six years
later, I attended her
funeral.
For a while I went to a support group for cancer survivors of
all types. That was my light-bulb
moment. The breast cancer
patients in that group began detailing the experiences – waking up
from surgery, the day after surgery, going home with drainage tubes
attached to their armpits.
"Tubes?" I shuddered. "I guess every kind of
cancer is its own version of hell."
Bingo.
In spring of 2008,
another friend was diagnosed with breast cancer. If only I had a dollar for
every time I said: My tumor was 11 centimeters. When was the last time
you heard of an 11-
centimeter breast tumor?
"No, Donna, it's
not early stage," my friend said. "The tumor is nine centimeters." My friend
had lobular breast cancer, which can grow into the chest instead of
outward.
A few months later she got a bonus -- a second primary of lung
cancer, the kind nonsmokers get.
She's had more surgery in 18
months than I've had in my whole life.
My friend is ten years younger
than me. Her husband is a doctor. She's always been trim and fit,
and she has not a mean bone in her body.
Color me
educated.
But don't color me pink. Or teal. I want a new color. I want a
rainbow. We use the word "cancer"
for what is probably a thousand
different diseases. The segregation and disparity in funding
between types of cancer is absurd. Name any cell in your body, and
you've just named a chance
for mutation and cancer – at any time,
for any person.
Even so, I suspect women are especially vulnerable.
Their bodies are designed to grow things.
Like babies. And, it
turns out, cancer, even if they don't smoke, and they eat healthy, and
breast-
feed their children. While men can get male-specific
cancers, women's cancers seem to be more
adept at hiding til it's
too late.
Which brings us back to bra colors. Yes, awareness is good –
unless people think awareness is as
good as action. Think before
you pink, says Breast Cancer Action.
Last night on the Facebook wall of
Matthew Zachary, founder of I'm Too Young for This (aka
Stupid
Cancer), the bra-color meme was topic one for the evening. "Awareness," Matthew
wrote,
"is the same as rhetoric. Like propaganda without the
marketing. It's air. I welcome any cultural
anthropologist to
demonstrate successful awareness without action."
Years ago I attended a
lunch gathering of cancer survivors and medical professionals. The event
was supposed to end with some kind of hilarious musical spoof on the
subject of "boobs," written
by a surgeon. At the last moment, the
song got spiked. Through the grapevine I heard that a
patient
facing mastectomy found the subject not one bit funny.
After walking a
mile in the shoes of my friends, I have to say I agree. I would find no comfort
in
Facebook games about colored lingerie that my new body no longer
needed, or tight tee-shirts
with cute slogans about saving "second
base" or the "ta-tas."
Or any other campaign that emphasized the
womanliness, the beauty, the importance of breasts.
Never mind the
breasts. Save the
women.
http://www.politicsdaily.com/2010/01/11/my-bra-color-me-furious/
What
Is Turner Syndrome? What Causes Turner Syndrome?
Turner syndrome, also known
as Turners syndrome, Ullrich-Turner syndrome or Gonadal
dysgenesis,
is a chromosomal disorder that affects only females. It is characterized by the
absence of part or all of a second sex chromosome in some or all
cells. Approximately 1 in every
2,500 to 3,000 girls is born with
the condition.
People without Turner syndrome have 46 chromosomes, of
which 2 are sex chromosomes.
Females have two X chromosomes. In
people with Turner syndrome, one of those sex
chromosomes is either
missing or has other abnormalities - the chromosome may be missing in
some
cells but not in others (mosaicism or Turner mosaicism). In other words, there
are two types
of Turner syndromes:
Classical Turner syndrome -
an X chromosome is completely missing.
Mosaic Turner syndrome (mosaicism
or Turner mosaicism) - the abnormalities only occur in the
X
chromosome of some of the cells in the body.
Chromosomes are strands of DNA
(deoxyribonucleic acid) that exist in all the cells of the human
body. Chromosomes contain instructions that make a human's behavioral
and physical
characteristics.
The syndrome is named after Dr.
Henry Turner (USA 1892-1970), an Oklahoma endocrinologist,
who
described it in 1938.
Turner syndrome can cause:
Physical
disabilities
Emotional disabilities
Educational disabilities
According
to Medilexicon's medical dictionary:
Turner syndrome is "a syndrome with
chromosome count 45 and only one X chromosome; buccal
and other
cells are usually sex chromatin-negative; anomalies include dwarfism, webbed
neck,
valgus of elbows, pigeon chest, infantile sexual development,
and amenorrhea; the ovary has no
primordial follicles and may be
represented only by a fibrous streak; some affected people are
chromosomal mosaic, with two or more cell lines of different chromosome
constitution; seen in
many animal species, in the meadow vole it is
the normal female state."
What are the signs and symptoms of Turner
syndrome?
A symptom is something the patient feels and reports, while a sign
is something other people,
such as the doctor detect. For example,
pain may be a symptom while a rash may be a sign.
The signs and symptoms
of Turner syndrome vary considerably and may even appear before
birth.
Signs and symptoms before birth
Unborn females
with Turner syndrome (TS) may develop lymphedema - fluid is not properly
transported around the organs of the body, excess fluid leaks into the
surrounding tissue,
resulting in swelling. It is not uncommon for
babies born with TS to have swollen hands and feet.
The unborn baby
may also have:
•Thick neck tissue
•Cystic hygroma - swelling of the
neck
•Lower than normal weight
The following signs and symptoms may be
present at birth or during infancy
•Broad chest
•Cubitus valgus (arms
turn outwards at the elbows)
•Eyelids that droop
•Fingernails that turn
upward
•High, narrow palate (roof of mouth)
•Low hairline at the back of
the head
•Low set ears
•Receding lower jaw
•Short
hands
•Slower/delayed growth
•Small lower jaw
•Smaller height at
birth
•Smaller weight at birth
•Swelling of the hands and
feet
•Web-like neck
•Wide neck
•Widely spaced nipples
In some cases
Turner syndrome may not become apparent until later on. The following signs and
symptoms that appear later may indicate Turner syndrome:
•Growth
spurts do not occur at expected childhood times. During the first three years
of life the
baby/toddler may be of normal height. However, by the
age of three their growth rate will be
lower than
average.
The person is much shorter than expected; about 8 inches (20
cms) shorter than expected for an
adult female member of that
family (without treatment).
•Learning difficulties - the majority of girls
with TS have normal intelligence, as well as good
verbal and
reading skills. There may be some problems with math, spatial concepts, memory
skills and fine finger movements.
•Social problems - the patient
may find it hard to properly interpret other people's reactions or
emotions.
•Non-functioning ovaries - during puberty a female's
ovaries generally start producing estrogen
and progesterone (sex
hormones). The majority of girls with TS will not produce these sex
hormones, resulting in:
•No onset of menstrual
periods
•Poorly developed breasts
•Possible infertility
Although the
TS female has non-functioning ovaries and is infertile, her vagina and uterus
(womb) will generally be normal and she will usually be able to
have a normal sex life.
Approximately 30% of females with TS will
undergo some physical changes during puberty.
About 0.5% of girls
with TS can become pregnant without fertility treatment.
Other possible
signs and symptoms - as well as those listed above, the following may also be
present:
•Eyes that slant downwards
•Prominent
earlobes
•Mouth abnormalities which can cause dental problems
•Narrowing
of the aorta which may result in heart murmur
•Hypothyroidism - an
underactive thyroid gland. This can be treated with thyroxine
tablets.
•Hypertension - females with TS are more likely to suffer from high
blood pressure
•Brittle bones (osteoporosis) - caused by insufficient
estrogen
•Otitis media (middle ear infection, glue ear) - very common among
young girls with TS
•Hearing loss in adulthood - usually caused by otitis
media during childhood
•Diabetes - older and overweight females with TS have
a higher risk of developing diabetes
compared to other women of the
same age or weight
•Moles - females with TS may have a large number of
moles
•Small spoon-shaped nails
•A shorter than normal fourth finger or
toe
What are the causes of Turner syndrome?
Experts say that the loss or
abnormality of the X chromosome occurs spontaneously. If
somebody
has a child with TS, this does not mean there is a higher risk of any
subsequent
children having the condition.
TS occurs when the
baby is conceived, when the sperm enters the egg (ovum) and the egg is
fertilized.
Only females are affected.
TS occurs when the
second X chromosome is either incomplete or missing
completely.
According to the National Health Service (NHS), UK, about 1
in every 2,500 baby girls is born
with the condition. If a baby is
conceived with a missing X chromosome the pregnancy usually
miscarries (aborts naturally).
Approximately 10% of all
miscarriages during the first trimester of pregnancy are caused by
TS.
Most of us are born with two sex chromosomes. Males inherit the X
chromosome for their
mothers and the Y chromosome from their
fathers. Females inherit one X chromosome from each
parent. When a
female has Turner syndrome one X chromosome copy is either absent or
significantly
altered. The following genetic alterations of Turner syndrome are
possible:
•Monosomy - one X chromosome is completely missing. Experts
believe this is caused by an
error either in the father's sperm or
the mother's ovum (egg). Every cell in the offspring's body
has one
X chromosome missing.
•Mosaic Turner syndrome (mosaicism or Turner
mosaicism) - during the early stages of fetal
development an error
may have occurred in cell division, resulting in some cells having two X
chromosome copies, while others only have one. In some cases there may
be some cells with both
X chromosome copies, and others with one
altered copy.
•Y chromosome material - a small number of patients with TS
have some cells with just one X
chromosome copy and other cells
with just one X chromosome copy as well as some Y
chromosome
material. The individual develops as a female, but has a higher risk of
developing
gonadoblastoma (a type of cancer).
The missing or
altered X chromosome causes errors during fetal development, as well as
subsequent development after birth.
What are the risk factors for
Turner syndrome?
A risk factor is something which increases the likelihood
of developing a condition or disease. For
example, obesity
significantly raises the risk of developing diabetes type 2. Therefore, obesity
is
a risk factor for diabetes type 2.
Experts say that the
risk of having TS is the same for females in all regions of the world, races,
nationalities and socioeconomic groups. The condition occurs
randomly and is not associated with
the age of the mother or
father.
There are no known toxins or environmental factors that appear
to alter the risk of developing
TS.
How is Turner syndrome
diagnosed?
Diagnosis during pregnancy and birth - during an ultrasound test,
for example, TS may be
suspected. Amniocentesis or Chorionic villus
sampling, both antenatal tests that detect
chromosomal
abnormalities, are possible ways to confirm a diagnosis. Diagnosis may also
eventually be made if heart or kidney problems, or swelling of the
hands and feet are present at
birth.
Diagnosis during
childhood - if the child has a wide or webbed neck, a broad chest and widely
spaced nipples TS may be suspected.
If the girl eventually
has a short stature and undeveloped ovaries, TS may be
suspected.
Sometimes diagnosis is not made until later, for example,
when puberty does not occur.
Karotype - this blood test can be used to
detect extra or missing chromosomes, chromosomal
rearrangements, or
chromosomal breaks. This may be done either by taking a sample of the
amniotic
fluid while the baby is still in the uterus, or taking a blood sample from a
child/baby. If
one of the X chromosomes is missing or incomplete,
TS is confirmed.
What are the treatment options for Turner
syndrome?
Turner syndrome is a genetic condition for which there is no
current cure. However, several
treatments may help with short
stature, sexual development and learning difficulties.
Early
preventative care - it is important that the child is checked regularly so that
the risk of
complications can be minimized. Blood pressure and the
thyroid gland need to be monitored
frequently, and any necessary
treatment given immediately.
Treatment with medical specialists - as
girls with TS are more likely to develop otitis media
(inner ear
infections, glue ear) they need to be treated promptly to minimize the risk of
hearing
difficulties later in life. Treatment should be carried out
by an ENT (ear, nose and throat)
specialist.
Hormone
therapy, which may include estrogen, progesterone and growth hormones, may be
required. These treatments will be done with an endocrinologist, or
pediatric endocrinologist.
Growth hormone therapy - as soon as it is
established that the girl with TS is not growing
properly growth
hormone should be administered. Effective therapy may prevent short stature
later in life. Treatment may start as early as the age of one or two
years. A daily injection is
given. Growth hormone therapy may add
an extra 10cm (4 inches) to the girl's eventual stature.
Estrogen and
progesterone replacement therapy - the girl needs these two hormones to develop
sexually. Estrogen will also stop her bones from becoming brittle
(osteoporosis). The ovaries of a
girl with TS do not produce
sufficient quantities of these hormones. How much the patient is
producing herself can be determined with blood tests.
Estrogen
replacement therapy will start at the onset of puberty (11 years of age). The
patient will
initially receive low doses, which are slowly
increased. Progesterone therapy is generally given
later to trigger
menstrual periods. TS patients require sexual hormone treatment for the rest of
their lives. Treatment may be given as tablets, injections or
patches.
IVF (in vitro fertilization) - the majority of patients with TS
are unable to become pregnant
without help. If a woman with TS wants
to become pregnant she will probably require assistance,
for
example, IVF. If the patient manages to become pregnant she will need to be
monitored
closely, because of the extra strain on her heart and
blood vessels.
Counseling and psychological therapy - some patients may
develop psychological problems and
will benefit from psychological
therapy.
Learning assistance - although girls with TS generally have
normal levels of IQ, there may be
problems with numeracy, spatial
concepts, memory skills and fine finger movements. Educational
support will help the child.
What are the possible complications
related to Turner syndrome?
Heart problems - some girls with TS are born
with either heart defects or very slight heart
abnormalities which
may raise their risk of complications later in life. Defects in the aorta, the
main blood vessel leading out of the heart raises the risk of
aortic dissection (a tear in the inner
layer of the aorta). If
there is a defect in the valve between the aorta and the heart there is an
increased risk of an aortic valve stenosis (narrowing of the
valve).
High blood pressure - people with TS are much more prone to
suffer from high blood pressure
(hypertension) compared to
others.
Diabetes - overweight or older women with TS have a higher risk
of developing diabetes
compared to other women of the same age and
weight.
Hearing - gradual loss of nerve function can cause hearing loss.
Girls with TS are much more
likely to develop glue ear (otitis
media, inner ear infection), which can lead to hearing loss.
Kidney
problems - approximately 30% of TS patients have some kind of kidney
malformation,
raising the risk of hypertension and urinary tract
infections.
Hypothyroidism - having an underactive thyroid gland is more
likely among patients with TS.
Tooth loss - patients with TS have a
higher risk of having poor or abnormal tooth development,
resulting
in more tooth loss. Also, because of the shape of the mouth and palate, the
patient is
more likely to suffer from crowded and poorly aligned
teeth.
Vision - strabismus is more common among girls with Turner
syndrome (eyes to not work in
parallel and appear to be looking in
different directions). Hyperopia (farsightedness, long-
sightedness)
is more common among girls with TS.
Bones - women with TS have a
significantly higher risk of developing osteoporosis. Sometimes
there may be problems with the curvature of the spine, leading to
scoliosis. There is also a risk of
kyphosis (forward rounding of
the upper back).
Pregnancy - a woman with TS who becomes pregnant has a
significantly higher risk of developing
complications, including
gestational diabetes, high blood pressure and aortic
dissection.
Psychology - there is a greater risk of problems with
self-esteem, anxiety, depression, ADHD
(attention deficit
hyperactivity disorder). There may also be difficulties in social
situations.
Written by Christian Nordqvist
Copyright: Medical News
Today
Not to be reproduced without permission of Medical News
Today
http://www.medicalnewstoday.com/articles/176083.php
Lives
Lived
Sharon Enkin
Wife, mother, grandmother, aunt to many, teacher,
community charitable leader, supporter of
Israel. Born March 18,
1927, in Winnipeg. Died Sept. 8, 2009, in Milton, Ont., of septicemia,
aged 82.
Sharon Enkin was one of three daughters of Buirt and
Fanny Segal. The Segals settled in St.
Walburg in northern
Saskatchewan during the Depression. They were the only Jewish family in
town. In addition to owning the general store, Buirt was one of the
town founders and served as
mayor for some years.
The family
retained their connection to Judaism and Israel, annually making the arduous
day-
long journey on mud roads into North Battleford to attend the
synagogue for major holidays.
Sharon displayed her talents early, winning
many public-speaking awards. When her family
moved back to
Winnipeg, she continued her education and interest in the arts at the
University of
Manitoba. In 1949, she went on a trip that changed
her life and sparked an abiding interest in
Israel. This was the
first Canadian trip permitted for students to the new state of Israel. Instead
of returning to Canada, Sharon stayed on for two years, studying at
the Hebrew University,
teaching English, becoming fluent in Hebrew
and establishing lifelong friendships.
On her return to Canada after her
father's stroke, Sharon headed to Toronto seeking a career in
radio
theatre productions. There she met Larry Enkin. They married in 1954 and moved
to
Hamilton, where Larry's father owned a men's clothing
manufacturing company. Sharon and
Larry had three children, Peri,
James and Marc. Throughout their marriage of more than 55
years,
Sharon's personality and talents thrived.
In Hamilton, Sharon started a
summer program for inner-city children called Painting in the Park.
She led this for 10 years, bringing art classes and theatre to
countless children. She followed this
by teaching drama to children
and acting in local productions.
In her 50s, Sharon furthered her education
in teaching and drama at the University of Toronto.
These studies
led to another bachelor's degree and the launch of Golden Horseshoe Players, a
non-profit professional theatre company presenting values-related
performances in Ontario
schools. Thousands of students saw these
plays, and many young actors got their professional
start with the
company. Sharon's most recent effort was to launch a fundraising initiative to
provide birthday parties for children in Israel who would otherwise
not have one.
Sharon suffered swelling in her legs from lymphedema, which
together with osteoarthritis made
walking extremely difficult, and
underwent several surgeries. Yet she continued to walk until the
end, rejecting any support except her cane, an example of her
indomitable will not to give in.
Larry Enkin is Sharon's husband, Robyn Rypp
is Sharon's niece and Howard Rypp is Sharon's
nephew.
http://www.theglobeandmail.com/life/facts-and-arguments/sharon-enkin/article1420043/
TINA
THE LINK FOR THIS NEXT ONE SAID THERE WAS AN ERROR but the study itself
I had a link that went thru ok, so that is what I am sending
below
error link: Physiotherapy cuts complications after breast
surgery
study published on bmj.com today showed that women who had received
phsyiotherapy had a
significanty reduced risk of secondary
lymphedema after breast ...
STUDY LINK: http://www.bmj.com/
Problem
of immortal time bias in cohort studies
Well designed observational studies
have made important contributions to our understanding of
the risks
and benefits of drug treatment. Such studies are often the first to identify or
confirm
important adverse health events associated with drugs and
can assess aspects of drug safety.
Cohort studies are often
preferred to case-control studies because they are less susceptible to
certain biases, but the inappropriate accounting of follow-up time and
treatment status in the
design and analysis of such studies can
introduce immortal time bias, say the authors of this
research
methods and reporting article, using the example of statins for preventing
progression
of diabetes.
THEN THE LINK FOR THE TITLE Problem
of immortal time bias... is: http://www.bmj.
com/cgi/content/citation/340/mar12_1/b5087
but there I needed to
be a member for any further info and I dont join things:
Therapy May
Relieve Breast Cancer Surgery Complication
A common complication of breast
cancer surgery can be prevented or reduced if patients receive
physical therapy, including massage and shoulder exercises, soon after
their operation, a new
study suggests.
Secondary lymphedema --
caused by damage to the lymphatic system during treatment -- results
in
fluid retention and arm swelling. It affects 71 percent of patients within 12
months of breast
cancer surgery and can cause disfigurement,
anxiety, depression and emotional distress.
Maria Torres Lacomba, a
professor of physiotherapy at Alcala de Henares University in Madrid,
Spain,
and colleagues selected 120 women who had breast cancer surgery involving
removal of
lymph nodes and divided them into two groups -- an
intervention group that received early
physiotherapy and education,
and a control group that received education only. Both programs
lasted three weeks and the patients were followed up four weeks after
surgery and again three,
six and 12 months after surgery.
The
therapy included lymph drainage, scar tissue massage and shoulder exercises
supervised by
a physiotherapist. The education program included
materials about the lymphatic system and
advice on how to avoid
injury and prevent infection.
After one year, 7 percent of women in the
intervention group and 25 percent of those in the
control group
developed secondary lymphedema. The researchers also found that secondary
lymphedema was diagnosed four times earlier in the control group than in
the intervention group,
according to the report published online
Jan. 12 in the BMJ.
Further research is needed to determine whether early
physical therapy after breast cancer
surgery offers longer-term
protection against secondary lymphedema, the researchers said.
More
information
The American Cancer Society has more about breast cancer
patients and lymphedema.
Copyright © 2010 ScoutNews, LLC. All rights
reserved.
http://www.palmbeachpost.com/health/therapy-may-relieve-breast-cancer-surgery-complication-
176500.html
Physical Therapy Can Cut Risk of Post-Surgical
Lymphedema
Condition is one of the most common complications of breast
cancer surgery
WEDNESDAY, Jan. 13 (HealthDay News) -- The risk of
secondary lymphedema in breast
cancer surgery patients can be
significantly reduced by the early introduction of post-surgical
physical therapy, according to a study published online Jan. 12 in
BMJ.
María Torres Lacomba, of Alcalá de Henares University in Madrid, Spain,
and colleagues
conducted a study of 120 women who underwent breast
cancer surgery involving the dissection of
axillary lymph nodes.
All the participants were given education about the lymphatic system and
on strategies to avoid injury and reduce the risk of infection. The
intervention group also
received a program of physical therapy,
including manual lymph drainage, scar tissue massage
and shoulder
exercises.
In all, 116 women completed follow-up at one year, and 18 (16
percent) developed secondary
lymphedema, including 14 (25 percent)
in the control group and four (7 percent) in the
intervention
group, the researchers found.
"This result emphasizes the role of
physiotherapy in the awareness, prevention, early diagnosis,
and
treatment of secondary lymphedema," the authors write. "Secondary lymphedema is
a
chronic condition, which has negative effects on the quality of
life of patients. The increase in risk
factors associated with
secondary lymphedema, such as ageing populations and the growing
prevalence of obesity, along with the gradual improvement in rates of
survival from cancer,
suggest that secondary lymphedema will remain
a
challenge."
http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Physical-Therapy-
Can-Cut-Risk-of-Post-Surgical-Lym/ArticleNewsFeed/Article/detail/651806?
contextCategoryId=40157
then the full text link:
http://www.bmj.com/cgi/content/full/340/jan12_1/b5396
FULL TEXT INFO - has
tables so not sure if they will be a problem for you and i didnt know if
you wanted all of this or not:
Research
Effectiveness of
early physiotherapy to prevent lymphoedema after surgery for breast cancer:
randomised, single blinded, clinical trial
María Torres Lacomba,
professor of physiotherapy1, María José Yuste Sánchez, professor of
physiotherapy1, Álvaro Zapico Goñi, professor of obstetrics and
gynaecology1,2, David Prieto
Merino, lecturer3, Orlando Mayoral del
Moral, professor of physiotherapy4, Ester Cerezo
Téllez, research
fellow1, Elena Minayo Mogollón, research fellow1
1 Physiotherapy Department,
School of Physiotherapy, Alcalá de Henares University, E-28871
Alcalá de Henares, Madrid, Spain, 2 Príncipe de Asturias University
Hospital, Alcalá de
Henares, Madrid, 3 Medical Statistics Unit,
Department of Epidemiology and Population Health,
London School of
Hygiene and Tropical Medicine, London, 4 Physiotherapy Department,
Provincial Hospital, Toledo, Spain
Correspondence to: M Torres
Lacomba
[email protected]
Abstract
Abstract
Introduction
Methods
Results
Discussion
References
Objective
To determine the effectiveness of early physiotherapy in reducing the risk of
secondary lymphoedema after surgery for breast cancer.
Design
Randomised, single blinded, clinical trial.
Setting University hospital in
Alcalá de Henares, Madrid, Spain.
Participants 120 women who had breast
surgery involving dissection of axillary lymph nodes
between May
2005 and June 2007.
Intervention The early physiotherapy group was treated
by a physiotherapist with a
physiotherapy programme including
manual lymph drainage, massage of scar tissue, and
progressive
active and action assisted shoulder exercises. This group also received an
educational strategy. The control group received the educational
strategy only.
Main outcome measure Incidence of clinically significant
secondary lymphoedema (>2 cm
increase in arm circumference
measured at two adjacent points compared with the non-affected
arm).
Results 116 women completed the one year follow-up. Of these,
18 developed secondary
lymphoedema (16%): 14 in the control group
(25%) and four in the intervention group (7%). The
difference was
significant (P=0.01); risk ratio 0.28 (95% confidence interval 0.10 to 0.79). A
survival analysis showed a significant difference, with secondary
lymphoedema being diagnosed
four times earlier in the control group
than in the intervention group (intervention/control, hazard
ratio
0.26, 95% confidence interval 0.09 to 0.79).
Conclusion Early physiotherapy
could be an effective intervention in the prevention of secondary
lymphoedema in women for at least one year after surgery for breast
cancer involving dissection
of axillary lymph nodes.
Trial
registration Current controlled trials ISRCTN95870846 [controlled-trials.com]
.
Introduction
Abstract
Introduction
Methods
Results
Discussion
References
Acquired
interruption or damage to the axillary lymphatic system after surgery or
radiotherapy
for breast cancer can lead to regional or generalised
accumulation of lymph fluid in the interstitial
space, known as
secondary lymphoedema.1 This condition is the most important chronic
complication
after dissection of the axillary lymph nodes2 3 4 5 and has a tendency to
progress.
Secondary lymphoedema can cause disfigurement, physical
discomfort, and functional
impairment. Anxiety, depression, and
emotional distress are more common in patients with than
without
secondary lymphoedema. This can affect social relationships, undermining body
image
and self esteem.6 7 8 The condition may also precipitate
cellulitis, erysipelas, lymphangitis, and
occasionally
lymphangiosarcoma.9 10 11
Reported incidence rates for secondary lymphoedema
vary depending on the method used for
measurement.12 Inconsistent
definitions and the lack of a standard classification system have
resulted in diverse incidence rates for secondary lymphoedema, ranging
from 5% to 56% within
two years after surgery.7 13 14 15 16 After
axillary lymph node dissection the incidence of
secondary
lymphoedema is about 23-38% if the criterion used to identify it is a greater
than 2 cm
increase in upper arm circumference measured at two
adjacent points compared with the
circumferences in the other
arm.17 Most women (71%) develop secondary lymphoedema within
12
months after surgery for breast cancer.18 19
The factors that might
influence the development of secondary lymphoedema after surgery are
the
number of lymph nodes removed, radiotherapy to the axilla, postoperative wound
infection,
postsurgical drainage time, lack of mobility, and
obesity.18 20 21 22 23 24
Currently, women with breast cancer have a 77%
probability of surviving at least 10 years.25 26
Consequently the
effective prevention and management of complications that can impair function
and affect quality of life after treatment are
important.15
Efforts have been made to reduce the risk of secondary
lymphoedema by preoperative and
postoperative counselling and
education27 28 and by early detection.27 29 A randomised clinical
trial on the prevention of secondary lymphoedema through exercises and
an educational strategy,
however, lacked sufficient evidence.30 We
determined the effectiveness of an early
physiotherapy programme in
reducing the risk of secondary lymphoedema in women after
surgery
for breast cancer involving dissection of axillary lymph
nodes.
Methods
Abstract
Introduction
Methods
Results
Discussion
References
We
carried out a randomised, single blinded, clinical trial of women after
unilateral breast cancer
surgery with axillary lymph node
dissection at the Príncipe de Asturias Hospital in Madrid
between
May 2005 and June 2007. We excluded women without axillary lymph node
dissection or
with bilateral breast cancer, systemic disease,
locoregional recurrence, or any contraindication to
physiotherapy.
Eligible women gave written informed consent to
participate in the study after breast cancer had
been confirmed by
biopsy. Each participant was assessed preoperatively and between days 3 and
5 after hospital discharge. Equal numbers of women were then randomly
allocated by computer
using EPIDAT version 3.1 (Xunta de Galicia,
Spain)31 to either early physiotherapy and an
educational strategy
(early physiotherapy group) or the educational strategy only (control group).
Both programmes lasted three weeks, with three visits each week.
The main outcome was the
incidence of secondary
lymphoedema.
Follow-up
Initially we scheduled four follow-up visits: four
weeks after surgery (shortly after the completion
of the
intervention) and three, six, and 12 months after surgery. These dates were,
however,
flexible, depending on the participant’s availability. At
all visits lymphoedema was assessed using
the same protocol.
If
patients experienced pain, discomfort, or any other symptoms, they could
contact the
physiotherapist and a visit would be arranged. If
secondary lymphoedema was diagnosed then
complex decongestive
physiotherapy was carried out,32 33 34 which would effectively interrupt
follow-up.
Interventions
Each group had one physiotherapist, who
carried out all interventions. Before the study it was
agreed that
both groups would receive the same educational intervention. The
physiotherapists
had more than five years’ experience in the
treatment of vascular diseases using lymphatic
drainage. They were
the only study members aware of group allocation.
Early physiotherapy
group—The intervention included the manual lymph drainage technique
used for the treatment of postoperative oedema (thorax, breast, axilla,
and upper arm of affected
side), using a modification of the
strokes described by Leduc (only resorption strokes were used)
32
34; progressive massage of the scar (progressing from Jacquet and Leroy pincer
to
Wetterwald pincer)32 35; stretching exercises for levator
scapulae, upper trapezius, pectoralis
major, and medial and lateral
rotators muscles of the shoulder36; and progressive active and
action assisted shoulder exercises, started in conjunction with
functional activities and
proprioceptive neuromuscular facilitation
exercises without resistance (rhythmic initiation
progressing from
passive to active-assistive to active movement in two diagonal symmetrical
bilateral patterns and asymmetrical reciprocal patterns: D1 into flexion
from hitch hike to swat
fly, and into extension from swat fly to
hitch hike, and D2 into flexion from hand in opposite
pocket to
carry tray, and into extension from carry tray to hand in opposite pocket).37
If axillary
web syndrome was diagnosed the physiotherapy protocol
extended the manual lymph drainage
technique to axilla and to
proximal ipsilateral arm and included specific thumb manual lymph
drainage on the characteristics taut cords, to make them gradually more
flexible. The early
physiotherapy group also did shoulder exercises
and stretching at home once daily during the
three week
intervention period.
Educational strategy (both groups)—The educational
strategy consisted of instruction with
printed materials about the
lymphatic system, concepts of normal load versus overload, the
source of secondary lymphoedema, the identification of possible
precipitating factors, and the
four categories of interventions to
prevent secondary lymphoedema (avoidance of trauma or
injury,
prevention of infection, avoidance of arm constriction, and use and exercise of
the arm),27
28 38 39 together with individual strategies for
implementing these measures.
Assessments
A different physiotherapist did
the two initial and four follow-up assessments of all participants
and remained blinded to group allocation. Participants were instructed
not to reveal their
allocation.
Lymphoedema—Direct measurement
of the presence and severity of lymphoedema is difficult
and
different diagnostic criteria have been described, including comparison between
preoperative
and postoperative measurements within the affected arm
and comparison of measurements
between the affected and unaffected
arms.16 29 40 41 42 43 For our main analysis we used the
criteria
stated in the trial protocol—that is, a 2 cm or greater increase in the
circumference of
any two adjacent points compared with measurements
in the other arm.19 41 44 45 46 We also
carried out the analysis
using other criteria (data not shown).
Arm measurements—Whatever the
criteria used for diagnosing lymphoedema they are all based
on
changes in size or volume of the arms. Arm circumferences were measured at each
visit and
always following the same procedure, using a standard 1 cm
wide, retractable, fibreglass tailor’s
tape measure (Babel, Spain).
With the patient in an upright sitting position with both arms on a
table, shoulders in neutral rotation and flexion of 45°, and forearms
at maximum supination, we
measured the circumference at 5 cm
intervals along both arms, using the elbow fold as the
reference
starting point. This has been reported as a valid and reliable method for
accurately
quantifying and diagnosing secondary lymphoedema.47 48
49
Other variables—During the preoperative assessment we collected personal
data on the
participants, including age, ethnicity, marital status,
body mass index, job, educational level,
socioeconomic status,
information on breast cancer, and medical history. In postoperative
assessments, data were collected on the type of surgery done, the
number of lymph nodes
removed, the use of adjuvant treatment, and
the development of seroma and infection.
Participants were also
asked an open question about whether they had any pain. If they did, a
physical
examination was carried out to find the source, including axillary web
syndrome. The
diagnostic criteria for axillary web syndrome were
pain and restriction of range of motion in the
shoulders, with
associated visible or palpable taut cords of tissue in the axilla in maximal
shoulder abduction.50 51 52 53 54 Other secondary outcomes were
measured according to the
protocol but are not reported
here.
Statistical analysis
The clinical criterion we chose to determine
lymphoedema (binary variable) was based on
changes in circumference
along the arm (continuous variable). The raw data are therefore
measures of circumference. To obtain the binary outcome several
intermediate variables need to
be computed from these measurements
(see web extra on bmj.com). The important variable here
would be
the maximum difference in arm circumference between any two adjacent points. A
patient would have a diagnosis of secondary lymphoedema if the
maximum difference between
any two adjacent points was 2 cm or
greater. Lymphoedema can also be determined from the
increase in
volume ratio of both arms (volume of affected arm divided by volume of
unaffected
arm). 29 30 42 44 55 56 The volume ratio is computed in
the variable "change in volume ratio"
(presented as percentages).
Although we chose not to use this as part of our criteria for clinical
diagnosis we include a continuous analysis on this variable. This
variable can be easily
interpreted as an increase or decrease of
the proportional difference of the volumes of both arms
(affected
minus unaffected; see web extra on bmj.com). Total arm volume was calculated by
adding up all the partial volumes between every two adjacent
measurements. Each of these
partial volumes was calculated by an
approximation to a truncated cone with the formula:
V=D(C12+C22+C1C2)/12
where C1 and C2 are the circumferences and the two adjacent locations and D
is the distance
between C1 and C2. We have not included hand volume
as this is difficult to model with a
truncated cone. Truncated cone
calculations of limb segment volumes using the circumference of
segments have been reported to be reliable.16
Power calculations and
sample size
Although the sample size was limited by patients’ availability
we did some power calculations.
With this sample size and after 3%
of dropouts, we would have a power of 70% to detect a
difference of
20% in the incidence of secondary lymphoedema between the groups. This assumes
an incidence of 30% in the control group (according to findings in
earlier studies16 17 19 44) and
setting a type I error of
0.05.
Statistical analyses were done using Stata version 10.0.57 For the
primary analysis we compared
the groups in three ways. Firstly, we
used a binary outcome analysis to compare the incidence of
lymphoedema, determined according to the chosen criteria. Secondly, we
used a continuous
outcome analysis to compare the variables
"maximum difference in arm circumference between
two adjacent
locations" and "change in volume ratio." Thirdly, as we had recorded the timing
of
diagnosis of lymphoedema we carried out a survival analysis for
the binary outcome. We
compared the incidence of lymphoedema using
Fisher’s exact test. Logistic regression was used
when we needed to
adjust for other variables. For the continuous outcomes sufficient data
ensured the asymptotic properties of Student’s t tests to compare
means. A Cox proportional
hazard model was used to compare the
survival rate between the
groups.
Results
Abstract
Introduction
Methods
Results
Discussion
References
Of
120 women recruited, 60 were assigned to early physiotherapy and an educational
strategy
and 60 to the educational strategy only (fig 1). All
variables were similarly distributed between
the groups at
randomisation (preoperative visit; table 1). The volume ratios were around 1 in
both
groups. This was expected as no lymphoedema was present at the
preoperative assessment.
Overall, 116 women completed the follow-up
assessments; 59 in the intervention group and 57 in
the control
group.
View larger version (28K):
[in this window]
[in a
new window]
[PowerPoint Slide for Teaching]
Fig 1 Progress of
participants through study
View this table:
[in
this window]
[in a new window]
Table 1 Comparison between
randomised groups at baseline. Values are numbers
(percentages)
unless stated otherwise
Table 2 shows the numbers of women in
both groups with a diagnosis of secondary lymphoedema.
The
incidence of secondary lymphoedema in the control group (14 cases, 25%) was
significantly
higher than in the intervention group (four cases, 7%;
P=0.010). Risk factors for secondary
lymphoedema18 22 23 24 were
similar between the groups, therefore adjustment for these was
not
necessary (table 1). Body mass index was higher in the intervention group,
therefore the odds
ratio for treatment was adjusted by body mass
index (table 2). The crude effect showed no
difference.
View this table:
[in this window]
[in a
new window]
Table 2 Comparison of secondary lymphoedema in groups
Table 3 compares the continuous variables for the outcome
(parametric tests) between the
groups. By the 12 month follow-up
visit the volume ratio between arms had increased in both
groups: in
the control group the volume of the affected arm was on average 5.1% greater
than
that of the unaffected arm, whereas in the intervention group
the affected arm was on average
only 1.6% greater than the
unaffected arm. The difference between groups was significant (P=0.
0065). The maximum difference between two adjacent points was on average
also larger in the
control group than in the intervention group
(1.15 cm v 0.68 cm, P=0.0207). Figures 2 and 3 show
the
distributions of these variables in the groups. The distributions in the
control group are more
skewed to the right.
View
larger version (20K):
[in this window]
[in a new window]
[PowerPoint
Slide for Teaching]
Fig 2 Increase in volume ratios between arms. Vertical
lines correspond to cut-off values for
diagnoses of lymphoedema in
other studies (>5% and > 10% increase)
View
larger version (20K):
[in this window]
[in a new window]
[PowerPoint
Slide for Teaching]
Fig 3 Maximum increase in arm circumference (affected
arm–unaffected arm) that could be
observed at least at two adjacent
points. Vertical line corresponds to binary criteria used here to
diagnose lymphoedema—that is, a 2 cm or greater increase in arm
circumference observed at
least at two adjacent points in affected
arm compared with unaffected arm
View this
table:
[in this window]
[in a new window]
Table 3 Continuous
analysis of circumferential and volume measurements. Values are means
(standard
deviations) unless stated otherwise
The rate of survival was
better in the intervention group than in the control group. Secondary
lymphoedema
developed four times more rapidly in the control group (intervention
group/control
group, hazard ratio 0.26, 95% confidence interval 0.09
to 0.79; P=0.010). The shape of the failure
curves (1 minus
survival) suggests that the protective effect of early physiotherapy remained
for
a long time, whereas the proportion of patients with a
diagnosis of secondary lymphoedema in the
control group increased
progressively (fig 4).
View larger version (26K):
[in this
window]
[in a new window]
[PowerPoint Slide for Teaching]
Fig 4
Failure time for development of secondary lymphoedema by group
Discussion
Abstract
Introduction
Methods
Results
Discussion
References
Early
physiotherapy with an educational strategy after surgery for breast cancer that
involved
dissection of axillary lymph nodes was associated with a
lower risk of secondary lymphoedema
than the educational strategy
only (control group) after 12 months of follow-up: 25% in the
control group compared with 7% in the intervention group. Secondary
lymphoedema developed
from six to 12 months postoperatively, which
agrees with previous studies.29 30 This could be
due to the sum of
various risk factors associated with secondary lymphoedema: axillary lymph
node dissection, the number of lymph nodes removed (between 10 and 20
nodes were removed in
17 of the 18 women with secondary
lymphoedema), overweight (12 of the 18 women had a body
mass index
>25), and postoperative complications (all 18 women had postoperative
complications) along with the effect of radiotherapy (completed in the
fourth postoperative
month) as well as the gradual weight gain (11
of 12 women with secondary lymphoedema who
were overweight at
baseline progressively increased in weight from six months after surgery).18
20 21 23 24 Further investigation of these risk factors is
needed.
Secondary lymphoedema is thought to be caused by damage to the
axillary lymphatic system,
impairing lymph drainage from the arm,
although there is strong evidence that total blood flow in
the arm
and vascular bed size are increased in secondary lymphoedema.1 Recently, a
study to
develop an animal model of postsurgical lymphoedema
reported that after nodal excisions the
limbs became progressively
more oedematous up to three days after node dissection and that the
swelling decreased but had not resolved 16 weeks after surgery.58
Taking this into account and
since the basic rule is that all
oedemas result from an imbalance between filtration and resorption
(tissue drainage), the implementation of a measure to restore this
balance during the period of
higher filtration should prevent or
delay the onset of secondary lymphoedema. Our study
included manual
lymph drainage, which is a special method involving gentle massage to improve
the lymph circulation, especially subcutaneous circulation, to
stimulate the initial lymphatics, and
to stretch the lymph vessels,
consequently improving the removal of interstitial fluid. Manual
lymph drainage encourages and improves resorption without increasing
filtration.34 59 It has
been shown to be effective in the treatment
of lymphoedema because it improves the removal of
fluid from
interstitial space.32 34 59 60 We therefore think that the implementation of
manual
lymph drainage after surgery for breast cancer in the early
physiotherapy group could have
contributed to the better results in
that group. This, together with early physiotherapy for other
effects of breast cancer surgery, and related to the onset of secondary
lymphoedema,18 20 21 23
24 could explain the effectiveness of early
physiotherapy in the prevention of secondary
lymphoedema in women
who have had surgery for breast cancer with axillary lymph node
dissection—at least during the first year after surgery.
We also
found that 12 of the 18 women who developed secondary lymphoedema had axillary
web
syndrome during the second and third week after surgery. The
axillary web syndrome is a known
but poorly studied complication of
surgery.54 61 62 No study has shown any link between the
axillary
web syndrome and the onset of secondary lymphoedema. We and others32 50 suggest
that the axillary web syndrome may be a sign of injury to the
lymphatic system and it could
produce a lymphatic overload as a
result of failure of the lymphatic system. This overload,
together
with other factors, could be responsible for the onset of secondary
lymphoedema. When
axillary web syndrome was diagnosed in the
postoperative period in the intervention group,
specific manual
lymph drainage strokes were applied, together with progressive active and
action
assisted shoulder and arm exercises. Manual lymph drainage
acted on the pain and inflexibility
inherent to the vascular
inflammation of the lymphatic vessel; also, if the axillary web syndrome
did produce a lymphatic overload, and therefore a possible subclinical
oedema, the action of the
manual lymph drainage could help with
reabsorption.32 34 59 60 63 Further research on a
possible relation
between the axillary web syndrome and the development of secondary
lymphoedema in women after breast cancer surgery is
needed.
Comparison with other studies
Secondary lymphoedema is a common
complication of breast cancer surgery.2 3 4 5 As far as we
are
aware, only one study has examined the effect of exercise and specific
recommendations
about self care to minimise the onset of secondary
lymphoedema.29 30 In addition, several
studies on the effectiveness
of early rehabilitation after breast surgery reported data on
lymphoedema as secondary end points.64 65 66 67 68 Box and colleagues
evaluated an
intervention to minimise postoperative lymphoedema in
65 women and stated that a
physiotherapy management care plan,
including exercise strategies that were not described in the
paper,
and progressive educational strategies may reduce the occurrence of secondary
lymphoedema two years after surgery.30 Our results for onset of
secondary lymphoedema one
year after surgery are better than their
results. Exercise is used in the management of secondary
lymphoedema
of the arm to promote the recruitment of collateral lymphatics pathways.69 This
might explain the difference in results between the studies. The
intervention programme in the
study by Box and colleagues did not
include the diagnosis and treatment of postoperative
vascular
complications (such as seroma and axillary web syndrome), which could be
related to the
onset of lymphoedema and could benefit from a proper
manual physiotherapy.50 51 52 53
Many studies have assessed the
effectiveness of rehabilitation in patients after breast cancer
surgery.64 65 66 67 68 All of them present limitations in the sample
size and assert that
physiotherapy is beneficial for shoulder
mobility and functional capacity without causing adverse
effects in
the postoperative period, but not in preventing secondary lymphoedema. All the
studies
focused on the recovery or maintenance of the mobility of
the shoulder so that the intervention
was based on mobility and
stretching exercises of the shoulder.64 65 66 67 68 Only one study
included massage (not manual lymph drainage) in one of the intervention
groups. This group
showed better results, but the onset of
lymphoedema was not prevented.65 The development of
restricted
shoulder mobility is one of the most important factors impairing functional
activities of
patients after breast surgery.70 A delayed onset
physiotherapy programme as required has been
suggested to improve
shoulder mobility and daily activities of living.71 None of these studies
could correlate the exercise programme with the incidence of
lymphoedema.64 65 66 67 68 Our
results in relation to the study by
Box and colleagues30 could result from the early diagnosis and
treatment of postoperative vascular complications.
Strengths and
limitations of the study
We believe that our study shows evidence of the
positive effect of early physiotherapy in the
prevention of
secondary lymphoedema, but the study is limited by the duration of follow-up
(one
year after surgery) and recruitment in just one hospital.
Although we have no reason to suspect
systematic differences in care
provided by this hospital and other regional hospitals or hospitals
in other developed countries, this may limit the external validity of
the results. Furthermore, that
the physiotherapy was provided by
trained physiotherapists may limit the generalisability of this
intervention to other settings.
Another limitation is that we chose
a particular criterion for diagnosing lymphoedema. We
followed the
criterion specified in our protocol but other criteria could have been used.
For
example, if the criterion of a greater than 10% increase in the
volume ratio between arms
(affected v unaffected) had been chosen,
the patients with a diagnosis of secondary lymphoedema
would be
those appearing to the right of the vertical line furthest to the right in
figure 2. Using
this criterion the early physiotherapy group would
have three cases (5%) and the control group
13 (23%), with a risk
ratio of 0.22 (95% confidence interval 0.06 to 0.74); results similar to those
in table 2.
A further limitation is the possibility of
measurement errors. We have no reason to believe,
however, that
this will have a differential effect on both intervention and control groups.
The
physiotherapist who took the measurements was blinded to the
patient’s treatment allocation.
Both groups were reasonably balanced
for baseline characteristics. The use of ratios between
arms also
reduces errors that could be correlated with some patient characteristics, such
as body
mass index. In general, we believe that measurement error
might have the effect of slightly
increasing the variance in the
measurement, but not in a biased way. At the most, this would
reduce statistical power of the comparisons to identify differences but
would not invalidate the
ones observed.
Conclusion
Early
physiotherapy could help to prevent and reduce secondary lymphoedema in
patients after
breast cancer surgery involving dissection of
axillary lymph nodes, at least for one year after
surgery. This
result emphasises the role of physiotherapy in the awareness, prevention, early
diagnosis, and treatment of secondary lymphoedema.
Secondary
lymphoedema is a chronic condition, which has negative effects on the quality
of life of
patients. The increase in risk factors associated with
secondary lymphoedema, such as ageing
populations and the growing
prevalence of obesity,18 23 24 along with the gradual improvement
in rates of survival from cancer,26 suggest that secondary lymphoedema
will remain a challenge.
Further studies are needed to clarify
whether early physiotherapy after breast cancer surgery
can remain
effective in preventing secondary lymphoedema in the longer
term.
What is already known on this topic
Secondary
lymphoedema is the most important chronic complication after breast cancer
surgery
with dissection of axillary lymph nodes
Early
postsurgical rehabilitation improves shoulder mobility and functional capacity
without
causing adverse effects but does not prevent secondary
lymphoedema
What this study adds
Early physiotherapy with an
educational strategy compared with the educational strategy alone
was associated with a lower risk of secondary lymphoedema 12 months
after surgery for breast
cancer with axillary node
dissection
The axillary web syndrome was an important complication in
the immediate postoperative period
Cite this as: BMJ
2010;340:b5396
--------------------------------------------------------------------------------
We
thank the staff and patients of the Gynecology Service of Príncipe de Asturias
University
Hospital (Madrid), the Physical Therapy Research Unit at
Alcala University (Madrid), and Jean
Claude Ferrandez for their
valuable suggestions. The Physical Therapy Department of Alcalá
University and Principe de Asturias Hospital provided the facilities for
the study.
Contributors: MTL conceived and designed the study. AZG recruited
the patients. MTL (blinded
assessor), ECT, EMM (physiotherapy and
educational strategies in the early physiotherapy
group), and MJYS
(educational strategies in control group) devised the interventions. DPM
(blinded analyst), MTL, and OMdM analysed and interpreted the data. OMdM
collected and
assembled the data. MTL, OMdM, and DPM wrote the
manuscript. All authors approved the
final manuscript.
Funding:
This study was funded by the Health Institute Carlos III (Protocol PI071124) of
the
Spanish Health Ministry.
Competing interests: All authors
have completed the unified competing interest form at www.
icmje.org/coi_disclosure.pdf (available on request from the
corresponding author) and declare (1)
no financial support for the
submitted work from anyone other than their employer; (2) no
financial relationships with commercial entities that might have an
interest in the submitted work;
(3) no spouses, partners, or
children with relationships with commercial entities that might have
an
interest in the submitted work; and (4) no non-financial interests that may be
relevant to the
submitted work.
Ethical approval: This study was
approved by the human research ethics committee of the
Príncipe de
Asturias
Hospital.
References
Abstract
Introduction
Methods
Results
Discussion
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This is an open-access article
distributed under the terms of the Creative Commons Attribution
Non-commercial License, which permits use, distribution, and
reproduction in any medium,
provided the original work is properly
cited, the use is non commercial and is otherwise in
compliance with
the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http:
//creativecommons.org/licenses/by-nc/2.0/legalcode.
dance step at a time for Colbert
By Diane Chiddister
Since being
diagnosed with an aggressive breast cancer nine months ago, Shelley Colbert has
endured chemotherapy, major surgery and radiation treatment. Along
with the resulting pain,
fatigue and anxiety of those treatments, Colbert has grappled with another challenge as well —
accepting
help from the community where she grew up, raised her children, and cared for
the
children of others.
“It’s very hard to ask for help,”
Colbert said in an interview last week. “I’m tremendously
grateful
to all who have stepped forward with help or good wishes.”
While asking for
help is a struggle for Colbert, who prides herself on her independence, she’s
reluctantly allowing her friends to ask for her. Specifically,
friends have organized a benefit
concert this Saturday, Jan. 16,
from 5 p.m. to midnight at the Emporium with a variety of local
musicians. The music is organized by Steve McColaugh.
Carl
Schumacher and Friends will play from about 5 p.m. to 7, Dawn Cooksey and Route
68
South at 8 p.m. and McColaugh’s band, the Undercovered, will
play from 9:30 p.m. on.
Colbert vetoed charging admission for the event,
according to her longtime friend and event
organizer Peggy
Koebernick, so there is no charge, but donations are welcome. The purpose of
the event is to help cover Colbert’s living expenses since she has been unable to work since last
March and will remain unable for the
foreseeable future. While most of Colbert’s medical
treatment is
currently covered by a special short-term form of Medicaid, and a benefit fun
run/walk last May raised enough money to pay Colbert’s living
expenses until now, those funds
are running out.
“I was thinking
about what it would be like to be in her shoes,” Koebernick said, regarding her
decision to organize the event. “I wanted to tap into the energy of
the community.”
The community’s energy so far has been extraordinary,
according to Colbert, who describes
herself as astonished at
people’s generosity, both in donating to a special fund at US Bank, and
offering goods and services. Those who can’t attend the fundraiser but
would like to make a
donation may do so at the Shelley Colbert Fund
at US Bank.
Colbert, one of a family of five children raised by her parents Chuck and Rita, grew up in Yellow
Springs. She left town to go to
college, and returned after earning a degree in early childhood
education. When her sons, Ben and Spencer Beggs, were small, Colbert
started her childcare
business at her Miami Drive home, where for
23 years she cared for village children until she
received her
diagnosis of Stage III breast cancer. At that time, doctors told her she would
no
longer be able to lift children after her treatment, Colbert
said, adding with a smile that they also
advised her to give up
chopping wood and hauling water from the well.
After chemotherapy ended in
August, Colbert, who is 60, had a mastectomy in September. And
cancer doesn’t deal out any favors. The night before her surgery, her
father, who had suffered a
stroke several weeks earlier, died at
Friends Care Community. It was rough, she said, with the
saving
grace that at least all her family had already come home for her surgery and
were here
when her father died.
The chemotherapy Colbert
initially received worked remarkably well, eradicating all traces of
tumors
on her scans. Her doctors were amazed, as a complete response is relatively
rare.
However, because her cancer had been so aggressive, they urged
her to “play her hand all in”
and to accept equally aggressive
treatments in surgery and radiation.
The decision to go ahead with seven
weeks of radiation — which ends this week — has been the
hardest of
all for Colbert. Her instincts told her that so much radiation can’t be good
for her body.
Radiation often causes significant damage to the
heart, lungs and thyroid, and her doctors couldn’
t guarantee those
side effects wouldn’t happen to her.
And Colbert knows something about side
effects. The tumors themselves caused lymphedema,
leading to pain
and swelling in her right arm and shoulder area. The condition is chronic, and
Colbert is working on finding ways to manage it. She thinks
swimming could be a good antidote,
as soon as she’s allowed back
into her beloved swimming pools.
As with each step of the nine-month ordeal
so far, Colbert has struggled with making decisions
that often seem
overwhelming. Mountains of information are available on the Internet, but the
amount seems impossible to sort through, although a good friend,
Mary Miller, has volunteered
her skills to analyze research
results. But the process often makes her feel crazy, ever focused
on
cancer, cancer, cancer.
The radiation left her in pain, with skin burns, and
Colbert still worries whether she made the
right choice, or
whether, even if the radiation does buy her time, it will be in a life that
feels not
worth living. But in the end, she pursued the aggressive
treatment that her doctors urged.
“I want people to know I’m doing
everything I have to do to stay alive,” she said.
There are people who say
that cancer has taught them how to live, or helped them to live better.
So far, Shelley Colbert is not one of those people, but she hasn’t
ruled out the possibility.
“I’m hoping maybe the silver lining will reveal
itself to me soon,” she said. And the silver lining
so far has been
that cancer helped her know who her friends are, and that she has far more
friends than she ever imagined.
“I don’t know how to thank people
for all they’ve done for me,” she said. “You don’t know how
many
people care about you, but they do. It’s been heartening and humbling. This is
a fantastic
community.”
And there’s a bright spot on the horizon.
That puppy that Colbert has been longing for is the first
thing on
her list after follow-up treatment begins and the weather warms up.
“I can’t
wait to get my puppy,” she said.
While Colbert loves to dance and would like
nothing better than to dance until midnight on Jan.
16, she’s
expecting that fatigue from the radiation treatments may prevent her from doing
so. But
she’ll do her best to show up, with her new sleek and short
hair. And if she has to go home early,
well, she’ll spend a cold
winter evening warmed by the thought of her many friends, new and old,
dancing the night away.
Contact:
[email protected]
http://www.ysnews.com/stories/2010/01/011410_colbert.html
My
Bra? Color Me Furious
The bra-color meme that's sweeping Facebook and
allegedly raising awareness of breast cancer
got a nice one-two
punch from my colleague Frances Tobin.
Get the new
PD
toolbar!
Allow me to pile on.
Not for myself, but for friends
I've watched face this beast. Many of them aren't wearing bras of
any color because their breasts are long gone. Instead they might be
wearing a lymphedema
sleeve on their arms, in some cases for the
rest of their lives.
As a member of the all-too-exclusive club of
long-term ovarian cancer survivors, let me first say I
used to
resent the enormous amount of attention breast cancer got over other cancers.
Breast
Cancer Awareness Month (also known as "pink nausea" by
certain folks) seemed to begin in
late July and end in late
November, totally eclipsing the far more lethal (per capita) cancers of
ovarian and pancreatic.
Where's all the teal in September? I
realize fountains are not so good for awareness, since
they're
always teal. But where are the endless rows of candy bars and other products
sporting
teal?
Where's all the purple in November? If you're
a playwright and you want your main character to
die, you choose
ovarian if it's a woman and pancreatic if it's a guy. So where's the love for
pancreatic cancer patients?
Cancer envy – wishing you could
trade in your bad-stat cancer for a more benign variety – is
known
only to those with personal experience with this dreadful disease.
Like
it was yesterday, I remember lunch with my friend Sherri. One year after my
diagnosis with
ovarian cancer, she'd been diagnosed with breast
cancer. She gazed out the window and said,
"This is going to kill
me."
"How can you say that," I replied. "I'd give anything to trade my
statistics for yours."
"Don't ask me how I know," she said. "I just
know."
Sherri was earlier stage than me. She was younger than me. I
thought about that when, six years
later, I attended her
funeral.
For a while I went to a support group for cancer survivors of
all types. That was my light-bulb
moment. The breast cancer
patients in that group began detailing the experiences – waking up
from surgery, the day after surgery, going home with drainage tubes
attached to their armpits.
"Tubes?" I shuddered. "I guess every kind of
cancer is its own version of hell."
Bingo.
In spring of 2008,
another friend was diagnosed with breast cancer. If only I had a dollar for
every time I said: My tumor was 11 centimeters. When was the last time
you heard of an 11-
centimeter breast tumor?
"No, Donna, it's
not early stage," my friend said. "The tumor is nine centimeters." My friend
had lobular breast cancer, which can grow into the chest instead of
outward.
A few months later she got a bonus -- a second primary of lung
cancer, the kind nonsmokers get.
She's had more surgery in 18
months than I've had in my whole life.
My friend is ten years younger
than me. Her husband is a doctor. She's always been trim and fit,
and she has not a mean bone in her body.
Color me
educated.
But don't color me pink. Or teal. I want a new color. I want a
rainbow. We use the word "cancer"
for what is probably a thousand
different diseases. The segregation and disparity in funding
between types of cancer is absurd. Name any cell in your body, and
you've just named a chance
for mutation and cancer – at any time,
for any person.
Even so, I suspect women are especially vulnerable.
Their bodies are designed to grow things.
Like babies. And, it
turns out, cancer, even if they don't smoke, and they eat healthy, and
breast-
feed their children. While men can get male-specific
cancers, women's cancers seem to be more
adept at hiding til it's
too late.
Which brings us back to bra colors. Yes, awareness is good –
unless people think awareness is as
good as action. Think before
you pink, says Breast Cancer Action.
Last night on the Facebook wall of
Matthew Zachary, founder of I'm Too Young for This (aka
Stupid
Cancer), the bra-color meme was topic one for the evening. "Awareness," Matthew
wrote,
"is the same as rhetoric. Like propaganda without the
marketing. It's air. I welcome any cultural
anthropologist to
demonstrate successful awareness without action."
Years ago I attended a
lunch gathering of cancer survivors and medical professionals. The event
was supposed to end with some kind of hilarious musical spoof on the
subject of "boobs," written
by a surgeon. At the last moment, the
song got spiked. Through the grapevine I heard that a
patient
facing mastectomy found the subject not one bit funny.
After walking a
mile in the shoes of my friends, I have to say I agree. I would find no comfort
in
Facebook games about colored lingerie that my new body no longer
needed, or tight tee-shirts
with cute slogans about saving "second
base" or the "ta-tas."
Or any other campaign that emphasized the
womanliness, the beauty, the importance of breasts.
Never mind the
breasts. Save the
women.
http://www.politicsdaily.com/2010/01/11/my-bra-color-me-furious/
What
Is Turner Syndrome? What Causes Turner Syndrome?
Turner syndrome, also known
as Turners syndrome, Ullrich-Turner syndrome or Gonadal
dysgenesis,
is a chromosomal disorder that affects only females. It is characterized by the
absence of part or all of a second sex chromosome in some or all
cells. Approximately 1 in every
2,500 to 3,000 girls is born with
the condition.
People without Turner syndrome have 46 chromosomes, of
which 2 are sex chromosomes.
Females have two X chromosomes. In
people with Turner syndrome, one of those sex
chromosomes is either
missing or has other abnormalities - the chromosome may be missing in
some
cells but not in others (mosaicism or Turner mosaicism). In other words, there
are two types
of Turner syndromes:
Classical Turner syndrome -
an X chromosome is completely missing.
Mosaic Turner syndrome (mosaicism
or Turner mosaicism) - the abnormalities only occur in the
X
chromosome of some of the cells in the body.
Chromosomes are strands of DNA
(deoxyribonucleic acid) that exist in all the cells of the human
body. Chromosomes contain instructions that make a human's behavioral
and physical
characteristics.
The syndrome is named after Dr.
Henry Turner (USA 1892-1970), an Oklahoma endocrinologist,
who
described it in 1938.
Turner syndrome can cause:
Physical
disabilities
Emotional disabilities
Educational disabilities
According
to Medilexicon's medical dictionary:
Turner syndrome is "a syndrome with
chromosome count 45 and only one X chromosome; buccal
and other
cells are usually sex chromatin-negative; anomalies include dwarfism, webbed
neck,
valgus of elbows, pigeon chest, infantile sexual development,
and amenorrhea; the ovary has no
primordial follicles and may be
represented only by a fibrous streak; some affected people are
chromosomal mosaic, with two or more cell lines of different chromosome
constitution; seen in
many animal species, in the meadow vole it is
the normal female state."
What are the signs and symptoms of Turner
syndrome?
A symptom is something the patient feels and reports, while a sign
is something other people,
such as the doctor detect. For example,
pain may be a symptom while a rash may be a sign.
The signs and symptoms
of Turner syndrome vary considerably and may even appear before
birth.
Signs and symptoms before birth
Unborn females
with Turner syndrome (TS) may develop lymphedema - fluid is not properly
transported around the organs of the body, excess fluid leaks into the
surrounding tissue,
resulting in swelling. It is not uncommon for
babies born with TS to have swollen hands and feet.
The unborn baby
may also have:
•Thick neck tissue
•Cystic hygroma - swelling of the
neck
•Lower than normal weight
The following signs and symptoms may be
present at birth or during infancy
•Broad chest
•Cubitus valgus (arms
turn outwards at the elbows)
•Eyelids that droop
•Fingernails that turn
upward
•High, narrow palate (roof of mouth)
•Low hairline at the back of
the head
•Low set ears
•Receding lower jaw
•Short
hands
•Slower/delayed growth
•Small lower jaw
•Smaller height at
birth
•Smaller weight at birth
•Swelling of the hands and
feet
•Web-like neck
•Wide neck
•Widely spaced nipples
In some cases
Turner syndrome may not become apparent until later on. The following signs and
symptoms that appear later may indicate Turner syndrome:
•Growth
spurts do not occur at expected childhood times. During the first three years
of life the
baby/toddler may be of normal height. However, by the
age of three their growth rate will be
lower than
average.
The person is much shorter than expected; about 8 inches (20
cms) shorter than expected for an
adult female member of that
family (without treatment).
•Learning difficulties - the majority of girls
with TS have normal intelligence, as well as good
verbal and
reading skills. There may be some problems with math, spatial concepts, memory
skills and fine finger movements.
•Social problems - the patient
may find it hard to properly interpret other people's reactions or
emotions.
•Non-functioning ovaries - during puberty a female's
ovaries generally start producing estrogen
and progesterone (sex
hormones). The majority of girls with TS will not produce these sex
hormones, resulting in:
•No onset of menstrual
periods
•Poorly developed breasts
•Possible infertility
Although the
TS female has non-functioning ovaries and is infertile, her vagina and uterus
(womb) will generally be normal and she will usually be able to
have a normal sex life.
Approximately 30% of females with TS will
undergo some physical changes during puberty.
About 0.5% of girls
with TS can become pregnant without fertility treatment.
Other possible
signs and symptoms - as well as those listed above, the following may also be
present:
•Eyes that slant downwards
•Prominent
earlobes
•Mouth abnormalities which can cause dental problems
•Narrowing
of the aorta which may result in heart murmur
•Hypothyroidism - an
underactive thyroid gland. This can be treated with thyroxine
tablets.
•Hypertension - females with TS are more likely to suffer from high
blood pressure
•Brittle bones (osteoporosis) - caused by insufficient
estrogen
•Otitis media (middle ear infection, glue ear) - very common among
young girls with TS
•Hearing loss in adulthood - usually caused by otitis
media during childhood
•Diabetes - older and overweight females with TS have
a higher risk of developing diabetes
compared to other women of the
same age or weight
•Moles - females with TS may have a large number of
moles
•Small spoon-shaped nails
•A shorter than normal fourth finger or
toe
What are the causes of Turner syndrome?
Experts say that the loss or
abnormality of the X chromosome occurs spontaneously. If
somebody
has a child with TS, this does not mean there is a higher risk of any
subsequent
children having the condition.
TS occurs when the
baby is conceived, when the sperm enters the egg (ovum) and the egg is
fertilized.
Only females are affected.
TS occurs when the
second X chromosome is either incomplete or missing
completely.
According to the National Health Service (NHS), UK, about 1
in every 2,500 baby girls is born
with the condition. If a baby is
conceived with a missing X chromosome the pregnancy usually
miscarries (aborts naturally).
Approximately 10% of all
miscarriages during the first trimester of pregnancy are caused by
TS.
Most of us are born with two sex chromosomes. Males inherit the X
chromosome for their
mothers and the Y chromosome from their
fathers. Females inherit one X chromosome from each
parent. When a
female has Turner syndrome one X chromosome copy is either absent or
significantly
altered. The following genetic alterations of Turner syndrome are
possible:
•Monosomy - one X chromosome is completely missing. Experts
believe this is caused by an
error either in the father's sperm or
the mother's ovum (egg). Every cell in the offspring's body
has one
X chromosome missing.
•Mosaic Turner syndrome (mosaicism or Turner
mosaicism) - during the early stages of fetal
development an error
may have occurred in cell division, resulting in some cells having two X
chromosome copies, while others only have one. In some cases there may
be some cells with both
X chromosome copies, and others with one
altered copy.
•Y chromosome material - a small number of patients with TS
have some cells with just one X
chromosome copy and other cells
with just one X chromosome copy as well as some Y
chromosome
material. The individual develops as a female, but has a higher risk of
developing
gonadoblastoma (a type of cancer).
The missing or
altered X chromosome causes errors during fetal development, as well as
subsequent development after birth.
What are the risk factors for
Turner syndrome?
A risk factor is something which increases the likelihood
of developing a condition or disease. For
example, obesity
significantly raises the risk of developing diabetes type 2. Therefore, obesity
is
a risk factor for diabetes type 2.
Experts say that the
risk of having TS is the same for females in all regions of the world, races,
nationalities and socioeconomic groups. The condition occurs
randomly and is not associated with
the age of the mother or
father.
There are no known toxins or environmental factors that appear
to alter the risk of developing
TS.
How is Turner syndrome
diagnosed?
Diagnosis during pregnancy and birth - during an ultrasound test,
for example, TS may be
suspected. Amniocentesis or Chorionic villus
sampling, both antenatal tests that detect
chromosomal
abnormalities, are possible ways to confirm a diagnosis. Diagnosis may also
eventually be made if heart or kidney problems, or swelling of the
hands and feet are present at
birth.
Diagnosis during
childhood - if the child has a wide or webbed neck, a broad chest and widely
spaced nipples TS may be suspected.
If the girl eventually
has a short stature and undeveloped ovaries, TS may be
suspected.
Sometimes diagnosis is not made until later, for example,
when puberty does not occur.
Karotype - this blood test can be used to
detect extra or missing chromosomes, chromosomal
rearrangements, or
chromosomal breaks. This may be done either by taking a sample of the
amniotic
fluid while the baby is still in the uterus, or taking a blood sample from a
child/baby. If
one of the X chromosomes is missing or incomplete,
TS is confirmed.
What are the treatment options for Turner
syndrome?
Turner syndrome is a genetic condition for which there is no
current cure. However, several
treatments may help with short
stature, sexual development and learning difficulties.
Early
preventative care - it is important that the child is checked regularly so that
the risk of
complications can be minimized. Blood pressure and the
thyroid gland need to be monitored
frequently, and any necessary
treatment given immediately.
Treatment with medical specialists - as
girls with TS are more likely to develop otitis media
(inner ear
infections, glue ear) they need to be treated promptly to minimize the risk of
hearing
difficulties later in life. Treatment should be carried out
by an ENT (ear, nose and throat)
specialist.
Hormone
therapy, which may include estrogen, progesterone and growth hormones, may be
required. These treatments will be done with an endocrinologist, or
pediatric endocrinologist.
Growth hormone therapy - as soon as it is
established that the girl with TS is not growing
properly growth
hormone should be administered. Effective therapy may prevent short stature
later in life. Treatment may start as early as the age of one or two
years. A daily injection is
given. Growth hormone therapy may add
an extra 10cm (4 inches) to the girl's eventual stature.
Estrogen and
progesterone replacement therapy - the girl needs these two hormones to develop
sexually. Estrogen will also stop her bones from becoming brittle
(osteoporosis). The ovaries of a
girl with TS do not produce
sufficient quantities of these hormones. How much the patient is
producing herself can be determined with blood tests.
Estrogen
replacement therapy will start at the onset of puberty (11 years of age). The
patient will
initially receive low doses, which are slowly
increased. Progesterone therapy is generally given
later to trigger
menstrual periods. TS patients require sexual hormone treatment for the rest of
their lives. Treatment may be given as tablets, injections or
patches.
IVF (in vitro fertilization) - the majority of patients with TS
are unable to become pregnant
without help. If a woman with TS wants
to become pregnant she will probably require assistance,
for
example, IVF. If the patient manages to become pregnant she will need to be
monitored
closely, because of the extra strain on her heart and
blood vessels.
Counseling and psychological therapy - some patients may
develop psychological problems and
will benefit from psychological
therapy.
Learning assistance - although girls with TS generally have
normal levels of IQ, there may be
problems with numeracy, spatial
concepts, memory skills and fine finger movements. Educational
support will help the child.
What are the possible complications
related to Turner syndrome?
Heart problems - some girls with TS are born
with either heart defects or very slight heart
abnormalities which
may raise their risk of complications later in life. Defects in the aorta, the
main blood vessel leading out of the heart raises the risk of
aortic dissection (a tear in the inner
layer of the aorta). If
there is a defect in the valve between the aorta and the heart there is an
increased risk of an aortic valve stenosis (narrowing of the
valve).
High blood pressure - people with TS are much more prone to
suffer from high blood pressure
(hypertension) compared to
others.
Diabetes - overweight or older women with TS have a higher risk
of developing diabetes
compared to other women of the same age and
weight.
Hearing - gradual loss of nerve function can cause hearing loss.
Girls with TS are much more
likely to develop glue ear (otitis
media, inner ear infection), which can lead to hearing loss.
Kidney
problems - approximately 30% of TS patients have some kind of kidney
malformation,
raising the risk of hypertension and urinary tract
infections.
Hypothyroidism - having an underactive thyroid gland is more
likely among patients with TS.
Tooth loss - patients with TS have a
higher risk of having poor or abnormal tooth development,
resulting
in more tooth loss. Also, because of the shape of the mouth and palate, the
patient is
more likely to suffer from crowded and poorly aligned
teeth.
Vision - strabismus is more common among girls with Turner
syndrome (eyes to not work in
parallel and appear to be looking in
different directions). Hyperopia (farsightedness, long-
sightedness)
is more common among girls with TS.
Bones - women with TS have a
significantly higher risk of developing osteoporosis. Sometimes
there may be problems with the curvature of the spine, leading to
scoliosis. There is also a risk of
kyphosis (forward rounding of
the upper back).
Pregnancy - a woman with TS who becomes pregnant has a
significantly higher risk of developing
complications, including
gestational diabetes, high blood pressure and aortic
dissection.
Psychology - there is a greater risk of problems with
self-esteem, anxiety, depression, ADHD
(attention deficit
hyperactivity disorder). There may also be difficulties in social
situations.
Written by Christian Nordqvist
Copyright: Medical News
Today
Not to be reproduced without permission of Medical News
Today
http://www.medicalnewstoday.com/articles/176083.php
Lives
Lived
Sharon Enkin
Wife, mother, grandmother, aunt to many, teacher,
community charitable leader, supporter of
Israel. Born March 18,
1927, in Winnipeg. Died Sept. 8, 2009, in Milton, Ont., of septicemia,
aged 82.
Sharon Enkin was one of three daughters of Buirt and
Fanny Segal. The Segals settled in St.
Walburg in northern
Saskatchewan during the Depression. They were the only Jewish family in
town. In addition to owning the general store, Buirt was one of the
town founders and served as
mayor for some years.
The family
retained their connection to Judaism and Israel, annually making the arduous
day-
long journey on mud roads into North Battleford to attend the
synagogue for major holidays.
Sharon displayed her talents early, winning
many public-speaking awards. When her family
moved back to
Winnipeg, she continued her education and interest in the arts at the
University of
Manitoba. In 1949, she went on a trip that changed
her life and sparked an abiding interest in
Israel. This was the
first Canadian trip permitted for students to the new state of Israel. Instead
of returning to Canada, Sharon stayed on for two years, studying at
the Hebrew University,
teaching English, becoming fluent in Hebrew
and establishing lifelong friendships.
On her return to Canada after her
father's stroke, Sharon headed to Toronto seeking a career in
radio
theatre productions. There she met Larry Enkin. They married in 1954 and moved
to
Hamilton, where Larry's father owned a men's clothing
manufacturing company. Sharon and
Larry had three children, Peri,
James and Marc. Throughout their marriage of more than 55
years,
Sharon's personality and talents thrived.
In Hamilton, Sharon started a
summer program for inner-city children called Painting in the Park.
She led this for 10 years, bringing art classes and theatre to
countless children. She followed this
by teaching drama to children
and acting in local productions.
In her 50s, Sharon furthered her education
in teaching and drama at the University of Toronto.
These studies
led to another bachelor's degree and the launch of Golden Horseshoe Players, a
non-profit professional theatre company presenting values-related
performances in Ontario
schools. Thousands of students saw these
plays, and many young actors got their professional
start with the
company. Sharon's most recent effort was to launch a fundraising initiative to
provide birthday parties for children in Israel who would otherwise
not have one.
Sharon suffered swelling in her legs from lymphedema, which
together with osteoarthritis made
walking extremely difficult, and
underwent several surgeries. Yet she continued to walk until the
end, rejecting any support except her cane, an example of her
indomitable will not to give in.
Larry Enkin is Sharon's husband, Robyn Rypp
is Sharon's niece and Howard Rypp is Sharon's
nephew.
http://www.theglobeandmail.com/life/facts-and-arguments/sharon-enkin/article1420043/
TINA
THE LINK FOR THIS NEXT ONE SAID THERE WAS AN ERROR but the study itself
I had a link that went thru ok, so that is what I am sending
below
error link: Physiotherapy cuts complications after breast
surgery
study published on bmj.com today showed that women who had received
phsyiotherapy had a
significanty reduced risk of secondary
lymphedema after breast ...
STUDY LINK: http://www.bmj.com/
Problem
of immortal time bias in cohort studies
Well designed observational studies
have made important contributions to our understanding of
the risks
and benefits of drug treatment. Such studies are often the first to identify or
confirm
important adverse health events associated with drugs and
can assess aspects of drug safety.
Cohort studies are often
preferred to case-control studies because they are less susceptible to
certain biases, but the inappropriate accounting of follow-up time and
treatment status in the
design and analysis of such studies can
introduce immortal time bias, say the authors of this
research
methods and reporting article, using the example of statins for preventing
progression
of diabetes.
THEN THE LINK FOR THE TITLE Problem
of immortal time bias... is: http://www.bmj.
com/cgi/content/citation/340/mar12_1/b5087
but there I needed to
be a member for any further info and I dont join things:
Therapy May
Relieve Breast Cancer Surgery Complication
A common complication of breast
cancer surgery can be prevented or reduced if patients receive
physical therapy, including massage and shoulder exercises, soon after
their operation, a new
study suggests.
Secondary lymphedema --
caused by damage to the lymphatic system during treatment -- results
in
fluid retention and arm swelling. It affects 71 percent of patients within 12
months of breast
cancer surgery and can cause disfigurement,
anxiety, depression and emotional distress.
Maria Torres Lacomba, a
professor of physiotherapy at Alcala de Henares University in Madrid,
Spain,
and colleagues selected 120 women who had breast cancer surgery involving
removal of
lymph nodes and divided them into two groups -- an
intervention group that received early
physiotherapy and education,
and a control group that received education only. Both programs
lasted three weeks and the patients were followed up four weeks after
surgery and again three,
six and 12 months after surgery.
The
therapy included lymph drainage, scar tissue massage and shoulder exercises
supervised by
a physiotherapist. The education program included
materials about the lymphatic system and
advice on how to avoid
injury and prevent infection.
After one year, 7 percent of women in the
intervention group and 25 percent of those in the
control group
developed secondary lymphedema. The researchers also found that secondary
lymphedema was diagnosed four times earlier in the control group than in
the intervention group,
according to the report published online
Jan. 12 in the BMJ.
Further research is needed to determine whether early
physical therapy after breast cancer
surgery offers longer-term
protection against secondary lymphedema, the researchers said.
More
information
The American Cancer Society has more about breast cancer
patients and lymphedema.
Copyright © 2010 ScoutNews, LLC. All rights
reserved.
http://www.palmbeachpost.com/health/therapy-may-relieve-breast-cancer-surgery-complication-
176500.html
Physical Therapy Can Cut Risk of Post-Surgical
Lymphedema
Condition is one of the most common complications of breast
cancer surgery
WEDNESDAY, Jan. 13 (HealthDay News) -- The risk of
secondary lymphedema in breast
cancer surgery patients can be
significantly reduced by the early introduction of post-surgical
physical therapy, according to a study published online Jan. 12 in
BMJ.
María Torres Lacomba, of Alcalá de Henares University in Madrid, Spain,
and colleagues
conducted a study of 120 women who underwent breast
cancer surgery involving the dissection of
axillary lymph nodes.
All the participants were given education about the lymphatic system and
on strategies to avoid injury and reduce the risk of infection. The
intervention group also
received a program of physical therapy,
including manual lymph drainage, scar tissue massage
and shoulder
exercises.
In all, 116 women completed follow-up at one year, and 18 (16
percent) developed secondary
lymphedema, including 14 (25 percent)
in the control group and four (7 percent) in the
intervention
group, the researchers found.
"This result emphasizes the role of
physiotherapy in the awareness, prevention, early diagnosis,
and
treatment of secondary lymphedema," the authors write. "Secondary lymphedema is
a
chronic condition, which has negative effects on the quality of
life of patients. The increase in risk
factors associated with
secondary lymphedema, such as ageing populations and the growing
prevalence of obesity, along with the gradual improvement in rates of
survival from cancer,
suggest that secondary lymphedema will remain
a
challenge."
http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Physical-Therapy-
Can-Cut-Risk-of-Post-Surgical-Lym/ArticleNewsFeed/Article/detail/651806?
contextCategoryId=40157
then the full text link:
http://www.bmj.com/cgi/content/full/340/jan12_1/b5396
FULL TEXT INFO - has
tables so not sure if they will be a problem for you and i didnt know if
you wanted all of this or not:
Research
Effectiveness of
early physiotherapy to prevent lymphoedema after surgery for breast cancer:
randomised, single blinded, clinical trial
María Torres Lacomba,
professor of physiotherapy1, María José Yuste Sánchez, professor of
physiotherapy1, Álvaro Zapico Goñi, professor of obstetrics and
gynaecology1,2, David Prieto
Merino, lecturer3, Orlando Mayoral del
Moral, professor of physiotherapy4, Ester Cerezo
Téllez, research
fellow1, Elena Minayo Mogollón, research fellow1
1 Physiotherapy Department,
School of Physiotherapy, Alcalá de Henares University, E-28871
Alcalá de Henares, Madrid, Spain, 2 Príncipe de Asturias University
Hospital, Alcalá de
Henares, Madrid, 3 Medical Statistics Unit,
Department of Epidemiology and Population Health,
London School of
Hygiene and Tropical Medicine, London, 4 Physiotherapy Department,
Provincial Hospital, Toledo, Spain
Correspondence to: M Torres
Lacomba
[email protected]
Abstract
Abstract
Introduction
Methods
Results
Discussion
References
Objective
To determine the effectiveness of early physiotherapy in reducing the risk of
secondary lymphoedema after surgery for breast cancer.
Design
Randomised, single blinded, clinical trial.
Setting University hospital in
Alcalá de Henares, Madrid, Spain.
Participants 120 women who had breast
surgery involving dissection of axillary lymph nodes
between May
2005 and June 2007.
Intervention The early physiotherapy group was treated
by a physiotherapist with a
physiotherapy programme including
manual lymph drainage, massage of scar tissue, and
progressive
active and action assisted shoulder exercises. This group also received an
educational strategy. The control group received the educational
strategy only.
Main outcome measure Incidence of clinically significant
secondary lymphoedema (>2 cm
increase in arm circumference
measured at two adjacent points compared with the non-affected
arm).
Results 116 women completed the one year follow-up. Of these,
18 developed secondary
lymphoedema (16%): 14 in the control group
(25%) and four in the intervention group (7%). The
difference was
significant (P=0.01); risk ratio 0.28 (95% confidence interval 0.10 to 0.79). A
survival analysis showed a significant difference, with secondary
lymphoedema being diagnosed
four times earlier in the control group
than in the intervention group (intervention/control, hazard
ratio
0.26, 95% confidence interval 0.09 to 0.79).
Conclusion Early physiotherapy
could be an effective intervention in the prevention of secondary
lymphoedema in women for at least one year after surgery for breast
cancer involving dissection
of axillary lymph nodes.
Trial
registration Current controlled trials ISRCTN95870846 [controlled-trials.com]
.
Introduction
Abstract
Introduction
Methods
Results
Discussion
References
Acquired
interruption or damage to the axillary lymphatic system after surgery or
radiotherapy
for breast cancer can lead to regional or generalised
accumulation of lymph fluid in the interstitial
space, known as
secondary lymphoedema.1 This condition is the most important chronic
complication
after dissection of the axillary lymph nodes2 3 4 5 and has a tendency to
progress.
Secondary lymphoedema can cause disfigurement, physical
discomfort, and functional
impairment. Anxiety, depression, and
emotional distress are more common in patients with than
without
secondary lymphoedema. This can affect social relationships, undermining body
image
and self esteem.6 7 8 The condition may also precipitate
cellulitis, erysipelas, lymphangitis, and
occasionally
lymphangiosarcoma.9 10 11
Reported incidence rates for secondary lymphoedema
vary depending on the method used for
measurement.12 Inconsistent
definitions and the lack of a standard classification system have
resulted in diverse incidence rates for secondary lymphoedema, ranging
from 5% to 56% within
two years after surgery.7 13 14 15 16 After
axillary lymph node dissection the incidence of
secondary
lymphoedema is about 23-38% if the criterion used to identify it is a greater
than 2 cm
increase in upper arm circumference measured at two
adjacent points compared with the
circumferences in the other
arm.17 Most women (71%) develop secondary lymphoedema within
12
months after surgery for breast cancer.18 19
The factors that might
influence the development of secondary lymphoedema after surgery are
the
number of lymph nodes removed, radiotherapy to the axilla, postoperative wound
infection,
postsurgical drainage time, lack of mobility, and
obesity.18 20 21 22 23 24
Currently, women with breast cancer have a 77%
probability of surviving at least 10 years.25 26
Consequently the
effective prevention and management of complications that can impair function
and affect quality of life after treatment are
important.15
Efforts have been made to reduce the risk of secondary
lymphoedema by preoperative and
postoperative counselling and
education27 28 and by early detection.27 29 A randomised clinical
trial on the prevention of secondary lymphoedema through exercises and
an educational strategy,
however, lacked sufficient evidence.30 We
determined the effectiveness of an early
physiotherapy programme in
reducing the risk of secondary lymphoedema in women after
surgery
for breast cancer involving dissection of axillary lymph
nodes.
Methods
Abstract
Introduction
Methods
Results
Discussion
References
We
carried out a randomised, single blinded, clinical trial of women after
unilateral breast cancer
surgery with axillary lymph node
dissection at the Príncipe de Asturias Hospital in Madrid
between
May 2005 and June 2007. We excluded women without axillary lymph node
dissection or
with bilateral breast cancer, systemic disease,
locoregional recurrence, or any contraindication to
physiotherapy.
Eligible women gave written informed consent to
participate in the study after breast cancer had
been confirmed by
biopsy. Each participant was assessed preoperatively and between days 3 and
5 after hospital discharge. Equal numbers of women were then randomly
allocated by computer
using EPIDAT version 3.1 (Xunta de Galicia,
Spain)31 to either early physiotherapy and an
educational strategy
(early physiotherapy group) or the educational strategy only (control group).
Both programmes lasted three weeks, with three visits each week.
The main outcome was the
incidence of secondary
lymphoedema.
Follow-up
Initially we scheduled four follow-up visits: four
weeks after surgery (shortly after the completion
of the
intervention) and three, six, and 12 months after surgery. These dates were,
however,
flexible, depending on the participant’s availability. At
all visits lymphoedema was assessed using
the same protocol.
If
patients experienced pain, discomfort, or any other symptoms, they could
contact the
physiotherapist and a visit would be arranged. If
secondary lymphoedema was diagnosed then
complex decongestive
physiotherapy was carried out,32 33 34 which would effectively interrupt
follow-up.
Interventions
Each group had one physiotherapist, who
carried out all interventions. Before the study it was
agreed that
both groups would receive the same educational intervention. The
physiotherapists
had more than five years’ experience in the
treatment of vascular diseases using lymphatic
drainage. They were
the only study members aware of group allocation.
Early physiotherapy
group—The intervention included the manual lymph drainage technique
used for the treatment of postoperative oedema (thorax, breast, axilla,
and upper arm of affected
side), using a modification of the
strokes described by Leduc (only resorption strokes were used)
32
34; progressive massage of the scar (progressing from Jacquet and Leroy pincer
to
Wetterwald pincer)32 35; stretching exercises for levator
scapulae, upper trapezius, pectoralis
major, and medial and lateral
rotators muscles of the shoulder36; and progressive active and
action assisted shoulder exercises, started in conjunction with
functional activities and
proprioceptive neuromuscular facilitation
exercises without resistance (rhythmic initiation
progressing from
passive to active-assistive to active movement in two diagonal symmetrical
bilateral patterns and asymmetrical reciprocal patterns: D1 into flexion
from hitch hike to swat
fly, and into extension from swat fly to
hitch hike, and D2 into flexion from hand in opposite
pocket to
carry tray, and into extension from carry tray to hand in opposite pocket).37
If axillary
web syndrome was diagnosed the physiotherapy protocol
extended the manual lymph drainage
technique to axilla and to
proximal ipsilateral arm and included specific thumb manual lymph
drainage on the characteristics taut cords, to make them gradually more
flexible. The early
physiotherapy group also did shoulder exercises
and stretching at home once daily during the
three week
intervention period.
Educational strategy (both groups)—The educational
strategy consisted of instruction with
printed materials about the
lymphatic system, concepts of normal load versus overload, the
source of secondary lymphoedema, the identification of possible
precipitating factors, and the
four categories of interventions to
prevent secondary lymphoedema (avoidance of trauma or
injury,
prevention of infection, avoidance of arm constriction, and use and exercise of
the arm),27
28 38 39 together with individual strategies for
implementing these measures.
Assessments
A different physiotherapist did
the two initial and four follow-up assessments of all participants
and remained blinded to group allocation. Participants were instructed
not to reveal their
allocation.
Lymphoedema—Direct measurement
of the presence and severity of lymphoedema is difficult
and
different diagnostic criteria have been described, including comparison between
preoperative
and postoperative measurements within the affected arm
and comparison of measurements
between the affected and unaffected
arms.16 29 40 41 42 43 For our main analysis we used the
criteria
stated in the trial protocol—that is, a 2 cm or greater increase in the
circumference of
any two adjacent points compared with measurements
in the other arm.19 41 44 45 46 We also
carried out the analysis
using other criteria (data not shown).
Arm measurements—Whatever the
criteria used for diagnosing lymphoedema they are all based
on
changes in size or volume of the arms. Arm circumferences were measured at each
visit and
always following the same procedure, using a standard 1 cm
wide, retractable, fibreglass tailor’s
tape measure (Babel, Spain).
With the patient in an upright sitting position with both arms on a
table, shoulders in neutral rotation and flexion of 45°, and forearms
at maximum supination, we
measured the circumference at 5 cm
intervals along both arms, using the elbow fold as the
reference
starting point. This has been reported as a valid and reliable method for
accurately
quantifying and diagnosing secondary lymphoedema.47 48
49
Other variables—During the preoperative assessment we collected personal
data on the
participants, including age, ethnicity, marital status,
body mass index, job, educational level,
socioeconomic status,
information on breast cancer, and medical history. In postoperative
assessments, data were collected on the type of surgery done, the
number of lymph nodes
removed, the use of adjuvant treatment, and
the development of seroma and infection.
Participants were also
asked an open question about whether they had any pain. If they did, a
physical
examination was carried out to find the source, including axillary web
syndrome. The
diagnostic criteria for axillary web syndrome were
pain and restriction of range of motion in the
shoulders, with
associated visible or palpable taut cords of tissue in the axilla in maximal
shoulder abduction.50 51 52 53 54 Other secondary outcomes were
measured according to the
protocol but are not reported
here.
Statistical analysis
The clinical criterion we chose to determine
lymphoedema (binary variable) was based on
changes in circumference
along the arm (continuous variable). The raw data are therefore
measures of circumference. To obtain the binary outcome several
intermediate variables need to
be computed from these measurements
(see web extra on bmj.com). The important variable here
would be
the maximum difference in arm circumference between any two adjacent points. A
patient would have a diagnosis of secondary lymphoedema if the
maximum difference between
any two adjacent points was 2 cm or
greater. Lymphoedema can also be determined from the
increase in
volume ratio of both arms (volume of affected arm divided by volume of
unaffected
arm). 29 30 42 44 55 56 The volume ratio is computed in
the variable "change in volume ratio"
(presented as percentages).
Although we chose not to use this as part of our criteria for clinical
diagnosis we include a continuous analysis on this variable. This
variable can be easily
interpreted as an increase or decrease of
the proportional difference of the volumes of both arms
(affected
minus unaffected; see web extra on bmj.com). Total arm volume was calculated by
adding up all the partial volumes between every two adjacent
measurements. Each of these
partial volumes was calculated by an
approximation to a truncated cone with the formula:
V=D(C12+C22+C1C2)/12
where C1 and C2 are the circumferences and the two adjacent locations and D
is the distance
between C1 and C2. We have not included hand volume
as this is difficult to model with a
truncated cone. Truncated cone
calculations of limb segment volumes using the circumference of
segments have been reported to be reliable.16
Power calculations and
sample size
Although the sample size was limited by patients’ availability
we did some power calculations.
With this sample size and after 3%
of dropouts, we would have a power of 70% to detect a
difference of
20% in the incidence of secondary lymphoedema between the groups. This assumes
an incidence of 30% in the control group (according to findings in
earlier studies16 17 19 44) and
setting a type I error of
0.05.
Statistical analyses were done using Stata version 10.0.57 For the
primary analysis we compared
the groups in three ways. Firstly, we
used a binary outcome analysis to compare the incidence of
lymphoedema, determined according to the chosen criteria. Secondly, we
used a continuous
outcome analysis to compare the variables
"maximum difference in arm circumference between
two adjacent
locations" and "change in volume ratio." Thirdly, as we had recorded the timing
of
diagnosis of lymphoedema we carried out a survival analysis for
the binary outcome. We
compared the incidence of lymphoedema using
Fisher’s exact test. Logistic regression was used
when we needed to
adjust for other variables. For the continuous outcomes sufficient data
ensured the asymptotic properties of Student’s t tests to compare
means. A Cox proportional
hazard model was used to compare the
survival rate between the
groups.
Results
Abstract
Introduction
Methods
Results
Discussion
References
Of
120 women recruited, 60 were assigned to early physiotherapy and an educational
strategy
and 60 to the educational strategy only (fig 1). All
variables were similarly distributed between
the groups at
randomisation (preoperative visit; table 1). The volume ratios were around 1 in
both
groups. This was expected as no lymphoedema was present at the
preoperative assessment.
Overall, 116 women completed the follow-up
assessments; 59 in the intervention group and 57 in
the control
group.
View larger version (28K):
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Fig 1 Progress of
participants through study
View this table:
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Table 1 Comparison between
randomised groups at baseline. Values are numbers
(percentages)
unless stated otherwise
Table 2 shows the numbers of women in
both groups with a diagnosis of secondary lymphoedema.
The
incidence of secondary lymphoedema in the control group (14 cases, 25%) was
significantly
higher than in the intervention group (four cases, 7%;
P=0.010). Risk factors for secondary
lymphoedema18 22 23 24 were
similar between the groups, therefore adjustment for these was
not
necessary (table 1). Body mass index was higher in the intervention group,
therefore the odds
ratio for treatment was adjusted by body mass
index (table 2). The crude effect showed no
difference.
View this table:
[in this window]
[in a
new window]
Table 2 Comparison of secondary lymphoedema in groups
Table 3 compares the continuous variables for the outcome
(parametric tests) between the
groups. By the 12 month follow-up
visit the volume ratio between arms had increased in both
groups: in
the control group the volume of the affected arm was on average 5.1% greater
than
that of the unaffected arm, whereas in the intervention group
the affected arm was on average
only 1.6% greater than the
unaffected arm. The difference between groups was significant (P=0.
0065). The maximum difference between two adjacent points was on average
also larger in the
control group than in the intervention group
(1.15 cm v 0.68 cm, P=0.0207). Figures 2 and 3 show
the
distributions of these variables in the groups. The distributions in the
control group are more
skewed to the right.
View
larger version (20K):
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Slide for Teaching]
Fig 2 Increase in volume ratios between arms. Vertical
lines correspond to cut-off values for
diagnoses of lymphoedema in
other studies (>5% and > 10% increase)
View
larger version (20K):
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[PowerPoint
Slide for Teaching]
Fig 3 Maximum increase in arm circumference (affected
arm–unaffected arm) that could be
observed at least at two adjacent
points. Vertical line corresponds to binary criteria used here to
diagnose lymphoedema—that is, a 2 cm or greater increase in arm
circumference observed at
least at two adjacent points in affected
arm compared with unaffected arm
View this
table:
[in this window]
[in a new window]
Table 3 Continuous
analysis of circumferential and volume measurements. Values are means
(standard
deviations) unless stated otherwise
The rate of survival was
better in the intervention group than in the control group. Secondary
lymphoedema
developed four times more rapidly in the control group (intervention
group/control
group, hazard ratio 0.26, 95% confidence interval 0.09
to 0.79; P=0.010). The shape of the failure
curves (1 minus
survival) suggests that the protective effect of early physiotherapy remained
for
a long time, whereas the proportion of patients with a
diagnosis of secondary lymphoedema in the
control group increased
progressively (fig 4).
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Fig 4
Failure time for development of secondary lymphoedema by group
Discussion
Abstract
Introduction
Methods
Results
Discussion
References
Early
physiotherapy with an educational strategy after surgery for breast cancer that
involved
dissection of axillary lymph nodes was associated with a
lower risk of secondary lymphoedema
than the educational strategy
only (control group) after 12 months of follow-up: 25% in the
control group compared with 7% in the intervention group. Secondary
lymphoedema developed
from six to 12 months postoperatively, which
agrees with previous studies.29 30 This could be
due to the sum of
various risk factors associated with secondary lymphoedema: axillary lymph
node dissection, the number of lymph nodes removed (between 10 and 20
nodes were removed in
17 of the 18 women with secondary
lymphoedema), overweight (12 of the 18 women had a body
mass index
>25), and postoperative complications (all 18 women had postoperative
complications) along with the effect of radiotherapy (completed in the
fourth postoperative
month) as well as the gradual weight gain (11
of 12 women with secondary lymphoedema who
were overweight at
baseline progressively increased in weight from six months after surgery).18
20 21 23 24 Further investigation of these risk factors is
needed.
Secondary lymphoedema is thought to be caused by damage to the
axillary lymphatic system,
impairing lymph drainage from the arm,
although there is strong evidence that total blood flow in
the arm
and vascular bed size are increased in secondary lymphoedema.1 Recently, a
study to
develop an animal model of postsurgical lymphoedema
reported that after nodal excisions the
limbs became progressively
more oedematous up to three days after node dissection and that the
swelling decreased but had not resolved 16 weeks after surgery.58
Taking this into account and
since the basic rule is that all
oedemas result from an imbalance between filtration and resorption
(tissue drainage), the implementation of a measure to restore this
balance during the period of
higher filtration should prevent or
delay the onset of secondary lymphoedema. Our study
included manual
lymph drainage, which is a special method involving gentle massage to improve
the lymph circulation, especially subcutaneous circulation, to
stimulate the initial lymphatics, and
to stretch the lymph vessels,
consequently improving the removal of interstitial fluid. Manual
lymph drainage encourages and improves resorption without increasing
filtration.34 59 It has
been shown to be effective in the treatment
of lymphoedema because it improves the removal of
fluid from
interstitial space.32 34 59 60 We therefore think that the implementation of
manual
lymph drainage after surgery for breast cancer in the early
physiotherapy group could have
contributed to the better results in
that group. This, together with early physiotherapy for other
effects of breast cancer surgery, and related to the onset of secondary
lymphoedema,18 20 21 23
24 could explain the effectiveness of early
physiotherapy in the prevention of secondary
lymphoedema in women
who have had surgery for breast cancer with axillary lymph node
dissection—at least during the first year after surgery.
We also
found that 12 of the 18 women who developed secondary lymphoedema had axillary
web
syndrome during the second and third week after surgery. The
axillary web syndrome is a known
but poorly studied complication of
surgery.54 61 62 No study has shown any link between the
axillary
web syndrome and the onset of secondary lymphoedema. We and others32 50 suggest
that the axillary web syndrome may be a sign of injury to the
lymphatic system and it could
produce a lymphatic overload as a
result of failure of the lymphatic system. This overload,
together
with other factors, could be responsible for the onset of secondary
lymphoedema. When
axillary web syndrome was diagnosed in the
postoperative period in the intervention group,
specific manual
lymph drainage strokes were applied, together with progressive active and
action
assisted shoulder and arm exercises. Manual lymph drainage
acted on the pain and inflexibility
inherent to the vascular
inflammation of the lymphatic vessel; also, if the axillary web syndrome
did produce a lymphatic overload, and therefore a possible subclinical
oedema, the action of the
manual lymph drainage could help with
reabsorption.32 34 59 60 63 Further research on a
possible relation
between the axillary web syndrome and the development of secondary
lymphoedema in women after breast cancer surgery is
needed.
Comparison with other studies
Secondary lymphoedema is a common
complication of breast cancer surgery.2 3 4 5 As far as we
are
aware, only one study has examined the effect of exercise and specific
recommendations
about self care to minimise the onset of secondary
lymphoedema.29 30 In addition, several
studies on the effectiveness
of early rehabilitation after breast surgery reported data on
lymphoedema as secondary end points.64 65 66 67 68 Box and colleagues
evaluated an
intervention to minimise postoperative lymphoedema in
65 women and stated that a
physiotherapy management care plan,
including exercise strategies that were not described in the
paper,
and progressive educational strategies may reduce the occurrence of secondary
lymphoedema two years after surgery.30 Our results for onset of
secondary lymphoedema one
year after surgery are better than their
results. Exercise is used in the management of secondary
lymphoedema
of the arm to promote the recruitment of collateral lymphatics pathways.69 This
might explain the difference in results between the studies. The
intervention programme in the
study by Box and colleagues did not
include the diagnosis and treatment of postoperative
vascular
complications (such as seroma and axillary web syndrome), which could be
related to the
onset of lymphoedema and could benefit from a proper
manual physiotherapy.50 51 52 53
Many studies have assessed the
effectiveness of rehabilitation in patients after breast cancer
surgery.64 65 66 67 68 All of them present limitations in the sample
size and assert that
physiotherapy is beneficial for shoulder
mobility and functional capacity without causing adverse
effects in
the postoperative period, but not in preventing secondary lymphoedema. All the
studies
focused on the recovery or maintenance of the mobility of
the shoulder so that the intervention
was based on mobility and
stretching exercises of the shoulder.64 65 66 67 68 Only one study
included massage (not manual lymph drainage) in one of the intervention
groups. This group
showed better results, but the onset of
lymphoedema was not prevented.65 The development of
restricted
shoulder mobility is one of the most important factors impairing functional
activities of
patients after breast surgery.70 A delayed onset
physiotherapy programme as required has been
suggested to improve
shoulder mobility and daily activities of living.71 None of these studies
could correlate the exercise programme with the incidence of
lymphoedema.64 65 66 67 68 Our
results in relation to the study by
Box and colleagues30 could result from the early diagnosis and
treatment of postoperative vascular complications.
Strengths and
limitations of the study
We believe that our study shows evidence of the
positive effect of early physiotherapy in the
prevention of
secondary lymphoedema, but the study is limited by the duration of follow-up
(one
year after surgery) and recruitment in just one hospital.
Although we have no reason to suspect
systematic differences in care
provided by this hospital and other regional hospitals or hospitals
in other developed countries, this may limit the external validity of
the results. Furthermore, that
the physiotherapy was provided by
trained physiotherapists may limit the generalisability of this
intervention to other settings.
Another limitation is that we chose
a particular criterion for diagnosing lymphoedema. We
followed the
criterion specified in our protocol but other criteria could have been used.
For
example, if the criterion of a greater than 10% increase in the
volume ratio between arms
(affected v unaffected) had been chosen,
the patients with a diagnosis of secondary lymphoedema
would be
those appearing to the right of the vertical line furthest to the right in
figure 2. Using
this criterion the early physiotherapy group would
have three cases (5%) and the control group
13 (23%), with a risk
ratio of 0.22 (95% confidence interval 0.06 to 0.74); results similar to those
in table 2.
A further limitation is the possibility of
measurement errors. We have no reason to believe,
however, that
this will have a differential effect on both intervention and control groups.
The
physiotherapist who took the measurements was blinded to the
patient’s treatment allocation.
Both groups were reasonably balanced
for baseline characteristics. The use of ratios between
arms also
reduces errors that could be correlated with some patient characteristics, such
as body
mass index. In general, we believe that measurement error
might have the effect of slightly
increasing the variance in the
measurement, but not in a biased way. At the most, this would
reduce statistical power of the comparisons to identify differences but
would not invalidate the
ones observed.
Conclusion
Early
physiotherapy could help to prevent and reduce secondary lymphoedema in
patients after
breast cancer surgery involving dissection of
axillary lymph nodes, at least for one year after
surgery. This
result emphasises the role of physiotherapy in the awareness, prevention, early
diagnosis, and treatment of secondary lymphoedema.
Secondary
lymphoedema is a chronic condition, which has negative effects on the quality
of life of
patients. The increase in risk factors associated with
secondary lymphoedema, such as ageing
populations and the growing
prevalence of obesity,18 23 24 along with the gradual improvement
in rates of survival from cancer,26 suggest that secondary lymphoedema
will remain a challenge.
Further studies are needed to clarify
whether early physiotherapy after breast cancer surgery
can remain
effective in preventing secondary lymphoedema in the longer
term.
What is already known on this topic
Secondary
lymphoedema is the most important chronic complication after breast cancer
surgery
with dissection of axillary lymph nodes
Early
postsurgical rehabilitation improves shoulder mobility and functional capacity
without
causing adverse effects but does not prevent secondary
lymphoedema
What this study adds
Early physiotherapy with an
educational strategy compared with the educational strategy alone
was associated with a lower risk of secondary lymphoedema 12 months
after surgery for breast
cancer with axillary node
dissection
The axillary web syndrome was an important complication in
the immediate postoperative period
Cite this as: BMJ
2010;340:b5396
--------------------------------------------------------------------------------
We
thank the staff and patients of the Gynecology Service of Príncipe de Asturias
University
Hospital (Madrid), the Physical Therapy Research Unit at
Alcala University (Madrid), and Jean
Claude Ferrandez for their
valuable suggestions. The Physical Therapy Department of Alcalá
University and Principe de Asturias Hospital provided the facilities for
the study.
Contributors: MTL conceived and designed the study. AZG recruited
the patients. MTL (blinded
assessor), ECT, EMM (physiotherapy and
educational strategies in the early physiotherapy
group), and MJYS
(educational strategies in control group) devised the interventions. DPM
(blinded analyst), MTL, and OMdM analysed and interpreted the data. OMdM
collected and
assembled the data. MTL, OMdM, and DPM wrote the
manuscript. All authors approved the
final manuscript.
Funding:
This study was funded by the Health Institute Carlos III (Protocol PI071124) of
the
Spanish Health Ministry.
Competing interests: All authors
have completed the unified competing interest form at www.
icmje.org/coi_disclosure.pdf (available on request from the
corresponding author) and declare (1)
no financial support for the
submitted work from anyone other than their employer; (2) no
financial relationships with commercial entities that might have an
interest in the submitted work;
(3) no spouses, partners, or
children with relationships with commercial entities that might have
an
interest in the submitted work; and (4) no non-financial interests that may be
relevant to the
submitted work.
Ethical approval: This study was
approved by the human research ethics committee of the
Príncipe de
Asturias
Hospital.
References
Abstract
Introduction
Methods
Results
Discussion
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(Accepted 9 October
2009)
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