RU2617258C1 - Method of rehabilitation after radical mastectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: active upper limbs exploration is performed by gymnastics and massage in the form of stages after radical mastectomy. First, gymnastics of upper limbs with or without weights is performed twice a day for 15-20 min in sitting and standing initial position (IP). Then - for spine cervico-thoracic, collar area 1-2 times a day for 10-15 minutes, in sitting or standing IP. Next - active, active-passive or passive carpal gymnastics 2-3 times a day for 15-20 minutes in IP of sitting at the table, hands on the table. Shoulder, elbow and radiocarpal joints, limited in motions, are influenced by abduction, flexion or extension. For this purpose, patient lies on a horizontal surface, the upper limb is laid in the abduction position on the surgery side, as it is possible due to pain, fixed by soft weights in the radiocarpal joint area and the oxter area, up to 40 minutes in this position. Then, the hand is spread in the flexion of the shoulder joint and fixed by soft weights, up to 20-30 minutes in this position. If the elbow joint motions are limited, laying on its flexion, extension is performed in the following positions: palmar surface upward, back surface upward, with position fixation. If the wrist joint motions are limited, laying on its flexion and extension is performed with the position fixation for 15-20 minutes, in the IP of sitting at the table with soft surface. Then, mechanotherapy is performed for 15-30 min by apparatus for flexion and extension development of the shoulder, elbow, radiocarpal joints, the flexion angle increase is not more than 5 degrees per day. The result is fixed for 2-3 sessions. After the course of layings and meachanotherapy, if liquorrhea, heat are absent, massage of the upper limb and the rear surface of the collar area is performed, continuing gymnastics daily 2-3 times a day. Breathing exercises are additionally performed.

EFFECT: method ensures acceleration of health and vocational rehabilitation processes, enables to increase and maintain the range of motions in the upper limbs, prevent the formation of bad posture.

2 cl, 2 ex

Description

Application area

The invention relates to medicine and can be used in the rehabilitation treatment of radically treated patients with breast cancer.

State of the art

Currently, special attention is paid to the early detection of cancer, including and breast cancer. Organ-preserving surgical procedures are being developed, and a combined treatment regimen is widely used.

The main problem is that in medical institutions the rehabilitation of patients after mastectomy is not provided. Patients face a number of complications after treatment:

- phantom pains;

- asthenic conditions;

- lengthening of the period of lymphorrhea (edema);

- the formation of a rough postoperative scar;

- limitation of motor function in the limb from the side of the operation.

A known method of treating postmastectomy syndrome after radical mastectomy (patent RU 94024349, IPC A61N 1/32, publ. 05/20/1996), by exposure to electric shock on the shoulder girdle and muscles of the hands. The muscles of the shoulder girdle and hands are affected by a low-frequency pulse current with a bipolar asymmetric shape of the pulses with a trapezoidal envelope with certain modes.

A disadvantage of the known technical solution is that rehabilitation is carried out only with the help of physiotherapy apparatus "Miorhythm", ie one factor that is not enough for patient recovery.

There is also known a method of rehabilitation treatment in the early postoperative period after radical surgery for breast cancer (patent RU 2318488, IPC A61H 39/00, published March 10, 2008), in which basic drug therapy, massage are performed in the early postoperative period after mastectomy , perform smooth active movements in the shoulder and elbow joints of the limb on the affected side, and exercise gentle physical therapy. Additionally, from 8-9 days after the operation, biologically active points (BAP) are daily exposed to infrared light.

The disadvantage of this method is the long recovery period.

SUMMARY OF THE INVENTION

The technical result consists in accelerating the processes of restoring health and working ability, increasing and maintaining the range of movements in the upper limbs, and preventing the formation of incorrect posture.

The technical result is achieved by the fact that the method of rehabilitation after a radical mastectomy, including an active effect on the upper limbs by gymnastics and massage, according to the proposed solution includes the following steps:

gymnastics for the upper extremities with and without weights, 2 times a day for 15-20 minutes, in the initial position (PI), sitting and standing,

gymnastics for the cervico-thoracic spine, collar region 1-2 times a day for 10-15 minutes, in the IP sitting or standing,

active, or active-passive, or passive hand gymnastics 2-3 times a day for 15-20 minutes, in the IP sitting at the table, hands are on the table,

the impact on the shoulder, elbow and wrist joints that are limited in movement by abduction, flexion or extension, for which the patient first lays on a horizontal surface, the upper limb from the side of the operation is placed in the abduction position as much as possible according to pain, and fixed with a soft burden in area of the wrist joint and the inner side of the shoulder, up to 40 min in this position,

then the hand is laid out in flexion in the shoulder joint and fixed with a soft burden, up to 20-30 minutes in this position,

when restricting movements in the elbow joint, make styling on its flexion, extension, with the following positions: palmar surface up, back surface up, with fixation of positions,

while restricting movements in the wrist joint, styling is performed on its flexion and extension with fixation of the position for 15-20 minutes, in an IP sitting at a table with a soft surface,

then, for 15-30 minutes passive mechanotherapy is carried out with devices for developing flexion and extension of the shoulder, elbow, wrist joints, and the increase in the angle of flexion is not more than 5 degrees per day, and this result is fixed for 2-3 lessons,

after a course of styling and mechanotherapy, in the absence of liquorrhea, elevated body temperature, massage the upper limb and the back surface of the collar region, while continuing therapeutic gymnastics daily 2-3 times a day.

In addition, it is advisable, when performing gymnastics, to additionally conduct breathing exercises.

The implementation of the invention

At the initial consultation, the rehabilitologist determines the state of health after surgery and draws up a plan for an individual rehabilitation program.

The rehabilitation method includes the following steps:

Gymnastics:

- for upper extremities with and without objects, with and without weights, individually, from the first day of treatment 2 times a day for 15-20 minutes (objects: ball, hand expander, sous-jock, gymnastic stick, rope; weight: bandage Martens, cuffs with weights, dumbbells).

In the IP sitting or standing;

- for the cervicothoracic spine, collar region 1-2 times a day for 10-15 minutes.

In the IP sitting or standing;

- carpal (vascular to the distal upper limbs) 2-3 times a day for 15-20 minutes with and without objects.

In the IP, sitting at the table, hands lie on the table (objects: hand expander (individually selected for stiffness; sous-jok, spiky ball with a diameter of 4-6 cm, matches, mosaic, beans, napkin). It is carried out actively, actively-passively or passively with the help of a gymnastics instructor,

- impact on the shoulder, ulnar and wrist joints limited in movement is carried out by abduction, flexion or extension of the joints in the supine, sitting, standing (laying position)

First laying position

The patient lies on the couch (on the floor), the upper limb from the side of the operation fits into the abduction position as much as possible according to pain and is fixed by soft burdening, for example, special sandboxes (at home it can be salt). Sandboxes are laid on the wrist joint area and on the side of the shoulder of its inner side. In this position, the patient can lie up to 40 minutes. But if complaints appear: tingling, numbness, whitening of the skin, blueness, intensification of pain, then styling is removed.

It is carried out 2 times a day (1 time with an instructor and 1 time at home). The instructor observes the increase in amplitude and corrects the correctness of the styling.

The second position of laying - the hand is laid out in flexion in the shoulder joint and fix this position with a soft burden.

If it is necessary to carry out several stylings, then the time is reduced to 20-30 minutes.

When restricting movements in the elbow joint, laying is done on its flexion, extension, with the position of the palmar surface up and the back surface up. Reached positions are also recorded.

If there is a restriction of movements in the wrist joint, then laying is carried out on its flexion and extension for 15-20 minutes. It is carried out in the IP sitting at the table, where there should be a soft surface (towel, diaper), the wrist joint is bent and surrounded by sandboxes or unbent.

If it is necessary to carry out several stylings, then the time is reduced to 20-30 minutes.

Mechanotherapy (passive)

Mechanotherapy includes the development of the shoulder and elbow joints on the ARTROMOT-S3 apparatus and the development of the wrist joint on the ARTROMOT-H apparatus for flexion-extension.

An increase in the bending angle is not more than 5 degrees per day with the obligatory fixing of the result during the next 2-3 classes (days).

Duration of exposure is 15-30 minutes.

Frequency of visit: daily 1-2 times a day or every other day, or 2 times a week (according to an individual program as a result of poor health due to chemotherapy).

The number of sessions with mechanotherapy is from 10 to 20 or more procedures, depending on the general well-being of the patient, the initial range of movements in the shoulder joint and the timing of treatment for rehabilitation.

After a 10-day course of styling and mechanotherapy, in the absence of liquorrhea, elevated body temperature, massage of the upper limb and the back surface of the collar region is prescribed. Number of procedures No. 12 daily or every other day.

You can prescribe first massage of the upper limb No. 12, then No. 10-12 massage of the cervicothoracic spine, depending on the patient's well-being and other circumstances.

Therapeutic gymnastics also continues daily 2-3 times a day, more time is devoted to problem areas of the body (hand, elbow, shoulder, shoulder joint, back, posture).

If necessary, continue styling i.e. (posture treatment) sitting, lying, standing.

Breathing exercises can be added to all complexes for therapeutic exercises for 2-3 exercises.

Case Studies

Example 1

Patient N., 51 years old - cancer of the right breast T2N0MO, a radical operation was performed to remove the right breast in January 2014. I turned to the rehabilitation center 1 month after the operation. The patient complained of: restriction of movements in her right hand, swelling of her right hand, crawling sensation in the shoulder area.

Objectively: restriction of movements in the shoulder joint, flexion of 80 degrees, abduction of 70 degrees, swelling of the shoulder and impaired posture, the range of movements in the elbow and wrist joints is complete.

Assigned rehabilitation doctor LFK:

1) Therapeutic gymnastics on the upper limbs - 10 lessons of 20 minutes daily in the IP, standing and sitting.

2) Hand gymnastics to improve blood circulation in the distal extremities - 10 lessons of 20 minutes daily.

3) Mechanotherapy - passive development of the shoulder joint on the apparatus ARTROMOT-S3 10 lessons of 20 minutes daily.

4) Laying on the abduction of the arm 10 times for 20 minutes daily.

As a homework, it was recommended: laying on bending the arm in the shoulder joint, exercises with an orange egg-shaped hand expander and a sujok needle massager every 1-2 hours throughout the day.

As a result of the course of treatment, the patient after 2 weeks noted an improvement in overall well-being, swelling of the shoulder decreased, the angle of flexion increased to 130 degrees, the angle of abduction was 90 degrees.

The rehabilitation period is 1 month after the operation. The duration of rehabilitation is 2 weeks.

Example 2

Patient K., 62 years old - cancer of the right breast, a radical operation was performed to remove the right breast in May 2015. I contacted the rehabilitation center 2 months after the operation.

When handling complained: restriction of movements in the right shoulder joint, swelling of the arm and fingers, pain in the arm during movement.

An objective examination: edema of the right upper limb is expressed in the shoulder region, slightly less in the forearm and hand, limitation of the flexion angle in the shoulder - 60 degrees, abduction angle - 50 degrees, restriction of movements in the right wrist joint.

Appointed by the doctor of exercise therapy:

1) therapeutic exercises for the upper limbs daily 2-3 times a day for 15-20 minutes;

2) hand gymnastics daily 2-3 times a day for 15-20 minutes with and without objects;

3) laying for abduction and flexion in the shoulder joint daily 2 times a day for 20 minutes;

4) laying on flexion and extension in the right wrist joint (as homework) daily 2 times a day for 15-20 minutes;

5) the use of the apparatus ARTROMOT-S3 for flexion in the shoulder joint 10 times daily for 20 minutes 1 time per day;

6) the use of the apparatus “ARTROMOT-N for flexion-extension in the right wrist joint daily 1 time per day for 15 minutes.

After 10 days, the patient felt an improvement in the form of a decrease in edema in the shoulder area, swelling from the forearm and hand went away, pain in the arm during movement decreased much, the angle of flexion in the shoulder joint increased to 90 degrees, and the lead angle to 80 degrees.

Restorative treatment was continued, massage of the upper right extremity No. 10 daily and collar area No. 10 was added.

Previously was 1 course

After 2 weeks of treatment, a positive effect was noted in the following: swelling from the arm decreased, range of motion in the right shoulder joint increased to 120 degrees, the full range of motion in the wrist joint was restored, the patient's general well-being and mood improved.

Further, rehabilitation on the Arthromot S3 apparatus was continued, over the next 2 weeks the range of movements was restored in the right upper limb, there was no edema.

At home, the patient continues to do therapeutic exercises on the upper limbs 1-2 times a day for 10-15 minutes. Feels satisfactory. No complaints.

In this patient, the duration of the course of rehabilitation treatment was 2 months.

Dates of rehabilitation - 2 months after surgery.

Rehabilitation using the proposed method were 26 people. Of these: 1 month after surgery 25% of cases, after 1.5-3 months - 75% of cases.

Age of women:

38-55 years old - 50%, over 55 years old - 50%.

Type of operation: radical mastectomy - 100% of cases.

40% of applicants completed a full rehabilitation course.

The main complaints when handling:

- limitation of range of motion in the shoulder joint - 100% of cases,

- swelling of the upper limb on the side of the operation - 25% of cases,

- restriction of movements in the elbow joint - 20%

- restrictions on movements in the wrist joint - 10%

- violation of posture - 15% of cases.

After a rehabilitation course, it is noted:

- increase in range of motion in the shoulder joint from 60-80 degrees to 130-150 degrees in 100% of cases,

- reduction of edema of the upper limb - 50% of cases.

All patients were examined to exclude relapse and metastases of breast cancer.

The proposed solution allows patients to recover physically faster, return to normal life, increase and maintain the lost range of movements in the upper limbs, and also form an elastic scar at the site of the operation and prevent the formation of incorrect posture. Recommended rehabilitation periods are 2-4 weeks after surgery, but no later. Late rehabilitation - 3-6 months after surgery. The rehabilitation complex, carried out in the early period, is repeated after 3-6 months for the purpose of prevention.

Claims (10)

1. A method of rehabilitation after a radical mastectomy, including an active effect on the upper limbs through gymnastics and massage, characterized in that it includes the following steps: gymnastics for the upper extremities with and without weights, 2 times a day for 15-20 minutes, in the initial position (PI), sitting and standing, gymnastics for the cervico-thoracic spine, collar region 1-2 times a day for 10-15 minutes, in the IP sitting or standing, active, or active-passive, or passive hand gymnastics 2-3 times a day for 15-20 minutes, in the IP sitting at the table, hands are on the table, the impact on the shoulder, elbow and wrist joints that are limited in movement by abduction, flexion or extension, for which the patient first lays on a horizontal surface, the upper limb from the side of the operation is placed in the abduction position as much as possible according to pain, and fixed with a soft burden in area of the wrist joint and the inner side of the shoulder, up to 40 min in this position, then the hand is laid out in flexion in the shoulder joint and fixed with a soft burden, up to 20-30 minutes in this position, when restricting movements in the elbow joint, make styling on its flexion, extension, with the following positions: palmar surface up, back surface up, with fixation of positions, while restricting movements in the wrist joint, styling is performed on its flexion and extension with fixation of the position for 15-20 minutes, in an IP sitting at a table with a soft surface, then 15-30 minutes passive mechanotherapy is carried out with devices for developing flexion and extension of the shoulder, elbow, wrist joints, and the increase in the angle of flexion is not more than 5 degrees per day, and this result is fixed for 2-3 lessons, after a course of laying and mechanotherapy, in the absence of liquorrhea, elevated body temperature, massage the upper limb and the back surface of the collar region, while continuing therapeutic gymnastics daily 2-3 times a day. 2. The method according to p. 1, characterized in that when performing gymnastics additionally conduct breathing exercises.