Effect of Transcutaneous Electric Nerve Stimulation on Pain after Total Knee Arthroplasty: A Blind Randomized Controlled Trial.

Transcutaneous electric nerve stimulation (TENS) has proven to be effective for postsurgical pain relief. However, there is a lack of well-constructed clinical trials investigating the effect of TENS after total knee arthroplasty (TKA). In addition, previous investigations reported that low- and high-frequency TENSs produced analgesic tolerance after 4 or 5 days of treatment. The aim of this study is to explore the effect of burst TENS on pain during hospitalization after TKA and to investigate whether burst TENS produces analgesic tolerance after 4 or 5 days of treatment. This stratified, triple blind, randomized controlled trial was approved by the University Hospital Brussels. Sixty-eight subjects were screened for eligibility before surgery; 54 were found eligible and 53 were included in the analyses. Patients were allocated to either a burst TENS or sham burst TENS group. TENS was applied daily during continuous passive mobilization. Knee pain intensity, knee range of motion, and analgesic consumption were assessed daily. Patients received burst TENS (N = 25) or sham burst TENS (N = 28). No significant differences in knee pain intensity were found between the groups (p > 0.05). Within the TENS and the sham TENS groups, the difference in knee pain before and after treatment did not evolve over time (p > 0.05). This study found no effects of burst TENS compared with sham burst TENS on pain during hospitalization after TKA.

Effects of Multidirectional Vibrations Delivered in a Horizontal Position (Andullation®) on Blood Microcirculation in Laboratory Animals: A Preliminary Study.

BACKGROUND A whole-body vibration technique delivered in a horizontal position through a massage mattress was introduced in 2007. The present study analyzed the effects of different exposure periods to these vibrations on microcirculation of mice. MATERIAL AND METHODS Different periods of vibrations (30Hz) were locally delivered in a horizontal position on the external abdominal skin in 3 randomized groups of mice (N=42). The 3 groups receiving vibrations were compared to an untreated control group (N=14). The 3 experimental groups received 3, 6, and 10 min of vibrations. The in vivo measurement of the arterial and venous diameters was done before and after each vibration period. RESULTS Average venous diameters (µm) after 6 to 10 min of vibrations were significantly increased (7% and 12%, p values 0.026 and 0.013, respectively), but 3 min did not significantly change average venous diameters. Arterial diameters (µm) did not significantly vary after 3, 6, and 10 min. In the control group, variations of arterial and venous diameters during 10 min were not significant. CONCLUSIONS This study shows a vasodilatory effect of low-frequency vibrations. The hypothesis of local cutaneous blood flow increase is retained. A phenomenon of shear stress of the endothelium induced by skin massage generates this local venous vasodilation and blood flow increase.

The Use of Noninvasive Imaging Techniques in the Assessment of Secondary Lymphedema Tissue Changes as Part of Staging Lymphedema.

Too often, in clinical settings, the diagnosis and evolution of lymphedema is determined by limb circumference measurements and/or volume calculations. Besides the unrecognition of small lymphedemas, these techniques provide little to no information concerning the stage of the lymphedema. This latter is important in choosing appropriate treatment modalities and making an accurate prognosis. Different imaging techniques are described in literature giving insights in tissue changes due to lymphedema. The aim of this article is giving an overview of possible texture changes linked to the different edema stages, visualized with noninvasive imaging procedures like ultrasonography, computed tomography, dual-energy x-ray absorptiometry, or magnetic resonance imaging.

Anatomical Effects of Axillary Nodes Dissection on Rat Lymphatic System Model: Indocyanine Green Mapping and Dissection.

BACKGROUND: Axillary nodes dissection (AND) is an important risk factor for the appearance of breast cancer-related lymphedema (BCRL). The anatomy and pathophysiology leading to the development of BCRL after AND are not completely understood. Despite the existence of lymphedema models after AND, none of them were able to create lymphedemas without additional chemical inflammatory drugs or auxiliary physical techniques (radiotherapy). In this study, we aimed to describe the anatomical changes of AND on a rat's front leg before and after a new surgery technique. METHODS AND RESULTS: AND was performed on seven Wistar rats with a new, posterior surgical approach. Indocyanine green mapping was done before and after surgery to detect "normal and secondary superficial lymphatic pathways" of the operated rat's front legs. Twelve months after surgery, dissections were performed. Subcutaneous blue dye injection of the hand was used to observe superficial and deep lymphatic pathways. Postsurgery, an acute edema of arm and shoulder appeared and persisted for 14-21 days. However, none of the rats showed a chronic secondary lymphedema. In two cases, seromas also appeared. All rats showed substitution functional lymphatic pathways as perforating lymph vessels around the surgical sites. CONCLUSION: This is the first description of perforating lymph vessels as lymphatic substitution pathways after AND on rats. These results help to understand why a chronic secondary lymphedema could not be created in rats after AND without additional chemical or physical interventions.

A systematic review investigating the relationship between efficacy and stimulation parameters when using transcutaneous electrical nerve stimulation after knee arthroplasty.

OBJECTIVE: To evaluate the clinical efficacy of transcutaneous electric nerve stimulation in the treatment of postoperative knee arthroplasty pain and to relate these results to the stimulation parameters used. DATA SOURCES: PubMed, Pedro and Web of Knowledge were systematically screened for studies investigating effects of transcutaneous electric nerve stimulation on postoperative knee arthroplasty pain. REVIEW METHODS: Studies were screened for their methodological and therapeutical quality. We appraised the influence of the stimulation settings used and indicated whether or not a neurophysiological and/or mechanistic rationale was given for these stimulation settings. RESULTS: A total of 5 articles met the inclusion criteria. In total, 347 patients were investigated. The number of patients who received some form of transcutaneous electric nerve stimulation was 117, and 54 patients received sham transcutaneous electric nerve stimulation. Pain was the primary outcome in all studies. The stimulation settings used in the studies (n = 2) that reported significant effects differed from the others as they implemented a submaximal stimulation intensity. Stimulation parameters were heterogeneous, and only one study provided a rationale for them. CONCLUSION: This review reveals that an effect of transcutaneous electric nerve stimulation might have been missed due to low methodological and therapeutical quality. Justifying the choice of transcutaneous electric nerve stimulation parameters may improve therapeutical quality.

Early contralateral shoulder-arm morbidity in breast cancer patients enrolled in a randomized trial of post-surgery radiation therapy.

INTRODUCTION: Shoulder/arm morbidity is a common complication of breast cancer surgery and radiotherapy (RT), but little is known about acute contralateral morbidity. METHODS: Patients were 118 women enrolled in a RT trial. Arm volume and shoulder mobility were assessed before and 1-3 months after RT. Correlations and linear regression were used to analyze changes affecting ipsilateral and contralateral arms, and changes affecting relative interlimb differences (RID). RESULTS: Changes affecting one limb correlated with changes affecting the other limb. Arm volume between the two limbs correlated (R = 0.57). Risk factors were weight increase and axillary dissection. Contralateral and ipsilateral loss of abduction strongly correlated (R = 0.78). Changes of combined RID exceeding 10% affected the ipsilateral limb in 25% of patients, and the contralateral limb in 18%. Aromatase inhibitor therapy was significantly associated with contralateral loss of abduction. CONCLUSIONS: High incidence of early contralateral arm morbidity warrants further investigations.

Scapula alata in early breast cancer patients enrolled in a randomized clinical trial of post-surgery short-course image-guided radiotherapy.

BACKGROUND: Scapula alata (SA) is a known complication of breast surgery associated with palsy of the serratus anterior, but it is seldom mentioned. We evaluated the risk factors associated with SA and the relationship of SA with ipsilateral shoulder/arm morbidity in a series of patients enrolled in a trial of post-surgery radiotherapy (RT). METHODS: The trial randomized women with completely resected stage I-II breast cancer to short-course image-guided RT, versus conventional RT. SA, arm volume and shoulder-arm mobility were measured prior to RT and at one to three months post-RT. Shoulder/arm morbidities were computed as a post-RT percentage change relative to pre-RT measurements. RESULTS: Of 119 evaluable patients, 13 (= 10.9%) had pre-RT SA. Age younger than 50 years old, a body mass index less than 25 kg/m2, and axillary lymph node dissection were significant risk factors, with odds ratios of 4.8 (P = 0.009), 6.1 (P = 0.016), and 6.1 (P = 0.005), respectively. Randomization group was not significant. At one to three months' post-RT, mean arm volume increased by 4.1% (P = 0.036) and abduction decreased by 8.6% (P = 0.046) among SA patients, but not among non-SA patients. SA resolved in eight, persisted in five, and appeared in one patient. CONCLUSION: The relationship of SA with lower body mass index suggests that SA might have been underestimated in overweight patients. Despite apparent resolution of SA in most patients, pre-RT SA portended an increased risk of shoulder/arm morbidity. We argue that SA warrants further investigation. Incidentally, the observation of SA occurring after RT in one patient represents the second case of post-RT SA reported in the literature.

Effect of tens on pain in relation to central sensitization in patients with osteoarthritis of the knee: study protocol of a randomized controlled trial.

BACKGROUND: Central sensitization has recently been documented in patients with knee osteoarthritis (OAk). So far, the presence of central sensitization has not been considered as a confounding factor in studies assessing the pain inhibitory effect of tens on osteoarthritis of the knee. The purpose of this study is to explore the pain inhibitory effect of burst tens in OAk patients and to explore the prognostic value of central sensitization on the pain inhibitory effect of tens in OAk patients. METHODS: Patients with knee pain due to OAk will be recruited through advertisements in local media. Temporal summation, before and after a heterotopic noxious conditioning stimulation, will be measured. In addition, pain on a numeric rating score, WOMAC subscores for pain and function and global perceived effect will be assessed. Patients will be randomly allocated to one of two treatment groups (tens, sham tens). Follow-up measurements will be scheduled after a period of 6 and 12 weeks. DISCUSSION: Tens influences pain through the electrical stimulation of low-threshold A-beta cutaneous fibers. The responsiveness of central pain-signaling neurons of centrally sensitized OAk patients may be augmented to the input of these electrical stimuli. This would encompass an adverse therapy effect of tens. To increase treatment effectiveness it might be interesting to identify a subgroup of symptomatic OAk patients, i.e., non-sensitized patients, who are likely to benefit from burst tens. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01390285.

Ultrasound elastography as an objective diagnostic measurement tool for lymphoedema of the treated breast in breast cancer patients following breast conserving surgery and radiotherapy.

BACKGROUND.: Lymphoedema of the operated and irradiated breast is a common complication following early breast cancer treatment. There is no consensus on objective diagnostic criteria and standard measurement tools. This study investigates the use of ultrasound elastography as an objective quantitative measurement tool for the diagnosis of parenchymal breast oedema. PATIENTS AND METHODS.: The elasticity ratio of the subcutis, measured with ultrasound elastography, was compared with high-frequency ultrasound parameters and subjective symptoms in twenty patients, bilaterally, prior to and following breast conserving surgery and breast irradiation. RESULTS.: Elasticity ratio of the subcutis of the operated breast following radiation therapy increased in 88.9% of patients, was significantly higher than prior to surgery, unlike the non operated breast and significantly higher than the non operated breast, unlike preoperative results. These results were significantly correlated with visibility of the echogenic line, measured with high-frequency ultrasound. Big preoperative bra cup size was a significant risk factor for the development of breast oedema. CONCLUSIONS.: Ultrasound elastography is an objective quantitative measurement tool for the diagnosis of parenchymal breast oedema, in combination with other objective diagnostic criteria. Further research with longer follow-up and more patients is necessary to confirm our findings.

Postmastectomy lymphoedema: different patterns of fluid distribution visualised by ultrasound imaging compared with magnetic resonance imaging.

OBJECTIVES: Postmastectomy lymphoedema remains a disabling complication caused by treatment for breast cancer. The increased thickness of the dermal layer and the increased volume of the subcutis represent the most important contributions to the total swelling of the arm. Ultrasound imaging of the subcutaneous layer results in different patterns of reflected ultrasound waves depending on the morphological alternations that occurred due to impaired lymphatic drainage. The aim of this study was to compare these echographic images with those obtained using magnetic resonance imaging to explain the nature of the morphological changes. DESIGN: Observational study. SETTING: Patients were recruited from the Breast Clinic at the University Hospital Brussels. PARTICIPANTS: Seven women (mean age 60 years) with unilateral breast cancer who subsequently developed lymphoedema. MAIN OUTCOME MEASURES: The water displacement technique was applied to determine arm volumes, and echographic and magnetic resonance images were used to evaluate changes in tissue structures. RESULTS: Volumetric measurements of the arm (mean affected arm 3241 ml vs unaffected arm 2538 ml) showed a significant increase in total arm volume of 703 ml (95% confidence interval 324 to 1084 ml). Using echography, the thickness of the dermal and subcutaneous layers showed an average increase of 0.2 to 0.8mm and 3.9 to 7.2mm, respectively. The differences between the affected arm and the unaffected arm for all upper and lower arm measurements (i.e. volumetry, dermal and subcutaneous thickness) were significant, but no significant differences were registered for hand measurements. On echography, the dermis showed uniform changes, with a homogenous hypo-echogenic appearance compared with the contralateral side due to water influx. Different patterns of structural changes could be visualised within the subcutis: (1) uniformly hypo-echogenic due to the diffuse spread of water through the subcutis; (2) hyperechogenic areas surrounded by hypo-echogenic streaks visualised on magnetic resonance imaging as adipose tissue surrounded by fluid embedded in fibrous tissue; and (3) homogenously hyperechogenic due to the overgrowth of adipose tissue with a minimal amount of water. CONCLUSIONS: Echographic images can help to determine the likelihood that complex physical therapy will reduce lymphoedema, and evaluate treatment results by measuring tissue thickness and evaluating tissue consistency.

Histological findings compared with magnetic resonance and ultrasonographic imaging in irreversible postmastectomy lymphedema: a case study.

Postmastectomy edema is a current complication after axillary lymph node dissection in cases of breast cancer treatment. Staging is important in order to select those patients who can benefit from complex physical therapy (CPT). Different imaging techniques can be used to evaluate the edema. Ultrasonography (US) is a harmless, cheap, and easily applicable technique to visualize the dermal and subcutaneous tissue, but interpretation of the obtained images is not always evident. The aim of this study was to compare ultrasound images of irreversible edema with tissue histology, magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS). Ultrasonographic images of the edematous dermis show an homogeneous hypoechogenic dermal layer that appears on tissue histology to be less compact, due to the excess of fluid in the interstitium separating the collagen fibres and making it more transparent on light microscopy. MRI of the dermis gives a hyperintense signal, indicating the presence of fluid. In the subcutis, increase of the adipose tissue could be observed on US, MRI, and tissue histology. In the case of lymphedema, the area and perimeter of fat cells is significantly (p < 0.05) increased. Hypoechogenic areas near the muscle fascia are registered on US corresponding with epifascial fluid on MRI, and hyperechogenic branches are embedded within the adipose tissue, on tissue histology seen as large fibrotic septa enclosing adipose cells. MRI has a honeycomb picture corresponding with fluid bound to fibrosis.