Linfedema dell'arto superiore in seguito a carcinoma mammario : misura della limitazione funzionale e dell'efficacia dei trattamenti riabilitativi

Lymphedema is an edema of the lymphatic system, characterized by the accumulation of fluid in the intercellular spaces. Lymphedema is a disabling impairment as it prevents the individual from expressing his capacity because of the functional limitation of the affected limb, because of lesions induced by secondary edema in nervous, muscular and vascular structures and because of the limitation of operational decisions that the individual is forced to operate. It is necessary to use an accurate and repeatable measurement for evaluating the initial degree of lymphedema, its natural progression over time and the variations induced by the different treatments carried out. Currently, in clinical practice of the Complex of Palliative Care, Pain Therapy and Rehabilitation of the National Cancer Institute of Milan , the centimetric method is used for the quantitative measurement of lymphedema. The values of limb circumferences are taken at a fixed distance from each other and these measures are then used to calculate, through the use of approximation formulas, the total volume of the limb. Since the centimetric method presents critical points, a more appropriate technology for the determination of the limb volume should be taken into consideration. Laser scanner could be used for a more precise and accurate measure of the edematous limb. Measures provided by this technology are more accurate and exceed the limitations that characterize the centimetric method. Laser scanners have the advantage of being relatively inexpensive, fast, accurate and non- invasive. According to the results of studies in literature, lymphedema can induce changes in the motor functions of the affected limb during the execution of movements such as flexion and abdo-adduction. This can be analyzed using specific protocols and specific instrumentation present in the motion analysis laboratories. 7 This scientific research was made possible thanks to the collaboration between the Department of Electronics, Information and Bioengineering (DEIB) of the “Politecnico di Milano” and the Complex Structure of Palliative Care, Pain Therapy and Rehabilitation of the “Istituto Nazionale dei tumori di Milano” (IRCCS) in the project "5Xmille Polisocial Award 2012-2013 ". The project is related to the quantitative volume assessment of limbs affected by lymphedema, the quantitative evaluation of functional limitations and the recovery after rehabilitative treatments. The purpose of this work is to: • Fulfill a laser scanner 3D technology-based quantitative evaluation of a group of patients suffering from upper limb unilateral lymphedema and compare the results with the same parameters measured by the centimetric method; characterize the pathological population compared to a healthy subjects sample and identify, within the pathological population, what arm districts are mostly affected by lymphedema; • Investigate the upper limb functionality in terms of shoulder joint mobility using the optoelectronic system. Specific protocols were applied to study the movement of reaching, raised front and side in a group of pathological subjects.; • Evaluate the effectiveness of treatments for lymphedema by comparing the measurements of the pathological limb, acquired using the laser scanner method, before and after treatments; The subjects analyzed are: • 200 pathological subjects with lymphedema, all female, with a mean age of 64 years, who constitute the group for the comparison between the two volume measurement methods; 8 • 12 pathological subjects with lymphedema, all female, with a mean age of 63 years, who were submitted to the functional assessment tests. • 24 pathological subjects with lymphedema, all female, with a mean age of 62 years, who constitute the group for the comparison between the laser scanner measurements taken before and after treatment; The centimetric method measurements were carried out on standing subjects with their arms extended. The measures were taken at regular intervals every 4 cm starting from the wrist. To take measurements using laser scanner, the subjects must stand with the limb in abduction to 90°, the elbow extended and the hand resting on an opaque, adjustable, support. The laser scanner used for acquisitions is the Rodin4D O & P Scan. The image and parameters processing has been realized thanks to the use of two softwares: Rodin4DScan, that makes the reconstruction of shape after scanning and Rodin4D that realizes the final shape and allows the processing of various parameters (perimeters and volumes). The optoelectronic system measurements required that the subject conducting the test has to sit on an adjustable height stool (without backrest and armrests), arms along the body and both feet parallel (bare) resting on the floor in a comfortable position; the subject has to keep the trunk and head as vertical as possible, look straight ahead and perform the movements widest, keeping the elbow extended . Tests were carried out in two sessions, the first without the load and the second with a 1 kg load, and were performed at natural speed for 30 repetitions. The quantitative evaluation of the upper limb functionality was performed at the Movement Analysis Laboratory "L. Divieti" of the “Politecnico di Milano”, using the optoelectronic system EL.I.TE. The data processing and parameter extraction was 9 realized using two software: SmartTracker, which allows to obtain a three-dimensional view of each marker movements and SmartAnalyzer that extracts all the parameters required for a complete biomechanical analysis of the motor gesture . A comparison between the upper limb measures taken using the centimetric measurement method and the laser scanner method was carried out. The measurements taken using the two methods are different, confirming the greater accuracy of the laser scanner and the problems related to the centimetric measurement method. The assessment of the functionality of the upper limb focused on the study of the glenohumeral joint. The application of the measurement protocols on the group of pathological subjects has led to see a decrease of the angle and speed parameters , especially with the introduction of the 1 kg load. It was also noticed an early arising of fatigue in the arm affected by lymphedema. This last aspect is evaluated thanks to the ROM shoulder trend and the presence of periods of " recovery " in correspondence with the minimum angles, in order to rest the muscles before the next repetition. The laser scanner technology has also been applied to compare the volume measures before and after a treatment cycle to determine the treatment effectiveness, selecting a subset of patients subjected to a combined treatment of banding and manual lymph drainage. It emerged a global maintenance or improvement situation , especially in certain areas considered critical for lymphedema . However, given the particular morphology of the limbs of patients with lymphedema, it was considered meaningful to compare the pathologic arm volume, detected with laser scanner, with the contralateral healthy arm volume of each individual patient. This comparison was made through the calculation of the asymmetry index Δpre that indicates which districts are most affected by lymphedema. 10 The results showed that the districts where the edema is more pronounced are generally the same obtained from the first analysis made considering volumetric measures (of pathological limb) without performing the calculation of any index. With this work we were able to demonstrate the effectiveness of laser scanner to measure limb dimensions, to quantify the functional limitation of the subjects taken into account and to determine the effectiveness of treatments through the use of the same technology applied for the volumetric quantitative analysis.