Effects of Intermittent Pneumatic Compression on Delayed Onset Muscle Soreness (DOMS) in Long Distance Runners

The purpose was to measure the effects of intermittent pneumatic compression (NormaTec, NT) on muscle inflammation after long distance running. Methods: Ten long distance runners, five males and five females, ages 18-55 years performed two, 20 mile runs at 70 VO2 max. The runs were followed by either no treatment (control) or NT treatment for five consecutive days. For the NT run, subjects were treated for one hour immediately following the run and daily for five days after. For the control run, subjects did not receive any treatment. Serum C - reactive protein (CRP), a marker of muscle inflammation, was measured pre and post run and daily thereafter for five days for both trials. Repeated measures ANOVA and two-way ANOVA were used to assess treatment differences. Results: The results indicated no significant difference (P \u3e 0.05) between the control and treatment runs in CRP levels. There was also no gender differences or order effect of runs. Subjective pain ratings indicated no significant difference in pain between the control and treatment runs except when comparing the first run compared to the second run (regardless of whether the first run was a treatment or control run) there was a significant difference in which the subjects experienced less pain on the second run. There was no significant difference in mean weight loss, fluid intake, sweat rate, heart rate, percentage of maximum heart rate, or percentage of maximum VO2 max. There was, however, a significant difference (P = 0.038) in running time when comparing the control run (196.2 minutes) against the treatment run (204.8 minutes). Conclusions: Although the test subjects recovered one day earlier when using the NT device (Day 4) compared to the control (Day 5), this difference was not significan

Effects of Intermittent Pneumatic Compression on Delayed Onset Muscle Soreness (DOMS) in Long Distance Runners

The purpose was to measure the effects of intermittent pneumatic compression (NormaTec, NT) on muscle inflammation after long distance running. Methods: Ten long distance runners, five males and five females, ages 18-55 years performed two, 20 mile runs at 70 VO2 max. The runs were followed by either no treatment (control) or NT treatment for five consecutive days. For the NT run, subjects were treated for one hour immediately following the run and daily for five days after. For the control run, subjects did not receive any treatment. Serum C - reactive protein (CRP), a marker of muscle inflammation, was measured pre and post run and daily thereafter for five days for both trials. Repeated measures ANOVA and two-way ANOVA were used to assess treatment differences. Results: The results indicated no significant difference (P \u3e 0.05) between the control and treatment runs in CRP levels. There was also no gender differences or order effect of runs. Subjective pain ratings indicated no significant difference in pain between the control and treatment runs except when comparing the first run compared to the second run (regardless of whether the first run was a treatment or control run) there was a significant difference in which the subjects experienced less pain on the second run. There was no significant difference in mean weight loss, fluid intake, sweat rate, heart rate, percentage of maximum heart rate, or percentage of maximum VO2 max. There was, however, a significant difference (P = 0.038) in running time when comparing the control run (196.2 minutes) against the treatment run (204.8 minutes). Conclusions: Although the test subjects recovered one day earlier when using the NT device (Day 4) compared to the control (Day 5), this difference was not significan

Effects of Intermittent Pneumatic Compression on Delayed Onset Muscle Soreness (DOMS) in Long Distance Runners

The purpose was to measure the effects of intermittent pneumatic compression (NormaTec, NT) on muscle inflammation after long distance running. Methods: Ten long distance runners, five males and five females, ages 18-55 years performed two, 20 mile runs at 70 VO2 max. The runs were followed by either no treatment (control) or NT treatment for five consecutive days. For the NT run, subjects were treated for one hour immediately following the run and daily for five days after. For the control run, subjects did not receive any treatment. Serum C - reactive protein (CRP), a marker of muscle inflammation, was measured pre and post run and daily thereafter for five days for both trials. Repeated measures ANOVA and two-way ANOVA were used to assess treatment differences. Results: The results indicated no significant difference (P \u3e 0.05) between the control and treatment runs in CRP levels. There was also no gender differences or order effect of runs. Subjective pain ratings indicated no significant difference in pain between the control and treatment runs except when comparing the first run compared to the second run (regardless of whether the first run was a treatment or control run) there was a significant difference in which the subjects experienced less pain on the second run. There was no significant difference in mean weight loss, fluid intake, sweat rate, heart rate, percentage of maximum heart rate, or percentage of maximum VO2 max. There was, however, a significant difference (P = 0.038) in running time when comparing the control run (196.2 minutes) against the treatment run (204.8 minutes). Conclusions: Although the test subjects recovered one day earlier when using the NT device (Day 4) compared to the control (Day 5), this difference was not significan

A comparison of three intervention methods for women with breast cancer-related lymphedema: a pilot study

The incidence of breast cancer related lymphedema (BCRL) is estimated to be at 30% for women who undergo breast cancer treatment, thus creating the need for effective treatment interventions. This thesis will compare the immediate and short-term effects of three different interventions for BCRL (e.g., Manual Lymphatic Drainage (MLD), Aqua Lymphatic Therapy (ALT), and a Casley-Smith based exercise routine (CSER)) and to record any changes in physical symptoms after each intervention. Sixteen women between the ages of 35 and 75 with Stage II lymphedema were recruited. Each intervention was completed once by each participant and lasted approximately 45 minutes. Bilateral limb measurements to estimate changes in volume were performed using bio-impedance spectroscopy and circumferential arm measures. The Lymphedema Breast Cancer Questionnaire was utilized to subjectively gauge any change in symptoms. The main findings were: ALT was the only intervention that showed a significant (p≤0.05) decrease in extracellular fluid (ECF) from baseline to 20-24hrs post-intervention. When compared to the MLD, the ALT intervention demonstrated a 3.31% greater (p=0.038) reduction in ECF volume over 24hrs. With respect to circumferential arm measurements, there was a significant difference (p=0.021) in the percentage change between ALT and MLD at 10 min post intervention. No other circumferential arm measurement differences exist between ALT vs CSER or MLD vs CSER. There were no changes or any worsening symptoms following any interventions. Conclusion: In the immediate to short-term post-intervention period, ALT appears to be the most effective intervention in terms of reducing BCRL

The reliability, validity and sensitivity to change over time of the figure of eight method measuring hand size in patients with breast cancer related lymphoedema

Breast cancer related lymphoedema (BCRL) affects approximately 21% of patients following treatment for breast cancer. The current gold standard method of measuring hand swelling associated with BCRL is to use water displacement (volumeter). However, this is not always possible in the clinical setting. The circumferential tape measurement method is often used clinically but this does not include the area on the dorsum of the hand where the oedema is most commonly situated. The figure of eight method, which involves wrapping a simple measuring tape around the hand in a specific way, may be an alternative method to measure BCRL. The aim of this study was to determine whether the figure of eight tape method was a valid and reliable method of measuring hand size in patients with hand oedema associated with BCRL. This was investigated by comparing the figure of eight tape method of measurement against the “gold standard” method of water displacement. The aim was also to establish whether the figure of eight tape method of measurement was reliable and valid for novice practitioners to ensure that the method could be used by any practitioner assessing a patient with BCRL. It was also investigated whether the figure of eight method of measurement was sensitive enough to detect change in hand size over time. In study 1, 24 patients with hand swelling associated with BCRL participated. Two novice testers performed three “blinded” figure of eight measurements and three volumetric measurements of the affected hand. In terms of inter-tester and intra-tester reliability, the intraclass correlation coefficients were all greater than 0.8 indicating high intra- and inter-tester reliability for the figure of eight method. For validity, a Pearson moment correlation was used to compare the figure of eight and volumetric methods. The results demonstrated a statistically significant correlation of 0.7 for both testers. The results from this study, therefore, found the figure of eight method to be a valid and reliable method of measuring hand swelling in this population, even when measurements were made by novice practitioners. Ten subjects, with hand oedema associated with BCRL, participated in study 2. One tester, who was an experienced lymphoedema practitioner, performed three “blinded” sets of figure of eight measurements, circumferential measurements and volumetric measurements of each hand. These measurements were taken at the start of a course of treatment for lymphoedema management and then again at the end of this treatment course. In terms intra-tester reliability, the intraclass correlation coefficients (3.1) were all greater than 0.9 for each of the measurement methods indicating high intra-tester reliability. For validity, a Pearson moment correlation was used to compare the results from the figure of eight and volumetric methods, and showed a statistically significant and strong correlation of 0.7 between these methods. The Pearson moment correlation between volumeter and circumferential measurement was 0.6 which indicated a good correlation, suggesting this method was also valid. In this study, sensitivity to change in hand size was also considered using the Wilcoxon signed rank confidence interval and, of the three measurement methods, only the figure of eight method indicated a difference in the pre and post treatment measurements. This may suggest this method is sensitive enough to detect change in hand size over time. It was recognized, however, that this study was carried out on a small sample. Further studies are required to investigate the sensitivity to change in hand size of this method on a larger sample. The study also highlighted the natural variability that occurred in the unaffected hand over the course of the treatment time and therefore, future work to establish the extent of this variability would enable the identification of a clinically significant change in hand size with treatment. The studies would support the use of the figure of eight method for monitoring hand oedema in patients presenting with BCRL. The early results, albeit on a small sample, indicate that the figure of eight method may be valid, reliable and responsive to change over time. The figure of eight tape measurement method is suitable for all patients, is inexpensive, quick and does not require specialist training

Effectiveness of physical therapy in axillary web syndrome after breast cancer: a systematic review and meta-analysis

The axillary web syndrome (AWS) is a surgical breast cancer sequel that limits the functionality of the patient and delays the protocol times of application of cancer treatments. This implies a long period of discomfort and limitations for the user. Objective: To investigate the different physiotherapy treatments for the AWS and how effective they are. Methods: A systematic review based on PRISMA protocol and registered in PROSPERO (CRD42021281354) was conducted. The research was performed using PubMed, Scopus, CINAHL, PEDro, and Web of Science databases during January 2022 and March 2022. All randomized controlled trials and controlled clinical trials were included in this review. Results: A total of 188 articles were identified, with 9 studies selected for the systematic review. These studies basically propose treatments based on exercises and stretching, manual therapy, and the combination of manual therapy and exercises. Conclusions: Exercise and stretching are the most effective therapies within the field of physiotherapy for the rehabilitation of axillary web syndrome. They restore range of motion faster, reduce pain, improve quality of life, and reduce disabilities. Manual therapy, scar massage, and myofascial release could help improve outcomes but with worse results. The meta-analysis conclusion is that pain is the only outcome with a significant reduction after the application of physiotherapy treatments − 0.82 [− 1.67; 0.03]. This conclusion is drawn from the only three studies with small sample sizesFunding for open access publishing: Universidad de Cádiz/CBUA This study was funded by the University of Málaga through a predoctoral grant support to JBGR, a PhD student at the university

Coordination between intrinsic and extrinsic mechanism in thoracic lymphatics.

The lymphatic system runs in parallel with the blood vasculature, it plays a key role in maintaining tissue fluid homeostasis, as a tissue-drainage system, and it contributes to the immunosurveillance by providing a route for migrating cells. The lymphatic system is a highly branched network of thin-walled blind-ended vessels, which drain fluid, macromolecules and cells from the extracellular spaces within most organs, carrying them into larger thicker-walled collectors running deeper in the body. Fluid and solutes extravasated from vascular capillaries into the interstitial space enter blind-ended initial lymphatics, which are anchored to the interstitial matrix via anchoring filaments and possess overlapping endothelial cell-cell junctions behaving like valve structures, only permitting unidirectional lymph entry into the lymphatic vessel lumen. Valves in collecting lymphatics consist of two modified adjacent endothelial cell leaflets which meet in the vessel lumen forming a funnel inside the vessel and separating adjacent lymphangions, the functional units of the lymphatic system. Lymph is formed along a hydraulic pressure gradient developing between the interstitial tissue and the lumen of initial lymphatics. This pressure gradient depends upon both extrinsic and intrinsic pump systems. Tissue movements provide the extrinsic factor affecting lymphatic function, causing cycles of external compression/expansion of the lymphatic vessels lumen.. Lymphangions, segments of lymphatic vessel delimited by unidirectional valves and surrounded by smooth muscle cells, represent the functional units of the intrinsic pump mechanism. Their rhythmic active contraction is essential to guarantee the correct lymph flow either as the only source of pressure gradient formation or along with the extrinsic pump, where the mechanical features of the surrounding tissue are able to generate such an external pump action. During active contraction, lymphatic smooth muscle cells create an increase in intraluminal pressure and generate a local positive pressure gradient which drives lymph propulsion. The subsequent relaxation of the smooth muscle layer generates a decrease in intraluminal pressure which drives lymph from the interstitial space into the vessel itself. The aim of the present thesis was to study the interaction between the intrinsic and extrinsic mechanisms in a highly moving tissue such as the diaphragm. By in vivo fluorescence staining of diaphragmatic lymphatics we were able to identify vessels organized in loop structures and located both in the tendineous and in the peripheral muscle region. Lymphatic loops were classified into four groups (active, hybrid, passive and invariant) according to their functional behavior, forming functionally distinct regions. By whole mount immunostaining against smooth muscle actin we identified a dense smooth muscle mesh surrounding actively pumping sites, whereas in not contracting tracts smooth muscle fibers were more sparsely organized, showing a lot of large gaps around the vessel wall. Actively pumping lymphatic sites did not differ in diameter from all other classes of vessels. We found that their amplitude of contraction was independent on vessel size but strongly correlated to contraction frequency. By temporal analysis we were also able to identify trigger sites which controlled the diameter change of both other active and passive sites belonging to the same network. We then made an extensive study on the temporal correlation of activity among active, hybrid and passive sites belonging to the same network, and were able to identify trigger regions and follower regions whose behavior was dependent upon their respective trigger sites Lastly, we started an ongoing project in order to understand the extrinsic pump effect due to respiratory and cardiogenic movements on diaphragmatic lymphatic function. By locally injecting KCl into the interstitium next to invariant longitudinal and/or transverse lymphatics we tested diameter and/or length changes and then intraluminal pressure gradients due to extrinsic forces. Further analysis are required in order to define the actual contribution of intrinsic and extrinsic mechanisms in diaphragmatic lymphatics

A Randomized Controlled Trial Comparing Contrast Baths to Cryotherapy in Patients with a Wrist Fracture

Cryotherapy and contrast baths are common modalities used to treat edema. Despite the fact that many hand therapists report using contrast baths with their patients, there is still little evidence on the effectiveness of them. A Randomized Controlled Trial-Repeated Measures Design was employed to compare the effectiveness of contrast baths to cryotherapy. Participants were recruited after a period of post-fracture immobilization. Blind assessors attained measurements in range of motion, pain, and edema in the 1st, 2nd, and 4th weeks. Participants were randomly assigned to either use cryotherapy or contrast baths at home during the 4-week study period. The participants in this study were asked to keep a home program log to record the number of times that they were able to complete their assigned modality. Also, at the final measurement appointment, the participants were asked to complete a survey indicating their satisfaction with their assigned home program. The results from the ANOVA indicated that there was statistical significance for all the measurements (p \u3c .05) except for palm circumferential and volumeter. The results from the home program logs indicated that the adherence for contrast baths had a mean of 2.03 (SD = 0.76) times per day and the cryotherapy group had a mean of 1.75 (SD = 0.98) times per day. The researchers also noted a trend that the contrast baths group may have a larger effect in the first two weeks of treatment, while the cryotherapy group may have more gradual improvements throughout the four weeks. The results of this study found that adherence for contrast baths and cryotherapy had similar home program adherence and that the participants had similar experiences

Proactive Management of Acute Oedema Following Hand and Minor Burn Injury

Burn injury is a unique trauma. The inflammatory process initiated with burn injury adversely influences all of the Starling equation variables, resulting in increased transvascular fluid filtration, so that oedema as a product of burn injury is more readily formed than in other forms of trauma. Localised wound oedema forms due to minor burn injury, with increasing systemic oedema associated with increased size of burn. It is now recognised that a marked inflammatory and immune response is created with non-severe burn injury, indicating a systemic component with all burns. The effect of oedema formation on the course of the burn healing is well described in the literature, due to its impact on the zone of stasis in the wound and its potential to result in progressive tissue loss or conversion if poorly managed. Burn conversion leads to an increase in the area and depth of the burn wound, necessitating surgical intervention, which increases the risk of scarring. Burn scarring may lead to altered function and poor aesthetic outcomes, which have the potential to adversely affect patient psychological well-being. Despite the influence of oedema on the healing of the burn wound and therefore the scar worn for life, there is little evidence to guide clinicians who aim to proactively manage this oedema, with only two published, controlled trials investigating methods to improve peripheral oedema in burn injury. The aim of the series of studies described in this thesis is to provide a holistic approach to the management of oedema following acute burn injury. To be able to effectively treat oedema, the clinician needs to be able to accurately assess the affected limb and wound for oedema. Oedema management in burn injury is often based on the clinicians’ preference of intervention, without good understanding of the optimal parameters of application or efficacy. Therefore, evidence is required for optimising the management of oedema in the acute burn injured patient. Furthermore, the hand’s unique anatomical structure that produces functional dexterity adds complexity to the assessment and management of oedema formation in the hand. Burn injury to the hand is common, as hands provide interaction with the world, and are generally vulnerable during activities of daily living. In the event of major accidents, the hands are reflexively used to protect the face and body, further predisposing them to significant injury. The ability to accurately measure oedema guides clinicians in their treatment of acute burn wound oedema. Current objective measures of oedema often lack sensitivity, increase pain, introduce a risk of infection from equipment contact with open wounds, or are cumbersome for repeated use in the clinical environment. They are also influenced by the cooperation of the patient, and burn injury often results in significant pain, impaired movement, and may require the use of medications that modify behaviour. As a result, oedema is usually assessed visually or through palpation of the tissue, noting the loss of skin creases or pitting of soft tissue. These assessments are subjective based on the clinician’s experience and do not provide objective measures that can be repeated between testers or between sessions. Demonstrating the effectiveness of proactive oedema management following acute burn injury is therefore dependent on the ability to accurately assess the oedema using a valid, reliable and sensitive objective measure. There is a lack of high-quality prospective studies investigating oedema management techniques in burn injury populations. In a 2011 systematic review, there was only one published randomised control trial, which investigated the use of electrical stimulation in addition to standard interventions for managing hand burn oedema, while a second conference presentation was reported as part of the review. There have been no further published studies in this space, providing clinicians with little guidance as to the optimal parameters to manage oedema in this challenging injury cohort. Measuring oedema in this patient group is similarly challenging. The study series in this thesis addresses the challenge of measuring hand burn oedema and wound healing. Bioimpedance spectroscopy (BIS) is a technology that has demonstrated reliability and validity for measuring whole body and limb oedema in burns patients during fluid resuscitation, and is sufficiently sensitive to measure oedema change with wound healing. Another BIS variable, Phase Angle, is validated to be a measure of cell health, as it measures the flow of current across the cell with respect to the voltage. Increased lag in the current is the result of increased cell mass and cell wall integrity (a healthier cell), resulting in an increased Phase Angle. This has been demonstrated to increase with healing in chronic wound populations, but has not been validated in acute burn injury. The first study in this thesis is a method validation study, investigating the measurement of hand volumes using a novel application of BIS. A technique to measure hand volumes using BIS has been described previously, however the burn injured hand is compromised by wounds. The guidelines for the use of BIS require that electrodes are placed on intact skin. The study compared different electrode configurations on the hand and arm to the previously described configuration in a non-injured population, to determine if different electrode configurations are valid for measuring hand volumes. The key findings of this study were that, when compared to previously described electrode positions on the dorsum of the hand and forearm, alternative electrode combinations on the volar surface of the hand and forearm, and an electrode array on the palm of the hand and the dorsum of the forearm, were both valid for measuring hand oedema volumes in an uninjured population. These outcomes provide novel evidence to guide electrode placements to measure hand volume using BIS where wounds precluded the use of standard electrode arrays. The second study in this series is a validation study, informed by and used the electrode positions assessed in the first study, to determine the validity and reliability of BIS for measuring hand (oedema) volumes in a burn injured population. Repeated hand volume measures were obtained in 100 patients presenting with hand burn injury with BIS, and with water displacement volumetry as a gold standard comparison. The results of this study demonstrated that the electrode positions assessed as valid for measuring hand volumes in an uninjured population in the first study, were valid, reliable and sensitive for measuring oedema in the hand following burn injury, showing high correlation with the gold standard comparator. This technique was used to assess the primary outcome – oedema volume change – in the third study of this series. The following studies in this thesis are intervention research, investigating techniques designed to proactively manage oedema in acute burn injury. The third study described in this thesis is the first randomised controlled trial to investigate different methods of applying compression to the hand to manage acute burn oedema. Compression is a commonly used technique to control oedema, reported to be applied based on clinician preference, which is dependent on the way each clinician was taught. In this study, 100 patients (the largest of its kind to the best of my knowledge), presenting with burn injury involving a portion of the hand were randomised to receive one of three commonly used methods of applying compression, to provide evidence as to which is the most effective at controlling acute burn wound oedema in the hand. In this study, the two most common methods of fabricating a custom compression glove using cohesive bandage were shown to be both equally effective at reducing post burn oedema in the hand, and both were more effective for reducing hand burn oedema than the control condition being an off the shelf compression glove. The patients in this study were also provided education regarding exercise to maintain function and promote oedema reduction, oedema management advice including elevation of the hand above the level of the heart at rest, and ensuring normal use of the hand while respecting the wound environment to minimise the risk of infection. These interventions resulted in significantly greater hand range of movement between test sessions, and a significant improvement in the QuickDASH (Disability of Arm, Shoulder and Hand) patient reported outcome measure. The effect of a low energy, long duration electrical stimulation on the acute burn wound was investigated in study four. Electrical stimulation has been demonstrated to improve the rate of healing of chronic wounds, and aid the reduction of oedema in a number of populations, including patients with hand burn injury when used in addition to standard physiotherapy. The novel application of electrical stimulation in this study utilised a small patient applied stimulation device for more than 20 hours per day for a period of up to 14 days, with the current applied across the wound with electrodes placed either side of the injured tissue on intact skin. This was designed as a within-patient control, randomised trial. Patients with similar size and similar depth burns to multiple limbs participated in this study. Electrical stimulation was applied to one wound, with the contralateral wound serving as the control wound. The outcomes investigated were change in oedema, as measured by the BIS variable R0, measuring the impedance of the extra-cellular fluid; and wound healing, measured by the BIS variable Phase Angle, and compared to clinical photography of the wounds, which were assessed by a consultant burns surgeon to determine wound re-epithelialisation, or healing. Phase Angle and wound impedance were demonstrated to be associated with wound healing. Electrical stimulation applied to a minor burn was shown to increase the rate of oedema reduction in the wound compared to the control wound, and increased Phase Angle at a faster rate than in the control wound, indicating an increase in cell and tissue health. This thesis presents a study series whereby the first two studies validated a new method of measuring hand burn oedema quickly, with minimal imposition on the patient. This method was demonstrated as viable and applicable in acute burn patients, in both research and clinical practice contexts, and informed the ensuing studies in this series. The final two studies presented in this thesis are randomised controlled trials investigating the proactive management of oedema in acute burn injury, and contribute significant new knowledge to the literature, providing guidance to the burn clinician who manages acute oedema to prevent conversion of the burn wound and deterioration in function. When presented with a hand burn injury, the clinician will be able to appropriately manage the ensuing oedema with a custom compression glove fabricated using a cohesive bandage with either of the most common methods therapists are taught. In addition, in minor burn wounds, the use of a small, easy to use, low energy long duration electrical stimulation device as an adjunct to standard burn wound care, will increase oedema reduction and improve the rate of wound healing compared to standard wound care alone