RU2845518C1 - Method for integrated medical rehabilitation in postmastectomy syndrome - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to medical rehabilitation, oncology, mammalogy, physiotherapy and psychotherapy. 10 daily procedures of manual lymphatic drainage massage (MLD) are performed based on Vodder massage after 5-minute procedure of diaphragm breathing, MLD procedures are performed daily for 50-60 minutes, with the repetition frequency of the massage technique – circular strokes and efflorescence – on the skin of a given area as ¼ of the patient's current heart rate. MLD is performed on the anterior abdominal, chest wall, supraclavicular, subclavian and axillary regions, neck, as well as on the operated arm. At the end of the MLD, diaphragm breathing is repeated for 5 minutes. Performing the machine lymphatic drainage massage of the extremity of the operated side with the help of the “Lympha-E” series pneumocompression apparatus and the “sleeve” 7-section cuff applied to it for 20 minutes in the mode of the “ascending travelling wave with pressure memorization” apparatus, successively filling 7 sections of the cuff "sleeve" in the direction from the fingers to the shoulder with air with pressure in the form of a gradient. Duration of a cycle to fill seven sections is 10 seconds with simultaneous disconnection of all sections of the sleeve cuff, 10 daily procedures. There are 10 daily group therapeutic exercises in the hall with hand motions to be repeated in hydrokinesitherapy in a swimming pool at neck water level with overcoming water resistance. Three times a week, course of 6 sessions is held for psychodynamic group psychotherapy with creative self-expression in the form of art therapy using projective drawing techniques. Psychorelaxation technique involves additional unassisted diaphragm breathing 3-4 times day for 5 minutes. That is followed by an apparatus correction of the psychoemotional state with biological feedback by audiovisual stimulation with the use of a hardware-software resonant-acoustic rehabilitation complex for the individual’s psychosomatic state correction (HRAC) in the “Relaxation” HRAC program mode. Binaural exposure is performed by transitioning from a beta activity state at 15 Hz through an alpha activity to a theta rhythm at 7 Hz with simultaneous demonstration of a relaxation video sequence on a monitor; the therapeutic course is 10 procedures of 30 minutes.

EFFECT: method allows to reduce time of in-patient medical rehabilitation to 10 days, increase the patients compliance to rehabilitation with the strengthening of their personal physical and psycho-emotional capabilities for the continuation of supporting effects on their own, at home, to ensure the absence of lymphoedema recurrence for at least 6 months when used at stage 1-2 lymphoedema and degree of postmastectomy syndrome.

1 cl, 1 ex

Description

The invention relates to medicine, medical rehabilitation, oncology, mammology, physiotherapy and psychotherapy, and can be used in health resort institutions and medical rehabilitation departments and institutions.

Postmastectomy syndrome (PMES) includes such manifestations as postmastectomy edema of the upper limb on the side of the operation, consequences of adjuvant therapy, psychoemotional disorders such as anxiety, depression, suicidal thoughts. After axillary, subscapular and subclavian lymphadenectomy is performed by an oncologist, the lymph outflow pathways from the upper limb change dramatically, so early edema of the limb occurs already on the 1st day after surgery. According to various authors, PMES accounts for up to 87.5% of cases after breast cancer (BC) surgeries. Limitation of range of motion in the shoulder joint, as well as increasing edema of the upper limb is observed in 28-57.5% of cases, manifestations of damage to the nerve trunks of the brachial plexus - in 0.4-73%. The prevalence of depression with a high risk of suicide after breast cancer surgery ranges from 13% to 32% of cases.

Lymphostasis (secondary lymphedema) of the upper limb is one of the most common complications of radical treatment of breast cancer. It is the result of pathological changes in the lymphatic system of the limb due to surgical and/or radiation exposure to the lymphatic apparatus of the axillary-subclavian-subscapular region, surrounding tissues and vessels (Lud N.G. et al. Rehabilitation of patients with breast cancer. // Bulletin of VSMU, 2008, Vol. 7, No. 3).

The following factors are important in the mechanism of development of lymphatic edema of the upper limb:

- partial disruption of innervation of the limb as a result of the intersection of small nerves during surgery;

-increased activity of the blood and lymph coagulation system;

-increased platelet aggregation in the vessels of the swollen limb with subsequent thrombosis, thrombophlebitis and lymphangitis;

- slowing of capillary and venous blood flow and increased permeability of the vascular wall;

- violation of microcirculation and development of tissue hypoxia;

-sclerotic changes in the dermis and subcutaneous tissue;

- progressive deterioration of lymphatic and venous outflow;

- violation of lymph drainage through the lymphatic collector after its surgical or radiation damage;

- severe venous insufficiency caused by compression of the main veins of the arm by fibrously altered tissues as a result of surgical radiation trauma.

The development of edema is facilitated by early complications, especially wound suppuration, erysipelas of the affected limb, and the use of tamoxifen, which causes the formation of blood clots and deep vein thrombosis.

As it develops, lymphatic edema causes increased neurovascular disorders and impaired limb function, the clinical manifestations of which are impaired skin sensitivity, a feeling of heaviness, increased fatigue, decreased muscle tone and strength, partial or complete loss of motor activity, and limited movement in the shoulder joint. Pain occurs when attempting to abduct or raise the arm. Erysipelas may develop at all stages of lymphedema.

Depending on the location of the edema on the limb and the percentage increase in the volume of the edematous limb in relation to the healthy one, there are 4 clinical degrees of lymphedema.

Stage I – the swelling is not permanent. The skin in the edematous area is easily folded. The volume of the edematous limb exceeds up to 25% of the volume of the healthy limb. The skin temperature of the hand decreases by 0.5-1.0°C.

Stage II – swelling decreases after rest, but does not completely disappear. The skin is difficult to fold. The volume of the swollen limb exceeds the volume of the healthy limb by 25-50%. The skin temperature of the hand and forearm decreases by 0.5-1.0°C.

Stage III – the swelling is dense and constant, fibrous-sclerotic changes in the skin and subcutaneous tissue are observed. The skin cannot be folded, hyperkeratosis develops. The volume of the edematous limb exceeds the volume of the healthy limb by 50-70%. The skin temperature of the hand and forearm decreases by 0.5-1.0°C.

IV degree – limb deformation, limited mobility, trophic disorders are observed. The volume of the edematous limb exceeds more than 70% of the volume of the healthy limb. A decrease in skin temperature of the hand, forearm and shoulder is 0.5-1.0°C.

The following variants of qualitative characteristics of edema are also distinguished:

Stage I (transient edema) – characterized by an inconstant increase in the volume of the limb. Skin mobility is completely preserved, and its thickening is not observed when cut.

Stage II (soft edema) – in this case, the edema of the limb remains completely. The skin is taken into a fold, but does not shift in relation to the underlying tissues; when pressing on it, a clearly visible deep pit remains. When the skin and subcutaneous tissue are cut, a clear transparent liquid is abundantly released, there is moderate thickening of the skin.

Stage III (dense edema) is characterized by an increase in the volume of the limb. Soft tissues are tense and dense to the touch. The skin does not fold or shift in relation to the underlying tissues. When pressing on the skin, there is no visible pit left on it. Often there are areas of hyperpigmentation of the skin. When cut, significant thickening and fibrosis of the skin and subcutaneous tissue are noted.

Stage IV (deforming edema) is characterized by disfigurement of the limb due to excessive growth of soft tissues. Movement in the joints of the limb is limited due to the increase in its mass. Papillomatosis and hyperkeratosis of the skin are often observed.

It should be noted that immediately after radical mastectomy, in most cases, lymphatic edema does not occur, but a latent period of 1-2 weeks to several years passes. This is explained by the fact that intervascular anastomoses are formed, a "lymphatic bridge" between the distal and proximal sections of the lymphatic pathways. Later, if it fails, dilation of the lymphatic vessels occurs, lymph outflow slows down, and lymph flows back to the distal sections.

In the prevention of late edema (lymphostasis), great importance is attached to measures used to prevent early edema, and the following measures are also recommended:

- limiting the load on the affected limb to 3 kg for 1 year;

- periodic elevation of the upper limb;

- exercise therapy for 6-7 months after surgery;

- daily warm (38-40°C) baths and showers;

- prevention of damage and microtrauma (injections, cuts, burns) and their subsequent infection.

Thus, PMES has a negative impact on both the physical and psychological health of a woman, her quality of life. Timely restorative treatment can significantly improve this condition.

Rehabilitation after radical treatment of breast cancer by mastectomy includes early initiation, reasonable choice of measures and stage-by-stage implementation (M.Yu. Gerasimenko et al. Use of general magnetic therapy and intermittent pneumatic compression in the early postoperative period in patients after radical mastectomy. // Bulletin of Restorative Medicine. 2018; 6(88): 85-90).

There are a number of known methods for treating PMES after radical mastectomy in patients with postmastectomy edema of the upper limb by:

- carrying out complexes of various physiotherapeutic interventions (Nazarova N.M. et al. Optimization of postoperative care of patients with breast cancer. // New day in medicine. 2016, 2(14), pp. 32-35; Stepanova A.M. et al. Postmastectomy syndrome: secondary lymphedema of the upper extremities after combined treatment of breast cancer (literature review and own results). // Modern oncology. 2018, v. 20, no. 2, pp. 45-49; Gaidarova A.Kh., Kotenko N.V. et al. Efficiency of medical rehabilitation of women after mastectomy for breast cancer. // Research and practice in medicine. 2017, v. 4, no. S2, p. 38);

- chymotrypsin electrophoresis using sinusoidal modulated currents (M.V. Ermoschenkova, E.V. Filonenko, A.D. Zikiryakhodjaev. // Federal clinical guidelines for the diagnosis and treatment of postmastectomy syndrome. - Moscow - 2013 - p. 29);

- application of low-frequency pulse currents with a bipolar asymmetric pulse shape (patent RU 2095095);

-electrotherapy by transcutaneous exposure to electrical bipolar pulsed current (patent RU 2365388; RU 2715616 C1, 02.03.2020);

- low-intensity magnetic therapy (Gerasimenko M.Yu. et al. Magnetic therapy in the rehabilitation of patients after radical mastectomy. // Issues of balneology, physiotherapy and therapeutic physical education. 2020, v. 97, no. 2, pp. 36-44);

- intermittent pneumatic compression (Gerasimenko M.Yu. et al. Use of general magnetic therapy and intermittent pneumatic compression in the early postoperative period in patients after radical mastectomy. // Bulletin of restorative medicine. 2018, 6 (88), pp. 85-90; Apkhanova T.V., Konchugova T.V., Kulchitskaya D.B., Yurova O.V., Styazhkina E.M., Marfina T.V., Agasarov L.G., Vasilyeva V.A., Berezkina E.S. New non-drug technologies for breast cancer-associated lymphedema: a literature review. // Bulletin of restorative medicine. 2024, v.23, no. 3, pp. 40-51; Myasnikova M.O. Justification and evaluation of the effectiveness of diagnostic and treatment methods for patients with postmastectomy edema of the upper limb. Abstract of diss... Doctor of Medical Sciences. 2002, St. Petersburg, 39 p.; Dyachenko N.A. et al. Use of pneumatic exercise machines in rehabilitation. // Translational Medicine, 2020, Vol. 7, No. S2, pp. 234-235).

At the same time, a number of clinical studies abroad have shown that manual lymphatic drainage cannot always significantly improve a woman’s condition with PMES (Mining Liang et al. Manual lymphatic drainage for lymphedema in patients after breast cancer surgery: A systematic review and meta-analysis of randomized controlled trials. // Meta-Analysis Medicine (Baltimore). 2020 Dec 4;99(49):e23192. doi: 10.1097/MD.0000000000023192).

A number of studies have also shown that water-based exercise improved pain perception and quality of life in patients with upper limb lymphedema (Maria Chiara Maccarone et al. Water-based exercise for upper and lower limb lymphedema treatment. // Review J Vasc Surg Venous Lymphat Disord. 2023 Jan;11(1):201-209. doi: 10.1016/j.jvsv.2022.08.002. Epub 2022 Aug 20).

At the same time, it is known that the use of aquatherapy is seriously limited by psychological barriers: the appearance and impossibility of using the exoprosthesis in water often prevent women from visiting the pool for fear of attracting the attention of others (Sokolov D.S. Mastopathy and breast cancer. Diagnostics, treatment, rehabilitation. Textbook for students. Smolensk. 2023, 52 p.).

In this regard, women with PMES need positive psychological support. The most important positive role of various types of psychotherapy in general in this pathological condition is known (Tsvetkova L.K. Rehabilitation of patients with breast cancer in the surgical department of mammary gland tumors. The role of a nurse. // Medical sister. 2013, No. 2, pp. 9-12; Grushina T.I. et al. Psychological aspects of physical rehabilitation of patients with breast cancer with late postmastectomy edema. // Palliative medicine and rehabilitation. 2016, No. 4, pp. 25-29; Tkachenko G.A. et al. Manual for doctors on the rehabilitation of patients with breast cancer. // Modern oncology. 2020, vol. 22, No. S3, pp. 3-34).

There are also known methods of psychotherapy for women with PMES, in particular, art therapy methods, art therapy using various drawing techniques with the restoration of the locomotor function of the upper limb (RU 2700536 C1, 17.09.2019, Gigineishvili G.R., Kotenko N.V., Lanberg O.A.; Gaidarova A.Kh., Gigineishvili G.R., Garshina O.V. Art therapy as a method of correcting the mental state of patients after mastectomy performed for breast cancer. // Research'n Practical Medicine Journal. 2016; 3; 2: 56-57),

The "gold standard" of rehabilitation in PMES can be considered a wide range of activities aimed at restoring and maintaining the quality of life, family and social adaptation of patients who have undergone radical surgery for breast cancer, using physiotherapy, psychotherapy, bandaging, skin care, lymphatic drainage massage - manual and hardware, post-isometric relaxation, balance therapy and other physical exercises, diet to reduce body weight (or at least prevent weight gain), the volume of physical activity should be at least 150 minutes per week (Ermoshchenkova M.V. et al. Federal clinical guidelines for the diagnosis and treatment of postmastectomy syndrome. // Bulletin of restorative medicine. 2014; 5: 68-84; Evstigneeva I.S. et al. Use of physical factors at the 1st stage of medical rehabilitation after radical surgical treatment of breast cancer. // Bulletin of restorative medicine. 2022, v. 21, no. 2, pp. 127-138; Briskin Yu.A. et al. Improving the functional state of the upper limb in women with postmastectomy syndrome by introducing a problem-oriented physical rehabilitation program. // Pedagogy, Psychology and Medical and Biological Problems of Physical Education and Sports. 2015, no. 11, pp. 20-25; Evstigneeva I.S. The impact of medical rehabilitation on improving the quality of life of patients with malignant neoplasm of the mammary gland in the early postoperative period. // Doctor. 2022, v. 33, no. 9, pp. 83-89; Khudoev E.S. et al. Medical rehabilitation at the resort of patients with breast cancer after combined treatment. // Resort medicine. 2020, no. 2, pp. 21-31; Khetagurova A.K. et al. Organization of rehabilitation of patients after mastectomy. // Problems social hygiene, health care and history of medicine. 2018. Vol. 26, No. 3, pp. 160-163).

Manual lymphatic drainage massage (MLD) of the upper limb for the prevention of lymphedema in PMES and the treatment of existing edema occupies a special place in complex rehabilitation. The most popular in this regard is Vodder's massage (see, for example, M.P. Vavilov. Self-administered lymphatic drainage: prevention and treatment. M. 2019, 85 p.).

At the same time, the overwhelming majority of specialists note the need for a personally oriented, individual focus of both psychological and physical rehabilitation measures in PMES (Lud N.G. et al. Rehabilitation of patients with breast cancer. // Bulletin of the Vitebsk State Medical University. 2008, Vol. 7, No. 3, pp. 39-51; Tkachenko G.A. et al. Interaction between a medical psychologist and a physiotherapist in the staged rehabilitation of patients with breast cancer. // Palliative medicine and rehabilitation. 2018, No. 3, pp. 15-17; Gaidarova A.Kh., Kotenko N.V. et al. Modern physical methods of rehabilitation of patients with postmastectomy lymphostasis of the upper limb after specialized treatment of breast cancer (review). // Bulletin of restorative medicine. 2016, 5 (75), pp. 12-18).

However, as a rule, the disadvantages of known methods are the need for long-term patient management, difficulties in understanding what unprepared patients need to do, long-term independent work with homework, lack of subsequent sufficient medical supervision, and encountering strong unpleasant experiences throughout the therapy.

As the closest analogue (prototype) of the proposed method, the method of complex rehabilitation of women with PMES after radical mastectomy for breast cancer, disclosed in the publication: Grushina T.I. et al. Psychological aspects of physical rehabilitation of patients with breast cancer with late postmastectomy edema. // Palliative medicine and rehabilitation. 2016, No. 4, pp. 25-29. It describes a comprehensive programmatic intervention during a 15-day rehabilitation course, including a whole range of physiotherapeutic interventions, such as wave-like (intermittent) pneumatic compression of the swollen limb using various multi-section devices in the "growing or running wave" mode, therapeutic drainage massage, exercise therapy, electrical neurostimulation and exposure to a low-intensity low-frequency alternating magnetic field, electrical stimulation of the shoulder girdle muscles, as well as mandatory psychocorrection taking into account psychoemotional disorders in women identified using valid scales and questionnaires.

The technical task of the proposed invention was to develop a shorter, but similar in effectiveness, rehabilitation complex for women of the described group, with the formation of greater awareness in them to eliminate the above-mentioned shortcomings of known courses of similar rehabilitation.

The technical result of the proposed method is a reduction in the duration of inpatient medical rehabilitation to 10 days, an increase in the compliance of patients to rehabilitation with the strengthening of their personal physical and psycho-emotional capabilities to continue supporting effects independently, at home, the absence of relapses of lymphedema for at least 6 months, when used at stages 1-2 and degrees of lymphedema.

For this purpose, we have proposed a method of complex medical rehabilitation for postmastectomy syndrome, including physiotherapeutic and psychotherapeutic interventions.

As a physiotherapeutic effect of the complex, 10 daily procedures of manual lymphatic drainage massage (MLD) are carried out based on Vodder massage after a 5-minute procedure of diaphragmatic breathing,

moreover, RLD procedures are carried out daily for 50-60 minutes, with the frequency of repetitions of the massage technique on the skin of a given area being ¼ of the patient’s current heart rate,

the initial position (IP) of the patient before RLD is lying on his back, starting with the efflorage technique - longitudinal sliding touches to the skin with the tips of 4 fingers of the hand from the pubis to the navel 6 times, then from the lower edge of the sternum to the navel 6 times,

then perform superficial circular stroking on the spot with the skin shifting with the pads of the middle fingers of both hands above the navel, first clockwise from the outside into the depths, then counterclockwise from the depths of the navel outward, 6 times each,

then – superficial circular stroking on the spot with the skin moving with both hands in the lower quadrants of the abdomen with counter movements: with the left hand – clockwise, with the right – counterclockwise, 6 times;

then – superficial circular stroking on the spot with the skin moving with both hands in the right and left hypochondrium, respectively, with the left hand – counterclockwise, with the right – clockwise, 6 times;

then – efflorescence on the skin of the anterior chest wall with the tips of 4 fingers of the hand from the operated mammary gland to the costal arch of the same side, 6 times;

then on the area of the scar of the operated mammary gland - five fingers of the doctor's hand lie on the outside of the scar, parallel to the costal arch, point the fingertips towards the abdomen, across the ribs and make superficial circular movements on the spot with the skin shifting: with a scar on the left - clockwise; with a scar on the right - counterclockwise, 6 times, the direction of movement is towards the navel;

then - in the subclavian region of the operated side, for which the working hand is positioned parallel to the collarbone, the fingertips are directed towards the axillary region, superficial circular movements are performed on the spot with the skin shifting in the case of a scar on the left - clockwise, in the case of a scar on the right - counterclockwise, 6 times, the direction of movement is towards the shoulder;

in the supraclavicular regions - place the fingertips in the supraclavicular fossa, make superficial circular movements on the spot with the skin shifting to the right - clockwise, to the left - counterclockwise, 6 times, direction of movement - towards the base of the sternum;

then move to the IP sitting and begin RLD of the neck by efflorescence with the tips of 4 fingers of each hand from the corner of the corresponding lower jaw along the lateral surfaces of the neck, down to the supraclavicular fossa, 6 times;

on the anterolateral region of the neck on the operated side - the fingers of the working hand are placed on the skin under the lower jaw parallel to it and directed towards the angle of the lower jaw, superficial circular movements are performed on the spot with the skin shifted in the case of a scar on the left - counterclockwise, in the case of a scar on the right - clockwise, the direction of movement is towards the same supraclavicular fossa, 6 times;

then efflorescence is performed on the skin of the arm on the operated side - from the fingertips to the armpit area, 6 times;

in the armpit of the operated side, RLD is performed in the IP of the patient lying on his back, the arm is bent at the elbow and maximally abducted, the hand of the doctor's working hand is located in the armpit of the patient on the operated side, so that the thumb is located in front, the other fingers grasp the shoulder along its outer surface; superficial circular movements are performed on the spot with displacement of the skin in case of a scar on the left - with the right hand clockwise, in case of a scar on the right - with the left hand counterclockwise, the direction of movement is towards the postoperative scar;

on the shoulder - the patient's IP is lying on his back, the arm of the operated side is raised vertically, the doctor's working hand with the entire palmar surface is located on the inner surface of the shoulder, superficial circular movements are made with the skin shifting, sequentially shifting like tiles, with the working hand being lifted from the skin, towards the elbow, then - the working hand with the palmar surface is located on the outer surface of the shoulder - the same superficial circular movements are repeated with the skin shifting, sequentially shifting like tiles towards the elbow, the direction of movement is towards the armpit, 6 times;

on the forearm - in the IP of the patient sitting at the table, the patient places his elbow bent at a right angle on the table, the doctor makes movements with the brush of the working hand similar to superficial circular movements on the inner surface of the shoulder, with a sequential shift like a "tile" from the elbow to the wrist, 6 times, then - the same movements, but on the outer surface of the forearm, 6 times; the direction of movement is towards the elbow;

on the hand - in the same IP as for RLD on the forearm, the doctor connects the tips of the thumb and index finger of his working hand, forming a “ring”, and, like a sliding sleeve, “puts it on” at a frequency of ¼ of the patient’s current heart rate sequentially on each finger of the hand on the operated side of the patient, starting from the tip of each finger to its base, the direction of movement is towards the wrist.

Moreover, at the end of the RLD procedure, diaphragmatic breathing is repeated for 5 minutes.

After the RLD procedure and diaphragmatic breathing, hardware lymphatic drainage massage of the limb on the operated side is performed using a pneumatic compression apparatus of the Lymph-E series and the 7-section cuff “sleeve” attached to it.

in this case, the effect is carried out for 20 minutes in the operating mode of the device “ascending running wave with pressure memory”, sequentially filling 7 sections of the cuff “sleeve” in the direction from the fingers to the shoulder with air with pressure in the form of a gradient:

- in the first section a pressure of 60 mm Hg is created,

- in the second – 55 mm Hg,

- in the third and fourth – 50 mm Hg,

- in the fifth and sixth – 45 mm Hg,

- in the seventh section – 40 mm Hg,

the duration of the cycle for filling 7 sections is 10 seconds, followed by the simultaneous shutdown of all sections of the cuff "sleeve",

total exposure time – 20 minutes; 10 daily procedures.

Conduct 10 daily group exercise classes in the gym:

pendulum movements in the form of bending forward with relaxed arms and swinging them back and forth and to the sides;

exercises for the shoulder joint in the form of raising the arms forward, to the sides and upwards; circular movements of the arms; bringing the shoulder blades together;

exercises for the elbow joint in the form of flexion and extension of the arms at the elbow joint; rotation of the forearms;

exercises for the hand and fingers in the form of clenching and unclenching the fingers into a fist; bending and unbending the hand; circular movements of the hand;

after the class in the gym, repeat the same exercises in a hydrokinesitherapy class in a pool with water level up to the neck, overcoming the resistance of the water when performing the movements;

rest between exercises – 1-2 minutes, during which diaphragmatic breathing is performed.

As a psychotherapeutic intervention, psychodynamic group psychotherapy with creative self-expression in the form of art therapy using projective drawing techniques is conducted 3 times a week, in a course of 6 sessions, on the topics of individual and/or group problems concerning one’s own past and present, one’s future, emotional experiences, relationships in the group, expectations from communication and its results, followed by a discussion of these topics in the group and with the psychotherapist.

As a psycho-relaxation technique, patients additionally perform diaphragmatic breathing independently 3-4 times a day for 5 minutes.

They also perform hardware correction of the psycho-emotional state with biological feedback by means of psychophysiological impact - audiovisual stimulation using a software and hardware resonance-acoustic rehabilitation complex for correction of the psychosomatic state of a person - PRAK, in the operating mode of the PRAK program "Relaxation", in which binaural impact is carried out by transition from the state of beta activity with 15 Hz through alpha activity to the theta rhythm at the level of 7 Hz, and simultaneous demonstration of a relaxation video sequence on the monitor screen, per course - 10 procedures of 30 minutes.

Additionally, this method can be recommended for the prevention of lymphedema and PMES after mastectomy.

The developed comprehensive rehabilitation program for patients with PMES includes comprehensive drainage therapy (hardware lymphatic drainage, manual lymphatic drainage massage based on Vodder massage, group sessions in the exercise therapy room and hydrokinesiotherapy in the pool) in combination with group psychotherapy, creative self-expression and passive training in psychological relaxation using the psychophysiological impact system - PRAK.

The psychotherapy technique used allows for short-term correction of clinically significant anxiety disorders and depression in such women, changing coping strategies from negative to positive, focused on socialization, with the formation of stable long-term results of this therapy, which significantly improve the quality of life of patients in terms of physical performance and psychological adaptation, which is reliably reflected in the indicators of depression, especially in the subscales of its somatic manifestations, reducing the number of general complaints, increasing the self-esteem of women.

The combination of complex drainage therapy and psychotherapy with creative self-expression and the hardware psychophysiological method of psychotherapy in the complex medical rehabilitation program PMES allows to improve the dynamics of women's condition in a shorter period of time, compared to the prototype, and to reduce the risk of developing somatic complications.

With the help of the proposed methods of psychotherapy through creative self-expression, women begin to realize the meaning of visual images and gradually understand and overcome their mental conflicts. The process of artistic creativity includes kinesthetic, perceptual and cognitive elements (using various means for drawing - brushes, different types of paints, pencils, markers, crayons, sand, plasticine and just fingers, as well as felt therapy - painting with unspun dyed sheep wool). Thanks to this, patients learn to identify suppressed feelings, form various associations with them, see new meaning in past events, and acquire new, healthier, adaptive defense mechanisms. Psychotherapeutic work in the rehabilitation program is an important condition for overcoming traumatic experiences and helps create a safe space for their expression. Discussion in a group and personally with a psychotherapist of individual and/or group topics, without directly touching on the topic of psychological trauma of a woman who has undergone a mastectomy, helps to improve her psycho-emotional state, returning resourcefulness through projective techniques, using artistic metaphors and associations.

As part of the discussion of the topics of psychotherapeutic sessions, short-term, skill-focused treatment is carried out for women, aimed at changing maladaptive emotional reactions by transforming their cognitive distortions (thoughts, beliefs, attitudes towards the situation), and, as a result, changes in the patients’ behavior.

Complex drainage therapy performed on patients includes manual lymphatic drainage massage (MLD) by a trained specialist (modified massage according to Vodder, see M.P. Vavilov. Self-administered lymphatic drainage: prevention and treatment. M. 2019, 85 p.) and hardware lymphatic drainage on a Lymph-E series pneumatic massager with a 7-section cuff “sleeve”, daily course, No. 10.

Manual lymphatic drainage involves rhythmic, gentle massage of the skin and deep massage of the lymph nodes. One session lasts about an hour. The specialist must perform massage movements very carefully, since the pressure on the tissues being treated should not exceed 40 mm Hg. This technique allows moving high-molecular proteins into the lumens of the lymphatic capillaries and stimulating the contraction of the walls of the lymphatic vessels, which enhances the movement of lymph through the plexuses under the skin and collateral vessels.

All impacts are made directly on the skin. It is important that the client's skin folds do not get between the specialist's fingers. The massage is carried out strictly in the direction of the lymph flow. The procedure is usually performed very slowly - no more than 10-12 movements per minute.

The procedure frees cells from waste and metabolic products. Lymphatic drainage facilitates and improves the activity of all cells, accelerates metabolism, due to which a person's weight is normalized. Under the influence of RLD, lymph flow accelerates. If the normal lymph flow rate does not exceed 0.4 cm/s, then during a massage session, the lymph flow increases 8 times. As a result, tissues and organs are cleared of waste products, due to which the human body receives a greater volume of oxygen and nutrients.

During the RLD massage, tissues are better washed, inflammation and swelling are relieved more quickly, skin turgor improves, and the normal structure of the subcutaneous tissue is restored.

The massage therapist performing the procedure must take into account the speed of the individual lymph flow. The massage is performed on clean skin. The massage therapist's hands move along the lymph flow lines. At first, the movements are slow, warming up, then the force of the impact gradually increases. In order for the massage to be as effective as possible, the specialist devotes enough time to warming up the area of the body on which the procedure is performed. The massage can be completed with patting movements.

RLD is completely painless and universal, suitable for rejuvenation, getting rid of excess weight, improving skin condition and relieving lymphatic edema, strengthens the immune system, improves mood and well-being.

Each lymphatic drainage session begins and ends with diaphragmatic breathing for 5 minutes. The most convenient way to do it is lying on your back, with your palms on your stomach. Three phases of breathing: inhale – exhale – pause. Inhale through the nose, quickly and vigorously. The stomach is inflated like a football. The anterior abdominal wall rises up, the back is pressed against the surface on which the patient lies. Exhale slowly, through pursed lips. The anterior abdominal wall is pulled in and goes down. Exhale as much and as long as possible. At the end of the exhale, squeeze the anus. Then pause – relax the anus and the anterior abdominal wall, try not to breathe, holding your breath, the longer the better.

With systematic exercise, the abdominal press and diaphragm are strengthened - the thoracoabdominal muscle. This muscle, in fact, is a venous heart. Its respiratory excursions promote microcirculation in the internal organs. Near it there are a large number of lymph nodes, which ensures pronounced absorption of lymph.

The diaphragm is considered a border lymphatic collector, which provides a connection between the parietal and visceral (in the abdominal cavity) lymphatic vessels. These are separate vessels that come from the diaphragm and flow into the thoracic lymphatic duct.

Diaphragmatic breathing stimulates the lymph nodes of the abdominal cavity. During exhalation, negative pressure is created in the chest cavity, which has a "suction" effect on the lymphatic vessels of the abdominal cavity, as well as contractions of the right leg of the diaphragm, which is fused with the cistern of the thoracic lymphatic duct. In the respiratory cycle, the cistern empties during exhalation and fills during inhalation.

RLD can be performed at any time of the day after diaphragmatic breathing, the RLD session lasts for 50-60 minutes, usually 2-3 times a week and ends with the diaphragmatic breathing procedure. The frequency of repetitions of each RLD technique in one place (capture) should be 1/4 of the current pulse rate in 1 min. (for example, with a heart rate of 80, 20 massage movements should be performed per minute).

Contraindications include the presence of erysipelas, pustules, abrasions, lymphangitis, acute thrombophlebitis, trophic ulcers, radiation erythema, cancerous lymphadenitis, cardiac and renal edema, as well as stages 3-4 and degrees of lymphedema, which are subject to surgical treatment only.

The hands of the massage therapist should be free of abrasions, clean, RLD is performed without oil, cream or talc. RLD should not cause pain or redness of the skin. The direction of the shearing tension of the skin (vector, movement) is strictly in the direction of lymph outflow (DLO).

Each RLD technique consists of 2 parts: 1st – shift phase, 2nd – relaxation phase. Contact with the skin (capture) is carried out with the palm and closed fingers ("hard hand"). It and the skin in the capture zone form a single whole, and the force on it, as a rule, is transmitted through the wrist and elbow – by the movement of the forearm and shoulder.

RLD techniques can be:

1) Efflorage – longitudinal light sliding touches to the skin of the selected area, 6-12 times.

2) "Permanent circles in place" (PC) with the hand pressed to the skin; in this case, the skin, together with the hand, moves along the first ½ circle and slightly shifts along the plane ("stretches") along the NOL (phase 1). This tension along the plane and depth is gradually weakened, and the circular movement of the second ½ circle is smoothly returned to the initial (zero) point (phase 2).

3) "Scooping" is performed with a rotational movement in the wrist joint. The axis of this rotation passes through the base of the 2nd finger. In the initial position (IP), the palm of the working hand is placed across, for example, on the inner surface of the left forearm, at the elbow. The thumb is located on the lateral and back surface of the forearm, and the others - on the inner (front). The technique (phase 1) begins with a rotation of the right elbow and a forward movement of the wrist. This "forward ulnar rotation of the wrist" resembles the rotation of the ladle handle at the beginning of scooping. It is transferred to the edge of the little finger of the working hand, increasing contact with the skin. Then, by bending the palm, the movement turns into a shearing transverse displacement of the skin to the elbow along the NOL. The 2nd phase begins with a backward rotation of the elbow and dorsal extension of the hand, spiraling to the 2nd finger until the hand returns to the IP.

4) "Pump" (P): in the IP, the span of the working hand is placed, for example, at the elbow on the inner surface of the left forearm so that the spread thumb and index finger are perpendicular to the skin. The wrist joint is maximally extended. At the beginning of the 1st phase, the palm is brought into contact with the skin, the vector is towards the elbow fossa. Palmar flexion of the wrist is continued so that the radius goes forward. Thus, the skin shift is carried out by the main joint of the thumb and, "rolling", by the same joints of the other fingers. Then (phase 2), with wide contact of the working palm, the pressure is weakened to zero, and the skin at the place of grip, due to its elasticity, slips under the working hand in the IP.

5) "Rotation": in the IP, the pads of the straightened fingers of the working hand with the thumb abducted are positioned along the NOL, perpendicular to the skin, the palm is raised above the skin. At the beginning of the 1st phase, the palm, starting with the little finger, is brought into close contact with the skin, and the thumb, sliding, is brought to the index finger. Then the palm moves the skin along the NOL with a slight rotation. In the 2nd phase (relaxation), the hand returns to the IP.

The conditions for the RLD procedure should be comfortable. Room temperature 18-20ºС. Nothing should distract attention from the RLD. The surface on which the patient lies should be flat, even and motionless. If it is not a bed, but a floor, a rug or foam rubber is needed. The wall should not interfere with the movements of the hands. The body is naked; a sheet is placed on top of it, part of which can be moved if necessary so as not to interfere with the masseur's working hand. The time of breaks for rest, in case of fatigue, is not included in the total duration of the session.

Before performing each RLD technique, the rigidity of the working hand (fingers closed) and the location of the grip are checked.

RLD is a “cutaneous” massage, i.e. a skin massage, because the lymphatic vascular network permeates the entire skin and, when working with the skin, we are, in fact, working with the lymph in the skin.

If all types of therapeutic massage, and there are about 2 dozen of them, can be designated as maximal massage according to the degree of physical effort of the massage therapist, then lymphatic drainage based on massage according to Dr. E. Vodder (according to Vodder) is mini-massage.

Constant circles on the spot (CC) are performed (with one grip) constantly with the same area of skin, with constant unchanging pressure on the skin, with a constant direction of skin shift along the NOL. The pressure ("adhesion" to the skin, "sticking" of the massaging palm to the skin) should be minimal when performing a circle and dosed with a directed shift at the end of the 2nd phase of the technique. If the CC technique is performed incorrectly, improperly, "heavyly", the lymphatic vessels can be "squeezed", and then you will have to work only with the skin, and not with the lymph in the skin. After all, the lymph in the skin needs to be, in fact, evenly "stirred" with circular rotational movements, without slipping onto adjacent areas.

Rotational circles on the spot should be performed very slowly and rhythmically, smoothly, constantly at the same speed, with a constant frequency of 1 min. The frequency of circles on the spot should correspond to the average frequency of contractions of the lymphangions (1-30 per 1 min), i.e., one quarter of the patient's individual pulse (with a pulse of 60 beats per 1 min - 15; with 72 beats - 18, with 84 beats - 21 per minute, etc.).

It is necessary to observe the requirements of minimum pressure on the skin, standard skin capture area, slowness and rhythm, two-phase reception, direction of skin shift NOL, position of the massaging hand, elbow and shoulder. The palm and skin at the capture site form a single whole, and the force on it, as a rule, is transmitted through the wrist and elbow - by the movement of the forearm and shoulder.

Our method also included daily group classes in the gym with a physical therapy instructor, followed by hydrokinesiotherapy in the pool with the same exercises, but using increased water resistance, daily, No. 10. The exercises were performed smoothly, without sudden movements, avoiding pain. The amplitude of these movements and the number of repetitions were gradually increased. During the classes, patients monitor their well-being and take breaks for rest if necessary.

Psychological correction included short-term psychodynamic group psychotherapy with creative self-expression, which was conducted 3 times a week using the art therapy method, using projective drawing with various techniques and tools (paints, crayons, felt-tip pens, pencils, sand, unspun wool, just fingers on paper).

The topics offered for drawing concerned both individual and group problems (chosen at each lesson), such as:

- your own past and present (for example, “My problem in communication”, “Situations in life in which I feel insecure”, “My typical day”);

- the future or abstract concepts (for example, “How I see myself through…”, “Three wishes”, “The island of happiness”, “Fear”);

- relationships in the group (for example, “What the group gave me, and I gave it”, “What I expect from participating in the group”, “What I expected and what I got from communicating in the group”).

This program of work allowed women to feel the support of the group, believe in their strength, increase self-esteem, and narrow the disease zone by orienting patients toward awareness of the already existing achievements in restoring functions. For this, psychotherapeutic persuasion, suggestion, and demonstration of training results were also used - everything so that the patient could be convinced of the ability of her own body to develop new conditioned reflexes and acquire new skills, new coping strategies. During classes, during individual and group discussions of the results of classes, the psychologist emphasizes the improvement of each patient's condition from class to class.

An important role in psychotherapeutic work was given to the development of emotional response and the formation of emotional regulation through projective techniques for transferring one's emotional states into the creation of creative products. Upon completion of the sessions, positive dynamics of the individual emotional state were noted. The use of projective techniques aimed at the formation of resource states, without analyzing the traumatic situation of mastectomy itself, without immersion in it, made it possible to achieve positive results in a short time - during a 10-day comprehensive rehabilitation course - and maintain this positive state in dynamics.

In the method of hardware psychotherapy using biofeedback therapy to correct the psychoemotional state, psychological relaxation programs were used, based on the transition from beta through alpha to theta state.

For this purpose, the hardware and software complex KAP KPS "EKRAN" (registration certificate of medical device No. FSR 2012/14162 dated 03.03.2023), developed in Russia, was used, which is included in the standards for equipping healthcare facilities based on Orders of the Ministry of Health No. 788n dated 31.07.2020, No. 450n dated 14.05.2021 and No. 1034n dated 30.12.2015, https://acsma.ru/wp-content/uploads/2023/10/metodicheskie-rekomendaczii-nmicz-rk-2023-prak-1.pdf.

This hardware and software complex is designed to correct the psychosomatic state of a person using programmed resonant-acoustic oscillations of EEG signals (KAP KPS "EKRAN").

In short, such an impact is called PRAK - programs of resonance-acoustic oscillations. When conducting psychosomatic correction, light and sound stimulation of the brain is used, generating a binaural rhythm (binaural beat) in the brain. Binaural beat is nothing more than an auditory illusion of perception, which occurs when two adjacent, but not coinciding frequencies are exposed to each ear separately. The acoustic impact of two tones with a slight frequency discrepancy for each ear creates the perception of a third tone, or binaural rhythm, the frequency of which is the absolute difference between the tones. These binaural rhythms arise in the subcortical structures of the brain, namely in the medial nucleus of the superior olivary complex, located on the border of the medulla oblongata and midbrain. Neurons of the superior olivary complex, which are sensitive to phase shifts, fire action potentials, generating the perception of a binaural beat with a frequency equal to the tonal difference of the sound stimuli supplied to the right and left ears. Thus, the generation of binaural beats has a purely neurophysiological nature.

When listening to sounds of similar frequency through different auditory channels (right and left), a person feels the so-called binaural beats, or binaural rhythms. For example, when one ear hears a pure tone with a frequency of 200 oscillations per second, and the other - a pure tone with a frequency of 204 oscillations per second, the result is beats with a frequency of 204 - 200 = 4 oscillations per second, but this is not a real external sound, but a "phantom". It is born in the human brain only when electromagnetic waves coming from two synchronously working hemispheres of the brain are added together. Neurophysiologists have established that by superimposing binaural beats on top of each other in several "layers", it is possible to form the rhythmic activity of the brain in the required direction and thus cause a corresponding EEG pattern in a person (i.e., a "picture" of bioelectric oscillations of the brain), and along with it the state of consciousness to which it is characteristic.

The beta range (13-45 Hz) characterizes active wakefulness. Beta waves are considered the fastest and predominate in the normal waking state, when a person observes the world around him with open eyes, or is focused on solving some current problems. Beta waves are usually associated with wakefulness, awakening, concentration on something and with cognition, and in case of their excess - with anxiety, fear and panic. A lack of beta waves is associated with depression, poor selective attention and problems with memorizing information.

Alpha frequencies are in the range of 8-13 Hz and reflect a relaxed state with simultaneous external and internal focus of attention. Low-frequency alpha waves correspond to deep relaxation and a light meditative state. Alpha waves are used for self-healing, accelerated learning, and creative processes. If you need to get out of an overly tense or, on the contrary, sleepy state, then passive training using alpha frequencies can ensure this by eliminating the internal stress dialogue that leads to loss of energy, which has a positive effect on well-being.

Theta frequencies are in the range of 4-8 Hz and reflect a deeply relaxed, “floating” state with an internal focus of attention. A person enters it before falling asleep or just before waking up. This state is the source of creative processes, “energy sleep”. It is also called “twilight”, since in it a person is between sleep and wakefulness. It is often accompanied by the vision of unexpected, dream-like images, accompanied by vivid memories, especially childhood ones. The “theta state” opens access to the contents of the unconscious part of the mind, free associations, unexpected insights, creative ideas. It is in the “theta state” that the human brain produces more beta-endorphins - its own “pleasure hormones” responsible for joy, relaxation and pain reduction. In 1848, Frenchman Maury gave this state (similar to hypnotic) the name hypnogogic (from the Greek hipnos - sleep and agnogeus - conductor, leader). The addiction of some people to alcohol and drugs is explained by the fact that the brain of such people is not capable of generating a sufficient number of alpha and theta waves in a normal state for various reasons, while in a state of drug or alcohol intoxication, the power of electrical activity of the brain in the alpha and theta range increases sharply. Thus, psychophysiological training of the brain in the theta range significantly increases a person's creative abilities, his ability to learn and independently solve various problems, without resorting to the destructive effects of alcohol or drugs.

The course with the help of PRAK included 10 daily procedures, the duration of one procedure is 30 minutes. During the procedure, with the help of the device's operation program "Relaxation", a smooth restructuring from the state of beta activity (15 Hz) through alpha activity to the theta rhythm (7 Hz) is performed. This causes gradual relaxation, stress relief, increased mental and physical performance, improved attention, memory and mood, and the elimination of affective disorders.

Resonant acoustic vibrations can be mixed with relaxing music and noise programs, which mask them and cause an additional sedative effect, practically without losing their properties. In addition, a special resource video sequence synchronized with the sound (including the use of the 25th frame effect, for example, with pleasant pictures of nature - the sea, forest, etc.), a comfortable, specially designed patient chair, chromotherapeutic lighting equipment (sedative or tonic color effect), additionally special sprayers with phytotherapeutic oils and extracts create a powerful complex psychotherapeutic effect.

Therefore, a prerequisite for the effective therapeutic effect of the KAP KPS "Ekran" complex is a room specially prepared to create a relaxation effect with soft comfortable chairs with headrests for the number of patients, comfortable headphones, appropriate software for the PRAK, a quiet room with subdued lighting and an air temperature of 22-24 ° C, the necessary video equipment (personal video monitor) for patients to view relaxation video programs. The workplace of the PRAK doctor-operator includes: a generator of resonant acoustic oscillations combined with a personal computer; a tablet for controlling the complex and lighting; a system of video monitoring of the patient's condition (https://acsma.ru/wp-content/uploads/2023/10/metodicheskie-rekomendaczii-nmicz-rk-2023-prak-1.pdf).

Examples of the method implementation

The study involved 30 women of reproductive age aged 30-55 who had undergone mastectomy for breast cancer (6 women - bilateral mastectomy, 13 women - left-sided mastectomy, 11 women - right-sided mastectomy), all had stage 1-2, 1-2 degree of lymphedema of the upper limb and belonged to the 3rd clinical group according to the oncologist's conclusion, did not have metastatic lesions. All patients expressed voluntary consent to rehabilitation and signed an informed consent form.

An open, randomized, controlled trial was conducted in 3 parallel groups into which the participants were divided:

- the main group (10 women) received a 10-day course in the form of the proposed complex of effects,

- the comparison group (10 women) received a 10-day course of treatment using the proposed method, except that instead of isotherapy methods, individual cognitive behavioral therapy (CBT) was used,

- the control group (10 women) received a set of interventions according to the prototype method (a 15-day rehabilitation course consisting of procedures for wave-like pneumatic compression of the swollen limb using a multi-section apparatus in the “growing or running wave” mode (Lymph-E series, “sleeve” cuff), manual drainage massage based on Vodder massage, exercise therapy in the gym, electrical neurostimulation, exposure to a low-intensity low-frequency alternating magnetic field, electrical stimulation of the shoulder girdle muscles, psychocorrection in the form of individual CBT.

To monitor the physical and psycho-emotional indicators of patients and to assess the effectiveness of the rehabilitation, the following scales and methods were used:

1) Quality of life questionnaire SF-36 (physical, emotional and psychological components), %.

2) Visual analogue pain scale (VAS), assessment of the severity of pain syndrome.

3) Testing of psycho-emotional status according to SAN (well-being, activity, mood).

4) HADS (Anxiety and Depression Scale).

5) Volume (circumference) of the swollen limb at the levels of the middle third of the shoulder and the middle third of the forearm, the middle of the hand.

6) Indicators of movement in the shoulder joint on the affected side.

The collection of registered parameters was carried out before the start of the rehabilitation course, after its completion and in the form of remote results (3 and 6 months after completion of the course).

The statistical significance of the obtained results was assessed for all patients using nonparametric statistical methods (Wilcoxon T-test for related samples and Mann-Whitney U-test for independent samples); normality of distribution was not tested. Variables were expressed as median with interquartile ranges. Two-sided p<0.05 indicated a statistically significant difference (confidence interval 0.95).

According to the results of the rehabilitation course, reliable (p<0.05) improvements were observed in women of the main group according to all the listed examination and testing methods, in particular, according to HADS, anxiety and depression were either relieved or their manifestation decreased to minimum values in points; according to VAS, pain syndrome was relieved to 1-2 points against 4-5 points at the beginning of the study. The quality of life improved by 15% or more. The circumference of the affected upper limb significantly decreased to the size of the healthy one in 70% of women in this group and decreased by more than half in the remaining 30%. The range of motion in the shoulder joint along all axes (flexion, extension, abduction and rotation) significantly improved by more than 15 degrees.

In women of the comparison group, there were no significant improvements in the psychological component according to SF-36, HADS scale (mild and moderate anxiety and depression remained) and VAS (pain severity decreased by 1-2 points), however, the range of motion in the shoulder joint significantly improved by an average of 12 degrees. In women of the control group, in addition to similar dynamics of quality of life indicators, pain level and anxiety-depressive manifestations, the circumference of the affected limb at the level of the middle third of the shoulder decreased insignificantly, the range of motion in the shoulder joint improved insignificantly by 10 degrees.

After 3 and 6 months, during follow-up observation, the positive effects in women of the main group persisted, while in the comparison group and in the control group, in 20 and 30% of cases, respectively, there were relapses of pain syndrome by 2-3 points, difficulty in movement in the affected limb (reduction in the range of motion in the shoulder joint by 8-10 degrees on average), an increase in anxiety and depression scores by 2-3 points, compared with those achieved at the end of the course.

In this regard, it appears that it is the addition of a certain psychological effect to the main physical rehabilitation effects within the framework of isotherapy in combination with psychophysiological effects through resonance-acoustic stimulation of the brain using PRAK that leads to faster (10 days compared to the prototype - 15 days) and more effective results in the rehabilitation of women with PMES, influencing the formation of more stable positive psychological changes, increasing and maintaining patients' commitment to treatment.

Clinical example.

Patient V., 52 years old. Condition after radical left-sided mastectomy according to Madden (2 months), metastases - 0, third clinical group, postmastectomy syndrome on the left, lymphedema of the left upper limb - stage 1, edema of the 1st degree (+23% of the volume of the healthy limb).

Complaints of low mood, suicidal thoughts, difficulty moving the left arm (reduced range of motion in all axes of the joint), pain syndrome (4-5 points on the VAS).

According to HADS, there is moderate depression, the quality of life indicators according to SF-36 are sharply reduced (for all components), and the number of points according to SAN is also reduced (30 points).

The patient received the proposed rehabilitation course, according to the invention formula.

Upon examination at the end of the course: quality of life according to the SF-36 questionnaire for all components improved by 55%, according to HADS – mild anxiety, no depression, no suicidal thoughts, SAN – 52 points, normal.

The circumference of the affected upper limb decreased by 30% of the initial volume. VAS – 1 point, the range of motion increased significantly (flexion +20 degrees, extension +12 degrees, abduction +32 degrees, free rotation).

During the control examination after 3 and 6 months, the achieved results are maintained, the swelling of the left upper limb is practically absent. The patient wears a left breast prosthesis, returned to professional activity and a full sexual life in the family.

To summarize the above, we note that the research work carried out during the creation of this method demonstrates the effectiveness and safety of the combined use of complex drainage therapy, physical exercises, hydrokinesiotherapy and psychotherapy of creative self-expression with hardware psychorelaxation in the program of medical rehabilitation of PMES in women after radical mastectomy for breast cancer, since this set of measures improves the quality of life of patients, improving the indicators of psychoemotional and physical comfort with long-term effectiveness (at least 6 months), allowing them to return to normal personal and social life.

Claims (38)

A method of complex medical rehabilitation for postmastectomy syndrome, including physiotherapeutic and psychotherapeutic interventions, characterized in that: - as a physiotherapeutic effect of the complex, 10 daily procedures of manual lymphatic drainage massage (MLD) are carried out based on Vodder massage after a 5-minute procedure of diaphragmatic breathing, moreover, RLD procedures are carried out daily for 50-60 minutes, with a frequency of repetitions of the massage technique on the skin of a given area _of ^1/4 of the patient’s current heart rate, the initial position (IP) of the patient before RLD is lying on his back, starting with the efflorage technique - longitudinal sliding touches to the skin with the tips of four fingers of the hand from the pubis to the navel 6 times, then from the lower edge of the sternum to the navel 6 times, then perform superficial circular stroking on the spot with the skin shifting with the pads of the middle fingers of both hands above the navel, first clockwise from the outside into the depths, then counterclockwise from the depths of the navel outward, 6 times each, then – superficial circular stroking on the spot with the skin moving with both hands in the lower quadrants of the abdomen with counter movements: with the left hand – clockwise, with the right – counterclockwise, 6 times; then – superficial circular stroking on the spot with the skin moving with both hands in the right and left hypochondrium, respectively, with the left hand – counterclockwise, with the right – clockwise, 6 times; then – efflorescence on the skin of the anterior chest wall with the tips of four fingers of the hand from the operated mammary gland to the costal arch of the same side, 6 times; then on the area of the scar of the operated mammary gland - five fingers of the doctor's hand lie on the outside of the scar, parallel to the costal arch, point the fingertips towards the abdomen across the ribs and make superficial circular movements on the spot with the skin shifting in the case of a scar on the left - clockwise, in the case of a scar on the right - counterclockwise, 6 times, the direction of movement is towards the navel; then - in the subclavian region of the operated side, for which the working hand is positioned parallel to the collarbone, the fingertips are directed towards the axillary region, superficial circular movements are performed on the spot with the skin shifting in the case of a scar on the left - clockwise, in the case of a scar on the right - counterclockwise, 6 times, the direction of movement is towards the shoulder; in the supraclavicular regions - place the fingertips in the supraclavicular fossa, make superficial circular movements on the spot with the skin shifting to the right - clockwise, to the left - counterclockwise, 6 times, direction of movement - towards the base of the sternum; then move to the IP sitting and begin RLD of the neck by efflorescence with the tips of four fingers of each hand from the corner of the corresponding lower jaw along the lateral surfaces of the neck, down to the supraclavicular fossa, 6 times; on the anterolateral region of the neck on the operated side - the fingers of the working hand are placed on the skin under the lower jaw parallel to it and directed towards the angle of the lower jaw, superficial circular movements are performed on the spot with the skin shifted in the case of a scar on the left - counterclockwise, in the case of a scar on the right - clockwise, the direction of movement is towards the same supraclavicular fossa, 6 times; then efflorescence is performed on the skin of the arm on the operated side - from the fingertips to the armpit area, 6 times; in the armpit of the operated side, RLD is performed in the IP of the patient lying on his back, the arm is bent at the elbow and maximally abducted, the hand of the doctor's working hand is located in the armpit of the patient on the operated side, so that the thumb is located in front, the other fingers grasp the shoulder along its outer surface; superficial circular movements are performed on the spot with displacement of the skin in case of a scar on the left - with the right hand clockwise, in case of a scar on the right - with the left hand counterclockwise, the direction of movement is towards the postoperative scar; on the shoulder - the patient's IP is lying on his back, the arm of the operated side is raised vertically, the doctor's working hand with the entire palmar surface is located on the inner surface of the shoulder, superficial circular movements are made with the skin shifting, sequentially shifting like tiles, with the working hand being lifted from the skin, towards the elbow, then - the working hand with the palmar surface is located on the outer surface of the shoulder - the same superficial circular movements are repeated with the skin shifting, sequentially shifting like tiles towards the elbow, the direction of movement is towards the armpit, 6 times; on the forearm - in the IP of the patient sitting at the table, the patient places his elbow bent at a right angle on the table, the doctor makes movements with the brush of the working hand similar to superficial circular movements on the inner surface of the shoulder, with a sequential shift like a "tile" from the elbow to the wrist, 6 times, then - the same movements, but on the outer surface of the forearm, 6 times; the direction of movement is towards the elbow; on the hand - in the same IP as for RLD on the forearm, the doctor connects the tips of the thumb and index finger of his working hand, forming a “ring”, and, like a sliding sleeve, “puts it on” at a frequency _of ^1/4 of the patient’s current heart rate sequentially on each finger of the hand of the patient’s operated side, starting from the tip of each finger to its base, the direction of movement is towards the wrist; moreover, at the end of the RLD procedure, diaphragmatic breathing is repeated for 5 minutes; after the RLD procedure and diaphragmatic breathing, a hardware lymphatic drainage massage of the limb on the operated side is performed using a pneumatic compression apparatus of the Lymph-E series and the 7-section cuff “sleeve” attached to it, in this case, the effect is carried out for 20 minutes in the operating mode of the device “ascending running wave with pressure memory”, sequentially filling 7 sections of the cuff “sleeve” in the direction from the fingers to the shoulder with air with pressure in the form of a gradient: - in the first section a pressure of 60 mm Hg is created, - in the second – 55 mm Hg, - in the third and fourth – 50 mm Hg, - in the fifth and sixth – 45 mm Hg, - in the seventh section – 40 mm Hg, the duration of the cycle for filling seven sections is 10 seconds, followed by the simultaneous shutdown of all sections of the cuff "sleeve", total exposure time – 20 minutes; 10 daily procedures; - conduct 10 daily group exercise classes in the gym: pendulum movements in the form of bending forward with relaxed arms and swinging them back and forth and to the sides; exercises for the shoulder joint in the form of raising the arms forward, to the sides and upwards; circular movements of the arms; bringing the shoulder blades together; exercises for the elbow joint in the form of flexion and extension of the arms at the elbow joint; rotation of the forearms; exercises for the hand and fingers in the form of clenching and unclenching the fingers into a fist; bending and unbending the hand; circular movements of the hand; after the class in the gym, repeat the same exercises in a hydrokinesitherapy class in a pool with water level up to the neck, overcoming the resistance of the water when performing the movements; rest between exercises – 1-2 minutes, during which diaphragmatic breathing is performed; - as a psychotherapeutic intervention, psychodynamic group psychotherapy with creative self-expression in the form of art therapy using projective drawing techniques is conducted 3 times a week in a course of 6 sessions on the topics of individual and/or group problems concerning one’s own past and present, one’s future, emotional experiences, relationships in the group, expectations from communication and its results, followed by a discussion of these topics in the group and with the psychotherapist; - as a psycho-relaxation technique, patients additionally perform diaphragmatic breathing independently 3-4 times a day for 5 minutes; - also carry out hardware correction of the psycho-emotional state with biological feedback by means of psychophysiological impact - audiovisual stimulation with the help of a software and hardware resonance-acoustic rehabilitation complex for correction of the psychosomatic state of a person - PRAK, in the operating mode of the PRAK program "Relaxation", in which binaural impact is carried out by transition from the state of beta activity with 15 Hz through alpha activity to the theta rhythm at the level of 7 Hz with simultaneous demonstration of a relaxation video sequence on the monitor screen, per course - 10 procedures for 30 minutes.