Active Exercise Program Research Articles

Ultrasound-guided injection of the psoas muscle with Botulinum Toxin A: Novel approach to treating chronic low back pain

Chronic low back pain due to multiple different aetiologies can be very difficult to treat. Previous studies have shown that Botulinum Toxin A (BTX-A) injected into superficial low back muscles as well as deeper injections into the psoas muscles can be beneficial in relieving low back pain. With chronic low back pain, there is often an imbalance between relatively overactive muscles and their less active antagonist muscle. A functional muscle imbalance in the lumbo-pelvic region can promote poor biomechanics and chronicity of pain. We propose a novel injection approach to treating chronic low back pain using BTX-A under ultrasound guidance to target the deeper psoas muscle. Three patients aged 31–47 were given unilateral injections posteriorly into the psoas muscle corresponding to the side of maximal discomfort. 200 U of BTX-A was injected via ultrasound guidance in a 4:1 dilution at the level of the L4 vertebrae. Patients then underwent an active exercise program. The mean VAS score dropped from 7.7/10 (pre) to 4.7/10 (post). Mean score on the Oswestry back pain questionnaire changed from 41/50 to 31.7/50. Based on these results, the potential exists for intramuscular injection of BTX-A to be used as an adjunct to specific muscle re-education and functional rehabilitation in this patient population.

Exercise Training in Pulmonary Hypertension

The response to exercise training reported in this issue of Circulation 1 should change the way we perceive and treat selected patients with pulmonary hypertension (PH) and brings into focus the problem of measuring the effects of drug therapy in this condition.2 Article p 1482 In a highly structured 15-week program of daily exercise, patients with PH experienced a mean increase of 96±61 meters in the 6-minute walking test from a baseline of 439±82. The increase in the 6-minute walking distance after exercise training was greater than that achieved with prostacyclin formulations, endothelin receptor antagonists,3 and phosphodiesterase inhibitors. By comparison, the baseline and incremental increases in the 6-minute walking distance in studies of successful drug therapies range from a low of 297+31 meters with epoprostenol4 to 342+51 with sildenafil.5 The study group consisted of 24 patients with idiopathic pulmonary arterial hypertension and 6 patients with chronic thromboembolic PH. Fifteen patients were initially entered into the active exercise program, and 15 control patients crossed over to the exercise program after the first 15 weeks. Although not explicitly stated, it appears that there were no patients with the scleroderma spectrum of disease entered in the study, presumably because of the inability to exercise. Other patients with musculoskeletal limitations were excluded as well. Clearly, the cohort in the present study had a higher baseline physical capacity than patients reported in most drug trials, and this may be partly responsible for the greater increase in 6-minute walk than previously reported. …

THE FIRST STEP TO ACTIVE HEALTH PROGRAM FOR OLDER ADULTS WITH PRE-DIABETES.

Purpose/Hypothesis: As the aging population increases, the number of individuals with chronic diseases will also continue to increase. The role of physical activity in chronic diseases such as diabetes is becoming increasingly important for both prevention and management. The purpose of this pilot study was to evaluate the effectiveness of the First Step to Active Health group exercise program in older adults referred by family physicians to the hospital wellness center. Number of Subjects: 7. Materials/Methods: Subjects were diagnosed with a cluster of obesity, diabetes, hypertension, and dyslipidemia (clinically referred to as “Metabolic Syndrome”). The group program met once a week to discuss behavioral changes and to gradually introduce a 4-step program that included cardiorespiratory, flexibility, strengthening, and balance activities. Each participant continued the program at home at least 3 additional days per week. Before and after the 10 week program, fitness was assessed with the Senior Fitness Test (Rikli & Jones, 2000). Data were analyzed with paired-sample t-test. Results: Systolic blood pressure decreased significantly by 9% (t = −2.62, p =.04), while diastolic blood pressure and body weight did not change. Upper body muscular strength & endurance (+32%, t=−4.94, p = .004) and lower body muscular strength and endurance (+17%, t=−2.98, p = .025) improved significantly. There were no significant improvements in upper or lower body flexibility. Gait, mobility, and cardiorespiratory fitness improved, although not significantly. There were no reported injuries with the program, and the subjective reports of the individuals indicate they enjoyed the program. All subjects are enrolled in an advanced program to continue their group exercise program. Conclusions: The First Step to Active Health Program significantly improved blood pressure and muscular strength and endurance in older adults with pre-metabolic syndrome. Results will be evaluated again in these individuals after completing another 10 weeks to examine longer-term effects of the program. Further research should increase sample size and evaluate other variables related to disease management such as glucose levels, blood lipids, and medication utilization. Clinical Relevance: The program shows promise as a structured intervention for management of chronic diseases with physical activity.

Effect on Active Exercise Programs in Employees with Chronic Low Back Pain

Effect on Thoracic Exercise Programs in Employees With Chronic Low Back Pain Jin­gang Hur, M.Sc., P.T. Dept. of Physical Therapy, Kangdong Sacred Heart Hospital, Hallym University1) The objectives of this study were to examine the relative efficacy of three active exercise programs for work-related, chronic low back pain, and to observe to what extent the programs affected the mechanical stability of the lumbar region. The subjects were 64 employees who were randomly divided into three groups to match the three active exercise programs which were performed 3 times a week for 6 months. All subjects were assessed with the same measurements at a pre-study examination, and then were reassessed at 2 weeks, 3months and 6 months after the study. The pain intensity didn't show any significant difference among the three groups. However, the Oswestry Disability Index showed significant differences among the three groups at 6 months and the lumbar and thoracic exercise groups showed significant decreases compared to the general physiotherapy group (p<.05). Maximal stretching with both hands in the overhead direction showed a significant difference among the three groups at 3 months and 6 months, and the thoracic exercise group at 6 months showed a significant increase in overhead stretching compared to the lumbar exercise and general physiotherapy groups (p<.05). The group that performed maximal stretching with both hands in the overhead direction showed the most significant among the 3 months and 6 months. At 6 months, the thoracic exercise group showed a significant increase in overhead stretching compared to the lumbar exercise and general physiotherapy groups (p<.05). The lumbar region angle of inclination showed significant differences among the three groups at 2 weeks 3 months, and 6 months, with the thoracic exercise group being decreased more significantly at 6 months than the lumbar exercise and general physiotherapy groups (p<.05). Exercise aimed at increasing thoracic mobility has an effect on lumbar stability. Furthermore, it is far more effective for lumbar stabilization than general physiotherapy and deep muscle strengthening lumbar exercise.

An evidence‐based approach to the management of low back pain and sciatica: how the evidence is applied in clinical cases

Low back pain and sciatica are common complaints that affect a major proportion of the population at some time in their lives. The treatment and management of this condition may vary widely. The present paper aims to provide an evidence-based approach to the management of low back pain and sciatica, and demonstrates how to search for the evidence and how to apply it practically in individual patients. The principles underlying evidence-based medicine are explained. The practice of evidence-based medicine requires initial formulation of the appropriate clinical question, followed by searching databases for relevant evidence. Finally evidence needs to be applied on a patient-specific basis. Best Evidence, the Cochrane Library, Embase and Medline were searched to obtain quality controlled information regarding the management of low back pain and sciatica. Current evidence shows that an active exercise programme promotes early recovery. This may allow patients to resume an active and sportive lifestyle. Epidural corticosteroid injections may help to resolve additional troublesome symptoms of sciatica. Two clinical cases are used to show how evidence-based medicine can be individualized to specific patients. A patient-focused strategy combining best evidence and clinical expertise is suggested as the mainstay for the management of low back pain.

Because of the risk of developing heterotopic ossification, are passive range of motion exercises contraindicated following traumatic injuries?

The purpose of “Evidence in Practice” is to illustrate the literature search process to obtain evidence that can guide clinical decision making. This article is not a case report. The examination, evaluation, and intervention sections are purposely abbreviated. A 62-year-old man was referred for outpatient physical therapy 2 weeks after he had fallen and fractured the head of his right radial bone. The fractured radial head was excised the day after the injury, and the patient had been using a sling on his right arm for comfort. The radiology report stated that good bony alignment was observed and that no bony abnormalities were present following surgery. The patient's goal was to return to his job as a courtroom deputy. The surgeon had referred the patient to me for examination, evaluation, and intervention, noting the need to increase range of motion in the right elbow, but he had specifically written “no passive range of motion exercise” on the consultation form. Upon initial examination, range of motion of the right elbow, as measured with a standard goniometer, as described by Armstrong et al,1 was 75 degrees to 115 degrees of flexion, 10 degrees of supination, and 20 degrees of pronation. Because of the surgeon's note, I was concerned that the absence of interventions designed to increase the range of motion of the right elbow could delay the recovery of function, and I was uncertain why he made this request. I therefore contacted the surgeon to discuss his rationale. He said that he was concerned that passive range of motion following a traumatic injury could lead to heterotopic ossification (the appearance of ectopic bone in the soft tissues around the elbow). I proceeded with the initial physical therapist examination of the patient and the creation of an active exercise program, but I …

Perioperative considerations in the patient with a left ventricular assist device.

Perioperative considerations in the patient with a left ventricular assist device.

Wirkungen kinetischer Stimuli auf die zerebrale Hämodynamik und den zerebralen Stoffwechsel am Beispiel von aktiven und passiv ausgeführten Bewegungen

Effects of Active and Passive Movement Stimuli on Cerebral Hemodynamics and the Cerebral Metabolism Introduction: In contrast to the well-examined cardiovascular changes during movement stimuli, up to now changes of cerebral hemodynamics and cerebral metabolism have rarely been studied. We investigated the question if active and passive movement stimuli cause changes in the cerebral hemodynamics and the cerebral metabolism. Method: Active and passive repetitive movement stimuli on 14 volunteers (8 females, 6 males, age 35 ± 8 years) were examined. As a parameter of cerebral hemodynamics the mean and the peak blood flow velocity (mCBFV_MCA, pCBFV_MCA) in the middle cerebral artery (MCA) were recorded by transcranial Doppler sonography. At the same time the noninvasive blood pressure (Penaz method) and the CO₂ expiration concentration were investigated on 8 volunteers of the collective. As cerebral metabolic parameters we examined in 4 volunteers additionally the cerebral respiratory chain enzyme cytochrome aa3 (ccytaa3) and the cerebral oxygen saturation (cHbO₂) by the transcranial near infrared spectroscopy. With each volunteer 4 measurement series were carried out with a special active and passive exercise program for the right upper as well as the right lower extremity. Each measurement series was formed according to the evoked flow test (R. Aaslid): Exercises were carried out for 20 s, followed by a break of 20 s; this was repeated 10 times for each series. Results: During active exercises of the right lower extremity we found an increase of 13.6% (p < 0.001) of pCBFV_MCA and an increase of 3.8% (p = 0.003) of mCBFV_MCA. During passive exercises of the lower extremity the increases ran up to 12.3% (p < 0.001) for pCBFV_MCA and 3.4% (p = 0.004) for mCBFV_MCA. The increases of pCBFV_MCA came up to 12.5% (p < 0.001) at active exercises of the right upper extremity, those of mCBFV_MCA to 3.5% (p = 0.15). During passive exercises of the upper extremity the pCBFV_MCA increased by 12.2% (p < 0.001) and the mCBFV_MCA by 4.6% (p = 0.007). Significant increases of ccytaa3 were measured during active exercises of the upper extremity (1.6%; p = 0.04) and of the lower extremity (2.7%, p = 0.007). We also found an increase of ccytaa3 during passive exercises of the upper extremity (1.5%, p = 0.04). Significant changes of cHbO₂ were measured with 2.5% (p < 0.05) at active exercises of the lower extremity. Conclusion: These studies show that active as well as passive clinical exercises cause an increase of cerebral blood flow velocity. We attribute the increase of cerebral hemodynamics and cerebral metabolism to cerebral activation and autoregulative mechanisms.

The efficacy of lumbar traction in the management of patients with low back pain

The literature on the efficacy of traction in the treatment of low back pain (LBP) is conflicting. The aim of this study was to examine its efficacy in this disorder. Forty-two patients with at least 6 weeks of nonspecific LBP were selected. Demographic data were obtained. All patients completed the Oswestry disability index (ODI) to assess disability and the 10-cm visual analog scale (VAS) for evaluation of pain. Subjects were randomly assigned into group 1, receiving only standard physical therapy, or group 2, receiving standard physical therapy with conventional lumbar traction. Standard physical therapy consisted of local heat, ultrasound for the lumbar region, and an active exercise program, given for ten sessions in all. The subjects received instruction on correct posture and recommended therapeutic exercises. They were reevaluated at the end of treatment and at 3-month follow-up. The mean outcome measures were global improvement and satisfaction with the therapy, as well as disability by ODI and pain by VAS. There were no group differences in terms of demographic and baseline clinical characteristics. There was a significant reduction in pain intensity and disability at the end of treatment in both groups. There was complete or mild improvement in 47.6% of group 1 and 40% of group 2. The satisfaction rate with both treatments was more than 70% immediately after the therapies. During the 3-month period, the outcome measures except disability remained statistically stable, with no difference amongst groups. Disability was significantly reduced at follow-up in both groups. Of the patients, 51% continued with the recommended exercises and had significantly lower disability scores than those who did not continue with the exercises. Pain and global improvement were also better in this group, but the difference was not statistically significant. In conclusion, no specific effect of traction on standard physical therapy was observed in our study group. We suggest focusing on back education and exercise therapy in the management of patients suffering from this chronic condition.

The Epidemic of Severe Obesity: The Value of Surgical Treatment

The Epidemic of Severe Obesity: The Value of Surgical Treatment

Chronic back pain: does bed rest help?

If your patients with uncomplicated back pain get relief with bed rest and pain relievers yet you are told that bed rest doesn't help, you are not alone in your belief. When researchers from the University of Washington surveyed several thousand physicians about back pain management, most believed in the utility of prolonged bed rest along with muscle relaxants and narcotics.1,2 Despite a plethora of research intended to guide physicians in their management of back pain, physicians still hold strong non-evidence based beliefs dating back to the 19th century. Uncomplicated back pain is common—the fifth most frequent reason patients visit their doctor, accounting for nearly 3% of all office visits.3 By uncomplicated we are referring to back pain that does not radiate below the knee in an otherwise healthy person between the ages of 20 and 55. Of course, primary care physicians treat only a small proportion of uncomplicated back pain; many patients go to orthopedists, chiropractors, physical therapists, and massage specialists. In fact, when studies have looked at outcomes of uncomplicated back pain, 95% of patients recover in 6 months (most within 30 days) regardless of health care provider or intervention. The specialty of the provider, however, was strongly linked to the number of visits, the cost of care, and patient satisfaction. Orthopedists had the fewest number of office visits, the greatest costs associated with care, and the least patient satisfaction. Chiropractors had the lowest cost per visit (although total care was equal to primary care physicians) and the greatest patient satisfaction. Orthopedists and chiropractors were far more likely to order tests and radiographs than primary care providers. The cost of care for uncomplicated back pain for orthopedists was $756 compared to $783 for chiropractors and $508 for primary care physicians.4. There is strong evidence that prolonged bed rest does not improve outcome (pain, disability, days missed from work, or functional ability). One randomized controlled trial5 comparing bed rest, exercise, and routine care showed that bed rest was associated strongly associated with three negative outcomes (more days off from work, intensity of pain, and disability). The next question is, if bed rest does not help, is there benefit to active exercise/physical therapy? The answer is less strong, but 14 of 18 controlled studies do report that active exercise can improve outcomes.6 Further, research suggests that specially tailored active exercise may result in fewer episodes of back pain in the future.7 Is there a role for imaging studies? Not in uncomplicated back pain, so say the studies and expert consensus panels.8 What about TENS units, ultrasound, massage, and cosset use to treat back pain? The one randomized controlled trial that looked at these treatment modalities found that those with more intensive contact with a provider resulted in the greatest satisfaction but that there were no significant differences in objective outcome measures.9 So although some patients may need to temporarily modify their activity during the acute phase of back pain, most should be encouraged to avoid bed rest and resume normal activity as soon as possible. For those so motivated, an active exercise program appears to improve outcomes and speed recovery.

Maintaining Quality of Life

To the Editor: I am writing in response to the case report by Dal Bello-Haas et al entitled “Physical Therapy for a Patient Through Six Stages of Amyotrophic Lateral Sclerosis” (December 1998). My compliments to the authors for writing and the Journal for publishing this report, which gives an overview of the diagnosis, examinations, and interventions for the individual with amyotrophic lateral sclerosis (ALS). The rehabilitation community too often neglects our patients with deteriorating pathologies. I want to comment on 3 concerns regarding this publication. The first concern relates to the prescribed exercise protocol for the patient with ALS. The prescribed exercise program included 10 minutes of cycling at 65% of the maximal heart rate 2 times a day in addition to stretching activities and an active resistance exercise program for the lower extremities. The patient was to exercise for 2 20-minute sessions a day, and the exercise prescription was continued even after her second visit to the clinic, during which she showed a decrease in muscle strength in all groups tested. The authors cite only 2 references that addressed the effects of resistive exercise for the person with ALS, one being a 1983 case study, and admit that there is no evidence of “functional change from a resistive exercise program.” At our clinic, we support Sinaki, who does not advocate “any vigorous exercise programs for persons with ALS” but rather feels that “everyday activities are enough.”1 Our patients and their caregivers are taught a range-of-motion/stretching program to be performed daily, but active-resistive or aerobic exercises are done only through functional tasks that are valued by the individual patient. Our patients who are golfers are taught how to modify their golf games, and those who enjoy walking go to the malls in the summer and decrease their target …

Passive and active exercises increase cerebral blood flow velocity in young, healthy individuals.

Unlike the well-examined cardiovascular changes during movement stimuli, changes of cerebral hemodynamics and cerebral metabolism in physical exercises have, as yet, rarely been studied. Our objective was to investigate whether there are changes in cerebral hemodynamics and cerebral metabolism caused by active and passive movement stimuli. Response to repetitive active and passive movement stimuli was studied in 14 volunteers (8 females, 6 males; mean age, 35.2+/-8 yr). Each volunteer was subjected to four measurement series while performing a defined active and passive exercise program of the right upper or right lower limb. Measurement series were designed according to Aaslid's "evoked flow test"; exercises were performed for 20 s, followed by a rest of 20 s. This sequence was repeated 10 times in each series. As a measure of cerebral hemodynamics mean and peak blood flow velocity of the middle cerebral artery were recorded by transcranial Doppler sonography (Multidop-X-DWL). In addition, cerebral metabolism was quantified in a subsample by means of oxygenic cytochrome aa3 (respiratory chain enzyme), cerebral oxygen saturation using near infrared spectroscopy (Critikon). As well, noninvasive blood pressure (Penaz method) and expiratory pCO2 were measured. Compared with resting measures, an increase in mean cerebral blood flow velocity of the middle cerebral artery of 3.8% (P = 0.003, paired t test) was observed after active exercises of the right lower limb and 3.5% after active exercises of the right upper limb. Respective changes were 3.4% (P = 0.004) for passive exercises of the lower limb and 4.6% (P = 0.007) for passive exercises of the right upper limb. Peak cerebral blood flow velocity of the middle cerebral artery showed an even more pronounced increase during passive and active exercises in all cases, with values of between 12.2% (P < 0.001) and 13.6% (P < 0.001). Significant increases (1.5-3%) of cytochrome aa3 and cerebral oxygen saturation were observed during active and passive exercises. These studies show that active as well as passive exercises are followed by an increase of cerebral blood flow velocity. We attribute the increase of cerebral hemodynamic and cerebral metabolism to cerebral activation and autoregulative mechanisms.

Recognition and management of IgA nephropathy.

IgA (immunoglobulin A) nephropathy is the most common form of primary glomerulonephritis worldwide. It generally has a good prognosis, with 15-year rates of kidney survival from the apparent onset of disease usually well in excess of 70%. Progression, when it occurs, is usually a slow, indolent process, and spontaneous remission of disease activity occurs in 7% of patients. It is possible to predict, from the initial presenting features and laboratory findings, renal biopsy and clinical course during follow-up, which patients are likely to have progressive renal disease. Identification of the factors likely to be associated with progression is of importance in helping to establish which patients will benefit from specific therapeutic intervention. For all patients, attention should be directed toward general health issues in an endeavour to reverse factors that are likely to have an adverse impact on renal function. This should include early detection and tight control of hypertension (present in 50% of all patients with IgA nephropathy during the course of their disease), along with utilisation of antihypertensive agents that have specific renoprotective effects, namely ACE inhibitors or calcium antagonists. Such therapy should also be considered in normotensive patients with heavy proteinuria, as a reduction of proteinuria is often achieved by this means. Other aims should include maintenance of desirable bodyweight, correction of hyperlipidaemia, cessation of smoking, participation in an active exercise programme, avoidance of exposure to nephrotoxins and maintenance of a high fluid intake. A low protein/low phosphate diet together with phosphate binder therapy should be commenced early in the course of renal impairment. Corticosteroid and/or cytotoxic drug therapy should be considered in the small percentage of patients with heavy proteinuria or a rapid decline in renal function. Such therapeutic endeavours are likely to delay the onset of renal failure in patients with progressive IgA nephropathy.

The treatment of lymphoedema by Complex Physical Therapy

Lymphoedema is a high protein oedema caused by a low output failure of the lymphatic system. Complex Physical Therapy is a conservative treatment which is designed to increase the transport capacity of the lymphatic system and remove the stagnant plasma proteins from the tissues. The treatment consists of massage, compression bandaging, an active exercise programme and care of the skin. Sometimes this is assisted by the use of a mercury compression pump and the prescription of one of the benzo pyrone drugs by the referring medical officer. The treatment is given daily for one hour, six days a week, usually over four weeks. At the completion of treatment, the limb is fitted with support hosiery.

Results of a Multicenter Trial Using an Intensive Active Exercise Program for the Treatment of Acute Soft Tissue and Back Injuries

Dissatisfaction with current nonsurgical treatment of acute soft tissue and back injuries initiated a search for more effective treatment. A multicenter trial, involving 12 clinics, treated 1,072 patients. Treatment consisted of intensive, time-limited exercises emphasizing mobility, muscle strengthening, work conditioning, sequence training, and appropriate education sessions. Return to full-time work was proof that the patient had recovered fully. Time off work and compensation costs were parameters used to evaluate results. A detailed study of 703 patients treated at five clinics, operational for more than 12 months, showed superior results when compared with the comparison group of 2,172 matched control subjects. The treatment group returned to work earlier and realized substantial cost savings. This treatment program has proved to be superior to the miscellaneous variety of treatment modalities used for acute soft tissue and back injuries provided to the comparison group.

Physical models of rehabilitation in neuromuscular disease.

Physical methods of treatment for neuromuscular diseases constitute the mainstay of current management. The overall goals of management are the maintenance of independent ambulation and the optimal functional state consistent with the disease process. Maintenance of muscle strength requires regular daily physical activity. An active exercise program can give limited increases of strength in muscular dystrophy dependent on the severity of the disease. Active exercise programs do not result in overwork weakness when properly supervised. Endurance exercise training does not appear to be suitable for Duchenne muscular dystrophy but may have value in the less rapidly progressive neuromuscular diseases. contracture development can be retarded by passive stretching and splinting initiated early in the disease course. Weight control is important both for ambulatory and wheelchair-bound patients. Reliable assessment of the results of physical therapy programs has been improved by the introduction of newer, more objective methods for measuring muscle strength.

Effect of exercise on aging--effect of aging on exercise.

The coincidence of age changes with alterations in body structure and function is striking. Increasing evidence indicates that many of the changes commonly attributable to aging can be retarded by an active exercise program. Physical exercise, properly supervised, is a safe and widely applicable form of therapy.

The Rational Diet for The Obese

To the Editor.— Dr. Retan's letter has called attention to the fact that present-day treatment of obesity of any degree is generally unsatisfactory. In my article, I simply elected to avoid a negative attitude. By no means is it necessary for every patient or even any patient to follow the suggestions I outlined. The ideal program is that which will be successful for that particular person, provided that the diet is nutritionally adequate and that there are no significant physiological abnormalities. As to commercial programs for weight control, I am sufficiently acquainted with only two to express an opinion. The Weight Watcher's Diet Program seems effective in some cases, but contrary to their views, I believe an active exercise program to be useful in obtaining valuable caloric balance. Also, it improves general health and vigor. The Counterweight Program sponsored by General Mills, Inc., provides both a nutritionally adequate diet and

Role of the surgeon in the rehabilitation of the breast cancer patient.

The role of the surgeon in restoring the breast cancer patient to near-normal preoperative form and function must include both pre- and postoperative considerations. Preoperatively the surgeon should stress any favorable characteristics of the tumor and become aware of the patients fears both conscious and unconscious. Postoperative depression can be allayed by having the patient discuss prostheses with a previously mastectomized patient and by initiating an active exercise program primarily aimed at preventing limitations of arm motion. Breast reconstruction should be delayed to avoid the possibility of liberating entrapped tumor cells and to allow time for the patients initial enthusiasm for the procedure to wane. A few patients develop delayed surgical complications the most important being axillary scarring which may be corrected by z-plasty and lymphedema the rate of which has been estimated as high as 35%. This latter condition may usually be controlled by low salt intake diuretics weight reduction frequent arm elevation compression of the lymphedematous extremity and as a last resort surgery. The highly lethal but rare complication of lymphedema lymphagiosarcoma makes more imperative the control of this condition.