Aim: Airway management is one of the key areas of pediatric anesthesia practice. In this study, we aimed to investigate the availability of equipment for dif-ficult airways in pediatric anesthesia and to increase the awareness on the subject among anesthesiologists. Material and Method: The survey was carried out using the forms.google.com. Our questionnaire was forwarded to the members on the internet by the Turkish Society of Anesthesiology and Reanimation. Anesthesiologists working in Turkey and willing to join the survey were included in the study. Results: The mean age of the 390 participants who completed our questionnaire was 39.40±7.26 years. The majority (34.6%) of the participants were working for training and research hospitals; 35.4% had been working for 1-5 years; 53.1% had attended a training course on airway management. The frequency of pediatric anesthesia every day was 32.8% and 46% of the participants had been administering pediatric anesthesia to few pediatric patients each week. A special kit of equipment for difficult airway management was available to 35.4%. The classical LMA was most frequently used equipment (95.6%). While 40.8% of the participants had encountered difficult airway in 1-5 pediatric patients, 7.9% also had the previous experience of an emergency surgical airway. Discussion: Our study has determined that the incidence of emergency surgical airway experience was low despite the high risk of encountering difficult airway management in pediatric anesthesiology. We believe that the success rates in difficult airway management would be increased by starting training courses with frequent periodicity on pediatric difficult airway management at different centers in our country, by widening the availability of required equipment and by increasing experience.

Keywords: Airway Devices; Devices; Difficult; General Anesthesia; Education

Introduction

Airway management is one of the key areas of anesthesia practice, it is also important for pediatric anesthesia. Because of anatomical differences, children are more prone to upper airway obstruction under anesthesia than adults. Also, children have a much higher oxygen consumption than adults, and as a result when they have airway obstruction or when they become apnoeic, hypoxemia develops much faster [1,2]. It has long been known that respiratory adverse events are the most encountered problem of perioperative critical events in pediatric patients [1,2]. Current guidelines addressing the difficult airway management in adults provide anesthesiologists a framework for managing the airway. Whereas in children, it is more difficult to establish guidelines due to fewer management options, failed airway management is less common, and recommendations would vary based on growth and development [3,4]. Supraglottic airway devices (SAD) inspired a fundamental change in the management of the difficult airway and are a key part of adult and pediatric difficult airway algorithms [5]. Use of SAD may reduce morbidity and in some cases be life-saving when used correctly and timely.

There is a little proof to determine the safest or most effective device to use for airway management. In addition, in difficult pediatric airway management, many of the adverse events occur frequently with unskilled personnel and insufficient resources available to respond to an unexpected crisis, often resulting in a worse outcome [6].

An unexpected pediatric difficult airway can lead to significant morbidity and mortality. Standardized emergency airway equipment should be available to prevent the adverse events related to a difficult airway. The aim of this study was to investigate the availability of difficult airway equipment in pediatric anesthesia in Turkey and to raise awareness on this subject among anesthesiologists.

Material and Method

The local ethics committee (Uludag University Ethics Committee Number: 2018-3/15) approved this study. Anesthesiologists who were working in Turkey and willing to participate were enrolled in this study. A survey approved by the Turkish Society of Anesthesiology and Reanimation was distributed using forms.google.com, among all members from Turkey.

All statistical analyses were performed using the IBM SPSS ver. 21.0 software package. While numeric variables were expressed as mean ± standard deviation, categorical variables were expressed in numbers and percentages. The Pearson’s Chi-Square and Fisher’s exact test were used to detect differences between groups of categorical variables. To determine risk factors binary logistic regression analysis was performed. A p-value < 0.05 was considered as statistically significant.

Results

A total of 390 participants were involved in the statistical analysis. Table 1 shows the demographic data of the participants. The study revealed that overall incidence of attendance among the participants to courses on the subject of respiratory airways was 53.1% (n=207); these being 62.9% in state universities, 54.8% in training and research hospitals, 50% in private hospitals, 47.7% in state hospitals and 44.4% in private universities. Overall attendance to adult type courses was 40.3% (n=157), to pediatric type courses was 14.6% (n=57), and to courses in other countries was 1.3% (n=5).

The experience of access to the equipment for difficult airways and using it is shown in Table 2. In this study, the classical laryngeal mask airway (LMA) was found to be the predominantly used equipment (95.6%) on which most experiences were based. The specially prepared kit of difficult airways equipment was available to 35.4% of the participants.

When the presence of a specially prepared kit was investigated on the basis of the hospital type, significant differences were found (p=0.030). Availability of specially prepared kit was noticed in state universities (44.3%), in training and research hospitals (41.5%), in state hospitals (28.5%), in private hospitals (28.3%), and in private universities 11.1%. There was also a significant relationship between the specially prepared kit and the frequency of pediatric anesthesia (p=0.001). Ownership of specially prepared kit was found 46.9% of the frequency of pediatric anesthesia every day, 30.9% of few pediatric anesthesia per week and 31.4% of few pediatric anesthesia per month.

Having encountered 1-5 cases of difficult pediatric airways, 40.8% of the participants have reported about it, while 19.2% had never observed a case. The incidence of the encounter of the pediatric difficult airway management was 50% among state hospitals, 43.7% in training and research hospitals, 30% in state universities, 26.1% in private hospitals and 22.2% in private universities.

Previous experience of the emergency surgical airway was 7.9% (n=31) among the participants. When the regression analysis of these data was performed, the experience of specialists affected these results significantly (p=0.001), but hospital type, course participation or age group did not (p> 0.05).

The term CICO (can’t intubate, can’t oxygenate) had been previously heard by 22.8% of the participants. Results of regression analyses on familiarity with the term CICO indicated that attendance to courses, having the specialist experience and the age group of participants were significantly effective (p<0.001, p=0.002 and p=0.026, respectively), whereas the hospital type was not (p=0.309). Results of regression analyses on hearing of CICO term demonstrate that attendance to courses, the specialist experience and the age group of participants were significantly effective (p<0.001, p=0.002 and p=0.026, respectively), whereas the hospital type was not effective (p=0.309). The lowest incidence (13.8%) of hearing of the term CICO was found to be in state hospitals, while it was in the 22.2-28% range in the other types of hospitals.

In short-term pediatric surgeries, such as for an inguinal hernia, 86.7% of the participants applied general anesthesia with LMA, and 9% preferred the endotracheal tube. In 97.7% of the laparoscopic surgery cases, general anesthesia was given by the endotracheal tube and 0.8% by using the LMA, preference is for the classical LMA (62%) followed by the I-gel LMA (28.5%). Reported difficulties with the SAD which limited their use included the performance of aspiration (64.9%), intraoperative displacement (56.2%), difficulty in placement (40.5%), postoperative airway problems 16.2% and hemorrhage related trauma during removal (11.9%). Other reasons limiting SAD use comprised unavailability of the suitable number (51.7%), inability to use with ease in infants under 5 kg body weight (26.4%), and not being generally used in pediatric cases (25.6%).

Of the participants, 85.6% think that further prospective randomized studies are needed in these subjects.

Discussion

In this study, we investigated the availability of airway equipment in pediatric anesthetic practice in Turkey. Classical LMA was most commonly used among airway equipment (95.6%). A specially prepared kit for pediatric difficult airway management was found in 35.4% of our participants. When the presence of a specially prepared kit was investigated on the basis of the hospital type and the frequency of pediatric anesthesia, significant differences were found. The survey has determined that availability of a specially kit of difficult airway equipment was high in state universities and training and research hospitals, with the highest availability being in the frequency of pediatric anesthesia every day. Only 7.9% of participants had previous emergency surgical airway experience. The rate of attendance of a course about difficult airway management was 53.1%.

In our study, the Macintosh laryngoscope, miller laryngoscope, Pro-seal LMA, and I-gel LMA were available over 40%. The McCoy laryngoscope, video laringoscope, fiberoptic bronchoscope, cricothyroidotomy kit, tube changer catheter, and gum elastic bougie were available at 20-40%. Optical stile, combitube, laryngeal tube, FastTrack LMA, and nasal airway were available at 9-20%. Jet ventilator, retrograde intubation equipment, the newer devices (Easy laryngeal tube, and Aintree catheter) were available at less than 5%. The reasons behind this could be the high-cost and the late entry of pediatric sizes for new equipment in our country. Fiber-optic intubation remains the gold standard for intubation of the difficult airway. In the present study, 30.3% of respondents had available fiberoptic bronchoscope, and 27.9% had experience with children in this technique.

SAD are frequently used in pediatric anesthesia [7]. In our study, general anesthesia with LMA in pediatric cases was preferred by 86.7% of participants in the short-term surgeries. The classical LMA being the most preferred type (%62), followed by the I-gel LMA (28.5%). Personal choice, availability, and institutional protocols may have influenced the selection of the device. In a meta-analysis using LMA during pediatric anesthesia, it is alarming that intraoperative displacement was a common problem encountered to their anesthesiologists whereas aspiration was not [8]. In our study, the difficulties of using SDA were as reported in the literature, mostly experienced during aspiration and intraoperative displacement.

Kaniyil et al. [7] reported a questionnaire survey among the anesthesiologists who participated in the National Pediatric Anesthesia Conference in 2016. The questionnaire evaluated the practice preferences of SAD in pediatric anesthesia and difficult airway management, availability of devices, and any difficulties in their usage. First-generation SAD were frequently present (97%), and 64% of the participants preferred to use it for short-term pediatric surgeries. They found that intraoperative displacement (55%) was a common problem and 11% of the participants found aspiration as a problem [7]. In our survey, the frequency of using SAD in pediatric short cases was 86.7% and the causes limiting their use were headed by the inability to do aspiration.

Calder et al. [9] conducted a survey with members of the Association of Pediatric Anesthetists of Great Britain and Ireland, European Society for Pediatric Anesthesiology, Canadian Pediatric Anesthesia Society, Society for Pediatric Anesthesia in New Zealand and Australia. They searched pediatric anesthetists’ knowledge, experience, and confidence with the difficult airway trolley, 633 (92%) of participants defined that they had a difficult airway trolley in their theater room. They considered that training and recent use of the difficult airway trolley would increase self-assurance of the anesthetists [9]. A specially prepared kit for pediatric difficult airway management was available in 35.4% of our respondents. In the study by Calder et al. [9], a majority (35%) of the participants were treating 5 pediatric anesthesia cases per week. In the present survey, the majority of the participants (46.4%) had been administering pediatric anesthesia to few pediatric patients each week.

The Difficult Airway Society suggested a number of educational materials including a Consultant Airway Coordinator, an Airway Training Room, and special lists for airway training [5,10]. It is important that training programs realize the individual and professional significance of experiences for new physicians. Education should support the development of constructive skills through discussion and learning [11].

Among the participants of our survey 40.8% had met 1-5 difficult airway cases while 19.2% had never experienced difficult airway. Low incidences may be due to the preferred use of LMA instead of the endotracheal intubation technique in the majority of pediatric cases. In our study, 86.7% of the participants opted for LMA for short pediatric surgeries such as an inguinal hernia.

The CICO scenario is a rare but life-threatening situation in pediatric anesthesia [12]. In pediatric CICO, the Difficult Airway Society guideline suggests some airway rescue techniques [12,13]. However, pediatric CICO is very rare, and this suggestion is mostly based on animal experimental results and expert opinions [5]. Therefore, further reports are necessary to consider the best strategy for pediatric CICO [14]. The recently released the American Society of Anesthesiologists recommended cannula cricothyroidotomy for management of the CICO scenario in the increasingly hypoxic and/or bradycardic child [15]. In our survey, 23.4% of the participants had knowledge about the meaning of the CICO and it was found that the experience of airway management in pediatric surgery was 7.9%. Anesthesiologists have to identify their strategies for the CICO rescue events and should increase their experience.

Kaniyil et al. [7] reported that most of their respondents (84%) felt the need for further randomized controlled studies on the safety of SAD in children. Similarly, in our survey, 85.6% of the participants admitted the need for further studies in this subject.

Limitations of our survey include the inability to reach all anesthesiologists in our country. Thus our results on the difficult airway equipment may not reflect the entire practice. Had the survey queried the difficult mask ventilation and difficult tracheal intubation separately, more detailed data could have been obtained. Other limitations were lack of knowledge about the frequency of pediatric anesthesia annually in Turkey and the number of pediatric anesthesiologists.

As a result, an early intervention in the difficult airway is very important. Our study has emphasized the areas with the potential for international development in pediatric difficult airway management. In hospitals admitting pediatric patients, a specially prepared kit for pediatric difficult airway management must be made generally available, and the variety in equipment types should be increased. There are no magical pieces of equipment in difficult airway management. Training about difficult airway management is an ongoing process, the most important structure of patient safety is preoperative evaluation and planning. We believe that by starting training courses on pediatric difficult airway management with frequent periodicity at different centers of the country; and by widening the availability of the required equipment, experience should be advanced for increased success in difficult airway management. Repetition of training sessions at frequent intervals can improve the performance in DA management and the critical decision in CICO.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.

Funding: None

Conflict of interest

None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.

References

1. Goldmann K. Recent developments in airway management of the paediatric patient. Current Opinion in Anaesthesiology. 2006;19:278-4.

2. Cohen MM, Cameron CB, Duncan PG. Pediatric anesthesia morbidity and mortality in the perioperative period. Anesth Analg. 1990;70:160-7.

3. Sunder RA, Haile DT, Farrell PT, Sharma A. Pediatric airway management: current practices and future directions. Pediatr Anesth. 2012;22:1008-15.

4. Brambrink AM, Braun U. Airway management in infants and children. Best Pract Res Clin Anaesthesiol. 2005;19:675-97.

5. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia. 2015;115:827-48.

6. Cook TM, Woodall N, Harper J,  Benger J. Fourth National Audit Project. Major complications of airway management in the UK: results of the Foruth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011;106:632-42.

7. Kaniyil S, Smithamol PB, Joseph E, Krishnadas A, Ramadas KT. A survey of current practice of supraglottic airway devices in pediatric anesthesia from India. Anesth Essays Res. 2017;11:578-82.

8. Luce V, Harkouk H, Brasher C,  Michelet D, Hilly J, Maesani M, et al. Supraglottic airway devices vs. tracheal intubation in children: A quantitative meta-analysis of respiratory complications. Pediatr Anesth. 2014;24:1088-98.

9. Calder A, Hegarty M, Davies K, Von Ungern-Sternberg BS. The difficult airway trolley in pediatric anesthesia: an international survey of experience and training. Pediatr Anesth. 2012;22:1150-4.

10. Henderson JJ, Popat MT, Latto IP,  Pearce AC, Difficult Airway Society. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia. 2004;59:675-94.

11. Engel KG, Rosenthal M, Sutcliffe KM. Resident’s responses to medical error: coping, learning, and change. Acad Med. 2006;81:86-93.

12. Sabato SC, Long E. An institutional approach to the management of the ‘Can’t Intubate, Can’t Oxygenate’ emergency in children. Pediatr Anesth. 2016;26:784-93.

13. Black AE, Flynn PE, Smith HL,  Thomas ML, Wilkinson KA, Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Pediatr Anesth. 2015;25:346-62.

14. Okada Y, Ishii W, Sato N, Kotani H, Iiduka R. Management of pediatric ‘cannot intubate, cannot oxygenate’. Acute Medicine & Surgery. 2017;4:462-6.

15. Caplan R, Benumof L, Berry F. Practice guidelines for management of the difficult airway: an updated report from the american society of anesthesiologists task force on management of the difficult airway. Anesthesiology. 2003;98:1269-77.

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Aim: Breast cancer screening age is between 40-69 years in women of our country. The purpose of this study is to examine the effect of breast cancer screen-ing on tumor diameter and surgical technique for women at or above the screening age interval. Material and Method: The data of 133 female patients aged 40 and above who underwent surgery due to the breast cancer between years 2010 and 2018 in Ordu, Turkey, were collected retrospectively. Patients were divided into two groups as Group 1 (n = 102, between ages 40-69) and Group 2 (n = 31, aged 70 and above). Results: In Group 1, the average tumor diameter of 48 patients (47.1%) diagnosed with physical examination (PE) was 2.96 ± 1.2 cm and average tumor diameter of 54 patients (52.9%) diagnosed with mam-mography (MG) was 1.48 ± 0.58 cm (p < 0,001). In Group 1, 36 (66.7%) of 54 patients diagnosed with MG underwent breast conserving surgery (BCS), and 18 (33.3%) underwent modified radical mastectomy (MRM). Meanwhile, 25 (52.1%) of 48 patients diagnosed with PE underwent BCS and 23 (47.9%) underwent MRM (p = 0.13). In Group 2, the average tumor diameter of 24 (77.4%) patients diagnosed with PE was 3.18 ± 1.48 cm and the average tumor diameter of 7 (22.6%) patients diagnosed with MG was 2.74 ± 0.79 cm (p = 0,55). In Group 2, 3 (42.9%) of 7 patients diagnosed with MG underwent BCS, and 4 (57.1%) underwent MRM. Meanwhile, 9 (37.5%) of 24 patients diagnosed with PE underwent BCS, and 15 (62.5%) underwent MRM (p = 0.79). Discussion: Tumor di-ameter was determined to be smaller in breast cancer screening group among women at or above the age interval of the breast cancer screening program. Although, the effect of screening on surgery type was not statistically significant, it has increased breast-conserving surgery. The breast cancer screening program should not be planned according to the chronological age, and instead, life expectancy should be regarded.

Keywords: Breast Cancer; Screening Program; Surgical Technique

Introduction

Breast cancer is the most common cancer type in women and it constitutes 23% of ~ 1.7 million cancers newly diagnosed in women every year [1,2]. The purpose of breast cancer screening is to detect tumor at a small size while it has not presented clinical symptoms yet, and thus provide a decrease in deaths associated with breast cancer. Five-year relative survival rates for breast cancers are as follows: 99 percent for localized cancers, 85 percent for regional cancers and 26 percent for metastatic cancers [3]. Breast cancer screening programs are performed until age 70 in many countries. Nevertheless, with the advancement of contemporary life standards, preventive medicine and the increases in treatment opportunities, lifespan has significantly increased. The incidence of breast cancer increases with age. More than 30% of breast cancer patients are older than 70 [4]. The purpose of our study was to compare tumor diameter between patients between ages 40-69 who were included in a breast cancer screening program, and patients aged above 70 years old, and to examine the relation between surgical techniques and mammography (MG) screening.

Material and Method

Patients aged 40 and above, who underwent surgery due to the breast cancer between years 2010 and 2018 in public hospitals connected to local health authority of Ordu, and whose data were available in the retrospective review, were included in the study. Patients were separated into two groups according to their age; Group 1 consisted of women aged between 40-69 years that is breast cancer screening age interval (and Group 2 consisted of women aged 70 and above. In our study, whether patients had undergone breast cancer screening, and data on tumor diameter and surgery techniques were reviewed retrospectively for screened and not screened patients. Ethical approval of the work has been approved by the Institutional Review Board of Ordu University.

Statistics

Descriptive statistics for continuous variables are presented as average, standard deviation, minimum and maximum values; and they are presented in numbers and percentage for categorical variables. Kolmogorov-Smirnov normality test has been performed in order to compare tumor diameters in numeric variables, and the Mann-Whitney U test was performed to compare the tumor diameter of groups. Chi-square test and Fisher’s test have been performed to determine the relationship between categorical variables (groups). In calculations, statistically significant level was assumed as 5% (p = 0,05), and SPSS (IBM SPSS for Windows, Ver.24) statistical package program has been used for calculations.

Results

All 133 patients who were included in the study were female, and the average age was 60.47 ± 12.77 (41-94) years. Group 1 included 76.7% (n=102) of patients, and 23.3% (n=31) of patients were assigned to Group 2.

Seventy-two (54.1%) patients were diagnosed based on their physical examination (PE) and 61 (45.9%) patients were diagnosed with MG. Forty-seven point one percent of Group 1 patients (n=48) were diagnosed with PE and 52.9% (n=54) were diagnosed with MG. Seventy-seven point four percent (n=24) of Group 2 patients were diagnosed with PE and 22.6% (n=7) were diagnosed with MG. There was a statistically significant difference between the two groups with regards to diagnosis method (p = 0003).

Average tumor diameters of patients operated for breast cancer were 2.35 ± 1.28 (min. 0.2 – max. 9) cm. Average tumor diameter was 2.17 ± 1.19 cm (min. 0.2- max. 6.5) in Group 1, and it was 2.92 ± 1.41 (min. 1.3 – max. 9) cm in Group 2. There was a statistically significant difference between groups with regards to tumor diameter (p = 0.001).

While the average tumor diameter of 48 patients diagnosed with PE in Group 1 was 2.96 ± 1.2 cm, average tumor diameter of 54 patients diagnosed with MG was 1.48 ± 0.58 cm. There was a statistically significant difference between diagnosis method and tumor diameter (p < 0,001).

While the average tumor diameter of 24 patients diagnosed with PE in Group 2 was 3.18 ± 1.48 cm, average tumor diameter of 7 patients diagnosed with MG was 2.74 ± 0.79 cm. Although not statistically significant, a quantitative difference was observed between the diagnosis method and tumor diameter (p=0,55).

Upon evaluating tumor diameter according to diagnosis method for all patients included in the study, average tumor diameter of 72 patients diagnosed with PE was 3.04 ± 1.3 (min. 1 – max. 9) cm, and average tumor diameter of 61 patients diagnosed with MG was 1.62 ± 0.73 (min. 0.2 – max. 3.7) cm. There was a statistically significant difference between diagnosis method and tumor diameter (p < 0,001).

With regards to the surgery type and diagnosis method in Group 1 patients, 66.7% of 54 patients diagnosed with MG underwent breast-conserving surgery (BCS) (n=36), and 33.3% underwent modified radical mastectomy (MRM) (n=18). Meanwhile, 52.1% of 48 patients diagnosed with PE underwent BCS (n=25), and 47.9% underwent MRM (n=23). Although diagnosis method affected the surgery type, there was no statistically significant difference (p=0.13).

Upon examining the surgery type and diagnosis method in Group 2 patients, 42.9% of 7 patients diagnosed with MG underwent BCS (n=3), and 57.1% underwent MRM (n=4). Meanwhile, 37.5% of 24 patients diagnosed with PE underwent BCS (n=9), and 62.5% underwent MRM (n=15). There was no statistically significant difference between those (p=0.79).

When all patients included in the study were examined for a difference between diagnosis method and surgery type, it was determined that 63.9% (n=39) of 61 patients diagnosed with MG underwent BCS and 36.1% (n=22) underwent MRM. Meanwhile, 47.2% of 72 patients diagnosed with PE underwent BCS (n=34), and 52.8% underwent MRM (n=38). There was no statistically significant difference between diagnosis method and surgery types (p=0.054). The data of the study are summarized in Table 1.

Discussion

Delays in diagnosis and treatment of breast cancer increase the morbidity and mortality in patients. Screening programs have great importance since breast cancer in the most common form of cancer observed in women and there is an increase in its prevalence. The most common method of early detection is MG, low dose X-ray imaging of the breasts used to identify abnormalities. Screening of breast cancer with MG was first performed starting from the 1960s in New York with the Health Insurance Plan [5]. Particularly after the 1980s, upon understanding the benefit of MG, MG screening became prevalent all around the world starting with the Western countries. The use of this method has shown a 25%-30% decrease in death due to the breast cancer as a result of 25-year follow-up [6]. The relationship between the combination of early stage and effective treatment and the good prognosis is obvious. According to the American Cancer Society’s 2014 data, 61% of breast cancer diagnoses can be determined at an early stage. Five-year survival expectancy of patients who were diagnosed at the early stage is 99%.

In 2014, the standards to follow in population-based breast cancer screening program studies have been re-established by Turkey Ministry of Health Public Health Institute and they were issued under the title ‘National Standards of Breast Cancer Screening Program’. Accordingly, in Turkey, it was adopted to perform screening MG once every two years in all women aged between 40-69 years old. In the breast cancer screening guidelines prepared by Turkish Society of Radiology, starting age for mammographic screening was adopted as 40 and yearly checks were recommended.

Nowadays, the number of patients aged over 70 years is increasing. The health status of a significant part of women aged 70 is good and their life expectancy may be longer than 10 years. According to 2016 data of Turkish Statistical Institute, overall lifespan in Turkey is 78 years; 75.3 years for men and 80.7 years for women. While life expectancy is 15.3 years for women aged 70, it is 8.7 years for women aged 80. According to 2010 data from the USA, approximately 50% of women aged 80 and 25% of women aged 85 will live for at least another 10 years [7,8]. The most important risk factor of breast cancer is advancing age [9]. According to 2013 data of American Cancer Society (ACS), breast cancer is predominantly a disease of older women with 43 % of incident cases, and 57.0 % of deaths due to breast cancer occurring in women aged 65 years and older. Breast cancer develops in the following 10 years in 3.8% of patients aged 70 and above [10]. In our study, a significant rate of (23.3%) breast cancer cases consisted of women aged 70 and above. So, can’t these women be included in the screening program for an earlier diagnosis?

When women aged 70 and above were included in the screening MG which were applied once every 2 years for 10 years, it was found that mortality due to the breast cancer decreased by 0.2% compared to patients who have attended those until age of 69 [8]. MG was confirmed to have high value for cancer detection rate and positive biopsy estimation rate in women aged 70 and above, and screening efficiency have been approved for elderly patients [11]. The American Cancer Society recommends that women continue participation in MG screening, regardless of age, as long as they have no serious chronic conditions or shortened life expectancy. MG screening should be performed in patients with life expectancy longer than 5 years without setting an upper age limit [12]. In our study, tumors were detected at an earlier stage (with smaller diameter) in women aged 70 and above who underwent breast cancer screening, as in young women.

The basic approach in the surgical treatment of breast cancer is choosing the method that is least likely to affect the quality of life of patients, after obtaining acceptable oncological results. Mastectomy is a more traumatic procedure than BCS for every woman with breast cancer. According to the clinical trials, there is no difference between total and disease-free survival between BCS and MRM [13]. Quality of life-determining problems such as anxiety, depression, psychosexual problems, being bothered by physical appearance and limitation in physical functions, which are experienced due to cancer, are observed less in patients who underwent BCS compared to patients who underwent MRM [14]. The tumor size of breast cancers detected with screening is smaller and they are more likely to be treated with BCS instead of MRM [11]. Independent from the age of breast cancer patients, tumor size of cases diagnosed with MG is smaller in our cases. Although many factors such as the life expectancy of the patient, experience of the surgeon, technical possibilities, the willingness of the patient, size of the breast and location of the tumor affect the surgery type, BCS rate is higher in quantity in screened patients, albeit not statistically different in our study.

Conclusion

Breast cancer is the most common malignancy observed in women and its prevalence increases with age. Since life-span of populations gets longer, the elderly population is ever-increasing. In parallel, the number of elderly women with breast cancer is also increasing. Independent from their age, tumors in women included in the screening program is determined at a smaller diameter. Consequently, life-span of people is getting longer, it would be more appropriate to plan a screening program according to the life expectancy instead of chronological age.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.

Funding: None

Conflict of interest

None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.

References

1. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin. 2015; 65: 87–108.

2. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2012; 62: 10–29.

3. Siegel RL, Miller KD, Jemal A. “Cancer statistics, 2016.” CA: a cancer journal for clinicians. 2016; 66(1): 7–30.

4. Kimmick GG, Balducci L. Breast cancer and aging. Clinical interactions. Hematol Oncol Clin North Am. 2000; 14: 213–34.

5. Shapiro S, Venet W, Strax P, Venet L. Periodic screening for breast cancer. The Health Insurance Plan Project and its sequelae, 1963-1986. Baltimore: Johns Hopkins University Press. 1988; 59–83.

6. Gotzsche PC, Nielsen M. Screening of breast cancer with mammography. Cochrane Database of Systemic Reviews. 2006; DOI:10.1002/14651858.

7. Walter LC, Covinsky KE. Cancer Screening in Elderly PatientsA Framework for Individualized Decision Making. JAMA. 2001; 285(21): 2750–6.

8. Walter LC, Schonberg MA. Screening Mammography in Older WomenA Review. JAMA. 2014; 311(13): 1336–47.

9. Crawford J, Cohen HJ. Relationship of cancer and aging. Clin Geriatr Med. 1987; 3(3): 419-32.

10. DeSantis C, Ma J, Bryan L, Jemal A. Breast cancer statistics, 2013. CA Cancer J Clin. 2014; 64: 52-62.

11. Monticciolo DL, Newell MS, Hendrick RE, Helvie MA, Moy L, Monsees B, et al. Breast Cancer Screening for Average-Risk Woman: Recommendations From the ACR Commission on Breast Imaging. J Am Coll Radiol. 2017; 14(9): 1137-43.

12. Smith RA, Brooks D, Cokkinides V, Saslow D, Brawley OW. Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening. CA Cancer J Clin. 2013; 63(2): 88–105.

13. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002; 347: 1233-41.

14. Zanapalıoğlu Y, Atahan K, Gür S, Çökmez S, Tarcan E. Effect of breast conserving surgery in quality of life in breast cancer patients. J Breast Health. 2009; 5: 152-6.

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Aim: Chronic exertional anterior compartment syndrome (ant-CECS) is a major cause of lower leg pain. Surgical fasciotomy is still the main treatment given with high success rate. Thorough physical therapy attempts as a non-operative treatment depends on manual therapy, modalities, and proper orthotic wear. Hence, there is a paucity of literature that compares the effects of two manual techniques on patients with ant-CECS. So, the purpose of this study was to compare the effects of Astym therapy and massage in patients with chronic exertional anterior compartment syndrome of the lower leg. Material and Method: This study was a prospective, randomized, single-blind, pre–post-test, controlled trial. The study was conducted at Beni-Suef University, Egypt. A total of thirty participants with chronic exertional anterior compartment syndrome pain enrolled in experimental and control groups. The outcomes were measured post- treatment to compare the effect of both interventions. Results: Mixed design MANOVA was used to compare the tested variables of interest. Post-treatment comparison showed a significant reduction in pain in favor of Astym group with significant differences in both lower extremity functional score and passive ankle dorsiflexion. (p > 0.05). Discussion: Pain and disability typically associated with ant-CECS reduced greatly after treatment of ant-CECS using ASTYM or massage. ASTYM treatment is more effective than massage therapy in reducing pain, improving overall functional level for patients with ant-CECS.

Keywords: Anterior Compartment Syndrome; ASTYM; Leg Pains; Massage

Introduction

Chronic exertional anterior compartment syndrome (ant-CECS) of the lower leg occurs when the elevated pressure within a small unyielding anterior fascial compartment precipitates chronic lower leg pain [1, 2]. It constitutes 27-33% of the causative factors [3, 4]. This syndrome most commonly occurs in young adults, athletes subjected to high lower limb stresses (uphill and distance runners, basketball and football players, gymnasts and hurdlers) and military personnel where pain may briefly persist after termination of exercise [2, 5]. Symptoms either subside within minutes to hours when the activity stops or worsen over time [6].

A major revision of diagnostic criteria is necessary, and the differential diagnoses include patient’s history, physical examination and if necessary radiographs, compartmental pressure measurements, arteriograms, angiography, bone scans and MRI [7]. Other diagnoses such as medial tibial stress syndrome, stress fracture, popliteal artery and common peroneal nerve entrapment may need to be excluded [1]. The anterior compartment contains the deep peroneal nerve, tibialis anterior muscle, and long toe extensors. Increased pressure in this compartment can cause signs of loss of sensation to the first web space and weakness with dorsiflexion of the toes and ankle. Physical exam may also include an assessment of gait or gait analysis because pronation is a common physical finding [8]. Because the syndrome primarily affects the venous system, arterial pulses are normally intact. To quantify the severity in patients with ant-CECS, a few investigators used visual analog scales [6, 9]. An ordinal scaled CECS specific measure has been introduced to grade the functional limitations resulting from pain provoked by CECS [9].

Fasciotomy is a surgical procedure to release the intracompartmental tension by severing the fascia covering the muscle compartment. However, a great range of surgical decompression is unsuccessful. Regarding outcome, results on operative intervention are good in the short term but these studies are limited with respect to follow up duration, involved many operative techniques, and the use of outcome measures [9]. Generally, nonsurgical treatment involves four treatment choices: massage, gait modification, chemo-denervation, and ultrasound-guided (USG) fascial fenestration [10]. Noninvasive interventions include arch support orthotics, ice massage to reduce swelling and pain, myofascial release, deep tissue massage, stretching before exercise, and training load modification [11]. These modalities are successful to modify the intra-compartmental pressures for short-term [12]. Conservative treatment methods include avoidance of running on hard terrains, footwear modification, alleviating the biomechanical techniques of running, and discontinuing the activity that elicits symptoms or decreasing the intensity of training. Massage therapy can also help alleviate symptoms by reducing the chronic muscular tension where patients are able to do more exercise without pain [11]. Astym® therapy is a manual technique with specific strokes used to enhance tissue healing, alleviate pain, and facilitate mobility hence, muscle performance improves through the application of specialized instruments that have shown evidence of stimulating soft-tissue healing [13, 14], and improving impairments such as pain, limitations in mobility, and muscle weakness that may accompany musculoskeletal pathology[15]. However, sinceAstym therapy and massage should theoretically reveal acceptable results, there is a dearth of literature that compare effects of these two techniques for patients with CECS. Therefore, the purpose of this study was to determine whether Astym therapy or massage applied to the lower leg would result in alleviation in pain, soft tissue mobility and ankle dorsiflexion.

Material and Method

The study was designed as a prospective, randomized, single-blind, pre–post-test, placebo-controlled trial. Ethical approval was obtained from the institutional review board at the Faculty of physical therapy, Beni-Suef University before study commencement [No: BSUPT04/25/07/2017]. The study followed the Guidelines of the Declaration of Helsinki on the conduct of human research. The study was conducted between July 2017 and November 2017.

Convenient samples of thirty patients recruited from the outpatient clinic of the faculty of physical therapy, Beni-Suef University were enrolled and assessed for their eligibility to participate in the study. All subjects of the study have read and signed an informed consent form approved by the Beni-Suef University. This study included participants diagnosed clinically with bilateral exertional anterior compartment syndrome of the lower leg. Their ages ranged from 18 to 35 years, they had ant-CECS for more than 3 months ago, with a Visual analog scale (VAS) Pain score > 4.All patients had no history of previous trauma to their legs and demonstrated normal roentgenograms of the tibia and fibula findings. Only patients with gradual cessation of the offending activity were involved. For individualsinsisting on continuing their exertional activities, surgical treatment (fasciotomy) is the choice. Exclusion criteria involved medical history of hemophilia or other blood coagulation disorders, medical history of cardiovascular disease including those with previous cardiovascular surgery and uncontrolled hypertension, current use of prescription blood thinners, a history of metastatic disease, neuropathy of the lower extremity, an active infection (or taking medication for an infection), conditions affecting both lower extremities and previous treatment that included fasciotomy, massage or Astym [16]. Bilateral involvement was reported in 60% to 90% of the time.

Each patient signed a consent form after explaining the scope, objectives, and value of the study, informing them about the right to refuse or withdraw at any time, and reassuring them about the confidentiality of information. Data coding assured anonymity. Patients allocated randomly into Astym and massage treatment groups by a blinded and an independent research assistant who opened sealed envelopes containing a computer-generated randomization card. No subjects dropped out of the study after randomization.

Participants were randomly assigned into two experimental groups (Group A) received ASTYM therapy (Figure 1) and the other group (Group B) received intermittent massage (effleurage and cross fiber frictions) (Figure 2) for 8 sessions over a four-week period healing [13-15]. Physiotherapy program for both groups included ice (20 minutes), ultrasound on the lower lateral leg (5 minutes 2 days/week), with an intensity of 1.5 w/cm2with a frequency of 1 Hz continuous mode of application [11], stretching before exercise (calf muscles, anterior tibial group) and strengthening exercises (dorsiflexors and evertors, core stability exercises). Exercise programs were individually designed based on the patient’s examination and clinical findings. Subjects were blinded to whether they received the Astym® treatment or massage treatment intervention. After a 5-minute warm-up on a lower leg, Astym® treatment starts. End-feel assessment is an integral part of the examination as a hard end feel may be indicative of joint dysfunction or soft tissue restriction and can help guide intervention.

The study outcomes were measured before starting the treatment program and at the end of the program. A subjective pain sensation as a primary outcome measure was assessed by scoring in the 10-point visual analog rating scale; zero indicates no pain while 10 represents the worst pain. While the secondary outcomes were the ankle dorsiflexion, lower extremity functional scale [17]. Measuring the range of motion of dorsiflexion as an objective measure is the third outcome.

Sample size and Statistical analysis

Sample size calculation prior to the study using G*POWER statistical software (version 3.1.9.2; Franz Faul, Universitat Kiel, Germany) reflected that the appropriate sample size for this study was n=30, which gave observed power equal to 0.85. Calculations made using alpha = 0.05, beta = 0.15 and large effect size. For comparing subject characteristics between both groups t-test was conducted. Then, normal distribution of data was checked using the Shapiro-Wilk test for all variables, hence Levene’s test for homogeneity of variances was conducted to test the homogeneity between groups. Mixed MANOVA was performed to compare within and between groups effects of treatment on VAS, functional scale and dorsiflexion ROM between the group A and B as between group comparison and between pre and post-treatment in each group as within-group comparison. Partial squared eta was considered as the effect size. Post-hoc tests using the Bonferroni correction were carried out for subsequent multiple comparisons. The level of significance for all statistical tests was set at p < 0.05. All statistical analysis was conducted through the statistical package for social studies (SPSS) version 19 for Windows (IBM SPSS, Chicago, IL, USA).

Results

A total of 30 patients with chronic exertional anterior compartment syndrome pain enrolled in experimental and control groups (fig 3). Table 1 showed the subject characteristics of both groups. There was no significant difference between both groups with respect to the mean age, weight, height and BMI (p < 0.05). Also, there was no significant difference in blood pressure between groups (p < 0.5). Mixed MANOVA revealed that there was a significant interaction of treatment and time (Wilks’ Lambda = 0.64; F (4,25) = 3.48, p = 0.02, η2= 0.35). There was a significant main effect of time (Wilks’ Lambda = 0.06; F (4,25) = 93.62, p = 0.0001, η2= 0.93). There was no significant main effect of treatment (Wilks’ Lambda = 0.8; F (4,25) = 1.51, p = 0.22, η2 = 0.19). Table 2 showed descriptive statistics of VAS, lower extremity functional scale and dorsiflexion ROM as well as the significant level of comparison between groups and the significant level of comparison between pre and post-treatment in each group. There was no significant difference between the Group A and B in all variables pre-treatment (p > 0.05). Post-treatment there was a significant increase in lower extremity functional scale, right and left dorsiflexion ROM of Group A compared with that of the group (p > 0.05). Also, there was a significant decrease VAS of Group A compared with that of Group A post-treatment (p > 0.05). There was a significant increase in the lower extremity functional scale, right and left dorsi flexion ROM post treatment compared with pre-treatment in both groups (p = 0.0001). However, both groups showed a significant decrease in VAS post-treatment compared with that pre- treatment (p = 0.0001).

Adverse events

There are no adverse events occurred during the study.

Discussion

The Osseo-fascial boundary of the anterior compartment could limit the swelling of the muscle in chronic exertional anterior compartment syndrome. Fronek et al. [5] stated the presence of different mechanisms explaining the cause of this swelling.The use of a non-operative approach to the treatment of CECS would be valuable when it could prevent the risk, complications, and costs related to surgical intervention. This study designed to compare the effects of Astym therapy and massage in patients withbilateral chronic exertional anterior compartment syndrome of the lower leg. Fronek et al. stated that the nonsurgical treatment of CECS was successful when it could prevent patients with CECS to develop an acute compartment syndrome through the ischemic producing mechanism as many acute cases with acute compartment syndrome superimposed on CECS.

There was a diversity of mechanisms precipitating muscle hypertrophy within a confined Osseo-fascial boundary. Canale et al. [18] postulated that isometric or isotonic muscle contraction, vigorous exercises through increasing muscle mass by 20%. While Brown et al. [19] explained that increased muscle blood volume was the causative mechanism. Sejersted [20] found that the compression of the interstitial fluid is another mechanism. Jacobbson et al. [21] revealed that post-exercise muscle swelling increases blood flow and fiber swelling which may reach up to 20 times more than the resting level and fluid retention. Therefore, the increase of intramuscular pressure could diminish venous return leading to capillary occlusion and consequently compartment ischemia. The ultimate Intracompartmental pressures render the muscle in the non-contractile state where the balance between intramuscular compartment pressure and the microvascular pressure determined the patency of perfusion and hence, the oxygen supply of the muscle. Scheer et al. [22] emphasized the importance of treatment type in providing tactile pressures and shear forces to stimulate tissue healing at a cellular level.

Results of the current study revealed that Astym had more pronounced effect than massage in the treatment of ant-CECS. Collins et al. [23] demonstrated that patients with CECS may have some improvement following manual therapy [24-26].Sevier et al. [24], Laudner et al. [25] and Loghmani et al. [26] showed that Astym therapy could induce leakage from dysfunctional capillaries that ends up with increased fibroblast activity, macrophage phagocytosis, and local growth factors released that enhanced more fibroblast recruitment, reduced pain and restored function in people with musculoskeletal pathologies including epicondylosis.

The study results are consistent with the conclusion of Mc Cormack [27]who revealed significant pain reduction with the improvement of the lower limb function in the patient with high hamstring tendinopathy. The finding of Chughtai [28] proved a significant gain in knee joint ROM in patient who underwent Astym therapy compared with standardized physical therapy program following total knee arthroplasty. Chughtai [28]and Paker [29] proved that the joint pain and ROM might be related to effects of Astym on the biomechanical properties of the injured tissues with enhancement of blood flow and possible angiogenesis in the vicinity of these tissues

Patients with Ant-CECS might have transient or permanent low-grade foot drop as a result of the weakness of dorsiflexors with or without paresthesia on the dorsum of the foot. Rest or cessation of exercise relieved symptoms by 85% of athletes. The involved muscles may be tender or not relying on whether the patient is symptomatic or not. Findings of Detmer [30] revealed that the majority of patients were symptomatic. Findings of our study contradict with Diebal 2012 [3] as they confirmed the failure of non-surgical management (anti-inflammatory drugs, stretching, prolonged rest, decreasing or avoiding the problematic activity, orthotics, and massage) to address symptoms.

There are some limitations of the current study that should be recognized. The main limitation of our study was the fact that the conventional program, which was prescribed for the two groups, is already effective by itself. Therefore, the results of this study failed to prove the independent effects of Astym or massage therapy alone. In addition, this study only reported the short-term effects of ASTYM or massage, so we cannot generalize about long-term effects.

Conclusion

Pain and disability typically associated with ant-CECS reduced greatly after the treatment of ant-CECS using ASTYM or massage. ASTYM treatmentis more effective than massage therapy in reducing pain, improving the overall functional level and ankle dorsiflexion for patients with ant-CECS.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.

Funding: None

Conflict of interest

None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.

References

1. Tucker AK. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskelet Med. 2010; 3(1-4): 32-37.

2. Van Zantvoort APM, de Bruijn JA, Winkes MB, Hoogeveen A R, Teijink J A W, Scheltinga M R. Role of repeat muscle compartment pressure measurements in chronic exertional compartment syndrome of the lower leg. Orthop J Sports Med. 2017; 5(6): 1-6.

3. Diebal AR, Gregory R, Alitz C, Gerber JP. Forefoot running improves pain and disability associated with chronic exertional compartment syndrome. Am J Sports Med. 2012; 40(5): 1060-7.

4. Franklyn-Miller A, Roberts A, Hulse D, Foster J. Biomechanical overload syndrome: defi ning a new diagnosis. Br J Sports Med. 2012:1-3.

5. Fronek J, Mubarak SJ, Hargens AR, Lee YF, Gershuni DH, Garfin SR, et al. Management of chronic exertional anterior compartment syndrome of the lower extremity. Clin Orthop Relat Res. 1987; (220): 217-27.

6. Howard JL, Mohtadi NG, Wiley JP. Evaluation of outcomes in patients following surgical treatment of chronic exertional compartment syndrome in the leg. Clin J Sport Med. 2000; 10: 176–84.

7. Roscoe D, Roberts A. Intramuscular Compartment Pressure Measurement in Chronic Exertional Compartment Syndrome: New and Improved Diagnostic Criteria. Am J Sports Med. 2014; 20(12): 1-7.

8. Frontera W. Essentials of physical medicine and rehabilitation. Canada: Hanley and Belfus; 2002. p. 256–61.

9. Schepsis AA, Fitzgerald M, Nicoletta R. Revision surgery for exertional anterior compartment syndrome of the lower leg: technique, findings, and results. Am J Sports Med. 2005; 33(7): 1040-7.

10. Rajasekaran S, Hall MM. Nonoperative Management of Chronic Exertional Compartment Syndrome: A Systematic Review. Curr sports Med Rep. 2016;15(3): 191-8

11. Gill CS, Halstead ME, Matava MJ. Chronic exertional compartment syndrome of the leg in athletes: evaluation and management. Phys Sports Med. 2010; 38(2): 126-32.

12. Matsen FA, Winquist RA, Krugmire RB. Diagnosis and management of compartmental syndromes. J Bone Joint Surg. 1980; 62(2): 286-91.

13. Pandit A. Study of Complication Profile in Type 2 Diabetes Mellitus Patients at First Visit to Tertiary Care Clinic in Central Indian Context. IJHSR. 2016; 6(6): 46-9.

14. De Oliveira RR, Lemos A, de Castro Silveira PV, Da Silva RJ, De Moraes SR. Alterations of tendons in patients with diabetes mellitus: a systematic review. Diabetic Medicine. 2011 ;28(8): 886-95.

15. Tajik A, Shokri E, Ghanbari A. The Effect of Kinesio Taping of Quadriceps Muscle on the Balance of Non-Elite Football Players After a Local Fatigue Induced Protocol. J Rehab Sci Res. 2016;16; 3(1): 5-10.

16. Kivlan BR, Carcia1 CR, Clemente1 FR, Phelps AL, Martin RL. The effect of Astym® therapy on muscle strength: a blinded, randomized, clinically controlled trial. BMC Musculoskelet Disord. 2015; 16: 325

17. Binkley JM, Stratford PW. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys Ther. 1999; 79(4): 371-83.

18. Canale S. Campbell’s operative orthopaedics. 9th ed. Philadelphia: Elsevier; 1998. p. 405–1411.

19. Brown Am, Stubbs DW. Medical physiology. New York: Wiley medical. 1983; p.284

20. Sejersted OM, Hargens AR. Regional pressure and nutrition of skeletal muscles during isometric contraction. In Hargens A.R (ed.): Tissue nutrition and viability. New York:Springer-Verlag. 1996; p. 263-83

21. Jacobbson S, Kjellmer I. Flow and protein content of lymph in a resting and exercising skeletal muscle. Acta Physiol, Scand. 1964; 60: 278.

22. Scheer NA, Alstat LR, Van Zant RS. Astym therapy improves bilateral hamstring flexibility and Achilles tendinopathy in a child with cerebral palsy: a retrospective case report. Clin Med Insights: Case Reports. 2016; 9:95-8.

23. Collins CK, Gilden B. A non-operative approach to the management of chronic exertional compartment syndrome in a triathlete: A case report. Intern J Sport phys. 2016; 11(7):1160-76.

24. Sevier TL, Stegink-Jansen CW. Astym treatment vs. eccentric exercise for lateral elbow tendinopathy: a randomized controlled clinical trial. Peer J. 2015; 19: 3:DOI: 10.7717/peerj.967. 

25. Laudner K, Compton BD, McLoda TA, Walters CM. Acute effects of instrument assisted soft tissue mobilization for improving posterior shoulder range of motion in collegiate baseball players. Int J Sports Phys Ther. 2014; 9(1): 1.

26. Loghmani MT, Warden SJ. Instrument-assisted cross fiber massage increases tissue perfusion and alters microvascular morphology in the vicinity of healing knee ligaments. BMC Complement Altern Med. 2013; 13(1): 240.

27. McCormack JR. The management of bilateral high hamstring tendinopathy with ASTYM® treatment and eccentric exercise: a case report. J Man Manip Ther. 2012; 20(3): 142–6.

28. Chughtai M, McGinn T, Bhave A, Khan S, Vashist M, Khlopas A, et al. Innovative multimodal physical therapy reduces incidence of repeat manipulation under anesthesia in post–total knee arthroplasty patients who had an initial manipulation under anesthesia. J Knee Surg. 2016; 29(8): 639-44.

29. Packer J D, Day MS, Nguyen JT, Hobart SJ, Hannafin JA, Metzl J D. Functional outcomes and patient satisfaction after fasciotomy for chronic exertional

compartment syndrome. Am J Sports Med. 2013; 41(2): 430-6.

30. Detmer DE, Sharpe K, Sufit RL, Girdley FM. Chronic compartment syndrome: diagnosis, management, and outcomes. Am J Sports Med. 1985; 13:162-70.

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Ragab IM, Ali OI, Hamada HA, Radwan R, Mosaad D. ASTYM versus massage in the treatment of chronic exertional anterior compartment syndrome of the lower leg: a randomized controlled trial. Ann Clin Anal Med 2019;10(4): 470-4

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