Original Article
Transcutaneous Electrical Nerve Stimulation Reduces Post-Thoracotomy Ipsilateral Shoulder Pain. A Prospective Randomized Study
La estimulación nerviosa transcutánea disminuye el dolor del hombro ipsilateral postoracotomía. Estudio prospectivo aleatorizado
Pedro Esteban González
, Nuria M. Novoa, Gonzalo Varela
Corresponding author
Servicio de Cirugía Torácica, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
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A Prospective Randomized Study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "621" "paginaFinal" => "626" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Pedro Esteban González, Nuria M. Novoa, Gonzalo Varela" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Pedro" "apellidos" => "Esteban González" "email" => array:1 [ 0 => "peg@usal.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Nuria M." 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Estudio prospectivo aleatorizado" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1149 "Ancho" => 1194 "Tamanyo" => 76852 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow chart of patient disposition.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Post-operative pain increases patient suffering, and can cause physiopathological changes that can increase the rate of post-operative complications, delay recovery, and increase hospital costs. The first consensus document on post-operative pain published in Spain in 2005<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> defines post-operative pain as pain that appears as a consequence of the surgical procedure. However, it is also often refered as pain occuring in a surgical patient caused by previous disease, the surgical procedure itself, or a combination of both.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Post-thoracotomy shoulder pain is typically ipsilateral, periarticular, diffuse, and independent from pain caused by the thoracotomy. The origin has not yet been determined, but it has been associated with direct muscle damage caused by the thoracotomy, pleural irritation produced by the surgical procedure, and reactivation of previous joint injuries.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> Up to 75% of thoracotomy patients report moderate to severe pain, despite receiving epidural analgesia in the immediate post-operative period.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several different methods are available for pain control, consisting mainly of pharmacological treatment, nerve blocks, and other non-pharmacological techniques, such as relaxation, acupuncture, hypnosis, and transcutaneous electrical nerve stimulation (TENS). Nonetheless, despite more-or-less standardized use of these analgesic resources, particularly pharmacological treatment, patients’ immediate post-operative quality of life continues to be diminished by shoulder pain.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this single-blind, randomized study, we investigated the efficacy of TENS in reducing post-thoracotomy ipsilateral shoulder pain and improving the functional recovery of the joint.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design</span><p id="par0025" class="elsevierStylePara elsevierViewall">This was a single-blind, randomized study conducted in patients undergoing muscle-sparing axillary thoracotomy for lung resection in the Thoracic Surgery Department of the University of Salamanca.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Population</span><p id="par0030" class="elsevierStylePara elsevierViewall">A total of 50 patients scheduled for lung resection between February 2013 and October 2013 were prospectively included in this study (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The cases were selected according to the following criteria: patients scheduled for major lung resection who did not require wall resection, who underwent muscle-sparing axillary resection. Exclusion criteria included: previous chemotherapy or radiation induction treatment, previous joint disease that would impede normal shoulder joint mobility and contraindications for the use of TENS, for example, patients with pacemakers or surgical wound infection. Patients were selected by the department's surgeons during the outpatient consultation held prior to admission. The hospital ethics committee approved the study and all patients signed informed consent for participation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Before anesthesia was induced, an epidural catheter for intraoperative and post-operative analgesia was placed at D5–D7 level. Analgesia was administered in the form of ropivacaine 0.2%, 6–8<span class="elsevierStyleHsp" style=""></span>ml/h in continuous infusion via the catheter, combined with administration every 8<span class="elsevierStyleHsp" style=""></span>h of paracetamol and a non-steroidal anti-inflammatory drug (NSAID) (ibuprofen) or metamizole, depending on the patient's possible allergic status. The epidural catheter was removed 48<span class="elsevierStyleHsp" style=""></span>h after the intervention. Some patients received oral tramadol 50<span class="elsevierStyleHsp" style=""></span>mg every 8 or 12<span class="elsevierStyleHsp" style=""></span>h after catheter removal.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Positioning of the patient on the table was standardized: lateral decubitus, resting on the non-affected side, thus procuring a cleavage zone at the level of the xiphoid apophysis; the resting arm was placed on an arm board, with the wrist flexed and secured in a safe position; the arm on the side of the intervention was abducted at 90° with the elbow flexed at 90°–100°. This arm was supported by straps once straining of the shoulder was ruled out and correct positioning of the hand was ensured in order to prevent radial nerve injuries (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">After the surgical procedure, all patients were extubated on the operating table and transferred to the post-operative recovery room, where post-operative physiotherapy exercises were started, as proposed by Varela et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> Twenty-four hours after the procedure, all patients were out of bed, walking and performing 15<span class="elsevierStyleHsp" style=""></span>min of aerobic exercise on the unloaded cycle ergometer twice a day.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Materials</span><p id="par0050" class="elsevierStylePara elsevierViewall">Apex<span class="elsevierStyleSup">®</span> DIGI-COMBO equipment was used for this study. These devices provide an asymmetric biphasic waveform at a frequency of 80<span class="elsevierStyleHsp" style=""></span>Hz and a pulse width of 120<span class="elsevierStyleHsp" style=""></span>μs. Four reusable 50<span class="elsevierStyleHsp" style=""></span>cm×50<span class="elsevierStyleHsp" style=""></span>cm self-adhesive, latex-free carbon film electrodes with long-lasting gel (Key Life S.L.) were placed as follows: 1 electrode on either side of the surgical incision (2<span class="elsevierStyleHsp" style=""></span>cm from the wound) and 2 on the shoulder, one on the anterior aspect and the other on the posterior aspect (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Randomization and Treatment Protocol</span><p id="par0055" class="elsevierStylePara elsevierViewall">On the day of admission to the hospital for the intervention, patients were assigned to the experimental or control group according to a series of random numbers generated by Excel<span class="elsevierStyleSup">®</span>. The numbers were retrieved in such a way that the assignation of the following patient was unknown until the time of admission.</p><p id="par0060" class="elsevierStylePara elsevierViewall">During the study period, patients followed the same general perioperative physiotherapy protocol,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> which does not include specific active-assisted mobilization of the shoulder. The TENS electrostimulation protocol for both groups consisted of 30-min sessions every 8<span class="elsevierStyleHsp" style=""></span>h, starting on the day following surgery. Patients in the control group were treated with a device that was identical to the standard device but manipulated to disable the pulse. The study physiotherapist was responsible for pre- and post-operative procedures and for placing the TENS electrodes.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Study Variables</span><p id="par0065" class="elsevierStylePara elsevierViewall">The following demographic variables were recorded to characterize the study population: age, sex, weight and height.</p><p id="par0070" class="elsevierStylePara elsevierViewall">At the time of admission, all patients underwent an initial evaluation, consisting of a study of the affected shoulder. Range of motion, internal and external rotation, and abduction were measured by goniometer, and pain intensity for each movement was determined on a 100<span class="elsevierStyleHsp" style=""></span>mm visual analog scale (VAS: range 0–10).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Starting 24<span class="elsevierStyleHsp" style=""></span>h after surgery, pain, mobility of the affected shoulder, according to goniometer, and VAS measurements were recorded at the same time every day, during the first 3 days. Study variables included shoulder pain and the degrees of flexion, internal and external rotation and abduction recorded for the shoulder ipsilateral to the surgery.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data Analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">A descriptive, comparative analysis was performed using parametric and non-parametric tests of demographic and study variables, as appropriate, after analyzing for normal distribution. Comparative studies were performed using parametric or non-parametric tests depending on the distribution of the variable under study. Statistical analysis was performed using Stata 12.1 software.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 50 patients was included, 25 in each study group. The demographic characteristics of each group were statistically similar (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). It is interesting to note that 80% of patients in the series were men. All 50 patients completed the treatment protocol and none suffered any complications, intolerance or other problems that might have required suspension of the TENS intervention.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Pain and shoulder mobility after the intervention were similar in both groups (<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>), except for pain intensity on flexion on post-operative days 2 and 3, which was significantly less in patients in the experimental group (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">In this study, we investigated shoulder pain relief and dynamic functional recovery analyzing shoulder joint movements: flexion, abduction and external and internal rotation. The results indicated that TENS is only useful from post-operative day 2 onwards, and specifically for flexion movements. However, we found that the reduction in the pain scale for this movement was clinically relevant, since it speeds up recovery of normal upper limb activity necessary for a multitude of activities of daily living.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The origin of post-thoracotomy pain has yet to be fully clarified. It has been related with various mechanisms and specific treatments have been suggested for each of these. The different theories can be grouped into 2 contrasting hypotheses: in one, post-thoracotomy pain is associated with pain from pleural inflammation mediated by the phrenic nerve<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2,5–8</span></a>; in the other, it is the result of perioperative damage or reactivation of a previous shoulder injury.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2,9–12</span></a> Pain mediated by the phrenic nerve is a result of the surgical procedure, therefore, epidural analgesia should be effective. Pain associated with joint lesions, however, should not respond to epidural analgesia but to NSAIDs or other medical intervention. In our study, all patients recieved epidural analgesia and anti-inflamatory drugs. Despite these inteventions patients reported pain on mobilization of the shoulder. The muscles of the chest wall (latissimus dorsi, serratus anterior, and pectoral muscles) play an important role in the mobility of the arm, so there is little doubt that any insult to this region will have a significant impact on the degree of pain and functional limitation of the shoulder.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> Bearing in mind the type of thoracotomy performed in our study, changes in functionality can only be associated with injury to the serratus anterior, which inserts into and stabilizes the scapula and is essential for upper limb flexion. We found that TENS was effective in relieving the pain caused by this movement. This analgesia technique is known to work by inhibiting the central transmission of nociceptive impulses sent by slow unmyelinated fibers using the overstimulation produced by a faster-traveling impulse transmitted via myelinated fibers. This is known as the gate-control theory.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The level of pain reported by patients may occasionally be high, since it ranges between 0 and 6, even on post-operative day 3. Although it mainly occurs on flexion, some patients report pain, albeit of lower intensity, when performing other movements (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). This pain is unrelated to muscle injury occurring during surgery, so must be attributable to one of the other proposed theories.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Several studies have evaluated the effectiveness of TENS in pain relief. Many of these were designed to evaluate waning requirements for analgesia in the presence of musculoskeletal pain. Johnson and Martinson<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> recently published a meta-analysis on the efficacy of TENS in reducing chronic musculoskeletal pain at any site. They looked at 38 studies with a total of 1227 patients and found a very significant reduction in pain (<span class="elsevierStyleItalic">P</span><.0005) in individuals who received TENS compared with placebo. Singling out studies on post-thoracotomy pain, we also find evidence<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">16–20</span></a> supporting the efficacy of TENS in reducing pain in the affected hemithorax, a reduced need for analgesia, and improvements in other parameters, such as respiratory function. Although most studies show benefits, others have reported little effect and results similar to other treatments. Stubbing and Jellicoe<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> did not find statistically significant differences in the need for oral analgesia or in peak-flow measurements between the experimental groups receiving TENS and control groups. Benedetti et al.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> conducted a study in 324 patients undergoing surgical procedures of different types. They concluded that TENS was not effective in the group that underwent posterolateral thoracotomy, but that it was useful in other thoracic procedures, such as median sternotomy and video-assisted thoracoscopy causing mild to moderate pain. Similarly, Freynet and Falcoz<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> subsequently found that TENS alone was not effective as pain control after posterolateral thoracotomy, but that it was very useful in the management of pain after muscle-sparing mini-thoracotomy or after video-assisted procedures. These authors reported a reduction in need for narcotic painkillers, improvements in forced vital capacity parameters, and improved grades of chest and shoulder mobilization.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Despite an exhaustive search, we were unable to locate any reports specifically analyzing the efficacy of TENS in post-thoracotomy shoulder pain, and we were unable to compare our results with those of other published studies. From this, we can conclude that this is the first study of its kind. We would like to emphasize one aspect of our study in particular: the range of joint mobility observed among our patients remains largely unchanged after post-operative day 1. Reeve et al.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> in a randomized study analyzed the influence of perioperative physiotherapy on shoulder mobilization, among other parameters. Patients in the experimental group carried out physiotherapy exercises specifically targeting the shoulder as part of a wider intervention protocol. Exercises were started before surgery and continued into the immediate post-operative period, and patients were instructed to continue them after discharge. After analyzing the data, the authors concluded that the inclusion of a targeted physiotherapy program improves general pain and specifically shoulder pain, but they found no differences between the groups in range of movement or strength of the upper limb, or overall quality of life. Comparing their tables with our data, we found that the range of movement of their patients was remarkably more limited than ours (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). We can offer no clear explanation for this finding, other than that it may be related with the general analgesic regimen used in our study; Reeve et al.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> do not specify the given analgesia.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Our study has some limitations that should be mentioned. Firstly, our sample size is small. However, this is a randomized, patient-blinded study, and as the groups are similar, the conclusions are very robust. The second limitation is a slight variability in the positioning of patients on the operating table. Variations in this variable are inevitable, unless the same person positions the patient every time, and this may affect the degree of pain experienced by the patient in the post-operative period. The third limitation to take into account is subjectivity in the perception and manifestation of pain. This issue may not be fully resolved but the visual analog scale for pain is a widely validated method.</p><p id="par0125" class="elsevierStylePara elsevierViewall">To conclude, the use of TENS reduces pain on flexion of the shoulder in patients undergoing axillary thoracotomy, and this method has now been included in the post-operative management of our patients. Further research could explore whether this outcome affects patients’ post-operative quality of life, since shoulder flexion is involved in the majority of activities of daily living.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of Interests</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors state that they do not have any conflict of interest that could cause any bias in relation to this work.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres587059" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec602834" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres587058" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec602835" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Population" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Materials" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Randomization and Treatment Protocol" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Study Variables" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Data Analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of Interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-07-27" "fechaAceptado" => "2014-11-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec602834" "palabras" => array:4 [ 0 => "Post-thoracotomy shoulder pain" 1 => "Transcutaneous electrical nerve stimulation" 2 => "Shoulder range of motion" 3 => "Muscle-sparing thoracotomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec602835" "palabras" => array:4 [ 0 => "Dolor de hombro" 1 => "Estimulación eléctrica nerviosa transcutánea" 2 => "Rango de movilidad del hombro" 3 => "Toracotomía lateral sin sección muscular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The patient's position during an axillary thoracotomy can cause postoperative pain and decrease mobility of the ipsilateral shoulder. In this study, we assessed whether the implementation of a standardized analgesia program using transcutaneous electrical nerve stimulation (TENS) decreases local pain and improves ipsilateral shoulder mobility.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Randomized, single-blind, single-center clinical trial of 50 patients who had undergone anatomical lung resection via axillary muscle-sparing thoracotomy. Patients were treated with TENS devices for 30<span class="elsevierStyleHsp" style=""></span>min every 8<span class="elsevierStyleHsp" style=""></span>h, beginning on postoperative day 1. Pain and mobility of the affected limb were recorded at the same time on postoperative days 1 through 3. A visual analog scale was used for pain assessment and shoulder mobility was assessed with a goniometer. Results were compared using a non-parametric test.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Twenty-five patients were randomized to each group. Mean age of the control group was 62.7±9.3 years and 63.4±10.2 years in the experimental group. Shoulder mobility parameters were similar in both groups on all postoperative days. However, pain during flexion significantly decreased on day 2 (<span class="elsevierStyleItalic">P</span>=.03) and day 3 (<span class="elsevierStyleItalic">P</span>=.04) in the experimental group.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The use of TENS decreases pain from shoulder flexion in patients undergoing axillary thoracotomy for pulmonary resection.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La posición del paciente durante la toracotomía axilar puede producirle alteraciones postoperatorias por dolor y disminución de la movilidad del hombro. En este estudio pretendemos evaluar si la aplicación de un programa estandarizado de analgesia mediante estimulación eléctrica transcutánea (TENS) disminuye el dolor e incrementa la recuperación de la movilidad de la articulación del lado intervenido en estos pacientes.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Ensayo clínico monocéntrico aleatorizado simple ciego, en pacientes sometidos a resección pulmonar por minitoracotomía axilar sin sección muscular. Los pacientes fueron tratados durante 30<span class="elsevierStyleHsp" style=""></span>min cada 8<span class="elsevierStyleHsp" style=""></span>h con dispositivos TENS, desde el día siguiente a la intervención. Se realizaron registros del dolor y movilidad del miembro afectado todos los días a la misma hora durante los primeros 3 días postoperatorios. Para evaluar el dolor se utilizó una escala visual analógica, y para valorar la movilidad del hombro, un goniómetro. Los valores obtenidos se compararon entre los 2 grupos mediante un test no paramétrico.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se han incluido 50 casos, 25 en el grupo experimental y 25 en el grupo control. La edad media del grupo control es de 62,76<span class="elsevierStyleHsp" style=""></span>años, y la del grupo expuesto, de 63,4<span class="elsevierStyleHsp" style=""></span>años. No se han obtenido diferencias significativas en la movilidad del hombro en ninguno de los días postoperatorios. El dolor a la flexión del hombro durante los días segundo (<span class="elsevierStyleItalic">P</span>=0,03) y tercero (<span class="elsevierStyleItalic">P</span>=0,04) fue significativamente menor en los pacientes del grupo experimental.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El uso de TENS disminuye el dolor a la flexión del hombro en pacientes sometidos a toracotomía axilar para resección pulmonar.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Esteban González P, Novoa NM, Varela G. La estimulación nerviosa transcutánea disminuye el dolor del hombro ipsilateral postoracotomía. Estudio prospectivo aleatorizado. Arch Bronconeumol. 2015;51:621–626.</p>" ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1149 "Ancho" => 1194 "Tamanyo" => 76852 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow chart of patient disposition.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1331 "Ancho" => 995 "Tamanyo" => 202919 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Standard positioning of patient in the operating room.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1359 "Ancho" => 750 "Tamanyo" => 207526 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">TENS placement.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1551 "Ancho" => 2178 "Tamanyo" => 94822 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Comparative graphic showing distribution of pain values on shoulder flexion in the 3 post-operative days.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control Group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TENS Group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Males \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Height (m) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Body mass index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.97 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab958598.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Compared using the Student's <span class="elsevierStyleItalic">t</span>-test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Demographic Data of Study Patients.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pain Intensity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control Group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TENS Group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Flexion on admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Flexion day 1 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Flexion day 2 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0–7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Flexion day 3 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Abduction on admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Abduction day 1 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Abduction day 2 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0–5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Abduction day 3 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Internal rotation on admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Internal rotation day 1 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Internal rotation day 2 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Internal rotation day 3 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0–3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.75 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab958599.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Compared using the Mann–Whitney <span class="elsevierStyleItalic">U</span> test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Post-Thoracotomy Pain on Moving the Ipsilateral Shoulder on Day of Admission and on the First 3 Post-Operative (PO) Days (Mean and Range).</p>" ] ] 6 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Compared using Mann–Whitney <span class="elsevierStyleItalic">U</span> test. All comparisons were statistically insignificant (<span class="elsevierStyleItalic">P</span>>.9).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control Group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TENS Group \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Degrees of flexion on admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">180 (180–180) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">180 (180–180) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Flexion day 1 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">180 (100–180) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">180 (160–180) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Flexion day 2 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">180 (150–180) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">180 (160–180) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Flexion day 3 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">180 (180–180) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">180 (160–180) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Degrees of external rotation on admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (90–90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (90–90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">External rotation day 1 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (90–90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (85–90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">External rotation day 2 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (80–90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (90–90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">External rotation day 3 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (85–90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (90–90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Degrees of internal rotation on admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (85–90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (90–90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Internal rotation day 1 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (80–90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (85–90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Internal rotation day 2 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (85–90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (85–90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Internal rotation day 3 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (85–90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (85–90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Degrees of abduction on admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (120–120) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (120–120) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Abduction day 1 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (100–120) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (80–120) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Abduction day 2 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (80–120) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (100–120) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Abduction day 3 PO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (100–120) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (100–120) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab958597.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Degrees of Mobility Achieved in Shoulder Ipsilateral to Thoracotomy on Day of Admission and 3 Initial Post-Operative (PO) Days (Mode and Range).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 3 | 10 |
| 2024 October | 47 | 29 | 76 |
| 2024 September | 47 | 31 | 78 |
| 2024 August | 84 | 51 | 135 |
| 2024 July | 51 | 34 | 85 |
| 2024 June | 68 | 34 | 102 |
| 2024 May | 96 | 28 | 124 |
| 2024 April | 53 | 45 | 98 |
| 2024 March | 51 | 14 | 65 |
| 2024 February | 46 | 24 | 70 |
| 2023 March | 15 | 3 | 18 |
| 2023 February | 54 | 22 | 76 |
| 2023 January | 51 | 41 | 92 |
| 2022 December | 55 | 29 | 84 |
| 2022 November | 64 | 20 | 84 |
| 2022 October | 54 | 33 | 87 |
| 2022 September | 99 | 33 | 132 |
| 2022 August | 61 | 35 | 96 |
| 2022 July | 62 | 53 | 115 |
| 2022 June | 36 | 27 | 63 |
| 2022 May | 79 | 46 | 125 |
| 2022 April | 50 | 32 | 82 |
| 2022 March | 66 | 55 | 121 |
| 2022 February | 45 | 41 | 86 |
| 2022 January | 77 | 50 | 127 |
| 2021 December | 68 | 46 | 114 |
| 2021 November | 73 | 51 | 124 |
| 2021 October | 103 | 48 | 151 |
| 2021 September | 137 | 44 | 181 |
| 2021 August | 59 | 72 | 131 |
| 2021 July | 50 | 22 | 72 |
| 2021 June | 45 | 47 | 92 |
| 2021 May | 57 | 40 | 97 |
| 2021 April | 174 | 83 | 257 |
| 2021 March | 79 | 32 | 111 |
| 2021 February | 70 | 25 | 95 |
| 2021 January | 54 | 14 | 68 |
| 2020 December | 39 | 31 | 70 |
| 2020 November | 37 | 32 | 69 |
| 2020 October | 38 | 19 | 57 |
| 2020 September | 39 | 24 | 63 |
| 2020 August | 32 | 17 | 49 |
| 2020 July | 38 | 29 | 67 |
| 2020 June | 29 | 8 | 37 |
| 2020 May | 46 | 24 | 70 |
| 2020 April | 78 | 30 | 108 |
| 2020 March | 32 | 18 | 50 |
| 2020 February | 47 | 21 | 68 |
| 2020 January | 43 | 32 | 75 |
| 2019 December | 42 | 22 | 64 |
| 2019 November | 56 | 25 | 81 |
| 2019 October | 37 | 17 | 54 |
| 2019 September | 36 | 26 | 62 |
| 2019 August | 31 | 20 | 51 |
| 2019 July | 37 | 30 | 67 |
| 2019 June | 58 | 25 | 83 |
| 2019 May | 40 | 37 | 77 |
| 2019 April | 97 | 67 | 164 |
| 2019 March | 50 | 36 | 86 |
| 2019 February | 44 | 37 | 81 |
| 2019 January | 65 | 36 | 101 |
| 2018 December | 40 | 26 | 66 |
| 2018 November | 56 | 38 | 94 |
| 2018 October | 48 | 32 | 80 |
| 2018 September | 39 | 16 | 55 |
| 2018 May | 22 | 1 | 23 |
| 2018 April | 49 | 9 | 58 |
| 2018 March | 22 | 20 | 42 |
| 2018 February | 31 | 10 | 41 |
| 2018 January | 14 | 7 | 21 |
| 2017 December | 32 | 10 | 42 |
| 2017 November | 32 | 7 | 39 |
| 2017 October | 23 | 7 | 30 |
| 2017 September | 24 | 14 | 38 |
| 2017 August | 27 | 11 | 38 |
| 2017 July | 18 | 8 | 26 |
| 2017 June | 39 | 18 | 57 |
| 2017 May | 31 | 6 | 37 |
| 2017 April | 25 | 6 | 31 |
| 2017 March | 33 | 10 | 43 |
| 2017 February | 21 | 8 | 29 |
| 2017 January | 19 | 7 | 26 |
| 2016 December | 17 | 19 | 36 |
| 2016 November | 30 | 18 | 48 |
| 2016 October | 37 | 19 | 56 |
| 2016 September | 22 | 11 | 33 |
| 2016 August | 29 | 8 | 37 |
| 2016 July | 40 | 10 | 50 |
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