what do you need to know about lymphedema? · • avoid trauma/injury and reduce infection risk...
TRANSCRIPT
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• January 22, 2015
• Joy C. Cohn PT, CLT-LANA
Lymphedema Team Leader – Penn Therapy and Fitness
Philadelphia, PA
What Do You Need to Know about Lymphedema?
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Objectives
• Learn what Lymphedema is
• Learn about risk factors and how to reduce your risk
• Learn what treatments are available for Lymphedema
• Learn about new treatments
• Learn where you can find more information
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Lymphedema
• Not all swelling is Lymphedema!
• A hi protein edema characterized by progressive swelling and tissue thickening due to inflammation
• Primary vs. Secondary
– Secondary is caused by known damage to lymphatics/nodes: surgery, radiation, or infection in Breast CA
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Symptoms of Lymphedema
• Achiness
• Heaviness
• Fullness
• Trouble with fit of clothes or jewelry
• Odd sensations
• Obvious swelling
• Symptoms that last 7 days…..
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Staging of Lymphedema
Stage Pathology Signs/Symptoms
0 Local tissue thickening Lymphatic damage
No edema, subjective complaints possible
I Hi Protein Edema Local tissue thickening
Pitting Edema, reduced by elevation, +/- ‘pain of congestion’
II Extensive thickening Fat proliferation
Brawny, hard swelling, no reduction with elevation
III As in Stage II Like Stage II with added skin changes- hyperkeratosis and papillomas
Foldi 2003
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Breast Cancer Related Lymphedema
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Breast Lymphedema
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Lymphatic System
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Lymphatic System
• A ‘sewer’ system separate from our blood flow
• Drains the tissues just under the skin
• Major functions:
– Recycles proteins (big molecules)
– Important part of immune system for fighting infection and cancer
– Helps with fat digestion (big molecules)
• Drains along with veins back to the heart
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Lymph System- Regional Nodes
• Number 600-700 in body
• Widespread in body
• Concentrated at head/neck, in gut, and at ‘root’ of each limb-
– Armpit (axilla)
– Groin
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Lymph Nodes
• Filter and adjust the amount of lymphatic fluid
• Monitor for foreign materials: cancer cells, bacteria and viruses, other debris
• Add immune cells to the lymphatic fluid and blood: T cells and other lymphocytes to fight infection and disease
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What happens in Breast CA ?
• Surgery to Breast
– Lumpectomy
– Mastectomy
• Axillary Nodes are removed
– Axillary dissection (6-20 nodes)
– Sentinel Node biopsy (2-6 nodes)
• Radiation Therapy may be done
Axillary nodes
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Lymphatic Damage
• Removal of nodes = less ‘plumbing’ to drain fluid from the tissues
• Radiation causes fibrosis = ‘thickening’ of the tissues surrounding the drainage system leading to less drainage from the tissues
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What area of the body might swell?
• Breast on the same side
• Arm on the same side
• Front and Back of the chest on the same side
• No other area
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Risk of Developing Lymphedema
• 6-20% of women treated for Breast CA
• Approximately 1 in 5 Breast CA survivors
• Likely to develop in first 1-3 years after surgery
• BUT- risk is lifelong
• Risk is lower with Sentinel Node Biopsy-
– Less nodes removed
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Other Known Risk Factors
• Weight Gain after Diagnosis/Treatment
• Radiation
– Size of radiation field matters
• History of injury to at risk area
• History of infections after surgery/treatment
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Risk Reduction
Lymphedema
Position Paper on Risk Reduction Practices for Lymphedema- ‘Live Smart’ advice
Source: www. lymphnet.org Accessed: 1/16/15
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How can you reduce your risk of developing/worsening lymphedema?
• Lymphedema risk reduction practices include:
– Skin care
– Activity/lifestyle
– Avoiding limb constriction
– Compression garments (If appropriate)
– Avoiding extremes of temperature
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Skin Care
• Avoid trauma/injury and reduce infection risk – Keep arm clean and dry – Apply moisturizer daily to prevent chapping/chafing of
skin – Attention to nail care; do not cut cuticles – Protect exposed skin with sunscreen and insect
repellent – Use care with razors to avoid nicks and skin irritation
(shave armpit with electric razor) – If possible, avoid punctures such as injections and
blood draws
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Skin Care
• Wear gloves while doing activities that may cause skin injury
• If scratches/punctures to skin occur, wash with soap and water, apply antibiotics, and observe for signs of infection
• If a rash, itching, redness, pain, increased skin temperature and swelling, fever, or flu-like symptoms occur, contact your physician immediately
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Activity/lifestyle
• Gradually build up the duration and intensity of any activity or exercise
• Take frequent rest periods during activity to allow for limb recovery
• Monitor the extremity during and after activity for any change in size, shape, tissue, texture, soreness, heaviness, or firmness
• Maintain a healthy weight
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Avoid Limb Constriction
• If possible, never have blood pressure taken on the arm at risk
• Wear loose fitting clothing and jewelry
• Wear a well fitted bra- avoid underwires if possible and wear wide straps with pads if large breasted.
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A well fitted bra!
• Wide, supportive sides
• No Underwire
• Padded straps
• Cup sizes up to N!
www.elilausa.com
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Compression Garments
• Should be well fitting
• Support the limb with lymphedema for strenuous activity (e.g. weight lifting!)
• If you have lymphedema, wear a well fitting compression garment for air travel
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Extremes of Temperature
• Avoid exposure to extreme cold, which can be associated with rebound swelling, or chapping of skin.
• Avoid prolonged (> 15 minutes) exposure to heat, particularly hot tubs and saunas
• Avoid immersing limb in water temperatures above 102 degrees
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What should I do on a plane?
• If you have lymphedema: wear a well fitted compression sleeve AND glove or gauntlet
• If you do NOT have lymphedema: consult a therapist for advice
• NEVER wear just a sleeve on a plane- it can cause swelling in your hand!
• The risk of swelling starting during a plane flight is less an 0.5%
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What can you do if you develop lymphedema?
• Get evaluated by your doctor or lymphedema therapist.
• Earlier treatment results in faster response to treatment thereby decreasing the length of therapy.
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Training of Lymphedema Therapists
• See Position Paper from NLN
• Be sure your therapist meets these minimum requirements
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“I haven’t lifted anything that weighs more than 5 pounds
since my surgery”
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A MYTH!!!!!!
• A gallon of milk weighs 8 pounds
• What does you handbag weigh? ☺
• Absolutely NO research that supports avoiding exercise!
• A great deal of research supports exercise thru out cancer treatment and beyond
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Why is Exercise Important?
• It can help you maintain your weight after Breast CA
• It can help you reduce the fatigue you feel during and after your treatments
• It can reduce the risk of injury/overload when you need to use your arm
• It can contribute to reducing your risk of recurrence of CA
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Exercise Guidelines for Cancer Survivors
• “Avoid Inactivity”
• Survivorship timeframe: “from the time of diagnosis until the end of life” – National Coalition for Cancer Survivorship
• ACSM Roundtable on Exercise Guidelines for Cancer Survivors – Schmitz KH et al 2010
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Why is exercise important?
• It can reduce your risk of developing lymphedema or having it get worse if you have lymphedema
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Strength After Breast Cancer
• Based on a large clinical trial conducted at Penn – 154 survivors WITHOUT lymphedema
– 141 survivors WITH lymphedema
• Women who participated had these benefits: – 50% reduced likelihood of lymphedema worsening
– 70% reduced likelihood of lymphedema onset among women with 5 or more nodes removed
– Improved strength and energy
– Improved body image
– Reduced body fat
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Strength After Breast Cancer Physical Therapy program based on
PAL Trial
• 5-6 sessions to learn:
– Exercises
– Correct Form
– How to Progress
– Learning about lymphedema
– Usually covered by insurance
– Physician Referral recommended
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Guidelines for SAFE exercise From PAL Trial
• START Low, GO Slow
• Have a well rounded program
– Warm Up
– Flexibility Exs
– Core Exercises
– Upper Body Resistance Exs
– Lower Body Weightbearing Exs
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Guidelines for SAFE exercise From PAL Trial
• Learn how to exercise with good form from an exercise professional to avoid injury
• Learn how to progress resistance exercise correctly
• Don’t ignore a symptom that lasts 7 days
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How is Lymphedema Treated?
• Complete Decongestive Therapy (CDT)
• Compression Pumps
• Surgery
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Treatment of Lymphedema
Lasinski BB et al: A Systematic Review of
the Evidence for Complete Decongestive
Therapy in the Treatment of Lymphedema
from 2004-2011. PM&R 4(8) 2012 p.580-
601.
Pub:2006
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ALFP Review of CDT
• Conclusions:
– CDT improves overall QoL and is effective for various degrees of lymphedema
– Continued use of compression is usually needed
– MLD enhances the effect of compression and improves QoL and Sx
– Longer term follow-up studies are needed
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Complete Decongestive Therapy
• PHASE 1: Decongestion • Meticulous Skin Care
• Manual Lymph Drainage
• Gradient Compression Bandaging
• Remedial Exercises
• Compression Garment
• PHASE 2: Maintenance • Meticulous Skin Care
• Day: Compression Garment
• Night: Gradient Compression Bandaging
• Self Manual Lymph Drainage
• Remedial Exercises
• Follow-up Assessment
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Meticulous Skin & Nail Care
• Low pH, gentle soaps
• Moisturizer (Low pH also recommended)
• Do not cut cuticles in manicures
• Prevents infection
• Keep skin working optimally
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Manual Lymph Drainage Expert Stretching of the Skin
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Manual Lymphatic Drainage
Source: Foldi 2003
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Manual Lymphatic Drainage
• Drains the congested areas
• Reduces the risk of infection
• Normalizes the size and pressure in the limb
• Reduces pain/discomfort
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Compression Therapy
• Gradient, short-stretch bandaging
• Medical compression garment
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Garment Measurement
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Elastic Garments for Day Use
www.BSNMedical.com www. Lymphedivas.com
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Bandage Alternatives
Appropriate for the maintenance
of reduction in volume
www.solarismed.com www.mediusa.com
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Compression Pumps
www.flexitouch.com
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Why NOT use a Pump for Lymphedema?
• Absorbing lymphatics are superficial, fragile, and low pressure
• Pumps cannot ‘remodel’ fibrotic areas
• Pumps can mobilize large fluid volumes, generally in those patients most at risk
• In the UEs – may cause truncal/breast swelling
• Pumps have not been proven to mobilize proteins
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Adequate Conservative Care? • Inadequate treatment often seen
– CDT principles not followed by therapists
• Treatment not intensive (only 1-2 days/week)
• Multilayer bandaging poorly done and not tolerable by patient
• Inadequate MLD ( treated while clothed, incomplete sequencing)
• Poorly fit and (often) non-custom garments causing pain and/or swelling
• Nighttime bandage alternatives not offered or considered.
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Adequate Self Care?
• Mistakes:
– Wearing elastic at night instead of during the day
– Taking a ‘vacation’ from regular self care
– Adherence to self care with chronic condition is hard!
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New Approaches to Lymphedema
• Vascularized Lymph Node Transfer Surgery
– Pioneered in Europe and Asia
– Designed to ‘replace’ lost nodes
– Nodes harvested from another part of body
– New in US
• Results: – 1/3 smaller in size
– 1/3 ‘feel better’
– 1/3 No change
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To Learn More: • Living Beyond Breast Cancer
– www.lbbc.org
• National Lymphedema Network
– www.lymphnet.org
• Oncolink- Univ of Penn
– www.oncolink.org
• BreastCancer.org
– www.breastcancer.org