Lymphedema: A Breast Cancer Patients Guide to Prevention and - PowerPoint PPT Presentation

Lymphedema: A Breast Cancer Patient’s Guide to Prevention and Management Lindsay Davey, MScPT, MSc, CDT Registered Physiotherapist, Certified in Combined Decongestive Therapy, Owner/Clinic Director of Toronto Physiotherapy

The Lymphatic System: What Does It Do?  Maintains a normal balance of fluid in our tissues and blood stream  20% of all tissue fluid returns to the heart via the lymphatic system (80% returns via veins)  Monitors for foreign material and bacteria in the body  Circulates immune cells for fighting infection

What is Lymphedema?  The swelling of a body part due to the accumulation of lymphatic fluid  Caused by an insufficiency of the lymphatic system to ‘drain’ fluid from the limb (or torso)  Reasons for impaired drainage: ◦ Surgical removal of lymph nodes from the armpit ◦ Radiation to the lymph nodes in the armpit/chest  Lymphedema can take weeks, months, or years to appear following cancer treatment

Who Gets Lymphedema?  Incidence rate of lymphedema in breast cancer population: 6% - 30%  Increased Risk*: ◦ Full mastectomy ◦ Higher number of nodes removed ◦ Radiation to armpit ◦ Tumour positive nodes ◦ Post-op complications ◦ Axillary Web Syndrome (Cording) ◦ Increased Body Mass ◦ Genetic predisposition? *Miaskowski C et al, PLoS One 2013: Apr 16; 8(4).

Symptoms of Lymphedema: Early Stage  May not see swelling  Sensation of heaviness, fullness, tightness, bursting sensation, aching pain, tingling  May see swelling or puffiness after exercise or more vigorous use of the arm  Elevating the arm may decrease swelling  Swelling may be ‘pitting’ when pressure is applied

Symptoms of Lymphedema: Later Stage  Swelling of the upper arm, forearm, hand, fingers and/or trunk  Non-pitting  Elevation has no effect  Areas of ‘hardening’ of the tissue  Skin changes  Chronic condition (but can be well managed !)

How is Lymphedema Treated? Gold Standard Treatment Approach: Combined Decongestive Therapy (CDT) 1. Manual Lymphatic Drainage Massage 2. Compression 3. Infection Prevention / Skin Care 4. Exercise

Manual Lymphatic Drainage Massage  NOT the same as a typical massage  Specific pressure  Specific strokes  Specific sequence  Re-routes fluid to bypass deficient pathways where nodes have been removed or exposed to radiation  Self-massage is a KEY component in management. *VIDEO*

Compression TWO Phases: 1. Arm Volume Reduction Phase  Short-stretch bandages (like tensor bandages)  Usually takes 3 – 6 weeks 2. Maintenance Phase  Compression garment, custom fit or off the shelf

Are These Garments Covered Under OHIP?  The Assistive Devices Program (ADP) will pay for 75% of the cost of garments  They cover 2 garments, 3 X per year  ADP form must be signed by a Physician (the first time it must be a specialist ), a CDT-Authorizor (like myself), and a Fitter  Some patients may also have coverage through extended health benefit plans

Infection Prevention & Skin Care  The arm is at higher risk for infection  Keep the skin well moisturized (glycerin-free products are best to prevent drying/cracking)  Caution with things that could break the skin: ◦ Insect bites ◦ Animal scratches ◦ Cuticle trimming/manicures ◦ Paper cuts or larger cuts ◦ Shaving the armpit ◦ Minor burns  Use antibiotic cream on all cuts/scrapes

Signs of Infection and What To Do Signs of Infection:  Redness (Cellulitis)  Streaking or Rash appearance (Lymphangitis)  Heat  Fever  Generally feeling unwell What To Do:  STOP heavy use of the arm  STOP self-massage and compression  Seek medical attention immediately (antibiotics)

Exercise: How Does It Help? For Breast Cancer Rehabilitation In General:  Aerobic exercise (ex- walking) can decrease fatigue, stress, depression, body mass, and improve immune responses  Strength exercises help battle deconditioning and generalized weakness  Patients’ Quality of Life scores are significantly higher among those who exercise!

Exercise: How Does It Help? For Lymphedema Prevention & Management:  Promotes fluid flow via pumping action of contracting muscles  Strengthening makes limb less susceptible to repetitive strain or other injuries (which can cause inflammation)  Stretching maintains tissue flexibility to promote flow through lymphatic channels  Decreases risk of lymphedema* *Schmitz K et al, JAMA 2010: 304, 2699-2705

Exercise Principles for Lymphedema Patients:  Wear compression during exercise  Avoid wearing tight jewelry  Pre- and Post-exercise self-massage promotes lymphatic flow  Keep cool  Include aerobic and resistance training  Progress exercises for the arm at slower rate; delay pectoral exercises?  Evidence supports lifting ‘heavy’ weights* *Cormie P et al, J Cancer Surviv 2013 Apr 20, epub

Scar, Radiation Damage, and Cording  YES WE CAN HELP!  Mastectomy, lumpectomy and/or node dissection scars  Adherent/tight tissue in radiation zone  Rope-like cord in armpit/arm  Specialized massage techniques*  Specific home exercises  Improves range of motion, improves lymphatic flow, decreases pain

Do’s and Don’ts !  Avoid injections and IV’s on the affected side  Avoid blood pressure cuffs on this side  Avoid hot tubs and saunas  Diuretics do not help lymphedema * * *  Do wear some form of compression on flights  Do learn self-massage of the arm, and neck!  Do learn diaphragmatic breathing!

Summary: Lymphedema and CDT  Incidence as high as 30% in breast cancer patients  Chronic condition, but can be well managed!  CDT effectively treats lymphedema  CDT can help prevent lymphedema  CDT therapists a great resource on topic of lymphedema, scar and radiation field tissue adhesions, cancer rehabilitation  We’re here to help! 

Resources Lists of CDT Therapists: ◦ Lymphovenous Association of Ontario www.lymphontario.ca ◦ Toronto Lymphocare Centre www.torontolymphocare.com

Resources Toronto Physiotherapy www.TorontoPhysiotherapy.ca On-line Resources: ◦ A copy of this talk ◦ Lymphedema educational material ◦ Self-Massage Video ◦ Lymphedema Blog: hot topics and latest research

Thank you! Lindsay Davey, MScPT, MSc, CDT www.TorontoPhysiotherapy.ca