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1
The Identification and Management of Oncologic
Treatment-Related Lymphedema
Tammy E. Mondry, PT, DPT, MSRS, CLT-LANA
Objectives
At the end of this course, the participant will be able to:
• Perform risk assessment for lymphedema
• Instruct patient in arm and leg care guidelines
• Identify lymphedema in the oncology patient population
• Determine when referral to a lymphedema specialist is appropriate
Anatomy and Physiology of the Lymphatic System
• Purpose of the lymphatic system
• Lymph fluid
• Lymph vessel
• Lymph node
• Quadrants
2
Initial Lymph Collector
http://philschatz.com/anatomy-book/contents/m46563.html
Lymph Vessels
http://www.nature.com/nature/journal/v438/n7070/fig_tab/nature04480_F1.html
Lymph Vessels
http://www.fgf.uk.com/content/lymphaticsystem
3
Lymphangion
http://openi.nlm.nih.gov/detailedresult.php?img=3284143_rsif20110751-g2&req=4
Lymph Node
http://www.organicbodyandsoul.com/Limphatic.htm
Nodal Basins
http://patient.info/diagram/lymphatic-system-diagram
4
Drainage of the Lymphatic System
What is Lymphedema?
• An abnormal accumulation of protein-rich fluid due to a low volume (mechanical) insufficiency of the lymphatic system
Classifications
• Primary vs. Secondary
• Lymphedema Praecox (onset at puberty)
• Lymphedema Tarda (onset after age 35)
• Benign vs. Malignant
5
Effects of Oncologic Treatments
• Surgery (excision of lymph nodes)
• Sentinel Lymph Node Biopsy
• Lymph Node Dissection
• Radiation Therapy
• Areas at risk for development of edema
Risk Factors
• More Advanced Disease
• Age
• Higher Number of Nodes Removed
• HTN
• Increased BMI
• Radiation Therapy
Incidence Rate
• Incidence of Breast Carcinoma-Related Lymphedema ranges from 6% -30%
• Onset may be delayed several decades
6
Incidence Rate
Breast Edema 6-48%
•Lumpectomy 6%
•SLNBx + XRT 23%
•ALND + XRT
•Node Negative 35%
•Node Positive 48%
Incidence Rate
Lower Extremity Lymphedema
• Cervical Cancer 21-49%
• Endometrial 11%
• Vulvar 6-12%
• Prostate 25-66%
• Melanoma 1.7-53%
Lymphedema versus Edema
Lymphedema
• Disease process
• Localized
• High protein edema
• Progressive without adequate treatment
• Diagnosed through patient history and clinical observation
Edema
• Symptom of a condition (CHF, CVI, Immobility)
• Generalized or Localized
• Inflammatory reactions
• Hypoproteinemia
• Kidney, liver or thyroid disease
• Malnutrition
• Excessive bleeding
• Chronic draining wounds
• Excessive burns
7
Clinical Presentation of Lymphedema
• Heaviness, tightness, aching, discomfort
• Intermittent swelling in a portion of the limb or the entire limb
• Pitting edema
• Swelling is worse as the day progresses
Compounding Factors
• Infection
• Inflammatory Disorders
• Obesity
• Psychosocial Issues
• Lymphangiosarcoma
Diagnosis of Lymphedema
• Diagnosis
- Medical History
- Stemmer’s Sign
• Differential Diagnosis
- Rule out DVT
- Rule out Malignant Lymphedema
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Diagnostic Imaging
• Lymphoscintigraphy
• MRI
• CT Scan
• Ultrasound
Clinical Assessment
• Stemmer Sign
• Girth Measurements
• Water Displacement Testing
• Perometry
• Bioimpedance
• Digital Photography
Stemmer Sign
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Girth Measurements
Volumeter
Perometer
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Bioimpedance
• L-Dex U400
http://www.impedimed.com/products/l-dex-u400/
American Physical Therapy Association Classification
• Mild (less than 3 cm differential)
• Moderate (3 to 5 cm differential)
• Severe (5-plus cm differential)
International Society of Lymphology Classification
• Stage 0 – Subclinical or Latency Stage
• Stage I – Reversible Lymphedema
• Stage II – Spontaneously Irreversible Lymphedema
• Stage III – Lymphostatic Elephantiasis
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Stage IReversible Lymphedema
Stage IReversible Lymphedema
Stage II – Spontaneously Irreversible Lymphedema
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Stage II – Spontaneously Irreversible Lymphedema
Stage II – Spontaneously Irreversible Lymphedema
Stage III – Lymphostatic Elephantiasis
13
Stage III – Lymphostatic Elephantiasis
Stage III – Lymphostatic Elephantiasis
Stage III – Lymphostatic Elephantiasis
14
Management of Lymphedema
• Prevention
• Preoperative Evaluation
• Baseline girth / volume measurements
• Note risk factors
• Preoperative Education
• Arm or Leg Care Guidelines
Goals of Treatment
• There is not a cure for lymphedema
• Decongest the affected limb
• Prevent / eliminate infections
• Maintain normal or near normal limb size
Treatment Options
• Vasopneumatic Sequential Compression Pump
• Surgical Options
• Low Level Laser Therapy
• HivaMat
• Diet / Medications
• Diuretics
• Coumarin
• Antibiotics
• Elevation
• Compression Garments (Day / Night)
• Complete Decongestive Therapy
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Intermittent Pneumatic Compression
• Comparing Types of Pumps (examples)
• Bio Compression Systems
• Tactile Medical
• Contraindications and Considerations
• Insurance Coverage
Bio Compression Systems, Inc
Bio Vest with One Arm
Model SC-2004 Sequential Circulator
http://www.biocompression.com/Home.aspx
Tactile Medical
Flexitouch System Upper Extremity Flexitouch System Lower Extremity
http://www.tactilemedical.com/products/flexitouch/flexitouch-mechanism-of-action/
16
Surgical Options
• Lymphatic bypass procedures
• Reductive procedures
• Lymph Node Transfer
• Liposuction
• Experimental Procedures
Low Level Laser Therapy
http://www.riancorp.com/Products/low-level-laser-therapy-lllt.html
Electrical Stimulation
•HivaMat (Histological Variable Manual Technique)
•Deep Oscillation
17
Diet and Medications
• Heart Healthy Diet
• Diuretics
• Coumarin (Benzopyrone)
• Antibiotics
Compression Garments
• Day use garments
• Night use garments
• Selecting garments based on patient functional ability
Day Use Garments
• Juzo, Jobst, Solaris, CircAid / Medi, LympheDIVAs, Sigvaris, Solidea, JoViPak, Farrow Medical, Reid Sleeve
• Circular Knit versus Flat Knit
• Off-the-Shelf versus Custom made
18
Night Use Garments
Complete Decongestive Therapy (CDT)
Two Phase Therapy• Treatment Phase
• One hour
• Five times per week
• Two to four weeks
• Maintenance Phase
• Lifetime of daily maintenance
• Six month reassessments
Contraindications for CDT
• Relative Contraindications
• HTN
• Paralysis
• Diabetes
• Bronchial asthma
• Absolute Contraindications
• Acute infection
• DVT
• CHF
19
Relative Contraindications
• Hypertension
• Paralysis
• Diabetes
• Bronchial Asthma
Absolute Contraindications
• Acute Infections
• Congestive Heart Failure (CHF)
• Deep Vein Thrombosis (DVT)
Treatment Phase
• Skin / Nail Care
• Manual Lymph Drainage (MLD)
• Compression Bandaging
• Therapeutic Exercise
20
Skin and Nail Care
• Avoid injections and blood draws in the affected arm
• Have blood pressure checked in the unaffected arm
• Avoid heavy lifting with the affected arm
• Report to your MD if you have any signs of infection
Manual Lymph Drainage
•Manual technique to facilitate lymph flow
• Increases pumping rate up to ten times (100-120 times /min)
MLD Compared to Massage
MLD
• Manual Technique
• Focus on Connective Tissue
• Gentle Pressure
• Working and Resting Phase
Traditional Massage
• Manual Technique
• Focus on Muscle Tissue
• Considerable Pressure
• Increases Lymphatic Load
21
Manual Lymph Drainage
Compression Bandaging
•Multilayer bandage
•Worn 24 hours per day during the treatment phase
•Short Stretch Bandages
Muscle / Joint Pump
Resting Pressure Working Pressure
22
Therapeutic Exercise
•Exercise performed after compression bandages are applied
• Increases pumping rate up to ten times
• Facilitates Muscle Joint Pump
Maintenance Phase
• Skin / Nail Care
• Self –MLD
•Compression Garments
•Home Exercise Program
•Girth and Volume Reassessment
Compression GarmentsSleeve, Gauntlet, Glove, Stocking
•Manufacturers
•Compression Class
• 30-40mmHg
• Life of the Garment
• Six Months
23
When Does CDT Fail?
• Malignant lymphedema
• Associated illnesses
• Lack of compliance
• Insufficient treatment
Palliative Care
• Provide Comfort
• Relief of Symptoms
• Maintain Function
• Lymphorrhea
Stage I – Reversible Lymphedema
Pre Post
24
Stage I – Reversible Lymphedema
Pre Post
Stage II – Spontaneously Irreversible Lymphedema
Pre Post
Stage II – Spontaneously Irreversible Lymphedema
Pre Post
25
Stage III – Lymphostatic Elephantiasis
Post
Pre
Lymphedema Lower Extremity
Pre-Treatment Post-Treatment
Lymphedema Lower Extremity
Pre-Treatment Post-Treatment
26
Truncal Lymphedema
Pre-Treatment Post-Treatment
Head / Neck Lymphedema
Pre-Treatment Post-Treatment
Patient Education
Arm and Leg Care Guidelines
• Skin Care
• Modification of Activity and Lifestyle
• Avoid Limb Constriction
• Use of Compression Garments
• Avoid Extreme Temperatures
27
Skin Care
• Avoid Cutting or Clipping Cuticles
• Avoid Punctures to the skin
• Wear gloves when gardening or using household cleaners
• Avoid injury
• Be aware of signs of infection
(red, hot, swollen, painful, fever or flu-like symptoms)
Activity and Lifestyle
• Activity or Exercise (gradually increase duration and intensity)
• Frequent Rest Periods for Limb Recovery
• Avoid Limb Constriction
• Avoid Extreme Temperatures
Activity and Lifestyle
• Avoid Prolonged Standing and Sitting
• Well-Fitted Footwear and Hosiery
• Compression Garments During Air Travel
28
Lymphedema and Exercise
• Cardiopulmonary warm up and cool down
• Flexibility Exercises
• Resistive Exercise
• Aerobic Exercise
LANA Certification
• 135 hours of CDT training
• Licensed PT, PTA, OT, COTA, RN, MD, DO, ATC, DC, Massage Therapist
• https://www.clt-lana.org/
Resource
National Lymphedema Network
www.lymphnet.org