multidisciplinary health care management of …...multidisciplinary health care management of...
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Multidisciplinary Health Care
Management of Patients with
Lymphedema and Other Cancer
Related Side-Effects
Amanda Grant, PT, DPT, FAAOMPT, MTC, CLT
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Objectives
Identify the patient population at risk
for developing lymphedema
Describe the early signs and
symptoms of lymphedema
Identify musculoskeletal impairments
often associated with lymphedema
Identify prevention strategies for
patients at risk for developing
lymphedema
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Cancer Incidence Rate
According to the American Cancer Society
>1 million people are diagnosed each year
Approximately 1,660,290 new cancer cases expected to be diagnosed in 2013
Lifetime risk: Male 1 : 2
Female 1 : 3
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Cancer Rate Incidence
According to the Journal of the
National Cancer Institute1
Decline in incidence rate in men
Stabilized incidence rate in women
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Chronic Cancer
Refers to anyone who is in a long term
treatment of recurrent cancer or
cancer metastases
Stable disease
Progression
Complete response or complete
remission
Partial response or partial remission
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Survivorship
Improve quality of life of cancer
survivors as they transition from
treatment to recovery2
The National Cancer Survivorship
Resource Center
Collaboration between the American
Cancer Society and the George
Washington Cancer Institute
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Survivorship
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Lymphedema Incidence Rate
Approximately 30% breast cancer
patients will develop lymphedema3,4
Greatest rate occurs with axillary node
dissection and radiation
Lymphedema can develop
immediately following surgery or
anytime thereafter
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Lymphedema
Definition
“…a subcutaneous accumulation of protein-rich fluid resulting from an insufficient or blocked drainage system…”5
Occurs most often in the arm(s) and/or leg(s), and occasionally in other parts of the body such as the trunk and genitalia.
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Anatomy Review
Lymphatic System is a specialized
component of the circulatory system.
Retrieves lymph fluid filtered out of the
circulatory system by capillaries and
returns it to the venous system for
circulation6
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Components of Lymphatic System
Thymus Gland Spleen Tonsils Peyer’s patches Lymph Nodes
Axillary Inguinal Abdominal Cervical
Lymph Vessels
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Function of the Lymphatic
System
Assists venous system in the removal of lymph fluid and protein from the interstitial space
Contributes to the immune system by producing white blood cells
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Function of the Lymphatic
System
Lymphedema
results when the
amount of
lymphatic fluid
exceeds the
lymphatic
transport
capacity 7
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The lymphatic
system originates
as lymph
capillaries in the
spaces between
cells
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Lymphatic Capillaries
Originate as
“blind ends” in
tissue space
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The lymphatic
capillaries join to
form larger
lymphatic
vessels.
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Lymph Vessel Hierarchy
Lymphatic Capillaries
Pre-collectors (like lymphatic capillaries but contain smooth muscle cells and valves)
Collectors (superficial and deep) (have three-layer wall like veins) (unlike veins they have thinner walls and valves closer together –from one to another)
Lymph Trunks and Ducts (largest lymph vessels)(similar to collectors but have thicker walls)
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Lymphatic Vessel Hierarchy
Thoracic Duct Largest lymphatic
vessel in the body
Made up from the R and L lumbar trunks
Empties into the L subclavian vein
1-5mm in diameter and 40cm long
Transports 75% of the daily lymphatic load Approximately 2-4L
daily
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Lymphatic Vessel Hierarchy
Right Lymphatic Duct
2.5cm in length
Located in the area
of the R venous angle (where R
internal jugular and R
subclavian vein
meet)
Transports 25% of the
total lymphatic load
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Thoracic Duct drains
the L and R lower
quadrants, L upper
quadrant, L head
and neck (75%)
Right Lymphatic
Duct drains the R
upper quadrant, R
head and neck
(25%)
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How Does Lymph Fluid Get From
Capillary to Duct?
What is the central pump for the arterial and venous circulation?
The lymphatic system has its own internal pump (intrinsic contractility) Referred to as “lymphangioactivity” or
“lymphangiomotoricity”
The funtional unit is referred to as lymphangion section between valves
Normal speed: approx 6 BPM
Speed when stimulated: approx 20 BPM
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How Does Lymph Fluid Get From
Capillary to Duct?
In addition to the intrinsic contractility lymph
flow is aided by:
Skeletal muscle contraction (muscle and
joint pump)
Arterial pulsation
Respiratory pressure changes
Negative pressure in central veins
External pressure (manual lymphatic
drainage, compression garments)
Production of new lymph (creates back
pressure)
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Lymph Fluid Flow…
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Respiration Effect on Lymphatic
Flow
Inspiration
↓
Descent of the diaphragm
↓
Increased intra-abdominal pressure
Decreased intra-thoracic pressure
↓
Thoracic duct lymph “pumped” into the venous system during inspiration
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Lymph Fluid
Interstitial fluid which is absorbed from
the extracellular space
Lymph fluid carries:
Proteins
Water
Cells (RBC, WBC, lymphocytes)
Waste products and other foreign
substances
Fat
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Lymph Nodes Found throughout the
lymphatic system
Vary in size (2-30mm)
Many shapes (long, oval, round, bean, kidney shaped)
600-700 lymph nodes in the human body
Majority found in abdomen, followed by head, neck, and less throughout the rest of the body
Generally located in adipose tissue
More afferent vessels than efferent vessels
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Lymph Nodes
The lymphatic
vessels are joined
together by lymph
nodes which act as
filters and empty
into the right
lymphatic duct or
the thoracic duct
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Functions of Lymph Nodes
Regulate fluid imbalance when
excess water in interstitium
Filtering station for noxious matter
such as bacteria, toxins, and dead
cells
Production of white blood cells
(lymphocytes)
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Functions of Lymph Nodes cont.
Regulates the concentration of
protein in the lymph
½ protein in systemic circulation found in
lymphatic system
Proteins recycled by the lymphatic
system
If higher concentration of protein in the
lymphatic system then increased water is
absorbed, and vice versa
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How Frequently Does Lymphedema
Occur?
Affects 1% of the US population – over
2.5 million people – usually from
breast cancer treatment4
Post-mastectomy: 25.5 %
Post-mastectomy with axillary lymph
node dissection and radiation
therapy: 38.3 %
Further increased with obesity and/or
infection
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Lymphedema
Primary Lymphedema
Due to an unknown cause, but usually
associated with a vascular anomaly
Can be present at birth, develop in puberty,
or in adulthood
Secondary Lymphedema (Acquired)
Due to a known cause
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Primary Lymphedema
Person is born with insufficient
lymphatic system
Unknown cause
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Primary Lymphedema
Hypoplasia-less than normal expected number
of lymph collectors
Hyperplasia-vessels are excessively dilated
Aplasia-significant absence of lymph collectors
Inguinal Node Fibrosis- fibrosis and degeneration
of the inguinal and iliac lymph nodes
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Primary Lymphedema
Present at birth = Lymphedema congenita
Develop in childhood = Lymphedema
Praecox
Under the age of 35
Develop in Adulthood = Lymphedema Tarda
Over the age of 35
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Primary Lymphedema
Of the primary lymphedema
population
87% are females
13% are males
Most common age of manifestation: 17
83% developing before the age of 35
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Secondary Lymphedema
Usually results from a trauma to the lymphatic system
Surgery Breast,
gynecological, head/neck, prostate, testicular, bladder, colon
Radiation therapy
Traumatic injury
Seroma Aspiration Lymphangitis Tumor
Cancer
Infection
C.V.I.
Iatrogenic
Obesity
Self Induced
Filariasis (200 million people worldwide)
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Filariasis
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Remember….
If lymph nodes are removed there is
ALWAYS a risk of lymphedema
38
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Secondary Lymphedema
There is a KNOWN cause
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Differential Diagnosis
Most important … Physical Exam and
History
Onset?
Location?
Pain?
Skin Changes?
Other Conditions?
Can the swelling be changed?
Diagnostic Tests?
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Early Signs of Lymphedema
Tingling / Numbness
Feelings of fullness or heaviness
Clothing fitting tight
Decreased active range of motion
Visible swelling (that may come and
go)
Especially distal swelling
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Lymphedema Incidence Rate
Increases with:
Amount of lymph nodes removed
Amount of trauma to the area
Radiation treatment6
Age of patient
Pre-existing sedentary lifestyle
Obesity8
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Alternative Causes of Swelling
DVT (Deep Vein Thrombosis)
Cancer return /Malignant Lymphedema
Lipedema
Venous Edema
Cardiac Edema
Congestive Heart Failure
Myxedema
Complex Regional Pain Syndrome
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Differential Diagnosis
Lipedema
Mainly in women
B symmetrical
swelling from iliac
crests to ankles
Painful to
palpation
Bruise easily
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Differential Diagnosis
Venous
Edema Non-pitting
Hemosiderin
staining
Fibrosis of
subcutaneous
tissues
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Differential Diagnosis
Acute Deep Venous Thrombophlebitis
Sudden onset
Usually unilateral
Painful
Cyanosis- depending on severity
+ Homan’s sign
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Differential Diagnosis
Cardiac Edema
Greatest distally
Always B
Pitting
Complete resolution with elevation
No pain
R heart insufficiency
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Differential Diagnosis
Congestive Heart Failure
Pitting edema
Orthopnea
Dyspnea on exertion
Jugular venous distention
B heart failure
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Differential Diagnosis
Malignant
Lymphedema
Pain, paresthesia,
paralysis
Central location
Rapid
development
Non-healing
open wounds
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Differential Diagnosis
Myxedema
Deposition of
mucopolysaccha
-rides substance
in the skin (thyroid
dysfunction)
Dry skin, brittle
nails, thinning
hair, orange
colored skin
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Differential Diagnosis
Complex Regional Pain Syndrome
Warmth, burning, edema, sensory
changes
Coolness, cyanosis, dry brittle nails
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How Does Lymphedema
Occur?
Decreased lymph flow from lymphatic
damage results in increased protein
concentration in the interstitial fluid
With increased protein concentration,
fluid is shifted into the interstitial space
due to oncotic pressure
With fluid accumulation in the
interstitial space, swelling/edema
occurs in that body part
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How Does Lymphedema
Occur?
Lymphatic damage and fluid stasis
leads to scar tissue/fibrosis
development with collagen and fibrin
deposition to vessel walls, therefore
further blocking lymph flow
Fluid stasis increases susceptibility to
infection with cycle initiated for
further lymphatic damage
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Lymphedema
Stages of Lymphedema9
Stage 0: Pre-lymphedema/Sub-Clinical
Stage 1: Spontaneously reversible
Stage 2: Spontaneously irreversible
Stage 3: Lymphostatic elephantiasis
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Lymphedema – Stage 0
Impaired lymphatic system
Amount of fluid the body can
transport is reduced
No visible/palpable edema
Subjective complains possible
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Lymphedema – Stage 1
Spontaneously Reversible
Accumulation in protein rich fluid
Limb size changes with position/ elevation
Pitting edema
<20% change in volume between limbs
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Lymphedema – Stage 2
Spontaneously
Irreversible
Non-pitting edema
Fibrotic tissue
beginning
Elevation/position
does not change
limb size
20-40% difference in
limb volume
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Lymphedema – Stage 3
LymphostaticElephantiasis
Fibrotic changes in tissues
Elephantine changes
>40% increase in limb volume compared to the non-involved side
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Types of Lymphedema Treatment
Lymphedema is a disease. All other
edemas are symptoms.
Cure of lymphedema is not possible.
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Types of Treatment Available
Medications: Antibiotics – decrease infection risk
Diuretics - decrease interstitial fluid
Proteases – break down interstitial proteins
Surgical: Not curative Excisional: Charles / Homans procedure
Debulking of the area to remove excess tissue to decrease volume
Physiological: Drainage of the area via lymph to lymph or
lymph to venous anastomosis
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Types of Treatment
Complete Decongestive Therapy
Manual Lymphatic Drainage
Muilti-layered compressive bandaging
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Effects of Lymphedema
Treatment
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Manual Lymphatic Treatment-
Phase One - CDT
Manual Lymphatic Drainage (MLD)
Antiseptic Moisturizing Cream
Low-stretch compression bandages
Active Exercise
Patient Education (see Phase 2)
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Manual Lymphatic Drainage
Treatment Goals
Improve cosmesis
Preserve skin integrity
Soften subcutaneous tissues
Avoid infection or lymphangitis
Decrease limb size
Avoid contracture of the involved
limb
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Manual Lymphatic Drainage
Gentle manual treatment which
improves the activity of the lymph
vascular system.
Re-routes lymph flow around blocked
areas into more centrally located
healthy lymph vessels.
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Compression Bandages
Minimally elastic bandages
applied to increase pressure
in extremity.
Reduces re-infiltration
Improves muscle pump
Helps to break up
deposits of accumulated
scar and connective
tissue.
Stays in place until next
MLD session.
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Exercises
Goal: enhance muscle pump activity
and promote improved venous and
lymphatic return in the involved
extremity
Employed throughout the span of the
CDT treatment program including
initial Phase I and Phase II.
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Types of Exercise10
Flexibility/Stretching
minimizing tightness and the effects of
scarring which can block lymph flow
Resistive
improve muscle power, stamina and tone
Greatest risk of tears/injury
Increases local blood flow and the production of waste products increasing load on the lymphatic system
Use in Conjunction with compression
Aerobic Conditioning
60% - 75% of the maximum heart rate (target heart rate)
Increased deep respiration (deep breathing) enhances venous and lymphatic return
Source: National Lymphedema Network
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Negative Aspects of Exercise
Blood flow is increased, possibly
causing an increase in lymphatic load
Increased muscle metabolism results in
increased metabolic waste
Improper exercise may cause
inflammation and trauma
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Manual Lymphatic Treatment
Phase II-CDT
Compression Stockings/Sleeves
Home Exercise
Skin Care
Patient Education
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What types of compression are
available in Phase II ? Compression stocking
can be used for treatment and maintenance
2 pairs are appropriate to maximize hygiene
last from 4 to 6 months
can be difficult to don or doff and keep in position
Compressive wrapping
better flexibility for specific problem areas and for
specific patients
patients and families can learn technique
allow greater activity level than pumps
can be time consuming to don
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Available Compression
in Phase II cont.
Compression pumps
not adequate for primary therapy
do not address proximal edema
high cost with decreased compliance
less convenient for associated exercise or mobility
variable protocols dependent on brand and type
but ranges:
single chamber/uniform/intermittent compression:
30-60 mm Hg
multi-chamber/differential/sequential compression:
60-120 mm Hg
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Compression Pumps
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Additional Musculoskeletal
Impairments
Postural limitations
Pain
Scar tissue
General deconditioning
Stiffness
Weakness
Numbness
Decreased ADL ability
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Precautions with Treatment
Slow exercise progression
Caution of application of ice and
heat
Slow increase in depth of manual
treatment
Caution of application/placement of
therapeutic devices
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Lymphedema Prevention
Protect the body part from the elements
Protect the body part from injury
Protect the body part from changes in pressure
Wear compression sleeve/garment when exercising
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Patient Education Wear protective garments for appropriate activities:
gardening or pruning
dishwashing
baking/cooking
sewing
Immediate contact with physician if presence of
infection
Carry heavy parcels or purses on the opposite limb
Sunscreen or long-sleeved garments for sun
exposure
Sleep with limb elevated
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Patient Education
Jewelry should not be worn on affected limb
Insect repellent for high risk exposure
Utilize electric razor for shaving
Check water temperature with other limb or thermometer before immersion
Avoid heavy lifting or repetitive movements with involved limb
Avoid tight-fitting garments to affected limb
Avoid climate temperature extremes
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Quick Check for Risk of
Secondary LymphedemaHas the individual had cancer?
Yes
Lymph nodes removed?
No
Radiation or Chemotherapy?
Yes
Increased risk for developing lymphedema
No
Low risk
Yes
Increased risk for developing lymphedema
No
Visited third world
country?
Yes
Increased risk for developing lymphedema
No
Low risk
Major surgery / trauma effecting lymphatic/vascu
lar system ?
No
Low risk
Yes
Increased risk for developing lymphedema
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Screening and Pre-diagnosis for
Cancer/Cancer Return
Red flags and other warning signs11-15
Change in BB habits
A sore that doesn’t heal
Unusual bleeding/discharge
Thickening lump
Indigestion or difficulty swallowing
Obvious changes in wart or mole
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Screening and Pre-diagnosis for
Cancer/Cancer Return
Red flags and other warning signs
cont.
Nagging cough or hoarseness
Unexplained/unintentional weight loss
Fever
Chills
Night sweats
Age >50
Hx of cancer
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Screening and Pre-diagnosis for
Cancer/Cancer Return
Listen to the patient…
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Cancer Metastases
Predictable sites of cancer
metastases
Bone
Liver
Lung
Brain
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Residual Short and Long Term
Impairments16-20
Scars and other skin changes
Persistent fatigue
Reproductive system changes
Damage to muscles/musculoskeletal
fibrosis
Osteoporosis
Hot flashes
Altered movement pattern
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Side Effects if Patient
Undergoing Chemotherapy
Cognitive impairments (chemo brain)
Myelosuppression
GI distress
Peripheral and central nervous system
effects
Decreased salivation
Alopecia
Nail damage
Organ toxicities
85
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Late Effects of Cancer
Treatment
Cardiotoxicity
Pulmonary fibrosis
“Chemopause”
Musculoskeletal Fibrosis
Risk of secondary cancer
Long lasting immune response impairment
Permanent alterations in GI function
Cognitive changes
86
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87
Persistent changes due to treatment. Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine roundtableon exercise guidelines for cancer survivors. Medicine and Science In sports and exercise. Jul 2010;42(7):1409-1426
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Side effects from Targeted
Therapies
Increased risk of PE and CVA
Increased risk of Osteoporosis
Loss of muscle mass, weakness
Arthralgias and myalgias
Bone pain
Vasodilation
Impaired healing
88
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General Therapy
Considerations
Therapy during chemo? Radiation?
Low level laser therapy?
Electrical Stimulation/TENS?
Grastin/ASTYM?
US?
Ice/Heat?
Ex guidelines?
Workoutcancer.org
89
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Patient Cases
90
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Patient A
91
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Patient A
92
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Patient B
93
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Patient B
94
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Patient B
95
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Patient C
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Patient C
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Patient D
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Patient D
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Patient E
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Patient F
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Questions??????????
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Resources
1. Jemal A, et al. Annual Report to the Nation on the Status of Cancer 1975-2009, Featuring the Burden and Trends in Human Papillomavirus (HPV)-Associated Cancers and HPV Vaccination Coverage Levels. Journal if National Cancer Institute. 2013;1-27
2. Quality of Life: Programs and Navigation. Expert Pannel Summit Workgroup Overview. National Caner Survivorship Resource Center. Accessed at http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-031410.pdf. Accessed July 13, 2013
3. American Cancer Society. Cancer Facts & Figures 2013. Atlanta: American Cancer Society; 2013.
4. Hayes S, Janda M, Cornish B, Battistutta D, Newman B. Lymphedema After Breast Cancer: Incidence, Risk Factors, and Effects on Upper Body Function. Journal of Clinical Oncology. 2008;26:3536-3542.
5. Little L, Proche DJ. Manual Lymph Drainage. Journal of the Association of Nurses in AIDS Care. 1998;9:78-82.
6. National Cancer Institute at the National Institute of Health. Available at http://www.cancer.gov/cancertopics/pdq/supportivecare/lymphedema/healthprofessional. Accessed July 13, 2013
7. LymphNetworkSpain. Available at http://www.lymphnetworkspain.com/lymphatic-system. Accessed July 13, 2013
8. Petrek JA: Commentary: prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy. Cancer J 10 (1): 17-9, 2004.
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Resources
9. 2009 Concensus Document of the International Society of Lymphology: The Disgnosis and Treatment of Peripheral Lymphedema. Lymphology. 2009;42:51-60
10. National Lymphedema Network. Position Paper: Exercise Available at http://lymphnet.org/resources/position-paper-exercise. Accessed March 15, 2014
11. Jensen AO, Jacobsen JB, Norgaard M, Yong M, Fryzek JP, Sorensen HT. Incidence of bone metastases and skeletal-related events in breast cancer patients: a population-based cohort study in Denmark. BCM Cancer. 2011;11:29
12. Leerar PJ, Boissonnault W, Domholdt E, Roddey T. Documentation of Red Flags by Physical Therapists for Patients with Low Back Pain. Journal of Manual & Manipulative Therapy(Journal of Manual & Manipulative Therapy). 2007;15)1):42-49
13. Ross MD, Boissonnault WG. Red Flags: to screen or not to screen? The Journal of Orthopaedic and Sports Physical Therapy. Nov 2010;40(11):682-684
14. Karavatas SG, Reicherter EA, White N, Strong A. Physical Therapy Management of Patients with Multiple Myeloma: Musculoskeletal Considerations. Rehabilitation Oncology. 2006;24(3):11-16
15. Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P, Irwig L. Red flags to screen for malignancy in patients with low-back pain. Chocrane Database Sys Rev.2013;2:CD008686
16. Schmitz KH, Speck RM, Rye SA, DiSipio T, Hayes SC. Prevalence of bresat cancer treatment sequelae over 6 years of follow up. Cancer. 2012;118(S8):2217-2225
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Resources
17. Schmitz KH, Prosnitz RG, Schwartz AL, Carver JR. Prospective surveillance and management
of cardiac toxicity and health in breast cancer survivors. Cancer. 2012;118(S8):2270-2276
18. Hayes SC, Johansson K, Stout NL, et al. Upper-body morbidity after breast cancer.
Cancer. 2012;118(S8):2237-2249
19. Swisher AKPTPCCS, Davison C, Aranda R, Eye D, Erickson M. Frequency and Severity
of Self-Reported Upper Extremity Impairments, Activity Limitations, and Participation
Restrictions Following Breast Cancer Treatment. Rehabilitation Oncology. 2010;28(1):3-9
20. Torres Lacomba M, Mayoral de Moral O, Coperias Zazo JL, Gerwin RD, Goni AZ.
Incidence of myofascial pain syndrome in breast cancer surgery: a prospective study.
The Clinical Journal of Pain. May 2010;26(4):320-325
21. Persistent changes due to treatment. Schmitz KH, Courneya KS, Matthews C, et al.
American College of Sports Medicine roundtable on exercise guidelines for cancer
survivors. Medicine and Science In sports and exercise. Jul 2010;42(7):1409-1426