Combined Decongestive Therapy for Lymphedema following Breast Cancer
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Lindsay Davey, Registered Physiotherapist and Clinic Director of Toronto Physiotherapy provides a brief overview of Lymphedema for breast cancer and the gold standard treatment, Combined Decongestive Therapy. The target audience for this presentation is the medical community. To learn more about lymphedema please visit http://www.torontophysiotherapy.ca/services/toronto_lymphedema_treatment.html
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Combined Decongestive Therapy for Lymphedema following Breast Cancer
- 1. LYMPHEDEMA FOLLOWING BREAST CANCER: EFFECTIVE TREATMENT BY COMBINED DECONGESTIVE THERAPY Lindsay Davey, MScPT, MSc, CDT Registered Physiotherapist, Certified in Combined Decongestive Therapy Owner/Clinic Director of Toronto Physiotherapy
- 2. What is Lymphedema? Chronic condition Impaired drainage of lymphatic fluid secondary to surgery and/or radiation therapy to lymph nodes (axilla) Can lead to fibrosis, pain, paresthesia, infection Patients report decreased quality of life, function, self-image issues, anxiety (c) Toronto Physiotherapy 2012
- 3. Incidence and Risk Factors Ranges from 6 – 30% depending on Method of detection Length of follow-up Surgical population Risk Factors: Total mastectomy Axillary lymph node dissection (ALND) Tumour positive axillary lymph nodes Axillary radiation after ALND Post-operative complications (c) Toronto Physiotherapy 2012
- 4. Treatment of Lymphedema Gold Standard approach: Combined Decongestive Therapy*: 1. Manual Lymphatic Drainage Massage 2. Compression 3. Education 4. Exercise *ISL Consensus Document, Lymphology 2009:42; 51-60. (c) Toronto Physiotherapy 2012
- 5. 1. 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/irradiated (c) Toronto Physiotherapy 2012
- 6. 2. Compression In limb volume reduction phase: short stretch bandages In maintenance phase: compression garment Assistive Devices Program covers 75% of cost of garments (c) Toronto Physiotherapy 2012
- 7. 3. Education The Do’s and Don’t’s about lymphedema management Skin care Scar management Self-massage / Self-bandaging (as necessary) (c) Toronto Physiotherapy 2012
- 8. 4. Exercise Strong evidence for the safety and benefits of exercise to decrease lymphedema risk* Individualized guidelines provided Functional exercise emphasized Program includes aerobic exercise AND low-load resistance training components *Schmitz K et al, JAMA 2010:304;2699-2705. (c) Toronto Physiotherapy 2012
- 9. Who Can Benefit From CDT? ALL post-operative breast cancer patients can benefit from CDT. Acute onset / early stage lymphedema Chronic / later stage lymphedema Preventative: CDT decreases risk of lymphedema after ALND* *Lacomba M. et al, BMJ 2010:340;b5396. (c) Toronto Physiotherapy 2012
- 10. Summary Breast cancer survival rates increasing Lymphedema incidence as high as 30% Lymphedema associated with decreased quality of life 4 Pillars of CDT treatment approach CDT can help prevent lymphedema CDT effectively treats lymphedema All patients should consult a CDT therapist post-operatively (c) Toronto Physiotherapy 2012
- 11. Thank you! Lindsay Davey, MScPT, MSc, CDT www.TorontoPhysiotherapy.ca
Editor's Notes
- As you know , lymphedema is a chronic condition. It is caused by impaired drainage…. Without intervention, lymphedema can lead to considerable fibrosis of the soft tissues… In fact, a recent publication in Cancer discussing patient perspectives of treatment side effects showed that some women report more distress related to the threat of lymphedema than with breast cancer itself (Binkley et al, 2012). This paper went on to show that patients ALSO report strong desire for education and intervention when it comes to lymphedema, and we see this in our patients as well.
- Total (VERSUS PARTIAL) mastectomy The EXTENT of the axillary node dissection (VERSUS SENTINEL NODE BIOPSY) THE PRESENCE OF tumour positive nodes… Axillary radiation after ALND Post-op complications such as SEROMA, HEMATOMA, INFECTION, or AXILLARY TRAUMA I should also mention that treatment-related weight gain has been shown to affect approx 50% of women undergoing treatment for breast cancer. and increased BMI is a risk factor for the development of lymphedema.
- The International Society of Lymphology’s Consensus document states that CDT as the evidence-based Gold Standard treatment approach for lymphedema. It is a practical, and long-lasting solution for patients who have lymphedema or who are at risk of developing it. CDT has 4 pillars of treatment which I will outline for you.
- Specialized form of massage that stimulates the smooth muscle sheath of the superficial lymphatic vessels , which increases their pumping rate . If the pressure is too great , this can cause spasm of the sheath and damage of the anchoring filaments that connect the lymphatic vessels to the surrounding connective tissue . All that to say, the specific pressure and strokes we use is an important component for the massage to work. By using a specific sequence of strokes, and importantly, by NOT stimulating areas where lymph nodes were removed or irradiated, we can successfully RE-ROUTE lymphatic fluid to bypass these deficient pathways. For these reasons a typical massage with a practitioner who is not trained in CDT can not only be futile in terms of attempting to drain the excess fluid, in fact could be detrimental to the patient if it is too viguorous.
- The second pillar of CDT is Compression. This takes on two different forms – short stretch bandage wrapping in the volume reduction phase (which usually lasts somewhere between 3 – 6 weeks) , and compression garments during the maintenance phase. Patients are measured for compression garments once we have seen maximal benefit and a PLATEAU in limb volume reduction. I, and the other CDT therapists on my team, are Authorizors for the ADP program, so we are able to sign off on patient’s forms so that they receive this funding.
- We make sure our patients understand what lymphedema is, how they can and need to participate in self-management strategies (or how they can help prevent it!). What we find is that many lifestyle and activity modifications that breast cancer patients make after their acute care has ended are NOT based on current research. So we give a comprehensive list of things to avoid, how to approach air travel, carrying/lifting rules of thumb, signs of infection they need to be aware of, how they can safely exercise and USE the limb, and so on. Skin care is a focus for us, because of the risk of infection in a limb with lymphedema. A big part of our education for them is how to do the appropriate SELF-MASSAGE techniques that are so critical to get the best possible outcomes both in the volume reduction phase of treatment, as well as when they are in the maintenance phase. To assist our patients with this, we actually have a VIDEO on our website demonstrating the basic massage strokes that all of our patients should be performing at home, so that they can follow along.
- There is compelling evidence for the SAFETY and BENEFITS of exercise to decrease lymphedema risk, and to promote optimal management of lymphedema in those that have it. We provide individualized and functional home exercise programs that incorporate both aerobic and resistance training components. Current Clinical Practice Guidelines for Breast Cancer Rehab recommends 30 minutes of moderate activity most days of the week , and so we help patient’s reach this goal as best we can, tailoring it to their specific interests and abilities. The strength training component is especially important to ensure that the lymphedematous arm (or at-risk arm) is not susceptible to repetitive strain or other injuries.
- The PREVENTATIVE case for CDT Therapy: So this was a 2010 study published in the British Journal of Medicine looking at breast cancer patients who had undergone axillary node dissection and who did NOT have lymphedema - and they found that those that received preventative manual lymphatic drainage massage, physiotherapy exercises, and education , were significantly less likely to develop lymphedema at one-year follow-up than those who received education alone . So CDT DOES work even in the PROPHYLACTIC sense.
- With survival rates continuing to improve, lymphedema will no doubt remain a challenge for breast cancer survivors, especially with an incidence of upwards of 30%. Patients report decreased functional status and QOL with ‘unmanaged’ lymphedema. I hope I have effectively described what this Gold Standard treatment approach to lymphedema is, specifically how the manual lymphatic drainage massage works and how it is different from a typical massage, and impressed upon you that the evidence shows that CDT can be effective both in preventing lymphedema AND treating it effectively. I therefore encourage you to direct all of your breast cancer patients to consult a CDT practitioner when they are finishing their surgical and radiation therapy treatments, so that they can become informed about the signs and symptoms to watch for, so that they can take some preventative measures, and certainly learn what to do about it if it unfortunately onsets. We’re here to help!