Physiotherapy Works

Lymphedemafor

• An American cost comparison study looked at two models of breast cancer-related lymphedema (BCRL) management. It showed the cost to manage early stage BCRL was 80% less per patient when using a prospective physiotherapy surveillance model compared with reacting to symptomatic presentation.5

• Case study evidence from an award-winning physiotherapy-led lymphedema service in the UK estimated that for every £1 spent on lymphedema services, £100 was saved by their National Health Service in reduced hospital admissions.6

• This includes the potential to reduce the £87 million cost of inpatient admissions for cellulitis, which can be a significant secondary complication of poorly managed lymphedema.6

$ Cost effectiveness of physiotherapy-led surveillance and treatment

It is estimated that over 300,000 Canadians suffer with lymphedema. Approximately 15.5% of people diagnosed with cancer develop secondary lymphedema. Individuals who have had non-cancer surgeries, disabled individuals in wheelchairs, and those with leg ulcers due to venous disease may also develop the condition. In addition, lymphedema is now recognized as a major challenge in the management of obesity. It is estimated that 80% of all morbidly obese individuals have an element of lymphedema.7

Epidemiology !

What is lymphedema?Lymphedema is a chronic condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system.1 It can be primary (congenital) or secondary to (acquired from), for example, cancer, cancer treatments, non-cancer surgeries, infections, or vascular or inflammatory diseases.1 Disabled individuals in wheelchairs may also develop this chronic condition, and obesity is now considered a significant risk for lymphedema.2 The condition is progressive and if untreated, permanent tissue changes can occur.

Though frequently occurring in the arms and legs, it can also develop in the body, groin, and head and neck regions. It may cause discomfort, reduced function, impaired mobility and recurrent infections.

Lymphedema can significantly affect the patient’s quality of life.3 The long-term effects of lymphedema are more effectively managed if the condition is diagnosed and managed before chronic changes can occur.4

Physiotherapy is effective at preventing and managing lymphedema, a complex long-term condition associated with physical and psychosocial problems.

1. The Canadian Lymphedema Framework. https://www.mcgill.ca/lymphedema-research/canadian-lymphedema-framework-clf.

2. Mehrara BJ, Greene AK. Lymphedema and obesity: is there a link? Plast Reconst Surg 2014; 134(1):154e-160e. doi:10.1097/PRS.0000000000000268.

3. Taghan NR, Miller CL, Jammallo LS, O’Toole J, Skolny MN. Lymphedema following breast cancer treatment and impact on quality of life: a review. Crit Rev Onco; Hematol 2014 Dec; 92(3):227-34 doi: 10.1016/j.critrevonc.2014.06.004. Epub 2014 Jul 2.

4. Lawenda BD, Mondry TE, Johnstone PAS. Lymphedema: A primer on the identification and management of a chronic condition in oncologic treatment. CA Cancer J Clin. 2009 Jan-Feb;59(1):8-24. doi: 10.3322/caac.20001

5. Stout NL, Pfalzer LA, Springer B, Levy E, McGarvey CL, Danoff JV et al. Breast cancer-related lymphedema: comparing direct costs of a prospective surveillance mode l and a traditional model of care. Physical Therapy. 2012;92(1):152-63

6. Macmillan Cancer Support. Specialist lymphedema services: An evidence review. London: Macmillan Cancer Support. 2011. https://www.macmillan.org.uk/documents/aboutus/commissioners/lymphedemaservicesanevidencereview.pdf

7. Keast DH, Despatis M, Allen JO, Brassard A. Chronic oedema/lymphedema: under-recognized and under-treated. Internat Wound J.June 2015;12(3):328-333. doi: 10.1111/iwj.12224. Epub 2014 Feb 12.

8. Lu S-R, Hong R-B, Chou W, Hsiao P-C. Role of physiotherapy and patient education in lymphedema control following breast cancer surgery. Therapeutics and Clinical Risk Management. 2015;11:319-327. doi:10.2147/TCRM.S77669.

9. Torres Lacomba M, Yuste Sánchez MJ, Zapico Goňi A, Merino DP, Mayoral del Moral O, Cerezo Téllez E, Minayo Mongollón E. Effectiveness of early physiotherapy to prevent lymphedema after surgery for breast cancer: randomized, single blinded, clinical trial. BMJ. Published online 2010 January 12. doi:10.1136/bmj.b5396

10. Alberta Lymphedema Association http://www.albertalymphedema.com/

References

A team of researchers and clinicians from the University of Alberta, University of British Columbia, the Cross Cancer Institute (Edmonton), and Tom Baker Cancer Centre (Holy Cross Hospital, Calgary) recently carried out a multi-centre trial that studied the use of night-time compression as a self-management strategy for women with BCRL.

As Margaret McNeely, PT, PhD, (study lead), explains, “Lymphedema is a chronic condition, and tends to have times when the swelling flares. At these times, the woman with breast cancer related lymphedema needs more intensive physiotherapy to reduce the swelling and to control symptoms.”

The research team wanted to see if the addition of night compression through either self-administered bandaging or use of a night compression garment helped women to control their lymphedema better than day-time compression alone.

One hundred and twenty women from across the three cities took part in the study. The study was funded by the Canadian Institutes of Health Research and Alberta Cancer Foundation.

“We found that night-time compression, either through self-administered bandaging or use of a night garment, resulted in significantly better control of the lymphedema than day-time compression alone.”(Dr. Margaret McNeely, PT, PhD). This finding is helping to guide physiotherapy practice and treatment recommendations given to women with breast cancer related lymphedema, leading to improved patient outcomes and management of the condition, and decreased long-term costs of care.

CASE STUDYEarly access to treatment and managementEarly access to treatment can prevent the more serious disabling aspects of lymphedema. There is evidence that physiotherapy can be an effective intervention in the prevention of secondary lymphedema following surgery for breast cancer.8, 9

It is, therefore, essential to:

• Ensure rapid access to a physiotherapist with training in lymphedema management.

• Provide education for potential referrers to achieve better awareness, screening for “at risk” groups and early referral.

• Regard lymphedema as a long-term condition. This includes resource allocation for patient education, risk stratification, treatment, and self management in conjunction with certified physiotherapists.

The Alberta Lymphedema Association recommends Combined Decongestive Therapy for the treatment of lymphedema. Treatment consists of:

• Manual lymph drainage: a specialized type of massage

• Compression therapy: the use of compression garments to control swelling

• Education: to understand the condition and how to manage it

• Exercise: to promote lymphatic flow

• Skin care: to prevent infection10

There is no cure for lymphedema. Lifelong monitoring including self-management (daily use of compression hosiery, skin care, self-massage and exercise) and regular compression garment review.

Providing early access to physiotherapists is essential to reduce the significant impact and socio-economic burden of this condition. Early identification of swelling and prompt referral to a physiotherapist is critical to ensure the best possible outcomes for patients. This helps to improve quality of life while also reducing long-term disability, work-related problems, and emotional difficulties.

Acknowledgement Adapted and used with permission of the Chartered Society of Physiotherapy.

Physiotherapy Works Lymphedema is an evidence-based briefing from Physiotherapy Alberta – College + Association www.physiotherapyalberta.ca 780-438-0338 info@physiotherapyalberta.ca