The assessment and care of people with limb lymphoedema secondary to cancer treatment. Dr Amanda Bobridge Lecturer School of Nursing and Midwifery Division of Health Sciences

‘ The doctor said: this-and-that indicates that this-and- that is wrong with you, but if an analysis of this-and-that does not confirm our diagnosis, we suspect you of having this-and-that, then…. and so on. There was only one question that Ivan Ilyich wanted answered: was his condition dangerous or not? But the doctor ignored that question as irrelevant’. Leo Tolstoy The Death of Ivan Ilyich

The Lymphatic System Intercellular interface  Fluid drains out of capillary bed  ECF, protein & other cellular components picked up & drained away by lymph capillaries

The Lymphatic System Lymph Vessel Valve Lymphatic vessels  Have inherent propulsion  Propulsion also influenced by  fluid load & muscular activity  One way valves to ensure uni– directional flow

The Lymphatic System Lymph nodes  Filter fluid & it’s contents  Will mount an immune response if bacteria etc. detected Lymph drainage  Legs, torso, L) arm & L) side of face & neck drain into the thoracic duct  R) arm, R) side of face & neck drain into R) lymphatic duct

How Does Lymphoedema Occur? Primary: born with malfunction in lymphatic system (commonly hereditary) Secondary: occurs after surgery or injury With cancer treatment:  Removal of lymph nodes reduces the number of ‘filtering’ stations and can cause damage to lymph vessels  New lymph vessels find it difficult to re-grow through scar tissue  Radiotherapy can cause damage to the lymph vessels and/or cause tissue hardening - making lymph propulsion difficult

Secondary Lymphoedema  Effects b/w 25 – 40% of pts who have ‘traditional’ cancer Tx (surg + lymph node dissection + radioTx)  Effects b/w 2 – 11% of pts who have Sentinel Lymph Node Biopsy  Can have a latency period of years  Can effect one part of or whole limb

Secondary Lymphoedema Lymphatic drainage Fluid tissue accumulation Fibrotic induration Limb swelling Macrophage activity Tissue hardening ROM Infection susceptibility Lymphatic drainage ADLs Cellulitis Symptoms Limb swelling Psychosocial morbidity

2 0 LO - What Makes it Worse? Increased fluid leakage into the extracellular space:  Inflammation  Hypertension  Thyroid dysfunction (hypothyroidism)  Heat Lymphatic vessel restriction/damage:  Obesity  Clothing (underpants, bras)  Additional surgery/injury to the area  Blood pressure measurement (?)

2 0 LO - Diagnosis  History of injury or cancer surgery/treatment  Rule out other causes for swelling - Organ dysfunction - Deep Vein Thrombosis - Chronic Venous Insufficiency - Ca recurrence  Subjective report of limb feeling tight, heavy  Initially swelling that comes & goes - jewellery or socks leave indentation - swelling worse at the end of the day

2 0 LO - Measurement Circumference measurements: - Ensure the tape measure is not held too tight - Can take measurements every 4cms from malleolor or ulnar styloid process OR - Leg: malleolar, mid calf, mid thigh - Arm: mid hand, wrist, mid forearm, mid upper arm

2 0 LO - Measurement Stemmar Sign: Unable to pinch skin at base of 2 nd toe Palpation: Pitting = earlier stages of LO = easier to treat Hard = later stages of LO = harder to treat

2 0 LO - Measurement ROM measurements:  Ask client how they cope with tasks like: - Hanging out the washing - Doing up their bra or - Walking up and down steps Subjective Symptoms:  Ask client to rate symptoms such as heaviness, tightness, aching on a 1-10 scale.

2 0 LO – General Advice To minimise skin dryness/breakage, irritation & potential infection:  Moisturise the limb daily with a plant based moisturiser  Treat cuts or scratches to the limb with antiseptic  Shave limb with an electric shaver To minimise pressure on lymphatic vessels:  Avoid restrictive clothing (ie: tight bra straps, underpants, socks)  Wear proper fitting shoes that don’t rub  Keep body weight within normal range  Avoid BP measurements being taken on the limb

2 0 LO – General Advice To minimise increased fluid leakage into tissues:  Try to avoid injury to the limb (ie: insect bites, venepuncture)  Avoid overheating or sunburning the limb  Treat any underlying medical conditions (ie: hypertension)  Incorporate a warming down routine after exercise  Wear a compression garment if flying > 4 hours  Limb elevation at the end of the day (in earlier stages of LO)

2 0 LO – Why Treat it? Arm LO Leg LO LO is a chronic condition which left untreated will worsen over time!

2 0 LO Health Professional Treatments  Complex Physical Therapy: manual lymphatic drainage, skin care, compression bandaging, limb exercises over 2-4wks followed by fitting of a compression garment  Manual Lymphatic Drainage: specific massage aimed at removing excess fluid & softening fibrotic tissue * Must be administered by a HP trained in the technique  Compression (bandaging or garment): graduated pressure that helps maintain volume reduction

2 0 LO Health Professional Treatments  Pneumatic Pump Therapy: single or multi–chambered pumps that envelopes & applies graduated pressure to the limb  Low Level Laser Therapy: uses wavelengths of ,000nm, may increase lymphatic pumping, promote lymph vessel regeneration & soften fibrotic tissue  Oral Pharmaceuticals: alpha & gamma Benzopyrones. Decrease tissue infiltrate, inhibit leukocytes, stimulate lymphatic contraction, reduce protein concentration

2 0 LO Self Management  Self/partner massage: HP teaches patient or their significant other a simplified version of MLD  Skin Care: daily moisturising  Elevation: can reduce tissue infiltrate and promote lymphatic & venous return  Exercise: can be progressive, resistive or sequential. Varies total tissue pressure to encourage lymphatic drainage

2 0 LO What About Exercise? Traditionally thought that the  in blood flow to the muscles during exercise =  in tissue infiltrate =  limb swelling, however:  Pole walking  Graduated hand weights (+ compression garment)  Aquatherapy (28 o C ok, 34 o C too hot!)  Dragon boat racing  Aerobic exercise  Tai chi based exercise Have been shown to not exacerbate LO and in fact often helps it

Comparison of Therapies for 2 0 Arm LO Percentage Reduction

Comparison of Therapies for 2 0 Leg LO Percentage Reduction

How do you know that therapy is working?  Stabilisation of or reduction in limb volume  Improvement in limb mobility  Improvement in skin condition  Improvement in subjective symptoms  Improvement in undertaking ADL’s/QOL

Thank you and Questions