Living well with Lymphoedema
Norah Kyne, MISCP, CDT Therapist
University Hospital Galway
GUH Cancer Centre Annual Report 2012
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Breast
Urological
Upper GI
Colorectal
Skin
Lung and cardiothoracic
Head and Neck
Endocrine
Haematological
Radiology
Pathology
Medical Oncology
Radiation Oncology
Cancer Nursing
Palliative Medicine
Cancer Research
Education and Training
Cancer Charity Support
Stem Cell Unit
Clinical Trials
Cancer and/or Neoplastic Diagnosis recorded 2012
 Gastrointestinal
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363
Breast
860
Genitourinary
964
Dermatology
1859
Gynaecologic
96
Lung and mediastinum
155
 Head and Neck
126
 Haematolymphoid
330
 Bone and soft tissue
67
 Other
84
Physiotherapy management
 Surgery - pre-operative as available, deep breathing exercises, anti – dvt exs,
posture, range of motion, scar management
 Chemotherapy – management of fatigue, graduated exercise
programme
 Radiation – range of motion, decreased skin mobility
 Rehabilitation - depending on diagnosis
 Lymphoedema management - based on presentation of
lymphoedema
Scar impact
Scar management
 Location :
 potential barrier for lymphatic drainage
 does it limit joint mobility
 Treatment
(2-3 weeks post surgery as per Doctor’s protocol)
Mobilization
Prevent adherence and hypertrophy
Scar products eg mepiform(silicon)
Foam (swell spot)
Kinesotape (post 4 weeks/no radiation)
Cording/Axillary Web
Causes
 Interruption to lymphatic vessels during biopsy or
lymph node dissection - fibrosiss
 Incidence : around 19%
 Treatment :
 Stretching and flexibility exercises
 Manual therapy
Definition of lymphoedema
 Lymphoedema is the accumulation of
protein rich fluid in tissues with
inadequate lymphatic drainage.
National Lymphoedema Network (May 2012)
What can cause lymphoedema after cancer ?
 Insult to the lymphatic system following surgery
and/or radiotherapy
 Extent of surgery
 Wound infection after surgery
 BMI > 26
LMost common presentations with secondary lymphoedema
Upper Limb
Incidence of breast cancer in Ireland from 2008 -2010
Females : 2,767 Males : 22
 Arm lymphoedema 24-67%
 Breast lymphoedema 20-40%
 Trunk lymphoedema
Swelling in the arm is common, but the breast,
chest and back areas can also develop
lymphoedema
Lower limb lymphoedema
cancers in the pelvic region
Incidence in Ireland 2008 – 2010
Cervix : 308 incidence of lymphoedema 18%
Uterus : 389 incidence of lymphoedema 17%
Ovary : 345 incidence of lymphoedema 7%
Other gynaecological cancers : 99 (incidence of lymphoedema
47%)
Prostate : 3,014 incidence of lymphoedema 4%
Testes : 175 incidence of lymphoedema ?10%
Penile : 2% of all male tumors incidence of lymphoedema 21%
Bladder : female – 124, male – 310 incidence of lymphoedema 16%
Gynecological Cancer Secondary Lymphedema
Upper limb or lower limb
Melanoma
Incidence of Melanoma in Ireland 2008 – 2010
Females : 463 Males : 349
 Sentinal node clearance : 1.7%
 Axillary node clearance : 1 – 12%
melanoma
Head and Neck
 Incidence of mouth and pharynx cancer in Ireland
2008-2010
 Females 119, Males 227
Treating Lymphoedema
CDT:
Complete Decongestive Therapy
Treatment of lymphoedema
 4 cornerstones of care:
1. Skin care
2. MLD/SLD
3. Compression via multilayer bandage or
garments
4. Exercise
CDT
Benefits of CDT
 Reduction of pain/discomfort
 Reduced risk of infection/cellulitis
 Maintain/improved skin texture
 Improve motion and ability to perform daily activities
 Decrease fear and increase control over the condition
of lymphoedema – empower
 Improve quality of life
Skin and nail care
 Decrease risk of infection
 Keep skin supple and clean
 Avoid injury (nicks, bites, burns etc)
 Clean all injuries immediately
 Lotions – non perfumed
Skin care : infection
 Signs/symptoms
 Red, warm/hot, pain, not feeling well, temperature,
increased swelling
 Go to GP or emergency department
MLD aims to redirect fluid from swollen areas to healthy lymphatic
vessels, transporting it back to the normal circulatory system .
With gentle, light but precise hand movements applied to the skin.
This encourages the fluid away from congested areas by bypassing
ineffective or injured lymph vessels.
The treatment is very gentle and a typical session will involve drainage of
the neck, trunk, and the affected extremity (in that order), lasting
approximately 40 to 60 minutes.
The technique was pioneered by Doctor Emil Vodder in the 1930s for the
treatment of chronic sinusitis and other immune disorders
Manual Lymphatic Drainage
Simple/self lymphatic drainage
Self Lymphatic drainage:
Deep breathing plus SLD
Multi layer compression bandage
 Reduce swelling and prevent re-accumulation of fluid
 Provides a firm support for muscles, whose
contractions against the lymph vessels enhance lymph
flow
Compression garments
Exercise
Exercise
 Pumping action moves lymph through the lymphatic
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system
Deep breathing stimulates lymph flow
Maintains strong muscles which give protection
Wear well fitting garments
Improve sense of health and well-being
Walk, bicycle, swim, yoga, dance, housework !
 OVERALL IMPROVE YOUR QUALITY OF LIFE
CDT
 CDT should be carried out by a certified lymphoedema
therapist
 Number and frequency of treatment depends on severity of
lymphoedema
 Access to service will influence management
 Compression garments as appropriate are fitted
On discharge self – management is key!
Self management
At discharge from treatment you should know
Day time compression products
Night time compression
Skin care
Exercise programme
Self manual lymphatic drainage
Self management
Compression garments daytime :
 Freedom of movement
 Provide pressure to control lymphoedema
 Strong but not too strong that it is difficult to get on or
off
 Well fitted
 No constrictions
Compression garments
Compression at night
 Depends on stage of management of condition
 In discussion with your therapist
 Made to measure garments available
Improved range of garments
Exercise (NLN)
 Start gradually/conservatively
 Add exertion slowly and in small increments only if
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there has been no increase in lymphoedema after
exercise to date
Stay well hydrated
Take periodic deep abdominal breaths – facilitate
lymph drainage
Avoid temperature extremes
Modify moves to accommodate your own needs
Warm up, cool down, stretch
Self management
 Lymphoedema cannot be cured but it can be
managed
 Self management is critical to reduce
exacerbations of lymphoedema, infections
and other symptoms associated with
lymphoedema.
Self management
Can you prevent lymphoedema ?
No-one can prevent lymphoedema once lymph nodes
have been removed or if radiation over lymph nodes
It can occur at any stage after surgery /irradiation
The goal is to
Reduce your risk
Risk reduction(National Lymphoedema Network NLN )
 Protect skin – insect repellent, sunscreen, nail care
 Avoid injections - in at risk limb
 Exercise – gradually build up duration and intensity; monitor
reaction of limb
 Avoid prolonged extreme heat or cold – (>15 mins) eg hot
tub/sauna
 Weight control – manage your weight and well being
 Know your body – pay attention to areas at risk
 If you notice early symptoms seek medical attention
Early symptoms
 Swelling – you may notice clothes feeling
tighter on affected side
 A feeling of heaviness in the limb
 Pain
Be informed/education
 The Irish Cancer Society – www.cancer.ie
 Irish Health – www.irishhealth.com
 Lymphoedema Ireland – www.lymphireland.com
 Manual Lymphatic Drainage Ireland – www.mld.com
 Gary Kelly Cancer Support centre – www.gkcancersupport.com
 LARCC(Lakelands area Retreat & Cancer Centre – http://larcc.ie/
 Arc Cancer Support – www.arccancersupport.ie
Information
 National Lymphoedema Network
 (www.lymphnet.org)
 Lymphatic Research foundation
 (www.lymphaticresearch.org)
Current Services
DCU/ICS research 2010, Living with Lymphoedema in Ireland
:Patient and Service Provider Perspectives
Key Findings
Service settings
 Public
 Private
 Cancer Support centre
 Hospice
 Community
Lymphoedema Practitioners
 Most work in large public hospitals 62.8%
 Profile of practitioners : physiotherapists 48.6%, breast care nurse
13.1%, PT manager 10.3%, MLD therapist 10.3%, OT 6.5%, Lymph nurse
specialist 1.9%, other 15%
 28 practitioners in a dedicated service
 No report of Social worker, Psychologist or Psychiatrist
in any service
Referral Systems
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Hospital oncology clinic
Hospital surgical clinics
Hospital Physiotherapy clinics
Hospital dermatology clinics
Community Physiotherapy clinics
General Practitioners
Patients self referring
Family/Friends of patients
Other (eg palliative care teams, Cancer Care Centres
etc
Areas providing lymphoedema
services
Area
% general service
N= 108
% dedicated service
N = 18
Dublin
33.3
50
Cork
14.8
11.1
Donegal
9.3
Galway
6.5
Laois
3.7
Cavan
3.7
Tipperary
3.7
Wexford
2.8
Westmeath
2.8
Meath
2.8
Louth
2.8
5.6
11.1
Lymphoedema Services cont
Area
% general service
n= 108
% dedicated service
N= 18
Limerick
1.9
5.6
Mayo
1.9
Monaghan
1.9
Wicklow
1.9
Waterford
0.9
Sligo
0.9
Clare
0.9
Kerry
0.9
Kildare
0.9
5.6
Current Services
DCU/ICS research 2010
 Some Key Findings
 Lymphoedema services are insufficient and patchy
 Key challenges exist with regard to sustainability of
services
 Delays with garments may compromise service
provision
 Patients identified eg barriers to treatment, impact of
lymphoedema on daily life, fear of uninformed health
professional inadvertently worsening their condition
Future Services – Good news !
 More information/education to public about
lymphoedema
 Physiotherapy training : Education about and management
of lymphoedema is included at undergraduate level
 HSE National Director of Quality and Patient Safety
 Philip Crowley – supported carrying out a survey of current
lymphoedema Services , awaiting feedback .
 NCCP are establishing a group to look at lymphoedema
prevention – Physiotherapist sitting on this group
 Thank you for your attention
 Any Questions ?