Lymphedema:

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Lymphedema

• Lymphedema is a progressive disorder
  characterized by abnormal accumulation of protein
  rich fluid in the interstitial space.
• In breast cancer, lymphedema is due to
  treatment-induced mechanical insufficiency of the
  lymphatic system.

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Incidence, Prevalence and Onset of Lymphedema

• Incidence
• Approximately 50 of women report some swelling
  of arm within 3 years of BC surgery (Petrek et
  al, 2001 Paskett et al, 2007)
• Prevalence
• 32 of women report persistent swelling 3-5 years
  from surgery (Engel et al, 2003 Paskett et al,
  2007)
• 13 (33/263) reported lymphedema measurements as
  SEVERE (gt5.0cm) (Petrek et al, 2001)
• Time of onset (Petrek et al, 2001)
• 77 (98/128) onset within 3 yrs post surgery
• The remaining women developed lymphedema at a
  rate of almost 1 per year

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Lymphedema Risk Factors
(Petrek JA et al, 2001 Kwan, 2002 Paskett et
al, 2007)

• Radiation (not identified by Paskett)
• Axillary Node Dissection
• Odds of swelling increases by 4 for every node
  removed
• Arm infection/injury
• Weight gain since operation
• Chemotherapy
• Tamoxifen
• Marital status
• Paskett only
• Note no relationship between lymphedema and
• exercise frequency or reconstructive surgery

4
Lymphedema Myths

• Dont exercise
• Dont do overhead activities
• Dont lift over 5 pounds
• Dont weight train

Quality of Recovery Advice Affects Morbidity and
Quality of Life Associated with Breast Cancer
Treatment Quality of Life and Upper Body
Function were highest among those who followed
minimal advice, who used their treated side as
much as their untreated side. Round et al, 2006
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Changing the Myths of Exercise and Lymphedema
McKenzie, Harris University of British Columbia
Courneya, Campbell, McNeely, Mackey University
of Alberta
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Secondary Shoulder Dysfunction

• Myofascial syndromes
• Impingement syndrome and other shoulder
  dysfunction related to abnormal biomechanics
• Impingement syndrome in lymphedema (Herrera
  Stubblefield, 2004)
• Peripheral Neuropathy
• Weakness of Serratus Anterior associated with
  Long Thoracic N. Neuropathy secondary to ALND in
  up to 30 of patients post ALND
• (Duncan, 1983 Kauppila, 1996)

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Functional Limitations and Quality of Life

• Many studies have reported short and long term
  reduction in quality of life during and following
  treatment for breast cancer
• At 3 months, lt 30 of patients have returned to
  normal activities of daily living (Gosselink,
  2003)
• Approximately ½ of women report difficulty
  lifting, carrying and sleeping at 1 year
  post-surgery (Karki, 2005)
• Significantly greater prevalence of functional
  limitation in women with
• ALND versus SNB
• Higher Body Mass Index
• Lower education
• (McCredie et al, 2001 Leidenius et al, 2005
  Barranger et al, 2005 Langer et al, 2007 Karki,
  2005 Gosselink, 2003 Ganz )

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Clinical Case
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• Eve is a 54 year old woman who is referred to
  physical
• therapy with arm swelling, shoulder/chest wall
  pain
• and fatigue.
• Breast cancer history
• Tumor was hormone receptor ve, Her2neu negative
  Stage II with 5 ve axillary lymph nodes
• 8 months post-mastectomy
• 4 rounds of adriamycin/cytoxin and 4 rounds of
  taxol
• 30 treatments of radiation to chest wall, axilla,
  supraclavicular lymph nodes completed 1 month ago
• Social
• Works at Delta- uses computer
• Married with 4 adult children
• Very concerned about using her arm based on
  previous advice
• Not exercising regularly, concerned about weight
  gain of 28 lbs since surgery

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Right Left
Shoulder Flexion 168 135 Pain at end range, tight pecs and latissimus mm. Abnormal Scapulo-humeral rhythm.
Shoulder Abduction 160 128 Pain at end range into upper extremity to elbow, visible axillary cording. Abnormal Scapulo-humeral rhythm.
Hand Behind Back (Ext/IR/Add) To L1 level To Left PSIS
UE Swelling N/A 21 gt than left ve Stemmers sign Pitting posterior aspect of forearm
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Additional Evaluation

• Posture
• Forward Head Posture, Dropped Shoulder
• Soft Tissue Palpation
• Decreased tissue mobility of mastectomy incision
  region, axilla, pectoralis major and latissimus
• Articular Mobility
• G-H joint mobility within normal limits
• Decreased mobility of A-C and S-C
• Upper Limb Tension Test
• Pain reproduced along cording in axilla and
  anterior cubital fossa in g-h abduction and elbow
  extension
• Muscle Length-Tension tests
• Tight pectoral, latissimus muscles
• Poor Core Stability

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Axillary Cording
Decreased Extensibility of Pectoral Muscle
Decreased Extensibility of Latissimus Muscle
Tightness Surgical Incision
Modified Radical Mastectomy with Chest Wall and
Axillary Radiation
13

Abnormal Scapulo-humeral Rhythm
Lymphedema
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Functional Status Measures

• Patient-Specific Functional Scale
• (Chatman et al, 1997 Westaway, 1998 Stratford
  et al, 1995)
• Upper Extremity Functional Index (UEFI)
• (Stratford et al, 1997)
• FACT-B at admission and discharge
• (Brady et al, 1997)

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Eves Plan of Care Week 1 and 2  

• Manual Therapy, Posture Education and Exercise
  for shoulder and chest wall pain and dysfunction
  (Wingate, 1985 Na, 1999 Box, 2002 Lauridson,
  2005 Shamley, 2007)
• Lymphedema Education
• Weight management
• Lymphedema Risk Factors
• Lymphedema Myths and Exercise
• Lymphedema Management
• Manual Lymph Drainage
• Bandaging
• General Range of Motion Exercise
• Skin Care and massage for lymphedema compression
  garments later
• (Preston, 2007 Harris, 2001, McNeely et al, 2006)

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Week 3-5  

• Added aerobic, strengthening and stretching
  exercise program to
• decrease fatigue
• increase quality of life
• Control/reduce weight
• Reduce risk of recurrence
• (Courneya et al, 1999,2002 Dimeo, 1999 McNeely
  et al, 2006 Ahmed, 2006 Mathews, 2007 Mutrie,
  2007 Holmes, 2005)
• Counseling
• Massage therapy
• Nutritional
• counseling

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Summary There is significant literature that
documents the morbidity associated with breast
cancer and supports the role of physical therapy
in increasing function in these women.
Referral to physical therapy remains the
exception rather than the norm and the barriers
to routine referral to rehabilitation for women
with breast cancer are significant. (Cheville,
2007)
21
Physical Therapists around the globe have a
responsibility to incorporate the literature into
practice to assist women with breast cancer to
move from
Surviving to Thriving
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