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Lymphoedema Whats New

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Title: Lymphoedema Whats New


1
Lymphoedema Whats New?
  • Maree OConnor
  • Physiotherapist
  • Victorian Lymphoedema Practice

2
Outline
  • Australian lymphoedema recommendations
  • Lymphoedema projects
  • ALA 2008 conference
  • The role of the BCN in lymphoedema management
  • Questions

3
Lymphoedema Recommendations in Australia
  • The Medical Service Advisory Committee 2004
  • Improved training should be promoted amongst all
    health professionals and that more specialist
    training was needed
  • Department Human Services Vic 2003
  • Highlighted an existing unmet need for services
  • Supported the need for more specialist services
    with equitable access.
  • ALA Lymphoedema National Service Equity Survey
    2002
  • Concluded that the distribution of services did
    not meet local demand.

4
Projects as a result of these recommendations
  • 2006 the ALA established the Education Training
    and Guidelines Subcommittee
  • 2006 Lymphoedema Association of Vic obtained
    funding for a General Practitioner education
    project
  • 2007 NBOCC obtained funding for a Lymphoedema
    Initiative

5
The ALA Lymphoedema Treatment Workforce Vision
  • Australia New Zealand will have a sustainable
    lymphoedema treatment workforce that is
    knowledgeable, skilled and adaptable.
  • The workforce will be suitably trained and
    competent and will be distributed to achieve
    equitable lymphoedema treatment.
  • The workforce will be valued and be able to work
    within a supportive environment and culture.
  • It will provide safe, quality and supportive care
    that is population and consumer focused and
    capable of meeting the needs of this group of
    consumers within the Australian New Zealand
    community.
  • This vision is based on The National Health
    Workforce Strategic Framework 2004

6
Levels of the ALA National Education Framework
  • Level A Undergraduate education program
  • Level B Lymphoedema education programs for
    health professionals that may come in
    contact with those at risk or who have
    lymphoedema
  • Level C Lymphoedema management treatment
    course

7
ALA Goals
  • Australia NZ lymphoedema service equity and
    workforce project.
  • Develop and implement lymphoedema education
    strategies to further develop and support the
    lymphoedema treatment workforce
  • Establish the National Lymphoedema Practitioners
    RegisterNLPR
  • Establish a lymphoedema education scholarship
    fund.

8
Goal 2 Develop and implement lymphoedema
education strategies to further develop and
support the lymphoedema treatment workforce
  • Develop and implement a national tertiary
    evidence-based, multidisciplinary lymphoedema
    management and treatment training course.
  • Establish a lymphoedema continuing professional
    development (LCPD) program for the National
    Lymphoedema Practitioners Register (NLPR). This
    will include a mentoring program

9
Goal 2
  • Develop disseminate lymphoedema education
    packages for health professionals in relation to
    primary lymphoedema
  • Develop a lymphoedema Train-the-Trainer

10
Graduate Certificate in Lymphoedema Management
  • Certificate will provide 50 points towards
    Masters Level
  • Possibility of having two distinct specialist
    certificates that after completion of both a
    graduate certificate is awarded.
  • The first specialist certificate equivalent to
    the level 1 course ( 25 points masters level)
  • Second specialist certificate equivalent to the
    level 2 course ( 25 points masters level)

11
Graduate Certificate in Lymphoedema Management 50
points at Masters Level
Specialist Certificate in Lymphoedema
Management 1 Equivalent to Level 1 Course 25
points at Masters Level
Specialist Certificate in Lymphoedema Management
2 Equivalent to Level 2 Course 25 points at
Masters Level

12
Graduate Certificate in Lymphoedema Management
  • University prerequisites
  • An undergraduate degree or equivalent
    qualification in medicine, nursing (div 1),
    occupational therapy or physiotherapy
  • Documented evidence of at least the equivalent of
    one years full-time relevant professional work
    experience in a medical, scientific or allied
    health environment.
  • Have current professional registration with the
    appropriate State or Territory Registration
    Board, or in states where there is no
    registration be part of an accreditation scheme.

13
Graduate Certificate in Lymphoedema Management
  • Credit points for previously completed level 1
    course after successfully completing an ALA
    examination for the level 1 course
  • Followed by successful completion of the second
    specialist certificate and be awarded a graduate
    certificate in lymphoedema management

14
Lymphoedema Diagnosis and Management in General
Practice
  • Joint project of Lymphoedema Association of Vic,
    GPDV NBOCC
  • Developed information card including assessment
    flow chart for secondary primary lymphoedema (
    based on evidence review)
  • GP seminars including interactive case studies

15
Case study 2 - Ms DN
  • Presentation
  • 45 year-old female accountant
  • Developed oedema in left arm following a bus tour
    of Outback Australia two months ago
  • Left arm swelling extending from her hand to
    upper arm
  • Feeling of tightness and heaviness in the arm
  • Swelling reduces somewhat at night
  • What information will you seek from the patient?

16
Case study 2 Ms DN
  • Medical history
  • Diagnosed with left breast cancer in 2002
  • Lumpectomy and ALND
  • Later received chemotherapy followed by
    radiotherapy to the breast
  • Walks 5 km daily, gym work twice a week
  • What would you look for on physical examination?

17
Case study 2 - Ms DN
  • Physical examination
  • Moderate swelling of left hand and forearm
  • 3cm difference in circumference between left and
    right arms
  • Soft, pitting oedema
  • No skin infection
  • Skin moist and supple
  • Breast and axillary examination - no lumps
    palpable
  • BMI 23 kg/m2
  • What differential diagnoses for the oedema would
    you consider at this stage?
  • How would you investigate the oedema?

18
Case study 2 - Ms DN
  • Test results
  • Mammogram normal
  • CT scans of chest and abdomen clear
  • No DVT on Duplex scan
  • How would you manage this patient?

19
Case study 2 - Ms DN
  • Referral to lymphoedema practitioner
  • Education on care of her arm, including skin
    care, and exercise program
  • Left arm circumference reduced by 1.5 cm
  • Daily exercises and occasional lymphatic massage
    for maintenance
  • What long-term management issues may arise for
    this patient?

20
Case study 2 - Ms DN
  • Follow-up opportunity
  • Patient comes into surgery 5 months later asking
    for antibiotics for a throat infection
  • On questioning about her lymphoedema
  • Says she is sick and tired of people asking her
    when her arm is going to get better
  • Tells you she has stopped going to the gym and is
    upset that shes putting on weight
  • She is concerned that returning to gym work will
    make the swelling worse
  • How would you respond to her concerns?

21
Case study 2 - Ms DN
  • Management intervention in GP
  • Liaison with lymphoedema practitioner re
    guidance on returning to gym work
  • Referral for psychosocial support (e.g. social
    worker at lymphoedema clinic or local
    psychologist)
  • Patient put in contact with peer support group
    through Lymphoedema Association of Victoria

22
NBOCC Secondary Lymphoedema Initiative
  • Governance structure
  • Steering Committee
  • Evidence Review Working Group
  • Health Professionals Working Group
  • Consumer Working Group
  • Aboriginal and Torres Strait Islander Working
    Group

23
  • Health professional resources
  • The management of secondary lymphoedema
    a guide for health professionals
  • The management of secondary lymphoedema workshop
    module for health professionals
  • Secondary lymphoedema workshop module for
    Indigenous health professionals
  • RHEF satellite broadcast
  • ACRRM on-line learning module

24
(No Transcript)
25
  • Consumer resources
  • Consumer leaflet and booklet about secondary
    lymphoedema (also available in Arabic, Chinese,
    Greek, Italian, Vietnamese)
  • Information pamphlet for Aboriginal and Torres
    Strait Islander consumers
  • Phone NBOCC 1800 624 973 www.nbocc.org.au

26
NBOCC 2008 Lymphoedema Evidence Review
  • Incidence after breast cancer approx 20 (
    ALND) 6 17 (SNB)
  • One in five following breast cancer may develop
    lymphoedema.
  • 4000 new cases per year across all cancers
  • Lack of evidence to support risk factors

27
NBOCC 2008 Lymphoedema Evidence Review
  • Lack of treatment may lead to progression
  • Conservative lymphoedema treatment is associated
    with volume reductions.
  • Further research required on the role of exercise
    and type of exercise
  • No evidence to support the use of specific
    pharmacological interventions

28
NBOCC 2008 Lymphoedema Evidence Review
  • Surgical intervention useful for only a small
    subset with secondary lymphoedema
  • Patient factors such as BMI, history of
    cellulitis, time between cancer treatment onset
    of lymphoedema, extent of surgery and duration of
    lymphoedema can lead to higher volumes and reduce
    the potential for effective treatment
  • Early diagnosis and treatment of lymphoedema may
    be an important factor in the success of
    treatment.
  • Patient compliance may affect the success of
    treatment.

29
ALA Conference March 2008Exercise Your
MindStretch Your Boundaries
  • Exercise in Lymphoedema or At Risk patients
  • A/Prof Katie Schmitz, Philadelphia
  • As women get stronger in a carefully controlled
    setting, activities of daily living that
    previously may have overstressed the
    musculoskeletal system, and thereby the lymphatic
    system, represent an increasingly lower
    percentage.
  • Trial with 288 breast cancer survivors

30
Assessment Interpretation Monitoring vs
intervention to alter the clinical outcome in
breastcancer related lymphoedema
  • Demonstrated the outcomes which can be achieved
    when a stepped and progressive approach to
    assessment and monitoring is used for early
    detection and intervention of breast cancer
    related lymphoedema
  • Dr Robyn Box

31
L-Dex XCA
Using low frequency bioimpedance to assess
unilateral lymphoedema of the arm
Courtesy of Impedimed
32
The L-Dex(Lymphoedema index) scale
  • A simple way to view impedance data
  • Comparison to normal range.
  • The XCA uses the L-Dex (Lymphoedema Index) for
    assessment of unilateral lymphoedema of the arm.
    The normal range for an L-Dex value for patients
    without lymphoedema is between -10 to 10.
  • The normal range for L-Dex was established from
    bioimpedance data gathered from a cross
    population study of healthy women 1. The mean
    (average) L-Dex value of healthy women without
    lymphoedema is defined as 0.0 within this normal
    range.

Courtesy of Impedimed
33
Nancy the benefit of patient education
Case study supplied by Louise Koelmeyer with
patients permission
Courtesy of Impedimed
34
PC Early intervention
Case study supplied by Dr. Robyn Box with
patients permission
Courtesy of Impedimed
35
Small Trials
  • Hand held massage unit 26 subjects
  • Elevation arm lymphoedema
  • 14 subjects
  • LPG technique two trials, 24 women, 10 women
    (compression bandaging also applied)
  • Bodyflow 16 active, 13 placebo

36
Table 1. Mean change in parameters at the end of
trial in the active and placebo groups Parameter
Active Placebo Leg Fluid Vol (mls) ? 200mls
p lt 0.01 ? 50mls p lt 0.05 Total Leg Vol (mls) ?
302mls p lt 0.01 ? 274mls p lt 0.01 Truncal Fluid
(mls) ? 200mls p lt 0.01 ? 200mls p n.s.
37
The Role of the BCN in Lymphoedema Management
  • Lymphoedema education
  • Correct bra fitting
  • Diagnosis
  • Referral
  • Lymphoedema treatment
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