A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course

Transcription

1 2014 Annual Breast Cancer Rehabilitation Healthcare Provider Event A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course November 7 th and 8 th, 2014 Mercer University, Atlanta, GA Sponsored By: TurningPoint s Edith Van Riper-Haase Breast Cancer Rehabiltation Advocacy Fund Presentations are Available on TurningPoint s Website: myturningpoint.org Click on Course Link itsthejourney.org thevisualab.com

2 A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course Lymphedema: Physiology, Risk Factors and Early Detection Cathy Furbish, PT, DPT, CLT This Presentation is available on TurningPoint s Website: myturningpoint.org From Homepage Click on Course Link

3 Lymphedema is Likely the Most Feared Survivorship Issue

4 What is the Lymphatic System?

5 The Lymphatic System The lymphatic system is a complex network of lymphoid organs (thymus, tonsils, spleen),lymph nodes, lymph ducts, lymphatic tissues, lymph capillaries and lymph vessels The system produces and transports lymph fluid from tissues to the circulatory system The lymphatic system is a major component of the immune system

6 Interstitial Fluid / Lymph Fluid Interstitial fluid is a clear fluid Circulates through your tissues to cleanse them and keep them firm, and then drains away through the lymphatic system.

7 Purpose of the Lymphatic System The lymph system is a one-way drainage route designed to rid the tissues of unwanted material and excess fluid. An essential function of the system is to transport proteins too large to re-enter the blood vessels directly.

8 Functions of the Lymphatic System Components Lymph Formation initial lymphatics Lymph Transport lymph collectors superficial / deep Lymph Concentration and Filtration lymph nodes

9 Microcirculation / Lymph Formation

10 Lymph Transport

11 Lymphatic Anatomy

12

13 Lymphangion Subject to stretch reflex Filling triggers contraction Longitudinal muscle opens valve Turbulence passively closes valve on relaxation Responds to internal and external pressure changes

14 Lymphangion Rate of contraction affected by External forces (pressure changes) Respiration Movement Arterial pulsation Internal forces Filling of lymphangion Greater volume of fluid transported = faster rate of contraction Under influence of autonomic nervous system

15 Lymph Vessels Lymph vessels collect lymph fluid and carry it to the lymph node Series of lymphangia make up the lymph vessel Lymphatic vessels (lymphatics) start in the superficial fatty tissue Become progressively larger closer to the trunk and are located near the veins. Lymphatic vessels resemble veins in structure except that lymphatics: have thinner walls. contain more valves to prevent retrograde flow ( backflow ) have well developed muscular walls contain lymph nodes located at certain intervals along their course.

16 Deep lymphatic system Within the body the lymphatic vessels (lymphatics) become progressively larger Lymphatics are located near the veins.

17

18 Lymph System Lymph pumps (lymphangions) are able to accommodate their activity to the lymphatic load (need) Highest possible lymphatic output = transport capacity Lymph collects at the cisterna chyli and fluid travels up the main lymph trunk into the venous system Each day approximately 2L of lymph fluid (containing essential proteins and immune cells) empties into the blood circulation

19 Lymph Nodes Filtration and Concentration Vary in size between.2 to 3.0 cm in adult Grouped in clusters or chains along the lymph collectors Do not regenerate Arranged sequentially along lymph path Function is to filter out and trap bacteria, viruses, cancer cells, and other unwanted substances, and to make sure they are safely eliminated from the body. Reabsorb ~ 40% of H 2 O from lymph fluid and returns it to the venous system Store Inert Particles

20 Lymph Nodes Immune Function Debris and Bacteria are then phagocytosed by immune cells such as macrophages Cancer cells are attacked by specific cellular elements like T-cells

21 Axillary Lymph Nodes Located between pectoral and latissimus muscles on the thorax per side

22 Node (Cluster) Placement Head and neck Supraclavicular fossae Axillae Medial cubital fossae Inguinal fossae Popliteal fossae Lumbosacral About 600 in body About 160 in head & neck

23 Direction Of Lymph Flow

24 Lymphatic Anastomoses

25 Upper extremity lymphatics

26

27 What is Lymphedema?

28 Lymphedema Lymphedema is the result of damaged or blocked lymphatic vessels caused by surgery, radiation therapy, injury, limb paralysis, infection, or an inflammatory condition. Surgery combined with radiation therapy for breast cancer is the most common cause of arm lymphedema for women in the United States

29 Lymphedema If lymph flow is disrupted, protein rich fluid accumulates in the tissues The ground substance (interstitium) swells As in any chronic inflammatory process: Monocytes migrate into the area Monocytes develop into macrophages and multiply Macrophages produce cytokines Cytokines induce fibroblasts and proliferate This increases formation of connective tissue Some fibroblasts develop into adipose tissue

30 Lymphedema may be acute or chronic, transient or progressive. Most often it is seen in the clinic as a chronic, progressive condition. If left untreated it may evolve into a permanent disfiguring condition which is manageable but irreversible.

31 Lymphedema Lymphedema while most commonly found in the arm, may also occur in the trunk, abdomen or breast, resulting from poor or abnormal flow of lymph from tissues to the blood circulation.

32 Incidence of lymphedema?

33 Incidence of Lymphedema Estimates of the incidence of lymphedema following breast surgery varies from 6 to 30% Petrek JA, 2001 Improvements in surgical and radiation therapy techniques have reduced the prevalence to around 20% Hayes, 2012

34 Incidence of Lymphedema survey of 1,151 women treated with surgery and post-op radiation for breast cancer 23% of subjects reported lymphedema in the first 2 years post treatment 45% reported lymphedema by 15 or more years post treatment. Erickson VS et al: J Natl Cancer Inst 93(2) (2001)

35 Typical Time for Onset of Lymphedema Onset is not usually immediate, but typically 6 months to 3 years post treatment 77% of women who develop lymphedema have onset within 3 yrs post surgery The remaining women developed lymphedema at a rate of almost 1% per year Petrek JA et al. Cancer 2001 Sep;92(6):

36 How can the transport capacity of the lymph system be affected in breast cancer?

37 VOLUME Normal Lymph Function Transport Capacity = Maximal Volume of Lymph Fluid Normal System Can Deal With Functional Reserve = Safety Valve Function Capacity is 10 x normal volume in healthy person Normal Volume of Lymph Fluid Leaving Upper Extremity TIME

38 VOLUME Lymph System Compromised Normal Transport Capacity Functional Reserve Decreased = Safety Valve Lower Gradually Reduced Transport Capacity After Breast Cancer Normal Volume Lymph Fluid Leaving Upper Extremity TIME

39 VOLUME Lymph System Insufficiency Visible Swelling Gradually Reduced Transport Capacity After Breast Cancer Volume of Lymph Fluid Increases Beyond Reserve Capacity Due to Increased Arterial Flow from Infection, Inflammation, Burn AND/OR Decreasing Transport Capacity TIME

40 Treatment Factors The most important factor that predisposes a patient to the occurrence of lymphedema is axillary lymph node dissection The incidence of lymphedema increases with the number of nodes removed

41 Determination of Axillary Node Axillary Node Dissection Status nodes removed usually through same incision as mastectomy, separate incision for lumpectomy pathological examination to determine if cancer cells Sentinel Node Biopsy Less invasive determination of axillary node status

42 Radioactive tracer +/- blue dye injected into tumor Wait 45 min 6 hours Scan or Geiger counter to determine location of sentinel node(s) Small incision to remove SN If positive, further axillary node dissection If negative, assume all nodes are negative and avoid further node removal Sentinel Node Biopsy

43 Radiation and Lymphedema Radiation therapy delays normal growth of lymphatics into tissues repairing after surgery and inhibits normal lymphatic proliferative response to inflammation Lymph node fibrosis occurs with radiation and decreases the filtering function of the nodes which deters the immune response Radiation therapy blocks or compresses lymph vessels through radiation fibrosis Herd-Smith et al: Cancer 92(7) , 2001

44 Radiation Therapy Radiation therapy improves survival for women with breast cancer whether treated with a lumpectomy or mastectomy.

45 Treatment Factors Lymphedema is found to only have a prevalence of 6 % in women who do not receive radiation therapy. Herd-Smith et al: Cancer 92(7) , 2001

46 Treatment Factors Development of arm lymphedema after breast surgery is a function of Extent of axillary node removal(0-18%) Radiation therapy (9-44%) Herd-Smith et al: Cancer 92(7) , 2001

47 Patient Factors Increased Body Mass Index (BMI) increases the incidence of lymphedema Ozaslan C et al: Am J. Surg. 187; , 2004

48 Patient Factors: Ethnicity 494 women: 271 White and 223 Black with DCIS Stage III-A breast cancer Circumferential measures for 50 months following diagnosis Factors associated with breast cancer Younger age of onset Obesity More than 10 lymph nodes removed Black women had a higher prevalence of lymphedema (28% vs. 21%) race as an independent variable was not associated with lymphedema

49 Patient Factors Patient factors that are unrelated to the development of lymphedema: Age Drug/chemotherapy Menopausal status Pathological status/tumor size Medical co-morbidities such as DM, CHF, hypertension and autoimmune diseases Vocation/Avocation

50 Predictors of Lymphedema after Breast Cancer Surgery Swenson KK et al: Oncol Nurs Forum. 36 ( (2009 Assessed 94 patients with lymphedema and 94 controls without lymphedema Patients with lymphedema : BMI over 25, axillary radiation more nodes removed than controls

51 Lymphedema Risk Factors Risk Factors: Radiation Axillary Node Dissection Petrek analyzed 15 other potential predictive factors and only 2 were statistically significantly associated in lymphedema: Arm infection/injury Weight gain since operation Herd-Smith et al: Cancer 92(7) 1783, 2001 ; Petrek JA et al. Cancer Sep;92(6):1368, 2001.

52 Predictors of Lymphedema after Breast Cancer Surgery Axillary Node Dissection Odds of swelling increases by 4% for every node removed Axillary Radiation * Arm infection/injury Weight gain since surgery Petrek JA et al, 2001; Paskett et al, 2007 Gur A et al 2009

53 Risk of Developing Lymphedema a Meta-Analysis Articles Excluded articles without a control group Lymphedema measured by circumference, water displacement, impedance, self-report Treatment factors included type of surgery, extent of lymph node dissection, radiation therapy, chemotherapy, presence of positive nodes Tsai, R et al: Ann Surg Oncol Apr.14, 2009

54 Risk of Developing Lymphedema a Meta-Analysis SUMMARY: Mastectomy increased risk of lymphedema compared with lumpectomy. AXILLARY DISSECTION HAS MORE THAN A 3-fold INCREASED RISK COMPARED WITH NO DISSECTION. AND compared with SNB risk was similar. Overall subjects who had received any radiation were at significantly increased risk of developing lymphedema. Among subjects that rec d RT, those who had the axilla radiated had increased risk for developing lymphedema There was NO association between chemotherapy and lymphedema Tsai, R et al: Ann Surg Oncol Apr.14, 2009

55 How can risk of getting lymphedema be reduced?

56 Myths and Realities The inability to identify reliably the factors that cause lymphedema fosters fear and frustration in patients with breast cancer. American Cancer Society Lymphedema Workshop 1998

57 Myths and Realities Many of the patient education materials in current use continue to promulgate behaviors and modifications emanating from an unsubstantiated, empirically derived conception of the physical forces that govern the progression of lymphedema. Rockson, S. Cancer 83: , 1998

58 Clinical Factors Do s and Don'ts have not changed appreciably in several generations of cancer therapy and unfortunately, few objective data have been accumulated to validate the recommendations. Rockson, S.Cancer 83: , 1998

59 The Origin of Lymphedema DO s and DON T s Nelson,P: Geriatrics 21: Avoid cuts, scratches, pinpricks, hangnails Do not dig in the garden or work with thorny plants Do not reach into a hot oven Do not permit injections, blood specimens or blood pressure readings in your arm Wear rubber gloves when washing dishes or cleaning house Use a thimble when sewing Apply lanolin based hand cream frequently Contact your doctor if your arm appears red, warm or swollen

60 The Myths That Women were Told about Lymphedema 2010 American Cancer Society Website: Avoid vigorous, repeated activities, heavy lifting, or pulling. Use your unaffected arm or both arms as much as possible to carry heavy packages, groceries, handbags, or children. Don t do overhead activities Don t lift over 5 pounds Don t weight train Avoid air travel

61 Risk Reduction Strategies? Many primary prevention strategies make sense- avoid sunburn, infection, trauma Other strategies such as avoidance of exercise and repetitive UE use may have potentially negative consequences Exercise may reduce risk of recurrence Clinical trials suggest that exercise may protect against lymphedema Quality of life

62 Lymphedema and Air Travel Air travel is thought to contribute to lymphedema due to the lowered cabin pressure exerting less atmospheric pressure on the limb. The addition of minimal movement while sitting in cramped seats may decrease the muscle pump contributing to the obstruction of lymphatic drainage

63 Lymphedema and Air Travel There are only four published studies on air travel and lymphedema One study by Ward is a single case study that examines the impact of multiple flights (21) over a years period of time. The subject a breast cancer survivor with established lymphedema performed self-impedance measures before and after flights. The impedance measures fluctuated over time and gradually worsened Ward L et al Lymphology 42 (3) , 2009 Graham reported in a retrospective study of 287 breast cancer survivors that there were no cases of permanent new or permanent increased swelling after flying and nine cases of temporary swelling Graham PH Breast 11, (2002)

64 Lymphedema and Air Travel A study on air travel and the appearance or exacerbation of lymphedema. The study was a retrospective, self-report questionnaire that indicated that 5% of women who traveled developed arm lymphedema. 27 of 490 women Casley-Smith J. Aviat Space Environ Med(67) 52-6 (1996)

65 Air Travel and lymphedema 72 at risk women 60 from Canada and 12 from Australia attending a dragon boat race in Australia. (5 women or 7% had lymphedema at the onset) Measured 2 weeks before flight and 6 weeks after flight using a bioimpedance device 95% of the women had no change in impedance measures indicating air travel did not cause increase in extracellular fluid. Worsening of lymphedema in 2 of the 5 women with preexisting lymphedema and 2 new cases (all from Canada)

66 Air Travel and lymphedema Overall the number of studies is low The incidence of lymphedema associated with air travel is low The majority of women who got lymphedema had axillary dissection, took long haul flights Each woman at risk for lymphedema must be evaluated individually. The relative risk for getting lymphedema with air travel is low; however, the patient s extent of treatment, whether or not they had axillary radiation, number of nodes removed, BMI, length of flight should be taken into consideration The prophylactic wearing of a compression garment for women without lymphedema is unlikely to be advantageous. (Graham found an increased swelling with prophylactic sleeve on short flights)

67 Lymph System Insufficiency Surgery and radiation may decrease the lymph flow capacity of the upper extremity, the axilla is like a kink in a garden hose Triggers that increase fluid volume in arm may act as triggers to lymphedema: infection inflammation heat decreased atmospheric pressure Fluid volume that exceeds maximal capacity results in visible swelling

68 Reducing Risk of Lymphedema Truths Early Physical Therapy Exercise aerobic and strength to maximize lymph flow Avoid infection Avoid inflammation Avoid excessive weight gain

69 Managing/Preventing lymphedema Weight loss, whether through reduced calorie intake or increased exercise demonstrated that weight loss reduced lymphedema volumes regardless of the method used to achieve wt loss. Shaw,C et al: Cancer 28 (2007)

70 MYTH: Exercise Causes Lymphedema REALITY Exercise encourages skeletal muscle contraction to help pump lymph and promote drainage

71 Lymphedema and Exercise No form of physical activity has been associated with lymphedema in the literature. Harris (2000) dragon boat paddling Ahmed (2006) weight training Cheema (2006) weight training Courneya (2007) aerobic exercise Lane (2005) resistance training & dragon boat paddling McKenzie (2003) resistance training and arm ergometer

72 REALITY Weight Training and Exercise for Women with Lymphedema: Randomized Controlled Trial Women with unilateral stable lymphedema Groups balanced for potential confounding factors, such as age, surgical history, radiation, obesity, etc. Weight Training Group (n=71) 2x/wk x 90 min x 1 year Community YMCA Supervised x 13 weeks Progressed weight when 10 reps achieved No upper limit on weight Control Group (n=71) Instructed to maintain current fitness activities Schmitz, 2009

73 Results: No significant difference in arm or hand swelling at 1 year Decreased number of flare-ups of lymphedema in weight lifting group Decreased number and severity of symptoms in weight lifting group Significant increase in upper and lower body strength in weight lifting group No upper limit for amount of weight

74 Early Physical Therapy Decreases Risk of Lymphedema in Women with Breast Cancer Locomba, MT et al., British Medical Journal, February, 2010 Results: 1. At 12 month follow -up the incidence of lymphedema was significantly lower in the physical therapy group at 7% (4 women) compared to 25% in the control group (14 women) 2. Women in the control group developed lymphedema more quickly after surgery 3. The study is the first demonstrate the relationship between axillary cording and subsequent development of lymphedema.

75 Reducing Our Risk of Lymphedema: Summary of the Scientific Evidence Approach should be based on individual risk of lymphedema Education re: early signs and symptoms of lymphedema to facilitate early intervention Baseline measures of upper extremity volume (ideally pre-op) to allow early detection (Gergich, 2008) Lifestyle Advice: Exercise Regularly- include stretching, strengthening and aerobic activity Maintain your ideal body mass index (19-22) Understand Potential Triggers Avoid injury, sprains and strains lift within your capacity, work up weights gradually Avoid infection gloves when gardening, extra care for cuts and burns, caution with heat/sun Take a compression sleeve with you for long trips so that you can initiate treatment at the first sign of swelling, including while flying

76 What are the signs and symptoms of lymphedema?

77 Signs and symptoms of Arm or Hand Lymphedema Feeling of tightness, fullness, tingling or heaviness Rings, watch or bracelet becomes tight Arm may swell during the day and diminish or disappear overnight Decreased visibility of the veins in the back of the hand Greater roundness or fullness of the elbow, wrist or forearm

78 Common Symptoms of trunk/ breast Lymphedema Trunk Vise-like pressure around the lower rib cage or thorax Waistband on clothing feels tighter at the end of the day Breast Feeling of fullness, tenderness, pain, heat in the breast tissue Vise-like pressure around the chest or thorax Bra feels tighter more uncomfortable at the end of the day

79

80 Lymphedema Screening Stemmer s Sign: Negative if you can pick up the skin on dorsum of the first bone (proximal phalanx) of the index finger. Knuckle Check: Make two fists. Check between knuckles for diminished space between knuckles. Forearm Tissue (Ulnar/Radius interstitial tissue) Boney contours of elbow Observe Arms outstretched (Abduction)

81 Lymphedema

82

83

84 Stout Gergich, N.L., Pfalzer, N. L., McGarvey, C., Springer, B., Gerber, L. H. and Soballe, P. (2008), Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer, 112: Pre-Operative Assessment of Breast Cancer Patients by Physical Therapists Improves Lymphedema Diagnosis and treatment All study participants were monitored pre-op and at one month post-surgery and at three-month intervals thereafter for one year even if they exhibited no swelling. Using both the pre- and postoperative assessments enabled investigators to diagnose lymphedema before it became visible The authors demonstrated the effectiveness of a surveillance program to successfully detect and treat lymphedema detection and management of lymphedema at early stages may prevent the condition from progressing Once lymphedema was diagnosed it was managed using a lightgrade compression sleeve and gauntlet for daily wear for 4 to 6 weeks and then PRN.

85 2014 American Cancer Society Website Try to get to / stay at a healthy weight Try to avoid infection Try to avoid constriction Exercise Use your arm as normally as you can, once you have healed from surgery or radiation Exercise regularly, but do not overtire your arm Avoid vigorous, repetitive activity Avoid heavy lifting or pulling

86 Summary 1. Risk factors for lymphedema are number of nodes removed and radiation 2. Increased fluid load may trigger lymphedema, but does not CAUSE it 3. Early physical therapy may reduce lymphedema risk 4. Early identification and management is key to controlling lymphedema 5. Exercise is not only safe, but important to risk reduction and treatment of lymphedema 6. While no one wants lymphedema, we can control it

87