A Physiotherapeutic Intervention of Lymph Edema Related to Berast (Sandy)

INTRODUCTION Women who have been treated for breast cancer may be at risk for lymphedema, or arm swelling. Most women who have had breast cancer will not develop lymphedema, but many will.

BREAST CANCER Breast cancer is a cancer that starts in the cells of the breast in women and men. Worldwide, breast cancer is the second most common type of cancer.

(According to WHO International Agency for Research on Cancer, June 2003)

INCIDENCE "World Cancer Report", 10.4% of all cancer incidence is breast cancer (both sexes counted) and the fifth most common cause of cancer death.

World Health Organization (February 2006)

STAGING OF BREAST CANCER Stage 0 Stage I Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IIIC Stage IV - Carcinoma in situ (DCIS) - Tumor (T) does not involve axillary lymph nodes (N). - T 2-5 cm, N negative, or T 5 cm, N negative, or T 2-5 cm and N positive (< 4 axillary nodes). - T > 5 cm, N positive, or T 2-5 cm with 4 or more axillary nodes - T has penetrated chest wall or skin, and may have spread to < 10 axillary N - T has > 10 axillary N, 1 or more supraclavicular or infraclavicular N, or internal mammary N. - Distant metastasis (M)

(Zuckerman, Diana, National Research Center for Women and Families)

TREATMENT OF BREAST CANCERThe mainstay of breast cancer treatment is surgery when the tumor is localized, with possible adjuvant hormonal therapy, chemotherapy, and/or radiotherapy.

Total (simple) mastectomy Total mastectomy with axillary clearance Patey's operation Scanlon's operation Auchincloss modified radical mastectomy(Bhat M.S 2007)

BREAST CANCER AND LYMPHEDEMA Removal of lymph nodes Changes the way of the flow of lymph fluid Development of lymphedema

(American Cancer Society, 2007)

LYMPHATIC SYSTEM AND PATHOPHYSIOLOGY OF LYMPHEDEMA

Lymphatic system Lymph fluid Lymphedema

(Morrell R.M, Halyard M.Y, et al 2005)

DEFINITION : LYMPHEDEMA Lymphedema has been defined as an abnormal accumulation of protein-rich fluid, edema, and chronic inflammation and can elicit pain, tightness, and heaviness in the upper extremity, as well as lead to recurrent skin infections.

(Bicego D, Brown K, et al 2005)

CLASSIFICATION OF LYMPHEDEMA Classification by Kinmonth et al. in 1957

Primary lymphedema Secondary lymphedema

CLINICAL PICTURE : LYMPHEDEMA

STAGING OF LYMPHEDEMASTAGEI

DESCRIPTIONReversible lymphedema

CHARACTERISTICSSwelling reduced with elevation of the swollen extremity Pitting Increased fibrous tissue with progressive skin hardening Frequent infections No pitting No reduction in swelling with elevation of the extremity

II

Spontaneously irreversible lymphedema

III

Lymphostatic elephantiasis

Progressive fibrosclerosis Skin changes (large hanging skin folds, papillomas) Association with Stewart-Treves syndrome

(Morrell R.M, Halyard M.Y, et al 2005)

DIAGNOSIS Early symptoms Sensation of arm fullness Mild discomfort Joint immobility Pain Skin changes Predisposed to infections

Physical examination Pitting of tissues Increased thickness of skin folds Enlargement of the affected limb Water displacement volumetry Tissue tonometry Circumferential arm measurement

Other quantitative measures Radiological imaging studies Computed tomography Magnetic resonance imaging (MRI) Ultrasonography Lymphoscintigraphy Lymphangiography

TREATMENT FOR LYMPHEDEMA Objectives of Treatment Prevent progression of lymphedema Encourage the flow of lymph through unaffected vessels Help patients cope with the psychological aspects of lymphedema Improve the patient's overall quality of life

TYPE OF TREATMENT PATTERNS

Pharmacological Non pharmacological

PHARMACOLOGICAL OR DRUG THERAPY Antibiotics Diuretics Benzopyrones (coumarin and flavonoids) Steroids

NON PHARMACOLOGICAL TREATMENT

Complex Decongestive Physiotherapy (CDP) Manual Lymph Drainage Multi-layer compression bandaging Exercise therapy

OBJECTIVE AND CONTRAINDICATION OF CDP Objective of CDP Encourage lymph movement Reduce fibrotic tissue Improve the shape of the limb Reverse skin condition Contraindication of CDP: Cellulitis Acute bronchitis Deep vein thrombosis Infection

MANUAL LYMPH DRAINAGE (MLD)MLD was developed in 1932 by Dr. E. Vodder and his wife. MLD is a gentle manual treatment technique that is designed to: Encourage the development of collateral lymph vessels Redirect lymph flow to unobstructed cutaneous lymphatic vessels Stimulate the flow of lymph Enhance lymphatic contractility

RESEARCH STUDY Aim - To investigate whether addition of MLD to standard therapy improved the outcome in women with modest lymphedema. Result - The study showed that both groups obtained a significant reduction in edema and that MLD did not contribute significantly to reduce edema volume.

(Acta Oncologica Vol. 39, No. 3, 2000)

COMPRESSION THERAPY Compression bandages Compression garments Gradient compression devices or pneumatic compression devices

(Morrell R.M, Halyard M.Y, et al 2005)

RESEARCH STUDY Aim MLD + Compression bandage (CB) Vs CB Result CB, with or without MLD, is an effective intervention in reducing arm lymphedema volume There may be an additional benefit from the application of MLD.

(Breast cancer research and treatment 2004)

KINESIO TAPING Kinesio Taping was developed by Dr. Kenso Kase, in 1973. Kinesio Taping is a versatile modality for the treatment of swelling due to lymphedema and other conditions. Benefits: supporting contraction of a weakened muscle reducing fatigue reducing cramping increase joint range of motion relieving muscle and joint pain

PNEUMATIC PUMPS Pneumatic pumps, also known as pneumatic compression garments. Treatment with pneumatic pumps is not very popular among patients because: It is very expensive It is very time consuming It does not help break down fibrotic tissue

FARADISM UNDER PRESSURE (FUP) Providing treatment for lymphedema using faradic type of current under pressure. Other electrical modalities: IFT LASER

THERAPEUTIC EXERCISES Therapeutic exercises are a recognized treatment of lymphedema. These include remedial exercises that aid lymph flow through repeated contraction and relaxation of muscles.

ADVICE TO PATIENT Use limb as normally as possible Avoid minor injuries Do not take hot bath Dont carry heavy objects Elevate limb while resting

SUMMERY Lymphedema is a chronic and debilitating disease that can arise from breast cancer treatment. Via different therapeutic approaches And techniques lymphedema can be completely cured although additional research on Breast Cancer Related Lymphedema (BCRL) is needed.

CONCLUTIONThe effects of lymphedema on a patients quality of life are substantial and can be devastating. Physiotherapists should strive to provide more patient education and increase awareness of BCRL symptoms along with supportive counseling, if necessary. Thus we can help to improve the quality of life to the BCRL patients WORLDWIDE.