Lymphoedema Whats New

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Lymphoedema Whats New?

• Maree OConnor
• Physiotherapist
• Victorian Lymphoedema Practice

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Outline

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

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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.

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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

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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

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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

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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.

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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

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Goal 2

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

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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)

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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

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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.

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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

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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

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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?

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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?

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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?

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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?

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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?

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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?

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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

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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

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• 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

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• 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

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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

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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

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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.

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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

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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

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L-Dex XCA
Using low frequency bioimpedance to assess
unilateral lymphoedema of the arm
Courtesy of Impedimed
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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
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Nancy the benefit of patient education
Case study supplied by Louise Koelmeyer with
patients permission
Courtesy of Impedimed
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PC Early intervention
Case study supplied by Dr. Robyn Box with
patients permission
Courtesy of Impedimed
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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

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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.
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The Role of the BCN in Lymphoedema Management

• Lymphoedema education
• Correct bra fitting
• Diagnosis
• Referral
• Lymphoedema treatment