Transcript Jill Binkley presentation

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.
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
•
13% (33/263) reported lymphedema measurements as SEVERE (>5.0cm)
al, 2003; Paskett et al, 2007)
(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
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
Lymphedema Myths…
• Don’t exercise
• Don’t do overhead activities
• Don’t lift over 5 pounds
• Don’t 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
Changing the Myths of
Exercise and Lymphedema
McKenzie, Harris University of British Columbia
Courneya, Campbell, McNeely, Mackey University of Alberta
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)
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, < 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; )
Clinical
Case
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
Shoulder Flexion
Right
Left
168 °
135 °
Pain at end range,
tight pecs and
latissimus mm.
Abnormal Scapulohumeral rhythm.
Shoulder
Abduction
160 °
128°
Pain at end range into
upper extremity to
elbow, visible axillary
cording.
Abnormal Scapulohumeral rhythm.
Hand Behind Back To L1 level
(Ext/IR/Add)
To Left PSIS
UE Swelling
21% > than left
+ve Stemmers sign
Pitting posterior aspect
of forearm
N/A
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
Decreased Extensibility of
Pectoral Muscle
Axillary Cording
Decreased Extensibility of
Latissimus Muscle
Tightness Surgical Incision
Modified Radical Mastectomy with Chest Wall and Axillary Radiation
Lymphedema
Abnormal Scapulo-humeral
Rhythm
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)
FUNCTIONAL GOAL AND OUTCOME WORKSHEET
PATIENT SPECIFIC FUNCTIONAL
SCALE ACTIVITIES
(10 = full function)
1. Doing Hair
2. Computer work
3. Reaching upper cabinets
PAIN SCORE:
(0 = no pain)
Upper Extremity Functional
Index (N=80)
FACT-B
Physical Well-Being ( /28)
Social/Family Well-Being ( /28)
Emotional Well-Being ( /24)
Functional Well-Being ( /28)
Additional Concerns ( /40)
Initial
2
3
2
6
45
18
15
16
12
20
KEY IMPAIRMENT MEASURES:
1. Shoulder Flexion
2. UE Volume
GOALS:
1. Shoulder Flex > 160 º
2. Pain < 2/10
3. (L) volume < 8%
4. UEFI > 70/80
5. Computer work > 8/10
6. FACT-B Functional > 22
7. Exercise Program in place
135 º
21%
Eve’s 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)
FUNCTIONAL GOAL AND OUTCOME
WORKSHEET
PATIENT SPECIFIC FUNCTIONAL
SCALE ACTIVITIES
(10 = full function)
1. Doing Hair
2. Computer work
3. Reaching upper cabinets
PAIN SCORE:
(0 = no pain)
Upper Extremity Functional
Index (N=80)
FACT-B
Physical Well-Being ( /28)
Social/Family Well-Being ( /28)
Emotional Well-Being ( /24)
Functional Well-Being ( /28)
Additional Concerns ( /40)
Initial
WK 2
2
3
2
4
3
5
6
2
45
57
18
15
16
12
20
KEY IMPAIRMENT MEASURES:
1. Shoulder Flexion
2. UE Volume
135 º
21%
151 º
12%
GOALS:
1. Shoulder Flex > 160 º
2. Pain < 2/10
x
3. (L) volume < 8%
4. UEFI > 70/80
5. Computer work > 8/10
6. FACT-B Functional > 22
7. Exercise Program in place
X
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
FUNCTIONAL GOAL AND OUTCOME WORKSHEET
PATIENT SPECIFIC FUNCTIONAL
SCALE ACTIVITIES
(10 = full function)
1. Doing Hair
2. Computer work
3. Reaching upper cabinets
PAIN SCORE:
(0 = no pain)
Upper Extremity Functional
Index (N=80)
FACT-B
Physical Well-Being ( /28)
Social/Family Well-Being ( /28)
Emotional Well-Being ( /24)
Functional Well-Being ( /28)
Additional Concerns ( /40)
Initial
WK 2
WK 4
2
3
2
4
3
5
10
5
10
6
2
2
45
57
66
18
15
16
12
20
WK 5
10
8
10
1
74
24
26
22
24
30
KEY IMPAIRMENT MEASURES:
1. Shoulder Flexion
2. UE Volume
135 º
21%
151 º
12%
158 º
6%
GOALS:
1. Shoulder Flex > 160 º
2. Pain < 2/10
165 º
8%
X
x
3. (L) volume < 8%
X
X
4. UEFI > 70/80
X
5. Computer work > 8/10
X
6. FACT-B Functional > 22
X
7. Exercise Program in place
X
X
X
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)
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 …