Lymphedema:

1. 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.

2. 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 al, 2003; Paskett et al, 2007) • 13% (33/263) reported lymphedema measurements as SEVERE (>5.0cm) (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

3. 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

4. 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

5. Changing the Myths of Exercise and Lymphedema McKenzie, Harris University of British Columbia Courneya, Campbell, McNeely, Mackey University of Alberta

6. 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)

7. 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; )

8. Clinical Case

9. 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

11. 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

12. Axillary Cording Decreased Extensibility of Pectoral Muscle Decreased Extensibility of Latissimus Muscle Tightness Surgical Incision Modified Radical Mastectomy with Chest Wall and Axillary Radiation

13. Abnormal Scapulo-humeral Rhythm Lymphedema

14. 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)

16. 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)

18. 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

20. 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)

21. 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 …