File #5

1. Oncology Rehabilitation: Web-based Learning for Physical Therapists Who Provide Rehabilitation to Patients with Breast Cancer File #5 Complications and Alternatives

2. Possible Complication with Breast Cancer Patients • Lymphedema

3. The Lymph System *

4. A network of the body that makes and stores cells that fight infection and clears the tissue spaces of excess fluid and cells. This system is composed of lymph vessels, lymph nodes and lymph organs such as the spleen. Lymph System: (www.lymphedemapeople.com, 2005)

5. Abnormal accumulation of lymph in the tissue, causing swelling in the arm or leg, due to inability of the lymph system (vessels and nodes) to transport the load of the lymph to the exits. Lymphedema (www.lymphedemapeople.com, 2005)

6. 2 Types of Lymphedema Primary: caused principally by underdevelopment of the lymph channel system. Secondary: caused by damage to the lymph channel system, such as infection, scarring, an accident, radiation therapy or surgery. (www.lymphedemapeople.com, 2005)

7. Initial evaluation • Patient education and precautions • Exercise program • Compression garments • Compression pumps • Manual massage techniques • Compression Wrapping • REID Sleeve • Pharmacological Treatment • Life Style Lymphedema Treatment Plan (www.lymphedemapeople.com), 2005

8. Lymphedema Training This slide is needed to show some of the training methods used in the treatment of lymphedema. Courses are intense and expensive. • Vodder……… 4 wks………..$2000.00 • Foldi………… 2 wks……... 2500.00 • Carley Smith… 2 wks……. 1000.00 • Bergel………… 4-5 days… 500.00 • Klose……………..135 hours..2500.00

9. Example of training to treat lymphedema • Pre-requisites: Profession of medical doctors, physical therapists, physical therapy assistants, occupational therapists, occupational therapy assistants, nurses, athletic trainers and massage therapists showing proof of 500 hours of training. • Course topics: • Anatomy, physiology and pathophysiology of the lymphatic system • Basic techniques and sequences of manual lymph drainage (Vodder technique) • Indications and contraindications of manual lymph drainage and complete decongestive therapy • Treatment of primary and secondary lymphedema • Lymphedema bandaging techniques for upper and lower extremities • Remedial lymphedema exercises • Hygienic skin and nail care for lymphedema • Measuring and fitting techniques for lymphedema support garments • Patient evaluation and weekly measuring (circumference and volume) • Home maintenance and self-treatment for lymphedema • (Klose Training & Consulting, LLC course description)

10. Symptoms associated with breast cancer lymphedema • Feeling of tightness in the upper extremity • Rings become tight • Weakness of upper extremity • Aching or heaviness in the arm • (http://www.oncologypt.org/.)

11. Avoid cuts, Scratches, and Irritations (Electric razor --cut nails straight across) • No injections in affected arm. • Avoid wasps, bees and other insects. (repel) • Avoid Extreme Temperatures (Hot & Cold) • Avoid Burns (Sun & Fire) • Avoid Arm Pressure (Blood Pressure, tight clothing or jewelry • Avoid underarm Irritation (deodorant-shave) • Avoid arm/leg Strain (10# limit--Position every 1/2 hour-- Don't cross legs) • Increased pressure on aircraft can increase swelling. • Call M.D. with problems (Temp, Red,Swell.) PREVENT LYMPHEDEMA (www.lymphedemapeople.com, 2005)

12. Treatment SequenceManual Lymph Drainage & Complete Decongestive Therapy • #1 Clear inguinal / axillary lymph nodes Fill & Clear thigh / upper arm Clear popliteal / cubital lymph nodes Fill & Clear leg / arm Clear inguinal / axillary lymph nodes • #2 Thigh / Upper arm Fill / Clear Proximal / Middle /Distal(To inguinal/axillary) • #3 Popliteal / Cubital Lymph nodes Fill/Clear #4 Leg / Arm Proximal/Middle/Distal. med & lat foot &toes • #5 Finish with clearing to inguinal / axilla This is just an example to clarify the expertise required to complete lymphatic massage. Improper techniques can certainly be harmful to the patient.

13. Contraindications to lymph massage • Acute swelling due to clot blocking a major vessel (Thrombosis) Could move clot to lung = Pulmonary Embolism. • Untreated Cancer with METS = Spread Ca cells • Bacterial Infection may spread with lymph • Radiation scar. Wait 5 wks, after medical treatments. Fragile • No intense abdominal work during menstruation, pregnancy or abdominal complaints. (Carriere, 1991)

14. Nutrition

15. The following slides are not to replace a nutritionist or make you a healer, but rather to make you aware of options that may become questions presented by your patient. If you have a question, refer to your team members.

16. Maintain healthy weight • Low fat / Low cholesterol diet • Control daily calories • Increase fiber in diet • Eliminate salt and food additives • Prevent or correct deficiencies Nutritional Goals: (Dollinger, 2002)

17. Diet history • Calculate nutrient intake • Anthropometric measurements • Lab tests • Functional measurements

18. Eat a variety of foods. • Maintain a healthy weight. • Choose diet low in fat, saturated fat, and cholesterol. • Choose diet of vegetables, fruits and grain. • Use sugar only in moderation. • Use salt only in moderation. • Alcohol only in moderation. (U.S. Government Dietary Guidelines) Healthy Diet

19. Variety of Foods (Food Pyramid) • Bread,cereal, rice and Pasta (6-11 servings per day) • Vegetables (3-5 servings per day) • Fruit (2-4 servings per day) • Meat, poultry, fish, dry beans, eggs, and nuts (2-3 servings per day) • Milk, yogurt and cheese (2-3 servings per day)

20. Active...............2,000+ calories / day • Sedate...............1,600 calories/day • Very Active.......2,400+ calories / day • Calculate daily calories: • Intake factors: • Sedentary = 1.2 • Moderate = 1.4 • Active = 1.6 • Body weight X 10 X activity factor = daily calorie intake Calories needed: (www.hopkinsbreastcenter.org, 2006)

21. Linked to Colon, Breast, and Prostate Cancers. • The American Cancer Society reports that diet modifications which decrease fat and increase fiber consumption have the potential to decrease cancer. • The American Institute for Cancer Research developed 50 Nutritional Tips, including such categories as: *Tips for Eating More Fruits, Vegetables and Grains. *Hints for Skimming the Fat. and *Ideas for Healthy Living. Diet (www.cancer.org, 1999)

22. Nutritional Problems associatedwith Cancer Patients • Chewing and swallowing problems. Example: Mouth and throat pain or lesions due to medical interventions. • Blockage of food passageways in some part of the digestive system. Example: Tumors • Altered taste perception. (Jennings-Dozier, 2002)

23. Possible signs of nutritional problems: • Nausea / Vomiting • Anorexia • Mouth Dryness • Mouth Sores • Diarrhea • Constipation (Jennings-Dozier, 2002)

24. Holistic Alternatives

25. HOLISTIC ALTERNATIVES • Chinese medicine • Yoga • Biomedicine • Vitamin Therapy • Acupuncture • Touch/Massage • Metaphysical Approach

26. The benefits of alternative medicine programs are unknown (Slide permitted by the American Cancer Society)

27. Many will reach for an alternative method, if they can afford the program. (Slide permitted by the American Cancer Society)

28. No harm with some alternatives (Slide permitted by the American Cancer Society)

29. Healing (Slide permitted by the American Cancer Society)

30. Surgery without cutting (Slide permitted by the American Cancer Society)

31. Alternatives may be acceptable as long as they are safe and routine procedures are completed.Understand that alternative methods can cost the patient greater than $10,000 per week.

32. Recurrence

33. Be aware of possible recurrence (Slide permitted by the American Cancer Society)

34. Time out Test • No test here. • Just make sure you review the lymphatic information, to avoid complications. Realize that there are therapist who only work with lymphedema, it is certainly a specialty. Help your patient avoid treatment from someone who does not have creditable skills. Avoiding problems is the best way of dealing with this system. • As for nutrition, do not take the place of a nutritionist, but be aware of possible complications. • As for Alternative Methods, suggest you patient stay on the medical path as well. • Recurrence is always a possibility, so keep patients aware of the benefits of early detection by following their physicians programs.