Pathways Fall 2022 (Volume 11, Issue 4)

Canada’s Lymphedema Magazine

Pathways Empowering patients and professionals

Acc e Digit ss Edit al ion See p age 4

FALL 2022

Psychological aspects

Canadian Publications Mail Sales Product Agreement No. 40065546

Compression management

Myths and misconceptions Updating practice guidelines Microlymphatic surgery report FRANÇAIS...

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Editor’s Message

Working together to advance education and best practices

D

espite advances in diagnosis, treatment and our understanding of lymphedema, there still remain many myths that are perpetuated by incorrect educational material.

It takes time for new research findings to be incorporated into clinical best practices and then to trickle down further to the general population. Heather Watts works in the Community Rehabilitation Inter-disciplinary Service (CRIS) clinic in Edmonton, Alberta and still encounters many myths.

The Canadian Lymphedema Framework is proud to announce it has been granted a Canadian Heritage Aid to Publishers Grant.

She helps debunk some of these in her article. We encourage all lymphedema clinicians and therapists to write us and share the untruths they still see and hear in their practice. We will devote a subsequent article to debunk more of these misconceptions and helping to further lymphedema education.

One of the misconceptions is that lymphedema affects only physical functions.

Gabriele Erbacher from the Foeldi Clinic in Germany, addresses the psychological

challenges that people living with lymphedema face. Being aware of how a chronic illness affects us is the first step to acknowledging these changes and learning to cope. Some of the practical suggestions she provides will hopefully help our readers in their lymphedema journey.

Margie McNeely’s group is working on an update to the Clinical Practice Guidelines for Breast Cancer-Related Lymphedema (CPG), which have not been updated since 2001.

The Canadian Lymphedema Framework (CLF) is proud to be involved in the development of these guidelines and appreciates the collaboration between the University of Alberta, the Oncology Division of the Canadian Physiotherapy Association and Cancer Care Alberta’s Guideline Resource Unit. Partial funding of the project is through a matching grant from Mitacs, a non-profit organization that promotes innovation, science and economic development in Canada through collaborative partnerships. Additionally, the working CPG group has just been awarded a Canadian Institute of Health Research (CIHR) planning and dissemination grant to support the next stage of the project. We encourage you to keep an eye out for exciting developments.

Compression therapy has always been a mainstay in the treatment of lymphedema, both in the initial intensive phase, as well as the maintenance phase. Orsi Kokai questions whether the recommended level

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of pressure is in fact actually being applied to the limb. She challenges us that only when we start focusing on measuring this pressure will we be able to quantify what the compression treatment dose is actually being delivered.

Surgical treatment is becoming an emerging treatment option. The Quebec Ministry of Health has recently published their INESSS Report on “The Use of Microsurgery for the Prevention and Treatment of Cancer-related Lymphedema.”

Marie-Eve Letellier summarizes their recommendations. I agree with her statement that the future of lymphedema management seems promising. LP

Anna Kennedy

Editor’s Note: We apologize for an error in the reimbursement table published in Pathways Summer 2022.

The reference to 100% paediatric and low-income coverage should have been applied to the Quebec column, not New Brunswick.

You can find the corrected table in www.lymphedemapathways.ca/ references/

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Contents

Psychological aspects of living with a chronic disease like lymphedema

5 ........................

Theoretical background and practical examples.

Fall 2022 n Volume 11 Issue 4

Publisher Pathways is published four times per year

by BCS Communications Ltd. on behalf of the Canadian Lymphedema Framework.

CANADIAN LYMPHEDEMA FRAMEWORK

PARTENARIAT CANADIEN DU LYMPHOEDÈME

Editorial Board Mei Fu PhD RN FAAN David Keast MD FCFP Lori Radke PT CLT Anna Towers MD FCFP Editor Anna Kennedy Editorial Assistants Bonnie Baker Nicole Boulet Rachel Li Advertising and Submissions We welcome your ideas, contributions, letters and ad copy. While all material is subject to Editorial Board approval, inclusion does not constitute an endorsement or reflection of the views and opinions of the CLF and its Editorial Board.

Contents may not be reproduced without written permission of the Canadian Lymphedema Framework.

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Single copies and back issues - $8.

Subscriptions/return mail to Canadian Lymphedema Framework 4800 Dundas Street West, Suite 204 Toronto, Ontario M9A 1B1 Telephone: 647-693-1083 Email: pathways@canadalymph.ca www.canadalymph.ca Photos: Foeldi Clinic.

Oncology Recovery Services Inc (ORSI).

Novel Electronics Inc All stock images are CanStock.

Canadian Publications Mail Agreement 40065546 ISSN 1929-1418 • Printed in Canada We acknowledge the financial support of the Government of Canada.

Financé par le gouvernement du Canada Funded by the Government of Canada

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Myths and misconceptions about lymphedema diagnosis, treatment and care

9

Perspectives from a non-cancer lymphedema therapist.

.....................

Updating Clinical Guidelines Breast Cancer Related Lymphedema.

.....................

12 15 ......................................

Compression in the management of lymphedema: Are we under (delivering) pressure?

Quebec report:

Use of microsurgery for the prevention and treatment of cancer-related lymphedema.

DEPARTMENTS: Hints and tips Did you know?

Letter to the Editor Canadian and International events

18

FOR SUBSCRIBERS The price of the annual subscription includes both a print and digital copy of Pathways.

Email: pathways@ canadalymph.ca

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Clinical Perspective

Psychological aspects of living with a chronic disease like lymphedema Foeldi Clinic and European Center for Lymphology.

Theoretical background and practical examples By Gabriele Erbacher

“Why me”? is a frequently asked question by people who have been newly diagnosed with a chronic disease. But the question “Why me?” (which often contains a question like “Did I do something wrong?”) often leads to no answer. Regardless, this question is essential at the beginning of the journey to manage a chronic disease. It is like an engine that drives you through several stages until you find a new way to live a good life—with (or despite) this chronic disease.

B

eing shocked or experiencing overwhelming feelings, fears or sadness can occur.

These are normal reactions to the initial diagnosis of a chronic diagnosis and an unusually stressful situation. It can’t be emphasized enough: all these reactions are normal (if not long lasting several months).

The abnormal, (or at least unusual,) is the situation itself: of being newly diagnosed with a chronic disease that changes one’s life.

In the process of coping with a disease, the question “Why me?” usually turns into new questions like: “What do I need?” (instead of focusing only on the needs of others), “What does the disease want to bring into my life?”; “Where are my new limits and how can I live a meaningful and fulfilling life within those limits?”.

It’s more complex than just lymphedema In most cases, chronic lymphedema is only one side of the coin. In secondary lymphedema, people additionally suffer

from another disease that caused the lymphedema. This underlying condition is also associated with various problems, such as managing a potentially life-threatening disease like cancer, dealing with obesity, or even morbid obesity, as a cause of obesity-related lymphedema. Although most studies have focused on secondary lymphedema in cancer patients, noncancer related lymphedema is much more common.1,2 The two most common causes of secondary lymphedema are chronic venous insufficiency and obesity.1,2 Therefore, the psychosocial impact is not only related to lymphedema, but also to the underlying disease. For example, a meta-analysis confirms a bidirectional relationship between obesity and depression.

Depression increases the risk of becoming obese and obesity increases the risk of developing depression.3 In addition, people with lymphedema are more likely to suffer from psychosocial burdens, such as financial and occupational.

Gabriele Erbacher MSc, is head psychologist at the Foeldi clinic and European Center for Lymphology. She is certified in psycho-oncology (ZIST), a board member of the International Lipoedema Association and member of the core group of the German Lipedema Guidelines.

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In most cases, chronic lymphedema is only one side of the coin. In secondary lymphedema, people additionally suffer from another disease that caused the lymphedema.

How will lymphedema affect my life?

This is the most frequent question that people with lymphedema must cope with.

The answer includes much more than only psychological aspects. It depends not only on the localization of lymphedema and its severity but also on relationships with friends, family and peers, as well as personal resources such as motivation, mental stability, disease coping strategies4, personality traits and mindsets5. The answer to how lymphedema will affect life also depends on these personal resources. For example, a patient with secondary face and neck lymphedema (Picture 1 on page 6) will be confronted with questions like: Will I be able to speak like before? Will I be able to continue working in my profession? Will my partner accept me Ly m p h e d e m a p a t h w a y s . c a 5

Body image issues in patients with chronic lymphedema have been shown to be significantly more prevalent than in patients with temporary physical impairments. the way I look now? Is there anything I can do myself to improve my lymphedema? Will my lymphedema get better or worse in the future?

Psychological aspects and psychosocial issues For individuals with lymphedema, two types of support are crucial: emotional support and informational support. For this, it is good to know about the psychosocial problems that can be associated with lymphedema.

Body image issues in patients with chronic lymphedema have been shown to be significantly more prevalent than in patients with temporary physical impairments.6,7

In studies using the Scale on Health and Physical Well-being (SGBK), lymphedema patients reported lower levels in Health and Physical Well-being, Consideration of Physical Efficiency, Personal Hygiene and Outward Appearance, Sexuality, Physical Self-acceptance, Physical Acceptance by Others and Aspects of Physical Appearance6,7 in comparison to patients with physical trauma. Body image concerns are frequent as patients are constantly reminded of the disease because of its visibility.6,8,9 Body image concerns were also found in almost half of women with secondary breast cancerrelated lymphedema.9 This may lead to social withdrawal, which increases the risk of a high level of psychological distress such as depressive symptoms, sadness, anger and feeling unheard.10 However, according to a review, the incidence of depression and anxiety is not significantly different in cancer patients with and without secondary lymphedema.11 For treatment, it is important to identify patients with a high level of distress.

A study of 310 lymphedema patients in an Austrian rehabilitation clinic found that about 35% had a level of psychosocial distress

Coping with lymphedema in general: What can help? u Seek information from professionals to help you understand your condition,

appropriate treatment, and self-management options. If you want more information, ask your doctor, nurse, or therapist for good sources where evidence-based information can be found. u If you have fear, ask yourself what is the worst thing that could happen (whether or not it could happen). Then turn your worry into a question and approach a professional with this question, who then can support you with information. u Find people who are good supports for you: close persons, health care professionals and/or lymphedema support groups. u Allow yourself to find your daily routine of self-care. Trust yourself in the re-organization of life. u Be kind to yourself, mindfully exploring emotions that might come up. If you have trouble coping with difficult emotions, don’t hesitate to get support from close persons and/or a psychologist. u Patients with high levels of psychological distress achieve better outcomes with psychological support, not only in terms of their mental state, but also in terms of their physical symptoms.6,16 u Find your own positive but realistic metaphors or words describing the effect of the treatment. For example, one of our wound patients said during the manual lymphatic drainage: “The lymph is my great garbage collector that helps me to heal.” u Develop a daily routine that allows you to live as normal and fulfilling a life as possible.

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Picture 1: Patient with face, neck and tongue lymphedema.

that required treatment6 and achieved good long-term treatment success after integrated psychological counseling.

Loss

of confidence in the body Individuals with lymphedema may experience that the body doesn’t work like it used to.

They may be unsure about what else could go wrong with the body. They may experience the lymphedema as chronic disability despite the fact that they are free of cancer.10 Impact on sexuality Sexuality concerns9,10 were reported for the person with lymphedema (e.g. feeling less sexually attractive), but also for the partner who may be uncomfortable with the appearance of the limb or have concerns of hurting the person during sexual activity.10 Although the quality of life is often reduced.12 it seems to be well compensated in primary and secondary lower lymphedema under optimal treatment.13 Traumatic experiences during treatment of the underlying disease, and its potential impact on lymphedema therapy The results of a study by Chan and colleagues14 show posttraumatic symptoms in about 20% of patients with high distress after cancer diagnosis. Such symptoms may also occur in patients who have experienced traumatic events during their treatment, such as complications from cancer treatment or surgery. These post-traumatic symptoms may involve flashbacks (like internal movies of the traumatic situation), nightmares, or horrific Fa l l 2 0 2 2

memories. In addition, there is severe fear, anxiety, or depression. Avoidance of anything reminiscent of the traumatic situation is also part of post-traumatic symptoms and can make them worse.

Touch during MLD does not only touch the body, but the whole person, including all kinds of emotions (both in the patient and the lymphedema therapist). Being aware of this can be a great resource for both the patient and the therapist. However, touch in the lymphedema areas or any similarities to the traumatic situation may be a trigger. (Picture 2).

People affected, as well as their therapists,

Picture 2: Touch during MLD.

should know that these kinds of post-traumatic symptoms are a normal stress reaction to an extreme situation. (The person is not abnormal, but the situation experienced is abnormal!)

If these symptoms do not fade away within a reasonable period of time, professional support of a psychologist or physician specialized in trauma-therapy e.g.

EMDR (Eye Movement Desensitization and Reprocessing) or trauma-focused cognitivebehavioral therapy can bring a relief.15 In the absence of contraindications, these types of symptoms related to a particular event can usually be easily and quickly modified through specific psychotherapy and can support the continuation of effective lymphatic therapy.

Lymphedema treatment in a palliative cancer situation Normally, we are happy when there is a cure.

However, in some cases there is no cure for the underlying disease as in cancer that has reached a palliative situation. Nevertheless, it is important to continue lymphedema therapy for as long as possible in a way that provides symptom-relief and helps to maximize the remaining time in the best possible physical

The Lymphedema Association of Québec presents, in collaboration with

McGill University Health Centre (MUHC) Lymphedema Program a 135-hour clinical certification course: Complex Lymphatic Therapy (CLT) is a method for treating lymphedema and other edemas that was developed by John and Judith Casley-Smith of Australia, pioneers in the field of lymphology.

This course meets the standards set by the Lymphology Association of North America (LANA).

The School: LymphEd, LLC, A Casley-Smith US affiliate member of Casley-Smith International (CSI) Language: English and French

Your Instructor: Dr Shelley Smith DiCecco, PT, PHD, CLT-LANA, CI-CS

Picture 3: Adele with ulcer and lymphedema before treatment.

Picture 4: Adele after multimodal inpatient treatment.

Complex Lymphatic Therapy

The Casley-Smith Method

Online portion begins: January 2, 2023 On-site portion: February 25 - March 5, 2023 Location: Varennes, Québec An intensive 135-hour clinical certification course in lymphedema treatment for physiotherapists, physicians, nurses, occupational therapists, kinesiologists, physiotherapy technologists, or occupational therapy technologists.

For the full course outline and objectives, instructor bio, questions and registration information, please contact: Marie-Claude Gagnon: (450) 230-2164 mcgagnon@infolympho.ca

Learn More: www.lymphed.com

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Picture 5: Maria with compression stockings at work.

Picture 6: Maria with compression stockings at the beach.

condition and psychological level.

Adele, who was being treated for a lower leg ulcer and secondary lymphedema of the legs, was in the palliative stage of cancer when she began multimodal inpatient wound care and lymphatic therapy (Picture 3 on page 7).

By working through difficult emotions such as depression, helplessness and despair, and being supported by an interdisciplinary team, she rediscovered her own inner image

of well-being that she had previously forgotten.

Mindfully she reconnected to her body and to her wishes and needs again. At the end of her inpatient treatment, she painted a sunflower (Picture 4 on page 7), saying “That’s me—my life wasn’t always easy, but now I am shining.” Spending the remaining time in the best possible condition is the greatest gift that all supporters, including the lymphedema therapist, can give.

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Good role models can facilitate acceptance of living with lymphedema and increase lymphedema awareness in society.

Maria is a professional physiotherapist/ lymphatic therapist who is also living with primary lymphedema of the legs and lower trunk quadrant (Pictures 5, 6). After some years of her journey living with this condition, she now describes her own experience and new attitude: “You decide how you want to be seen with lymphedema because you can be the poor person who has a disease and hides it, or the amazing person who shows how to feel perfect with the imperfections.” She now lives more and more perfect with her imperfections—and empowers her patients to be imperfectly perfect. LP A full set of references can be found at https://canadalymph.ca/pathwaysreferences/

NOTE: All patients in the photographs have provided written permission for inclusion in this article.

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Therapist Perspective

Perspectives from a non-cancer lymphedema therapist Myths and misconceptions about lymphedema diagnosis, treatment and care

By Heather Watt 1 Your legs are large because you are overweight. There is nothing that can be done; you need to lose weight.

Too often our clients tell us that their doctors have told them they have to lose weight, their legs are just fat, and that there is no treatment.

Many people who have obesity also have chronic edema or lymphedema.

Physicians should be completing a thorough assessment of the severity of edema, skin integrity changes, and the potential for development of wounds and cellulitis, to determine if treatment is required.

Early diagnosis can lead to earlier treatment, preventing their lymphedema from worsening. Lymphedema secondary to obesity can lead to significantly misshapen limbs, severe mobility impairments, and chronic wounds. Due to the shape and size of the legs, wounds become very difficult to treat because it is difficult to apply compression wraps and wound dressings that allow healing. There is always a way to treat a limb with obesity-related lymphedema but the earlier they are seen the better.

2 Lipedema is lymphedema.

Lipedema is a very misunderstood condition and most health professionals are likely unaware it even exists. Lipedema is a fatty tissue disorder mostly affecting the lower limbs of women. Patients present with larger legs with significant skin tenderness to palpitation or pain. With weight loss there may still be some disproportion in the legs compared to the arms.

Due to the clinical presentation, it can be misdiagnosed as lymphedema. When closer examination is completed, the assessor will see that the tissues are soft, bounce back when palpated, and there is little or no presence of pitting edema. Typical treatments for lymphedema, such as compression, may significantly reduce the discomfort in the legs in lipedema, but will not reduce the size of the limb. This can be very disheartening for patients to hear.

There is ongoing research on the best ways to manage lipedema. Currently the most successful is weight management, exercise,

Heather Watt OT, CLT graduated from the University of Alberta and has worked in various community settings as an Occupational Therapist and Certified Lymphedema Therapist. She has been an integral part of the development of an outpatient lymphedema clinic since 2010. This clinic focuses on treatment of primary and secondary noncancer lymphedema.

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compression for pain relief and edema management if present, and sometimes specific liposuction surgery. The signs and symptoms of lipedema and lymphedema are different but lipedema with accompanying obesity can eventually lead to lymphedema.

Patients with lipedema should monitor their legs closely for signs of edema and skin changes. Patients need to be educated regarding the treatment and management of both lipedema and lymphedema.

3 Lymphedema only results from damaged or absent lymphatics due to cancer or developmental/genetic malformations.

The recent LIMPRINT study indicates that the leading causes of secondary lymphedema are in fact not cancer, but rather venous insufficiency, and obesity. New research on fluid exchange at the capillary level indicates that there is no net reabsorption of tissue fluid by the capillaries and that excess fluid in the interstitial space must be removed by the lymphatic system. Any presence of edema indicates the lymphatic vessels are either not able to keep up to demands and/or there is dysfunction to the lymph vessels or nodes. This makes lymphedema difficult to diagnose and sometimes may not be recognized at all.

A thorough look into the medical history is required to determine ALL conditions, surgeries, trauma or lifestyle factors that could be contributing to the presence of lymphedema.

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There is much evidence to show that exercise is not harmful for patients with lymphedema. The muscle pump is essential in helping move fluid through the lymph vessels and the veins to promote venous flow.

4 Lymphedema can be cured with surgery.

Lymphedema cannot be cured.

It is a chronic condition that can be effectively managed with lifelong-long treatment strategies. This treatment includes the use of compression, good skin care, staying active, and living a healthy lifestyle.

Information and research on lymphatic surgeries is growing and it is a very exciting topic in the lymphedema world. It is important to know that these surgeries are not a cure. They can help manage edema better in a limb that is already being managed with conservative measures.

They do not eliminate the need for typical lymphedema treatments.

5 The hardest part of treatment is reducing the edema.

Reducing edema can be difficult but the most challenging part of treatment for the patient is the maintenance phase. In the reduction phase patients take a very passive role in their treatment, as at this point the therapist is doing most of the work. Patients are required to show up for appointments, complete their exercise routine, and make efforts to maintain the integrity of the wraps. The roles reverse in the maintenance phase as the work transfers primarily to the patient. Strategies to manage lymphedema are lifelong. They can be timeconsuming, physically demanding, disruptive to daily routines, frustrating, and costly. For this reason, it is crucial to include the patient in creating their treatment plan and ensure 10 L y m p h e d e m a p a t h w a y s . c a

they are agreeable to this plan for the long term. While transitioning to the maintenance phase, monitor and support patients to ensure compliance, and be prepared to “tweak” treatment plans to help with adherence.

Transitioning to the maintenance phase is a BIG DEAL and our patients need our support the most during this time to be successful.

6 Once my patient is in compression garments they can be discharged.

As stated in the previous point, it is most important to continue to monitor patients through the maintenance phase. They should not be discharged as soon as they transition to compression garments. It cannot be assumed that the initial treatment plan created is going to be appropriate and effective.

It is important to ensure that the garments prescribed are effective in managing the edema and that the client is managing the garments and the new routine. Initially, weekly follow ups should include volume measurements, a check regarding proper donning and care of garments, and teaching clients how to monitor their edema long term.

When these follow ups are missed, clients are at a higher risk of failing and requiring active treatment again. Patients should be educated on potential fluctuations in edema, progression of disease, and regular replacement of garments. Increased success is possible when therapists are accessible to their patients long term and patients are encouraged to contact them at any time if concerns arise.

7 Once lymphedema is reduced, it will stay reduced, it won’t come back.

Lymphedema fluctuates and can change on a day-to-day basis even when patients are adherent with compression garments. Many things can cause fluctuations: diet, activity level (whether it be increased or decreased), hot weather, hormone changes, stress and other medical conditions. Clinicians need to educate patients that fluctuations will happen, and patients need to try to determine the cause of these fluctuations to limit their effect. Therapists should teach clients how to

monitor for these changes, and provide tools for them to use when needed. Tools might include self-bandaging, Velcro compression systems, nighttime garments, manual/self lymphatic drainage, or different forms of exercise such as swimming. The more tools, the better the outcome.

8 Exercise is bad for lymphedema, keep your feet elevated all day.

There is much evidence to show that exercise is not harmful for patients with lymphedema. The muscle pump is essential in helping move fluid through the lymph vessels and the veins to promote venous flow. Other benefits of exercise include weight maintenance or reduction, improved cardiovascular health, and improved mobility. There is evidence that lymphatic vessels do not function as they should in people with excess weight. Weight maintenance or reduction can make the management of lymphedema much easier.

Elevation is important for management of lymphedema but it should be prescribed carefully. Elevation promotes inactivity which is not healthy for any chronic condition. Patients should have a good mix of activity and rest throughout the day. It is best to elevate legs when resting whenever possible.

9 Diuretics are helpful for the treatment of lymphedema.

Lymphedema may be present in patients who also have conditions like heart failure or kidney disease and for which a diuretic may be indicated and helpful to promote the excretion of excess water from the body.

The swelling associated with lymphedema has a high protein content.

When diuretics are used, the water is removed but the proteins remain in the tissues. High concentrations of protein in the tissues can lead to more fluid, increased fibrosis and inflammation. Once the diuretic loses effectiveness, it can cause more water to filter into the tissues causing an increase in Fa l l 2 0 2 2

lymphedema. Too often we find that diuretics are prescribed solely to treat chronic limb swelling with little benefit.

Patients should be encouraged to discuss the use of diuretics with their doctors and understand why it was prescribed and whether it is actually effective for their edema. Diuretics may also be effective in the palliative stage of lymphedema disease.

J Lymphedema occurs immediately after injury to the lymphatic system.

Lymphedema can occur immediately or many years after the lymphatic system has been injured. Trauma to the lymphatic system can be due to cancer or cancer treatments, orthopedic surgery, or a fracture or other severe tissue injury. It is important to obtain a good medical and surgical history. An injured lymphatic system may be able to compensate for many years after an injury but then start to fail and show signs of lymphedema. It is difficult to predict who will develop lymphedema after an injury and there is some evidence that people

who do may be predisposed genetically or actually have primary lymphedema.

K The only thing to consider when choosing compression garments is the severity of edema.

When choosing compression garments, therapists should consider the severity of edema, but also the patient’s physical abilities, finances, motivation, support systems, and comorbidities. For a patient who is motivated to don their own stockings, but is barely able to touch their feet due to back problems, the therapist might consider a stocking with a lower compression level and/or a lower stiffness. Knowing this may not contain their edema they may have to consider a nighttime compression device. The therapeutic aim might no longer be removal of pitting edema and full limb reduction, as this would be more

difficult to maintain. Consider the example of a patient with mild thigh edema and/or toe edema who would typically benefit from thigh high stockings and toe cap. This patient has never worn compression stockings before, is very overwhelmed, has no assistance at home and does not have a lot of energy for managing their edema. The therapist should think about compliance by making the compression garment plan as easy as possible.

Consider starting with a knee high stocking the first year, discuss the risks and benefits of not treating the thigh or toes, and re-evaluate the compression garment plan next year.

At this time the patient will be more familiar with compression garments and might be more willing to treat the full leg and toes. Considering all of these factors will improve a patient’s adherence and success at managing their lymphedema longterm. LP

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Clinical Guidelines

Development of Canadian Clinical Practice Guidelines For the care and treatment of breast cancer related lymphedema

By Margie McNeely and Naomi Dolgoy Background In 2001, an expert panel of clinicians from across Canada published the first Canadian clinical practice guidelines (CPG) for the care and treatment of breast cancer related lymphedema (BCRL).18 The guidelines were developed based on evidence from a systematic review of the literature performed by researchers at the British Columbia Cancer Agency, with dates encompassing 1966 to 2000. At the time, there was a lack of highquality research in the field, namely randomized controlled trials, limiting the evidence available to inform practice. Since that time, over 100 randomized controlled trials and more than 50 systematic reviews have been published in the area of cancer related lymphedema. Given the growing numbers of individuals living with BCRL, new scientific research, improvements in breast cancer surgical and radiotherapy techniques, as well as new diagnostic and measurement technologies for lymphedema, an update to the CPG is long overdue.

At the Canadian Lymphedema Conference Toronto on November 1st, 2019, a meeting was held involving researchers and clinicians with expertise in lymphedema, as well as patient representatives. Twenty stakeholders from across Canada took part in the initial meeting which was funded by the Oncology Division of the Canadian Physiotherapy Association. The

British Columbia Cancer Agency. purpose of the meeting was to discuss the need for an updated Canadian CPG. Attendees proposed topic areas, identified key questions and discussed clinical issues in order to inform guideline development. A draft framework for the guidelines was developed based on four main categories: 1) diagnosis, 2) risk reduction, 3) management, 4) long-term outcomes and surveillance (Table 1).

Updated CPG work The proposed CPG update is an initiative of the Canadian Lymphedema Framework in partnership with the Oncology Division of the Canadian Physiotherapy Association and Cancer Care Alberta’s Guideline Resource Unit.

The objective of the updated CPG is to provide information and recommendations for

Margie McNeely is a Professor in the Department of Physical Therapy at the University of Alberta. She performs clinical research for Supportive Care Services, Cancer Care Alberta, in the Rehabilitation Medicine Department at the Cross Cancer Institute.

Naomi Dolgoy M.OT, CLT, PhD is an Occupational Therapist (M.OT(c)), Certified Lymphatic Therapist (CLT), and research scientist (PhD) whose work focuses on functional outcomes in cancer survivorship.

12 L y m p h e d e m a p a t h w a y s . c a

women and their physicians when making decisions about the diagnosis, risk reduction practices, and management of lymphedema related to breast cancer. The new guidelines will encompass a patient-oriented research approach—which means that individuals with breast cancer related lymphedema will be involved in all stages of the guideline development.

Given the chronic nature of lymphedema, we will follow the principles of the positive health model introduced in the Netherlands in 2011.20 In this model, health is defined as the ‘ability to adapt and to self-manage, in the face of social, physical and emotional challenges’. This definition of health focuses on the individual’s capacity for resilience and for coping with new situations and chronic health conditions over the life span. Thus, in keeping with this model, the focus will be on providing guidance on the best ways for individuals with breast cancer to self-manage their lymphedema.

The protocol for the CPG development has undergone rigorous peer-review and has recently been accepted for publication in the Canadian Medical Association Journal.

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FIGURE 1

Timeline of Guideline Development Stage 1 Months: 0

1

2

Stage 2 3

4

Literature search Planning

– Define topic, formulate clinical questions, develop protocol – Identify leadership team, partner organizations, management team – Manage conflicts of interest

Identify Clinical Practice Guidelines from last 5 years; Perform AGREE II Appraisal of Clinical Practice Guidelines; mapping of findings to categories

Modified DELPHI process

Patient engagement on priority areas

Steering Committee Meeting #1

5

6

7

8

Stage 3 9

Appraisal of systematic reviews and clinical trials

Identify best evidence for key specific questions

Steering Committee Meeting #2

Refine key action statements for areas with strong evidence; identify areas where evidence is lacking or contentious

10

11

12

13

Steering Committee Meeting #3 Perform any needed systematic reviews Remedy any deficiencies

Refine key action statements

Development of draft guideline Appraisal of draft guideline clarity, quality and appropriateness for Canadian context

Stage 2 of the project will involve evaluating the research evidence from existing systematic reviews and meta-analysis relevant to the identified gaps in the domains in Stage 1. The goal is to align findings with Fa l l 2 0 2 2

14

15

Steering Committee Meeting #4

Review and approval of draft guideline by Steering Committee

Finalize draft guideline

Preparation of draft guideline for external review

Refine scope and definitions, create working groups for key topic areas, construct draft framework for guideline action statements

Guideline development stages Stage 1 of the project will involve reviewing existing guidelines from within and outside of Canada that have been published between 2013-2021. The quality of existing clinical practice guidelines will be assessed by four appraisers using the Appraisal of Guidelines Research and Evaluation II instrument,3 and will be scored. The recommendations from the appraised guidelines will be summarised for each of the identified domains: 1) diagnosis, 2) risk reduction, 3) lymphedema management, and 4) longterm outcomes. The findings from this review were presented to the Steering committee at meeting #1 in December 2021. The objective of this stage will be to identify gaps in evidence, and determine the relevance to, and the need for adaptation of guideline recommendations given the Canadian context.

Stage 4

the list of clinical questions from the November Stakeholders meeting. A quality rating for the selected systematic review/meta-analyses and randomized controlled trials will be assigned according to criteria established by the Centre for Evidence-Based Medicine.21 The findings will be presented to the Steering Committee at virtual meeting #2 in fall 2022.

The objective of this stage will be to, where possible, fill in gaps identified in Stage 1, and inform the need for new or updated systematic reviews.

Stage 3 will involve performing/evaluating evidence from our own systematic reviews, as well as recent clinical trials, to inform gaps where research is lacking in Stages 1 and 2 above. As necessary, for questions important to patients and healthcare professionals where there is little evidence to guide the answers, we will aim to establish expert consensus on recommended diagnosis, risk reduction practices, management strategies and longterm outcome measures and surveillance.

The draft guidelines will be finalized at virtual meeting #3 in early 2023.

16

17

18

19+

External review of the guidelines Review guideline appraisal report; refine key action statements

Public review of guideline

Final guideline released for a period of public comment and review

Steering Committee Meeting #5

Knowledge translation activities

Finalize guideline – Submission for based on feedback publication – Conference from public Presentations review – Development of videos for websites

Impact

Audit and feedback survey planned for one year after guideline release to evaluate impact on healthcare professionals and stakeholder groups

The updated CPG is to provide information and recommendations for women and their physicians when making decisions about the diagnosis, risk reduction practices, and management of lymphedema related to breast cancer.

Stage 4 will involve sending out the draft guidelines for review by content experts and stakeholder groups including representatives from the Canadian Physiotherapy Association and the International Lymphoedema Framework.

Team The Canadian Lymphedema Framework comprised a Steering Committee to oversee the CPG work. The Steering Committee includes two co-chairs, the 2001 Canadian Guideline chair, a palliative care physician, a breast cancer L y m p h e d e m a p a t h w a y s . c a 13

TABLE 1

Key Questions Category Key Questions Rationale

Primary outcome of interest

Diagnosis

Sensitivity and specificity

What signs and symptoms constitute the need for further evaluation?

Guidance is lacking on best methods for early identification of BCRL

Risk reduction

What is the evidence Controversies exist over supporting risk many of the recommended reduction strategies? risk reduction strategies

Incidence rates; presented as percentages, fractions or simple frequencies

Effective management

What is the state of the evidence supporting conservative, pharmacological and surgical management of BCRL?

Inconsistencies are found across guideline recommendations and Grades of Evidence for best management of BCRL

Arm lymphedema volume metric is used clinically for decisions related to treatment

Measurement outcomes

What metrics need to be captured to inform ongoing care of BCRL over the longer term?

Guidance is lacking on best practices related to follow-up and surveillance of chronic BCRL

Valid, reliable and sensitive methods

oncologist, a physical medicine and rehabilitation resident, a nurse specialist, a breast cancer rehabilitation researcher, a representative from the Oncology Division of the Canadian Physiotherapy Association, and three patient advisors.

A management team was created to conduct the tasks associated with the guideline update. The management team includes a cochair, a funded postdoctoral fellow, two clinical physical therapists, and two graduate students.

The project will be guided by a knowledge management specialist from Alberta Health Services’ Guideline Resource Unit, and a research librarian from the University of Alberta.

Research funding was provided by an

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internal grant from the Oncology Division of the Canadian Physiotherapy Association and the Canadian Lymphedema Framework.

Dr. Naomi Dolgoy’s involvement is supported by a Mitacs accelerate postdoctoral fellowship.

Knowledge translation To ensure the guideline recommendations are accessible to both patients and physicians, the updated CPG will be published in an open access journal. As part of the dissemination and implementation of the CPG, the Steering Committee will share the preliminary findings at a future National Lymphedema Conference and Canadian Physiotherapy Conference.

A webinar will be hosted by the Canadian Lymphedema Framework. In addition, we will apply for further funding to create videos to disseminate our findings for our key targeted groups: 1) individuals with breast cancer related lymphedema, and 2) healthcare professionals.

Following completion of the guidelines, a series of two-to-four 1-to-2-minute video clips, in both English and French languages, will be created to inform the key guideline messages. The series of videos will be hosted on the website of the Canadian Lymphedema Framework. LP A full set of references can be found at www.lymphedemapathways.ca

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Clinical Perspective

Compression in the management of lymphedema: Are we under (delivering) pressure?

By Orsi Kokai

The treatment for lymphedema is multimodal and includes the application of compression as the most widely used element. The dose of treatment, or the actual applied pressure to the limb however, remains unknown.

This is in contrast to the pharmacological management of most other chronic conditions, where the dose is well studied, and the administration is clear. or the management of lymphedema using compression, international guidelines based on expert opinion recommend certain levels of pressure to be applied to the limb.

Recommended levels of compression are 20–30 mmHg for the upper limb and up to 60 mmHg for the lower limb when swelling or venous disease is present.1 However, unless the pressure under the compression is measured, how do we know whether the recommended compression is being applied to the limb?

Measuring the pressure under the compression bandage or garment would allow quantification of the treatment dose for lymphedema.

Direct assessment of the pressure applied by the compression to the limb surface, referred to as interface pressure, can be performed using a wide range of measuring devices with varying levels of design sophistication and application. Past studies of bandages systems and garments have found that the measured pressure applied to the limb is frequently outside the expected range.2–4

This discrepancy has been largely attributed to how compression is applied2,5,6 or the clinicians’ skill in applying the compression bandages.7–9 The ability of the measuring device to accurately quantify interface pressure, however, had not been considered as a factor in this discrepancy.

Our research team at The University of Sydney conducted a systematic review to investigate the performance of interface pressure measuring devices. The surface used for sensor evaluation also varied across the studies, with most sensors assessed on either a cylinder or a wooden leg model.

We found that no sensor type outperformed the others; however, a number of individual sensors had acceptable accuracy and/or precision.10 Critically, this systematic review identified that two major factors are important to consider when choosing a sensor for measuring interface pressure: the amount of applied pressure and the calibration method used. It is therefore advisable to know the optimal conditions under which a sensor

Orsi Kokai is a German trained physiotherapist with a special interest in cancer care and lymphedema management. She has been working as a clinician for 20 years and established a multidisciplinary cancer rehabilitation clinic in Sydney in 2015. Orsi completed her Higher Degree by Research Master’s at The University of Sydney in 2020, investigating upper limb lymphedema and compression.

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Measuring the pressure under the compression bandage or garment would allow quantification of the treatment dose for lymphedema. performs best when considering a measuring device to assess interface pressure clinically or for research purposes.10 With a stronger understanding of the tools to assess interface pressure, a second study was undertaken to investigate the actual pressures applied by compression garments in the community.

This investigation was necessary as the prescription and advice we currently give patients on the use of compression for the management of lymphedema is often based on trial and error. Clinicians rely on the information garment manufacturers provide on the expected garment pressures. However, past studies investigating interface pressure under compression found deviations from the expected pressures, when interface pressure was assessed on leg models, on healthy subjects using sports garments, or on computerized 3D models.2,3,11 It is therefore questionable whether compression garments L y m p h e d e m a p a t h w a y s . c a 15

Photos: Oncology Recovery Services Inc (ORSI). novelusa.com/pliance

F

used in the community for the management of lymphedema deliver the expected pressures. If garments fail to deliver the expected pressures, could factors such as age of garment, frequency of washing, or the severity of the patient’s lymphedema be hypothesized to contribute to the deviation?

To investigate these questions, we recruited 41 participants with upper limb lymphedema using a compression garment.

All participants completed a questionnaire collecting information such as body mass index, limb dominancy, number of cellulitis infections and changes of body weight since their garment was prescribed. Lymphedema status was assessed using the pitting and palpation tests, interlimb circumference and bioimpedance measurements. Factors related to the

garments, such as compression class, type of garment, age, and frequency of wear and wash, were also collected. Interface pressure was measured under each garment using the Pliance-X capacitive sensor (Novel/Germany), which in the systematic review showed highest accuracy when tested in vivo.10 The sensor was placed underneath the garment of each participant. Interface pressure was measured at the forearm and the upper arm to further investigate whether a graduated pressure was present along the limb.

To understand how the garments were performing, the expected pressure values for each garment were established according to the compression class listed for the garment by the manufacturers. This value was compared with the measured pressure, and the difference between the expected and measured pressures were categorized as below, within or above the expected pressure. These categories of measured pressure were then analyzed against participant and garment factors using chi square analysis. A change of ≥ 3 mmHg between the

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Pliance-X capacitive sensor. measured pressure at the forearm and upper arm was classified as graduated pressure.

Astonishingly, the majority of measured pressures exerted by garments were below the expected pressures (n = 30, 75%). Despite guideline recommendations for graduated pressure with the use of compression, only 33% of garments displayed decreasing pressures from distal to proximal. No relationship was found between the category of measured pressure and any of the participant-related factors, including lymphedema status or changes in weight. Likewise, there was no relationship between the category of measured pressure and the age of garments, garment type or

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In summary, compression garments for the management of upper limb lymphedema do not appear to deliver the expected pressures and frequently measure below the recommended level of compression. frequency of wear and wash. In summary, compression garments for the management of upper limb lymphedema do not appear to deliver the expected pressures and frequently measure below the recommended level of compression. No participant or garment-related factors were identified as a reason for this.

Our investigations have highlighted a gap in our current knowledge regarding the dose of treatment for managing lymphedema using compression. When managing a chronic

condition such as lymphedema, would it be advisable to know the dose of treatment?

Therefore, should we start to routinely measure interface pressure under compression?

Quantifying the pressure we apply when using compression would not only allow us to

administer a known dose of treatment, but also to monitor changes of pressure over time. LP A full set of references can be found at https://canadalymph.ca/pathwaysreferences/

NOTE: This article was originally published in Lymph Exchange (July 2021) and has been reprinted with minor edits, with permission from the author and the Australasian Lymphology Association.

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Surgery Report

An important new scientific review of lymphatic microsurgery from Quebec

By Marie-Eve Letellier

O

n July 12th, 2022, the Quebec “Institut national d’excellence en santé et en services sociaux (INESSS)”, published a report entitled “Use of microsurgery for the prevention and treatment of cancer-related lymphedema.”

This study, mandated by the Quebec Ministry of Health, involved a systematic review of the literature and on the last four years of experience of lymphatic surgeries in the province.

The programs for lymphatic surgeries are in their infancy in Quebec, as they started to be offered only in 2018. At the moment, two health care facilities are offering microsurgeries for the treatment of lymphedema of any etiology, and a third one will be offering soon. Those three centers are all located in Montreal.

The INESSS report is a thorough evaluation of the literature. Their mandate was to evaluate the clinical relevance of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), both in prevention (the procedure is called LYMPHA) and in treatment of cancer-related lymphedema. With this report, the INESSS is providing recommendations regarding the organization of lymphatic surgery services in the province of Quebec. The full report and summary are available at: Avis - Utilisation des microchirurgies pour la prévention et le traitement du lymphœdème lié au cancer

(inesss.qc.ca). (The full report is available only in French, however a six-page English summary is included).

The document is divided into two main sections: 1) Methodology, and 2) Results.

Everything is covered in 267 pages, under five dimensions and 12 specific questions aiming to answer the overarching question of whether preventative lymphatic surgery (LYMPHA) and/or LVA and/or VNLT should be offered in Quebec’s health care facilities, and if so, which modalities and for which target patients. Their original work was searching for evidence for all cancer-related lymphedema. However, the level of evidence available enabled them to conclude only for breast cancer-related lymphedema (BCRL).

They recognize that actual lymphedema management involves complex decongestive therapy (CDT), which has the capacity of reducing the limb volume without restoring the damaged lymphatic network.

They acknowledge that CDT represents a significant burden on the patient: limited access, psychosocial issues, financial and time investment, and compliance to daily care (e.g. compression, exercises).

On the other hand, the rationale behind offering lymphatic surgery is that it could restore the damaged lymphatic vessels,

Marie-Eve Letellier, PhD, is a kinesiologist, a lymphedema therapist (Vodder) and an aqualymphatic therapy instructor (Tidhar). She is a clinician-researcher working in a hospital setting and she also has a private practice. She is a theory lymphedema instructor for the Vodder School International.

18 L y m p h e d e m a p a t h w a y s . c a

which could ultimately reduce the burden of lymphedema. Their cost analysis estimated that LYMPHA surgery would involve a total cost of $5,149 per patient to the Quebec hospital system, whereas LVA would cost $9,956 and VLNT $15,745. From expert opinion, they assume that approximately 25% of people with lymphedema could be candidates for microsurgery. Lymphatic surgeries could ultimately require a budget commitment between $1.4 million and $3.8 million annually. However, for example, this budget does not take into account the possible reduced costs related to less cellulitis hospitalization and/or wound care related to lymphedema.

The INESSS summarizes their position and recommendations as follows: Considering: 4 The important health needs of people with lymphedema related to all types of cancer in Quebec; 4 The promise of microsurgeries for the prevention and treatment of lymphedema related specifically to breast cancer, although the evidence currently available does not allow concluding with certainty as to the clinical benefit of these microsurgeries compared to complex decongestive therapy; 4 The limited service offer already in place in some centres in Quebec and the quality of clinical studies currently underway that will complete the level of scientific evidence.

INESSS supports the development of therapeutic microsurgeries, i.e. lymphaticovenous anastomosis and vascularized lymph node transfer, for the treatment of lymphedema specifically related to breast cancer.

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Considering: 4 the presence of significant organizational issues, the difficulty in targeting patients who might benefit from preventive microsurgery, and the anticipated decrease in need over time.

INESSS does not support the development of a systematized and expanded practice of LYMPHA for the prevention of breast cancerrelated lymphedema.”

This report proposes priorities and future directions for development that could be an important game changer and/or impact strategic planning for lymphedema programs, such as: – To evaluate the long-term effectiveness of CDT; – To develop and disseminate information and teaching tools related to lymphedema and its management; – To educate health care professionals regarding risk reduction strategies regarding lymphedema; – To advocate for early detection of lymphedema following oncology surgery.

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The INESSS report seems to be well received by the lymphedema community in Quebec.

Programs will get organized to offer LVA and/ or VLNT to BCRL in specific health care facilities under specific candidate selection and pre/post-op care. Patients can be reassured that, regardless of the actual INESSS recommendations, Quebec surgeons will continue to advocate for preventative lymphatic surgeries and to offer LVA and/or VLNT to those with other lymphedema etiologies.

In the Pathways Fall 2021 edition, I had the opportunity to write the article “Overview of Lymphatic Surgeries” where I ended saying: “To conclude on a more serious note, lymphatic surgeries are not a cure and should not be seen as a “quick fix.” They are a “no go” if the person is not a good candidate. Finally, they may potentially help patients who are already compliant with conventional therapies, have plateaued, have recurrent episodes of cellulitis, and/or want to obtain further improvement through lymphatic surgery. A full multidisciplinary team should be involved to work hand-in-

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hand, in a patient-centered approach.”

Now a year later, having read the INESSS report, I would conclude that progress is made toward a better management of cancer-related lymphedema. As the INESSS report states, a collaborative effort needs to be put in place in order to be successful.

As of now, it is BCRL that is considered.

Knowledge will be gained through further research, and ultimately this information will hopefully be able to benefit patients with all lymphedema etiologies.

Let’s all collaborate and work hand-in-hand with each other! The future for lymphedema management seems promising. LP

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Helpful Suggestions

Hints and Tips: Lymphedema self-management

Q

Q

Deep abdominal breathing can promote lymph drainage by stimulating deep lymphatic structures such as the thoracic duct. When we breathe in fully, our lungs expand and the diaphragm moves downwards to allow for this expansion. When we breathe out the diaphragm moves back up to its original position. The downward and upward movement of the diaphragm, and related pressure differences, create a pumping action that helps transport lymph fluid back into the bloodstream. Deep abdominal breathing can also help us to relax and calm down.

Good posture also has a positive impact on our lymphatic system. Maintaining good posture helps to keep our bones and joints in proper alignment, which helps our muscles function well. Try to keep your ears and shoulders aligned in a straight line. This helps stop us from slouching.

When we stand or sit in a good posture, our lungs have more room to expand.

Increased lung capacity helps our body deliver oxygen to our blood. Good posture can also increase the circulation to and from your heart.

Is it true that the 3-part yoga breath can create a pump for the lymphatic system?

What kind of impact does posture have for us?

LP

Pam Hammond RMT, CDT works part-time in the Cancer Rehabilitation and Survivorship (CRS) Program at the Princess Margaret Cancer Centre where she provides education, support and training in lymphedema self-management skills to patients with cancer-related lymphedema.

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Research Advances

Did You Know?

Exploring disease interrelationships in patients with lymphatic disorders

Emerging data suggest that lymphatic dysfunction can be pivotal in the initiation and development of a variety of diseases across broad organ systems. Understanding the clinical associations between lymphatic dysfunction and non-lymphatic morbidity provides valuable evidence for future investigations and may foster the discovery of novel biomarkers and therapies. Methods: We retrospectively analysed the electronic medical records of 724 patients referred to the Stanford Center for Lymphatic and Venous Disorders. Patients were assigned to groups of secondary lymphedema, lipedema or primary lymphovascular disease.

Individuals found to have no lymphatic disorder were served as the non-lymphatic controls.

The prevalence of comorbid conditions was enumerated. Pairwise co-occurrence pattern analyses, validated by Jaccard similarity tests, was utilized to investigate disease-disease interrelationships. Results: Comorbidity analyses underscored the expected relationship between the presence of secondary lymphedema and those diseases that damage the lymphatics. Cardiovascular conditions were common in all lymphatic subgroups.

Additionally, statistically significant alteration of disease-disease interrelationships was noted in all three lymphatic categories. Conclusions: The presence or absence of a lymphatic disease significantly influences disease interrelationships in the study cohorts. As a physiologic substrate, the lymphatic circulation may be an underappreciated participant in disease pathogenesis. These relationships warrant further, prospective scrutiny and study.

Source: Clin Transl Med. 2022 Apr;12(4):e760.

Role of subcutaneous adipose tissues in the pathophysiology of secondary lymphedema

Does venipuncture increase lymphedema?

Although the relationship between LE and subcutaneous adipose tissue increase has been reported clinically, their pathophysiological relationship remains unknown. Thus, we aimed to verify whether subcutaneous adipose tissue increase is involved in the pathophysiology of secondary LE. Methods/Results: The hindlimb model of secondary LE was created using male rats. Skin samples were obtained on postoperative day 168. Histological examination and quantitative real-time polymerase chain reaction analysis of inflammatory adipokines, tumor necrosis factor-alpha (Tnf-α), C-C chemokine ligand 2 (Ccl2), and interleukin-6 (Il-6) were performed. Limb volume and subcutaneous adipose tissues significantly increased in the LE group compared with those in the control. Macrophages aggregated in the augmented adipose tissues, around the adipocytes, and formed crown-like structures (CLSs). The number of CLSs significantly increased in the LE group. These macrophages expressed transforming growth factor-beta 1 (TGF-β1). Inflammatory adipokine secretion was not observed. Although Il-6 expression increased in the LE group, IL-6 was expressed in subcutaneous myofibroblasts but not in subcutaneous adipocytes. Conclusion: As TGF-β1 derived from subcutaneous myofibroblasts is involved in skin fibrosis during LE, TGF-β1 derived from adipose tissues may also play a similar role. Drug treatment for subcutaneous adipose tissue reduction may improve the skin condition in secondary LE and may be a new therapeutic strategy.

Recent guidelines recommend avoiding venipuncture to prevent lymphedema (LE) for breast cancer patients. This study investigated whether single or multiple sterile venipuncture procedures develop a systemic inflammation or infection and increase LE in the rabbit ear lymphedema model. Methods/Results: 18 rabbits were included. The right ear LE model was created by surgical procedure. Single and multiple venipuncture procedures were applied at the 60th day after surgery for Group I and II, respectively. Group III was a control group.

C-reactive protein (CRP) and procalcitonin (PCT) levels were analyzed to determine inflammation and infection. Ear thickness measurements were applied using a vernier caliper to assess the differences in LE between the ears.

Histopathological analysis was performed to evaluate LE by measuring tissue thicknesses.

Ear thickness measurements showed that ear LE was developed and maintained with surgical operation in all groups. There was no difference in the ear thickness measurements between and within-groups results.

CRP and PCT levels were below the lower detection levels in all groups. According to the differences of histopathological ear distances, there were significant differences within-groups for all groups (p < 0.05), and no differences were identified between groups (p > 0.05).

Conclusion: This experimental study demonstrated that single or multiple sterile venipuncture procedures did not trigger infection or inflammation and did not exacerbate LE in the rabbit ear lymphedema model.

Source: Lymphat Res Biol. 2022 Apr 7. doi: 10.1089/lrb.2021.0054.

Source: Lymphat Res Biol. 2022 Jun 10. doi: 10.1089/lrb.2021.0095.

2023 National Lymphedema Conference Participate in our planning survey for $25 off your registration Answer 10 questions here: www.canadalymph.ca/feedback https://canadalymph.ca/feedback

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L y m p h e d e m a p a t h w a y s . c a 21

Education Education

Canadian and International Events September 30, 2022 – VIRTUAL 2022 LE&RN Centers of Excellence Lymphatic Summit.

Lymphatic Disease: The Clinician/Patient Interface in State-of-the-Art Diagnosis and Management will be presented www.lymphaticnetwork.org/virtual-lymphaticonline in its entirety. n www.lymphaticnetwork.org/ summit-2022 virtual-lymphatic-summit-2022 October 3-4, 2022 – Staffordshire, UK British Lymphology Society. The conference highlight will be a debate featuring lymphedema experts panel on ‘Manual Lymphatic Drainage—is it time to come off the fence?’ nhttps://thebls.regfox.com/the-bls2022-conference www.thebls.regfox.com/the-bls2022-conference October 13-16, 2022 – Toronto, ON Wounds Canada. This national conference (including a French stream) is organized as a hybrid: virtual and live event. October 13 is a pre-conference day option. n www.woundscanada2022.ca Oct 13-16, 2022 – New Orleans, LA American Vein & Lymphatic Society - 36th Annual Congress.

Theme: Veins and all that Jazz. Registration: In-person and at-homehttps://www.myavls.org/annual-congress-2022.html rates. n www.myavls.org/annual-congress-2022 November 17-20, 2022 – Cleveland, OH National Lymphedema Network - Cleveland Clinic.

Health professionals will have the option to obtain the NLN Expert Clinician certification during the first day of the conference.https://lymphnet.org/2022/cleveland n www.lymphnet.org/conference June 13-15, 2023 – Nottingham, UK The 11th International Lymphoedema Framework (ILF) in collaboration with the Lymphoedema Network Wales. n www.lympho.org/conferences/

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eting nning a me We are pla f o r I Ministe with the PE ring was wonde Health… I ave access if I could h ways article to the Path st bout the co that talks a ion. It was of compress le that really a great artic of tes the lack demonstra ld u o PEI. It w services on l. be so helpfu Goulet Rose-Lune PEI Mt-Stewart,

Thank you fo r keeping this informa tion out the re for doctors, massage therapists a nd us, the general pub lic, who dea l with lymphe dema dayto-day. Appre ciate the time you pu t into this.

Barb Osborn e Pickering, O ntario

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______ ______ _____ ______ _____ ______ ______ _____ __ __ _____ ______ ______ __ __ _____ ____ _ __ _ __ _ _____ _ _____ ______ _____ __ __ _ _____ _____ ______ __ __ _ __ _____ __ _____ ______ __ _ __ _ _ _____ _____ ______ __ _ _ __ _____ _____ ____ __ __ _ _ _ _____ _____ ____ __ __ _ ______ _ _ __ _____ _____ _____ _____ _____ ______ _____ ______ _____ ______ _____ _____ ______ ___ ___ ______

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I loved you (Summ r last issue er Pathwa 2022) of ys! Esp article ____ ecially th _____ on ____ e _____ _____ equ__it_ie_______re-imbu__r_s_e__m__________ ent ____ s iss_u_e______ _____ __A __u___ st_ra__li_a__)___ s. W_e___(_in___________ ___ ha__v_e__ju _____ _____ __g __a_r_m st _g_o__t____ ___e_n __t_s__a _____ _ n _ _ _ __ d___w__ra__p_ _____ s ____u_cc _s____ ___e __s_s_f_ull _____ ___y__on _____ _____ reim ____t_he _ _____ bu _____ _____ rsem _____ _____ ent _____ _____ list ____ _____ garm _ _ _ _____ ____(_2 e _____nts x 2 _____ _____ _ p _ _____ _____ er yea __ _____ Pro _____ r _____ fess _____! _____ or N _____ _____ eil P _ _ _ ____ Adelaid _______il__le_ r __ e, Aust ralia ____________

If you would like to drop us a line, please do so at: pathways@canadalymph.ca

___

The Canadian Lymphedema Framework (CLF) wishes to thank these partners for their support in making this magazine a reality.

Pathways is available by subscription either directly from the CLF or as a benefit of membership through one of our Provincial Association partners. www.canadalymph.ca/subscriptions

CANADIAN LYMPHEDEMA FRAMEWORK

PARTENARIAT CANADIEN DU LYMPHOEDÈME

ABOUT THE CLF: The CLF is an academic and patient collaboration, working to improve lymphedema management for lymphedema and related disorders in Canada.

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