Pathways Summer 2017 (Volume 6, Issue 3)

Canada’s Lymphedema Magazine

Pathways

Acc Path ess w Onli ays ne See pag e4

SUMMER 2017

Empowering patients and professionals

Nutrition for lymphedema

Resistance exercise Edema-causing medications Head and neck lymphedema NOUVEAU...

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une sélection d’articles traduits en français disponible au fr.infolympho.ca/revue-pathways 6/2/17 1:38 PM

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Editor’s Message

A time for celebration

S

ummer is finally here. Its time to open windows, enjoy long walks in the sunshine, and embrace the changing seasons—the wonderful benefits of living in Canada. This year is particularly monumental for Canadians as we celebrate our 150th year as a nation. We can be proud that we are all integral to the rich tapestry that makes up our country. It is also the 150th year anniversary of Ontario as a province and an amazing 375 years for the city of Montreal. This historic city is the site for our national conference this fall; an opportunity for conference delegates to experience the city’s unique culture and joie de vivre during their celebrations.

2017 also marks the 5th anniversary of Pathways. You are 2017 now reading the marks the 22nd issue of the th 5 anniversary magazine, made of Pathways. possible through the support of our sponsors, advertisers, contributors, subscribers and Editorial Board. Sadly we say goodbye to three editorial board members, after five years of dedicated support. Lucette Wesley, Janice Yurick and Roanne Thomas—we thank you and will miss you. Its not an easy

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task to fill the big shoes you leave behind! Readers can also read about Roanne Thomas’ work in the researcher profile section.

We thank Brad Smith for his article and photographs on head and neck lymphedema—a largely unaddressed and untreated area. Most lymphedema therapists would have little experience in this area and so we hope this article will help shed some light.

Three International Lymphoedema Framework (ILF) Directors contribute to this issue. Drs Keeley and Piller graciously provide an excellent snapshot on medications that may contribute to swelling—an article that we encourage you to share with your physician if you are concerned that some of your medications may be impacting your lymphedema.

Margaret Sneddon outlines the exciting ILF Education project that she is leading to create international benchmarks for physicians and other health professionals.

Our personal perspective section is written by Bev Lanning, who contributes a

unique story of her son living with primary lymphedema, and his mother’s devotion to helping him by augmenting her training as a nurse to become a certified lymphedema therapist. You can hear both Bev and James as guest speakers at our national lymphedema conference this fall.

Nutrition and lymphedema is a relatively unexplored research area with only preliminary research providing some promising results. Jean La Mantia, a registered dietitian, reviews this research and explores potential links between nutrition and lymphedema, giving us some food for thought regarding weight management.

Another key component of managing weight and lymphedema is exercise.

Mona Onazi and Margie McNeely guide us through the shift from conservative management techniques for lymphedema to more progressive resistance exercise (PRE) by reviewing the research literature supporting this change.

We hope that this information will give lymphedema patients the confidence to build up an exercise regime, under the guidance of a professional, of course.

With the summer weather here, we encourage everyone to get out and enjoy some exercise. It is good for your body, your heart, and your brain! LP

Anna Kennedy

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Contents

Nutrition for lymphedema Promising research provides interesting food for thought Two key areas linking nutrition and lymphedema.

Summer 2017

n

Volume 6 Issue 3

Publisher Pathways is published four times per year by BCS Communications Ltd. on behalf of the Canadian Lymphedema Framework (CLF) and its provincial affiliates.

Editorial Board Pamela Hodgson PT David Keast MD FCFP Roanne Thomas PhD Anna Towers MD FCFP Lucette Wesley CIM Janice Yurick PT Editor Anna Kennedy Editorial Interns Nicole Boulet, Rhianna Davis 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.

Subscription Rates (1 year) Canada–$25.

United States–$50.

International–$65.

Single copies and back issues–$7.

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 Stock photos in this issue: CanStockPhoto Other photos are courtesy of B.Lanning, LympheDivas, M.McNeely, B.Smith, R.Thomas, Medi and Valco.

Canadian Publications Mail Agreement 40065546 ISSN 1929-1418 Printed in Canada

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Resistance exercise with compression for women with lymphedema:

A systematic review of more aggressive exercise and lymphedema.

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What’s different about head and neck lymphedema?

Evaluation and treatment of an often overlooked lymphedema.

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Edema-causing medications An overview of the most commonly used drugs that can cause edema

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Take note of your medications and talk with your doctor.

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Gauntlets/gloves and compression sleeves Addressing the controversies and concerns around hand lymphedema.

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Profile of a researcher: Roanne Thomas

Merging arts and creativity with research interests can be rewarding.

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A mother and son journey of self-education

Managing lymphedema, infections and the teen years.

Lymphoedema Education Benchmark Statements (LEBS)

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Imagine if… all health professionals knew about and understood lymphedema.

Cana

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TO ACCESS PATHWAYS ONLINE Login information: www.canadalymph.ca/pathways-online User name: PathwaysSubscriber Password: vessels

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Research Perspectives

Nutrition for lymphedema

Promising research provides interesting food for thought

By Jean LaMantia

Nutrition care for lymphedema appears to be an area that is unexplored, yet full of potential. After recently undertaking an exhaustive review of the published literature, I want to present on two key areas in which nutrition shows potential for helping with lymphedema.

Body weight and lymphedema A study published in 2007 by researchers in London, UK, tested whether weight loss might be beneficial for lymphedema.

A clinical trial was designed with 21 women.

Half were assigned to limit their calorie intake to between 1000 and 1200 per day for 12 weeks. After 12 weeks, the women in the weight loss portion of the study lost an average of 3.3 kg (7 lbs). While this may not seem like a lot of weight loss, it allowed these women to lose 350 ml of volume in their affected arm (compared to 121 ml in their unaffected arm). Compare this to the non-weight loss group that lost only 11 ml in their affected arm.

In a second study published in the same year, by the same UK researchers, they compared the effects of a low calorie

diet versus a low fat diet on lymphedema.

This study lasted twice as long; 24 weeks.

In this study there were two different diets tested. The first diet restricted calorie intake to 1000-1200 per day. This was called the ‘weight reduction diet’. The second diet restricted fat to 20% of calories. This was considered the ‘low fat’ diet. There was also a control group, who simply continued with their usual diet for the duration of the study. Among other things, the researchers measured the ‘excess arm volume’. This was the difference in volume between the arm with lymphedema and the arm without.

After six months, there was a reduction in excess arm volume, but it didn’t depend on the type of diet. What was seen however, was a greater reduction in excess arm volume when weight was lost. There were small

Jean LaMantia is a registered dietitian, cancer survivor and author of The Essential Cancer Treatment Nutrition Guide and Cookbook. She provides one-on-one nutrition counselling over the phone and in person at the Markham Lymphatic Centre (Ontario) where she also provides a group weight loss program and Nutrition Seminars for lymphedema the last Tuesday of each month.

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Even though the women in the control group and the low fat diet group were not supposed to lose weight, several did, and when they did—they lost more arm volume.

changes in arm volume in the unaffected arm over the 24-week study compared with changes in the arm with lymphedema, so we know there was more than just weight loss that could explain the decrease in volume. Even though the women in the control group and the low fat diet group were not supposed to lose weight, several did, and when they did—they lost more arm volume. This made it difficult to see if a low fat diet without weight loss would reduce lymphedema, but it did show that weight lost—no matter the diet to achieve it, resulted in lower lymphedema volume.

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Dietary fat and lymphedema The lymphatic system is very involved in digestion. This is especially true for the digestion and absorption of fat in the diet.

Fat includes vegetable oils, butter, margarine, nuts and nut butters, fat from meat, dairy, eggs and hidden fat in foods. Once you swallow your food, the body begins to break the food apart and break it down into its A few fatty acids: Pecans, lentils, Omega 3, hazelnuts, almonds, flax seeds, chia and walnuts. smallest component parts.

Fat is broken down into these lymph system into the thoracic duct and into surgery plus radiation and chemotherapy components: monoglycerides, diglycerides, the blood. were in the study. The control group received glycerol and fatty acids. Fatty acids are

We can make at least 4 litres of lymph physiotherapy three times a week for four classified by length. They are either short fluid per day, and a significant percentage weeks and used corn oil in their diet. The (less than 6 carbons), medium (6-12 of this is formed in the gastrointestinal tract. study group received the same physiotherapy carbons) or long (13-21 carbons). Glycerol, Lymph flow increases after a meal, especially but used MCT oil in their diet. The researchers short chain fatty acids and medium chain a fatty one.

This information raises the compared several variables between the two fatty acids are small enough that they can groups. The most dramatic difference was in travel through the semi-permeable membrane question; if you change the type or amount of fat in the diet will it improve lymphedema? arm volume. The women who used the MCT of the stomach and be absorbed into the After an exhaustive search, two publications oil lost 200 ml of arm volume, whereas the blood stream. The other components are too were found that addressed this question. corn oil group actually gained in volume. big to do this and continue to travel through the digestive system into the small intestines. The first publication is a case study. As far as research goes, case studies are considBottom line Once there, they are bound to protein and ered the lowest on the scale in terms of Although they provide preliminary data, form a chylomicron and travel through the evidence-based credibility, but with so little these four studies give us interesting food research available, it is worth sharing. The for thought. Weight loss has many benefits, case study involved two women, both with and if these studies are corroborated by primary lymphedema in their right legs. further research, we may be able to add volume reduction to that list. As for the MCT Patient A was a 30 year old woman who oil I do not suggest that everyone run out was put on a weight loss, low fat diet plus and buy MCT oil and start taking it. Like any a specialized oil called medium chain change in diet, there needs to be a thoughtful triglyceride (MCT), for 4 months. MCT oil consideration of each individual’s situation. is not naturally occurring. It is made by I suggest working with a registered extracting only the medium chain fatty acids dietitian to guide you in the process of diet Make your home safe. Don’t bring from either coconut or palm kernel oil. change. Diet for lymphedema has a lot of home food that you know you unexplored potential. To find a registered shouldn’t be eating.

Patient B was put on a low fat diet plus MCT dietitian in your area, you can use the ‘find oil for 4 months. For the diet they avoided a dietitian’ tool on the dietitians of Canada Late night cravings are not about hunger. They are usually your body’s fatty meat, cheese, fish, butter and oils website www.dietitians.ca, I suggest you use way of saying you are bored, with the exception of 1 tsp. of sunflower oil search terms like ‘cancer’ or ‘lymphedema’ tired, lonely, scared, worried per day. They were allowed to use MCT oil. to find a specialized expert. LP or some other negative Patient A lost 22 lbs (11 kg) and reduced emotion. Don’t treat these A full set of references can be found online at the leg with lymphedema by 7 cm. Patient feelings with food—give your www.lymphedemapathways.ca.

B didn’t lose weight (didn’t need to) and body what it really wants, for reduced her leg circumference by 3 cm. I example, sleep, stress relief, Editor’s Note: companionship or a pleasant should point out that in addition to the diet, distraction or hobby.

It is important to remember that they both were receiving physiotherapy. these research results are preliminary.

The second study on this topic is a clinical When making changes to your However, experts do agree that weight eating habits, start with the easiest trial. This one was published in 2008 in control is important to help manage change first.

San Paulo, Brazil. Ten women with upper lymphedema. arm lymphedema following breast cancer

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Exercise

Resistance exercise with compression for women with lymphedema A systematic review

By Mona Onazi and Margaret McNeely

E

very day, approximately 70 Canadian women are diagnosed with breast cancer and on average 57 of these women will survive for at least five years1. Despite advances in breast cancer treatment, which account for the increased number of survivors, many women still fear that they will develop lymphedema. Breast cancer related lymphedema (BCRL) is an incurable and progressive condition that occurs in around one in five women who survive breast cancer2. It is a chronic swelling that develops in the interstitial tissue of the breast, chest wall and arm on the side of the breast cancer.

BCRL compromises survivors’ quality of life, as it is associated with multiple impairments that affect women physically, functionally and psychosocially. These impairments include pain, arm heaviness, fatigue, and decreases in shoulder range of motion and arm strength, and may negatively affect survivors’ body image and self-esteem3,4.

lymphatic clearance by using range of motion and light resistance exercises. More recently, the focus has shifted to progressive resistance exercise (PRE). Multiple studies have been conducted supporting its safety for women with arm lymphedema. Although the evidence supports a neutral effect on lymphedema symptoms and swelling5-12, little is known about the therapeutic benefits of combining compression therapy with PRE in managing the symptoms and swelling associated with BCRL.

What is new in lymphedema management?

For decades, conservative management techniques have been prescribed for survivors with lymphedema. These techniques aim to enhance the effect of muscle pump on the

Mona M. Al Onazi, a graduate student in Faculty Rehabilitation Medicine at the University of Alberta is a physiotherapist and certified lymphedema therapist with clinical experience. Her research interests lie in the area of breast cancer rehabilitation and lymphedema management.

Margie McNeely, PT, MSc.PT, PhD is an Assistant Professor in the Department of Physical Therapy at the University of Alberta and Cross Canada Institute in Edmonton. Dr. McNeely’s research interests are in the area of cancer rehabilitation and exercise. She sits on the National Lymphedema Conference Scientific Committee and is a Canadian Lymphedema Framework board member. * The contents of this article are adapted in part from a systematic review published in The Gas Exchange: Newsletter of the Cardiorespiratory Division of the Canadian Physiotherapy Association. Summer 2016.

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What was the aim of this systematic review?

The aim of this systematic review was to examine whether a combined program of compression therapy and resistance exercise has a beneficial, therapeutic effect on BCRL. What method did we use to answer our question?

We conducted electronic database searches in Medline, EMBASE, CINAHL and PEDRO. To be eligible, studies were required to assess a combined therapy using compression and resistance exercise as an intervention for BCRL. The primary outcome for the review was to examine the effect of this combined program on arm lymphedema volume. The secondary outcomes included shoulder range of motion, upper limb muscle strength and survivors’ quality of life. Secondary outcomes were not required in studies that assessed the acute effect of resistance exercise on lymphedema. We performed a qualitative analysis of the selected studies based on Sackett’s levels of evidence.

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This method is used to summarize the strength of the findings and provide clinical recommendations based on the quality of the studies.

The effect of resistance exercise program on arm lymphedema volume and other outcomes: The findings from seven5-7,9-12 studies indicate that PRE is safe and is not associated with What were the results? an increase in lymphedema arm volume.

Our initial search found forty-eight studies, Moreover, PRE may help in reducing proximal arm volume. The results also and after screening for the inclusion suggested that exercise helps to criteria, eight studies were found to be 5-12 improve the shoulder range of eligible . These studies generally prescribed mild to moderate motion, upper body strength, intensity resistance exercise, and quality of life. In addition, with or without using resistance exercise can weight, in conjunction improve self-reported with the use of a severity of lymphedema compression garment. symptoms and reduce Sackett’s levels of evidence. the incidence of The acute effect of resistance exercise lymphedema exacerbations. on arm lymphedema volume: What were the results from using One of the included studies measured the compression garment? the short-term effect of a single bout of Generally, the details on compression resistance exercise on limb lymphedema methods as well as the garment type and volume8. The results suggested that, whether women wore a compression sleeve or not, characteristics were lacking. The adherence resistance exercise increased lymphedema to compression use during exercise was volume temporarily, but that this increase measured in only three studies5,7,10 and only one reported the actual adherence rates10. resolved within 24 hours.

This lack of information about the adherence to compression garment/ bandaging use limits our ability to offer clear guidelines on the potential benefits of compression use during exercise.

What kinds of exercises were used in the included studies?

Home Resistance Exercise Program: Three of the included studies prescribed a specifically designed home exercise program, and the duration of these programs varied between

Home Resistance Exercise Program

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Progressive resistance exercise (PRE) is a strength training method used to progressively increase strength in muscles and muscle groups. With PRE, the participant exercises their muscles against some type of resistance such as dumbbells, weight machines or their own body weight.

As the participant’s muscle strength improves, the exercise is made harder by increasing the resistance or weight, the number of repetitions or the number of sets of the exercise.

six and 18 weeks10,11,12. Exercise intensity also varied between gravity resistance exercise (no weight used), light, and light progressive resistance exercise. Participants did their initial exercise sessions under supervision and home exercises were monitored weekly by phone.11

Supervised resistance exercise program: The other four studies involved a supervised resistance exercise program. The durations of the programs reported in these studies were 8 weeks (two studies), 17 weeks and 52 weeks5,6,7,9. The intensity of exercise also varied from low- to moderate-intensity resistance exercise. Gravity resistance exercise was used in one of the supervised studies5 and the other programs were based on weight exercises such as seated row, bench press, triceps pull down, and biceps curl6,7,9.

The frequency of the PRE program in the included studies varied based in the intensity of the exercise program from daily for low intensity programs to 2-3 times a week for progressive and moderate intensity weight programs.

Can survivors with lymphedema start a resistance exercise program?

The National Lymphedema Network (NLN) resistance exercise guidelines suggest that survivors with lymphedema follow a program that slowly progresses from low- to moderateintensity exercise.13 The findings from this review support the NLN guidelines and the suggestion for exercise in conjunction with compression use. However, currently there is no protocol outlining the exact exercises or programming for survivors seeking to start a resistance exercise program.

What are the implications for future research?

Based on the findings from this review, preliminary evidence suggests potential benefit from combining compression therapy and PRE in reducing the proximal arm volume and severity of lymphedema symptoms. To date, there are no large, randomized controlled studies that specifically examine a combined compression therapy and PRE approach. Further research is needed to examine the mode and characteristics of compression therapy (e.g., bandaging vs. compression garment, compression level). In addition, to allow for better interpretation of findings, adherence to compression therapy both during and after resistance exercise sessions needs to be monitored among survivors and reported.

What are the implications of this systematic review on clinical practice?

The use of combined compression and PRE for BCRL may help to reduce lymphedema exacerbations; and improve lymphedema symptoms, shoulder range of motion and arm strength, and survivors’ quality of life, but has not conclusively been shown to reduce arm lymphedema volume. LP A full set of references can be found online at www.lymphedemapathways.ca.

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Clinical Perspectives

What’s different about head and neck lymphedema?

Evaluation and treatment of an often overlooked lymphedema

By Brad Smith

L

ike lymphedema elsewhere in the body, head and neck lymphedema (HNL) is chronic, progressive swelling that occurs due to an impaired lymphatic system.

HNL can occur anywhere in the face, oral cavity, or neck, and while it can be a component of certain genetic conditions, primary lymphedema affecting the head and neck region is rare. Most commonly, HNL develops after treatment for head Lymphedema of neck and neck cancer (HNC) after radiation. with surgery and/or radiation, though it can also arise after chronic skin infections (cellulitis) or other sources Edema above surgical scar. of soft tissue and lymphovascular trauma. The focus of this article is the evaluation and management of HNL following cancer treatment.

Head and neck cancer The head and neck region is anatomically very complex, featuring many structures crucial to breathing, swallowing, speech and voice production, vision, hearing, and other functions. A complex matrix of blood and lymphatic vessels, lymph nodes, nerves,

Airway occlusion from lymphedema when lowering head.

muscles, glands, bony and cartilaginous structures, and other soft tissues are interconnected in a relatively small space and must work seamlessly for the body to function normally. Cancer of the head and neck region may arise in one or more key areas.

Early and accurate diagnosis Head and neck cancer is rare, accounting for approximately 4% of all cancers diagnosed each year. Individuals who are concerned that they may have head and neck cancer should be evaluated by an otolaryngologist/head and neck surgeon who has experience with cancer management to determine the proper diagnosis and treatment.

Surgery for HNC The initial decision to treat tumours that arise in this area with surgery, radiation, or chemo-radiation will be based on the tumour location, size, presence of neck disease, and the expertise of the treating physicians.

Surgery must remove the mass with the least amount of collateral damage possible, preserve function of the affected structures if possible, and minimize disfigurement.

Brad Smith is a speech-language pathologist and certified lymphedema therapist at the Baylor Sammons Cancer Center in Dallas, Texas. He is a frequent instructor at state, national, and international conferences, has authored a textbook chapter, and co-authored two peer reviewed articles regarding evaluation and management of head and neck lymphedema.

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Severe scarring in this area can interfere with drainage, essentially damming the lymphatic flow and creating areas of “pooling” or outpouching above the scar, sometimes referred to as a “trap door effect”. This pattern of swelling can be more persistent than swelling that arises without scarring and may be more difficult to treat, since the typical drainage routes used during manual lymph drainage (MLD) treatment may not be as effective, requiring an alternative pathway.

In addition to major surgeries, surgical removal of lymph nodes (lymphadenectomy or neck dissection) is commonly performed in this population due to either the presence of active disease in the cervical lymph nodes or to prevent high-risk disease from spreading into the neck. While the intent of neck dissection is to prevent disease spread, risk of lymphedema is often increased due to the removal of the lymph nodes, ligation of the lymphatic vessels, and the associated neck scarring.

Typically, the more extensive the surgery, the greater the risk for HNL development. However, the neck contains more than 1/3 of the body’s lymph nodes, which create a very effective drainage system that allows excellent recovery of function in most cases. It is not uncommon for patients to undergo a neck dissection involving >40 lymph nodes and still not develop HNL. Interestingly, HNL is not commonly observed after non-cancer related surgeries involving the face or neck, presumably since the lymph nodes are not typically involved.

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Chemotherapy At this time, there is not enough evidence to suggest a direct correlation of HNL with either chemotherapy or immunotherapy, unlike the limbs, which have been documented to develop lymphedema after treatment with Taxane based chemotherapy. While there have been published accounts of facial edema following chemotherapy for lung cancer, there are no publications documenting HNL after receiving any type of chemotherapy for treatment of HNC in isolation. Likewise, there is currently not enough data to assess the impact of chemotherapy on HNL in those patients who received it in combination with radiation treatment.

Radiation Typical radiation treatment regimens range from 5-7 weeks, 5 days per week. During this process, most patients experience a somewhat predictable series of progressive side effects that usually begin at the midpoint of treatment. These include but are not limited to erythema (redness) and

peeling of the skin, dry mouth (xerostomia), taste changes (dysgeusia), mouth sores (mucositis), pain while swallowing (odynophagia), difficulty swallowing (dysphagia), malnutrition, dehydration, and weight loss. HNL is a common complication following radiotherapy, commonly developing between 8 and 12 weeks after completion of treatment. It is thought that the radiotherapy creates more diffuse tissue damage than surgical intervention and that it requires a longer period of time for tissues to begin thickening and become more firm, reflecting decreased fluid drainage and onset of lymphedema.

Prevalence of HNL While a certain degree of edema is usually expected after surgery or during the acute phase of radiotherapy (when the skin can be severely damaged), it is anticipated that most post-treatment edema will resolve within the first 4-6 weeks. Swelling that persists beyond the expected timeframe after surgery or develops several weeks after completion

of radiotherapy is typically considered head and neck lymphedema (HNL). However, it is important that other sources of edema, such as allergic reactions, infection, venous obstruction, or tumour recurrence are ruled out before lymphedema treatment is initiated since not all swelling is lymphedema and it is not always appropriate to provide lymphedema treatment when swelling is observed.

HNL is encountered much less often than edema elsewhere in the body. This is because cancer of the head and neck accounts for approximately 4% of all cancers diagnosed each year and not all patients who undergo treatment for head and neck cancer will develop HNL. According to a study of 81 patients from Vanderbilt University, head and neck lymphedema was noted in up to 75% of patients who completed treatment for head and neck cancer at least 3 months earlier. All patients were evaluated with traditional external assessment methods and also endoscopic assessment. Results indicated 50% presented with edema in the external neck or face, AND internally within

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the posterior oropharynx or larynx. Only 9.8% presented with solely external edema, suggesting that many patients who are seen for traditional lymphedema management may have undiagnosed internal edema, since most evaluating therapists do not perform endoscopic assessments. An older study looking at a larger cohort of >800 patients reported 48% of their study group developed head and neck lymphedema after treatment for cancer of the head neck. Given these statistics, the number of people who will be diagnosed with head and neck lymphedema each year equates to approximately 1-2% of all patients diagnosed with cancer. As a result, head and neck lymphedema is not frequently encountered by most physicians or therapists.

This lack of exposure sometimes results in decreased familiarity and misperceptions regarding the treatability of HNL. However, interest in the management of head and neck lymphedema is increasing due to an unfortunate rise over the past 10-15 years in the number of patients diagnosed with oropharynx (posterior mouth and throat) cancer related to the human papilloma virus (HPV). It is anticipated that this rising trend of HPV+ oropharynx cancers will continue over the next 10-20 years. Since this type of cancer is most frequently treated with chemotherapy, radiation, and sometimes surgery, there will likely be increased demand for skilled lymphedema therapists who can treat HNL. This trend has already been observed, since this patient population is typically younger, between the ages of 40 and 60, and generally healthy, with many of them returning to work after their cancer treatment. Among this demographic, there is a decreased tolerance of disfigurement and disability, prompting more patients to request treatment for head and neck lymphedema in recent years.

HNL is different Lymphedema of the head and neck is not identical to lymphedema elsewhere in the body. While lymphedema in the arm or leg is typically considered a lifelong condition, mild to moderate HNL typically responds very well to treatment, especially when manual lymph drainage (MLD) and compression are started during the early stages of swelling.

Like edema elsewhere in the body, once the 14 L y m p h e d e m a p a t h w a y s . c a

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tissues become firm and fibrotic, reversal of the edema becomes more difficult and swelling remains more persistent with more chronic functional impairment. When edema affects the lips, tongue, eyes, or throat, there may be substantial impairment of speech, swallowing, breathing, or tasks like walking or driving when vision is affected.

Severe lymphedema affecting the head and neck is quite difficult to hide and aside from the functional deficits it creates, there may also be increased levels of anxiety and self-consciousness, sometimes resulting in isolation and decreased socialization.

As a result, head and neck lymphedema can have severe consequences and its treatment is of utmost importance.

Anterior drainage pathway.

Posterior drainage pathway.

HNL evaluation Once diagnosed with head and neck lymphedema by their physician, patients should undergo a thorough lymphedema evaluation prior to initiating any treatment. Ideally, this will occur during the early stages of Non-custom chin strap swelling in order for neck edema. to provide the best chance for reversal and elimination of the edema. The evaluation should include a thorough case history to ensure that the edema is not related to a different etiology like allergies or infection, which require medical intervention. It is critical to obtain documentation of both size and firmness of the affected tissues using tape measurements and photographs to document baseline appearance and function, as well as changes over time. There are several published head

and neck measurement and staging protocols that are appropriate for this patient population.

In addition, brief assessment of speech, swallowing, cervical range of motion, and upper extremity function are also important for patients with head and neck lymphedema.

Since HNL can affect the oral cavity, efforts should be made to assess the lips, tongue, and remainder of the mouth in order to identify any edema that could be missed with a cursory examination. Patient feedback is of utmost importance, since the patient may perceive swelling that may be missed by the examiner with tactile and visual assessment.

HNL treatment The approaches used for manual lymph drainage for the head and neck are slightly different than those used for the limbs and trunk, but the general premise is the same.

It is important that the trunk be decongested before the edematous face and neck are treated in order to provide an adequate drainage pathway. Typically, the drainage target for patients with HNL is the axillary lymph nodes bilaterally. In cases when the axillary nodes are unavailable, drainage may be rerouted to the opposite axilla or inferiorly to the inguinal lymph nodes. The drainage pathway utilized during MLD will depend on the severity of scarring within the neck, but in general, decongestion is performed in the trunk first, then the neck, face, and oral cavity if required. The sequence is then reversed and followed by the use of compression padding, typically held in place by a compression garment or bandage. In cases of pitting edema, compression padding is also used immediately prior to treatment to soften and prepare the tissues for MLD by increasing the elasticity of the skin. This protocol has been shown to be quite effective, even with severe cases of head and neck lymphedema. Compression is usually used at night, because, contrary to that seen with limb edema, HNL tends to get worse with the recumbent position.

While outpatient treatment is always preferred, mild to moderate cases of head and neck lymphedema can frequently be treated effectively by the patient in a self-administered home program featuring a modification of MLD techniques in Summer 2017

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Custom facemask for facial edema.

combination with compression pads and garments. Previous studies from M.D. Anderson Cancer Center have shown excellent treatment results, whether patients performed a self-directed home management protocol, or if they received outpatient rehabilitation as well. Compliance with recommended protocol was the most significant factor associated with success, regardless of approach.

Why does HNL respond so well to treatment?

In general, HNL should respond well to treatment, especially in mild to moderate cases where treatment can often be discontinued over time and the edema not

return. One potential reason is related to the gravitational/positional benefit that occurs once the patient becomes upright and mobile each day. This is evident by observing increased levels of swelling in the head and neck with most patients when they first rise and a fairly rapid reduction of swelling during the first two hours of being mobile in the mornings. This pattern is not typically observed with edema elsewhere in the body. In patients with severe neck scarring, however, the pattern may be reversed, with more persistent edema and greater swelling at the end of the day due to the disruption of drainage pathways created by the scar.

Summary Head and neck lymphedema is a common occurrence following treatment for head and neck cancer that may be quite mild and cosmetic in nature or can progress and become very severe, with functional impairments. It is often very responsive to treatment, especially with early intervention using manual lymphatic drainage and compression

Mild edema – baseline.

After 2 months of home program, 3-days/week.

therapy, but there are times when the edema is persistent and difficult to manage. It is important to remember that HNL differs from edema elsewhere and proper training is required for head and neck lymphedema management for maximum success. LP A full set of references can be found online at www.lymphedemapathways.ca.

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Summer 2017

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Ask the Expert

Edema-causing medications

Take note of your medications and talk with your doctor

By Vaughan Keeley and Neil Piller Introduction Some medications may cause edema in people who do not normally have swelling.

They can also exacerbate swelling in those who already have lymphedema and may be contributing factors in those who have chronic edema due to a number of causes, particularly the elderly. This means that the potential role of medications in the cause of edema needs to be considered in all people with chronic swelling.

Most medications which cause edema do so by increasing the amount of fluid filtered from the blood capillaries into the tissues but some may impair the lymph drainage.

Q

Do many drugs cause edema?

A

The list of medications which may cause edema is very long. For some, it may be a common side effect, but for others it is rarely seen.

The most commonly used drugs which can cause edema are: • calcium channel blockers e.g. amlodipine • nonsteroidal anti-inflammatory drugs (NSAIDs) e.g. ibuprofen • corticosteroids e.g. prednisolone • hormones and related compounds e.g. tamoxifen

Calcium channel blockers (CCBs) These are probably the medications most frequently implicated in causing edema, potentially affecting up to 50% of those who take them, depending upon the specific type and dose. They are used to treat high blood pressure. They cause edema by increasing capillary filtration of fluid and may also reduce lymphatic drainage.

The time to onset of edema after commencing CCBs may vary with different drugs, e.g. one month with amlodipine; two months with nifedipine.

Nonsteroidal anti-inflammatory drugs (NSAIDs) These medications are commonly used in the treatment of a wide variety of conditions e.g. arthritis.

They cause edema by fluid retention. The likelihood of this depends upon the individual drug e.g. up to 9% with naproxen.

Corticosteroids Corticosteroids can cause sodium retention through a direct action on the kidney. This can result in fluid retention and hypertension.

The effect is dependent upon the dose and duration of treatment. Corticosteroids are used to treat a variety of illnesses. These include some inflammatory conditions in which edema can be a feature e.g.

rheumatoid arthritis. In these situations long term corticosteroids can help reduce the inflammatory edema but may cause leg swelling. A decision about their continued use will depend on the balance of benefit v. side effects. In some conditions such as asthma, short courses of corticosteroids are used e.g. up to 2 weeks and during this time leg swelling is unlikely to occur. Corticosteroids are also used to treat peripheral edema in advanced cancer (they work by reducing the inflammatory edema around the cancer) but again decisions on duration and dose depend on weighing up the benefit v. side effects.

Sex hormones and related compounds Whilst the combined oral contraceptive pill and hormone replacement therapy can cause edema in some women, hormone treatments such as those used in breast cancer e.g. tamoxifen, anastrozole and megestrol may lead to edema in 7 to 14% of women taking them.

Other drugs Other drugs which may be responsible for edema include anticonvulsants used in pain management e.g. pregabalin (affects 5 to 12%), antidepressants e.g. trazodone (10%), anti-diabetics e.g. rosiglitazone (5%), antipsychotics e.g. risperidone (16%), bisphosphonates e.g. zoledronic acid (21%), chemotherapy agents e.g. docetaxel (47 to 64%) and immunosuppressants e.g. sirolimus (more than 10%).

Vaughan Keeley, PhD, FRCP is a Consultant Physician in Lymphoedema, Derby, UK and a Director of the International Lymphoedema Framework. Neil Piller, PhD, FACP, is a Director of the International Lymphoedema Framework and Director of the Lymphoedema Clinical Research Unit, Department of Surgery, Flinders University School of Medicine, Australia.

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Q

How can we tell if a medication is contributing to the edema?

A

There may be a clear time relationship between starting the medication and the onset or worsening of swelling. For some medications, e.g. corticosteroids, the effect may take some weeks to develop.

Checking whether edema is a common side effect for a particular medication is important, but it is still necessary to consider the potential role of a medication, which only causes edema rarely. A medication may cause more widespread edema in someone with a pre-existing localized swelling, eg. it could cause swelling, eg. in both legs in someone who may have lymphedema previously affecting one leg only.

Q A

If a drug effect is suspected, how should this be managed?

Ideally, e.g. with calcium channel blockers used to treat high blood pressure, the medication should be withdrawn or switched to another product.

However in some circumstances where the blood pressure has been difficult to manage, continuing the medication but with a reduced dose may improve the edema. In some cases, however, the medication may be essential in treating a serious medical condition and therefore managing the side effect, eg. with compression garments or the use of diuretics in certain instances, may need to be considered.

Conclusions For many people with chronic edema, the cause of the swelling is often multifactorial.

Medications can play a significant part in this and it is important to consider what role they may have and whether changes should be made to improve the control of the edema. LP

Some medications may cause edema in people who do not normally have swelling.

They can also exacerbate swelling in those who already have lymphedema.

References 1. Keeley, V (2008) Drugs that may exacerbate and those used to treat lymphoedema.

Journal of Lymphoedema 3(1).

2. Given the prevalence of use of Calcium Channel blockers the following older article may be of interest. It indicates their mechanisms of actions and provides a generic review of our thinking. Sica, D A Calcium Channel Blocker-Related Peripheral Oedema: Can It Be Resolved Journal Clinical Hypertension (Greenwich).

2003 5(4):291-4.

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Featuring over 100 patterns, crystals and color options for both women and men, LympheDIVAs truly has something for everyone. All garments are made in the USA featuring a completely hypoallergenic construction free of latex and silicone.

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Clinical Perspectives

Using gauntlets/gloves and compression sleeves

Lymphedema management and prevention

By Andrea Cheville

C

ontroversy persists regarding the benefits of compression garments in preventing lymphedema. A key stumbling block is the possibility of triggering hand lymphedema when wearing a sleeve without a glove or gauntlet. Compression applied to the arm may reduce lymph flow from the hand.

Even a normal lymphatic system works harder to drain lymph from the hand than other parts of the arm. This fact explains why hand lymphedema is often the most challenging to treat and why lymphedema specialists take great pains to prevent it.

Concern that compression sleeves may inadvertently trigger hand lymphedema underlies the recommendation to always wear a compression gauntlet or glove with a sleeve.

A gauntlet or glove should be used in conjunction with compression sleeves when used for lymphedema prevention.

Most women at risk for lymphedema who have not noted increased arm volume, or other indicators of early lymphedema wear their sleeves during activities that increase lymph production. Examples include airplane travel, vigorous exercise, and repetitive activities performed in an intense fashion. It is important that women using preventative

compression combine their sleeve with either a gauntlet or glove during such activities.

Particular attention should be paid to constriction at the shoulder band, elbow, and wrist crease. Sometimes overlap of a gauntlet and sleeve at the wrist can cause excessive pressure.

For women with established lymphedema the decision to use a gauntlet or glove is based on slightly different considerations.

Lymphedema of the upper limb may be distributed in a surprisingly patchy manner. For example, lymphedema may be restricted to the underside of the upper arm or the back of the hand. Lymphedema is a very individual phenomenon. Many women with lymphedema never note hand involvement despite use of an arm compression sleeve for many years. However, even these women should remain watchful for hand swelling since lymphedema is a dynamic process with the potential to change over time. A quick check for hand edema after engaging in the activities listed above is always warranted.

Differences in skin texture or the visibility of bones, veins and tendons may indicate lymphedema. These changes suggest a need to consider some form of hand compression.

Of particular concern are women with lymphedema that plan to begin an exercise program or to significantly increase their

Dr. Andrea Cheville, currently is Senior Associate Consultant at the Mayo Clinic in Rochester, MN, specializing in cancer rehabilitation, lymphedema, and survivorship. A leader in the field of cancer rehabilitation, pain control and symptom management, Dr. Cheville has published papers on cancer rehabilitation and is a nationally recognized expert in this field.

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activity and do not use hand compression.

For these individuals use of hand compression during exertion is crucial until a stable level has been established. At that point, a woman may carefully experiment with using a sleeve alone. However, it is always prudent to use hand compression during vigorous arm activity. Hand lymphedema is more difficult to control than arm lymphedema, because of the the hand’s irregular shape, its critical role in daily activities and the difficulty inherent in precisely fitting a gauntlet/ glove. It is vital that early signs of hand lymphedema be taken seriously and that appropriate modifications are made to a patient’s lymphedema maintenance program.

In summary, a gauntlet or glove should be used in conjunction with compression sleeves when used for lymphedema prevention.

Women with established lymphedema who have not required hand compression should consider adding a glove or gauntlet in situations that may increase lymph production in their arms. Many patients with lymphedema spend their entire lives well-controlled with use of a sleeve alone. The risk of having hand lymphedema is present in all women with arm lymphedema and those at risk. Adding a gauntlet buys some protection against this event and like all insured risk, we do not know who will be helped by the insurance and who might not even need it. Working with physicians and therapists skilled in lymphedema management will ensure that each woman develops a safe and effective compression plan tailored to her unique needs. LP

Reprinted with the permission of LympheDIVAs LLC and Andrea Cheville, M.D. Summer 2017

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Researchers Profile

Profile of a Researcher: Roanne Thomas

Merging arts and creativity

with research interests can be rewarding

Roanne Thomas, PhD is Canada Research Chair in Creative Practices and Well-being and Professor, School of Rehabilitation Sciences at the University of Ottawa. Her research focuses on psychosocial supports for people living with chronic illnesses.

Q A

What prompted your interest in doing research on lymphedema?

My research on lymphedema began about 15 years ago as I was interviewing women who had breast cancer for my PhD dissertation. A few of the participants mentioned lymphedema and were wearing compression garments. I was not familiar with the condition and without much on-line information back then, it was really difficult to learn more about this condition. But, those women made it clear to me that lymphedema could have a significant impact on people’s everyday lives. I then decided to interview women about lymphedema for my next project, focusing on quality of life and gaps in healthcare. At that time, my interest in lymphedema was also fuelled by a conference organized by the Lymphedema Association of Quebec in 2003 and connections that I made there.

These events are essential to building research capacity. Those connections and the small study of women’s experiences with lymphedema eventually led to a much larger, national study of women with breast cancer in which we tracked the incidence and impact of lymphedema and other arm problems over five years. We’ve published several articles on our findings and produced an infographic from that study (www.roannethomas.ca/ research/dabc-study.html).

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Q A

What types of research would you like to see in the future?

I would like to see an expansion of what counts as evidence for turning research into practice. I recognize the importance of clinical trials, but not all of our interventions or programs lend themselves to the same research approaches as one might use in a drug trial, for example. Lymphedema is so multi-dimensional, especially if the focus is on people’s emotional and social well-being.

Everyone leads complicated lives and I think more research could reflect that, but I do realize that it is absolutely essential to treat the physiological aspects of lymphedema. In an ideal world, there would be a range of readily available treatments and supports to address the whole person.

Q

Who are your collaborators?

Who is on your teams? What is their role?

A

I’m really proud of our interdisciplinary teams. I’ve worked with physicians, physiotherapists, occupational therapists, psychologists, and nurses, as well as other sociologists. I very much enjoy working with students and postdoctoral fellows in our Creative Practices Centre at the University of Ottawa. It is a bit of a cliché, but each person brings their own piece of the puzzle to the table and that helps us to better understand the impact of lymphedema and how people might be best supported socially and psychologically as they live with it.

Q A

What happens in a typical day in your lab or research facility?

While we have an active research lab, most of our research actually takes place in the community. My research has seen me co-facilitating creative writing groups, making a collage alongside participants, and running (or mostly walking!) trails in Ottawa. A key project has been developing a hope and coping program for men and women with lymphedema. I’ve been collaborating with a sport psychologist on that study. It has been interesting combining my interests in creativity with some of the strategies and techniques that he uses with professional athletes. Also, one of my PhD students is a filmmaker and it has been really exciting to have opportunities to work with her. We’ve produced a video with men and women living with lymphedema that is freely available on YouTube. I’ve even travelled with research participants for a readers’ theatre project.

Each day is different and it’s never boring!

Q A

How has the focus of your research shifted over time?

My research has shifted from documenting the impact of lymphedema, as well as arm pain and range of motion restrictions after breast cancer, to learning more about what supports people might find helpful to enhance their sense of well-being. In this way, my own personal interests in arts and creativity are merging with my research interests and that’s been very rewarding.

LP

Current Team Members: Stephanie Saunders, Brianna Hammond, Chad Hammond and Viviane Grandpierre.

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Personal Perspective

A mother and son journey of self-education Managing lymphedema, infections and the teen years

By Bev Lanning

M

y son James was diagnosed with primary lymphedema praecox at age 14. He presented with swelling to the proximal left thigh, which was first noticed by his friends in a hockey dressing room.

It took James about two weeks to tell me something was wrong… my first thought was panic! I was an emergency room nurse who immediately had him diagnosed with cancer.

Why else would his thigh swell in the absence of injury? A visit to our local emergency department did nothing to calm my fears as the physician expressed concern that there might be an underlying pathology such as a tumour causing his swelling. CT scans and a battery of blood work ruled out a cancer diagnosis, but the explanation given for the swelling was a whole new worry… “primary lymphedema praecox”.

James was promptly sent to the only physician in the province who had an interest in paediatric, primary lymphedema.

This began our long journey of self-education and navigating a health care system that

Night Compression Cellulitis largely ignores this condition.

Thankfully I did meet some very knowledgeable people along the way, to whom I am forever grateful.

Going through the teenage years James not only had to deal with adolescence, but he also had to learn to manage this

Bev Lanning RN, BN, CLT- LANA completed her lymphedema training (Norton School of Lymphatic Therapy – 2008) and Lymphology Association of North America certification in 2011. Bev works as the Regional Lymphedema Nurse for Central Health providing treatment and management to persons affected by lymphedema. James Lanning graduated with a Bachelor of Commerce in 2014. He recently completed his Chartered Professional Accountant (CPA) designation in 2016 and now works as an assistant controller for a group of companies in St. John’s, NL.

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life-long chronic condition. Having to wear compression stockings as a 14 year old was difficult. The daily bandaging and participation in sports such as golf and hockey presented a real challenge.

About six months after his diagnosis, James encountered his first infection.

Multiple fly bites were thought to be the trigger for his sepsis. A lengthy hospital admission was to follow, with a significant increase in his left leg swelling.

A susceptibility to frequent infections plagued his teenage years, with every infection contributing to further swelling, worsening his lymphedema. At one point it was suggested he give up his sports as this was felt to be contributing to the frequent infections. James will admit this was a very challenging time in his life.

Lack of availability of physicians and therapists trained in lymphedema management led me to pursue a lymphedema certification. As a nurse I qualified to enroll in one of the recognized schools in North America, finishing complete decongestive therapy training through Norton School in Red Bank, NJ (USA). I did the training primarily so I could assist with Summer 2017

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This began our long journey of self-education and navigating a health care system that largely ignores this condition. Thankfully I did meet some very knowledgeable people along the way. the management of my son’s lymphedema.

A career opportunity presented later and I now work full time as a lymphedema nurse/ therapist for Central Health, one of the four regional health authorities in Newfoundland and Labrador (NL). My practice has seen over 500 patients with various types of chronic edema.

I am proud that NL offers services to those affected by lymphedema, but we are still in the infancy stages. Many patients like James who live with lymphedema have few resources to help them manage. Custom compression garments and other equipment used in the treatment of lymphedema are not covered for most people in our province.

Poor management often leads to frequent

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infections and the potential for decreased quality of life, not to mention the burden to a health care system that already has stretched resources.

I am grateful to James for allowing me to share his story as I advocate for better care for those affected by all types of lymphedema. Raising awareness within the medical community and at government levels is a must if we are going to improve outcomes for those affected.

James today continues his battle with lymphedema. As I write this article he is admitted to hospital for yet another infection.

The constant education to his health care providers continues as we try and navigate the system. He is now 25 years old! LP

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Education

Lymphoedema Education Benchmark Statements (LEBS)

Imagine if… all health professionals knew about and understood lymphedema!

By Margaret Sneddon

A

project developed by the International Lymphoedema Framework (ILF) Education Committee is aiming to make understanding and awareness of lymphedema a universal reality. How good would it be if those who experienced a little swelling went to their doctor, nurse, physiotherapist etc. and were immediately offered advice on caring for their skin, exercise and risks while awaiting their referral to a specialist for assessment? Better still, what if in a routine consultation, it was recognised that an individual was at risk of developing lymphedema and were given sound advice on what they could do to minimise their risk and where to get more information?

International consensus has been achieved for Lymphedema Education Benchmark Statements (LEBS), which comprise six basic statements in relation to professional knowledge and understanding of: 1 A natomy and physiology of the lymphatic system 2 Pathophysiology of lymphedema 3 R ecognition of various causes of edema 4 Recognition of lymphedema 5 Patient education/support needs 6 Components of treatment

For each statement, objectives have been set. Professional health care education programs will be encouraged to benchmark their curricula against the statements and objectives and assess the extent to which their programme prepares students to achieve the objectives. For teachers who may lack knowledge in this area, LEBS offers guidance on content and relevant points at which lymphedema-related information could be integrated. We are developing free online resources to make this as easy as possible, with minimal demand for extra curriculum time. The program is currently being piloted in Australia with plans to expand later in 2017. Dissemination will be via the ILF website and National Lymphedema Frameworks.

The aim of this endeavour is to ensure that future health care professionals of all disciplines have a basic understanding of lymphedema. Due to increasing prevalence of lymphedema and chronic edema and a growing ‘at risk’ population, the ILF expert

Margaret Sneddon is an Honorary Lymphoedema Clinical Specialist in NHS Forth Valley in Scotland and an Honorary Senior Research Fellow in the School of Medicine, Dentistry and Nursing in the University of Glasgow. She is currently Acting Vice Chair for the British Lymphology Society and a Director of the International Lymphoedema Framework.

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panel agreed that the most effective way to encourage early identification and intervention and to improve patient outcomes, quality of life and reduce the burden on health services was to improve the education of health professionals.

Professionals need to know the various causes of lymphedema, how to recognize it, components of treatment and have the tools to provide patients with basic education and support. This is not a ‘quick fix.’ We will need to educate registered health professionals for many years to come, but if future health professionals start their careers with an understanding of the condition, the ability to recognize it and provide appropriate advice and information on risk reduction, self-care and where to get help, we will have moved a long way!

The LEBS can be seen on the ILF website at www.lympho.org/lebs. At present there is only an example of the guidance and resources we plan to offer. However, it is currently being tested with educators and the feedback is that even now, it is helpful in identifying gaps in existing curricula. We appreciate the help of anyone involved or in contact with providers of health care professional education to draw attention to the existence of LEBS as the project evolves. LP Summer 2017

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Helpful Suggestions

Hints and Tips

Take a load off For those living with leg lymphedema— gravity is not your friend. When sitting down at your computer for long periods of time, rest your affected leg by elevating it on a box or upside-down recycling blue bin under your desk.

Bugs beware Since most bactericidals can irritate your skin, try adding a few drops of tea-tree

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oil to your skin cream that you are applying to the lymphedematous limb.

Although it may stink a bit, it is a very good repellent of mosquitoes, fleas, ticks and other bugs. These insects are attracted to the blood collecting under the skin that is compressed, so they will try hard to bite through the compression garment.

Leda Raptis, Kingston, Ontario.

Cold compression In very warm weather, if you are not near an air conditioner—try wetting your compression garment to keep

your body temperature down and your limb cool. However, don’t keep it wet too long, because bacteria are lurking and you could get an infection.

Leda Raptis, Kingston, Ontario LP

Send us your hints and tips Why not make it easier for those living with lymphedema by sharing your practical dayto-day living tips with us?

We invite patients, caregivers and health professionals to send in your suggestions and photos to pathways@canadalymph.ca.

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Research and Community

Did you know?

Estimated prevalence growing

Prevalence statistics and demographic trends from a cross-sectional study (Moffatt, Keeley, Franks et al.) indicate that chronic edema is a major and growing health care problem.

The study was designed to estimate the point prevalence of chronic edema (CE) within the health services of one urban population (Derby City) and to determine the proportions that have concurrent leg ulceration.

Within the study population 971 patients were identified with CE (estimated prevalence 3·93 per 1000).

The prevalence was the highest among those aged 85 or above (28·75 per 1000) and was higher among women (5·37 per 1000) than men (2·48 per 1000). The prevalence among hospital inpatients was 28.5%. Only five (3%) patients in the community population had edema related to cancer or cancer treatment.

Source: Int Wound J. 2016 Dec 04

Lifetime achievement award

Saskia R.J. Thiadens was recently recognized by Klose Training and the Lymphedema Community for her lifetime contributions and tireless advocacy on behalf of individuals living with lymphedema. Outstanding achievements include; opening the

first USA lymphedema clinic (San Francisco, 1987); founding the National Lymphedema Network (1988) serving as President and Executive Director for 27 years; founding the Lymphedema Special Interest Group of the Oncology Nursing Society; organizing 12 successful conferences; establishing the Marilyn Westbrook Garment Fund; coordinating Position Papers and, creating March 6 Lymphedema Awareness Day, now recognized internationally as World Lymphedema Day. Saskia’s leadership has had a profound impact and her legacy is best measured by the innumerable lives she has touched.

Source: Klose Training & Consulting LP

Lymph

The Most Refined Mechanism of the Body

A properly functioning lymphatic system is an essential part of our health and an important prerequisite for a successful immune response and for healing of inflammation.

LYMPHDIARAL® is a German-made homeopathic remedy with more than 50 years of clinical experience used to relieve symptoms of: • Pain • Swelling • Inflammation

www.pascoe.ca

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Education Education

Canadian and International Events Sep 25-29, 2017 26th World Congress of Lymphology.

Barcelona, Spain Hosted by the International Society of Lymphology (ISL). n www.lymphology2017.com Oct 11-15, 2017 National Lymphedema Network Lake Buena Vista, (NLN) Conference. Theme: The future Florida of lymphedema care— Patient engagement and clinical collaboration.

At Disney’s Coronado Spring Resort, at Walt Disney World. n www.lymphnet.org Oct 27-28, 2017 National Lymphedema Conference Montreal, Quebec will be co-hosted by the Canadian Lymphedema Framework and the Lymphedema Association of Quebec in collaboration with the McGill University Health Centre and Concordia University. This bilingual conference will feature international keynote speakers and be simultaneously translated into French. Patients are invited for the Saturday program. n www.canadalymph.ca/conference Oct 29-Nov 1, 2017 Aqua Lymphatic Therapy Montreal, Quebec certification course with Dorit Tidhar (M.Sc., PT, ALT, CLT).

Lymphedema therapists certified and practicing Combined Lymphedema Therapy (CDT) or (CLT) are eligible to register. Location: Centre sportif UQAM. n www.infolympho.ca/courses-andworkshops

Letters to the Editor... a phedem re in lym a c lf e d s n ga a s ents a Using yo e to pati messag issue). l fu e s u ll 2017 wa s a ways Fa th a P ( nals a for the professio sing yog u n a g . You e we b r results In 2002 shed ou li b u our p d e an ram in y first tim our prog n o in for rt a o g a rep k you a carried e. Than u s is b site e 4 w 1 r 20 isit our v to summe u o ey s. I invit Pathway n .i .org www.iad Narahari Dr. S.R. d of Applie I congratula Institute ) D te you on A (I logy Pathways m Dermato ia ag d azine, a In od, high-quality, Kasarag informative, and attractive pu blication. Yo u continue to do valuable work in the lymph edema world , . and I thank anks you for that e! Th . in z a e mag Ruby Kreindl arEas your er r, We e Love n w O – To ronto, Ontar h it e K io Phyllis aho d I , Boise

We would love to hear from you...

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

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

Platinum Sponsorship

Gold Sponsorship

The CLF has affiliate agreements with its provincial partners for distribution of Pathways including customized inserts.

Alberta Lymphedema Association Atlantic Clinical Lymphedema Network BC Lymphedema Association Lymphedema Association of Manitoba

Silver Sponsorship

Lymphedema Association of Newfoundland and Labrador Lymphedema Association of Ontario

CANADIAN LYMPHEDEMA FRAMEWORK

PARTENARIAT CANADIEN DU LYMPHOEDÈME

About the CLF The Canadian Lymphedema Framework is an academic and patient collaboration, working to improve lymphedema management for lymphedema and related disorders in Canada.

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Lymphedema Association of Quebec Lymphedema Association of Saskatchewan Charitable Registration 85160 1260 RR0001

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Pathwa

INTRODUCING JOBST® RELAX A REVOLUTIONARY COMPRESSION GARMENT FOR MORE THAN JUST A GOOD NIGHT’S SLEEP

THERAPIES. HAND IN HAND. www.jobstcanada.com

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2017 National Lymphedema Conference

Reserve your spot at

canadalymph.ca

Montreal • October 27-28 • Hotel Omni Mont-Royal

for this global knowledge-sharing conference!

CHRONIC EDEMA AND LYMPHEDEMA: A growing problem in Canada A bilingual conference co-hosted by the Canadian Lymphedema Framework and the Lymphedema Association of Québec in collaboration with the McGill University Health Centre and Concordia University.

This collaborative event will bring together a national and international audience to strengthen the discussion of lymphedema care in Canada. Healthcare professionals, researchers, patients, and community leaders will gather in Montreal to learn from experts in lymphedema research, diagnosis, treatment and self-care.

We invite you to come and learn from our extensive roster of invited speakers and workshop leaders: Dr. David Keast, Prof. Robert Kilgour, Marie-Eve Letellier, Dr. Catherine McCuaig, Prof. Margie McNeely, Dr. Nadia Paquette, Prof. Sheila Ridner, Dorit Tidhar, Dr. Anna Towers and more!

KEYNOTE SPEAKERS • Dr. Tobias Bertsch (Germany) Obesity and lymphedema • Prof. Christine Moffatt (England) Prevalence • Dr. Alex Munnoch (Scotland) Surgical options • Dr. Isabelle Quéré (France) Pediatric lymphedema SPECIAL FEATURES •3 .5 hour pediatric lymphedema interactive workshop • Full day community nurses training module

INDUSTRY SPONSORS Diamond

Platinum

Silver

Bronze

COMMUNITY SPONSORS

Diamond Gold

Gold

Gold

With additional funding provided by Palliative Care McGill, Tourisme Montréal, University of Montreal, and Quebec Ministry of Health and Social Services

resenting key topics related to CHRONIC EDEMA and LYMPHEDEMA: P Obesity, Lipedema, Pediatrics, Self-Management, Exercise, Compression, Measurement, Skin Care, Surgery, Wound Care, Psychosocial and Clinical Services. www.canadalymph.ca B936_CLF_Pathways_Summer2017.indd 28

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