USING AQUATIC EXERCISE WITH THE LYMPHEDEMA PATIENT Combined Section Meeting 2016 Anaheim, CA February 2016 Lynette Jamison, MOT, OTR/L CPO, CLT
Course Description & Objectives: The workshop, Using Aquatics with the Lymphedema Patient, will provide the information necessary for a therapist to develop and implement an aquatic treatment plan which will augment a full lymphedema management program. The participants will be provided with the didactic evidence to support the use of an aquatic treatment plan for this patient population. Anatomy, physiology and some possible pathologies of the lymph system will be discussed. Treatment, and after care protocols will be presented including Manual Lymph Drainage, aquatic exercise and use of compression bandages and garments. Specific exercises will be practiced in water. Case studies will be presented. Information regarding specific training for Manual Lymph Drainage and purchasing compression products will be provided. Objectives: Upon completion of this course, participants will be able to: Describe the pathways of the lymph system. Justify using aquatic exercise versus land based exercise using evidenced based information. Develop an aquatic exercise program for a patient with lymphedema to enhance lymph drainage and circulation. I. Introduction and opening discussion II. Types of Lymphedema A. Phlebo-Lymphedema B. Primary Lymphedema C. Secondary Lymphedema D. Lipedema E. Wounds III. Stages of Lymphedema A. Stage 0 The potential of lymphedema B. Stage I The swelling comes and goes C. Stage II Pitting is present D. Stage III Skin is so hard it no longer pits IV. Breast Cancer Related Lymphedema A. Over 2 million women in the United States are breast cancer survivors. The American Cancer Society estimates that 10-15% of these women (200,000-400,000), although others have proposed an even higher estimate of 30-40% (600,000 to 800,000) women will develop lymphedema over their lifetime. B. Lymphedema may develop weeks, months or years following treatment for breast cancer, it is difficult to accurately determine the exact causes of lymphedema. Long-term studies of women with differing life styles, treatments and backgrounds have not shown a relationship between age, obstructive drainage, number of lymph nodes to which cancer had spread, or weight at diagnosis. C. The foremost reasons why women developed late-onset lymphedema (3 or more years following therapy) are: 1. weight gain following cancer treatment 2. infection 3. injury Petrek, Jeanne, et al. Lymphedema in a Cohort of Breast Carcinoma Survivors 20 Years after Diagnosis. Cancer; 2001:92(6) 1368-1377.
V. Types of Breast Cancer Surgery A. Lumpectomy B. Mastectomy C. Modified Radical Mastectomy D. Radical Mastectomy E. Quadrectomy F. Skin Sparing Mastectomy G. Phebo-Lymphedema H. Phlebo-Lymphedema VI. VII. VIII. IX. Assessment A. History B. Surgeries C. Circumferential measurements D. Skin fold thickness E. Skin thickness/fibrosis F. Skin Color G. Stemmer sign Manual Lymph Treatment Different approaches combat the effects of lymphedema. A. Vodder Method of MLD B. Leduc C. Casely-Smith D. Foldi E. Complex Lymphedema Therapy F. Complete Decongestive Therapy G. Lymphology Association of North America Evaluation A. Medical History B. ROM C. Muscle strength D. Sensation E. Volume F. Skin Condition G. Pain H. ADL s X. Treatment A. Manual Lymph Treatment--To drain the lymph fluid from the affected extremity utilizing the superficial lymph vessels with a non-invasive, technical therapy massage technique. B. Home Edema Management C. Self Massage D. Compression Bandaging using short stretch compression bandages, foam and under stocking. Compression to the limb aids in the reduction of edema especially during exercise. This assists in pumping lymph from the extremity
XI. XII. XIII. E. Progressive Therapeutic Land and Aquatic Exercise with muscle strengthening and cardiovascular strengthening 1. Closed Kinetic Chain 2. Active and passive range of motion 3. Cardiovascular Exercise 4. UBE 5. Therapeutic Aquatic Exercise a) Hydrostatic compression b) Viscosity c) Buoyancy--provides resistance with equipment. This allows for eccentric contractions when using floatation devices d) Torque e) Effects of Hydrostatic Pressure on Lymphedema f) One foot of water depth is equal to 22.4mmHg. g) The deeper an object is immersed in water the greater the pressure. h) Viscosity increases torque resistance to encourage the proximal lymph centers. F. Kinesio taping G. Sequential gradient compression pump H. Skin care I. Avoid constrictions J. Deep breathing exercises Edema Certifications A. MLD Manual Lymph Drainage B. LANA Lymphology Association of North America C. NLN National Lymphedema Network D. DPT Decongestive physiotherapist. It also means Doctorate of Physical Therapy E. CDT Complete Decongestive Therapy F. CLT Certified Lymphedema Therapist Web Sites A. www.vodderschool.com B. www.lymphnet.org C. www.lymphnotes.com/index.php D. www.clt-lana.org/main.html E. http://www.lymphaticresearch.org/main.php?content=home F. www.lymphnet.org G. www.lymphedemablog.com
Resources 1. The Benefit of Aquatic Exercise for Lymphedema, By Joachim Zuther, on January 20, 2011. 2. Aqua lymphatic therapy in women who suffer from breast cancer treatment-related lymphedema: a randomized controlled study Dorit Tidhar, Michal Katz-Leurer, June 03, 2009, 3. Exercise in patients with lymphedema: a systematic review of the contemporary literature, Marilyn I Kwan, Joy C Cohn, Jane M Armer, Bob R Stewart, Janice N Cormier, Journal Cancer Survive 2011. 4. Water Exercises for Lymphedema, Lymph Notes, October 29, 2014. 5. Aqua Lymphatic Therapy in Managing Lower Extremity Lymphedema Dorit Tidhar, BPT, Jacqueline Drouin, PhD, PT, and Avi Shimony, MD April 2007. 6. Management of Secondary Lymphedema Related to Breast Cancer, Canadian Family Physician December 2010 6. M Foldi, E Foldi, S. Kubik (Eds.)Textbook of Lymphology: for Physicians and Lymphedema Therapists 2003 7. Stanley G. Rockson The Lymphatic Continuum Revisited 8. Horst Weissleder and Christain Schuchhardt (eds.) Lymphedema: Diagnosis and Therapy 2001 9. Andrew Cole and Bruce Becker (Etl). 1997 Comprehensive Aquatic Therapy by 10. Petrek, Jeanne, et al. Lymphedema in a Cohort of Breast Carcinoma Survivors 20 Years after Diagnosis. Cancer; 2001:92(6) 1368-1377. 11. Resources cont 12. Exercise for Women With or at Risk for Breast Cancer Related Lymphedema Physical Therapy. Volume 86. Number 10. October 2006 13. Randomized Controlled Trial of Weight Training and Lymphedema in Breast Cancer Survivors. Journal of Clinical Oncology. Rehana L. Ahmed, William Thomas, Douglas Yee, and Kathryn H. Schmitz