File #5File #5

Complications and Complications and AlternativesAlternatives

Oncology Rehabilitation: Web-based Learning for Physical Therapists Who Provide Rehabilitation to Patients with Breast Cancer

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Possible Complication with Breast Possible Complication with Breast Cancer PatientsCancer Patients

• LymphedemaLymphedema

The Lymph SystemThe Lymph System

**

Left atrium

Left ventricleRight atrium

Right ventricle

Heart

Pulmonary veins

Lung

Hepatic vein

Portal vein

Liver

Capillaries ofgastrointestinal tract

Large intestines

Small intestines

Kidney

Renal vein

Innominate vein

Jugular vein

Basilic vein

Femoral vein

Inferior vena cava

Small saphenous vein

Great saphenous vein

Popliteal vein

Anterior tibial vein

Peroneal vein

Posterior tibial vein

VEIN NETWORK

Alveolar capillaries

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Lymph System:Lymph System:

A network of the body that makes and stores cells that fight infection and clears the tissue spaces of excess fluid and cells. This system is composed of lymph vessels, lymph nodes and lymph organs such as the spleen.

(www.lymphedemapeople.com, 2005)

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Lymphedema Lymphedema

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

(www.lymphedemapeople.com, 2005)

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2 Types of2 Types of Lymphedema Lymphedema

Primary: caused principally by underdevelopment of the lymph channel system. Secondary: caused by damage to the lymph channel system, such as infection, scarring, an accident, radiation therapy or surgery.

(www.lymphedemapeople.com, 2005)

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Lymphedema Treatment PlanLymphedema Treatment Plan • Initial evaluation• Patient education and precautions• Exercise program• Compression garments• Compression pumps• Manual massage techniques• Compression Wrapping• REID Sleeve• Pharmacological Treatment• Life Style

(www.lymphedemapeople.com), 2005

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Lymphedema TrainingLymphedema Training

• VodderVodder……… 4 wks………..$2000.00……… 4 wks………..$2000.00

• FoldiFoldi………… 2 wks……... 2500.00………… 2 wks……... 2500.00

• Carley SmithCarley Smith… 2 wks……. 1000.00… 2 wks……. 1000.00

• BergelBergel………… 4-5 days… 500.00………… 4-5 days… 500.00

• Klose……………..135 hours..2500.00Klose……………..135 hours..2500.00

This slide is needed to show some of the training methods used in the treatment of lymphedema. Courses are intense and expensive.

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Example of training to treat lymphedemaExample of training to treat lymphedema

• Pre-requisites: Profession of medical doctors, physical therapists, physical therapy Pre-requisites: Profession of medical doctors, physical therapists, physical therapy assistants, occupational therapists, occupational therapy assistants, nurses, athletic assistants, occupational therapists, occupational therapy assistants, nurses, athletic trainers and massage therapists showing proof of 500 hours of training.trainers and massage therapists showing proof of 500 hours of training.

• Course topics: Course topics: – Anatomy, physiology and pathophysiology of the lymphatic systemAnatomy, physiology and pathophysiology of the lymphatic system– Basic techniques and sequences of manual lymph drainage (Vodder technique)Basic techniques and sequences of manual lymph drainage (Vodder technique)– Indications and contraindications of manual lymph drainage and complete Indications and contraindications of manual lymph drainage and complete

decongestive therapydecongestive therapy– Treatment of primary and secondary lymphedemaTreatment of primary and secondary lymphedema– Lymphedema bandaging techniques for upper and lower extremitiesLymphedema bandaging techniques for upper and lower extremities– Remedial lymphedema exercisesRemedial lymphedema exercises– Hygienic skin and nail care for lymphedemaHygienic skin and nail care for lymphedema– Measuring and fitting techniques for lymphedema support garmentsMeasuring and fitting techniques for lymphedema support garments– Patient evaluation and weekly measuring (circumference and volume)Patient evaluation and weekly measuring (circumference and volume)– Home maintenance and self-treatment for lymphedemaHome maintenance and self-treatment for lymphedema

(Klose Training & Consulting, LLC course description)(Klose Training & Consulting, LLC course description)

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Symptoms associated with breast cancer Symptoms associated with breast cancer lymphedemalymphedema

• Feeling of tightness in the upper extremityFeeling of tightness in the upper extremity

• Rings become tightRings become tight

• Weakness of upper extremityWeakness of upper extremity

• Aching or heaviness in the armAching or heaviness in the arm

• (http://www.oncologypt.org/.)(http://www.oncologypt.org/.)

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PREVENT LYMPHEDEMAPREVENT LYMPHEDEMA• Avoid cuts, Scratches, and Irritations

(Electric razor --cut nails straight across)• No injections in affected arm.• Avoid wasps, bees and other insects. (repel)• Avoid Extreme Temperatures (Hot & Cold)• Avoid Burns (Sun & Fire)• Avoid Arm Pressure (Blood Pressure, tight clothing or

jewelry• Avoid underarm Irritation (deodorant-shave)• Avoid arm/leg Strain (10# limit--Position every 1/2 hour--

Don't cross legs)• Increased pressure on aircraft can increase swelling.• Call M.D. with problems (Temp, Red,Swell.)

(www.lymphedemapeople.com, 2005)

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Treatment SequenceTreatment SequenceManual Lymph Drainage & Complete Decongestive TherapyManual Lymph Drainage & Complete Decongestive Therapy

• #1 Clear inguinal / axillary lymph nodes #1 Clear inguinal / axillary lymph nodes Fill & Clear thigh / upper arm Fill & Clear thigh / upper arm Clear popliteal / cubital lymph Clear popliteal / cubital lymph nodes Fill & Clear leg / arm nodes Fill & Clear leg / arm Clear inguinal / axillary lymph Clear inguinal / axillary lymph nodesnodes

• #2 Thigh / Upper arm Fill / Clear #2 Thigh / Upper arm Fill / Clear Proximal / Middle /Distal(To inguinal/axillary)Proximal / Middle /Distal(To inguinal/axillary)

• #3 Popliteal / Cubital Lymph nodes Fill/Clear #3 Popliteal / Cubital Lymph nodes Fill/Clear #4 Leg / Arm #4 Leg / Arm Proximal/Middle/Distal. med & lat foot &toesProximal/Middle/Distal. med & lat foot &toes

• #5 Finish with clearing to inguinal / axilla#5 Finish with clearing to inguinal / axilla

This is just an example to clarify the expertise required to complete lymphatic massage. Improper techniques can certainly be harmful to the patient.

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Contraindications to lymph massageContraindications to lymph massage

• Acute swellingAcute swelling due to clot blocking a major due to clot blocking a major

vessel (Thrombosis) Could move clot to lung = vessel (Thrombosis) Could move clot to lung = Pulmonary Embolism.Pulmonary Embolism.

• Untreated CancerUntreated Cancer with METS = Spread Ca cells with METS = Spread Ca cells• Bacterial InfectionBacterial Infection may spread with lymph may spread with lymph• Radiation scarRadiation scar. Wait 5 wks, after medical . Wait 5 wks, after medical

treatments. Fragiletreatments. Fragile• No intense abdominal work during menstruation, No intense abdominal work during menstruation,

pregnancy or abdominal complaints.pregnancy or abdominal complaints.

(Carriere, 1991)

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NutritionNutrition

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

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Nutritional Goals:Nutritional Goals:

• Maintain healthy weight• Low fat / Low cholesterol diet• Control daily calories• Increase fiber in diet• Eliminate salt and food additives• Prevent or correct deficiencies

(Dollinger, 2002)

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

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Healthy DietHealthy Diet• Eat a variety of foods.• Maintain a healthy weight.• Choose diet low in fat, saturated fat, and cholesterol.• Choose diet of vegetables, fruits and grain.• Use sugar only in moderation.• Use salt only in moderation.• Alcohol only in moderation.

(U.S. Government Dietary Guidelines)

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Variety of Foods Variety of Foods (Food Pyramid)(Food Pyramid)

• Bread,cereal, rice and Pasta (6-11 servings per day)

• Vegetables (3-5 servings per day)• Fruit (2-4 servings per day)• Meat, poultry, fish, dry beans, eggs, and nuts

(2-3 servings per day)• Milk, yogurt and cheese

(2-3 servings per day)

2020

Calories needed:Calories needed:

• Active...............2,000+ calories / day• Sedate...............1,600 calories/day• Very Active.......2,400+ calories / day

• Calculate daily calories:• Intake factors:

• Sedentary = 1.2• Moderate = 1.4• Active = 1.6

• Body weight X 10 X activity factor = daily calorie intake

(www.hopkinsbreastcenter.org, 2006)

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DietDiet• Linked to Colon, Breast, and Prostate Cancers.• The American Cancer Society reports that diet

modifications which decrease fat and increase fiber consumption have the potential to decrease cancer.

• The American Institute for Cancer Research developed 50 Nutritional Tips, including such categories as: *Tips for Eating More Fruits, Vegetables and Grains. *Hints for Skimming the Fat. and *Ideas for Healthy Living.

(www.cancer.org, 1999)

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Nutritional Problems associatedNutritional Problems associated with with Cancer PatientsCancer Patients

• Chewing and swallowing problems. Example: Mouth and throat pain or lesions due to medical interventions.

• Blockage of food passageways in some part of the digestive system. Example: Tumors

• Altered taste perception.

(Jennings-Dozier, 2002)

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•Possible signs of nutritional problems:Possible signs of nutritional problems:

•Nausea / VomitingNausea / Vomiting

•AnorexiaAnorexia

•Mouth DrynessMouth Dryness

•Mouth SoresMouth Sores

•DiarrheaDiarrhea

•Constipation Constipation (Jennings-Dozier, 2002)

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Holistic AlternativesHolistic Alternatives

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HOLISTIC ALTERNATIVESHOLISTIC ALTERNATIVES

• Chinese medicine• Yoga• Biomedicine• Vitamin Therapy

• Acupuncture• Touch/Massage • Metaphysical Approach

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The benefits of alternative The benefits of alternative medicine programs are medicine programs are unknownunknown

(Slide permitted by the American Cancer Society)

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Many will reach for an alternative Many will reach for an alternative method, if they can afford the program.method, if they can afford the program.

(Slide permitted by the American Cancer Society)

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No harm with some No harm with some alternatives alternatives

(Slide permitted by the American Cancer Society)

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HealingHealing

(Slide permitted by the American Cancer Society)

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Surgery without cuttingSurgery without cutting

(Slide permitted by the American Cancer Society)

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Alternatives may be acceptable as Alternatives may be acceptable as long as they are safe and routine long as they are safe and routine procedures are completed.procedures are completed.

Understand that alternative methods Understand that alternative methods can cost the patient greater than can cost the patient greater than $10,000 per week.$10,000 per week.

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RecurrenceRecurrence

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Be aware of possible recurrenceBe aware of possible recurrence

(Slide permitted by the American Cancer Society)

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Time out TestTime out Test

• No test here. No test here.

• Just make sure you review the lymphatic information, to avoid Just make sure you review the lymphatic information, to avoid complications. Realize that there are therapist who only work with complications. Realize that there are therapist who only work with lymphedema, it is certainly a specialty. Help your patient avoid lymphedema, it is certainly a specialty. Help your patient avoid treatment from someone who does not have creditable skills. treatment from someone who does not have creditable skills. Avoiding problems is the best way of dealing with this system.Avoiding problems is the best way of dealing with this system.

• As for nutrition, do not take the place of a nutritionist, but be aware As for nutrition, do not take the place of a nutritionist, but be aware of possible complications.of possible complications.

• As for Alternative Methods, suggest you patient stay on the medical As for Alternative Methods, suggest you patient stay on the medical path as well.path as well.

• Recurrence is always a possibility, so keep patients aware of the Recurrence is always a possibility, so keep patients aware of the benefits of early detection by following their physicians programs. benefits of early detection by following their physicians programs.