The Therapists Resposibilities What can the patient expect? Responsibilities Focus on the problem expressed by the patient. Physical Swelling/tightness due to my lymphedema 2,03 Physical Feeling physically aware of my lymphedema all the time 1,77 Physical A feeling of heaviness due to my lymphedema 1,63 Subjective symptoms How can you measure subjective symptoms? • VAS – visual analogue scale No discomfort • Likert scale eg. 0-3 or 0-6 or 0-10 Worst imaginable Treatment outcome related to subjective symptoms Reduction Compression treatment Johansson et al. 1998 (garment) Johansson et al. 1999 (bandage) Thightness Heaviness p=0,004 p<0,001 p=0,01 p=0,006 VAS VAS Treatment outcome related to subjective symptoms Reduction Thightness Heaviness - p<0,001 B Bandage + Additional MLD Johansson et al. 1999 (bandage) p<0,001 p<0,001 A Bandage + Continued bandaging Johansson et al. 1999 (bandage) p<0,001 p<0,006 A n.s. A Complex Decongestive Therapy (CDT) Haghighat et al. 2010 Garment + Additional Intermittent pneumatic compression (IPC) Johansson et al. 1998 n.s. A = VAS, B= Likert scale ”Treatment outcome” related to subjective symptoms Reduction Garment + Exercise Mosely et al. 2005 Jönsson & Johansson, 2014 Thightness Heaviness p<0,001 p<0,03 p=0,01 n.s B A A = VAS, B= Likert scale Responsibilities Focus on the problem expressed by the patient. practical Finding clothes and shoes that are comfortable and attractive, the right size and type of material Keep the volume low Objective outcomes 129 1,58 How can you measure volume? Circumferencial measurement Calculate volume Water displacement method Treatment outcome related to volume reduction RCT studies Excess volume reduction Compression treatment Brambilla et al. 2006 (garment) Badger et al. 2000 (bandaging) p≤0,001 p≤0,001 Circ Circ/Pero Compression + MLD McNeely et al. 2011 Huang et al. 2013 p=0,02 n.s. (Meta, 5 studies) (Meta, 6 studies) Treatment outcome related to volume reduction Volume Reduction IPC Devoogdt et al. 2010 Shao et al. 2014 (2 RCT = reduction) n.s. Compression + Exercise Mosely et al. 2005 Jönsson & Johansson, 2014 A = VAS, B= Likert scale p=0,07 p=0,015 (1 RCT = IPC equal to MLD) (Meta, 7 studies) gentle exercises heavy exercises ”Treatment outcome” related to volume reduction Diagnosis as early as possible Simple methods for early diagnosis Volume measurement Increased skin thickness Symptom scale: Tightness BIS – Bioimpediance spectroscopy TDC- Tissue dielectric constant 10 YEAR FOLLOW-UP OF EARLY DIAGNOSED BCRL 35 30 25 n=98 20 LRV % 15 10 5 0 -5 0 50 100 5 years 150 10 years Months Treatment Distribution over time of lymphoedema relative volume, LRV (%) 35 30 25 20 Reg. treatment LRV % 15 Non-reg. treatment No treatment 10 5 0 -5 0 50 5 years 100 10 years 150 Months THE FUTURE? Treatments Breast cancer Lymphedema 1980’s Mastectomy + axillary node dissection + RT IPC + sleeve 1990’s Partial mastectomy CDT 2000’s Sentinel node CDT 2010’s Individual chemo Change? Individual? How to differ treatment • Impact on Quality of life • Motivation for treatment and compliance • Measurements to evaluate treatment – Subjective symptoms – Volume – QoL What’s new? • • • • Early diagnosis Compression should be the first treatment Add physical activity Reduce over-weight Responsibility Measure • Additional MLD may work in some cases results • Additional IPC may work in some cases • ? may work in some cases Responsibility • Be updated – Go to conferences expencive? – Create networks - evidence based discussions – Consensus documents Care programs(recommendations) Scientific reviews out of date? out of date? Responsibilities Focus on the problem expressed by the patient. practical The constant self-care I need to do to stop my lymphedema from getting worse Self-care 1,56