The Therapists Resposibilities What can the patient expect?

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