Archives for the month of: April, 2014

It seems like a lifetime ago already – thank goodness I have my conference handbook to refer to because I wouldn’t remember one-tenth of the topics that were covered otherwise.

First up on Saturday morning there was a discussion on the relationship between clinical measures and underlying physiological changes – a couple of interesting points here – it has been demonstrated that tissue composition changes are evident in those with mild lymphoedema and that the impact of these changes depends on whether the affected arm is dominant or non-dominant.  What that means is that generally, there is more fat present in the unaffected limb if the non-dominant arm is affected!  Interesting.

Next was a presentation on segmental impedance thresholds for early detection and monitoring of upper limb lymphoedema. Early detection of LE is important for effective treatment outcomes so finding a way of measuring changes effectively is essential.  Segmental measurements of the arm with Bioimpedence Spectropscopy was shown to be a reliable way of measuring early changes after measuring one hundred women without a history of breast cancer or lymphoedema.

There was a clinical practice review of the pitting test.  The pitting test is widely used to assess oedema in healthcare, but there is no standardisation between clinicians – each person’s touch is significantly different.  Three different therapists performed a pitting test assessment on six women with unilateral breast cancer related lymphoedema.  The therapists were all reliable in determining whether the tissue was pitting or non-pitting but had less agreement on the tissue qualities.  This study reinforces the need to develop a standardised pitting test protocol with guidelines for interpreting the test results.

Assessment of oedema in the breast skin following skin-sparing mastectomy and immediate reconstruction.  As more women are choosing to undergo the above procedure it has been noticed that many experience oedema in the skin postoperatively but assessment of change has only been subjective so far.  53 patients were measured using the Delfin MoisturemeterD Compact to determine the percentage of fluid within the dermis.  The conclusion was that the use of the Mosituremeter allows accurate documentation of localised and sub-clinical oedema in breast skin following mastectomy and reconstruction.

A patient self examination survey for staging the severity of lymphoedema.  Fifty patients with either unilateral primary or secondary LE completed a number of questionnaires.  One form was repeated one week after either by email or posted off.  The patients were assessed with bioimpedance and staged by two therapists using the ISL staging system.  The results of this study are currently being collated.

Current overview of surgical treatment of lymphoedema.  Dr Suami spoke of the different types of surgical treatment available for LE: Liposuction, lymphovenous shunting, lymphatic grafts and vascularised lymph node transfers.  Refinements in microsurgical techniques and improved imaging devices may lead to the establishment of standard surgical treatment of lymphoedema – wouldn’t that be amazing!!

Liposuction.  The Macquarie University Cancer Institute is developing protocols for maximising outcomes for liposuction surgery for fatty lymphoedema limbs in Australia and NZ.  There are very specific criteria for eligibility and bioimpedance and MR imaging were used to determine eligible candidates.  Patients had pre-operative intensive treatment at Mt Wilga Hospital and there was a significant mean excess volume reduction pre-surgery.  The conclusion of this prospective study demonstrates that in patients with large non-pitting limbs with L-Dex and MRI indicating deep fluid pocketing, a brief pre-operative CLT (that’s MLD, bandaging and physio) session can reduce the liposuction volume needed to achieve maximum outcomes.

Liposuction in the management of persistent arm swelling following conservative management of LE – a similar study to the one above (Alex Munnoch happily admitted that Mt Wilga’s results of pre-surgical CLT seemed much more effective than what they were achieving!).  The conclusion of his study said that liposuction and continuous postoperative compression is an effective treatment for advanced arm lymphoedema.

Diet and its relationship to lymphoedema.  This was a very interesting talk by Dr Kieron Rooney, with whom I had the pleasure of talking during the lunch break – he had been drinking numerous fizzy drinks daily and eating junk food and suddenly realised he was doing research on diet but yet wasn’t reading his own advice!  He gave up sugar and lost a significant amount of weight which he has kept off easily simply by keeping off the refined sugar (yes, he does exercise too!).  He is looking to see what fuels the capacity for change of lymphatic fluid into adipose tissue.  It’s the advice we hear again and again, eat food in as close to its natural state as you can – avoid the processed food, stick with real food.  Right on!

Liposuction for advanced LE – impact of liposuction on limb volumes. Surgical treatment results from Macquarie University Advanced LE Assessment Clinic. The conclusion of this study stated that liposuction is a safe and effective option for carefully selected patients with advanced lymphoedema.

Liposuction for leg LE.  Alex Munnoch reviewed 7 years’ experience of performing liposuction for primary and secondary leg LE.  The conclusion of the review stated that liposuction and continuous postoperative compression is an effective treatment for leg lymphoedema, although obtaining 100% reduction is much more challenging, particularly in primary LE patients.

Vascularised lymph node transfer for secondary LE.  This was of particular interest to me because of my contact with Helen here in Sydney who has had the procedure.  (Helen, you have a lovely lymphoscintigraph!)  Lymph node transfer is emerging as a treatment for LE.  Eight patients who had tried conservative therapy and experience progressive swelling, frequent infections or inabilitly to tolerate compression garments were offered LNT.  All had MRIs, lymphoscintigrams, L-Dex readings and limb volume measurements pre and post operatively as well as ultrasound.  The early results indicated no significant volume reduction with LNT but there were subjective improvements in skin infection frequency, softer arms as well as maintenance of oedema control without garment wearing.

Finally, there was a presentation by Dr Susan Gordon of James Cook University on the prevention and management of lymphatic filariasis related LE. Very interesting talk – way too much info to put into a few words.

And that brought us to the conclusion of the Conference.  Oh wait.  There was the closing ceremony, the one with the Islander dancers, the one where they got poor victims up on the stage to try the death-defying hip gyrations that were exhausting to watch, far less try to do.  But well done to all who participated (I kept my head so far down it was almost in my lap!).

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The second day was always going to be full … I was to attend the Smith and Nephew hosted breakfast session – breakfast at 7.30 and a talk at 8, followed by the full schedule of talks from 9am to 5.15pm, followed by the Conference Dinner at the War Memorial from 7pm till 11pm.  But it started slightly differently – I woke up and thought, “wow, it’s much lighter than yesterday” then looked at the clock and saw it was 7.35am!  Not a good start.  I did manage to get to the start of the Smith and Nephew talk, well, it was 8.03 and I had only missed the introduction.  I thought that was a pretty heroic effort.

The talk was pretty much the launch of the JOBST Elvarex Plus, the latest innovation in compression.  The garments are made using 3D knitting techniques and are seamless and the edges have been improved so there is no unravelling.  We were shown some of the machinery that was designed specifically to test the hardiness of the material.  They look pretty impressive, the fingers and toes have no ridging or seams and they seem to be exceptionally well designed, click here for more information.  At the moment they are only available in custom-made garments.

There were a number of presentations on studies that morning, I’ll give the titles of the talks and the conclusions in brackets – The prevalence of LE following gynaecological cancer (one-third of women have swelling by 12 months post surgery, three-quarters by 24 months); incidence and risk factors for LE at 18 months following surgery for early breast cancer (at 18 months, 10% had swelling, mainly in women who had node dissection); generalised oedema post taxane-based chemo in women with early breast cancer (incidence of LE in the arm on affected side increased at 6 months after completion of taxane-based chemo); Improving the way we measure bilateral upper- and lower-limb lymphoedema (Bioimpedance spectroscopy (BIS) is an effective diagnostic tool for measuring lymphoedema).

I attended a Kinesio taping workshop that has inspired me to go off and do the course.  We used it on a muscular level, as we didn’t have guinea pigs with lymphoedema to experiment on, but we saw instant improvements in the range of motion in a number of people with shoulder issues, pretty amazing.  I’ve already sent off for details of the next course!

Kinesio tape

Kinesio tape

The afternoon session had talks on: the feasibility of night-time compression systems for breast cancer related lymphoedema (early results suggest use of night-time compression is not significantly better than standard care, however, they are preferred due to their comfort and convenience in application); Review of the evidence of lymphoedema treatment effect (reviews consistently concluded that complex physical  therapy is effective at reducing limb volume. Reductions were also recorded using compression garments, manual lymphatic drainage and compression pumps. Insufficient evidence to support these treatments as stand-alone strategies); low-level laser therapy (LLLT) for lymphoedema (this was a review of a number of studies, which concluded that there is an emerging and reliable evidence base for the positive effectiveness of LLLT for lymphoedema); LLLT for fibrosis, capsular contracture of post-mastectomy breast implants (this study was done on mice, placing silicone implants subcutaneously on mice then irradiating the site to induce fibrosis.  Results – no capsular contracture in either group, but the implants receiving LLLT had tissue that was better “organised” and had less inflammation.); Do women with breast cancer-related LE need to wear compression during resistance-exercise? (no change in L-Dex readings were observed for either compression or non-compression control groups, immediately post-exercise and 24 hours post-exercise); The acceptability and perceived effectiveness of treatments prescribed for the management of LE (this was a survey sent out to members of the LA Associations of Victoria and Queensland – outcome was – understanding patients’ perceived acceptability and effectiveness of treatments is necessary to determine whether treatment strategies proven clinically effective are feasible in the real-world settings); Imaging in LE in clinical practice (Dr Keely talked about Venous Duplex Scans, Ultrasound of soft tissue and Echocardiography).

A lot of the talks were very evidence-based and statistical which is why I chose to list them out with their conclusions.  The ones that made an impact on me were: the studies on using the Low Level Laser, these showed benefits to using LLLT and I felt justified in purchasing one last year; and the study on wearing compression during exercise – I would have expected there to be a difference, but I think the take away message was that it’s a personal choice, wearing the sleeve will not do harm (of course there’s always the odd person who’ll prove that wrong!) and for some there may be an improvement, but try it and see.

Then there was the conference dinner.  It was held at the beautiful War Memorial.

war memorial view We walked through parts of the Museum to get to the event but it wasn’t really long enough to have a proper look at the exhibits unfortunately.  There was an opening ceremony with Maori dancers performing a number of dances, culminating of course with the Hakka, always an awe-inspiring event.  Literally as we finished the main course a DJ started to crank up the music and in an instant the dance floor was filled with women – I’ve never seen so many women dancing in one spot in my life. I asked one of the guys the next day if he found it odd – he really did!  And we boogied until after 11 (I was dragged onto the dance floor by those who shall remain nameless … Kelly!!!!!).

All in all a very full day.

If you’d like info on any of the talks, please message me.

Day 3, coming up!

Where to begin.  Well, let’s just say there is no way I’m going to cover even a fraction of what I saw/heard at the conference, there was just so much content. I’ve counted that there were 39 presentations in three days, one of those was broken into case studies with different presenters being allocated 2 minutes (in one hour there were 12 presentations)! So I’ll go for the stand-out highlights for me and I’ll do a few different posts over the next week or so to not bombard you with too much info.

I attended three workshops – we got to choose those when we registered and two of them I found fantastic.  The first was on Differential Diagnosis of Lymphoedema, presented by my favourite, Prof Neil Piller of Flinders University, and Vaughan Keeley of the Royal Derby Hospital, UK.  Was really pleased that they focussed on lipoedema and the difficulties of diagnosing some cases.

I found the presentations by Dr Hiroo Suami of the University of Texas MD Anderson Cancer Centre to be very interesting and amazingly upbeat and humourous (quite difficult I reckon when showing slides of cadavers).  He has pioneered The Lymphosome Concept, a way of “visualising the lymphatic system using hydrogen peroxide and a radio-opaque medium injected into cadavers then using radiographs and three-dimensional computed tomography scans to see how and where lymphatic fluid flows, which vessels, nodes and territories it uses.  Fascinating.  He also talked about surgical treatment for lymphoedema, including creating new channels to increase the capacity to transport lymph fluid; liposuction or lymphovenous shunting, lymphatic graft and vascularised lymph node transfer.

One of the most interesting things I heard was in one of the “breakaway sessions” of four talks.  It was by another of my favourite presenters, Alex Munnoch, of Ninewells Hospital in the UK.  He noted that surgical staff who perform long surgeries often complain of leg discomfort and oedema, so they set up a small trial to see whether T.E.D. stockings (those beautiful white stockings you are given when you’ve had some surgery in hospital) have an effect on the level of oedema.  One leg was randomised (by the flipping of a coin, very scientific criteria indeed!) to wear a T.E.D. stocking and the control leg (the other side) would receive no compression at all.  Fluid levels were measured before and after the surgeries.  40 legs were studied in all with an average operating time of 9.5 hours.  Results?  T.E.D. stockings were found to reduce the increase of fluid and interestingly, when they tried the experiment using compression stockings instead of T.E.D. stockings the degree of oedema increased!  What!! That was a surprise indeed.  He conceded that such a small study was perhaps not conclusive and more study was definitely warranted.

On the first day there I also attended presentations on head and neck lymphoedema management; lymphoedema and osteopathic care; reducing oedema after lower limb cellulitis; wounds and lymphoedema; and case study presentations on things such as; TRAM flap reconstruction; layered compression garments; liposuction; bioimpedance spectroscopy; kineseotape post radiotherapy; yellow nail syndrome …. the list goes on.

My head was swimming by the end of the day, that’s for sure.

If you’d like more info on any of the topics I mentioned, please leave me a comment and I’ll add some more infomation.  To access more information about lymphoedema and it’s treatment, visit the ALA website here.

But it wasn’t all hard work – here’s a photo from the closing ceremony of two of my favourites … Prof Piller and Alex Nunnoch, good on them for getting into the spirit of things!

 

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Prof Neil Piller and Alex Munnoch, letting their hair down

I won’t have the time to write a proper blog post about the conference until I get back to Sydney next week, but I thought I’d share a few photos in the meantime. I’m posting from the iPad, so apologies for any lack of formatting and alignment.

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The Jobst Man, I thought a very clever way of showing all over compression.

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Compression from Cosmac.

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Kinesiotaping workshop

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Auckland War Memorial, conference dinner and lots of dancing – the male delegates (about twelve of them) must have felt slightly outnumbered on the dance floor!

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View from the War Memorial

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Closing Ceremony celebration

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