Barriers and facilitators to implementation of APTA's breast cancer-related lymphedema diagnosis and intervention clinical practice guidelines.

PURPOSE: The purpose of this study was to identify barriers and facilitators influencing implementation of the diagnosis and intervention clinical practice guidelines (CPGs) related to the management of patients with breast cancer-related lymphedema (BCRL). METHODS: A descriptive, cross-sectional web-based survey was conducted. Participants included physical therapists and assistants who were members of the APTA's Academy of Oncologic Physical Therapy and Lymphology Association of North America. Desriptive statisitcs were computed for all demographic and barriers and facilitators data. Individual exploratory factor analyses (EFA) were performed on survey items for both CPGs to identify themes of barriers and facilitators to implementation. RESULTS: A total of 180 respondents completed the survey. 34.9% of respondents read the diagnosis CPG and 22.4% read the intervention CPG. A total of 77.8% reported that they did not have issues in changing their clinical routines and 69.5% did not have resistance working according to CPGs. The EFA resulted in 3 themes for each CPG, accounting for 46% of the variance for the diagnostic CPG and 54% of the variance for the intervention CPG. The 3 themes, clinician characteristics, patient demographics, therapist practice setting and beliefs/values, were weighted differently for each EFA. CONCLUSION: Most respondents did not read either CPG, however, report a willingness to make changes to clinical practice and utilization of CPGs. For those who have attempted to implement the CPGs, this study was the first to identify the barriers and facilitators impacting the implementation of the CPGs related to the management of BCRL. IMPLICATIONS FOR CANCER SURVIVORS: The results will inform the development of targeted implementation strategies to improve access to and adherence to recommendations from the CPGs ultimately improving the efficiency and efficacy of care delivery to patients.

Lymphedema self-care: economic cost savings and opportunities to improve adherence.

BACKGROUND: Breast cancer-related lymphedema (BCRL) imposes a significant economic burden on patients, providers, and society. There is no curative therapy for BCRL, but management through self-care can reduce symptoms and lower the risk of adverse events. MAIN BODY: The economic burden of BCRL stems from related adverse events, reductions in productivity and employment, and the burden placed on non-medical caregivers. Self-care regimens often include manual lymphatic drainage, compression garments, and meticulous skin care, and may incorporate pneumatic compression devices. These regimens can be effective in managing BCRL, but patients cite inconvenience and interference with daily activities as potential barriers to self-care adherence. As a result, adherence is generally poor and often worsens with time. Because self-care is on-going, poor adherence reduces the effectiveness of regimens and leads to costly treatment of BCRL complications. CONCLUSION: Novel self-care solutions that are more convenient and that interfere less with daily activities could increase self-care adherence and ultimately reduce complication-related costs of BCRL.

Pre- and Post-Microsurgical Rehabilitation Interventions and Outcomes on Breast Cancer-Related Lymphedema: a Systematic Review.

PURPOSE OF REVIEW: Breast cancer-related lymphedema (BCRL) is a debilitating progressive disease resulting in various impairments and dysfunctions. Complete decongestive therapy embodies conservative rehabilitation treatments for BCRL. Surgical procedures performed by plastic and reconstructive microsurgeons are available when conservative treatment fails. The purpose of this systematic review was to investigate which rehabilitation interventions contribute to the highest level of pre- and post-microsurgical outcomes. RECENT FINDINGS: Studies published between 2002 and 2022 were grouped for analysis. This review was registered with PROSPERO (CRD42022341650) and followed the PRISMA guidelines. Levels of evidence were based upon study design and quality. The initial literature search yielded 296 results, of which, 13 studies met all inclusion criteria. Lymphovenous bypass anastomoses (LVB/A) and vascularized lymph node transplant (VLNT) emerged as dominant surgical procedures. Peri-operative outcome measures varied greatly and were used inconsistently. There is a dearth of high quality literature leading to a gap in knowledge as to how BCRL microsurgical and conservative interventions complement each other. Peri-operative guidelines are needed to bridge the knowledge and care gap between lymphedema surgeons and therapists. A core set of outcome measures for BCRL is vital to unify terminological differences in the multidisciplinary care of BCRL. Complete decongestive therapy embodies conservative rehabilitation treatments for breast cancer-related lymphedema (BCRL). Surgical procedures performed by microsurgeons are available when conservative treatment fails. This systematic review investigated which rehabilitation interventions contribute to the highest level of pre- and post-microsurgical outcomes. Thirteen studies met all inclusion criteria and revealed that there is a dearth of high quality literature leading to a gap in knowledge as to how BCRL microsurgical and conservative interventions complement each other. Furthermore, peri-operative outcome measures were inconsistent. Peri-operative guidelines are needed to bridge the knowledge and care gap between lymphedema surgeons and therapists.

Practice patterns of physical therapists and physical therapist assistants treating patients with breast cancer related lymphedema.

Clinical Practice Guidelines (CPGs) aim to improve patient outcomes through implementation of proven interventions and decrease variation in practices. The relevance of this article is to describe the current state practice of physical therapists who diagnose and treat patients with Breast Cancer Related Lymphedema (BCRL). It also provides a description of physical therapist-reported adherence to the BCRL CPG recommendations which establishes the need for implementation interventions to improve adherence. PURPOSE: The purpose of this study is to describe practice patterns of physical therapists (PT) and physical therapist assistants (PTA) who treat patients with breast cancer-related lymphedema and determine if they are adherent to best evidence recommendations for lymphedema diagnosis and intervention. METHODS: An electronic survey to collect practice pattern data of PTs and PTAs who treat patients with BCRL was distributed. A descriptive and quantitative statistical analysis was performed. RESULTS: Twenty-six percent of respondents read the American Physical Therapy Association sponsored lymphedema diagnosis clinical practice guideline (CPG) and 20% read the lymphedema intervention CPG. Lymphoscintigraphy was the only diagnosis or intervention tool with a significant difference in use between therapists who read versus did not read the CPGs. Adherence to "should do" recommendations was variable: bioimpedance (18.2%), volume calculation (49.3%), ultrasound (0%), patient reported outcome tools (64.9%), compression garments (43.9%), exercise (87.2%), and compression bandaging (56.8%). CONCLUSIONS: There is variability in adherence to recommendations for both the lymphedema diagnosis and intervention CPGs. Interventions to improve implementation and adherence to CPG recommendations are warranted.

A non-randomized, open-label study of the safety and effectiveness of a novel non-pneumatic compression device (NPCD) for lower limb lymphedema.

Lower extremity lymphedema (LEL) can result in detriments to quality of life (QOL) and impose a significant economic burden on patients and payers. A common component of treatment is pneumatic compression, which requires patients to remain immobile. We investigated a novel non-pneumatic compression device (NPCD) that allows patients to remain active during compression treatment, to see if it reduces swelling and improves QOL. We conducted a non-randomized, open-label, 12-week pilot study of adult patients with primary or secondary unilateral LEL, and measured changes in limb edema and QOL using the Lymphedema Quality of Life Questionnaire (LYMQOL). Twenty-four subjects were enrolled; the majority were female (17) with secondary lymphedema (21). Eighteen completed the study. Statistically significant improvements were observed in overall QOL, aggregated LYMQOL total score, and three of four LYMQOL subscales (Function, Appearance, Mood). The fourth (Symptoms) trended toward significant improvement (p = 0.06). The average reduction in affected limb edema was 39.4%. The novel NPCD produced statistically significant improvements in QOL, functioning, and edema volume of patients with LEL. Innovations in devices to manage LEL can be effective while allowing patients to maintain mobility and physical activity during treatment.

Clinical Evaluation of a Novel Wearable Compression Technology in the Treatment of Lymphedema, an Open-Label Controlled Study.

A diagnosis of lymphedema comes with a lifetime requirement for careful self-care and treatment to control skin deterioration and the consequences of excessive fluid and protein buildup leading to abnormal limb volume and an increased risk of infection. The burden of care and psychosocial aspects of physical disfiguration and loss of function are associated with compromised quality of life (QoL). The current standard therapeutic intervention is complex decongestive therapy with manual lymph drainage and frequent wearing of compression garments. With insurance limitations on therapy visits and the time and travel required, additional home treatment options are needed. Pneumatic compression pumps that mimic the manual massage pressure and pattern are sometimes prescribed, but these are bulky, difficult to apply, and require immobility during treatment. An open-label pilot study in 40 subjects was performed to evaluate the QoL and limb volume maintenance efficacy of a novel wearable compression system (Dayspring™) that is low profile, easy to use, and allows for mobility during treatment. After 28 days of use, subjects had a statistically significant 18% (p < 0.001) improvement in overall QoL as measured by the Lymphedema Quality-of-Life Questionnaire compared with baseline. Individual QoL domains, and limb volume improved with therapy. Adherence was 98% over the course of the study. Results of the clinical evaluation suggest the Dayspring wearable compression device is safe and effective and improves QoL and limb volume. The novel, low-profile device is easy to use and allows for mobility during treatment, addressing a potential barrier to adherence with pneumatic compression devices.