Vascularized Lymph Node Transfer for Patients with Breast Cancer-Related Lymphedema Can Potentially Reduce the Burden of Ongoing Conservative Management.

Background: Vascularized lymph node transfer (VLNT) microsurgery is conducted in selected specialist lymphatic programs as a surgical treatment option for breast cancer-related lymphedema (BCRL) with variation in treatment outcomes. Methods and Results: Ten patients with BCRL underwent VLNT from 2012 to 2015. Donor sites were the inguinal (n = 6) or supraclavicular fossa/neck (n = 4) regions and recipient sites were the axilla (n = 6) or elbow regions (n = 4). Outcomes included changes in limb volume and extracellular fluid ratios, postoperative garment use, number of cellulitis episodes, and self-reported symptom improvement. At a mean follow-up of 46 months from surgery (range: 28-66 months), the excess volume in the affected arm had reduced (n = 4) or remained stable (n = 1) for 5 of 10 patients (50%) (mean change: -106.4 mL, range: -515.5 to +69.6 mL). Four of these five patients had also reduced (n = 3) or discontinued (n = 1) wearing compression garments and three reported a reduction in episodes of cellulitis. The remaining five patients had an increase of over 100 mL in postoperative excess volume (mean change: 295.8 mL, range: 142.1-382.8 mL). Three of these five patients reported noncompliance with compression garments. Despite the increase in limb volume, some patients reported softness in swelling (n = 3) and better response to conservative treatment (n = 1). Conclusion: Our results warrant continuation of VLNT as a surgical treatment option for patients with BCRL and show that the burden of conservative management such as wearing garments can be reduced over time for some patients. Longer term follow-up with standardized measures across all centers is required to further investigate VLNT.

A new indocyanine green fluorescence lymphography protocol for identification of the lymphatic drainage pathway for patients with breast cancer-related lymphoedema.

BACKGROUND: Breast cancer related lymphoedema (BCRL) is a common side effect of cancer treatment. Recently indocyanine green (ICG) fluorescent lymphography has become a popular method for imaging the lymphatics, however there are no standard protocols nor imaging criteria. We have developed a prospective protocol to aid in the diagnosis and therapeutic management of BCRL. METHODS: Lymphatic imaging procedures were conducted in three phases. Following initial observation of spontaneous movement of ICG in phase one, manual lymphatic drainage (MLD) massage was applied to facilitate ICG transit via the lymphatics in phase two. All imaging data was collected in phase three. Continuous lymphatic imaging of the upper limb was conducted for approximately an hour and lymphatic drainage pathways were determined. Correlations between the drainage pathway and MD Anderson Cancer Centre (MDACC) ICG lymphoedema stage were investigated. RESULTS: One hundred and three upper limbs with BCRL were assessed with this new protocol. Despite most of the patients having undergone axillary node dissection, the ipsilateral axilla drainage pathway was the most common (67% of upper limbs). We found drainage to the ipsilateral axilla decreased as MDACC stage increased. Our results suggest that the axillary pathway remained patent for over two-thirds of patients, rather than completely obstructed as conventionally thought to be the case for BCRL. CONCLUSIONS: We developed a new ICG lymphography protocol for diagnosing BCRL focusing on identification of an individual patient's lymphatic drainage pathway after lymph node surgery. The new ICG lymphography protocol will allow a personalised approach to manual lymphatic drainage massage and potentially surgery.

Reliability and Validity of Measurement Tools for Residual Limb Volume in People With Limb Amputations: A Systematic Review.

BACKGROUND: Measurements of residual limb volume often guide decisions on the type and timing of prosthetic prescription. To help inform these decisions, it is important that clinicians use measurement tools that are reliable and valid. PURPOSE: The aim of this systematic review was to investigate the reliability and validity of measurement tools for residual limb volume in people with limb amputations. DATA SOURCES: A comprehensive search on MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science was performed on July 11, 2016. STUDY SELECTION: Studies were included if they examined the reliability or validity of measurement tools for residual limb volume, were conducted on humans, and were published in English. DATA EXTRACTION: Data were extracted from 11 reliability and 4 validity studies and included study characteristics, volumetric estimates, and reliability and validity estimates. The quality of the studies was also rated. DATA SYNTHESIS: Data from 2 studies (38 participants) indicated good to excellent intrarater (intraclass correlation coefficient [ICC] ≥0.88) and interrater (ICC ≥0.88) reliability and high between-session reliability (coefficient of variation [CV] = 10%) for water displacement volumetry. One study (28 participants) reported excellent intrarater and interrater reliability (ICC ≥0.93) for the circumferential method, and data from 2 studies (19 participants) indicated high between-session reliability for the optical surface scanner (CV ≤9.8%). Three studies (26 participants) indicated good to excellent between-session reliability results for computed tomography (CV = 9.2%-10.9%). One study (7 participants) showed moderate within-session reliability (CV = 50%). Using water displacement volumetry as the gold standard, 2 studies (79 participants) indicated excellent validity for the circumferential method ( r ≥0.92; ICC ≥0.92). All studies reporting measures of reliability or validity were performed with people who had transtibial amputations. LIMITATIONS: Only studies published in English and in which water displacement volumetry was used as the gold standard were included in this review. The reliability and validity of the quality rating scale used in this review have not been tested. CONCLUSIONS: On the basis of a limited number of moderate- to high-quality studies with small sample sizes, circumferential and water displacement methods were found to be reliable, and the circumferential method was found to be valid in people with transtibial amputations. There are inadequate data for drawing conclusions about volume measurement methods in people with other types of limb amputations.

Does Lymphedema Severity Affect Quality of Life? Simple Question. Challenging Answers.

PURPOSE: Lymphedema can have a negative impact on the function and quality of life (QOL) of patients, but most studies have examined lymphedema as a binary variable, rather than a multidimensional disease that ranges in severity. This study explored the potential impact of lymphedema severity on function and overall QOL. METHODS AND RESULTS: Of the 54 lymphedema patients recruited, 40 reported their most severe swelling to be in a limb. These participants underwent bioimpedance measurement (L-Dex®) and completed either the disabilities of the arm, shoulder, and hand (DASH) questionnaire or the lower extremity functional scale (LEFS). All participants completed the lymphedema quality of life questionnaire (LYMQOL) and were categorized for severity using International Society of Lymphology (ISL) stage. Mild (Stage 0-I), moderate (Stage IIa), and severe (Stage IIb-III) lymphedema accounted for 22%, 50%, and 28% of the participants, respectively. The median [inter-quartile range (IQR)] L-Dex score was 17.8 (6.6-52.7) for arm participants and 36.4 (15.9-93.5) for leg participants. Apart from a mild difference in LYMQOL ARM Appearance domain (p = 0.046), ISL staging did not have any relationship with DASH, LEFS, and LYMQOL domains, or overall QOL. Higher L-Dex was related to poorer function (DASH p = 0.015; LEFS p = 0.019), but was not related to overall QOL of limb lymphedema participants (p > 0.05). CONCLUSIONS: Lymphedema severity did not appear to impact QOL. ISL staging may not be used alone to describe lymphedema severity. Other methods such as bioimpedance, imaging, and self-report of symptoms are required to fully evaluate the impact of lymphedema severity on function and QOL.

Estimation of Arm Adipose Tissue Quotient Using Segmental Bioimpedance Spectroscopy.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a chronic condition characterized by accumulation of lymph fluid that may subsequently become fibrotic with infiltration of adipose tissue. Bioimpedance spectroscopy (BIS) is the preferred method for early detection of lymphedema as it can estimate extracellular lymph fluid. This study developed a modified impedance technique that concurrently estimates both lymph accumulation and increases in adipose tissue. METHODS AND RESULTS: BIS was used to estimate the adipose tissue volume in a cohort of healthy women (n = 171), which was found to be highly correlated (r > 0.87) with measurements of adipose tissue obtained using the reference method of dual-energy X-ray absorptiometry (DXA). In a separate cohort of women with BCRL (n = 16), adipose volumes measured by BIS and reference method, respectively, were 2452.9 ± 933.3 mL and 2109.1 ± 824 6 mL for affected arms; 1770.9 ± 747.8 mL and 1801.4 ± 775.7 mL for unaffected arms; and comparable values for a group of age-matched controls were 1862.5 ± 661.6 mL and 1657.0 ± 641.1 mL for age-matched control arms. The increase in adipose tissue in affected arms was significant irrespective of the method of measurement, p < 0.02 and p < 0.001 for BIS and DXA, respectively. CONCLUSIONS: An impedance method is described that can estimate increase both in lymph accumulation and adipose tissue in breast cancer-related lymphedema.

Breast Cancer-Related Arm Lymphedema: Fluctuation over Six Months and the Effect of the Weather.

BACKGROUND: An understanding of normal fluctuation of lymphedema over time is important to identify real change, whether it is from response to treatment or worsening of the condition. The weather is another factor that possibly influences lymphedema but has had minimal investigation to date. The purpose of this study was to determine the extent to which breast cancer-related lymphedema (BCRL) fluctuated over a 6-month period and the influence of temperature, humidity, and barometric pressure. METHOD AND RESULTS: Women with unilateral BCRL (n = 26) and without BCRL (n = 17) were measured on nine occasions over 6 months using a standardized protocol. Measures included self-reported arm swelling, arm volume, and extracellular fluid with bioimpedance. Daily weather data were obtained for analysis of effects on lymphedema. Neither arm volume nor extracellular fluid varied significantly for women with lymphedema; coefficients of variation were 2.3% and 3.7%, respectively. Women without lymphedema had even less fluctuation, with coefficient of variation of 1.9% for arm volume and 2.9% for ECF. Correlation of weather and lymphedema data showed that temperature was the only aspect of the weather to have any effect on BCRL, with the maximum temperature on the day before measurement slightly affecting ECF (r = 0.27, p < 0.001), arm volume (r = 0.23, p < 0.001), and self-reported swelling (r = 0.26, p < 0.001). For women without lymphedema, the weather did not affect any measure. CONCLUSIONS: Established BCRL is relatively stable over a 6-month period. Temperature was the only aspect of the weather found to impact lymphedema.

Assessment of breast cancer-related lymphedema: a comparison of moisture meter and spot bioimpedance measurement.

BACKGROUND: Tissue dielectric constant (TDC) and spot bioimpedance measurement (BIA) have a role in the assessment of tissue composition changes in breast cancer-related lymphedema (BCRL). Our aims were to determine whether TDC and spot BIA measures could detect inter-limb differences in BCRL, explore the relationship between methods, and establish the intra-rater reliability and technical error of measurement for TDC. METHODS AND RESULTS: Women with (n=20) and without (n=4) unilateral BCRL participated. Circumference, TDC, and spot BIA measures were completed on the most affected region of the arm for BCRL participants and at a standardized forearm point in women without lymphedema. All measures were compared to measurements from an identical location on the contralateral arm. The affected arm differed significantly to the unaffected arm of women with BCRL for TDC and spot BIA measures. The median (IQR) differences were: extra-small probe 5.75 (3.10-8.21), small probe 3.50 (1.16-6.89), medium probe 5.08 (0.88-10.91), and for spot BIA measurement (-35.20 Ω; -59.75 to -14.85 Ω). The small and medium TDC probe measures were moderately correlated to spot bioimpedance measurements (r=-0.54 and r=-0.43, respectively). Intra-rater reliability coefficients (ICC2,1) of TDC measures ranged from 0.50 (95% CI: 0.12-0.75) to 0.92 (0.82-0.96). TDC technical error of measurement for women with lymphedema varied from 10.5% to 13.3%. CONCLUSIONS: Both TDC and spot bioimpedance may have a role in clinical assessment of tissue compositional change in BCRL. Their relationship with tissue composition, assessed by imaging, is now required.

Assessment of segmental arm soft tissue composition in breast cancer-related lymphedema: a pilot study using dual energy X-ray absorptiometry and bioimpedance spectroscopy.

BACKGROUND: Changes in arm soft tissue composition, especially increased adipose tissue, has been found in advanced, non-pitting breast cancer-related lymphedema (BCRL). The aim of this study was to examine whether these changes were localized to any particular region of the arm and whether they occurred in lymphedema which still pitted to pressure. Secondary aims were to explore relationships between arm segment volumes, bioimpedance spectroscopy (BIS) measurements of extracellular fluid (ECF), and dual-energy X-ray absorptiometry (DXA) measurements of tissue composition. METHODS AND RESULTS: Nine women with unilateral BCRL participated. The dominant arm was affected in 4 women, and all presented with lymphedema that pitted to pressure. Arm volume was calculated from circumferences by the truncated cone method, ECF was determined with BIS and fat and lean tissue content measured by DXA. BIS and DXA measurements for women with lymphedema were made of the whole arm and also of four 10 cm-segments measured from the ulnar styloid at the wrist. Whole arm DXA data were compared to those of 45 women of similar age and body mass index without lymphedema. All women with lymphedema had a significantly larger absolute fat mass in their affected arm compared to their unaffected arm, (median difference between arms 146.9 g). The forearm segment 10 - 20 cm proximal to the wrist had the highest median inter-limb fat difference of all four arm segments. CONCLUSIONS: The soft tissue composition changes associated with BCRL may occur in the presence of pitting and predominantly affect the proximal forearm.

Reliability and concurrent validity of the perometer for measuring hand volume in women with and without lymphedema.

BACKGROUND: Lymphedema of hand after breast cancer treatment causes significant loss of hand function. Although there are several ways of assessing limb volume, measuring hand volume has been problematic due to technical difficulties associated with assessment of finger volumes. The aim of this study was to investigate the criterion validity and reliability of Perometer™ for measuring hand volume in woman with and without lymphedema. METHODS AND RESULTS: Hand volume of forty women with (n = 20) and without lymphedema (n = 20) was assessed twice by one rater and once by another rater using the Perometer, and once by one rater using the water volumetry method. Intra- and inter-rater reliability was determined from the intraclass correlation coefficients and Percent Close Agreement. Agreement between the Perometer and water volumetry was determined using a limit of agreement and Lin's concordance correlation. The Perometer had high intra [ICC(2,1) = 0.989 (95% CI: 0.98-0.99)] and inter-rater reliability [ICC(2,1) = 0.993 (95% CI: 0.99-1.0)]. Percent close agreement revealed that 80% of the measures were within 9 ml for inter-rater reliability and within 15 ml for intra-rater reliability. In addition, there was high concordance between hand volumes obtained with the Perometer and water volumetry method (R(c) = 0.88). However, the Perometer overestimated the volume of hand compared to water volumetry method (bias: 7.5%). CONCLUSIONS: The Perometer can be used with high reliability to measure hand volume but caution should be exercised when data are compared with measures derived from the water volumetry method.

Assessment of bilateral limb lymphedema by bioelectrical impedance spectroscopy.

OBJECTIVE: The aim of the present study was to determine if the ratio of extracellular fluid (ECF), including the lymph, to that of intracellular fluid (ICF), as measured by bioimpedance spectroscopy (BIS), could be used to assess bilateral lymphedema (LE). BACKGROUND: The presence of LE is commonly determined as an increase in tissue volume due to the presence of excess lymph relative to the volume of a comparable unaffected body region or to comparative normative data. However, in bilateral LE of the limbs, a comparable body region, the contralateral limb, is also affected, precluding normalization. An alternative is to normalize the increase in lymph volume, as ECF, to that of ICF volume. METHODS: Extracellular/intracellular fluid ratios, expressed as the ratio of intracellular impedance (Ri) to extracellular impedance (R0), for the limbs of 277 female and 224 male controls were determined from an accumulated database of impedance data. Equivalent data were obtained for an opportunistic cross-sectional sample of 37 female and 5 male participants with bilateral LE of the legs. The ratios of Ri/R0 in the lymphedematous legs of the affected participants were compared with the equivalent ratios in the unaffected arms of the same participants and with those of the controls using box plots and visualized as bivariate data using tolerance ellipses. RESULTS: Despite Ri/R0 ratios varying with age, sex, and limb dominance, comparison of the ratio for affected legs (normalized to the ratio in the unaffected arms) with equivalent ratios observed in a control population (as bivariate tolerance plots) was capable of discriminating between 70% and 89% of the participants with LE. CONCLUSIONS: Bioelectrical impedance spectroscopy and determination of Ri/R0 ratios as indices of ECF/ICF ratios holds promise for the semiquantitative assessment of bilateral LE.

Segmental measurement of breast cancer-related arm lymphoedema using perometry and bioimpedance spectroscopy.

PURPOSE: To determine if bioimpedance spectroscopy (BIS) could detect localised lymphoedema of the arm and to compare BIS measurements with equivalent measures of limb volume by perometry. METHODS: Women with mild to severe upper limb lymphoedema (n = 29) and women with no history of lymphoedema (n = 11) participated. Commencing at the ulnar styloid of the wrist, 4 × 10 cm segment measurements were made of each arm using both BIS and perometry. RESULTS: Average BIS inter-limb ratios for the total arm and each arm segment were higher than comparable perometry measures in women with lymphoedema, but similar to perometry measures for women without lymphoedema. Limits of agreement analysis showed that the mean difference between methods varied according to segment measured, ranging from 8.5% for the uppermost segment of the arm to 16.6% for the forearm segment just below the elbow. For all limb segments, there was a positive bias towards BIS measurements, which increased as lymphoedema severity increased. CONCLUSION: BIS can be used for localised measurement of lymphoedema. Because it is specific to extracellular fluid, BIS is more sensitive to localised lymphoedema than perometry.

Operational equivalence of bioimpedance indices and perometry for the assessment of unilateral arm lymphedema.

BACKGROUND: The aim was to assess the agreement between bioimpedance indices and inter-limb volume differences, as assessed by perometry, for assessment of unilateral arm lymphedema. METHODS: Impedance was measured in the arms of 45 women with lymphedema and a separate control group without lymphedema (n = 21). Arm volume was measured at the same time by perometry. The impedance indices, (ratio of impedances between limbs and the L-dex scores) were compared to the inter-limb volume differences using concordance correlation analysis. RESULTS: Impedance indices were highly correlated (r = 0.926) with the difference in arm volume measured by perometry. CONCLUSIONS: Bioelectrical impedance analysis, although not providing a quantitative volume measurement of lymphedema, provides a measurement index that is highly correlated with quantitative measurements of the volume increase in limb size seen in lymphedema. The speed and ease of the impedance technique renders it a suitable alternative to perometry for the assessment of lymphedema.

A profile of physiotherapy clinical education.

The purpose of the study was to examine clinical education placement data to generate a profile of providers and examine the students' exposure to health care and educational factors during clinical education. A retrospective audit of clinical placement rosters was undertaken for 3 calendar years (2001-2003). Data were analysed overall and by clinical school for sites and placements, public or private sector and type of placement. Over the 3-year period, 209 sites provided 3475 clinical placements, with the number of placements increasing from 1066 placements in 2001 to 1133 in 2002 and to 1276 in 2003. Overall, 72.2% of placements were located in metropolitan Sydney. The proportion from regional providers increased over the 3 years from 11.8% to 15.1%. Overall 85.8% of placements were delivered by public providers. The profile indicated that a considerable number of clinical sites were utilised with an emphasis on large public hospitals. The challenge for curriculum development is to reduce the clinical education demands on current providers while ensuring graduates meet entry-level standards of physiotherapy.