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Weight Lifting and LE: Clearing Up Misconceptions
NLN Position Papers: Risk Reduction, Treatment, Exercise, Air Travel, Training
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100 Questions and Answers About Lymphedema
Lymphedema Management: A Comprehensive Guide for Practitioners
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Action Needed (Contact Your Local Representative)
Patient Participation in Clinical Trials
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National Lymphedema Network
Volume 22, No. 1 January - March, 2010
- Florida Hospital: A Continuum Of Care For Lymphedema Patients
Volume 21, No. 4 October - December, 2009
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An Assessment of the Role of Low-Level Laser Therapy in the Treatment of Lymphedema
Volume 21, No. 3 July - August, 2009
- Successful Management Requires a Team Approach: The Why, Who, and How of a Team"
A continuum of care that services a community beyond the clinical setting, providing services in acute care and home, is vital to both the success of rehabilitation and the growth of lymphedema practices. Currently, lymphedema treatment in the United States is provided primarily in the outpatient setting. It is important to realize that one treatment setting may not serve the individual needs of all patients. However, in European countries, specifically Germany, inpatient lymphedema clinics exist which provide intensive therapy twice daily. Understanding this model of therapy can help clinicians in the United States broaden their perspective and assess the benefit of offering lymphedema services as part of a continuum of care.
Florida Hospital in Central Florida has been providing a continuum of care for our lymphedema patients over the past 10 years. Offering services in acute care, outpatient, and the home care setting provides patients with the opportunity to receive treatment in an environment that best suits their needs. In our experience, each specific treatment setting has its own unique focus, challenges, and successes that promote optimal patient outcomes.
Treatment in the hospital setting has its own set of unique opportunities and challenges. Initially, the lymphedema patient must be medically stable enough to participate in inpatient therapy, as with any other lymphedema treatment setting. Therefore, it is important for the lymphedema team and the medical director to establish protocols to determine the appropriateness of lymphedema treatment with patients with acute co-morbidities. When it is deemed appropriate, acute care lymphedema treatment can help achieve an excellent level of success in many patients.
Patients admitted to acute care are initially assessed by our nursing staff to identify those at risk for, or who currently have lymphedema. These individuals are then provided with a vascular alert band placed on their involved extremity/ies identifying the at risk limb. This signals all staff to avoid veni-punctures and blood pressure monitoring on the affected limb to prevent onset or exacerbation of lymphedema. Next, the therapy department is notified, and our staff of experienced certified lymphedema therapists completes appropriate evaluations. Our staff works closely with family members, physicians, nursing, wound care specialists, and other therapists to establish a foundation of care to address lymphedema.
Therapy is provided up to seven days per week, depending on the patient’s medical condition and assessment of need. Our acute care staff is able to provide complete decongestive therapy, including manual lymph drainage at the bedside and compression bandaging. Good communication between nursing and therapy staff the enhances the ability to observe patients 24 hours per day and allows a team approach to monitor co-morbidities, skin condition, circulation, and vital signs to promote patient safety during the course of CDT. Due to the chronic nature of lymphedema, most patients will need to transition to outpatient or home care following their inpatient stay. In many cases, we are able to assess for compression garments or adjustable compression devices prior to discharge to facilitate a smooth transition to the next treatment setting. To further facilitate the continuum of care, we communicate directly with Florida Hospital’s outpatient and home care staff depending on individual patient’s preferences/needs, a crucial step that helps to provide more efficient care and ensure a smooth transitional plan.
The outpatient setting is ideal for those patients who are safely able to leave their home. This traditional setting provides advanced lymphedema care and is the ideal setting for the therapist as rehab equipment is readily available. The environment is conducive for healing and education, providing patient and staff support. Further, the patients are usually medically stable and independent with self-care, or have the assistance needed to complete self-care tasks. Therapy is provided up to five days per week, following standard CDT protocols. Since this population is more mobile, they are able to shop for various vendors to purchase day- and night-time support on and off campuses. Boutiques that cater to cancer and lymphedema patients are available on site to address cancer and lymphedema-related needs such as garments, bra-fitting, prosthetics and spa services. Relationships with surgeons and other cancer related programs allow for the coordination of pre- and post-measurements of limb, and to provide education on precautions and prevention. Patients are encouraged to attend support groups to offer emotional support, motivation, and ideas on how to cope with lymphedema.
As therapists in this setting, we also educate patients to become their own advocates. Patients are made aware of community and national resources and conferences for the advancement of lymphedema treatment. If for some reason the patient becomes medically unstable during the course of treatment, or their mobility status is compromised with compression therapy, acute in-patient care or home health care CDT is available as an option to continue with care. Again, communication between staff in the in-patient and home-care settings is a vital component to ensure successful patient outcomes.
The home care setting for treatment of lymphedema is available for those patients who qualify for homebound status under Medicare guidelines. Patients are treated for lymphedema in their home environment. Variations to manual lymph drainage and compression therapy may be incorporated into treatment strategies to allow for maximum reduction of swelling and appropriate self-management. Therapy is provided three to five days per week. Patient and family training is initiated during the evaluation to assess for patient compliance and family’s ability to assist with lymphedema management. Therapists travel with a car stock of bandaging supplies to allow for prompt treatment. While homebound, the patients are often unable to leave their home to purchase daytime and nighttime support. Therefore, the therapist must measure for daytime and nighttime support garments and educate the patient on donning and doffing techniques. Patients often order supplies over the internet and at times the therapist must pick up garments from local vendors to deliver to the patient. An interdisciplinary approach is essential as home care staff may recognize potential safety and medical issues that may arise during the course of CDT. A home care clinician may initiate referrals to the physician for acute care management or progression to an outpatient setting for continued care.
The goal of our comprehensive lymphedema program at Florida Hospital is to safely manage LE, educate, and train the patient and family in on-going LE care, develop a maintenance plan, and prepare the patient for the next phase of treatment. Working together as a team, we are able to bridge the gaps among treatment settings. Semi-annual meetings facilitate communication and team building among therapists in the three settings. Secure electronic communication and phone calls allow for further coordination of care. Competencies and a mentoring program have also been established to ensure consistent delivery of treatment. Additionally, a committee of therapists representing each setting has created an educational booklet, which is provided to all LE patients.
Our team approach to the management of lymphedema promotes a continuity of care, ultimately providing a unique and comprehensive program. Most importantly, patients receive services that accommodate their individual needs for optimal outcomes.
Light has been used to treat disease since the dawn of time. Nevertheless, its popularity has fluctuated over the years. Early use, such as that recorded by the Greeks and Romans, emphasized its thermal effects and, as recently as the early 1900's, the Nobel Prize in Physics was awarded for the use of the ultraviolet portion of the light spectrum in the treatment of tuberculosis. Subsequent improvements in medical care, however, led to a gradual decline and near extinction of interest in the therapeutic use of light.
The invention of the laser (Light Amplification by Stimulated Emission of Radiation) in the early 1960's led to a new attention to light's non-thermal capabilities and a reversal of this trend. At the heart of this interest was the belief that specific wavelength of light (i.e. colors) at intensities too low to increase a tissue's temperature more than a few tenth's of a degree can alter cellular and tissue activities. Initial work began in Eastern Europe and focused on the treatment of non-healing wounds.
The next few decades saw a rapid expansion of interest and a variety of names applied to the approach. Although terms such as Biostimulation, Cold Laser and Low Intensity Laser have been used, nowadays, Low Level Laser Therapy (LLLT) is the most generally accepted term.
As noted above, LLLT involves the application of low powers and energies of laser irradiation to tissue with the goal of producing benefits by non-destructively altering cellular or tissue function. Early lasers were gas-filled devices (e.g., helium and neon, krypton and argon), but by the 1980s these instruments began to be replaced with cheaper and easier to use superluminous diodes. Today, diode use prevails and with the exception of some helium-neon lasers, most "laser treatments" are in reality performed with individual or groups of Gallium-Arsenide (GaAs) and Gallium-Aluminium-Arsenide (GaAlAs) diodes.
While laser and diode radiation might have therapeutic benefits, the conditions most likely to respond and the extent of these benefits remain areas of active investigation. The answer to the first question, why these devices may have benefits, is now generally accepted to be that as their radiation is purer (in other words has a narrower bandwidth) than light from other sources, it is more capable of producing wavelength-dependent resonant frequency interactions with cell organelles such as the mitochondria. There is also a general, but not universal, acceptance that multiple treatments are necessary, that the treated tissue must be under stress, and the energies involved in treatment should be low (between 1-4 J/cm2). Most devices, in fact, are relatively low-powered and have outputs between 30 and 500 mW (power). Treatment typically is delivered at multiple sites with the laser applicator in contact with the skin, or in a noncontact approach in which the beam is scanned over the area to be treated. While attention may be placed on waveform of a device's output, evidence supporting the benefits of a specific pattern of pulsing over a simple continuous wave is limited.
LLLT, by definition, involves low amounts of energy and no risk of thermal injury. While some have raised the thought that stimulation could accelerate cancer growth, this issue remains theoretical. As a result, safety concerns related to LLLT are low and adverse effect reports rare. In fact, an attractive aspect of LLLT is that treatment does not raise tissue temperature significantly. Therefore, LLLT can be used during the acute stages of an injury or in conditions for which heat might be expected to worsen swelling or inflammation.
Soft tissue and musculoskeletal injuries have proven particularly intriguing as these sites tend to be superficial and LLLT is claimed to have both analgesic and tissue healing effects. Laboratory studies support the concept that LLLT can increase collagen production, alter DNA synthesis, reduce the expression of inflammatory markers, and enhance the function of damaged muscles and nerves. Extension of these effects to animals and humans has proven more difficult to establish. Although many investigations find benefits from LLLT in a variety of musculoskeletal, arthritic, soft tissue, and painful conditions, differences in their designs, parameter choices, and subject populations make it difficult for systematic and meta-analytic studies to confirm LLLT's clinical benefits. Fortunately, study designs are improving and the existence of a growing number of larger, well-designed studies may change the current situation. Similarly, a frequent lack of a head-to-head comparison with alternative treatments such as ultrasound and massage often complicates assessment of clinical utility.
Lymphedema, at first blush, might not appear to be particularly amenable to LLLT, given past emphasis on its use to promote healing and to alleviate musculoskeletal dysfunction and pain. Nevertheless, while still in its early days, the idea that LLLT might be beneficial may not be far-fetched, given its documented effects on processes as diverse as protein and prostaglandin synthesis, cell membrane transport, inflammation and intracellular metabolism. In fact, a number of investigators have reported reductions in swelling and improved comfort following treatment. As is true for LLLT in general, the initial studies, while intriguing, are too small and frequently too poorly designed to do more than suggest benefits. Subsequent work has been marked by improving designs and while the amount of research completed is still limited, it is worthwhile to review its strengths and weaknesses.
For example, a recent study by Kozanoglu and colleagues reports on 47 women with post-mastectomy edema following modified radical mastectomies and axillary dissections. Subjects were randomized to receive either twenty 2-hour sessions of pneumatic compression therapy or twelve 20-minute sessions of LLLT over the antecubital fossa and axilla with a 904nm infrared pulsed Ga-As laser device over a four-week period. All subjects received a home program of daily exercise, range of motion and skin care. The investigators found that while both groups showed significant improvements in their limb circumferences following treatment, those improvements in the LLLT group tended to be larger and more prolonged in the study's impressively long, 1-year follow-up period. No significant inter-group differences were noted in terms of pain relief or grip strength.
Carati and colleagues reported in 2003 on a rather complex trial in which 61 women with breast cancer-related arm lymphedema were divided into groups receiving either nine sessions of pulsed 904 nm irradiation at 17 sites along the axilla over a 3-week period, or an identical placebo treatment with an inactive device. At the end of this trial, a second experiment was performed comparing the relative benefits of one versus two courses of radiation.
The investigators reported two interesting and related findings: while a single course of treatment had no effect on their subjects' lymphedema, two courses did; and the benefits became noticeable at follow-up one month after the completion of treatment. No effects on range of motion were noted.
Kaviani and colleagues reported in 2006 on a small double-blind controlled trial in which 11 women with post mastectomy lymphedema were assigned to either receive 890 nm radiation over the axilla and arm from a GaAs laser device or identical treatment with a sham device. Evaluation of the eight who completed the treatment over a 22-week period revealed improvement in both groups. The authors noted the improvements tended to be more pronounced in subjects treated with the active device. The authors concluded that their results were encouraging but that further research was needed.
Piller and Thelander provide two reports of a group of 10 women with post-mastectomy lymphedema who underwent an uncontrolled 10-week trial involving sixteen treatments with a laser which was scanned over the treated area rather than held at a number of fixed positions. Evaluation at the end of treatment revealed a roughly 20% reduction in volume, as measured by limb circumference. Follow-up of seven of these subjects indicated by self-assessment that their limb volume improvements persisted.
White and colleagues recently published an abstract describing a randomized trial that compared LLLT to "standard care" for the initial treatment of breast cancer-related lymphedema. The 148 participants received either two weeks of LLLT or decongestive therapy. A statistically significant reduction in arm circumference relative to the control group was noted after LLLT in participants with mild but not moderate lymphedema. It should be noted that while the results are intriguing, conclusions and generalization are limited, as bandages were not worn between therapy sessions in the decongestive group and details about the nature of LLLT were not provided in this preliminary report.
This paper has provided an overview of LLLT and the relevance of its research findings to lymphedema. A number of observations are possible. The first is that the evidence supporting the use of LLLT in its initial areas of pain and musculoskeletal applications is promising, but still limited by heterogeneity in study designs (with studies characterized by small sample size with limited follow-up in many cases), irradiation and outcome measures. The second is that the study of the application of LLLT to lymphedema is following a pattern similar to that of LLLT as a whole: small, uncontrolled studies (e.g., Piller and Thelander) followed by larger and better designed trials such as that by Carati and colleagues. The results are encouraging, but the pool of evidence is limited and further work by multiple investigators, as well as more comparisons with alternative treatments, is needed before the benefits of LLLT for lymphedema can be accepted comfortably as established. Further, how or whether LLLT should be integrated in conventional complex decongestive therapy (CDT) remains uncertain. Until rigorous trials permit therapeutic comparison of CDT and LLLT, patients should be informed that LLLT does not eliminate their need for phase II CDT maintenance treatments.
Drs. Basford and Cheville are with the Department of Physical Medicine and Rehabilitation-Mayo Clinic, 200 Second Street SW, Rochester, MN 55902
By Jean O'Toole, PT, MPH, CLT-LANA
The many quality of life challenges that patients face following treatment for breast cancer are well documented. 1-5 Lymph edema is clearly one of the major challenges for patients in whom it occurs. It can also be a significant source of distress for patients who fear its development.6 Four years ago, a few of us involved in the care of these patients questioned if, as a Breast Center, we were doing enough to confront this often devastating side effect of breast cancer treatment. We recognized that the needs of patients with breast cancer-related lymphedema were varied and complex, requiring the skills of different disciplines. As in many other models in medicine, we determined that this problem would likely be more effectively managed if we took a structured multidisciplinary approach to breast cancer related lymphedema.7,8 Thus, our multidisciplinary team was created with only three initial members. We agreed on the overarching goal of addressing breast cancer related lymphedema proactively, aggressively and comprehensively, and to stay focused around patient centered goals. Since its inception, our team has added members, learned and reflected on our efforts, and has continued to evolve. However, our mission has remained the same: to identify lymphedema as early as possible, empower patients to manage lymphedema with as little burden as possible while keeping their goals central to decision making, and to contribute to the scientific literature regarding evaluation and management.
Appreciating that a variety of providers would bring a broader perspective to the patient experience, we have made a conscious effort to be inclusive. We worked to develop a network of colleagues who were passionate about organizing their efforts around this problem. Presently, the team members include the patient and their support system, colleagues from surgical, medical and radiation oncology, and certified lymphedema therapists. We consider the Cancer Center nutritionists, social workers, our Cancer Resource room staff, and representatives from the Wellness community as essential to the team effort. The Durable Medical Equipment (DME) provider is also an important member of the team. The roles of team members are varied and the level of involvement of team members depends on the needs of the patient. However, discussing lymphedema openly and willingly with all patients is an expectation for everyone at the Breast Center. Attention to breast cancer related lymphedema has grown in our setting. Throughout our Breast Center, it is universally recognized as a serious and real side effect that warrants ongoing monitoring and attention.
Our lymphedema team coordinator is from the department of radiation oncology and has the primary responsibility of measuring patients on the perometer, organizing and interpreting the data. Patients are measured at the time of diagnosis, post-operatively, at the completion of chemotherapy, at the end of radiation, and then every four to six months for all of their years of follow up. This has provided us the opportunity to understand the natural history of lymphedema and enabled us to embark on projects of scientific inquiry. The presence of the perometer in the Breast Center has made regular assessment of arm volume possible and efficient. It affords the patients a readily accessible tool to help address their concerns regarding edema development. Furthermore, it also accurately quantifies the efficacy of our interventions.
The medical, surgical and radiation oncology providers of care are essential. We rely on them to rule out occult disease or a vascular event that might be responsible for new lymphedema. These physicians and nurses are in a pivotal position to refer patients for care, ensure that perometer readings are performed regularly, and communicate patients' medical considerations to the rest of the team.
The social workers assigned to the Breast Center play an essential role, providing emotional support, assisting with transportation, pursuing opportunities for financial assistance and providing a link to commu nity resources. It is these social workers who assist patients with completing forms for financial need. They are available for ongoing psycho-social support as patients cope with their lymphedema. In situations where additional mental health services are warranted, our physicians in the Psychiatric Oncology Department become involved. Our Cancer Center nutritionists also are involved as they are able and available to counsel patients on dietary considerations. Given the association of high body mass index with lymphedema their efforts in helping patients control their weight are invaluable.9,10
There are three certified lymphedema therapists on our main campus in Boston, and two in hospital affiliated healthcare centers located outside of the city of Boston. These five clinicians are also experienced orthopedic therapists who are capable of managing not only patients' lymphedema, but their musculoskeletal problems as well. We have intentionally supported these staff members, enabling them to go through the lymphedema training and certification as edema therapists and placed them in strategic locations to make it easier for patients to receive care closer to their homes. In addition, with intent to increase the number of trained providers in our area, MGH Physical Therapy Service hosted the Lymphedema Certification Course on three occasions. We also have compiled a list of certified lymphedema therapists by geographical area, locally and throughout New England, which enables us to recommend qualified providers in areas more accessible for our patients who do not live near our hospital.
We rely on a licensed DME provider to measure for custom garments and bill insurances. Specifically, our clinic has an experienced fitter who comes to the hospital on a weekly basis and provides this much needed service to our patients. The Cancer Resource Room at our hospital contains booklets and books on all cancer related topics, has computers available for patient use, and a classroom. Free classes and workshops on lymphedema, exercise, nutrition and fatigue are offered daily, and members of our team participate regularly, depending on the topic.
Open and regular communication strategies enable the team to coordinate their efforts. The team meets regularly to review goals and progress and adjust plans accordingly. In between meeting times, email serves to share ideas, pose questions, obtain feedback on abstracts, manuscripts, and report on any educational meetings, talks or opportunities. The electronic medical record (LMR) serves as a central repository for patients' visit data, phone calls, pathology reports, operative notes etc. Perometer readings are also documented in LMR, so all providers can easily access that information. If patients present with an urgent problem, a needed colleague can be contacted by page to address the request for help. A recent case demonstrates this well: A patient was coming in for regular Complete Decongestive Therapy (CDT) and her edema was responding well to treatment. She came to her regular appointment on a Monday, reporting a 24-hour period of increased swelling and pain. Indeed, on examination, her arm was markedly more edematous and discolored. The lymphedema therapist paged the nurse practitioner for the medical oncologist who was caring for the patient. The patient was measured on the perometer and a doubling of her volume was confirmed. She was referred for imaging within a few hours, and revealed a deep vein thrombosis in the subclavian vein. Anti coagulation was initiated immediately.
The challenge of obtaining funds for patients whose insurance does not cover garments has been facilitated by a grant funded by a local philanthropic group. The distribution of funding is managed by our social workers who are just an email away when there is a patient in need. We have also obtained funding for this purpose through a grant from our Friends of the Cancer Center.
Some examples of our team efforts are:
1. A lymphedema teaching sheet was developed to provide patients with reliable information regarding risk factors and answers to frequently asked questions specifically for breast cancer related lymphedema.9,11,12 It was created utilizing input from the surgical and nursing staff in the Breast Center as well as the lymphedema therapists. The draft was reviewed by the team and feedback from all of the Breast Center providers was incorporated. It is now available to patients in hard copy and also on our Cancer Center website.
2. The HOPES Program (part of our patient support services), the Breast Center and an affiliated Health Club are sponsoring an eight-week Pilates Following Breast Cancer class. This is made available free of charge to our patients through a special fund from the Breast Center, which was made possible through a grant request submitted by one of the lymphedema therapists. The Pilates instructor, lymphedema therapist, social worker and a nurse practitioner from the Plastic Surgery department met and discussed any restrictions required for individuals enrolled in the class. HOPES obtained consent from the patient's surgeon and/or medical oncologist. Perometer readings will be performed pre and post class.
3. We also reach out to members of The Wellness Community who are providing exercise classes for patients, so that we can be aware of the content and feel confident about referring patients to other venues. The data from the exercise trials that are evaluating the impact of exercise on lymphedema is rich and our team works to stay abreast of new developments and resources that are available for patient near their home or work.13-17
4. The social workers run several support groups for breast cancer patients and routinely include the lymphedema therapists, who come and talk with patients about lymphedema, exercise and caring for their bodies. Patient feedback has been very positive as patients with lymphedema as well as those without this condition voice appreciation that the topic is so out in the open here. They tell us that they feel comfortable and safe discussing lymphedema and asking any questions they may have. These are just some examples of the many types of interactions the team has that focus on actively working together in the effort of approaching breast cancer related lymphedema with educational and exercise opportunities. Other team projects and team efforts around patient care will be demonstrated in the following article and case studies.
A team approach is possible when even a few committed providers who are passionate about addressing lymph edema begin to work together to identify needs and develop action plans. It has been our experience that a willingness to openly discuss lymphedema very early on in the patient experience and regular respectful communication are key behaviors for success. It seems that this openness establishes a culture of recognition in the practice environment, that lymphedema is a serious problem and worthy of proactive management. Strong communication strategies allow all parties involved to remain abreast of developments regarding patient needs and also provide opportunities for growth. It has been our experience that a dynamic team evolves and expands over time, and we continue to appreciate the need for other disciplines to join in the effort.
We believe that this team concept is applicable to other causes of lymphedema, and the composition of the team will vary depending on patient populations and resources. For example, in a team dedicated to vascular edema, nutritionists and exercise physiologists may play a major role. A team working together on edema related to pelvic surgery may need to include practitioners skilled in managing pelvic floor dysfunction. Regardless of the practice setting, we encourage our colleagues around the world to partner with others in their locale to take this problem on, not just as sole practitioners, but in a collegial approach with the needs of the patient driving their efforts. It can begin as a small group,with modest goals, but we will never know what can be accomplished, unless we begin.
1. Hayes SC, Janda M, Cornish B, et al: Lymphedema after breast cancer: incidence, risk factors, and effect on upper body function. J Clin Oncol 26:3536-42, 2008
2. Paskett ED: Breast Cancer-Related Lymphedema: Attention to a Significant Problem Resulting From Cancer Diagnosis. J Clin Oncol, 2008
3. Ridner SH: Quality of life and a symptom cluster associated with breast cancer treatment-related lymphedema. Support Care Cancer 13:904-11, 2005
4. Oliveri JM, Day JM, Alfano CM, et al: Arm/hand swelling and perceived functioning among breast cancer survivors 12 years post-diagnosis: CALGB 79804. J Cancer Surviv, 2008
5. Beaulac SM, McNair LA, Scott TE, et al: Lymphedema and quality of life in survivors of early-stage breast cancer. Arch Surg 137:1253-7, 2002
6. Lee TS, Kilbreath SL, Sullivan G, et al: The development of an arm activity survey for breast cancer survivors using the Protection Motivation Theory. BMC Cancer 7:75, 2007
7. Dos J, Gorska-Dos M, Szuba A: The integrated and interdisciplinary treatment of chronic lymphedema. Rocz Akad Med Bialymst 50 Suppl 1:141-4, 2005
8. Salas E, Wilson KA, Murphy CE, et al: Communicating, coordinating, and cooperating when lives depend on it: tips for teamwork. Jt Comm J Qual Patient Saf 34:333-41, 2008
9. Vignes S, Arrault M, Dupuy A: Factors associated with increased breast cancerrelated lymphedema volume. Acta Oncol 46:1138-42, 2007
10. McLaughlin SA, Wright MJ, Morris KT, et al: Prevalence of Lymphedema in Women With Breast Cancer 5 Years After Sentinel Lymph Node Biopsy or Axillary Dissection: Patient Perceptions and Precautionary Behaviors. J Clin Oncol, 2008
11. Nielsen I, Gordon S, Selby A: Breast cancer-related lymphoedema risk reduction advice: A challenge for health professionals. Cancer Treat Rev 34:621-8, 2008
12. Tsai RJ, Dennis LK, Lynch CF, et al: The Risk of Developing Arm Lymphedema Among Breast Cancer Survivors: A Meta-Analysis of Treatment Factors. Ann Surg Oncol, 2009
13. Cheema B, Gaul CA, Lane K, et al: Progressive resistance training in breast cancer: a systematic review of clinical trials. Breast Cancer Res Treat 109:9-26, 2008
14. Cheema BS, Gaul CA: Full-body exercise training improves fitness and quality of life in survivors of breast cancer. J Strength Cond Res 20:14-21, 2006
15. Ahmed RL, Thomas W, Yee D, et al: Randomized controlled trial of weight training and lymphedema in breast cancer survivors. J Clin Oncol 24:2765-72, 2006
16. Knobf MT, Insogna K, DiPietro L, et al: An aerobic weight-loaded pilot exercise intervention for breast cancer survivors: bone remodeling and body composition outcomes. Biol Res Nurs 10:34-43, 2008
17. Hayes SC, Reul-Hirche H, Turner J: Exercise and secondary lymphedema: safety, potential benefits and research issues. Med Sci Sports Exerc 41:483-9, 2009
Jean O'Toole works as a Clinical Specialist in the Physical Therapy Department of Massachusetts General Hospital. She received her B.S. in Physical Therapy from Northeastern University in 1970, a Masters in Public Health from Boston University in 1991, Klose-Norton training for lymphedema in 2002, and was LANA certified in 2003. Email jotoole2@partners.org
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