Canada’s Lymphedema Magazine
Pathways Empowering patients and professionals
Acc e Digit ss Edit al ion See p age 4
SUMMER 2022
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Head and neck lymphedema
Public support for lymphedema care Reimbursement inequities Mobile apps FRANÇAIS...
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Editor’s Message
Public funding and support for all lymphedema patients
I
t was at the 2009 National Lymphedema Conference in Toronto where I met Julio, a kind and quiet gentleman, living with head and neck lymphedema. I listened intently as he shared with me his unique challenges of lymphedema; they were so different than mine. Julio had to live with the fear of not being able to breathe, swallow and eat normally; things we all take for granted. He was already slurring his words and worried that his speech would deteriorate to a point where eventually he would not be able to be heard or understood.
Reimbursement inequities for compression garments exist around the world, including Europe and North America. It made my leg lymphedema problems seem insignificant. Although lower limb and also primary lymphedema are less understood than breast cancer related lymphedema, I knew that people like Julio would have an even more difficult time finding proper assessment, treatment and support. I was thankful that I was not in his shoes. Marize Ibrahim is a physiotherapist working on a team at the McGill University Health Centre – Lymphedema Clinic (Montreal, Canada) using a multidisciplinary approach to evaluate head and neck lymphedema. She
has written an article within a series— focusing in this issue on assessment and diagnosis. We thank her for diligence in easing the challenges for this often-neglected group of lymphedema patients. An abstract entitled “Public perspectives on lymphedema surgery” was presented by Yasser Almadani at the 2022 virtual national conference. Yasser shares the results of his group’s study highlighting valuable insights into public funding for lymphedema surgery along with the difficulties lymphedema patients have in accessing comprehensive health services. Importantly, his group uncovered broad support amongst the public for a healthcare policy that provides comprehensive funding for lymphedema care. Reimbursement inequities for compression garments exist around the world including Europe and North America. Specifically within Canada, the province where you live determines the type of pubic health funding available for garment funding. Sadly, authors Mona Al Onazi, Erica Park and Michelle Phung discovered there are not many changes from our 2017 report on this topic, as funding discrepancies are still rampant. With national health decisions made at the provincial level, advocacy efforts to change reimbursement must be duplicated for each province, one step at a time. Thankfully there are provincial lymphedema associations who have volunteers working tirelessly to advocate for change.
We encourage you to join their efforts to improve accessibility to comprehensive lymphedema care in your province. What the public also wants is more options in managing health care. Mobile apps can help and already exist for patients with chronic diseases such as diabetes, obesity and heart disease. However, apps related to supporting lymphedema care are few and far between. We scoured the Internet to find those most relevant to patients and their healthcare providers. Innovative ways to make managing lymphedema from the comfort of your home will make all our lives easier. I hope that both private and public funding will designate resources to create more mobile phone apps to support the lymphedema community in the future. LP
Anna Kennedy
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Contents
Assessment of head and neck lymphedema
5 ................................................ A significant and commonly neglected side effect remaining underdiagnosed and understudied.
Summer 2022 n Volume 11 Issue 3
Rethinking the safety net
Publisher Pathways is published four times per year by BCS Communications Ltd. on behalf of the Canadian Lymphedema Framework.
CANADIAN LYMPHEDEMA FRAMEWORK
PARTENARIAT CANADIEN DU LYMPHOEDÈME
Editorial Board Mei Fu PhD RN FAAN Pamela Hodgson MT MSc David Keast MD FCFP Lori Radke PT CLT Anna Towers MD FCFP
The case of public support for revamped (or expanded) lymphedema care.
8 ........................................................................ 11 ........................................................................ Ask the Expert
Q&A’s from the 2021 National Lymphedema Conference.
Inequities in garment funding across Canada
Editor Anna Kennedy
12 .............................................
Editorial Assistants Bonnie Baker Nicole Boulet Rachel Li Advertising and Submissions We welcome your ideas, contributions, letters and ad copy. While all material is subject to Editorial Board approval, inclusion does not constitute an endorsement or reflection of the views and opinions of the CLF and its Editorial Board. Contents may not be reproduced without written permission of the Canadian Lymphedema Framework. Subscription Rates (1 year) Canada - $30. United States - $60. International - $75. Single copies and back issues - $8. Subscriptions/return mail to Canadian Lymphedema Framework 4800 Dundas Street West, Suite 204 Toronto, Ontario M9A 1B1 Telephone: 647-693-1083 Email: pathways@canadalymph.ca www.canadalymph.ca Cover: NLNet; Impressed by You Photos: MUHC Lymphedema Clinic. All stock images are CanStock. Canadian Publications Mail Agreement 40065546 ISSN 1929-1418 • Printed in Canada We acknowledge the financial support of the Government of Canada. Financé par le gouvernement du Canada Funded by the Government of Canada
4 Ly m p h e d e m a p a t h w a y s . c a
Where are we in 2022?
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Clinical Perspective
Assessment of head and neck lymphedema By Marize Ibrahim
T
he World Health Organization estimates the incidence of head and neck cancers (HNC) worldwide is more than 550,000 cases per year.1 In Canada, an estimated 7,400 Canadians will be diagnosed with head and neck cancer annually.2 About 90% of all head and neck cancers are squamous cell carcinomas, making it the sixth leading cancer by incidence worldwide.1 A strong association exists between HNC and certain environmental and lifestyle risk factors including tobacco and alcohol use, with evidence implicating human papilloma virus exposure.3 Multimodal treatments for HNC may include surgery, radiotherapy and chemotherapy. These may have significant acute and/or late side effects that could be physically, functionally, and psychologically debilitating.4-6 There is a need to investigate and address these side effects as early as possible in order to limit their long term sequelae.4 Head and neck lymphedema (HNL) is a significant and commonly neglected side effect that unfortunately remains underdiagnosed and understudied.7 HNL is defined as a build-up of fluid and inflammatory products in the interstitial space caused by a disruption of lymphatic flow, from surgery and/or radiation therapy.8 HNL could manifest externally (e.g. skin, face, neck, head), internally (e.g. oral cavity, tongue, pharynx) or both.8 This may profoundly impact critical physical functions (e.g. speech, breathing, swallowing, and eating), decreased quality of life (QOL), increased infection risk along with body image and psychological sequelae (e.g. anxiety, depression).4,6,8,9
The prevalence of HNL among those treated for HNC is significant but needs to be further defined. The literature has identified a prevalence range between 12% to 90%4,9 for external HNL, and as high as 97%6 for internal HNL. As external HNL is visible, it receives the greatest attention as it can easily be captured over time with a specialized lymphedema assessment including circumference measures and photographs.8 There are growing reports on the importance of addressing internal HNL, including the use of a transnasal laryngoscopy, which has been documented to be the best way to assess internal HNL.4,7-9 As this requires skilled technicians or physicians to perform; currently lymphedema therapists still have to
Marize Ibrahim MSc, PT, CLT-LANA is a lymphedema therapist working at the McGill University Hospital Center Lymphedema Clinic with Dr. Towers and her multidisciplinary team. She is a certified Clinical Specialist in Oncology by the Physiotherapy Specialty Certification Board of Canada.
Summer 2022
Head and neck lymphedema (HNL) is a significant and commonly neglected side effect that unfortunately remains underdiagnosed and understudied. rely on a physical evaluation to estimate the extent of the HNL. There is to date no gold standard for assessing HNL. In fact, a lack of common evaluation tools has led to a wide variation in assessment methods between institutions currently managing HNL. An assessment protocol has been established at the McGill University Health Centre – Lymphedema Clinic, a Lymphatic Education & Research Network (LE&RN) of Excellence, using a multidisciplinary approach to evaluate HNL. The following is a brief outline of the assessment evaluation utilized. Ly m p h e d e m a p a t h w a y s . c a 5
Images of four patients from the MUHC Lymphedema Clinic displaying Head and Neck Lymphedema at various stages. Pictures attained with permission of patients. 1 Medical history: a thorough history is taken, including surgery, extent of lymph node dissection, chemotherapy and/ or radiotherapy. Surgical and pathology reports, if available, are verified to assist with the medical history intake. Medical imaging and notes regarding any cancer recurrence are reviewed to understand the extent of the HNC. 2 Both internal and external edema information: is recorded including trigger of lymphedema, location, frequency of infection (cellulitis), and treatment management (including compression) to date, whether successful or not. 3 Functional evaluation: is performed using a head and neck function and symptom tool. Six conceptual domains are evaluated by the patient and therapist, regarding the impact of HNL on function and QOL, including: (a) Range of motion (neck mobility/stiffness, mouth opening/ 6 Ly m p h e d e m a p a t h w a y s . c a
temporomandibular joint mobility, tongue mobility, scar tissue restrictions, radiation fibrosis); (b) Difficulty with swallowing/ chewing (i.e. dysphagia; difficulty swallowing soft solids, solids, mashed or pureed food, thick liquids; difficulty chewing; teeth/ dentures present/absent/pending, etc.); (c) Speech, hearing and visual impairments (i.e. hoarseness, dysphasia, difficulty talking and/or being understood by others, voice changes, tinnitus, blurred vision, headache) (d) Appetite (i.e. increased/decreased, decreased salivation production and/or dry mouth, thick saliva/ increased secretions); nausea/vomiting, frequent hydration, change in taste, altered senses including smell and weight loss (e) Lymphedema location (i.e. head, face, neck, throat, chin, cheeks, tongue) and (f) Psychological impact (i.e. pain, anxiety, feeling grouchy, tired/fatigued/lack of energy, depression, difficulty sleeping).
Objective evaluation includes four sections: 1 General observation and posture evaluation: mobility device usage and type, gait disturbances, posture. (i.e. torticollis tendencies, neck and scar contractures, cervical and thoracic spine kyphosis, scapular winging, shoulder depression/protraction, stoma and or PEG presence, scar mobility, etc.). Additionally, a visual observation is made on the location and severity of swelling. 2 Tissue change evaluation: dryness, radiation dermatitis, neck pitting edema, fungal infection (thrush), induration, radiation fibrosis: mild/moderate/severe, trismus, and if any wounds or ulcers are present. 3 Range of motion: shoulder mobility, cervical spine/neck mobility (flexion, extension, rotation, side flexion combined movements), tongue mobility (frenulum, elevation, protrusion, lateralization bilaterally) and TMJ (depression, elevation, protrusion, retraction and lateral movements). TMJ mouth opening is taken based on a 3-finger test used in a clinical assessment to document any trismus.7 4 Lymphedema circumference measures are based on Lymphedema Outcomes in Patients with Head and Neck Cancer by Smith et al.10 Neck composite, circumferential measures are taken (i.e. superior, middle and inferior neck) along with right and left facial composite (i.e. tragus to: mental, mouth corner; mandible to: nasal wing, internal and external eye and mental; internal eye to mental). Furthermore, tragus-to-tragus measurements are taken. Although internal cheek edema may be palpated by the therapist, internal neck lymphedema is not traditionally assessed by the lymphedema therapist. Because this requires skilled technicians or physicians to perform, the lymphedema therapists have to rely on a physical evaluation to estimate the extent of the HNL. The revised Patterson Edema Scale is appropriate for use by trained professionals who regularly use endoscopy to assess patients with HNL to determine the degree of laryngeal and pharyngeal edema.11 Summer 2022
TABLE 1
MDACC Head and Neck Lymphedema Rating Scale Levels
Description
0
No visible edema but patient reports heaviness
1a
Soft visible edema; no pitting, reversible
1b
Soft pitting edema; reversible
2
Firm pitting edema; not reversible; no tissue changes
3
Irreversible; tissue changes
Reference: Smith, B. G. (2019). Lymphedema in Head and Neck Cancer. In Clinical Care and Rehabilitation in Head and Neck Cancer (pp. 377-396). Springer, Cham.
Once the assessment has been completed, the lymphedema therapist may establish the stage of lymphedema using the M.D. Anderson Cancer Center (MDACC) head and neck lymphedema rating scale, which was adapted from the Foldi Lymphedema Rating Scale.12 The scale is divided into 5 levels: a) 0 = no visible edema present, but patient reports heaviness; b) 1a = soft visible edema is present, with no pitting (reversible); c) 1b = soft pitting edema is present (reversible); d) 2 = firm pitting edema is present, no
reversible edema and no tissue changes, e) 3 = irreversible edema and tissue change are present. Along with the stage of lymphedema, the therapist identifies a list of identified rehabilitation needs, to then establish and create an individualized treatment plan for the patient. Further details on the management of head and neck lymphedema will be discussed in a future article. In summary, the treatment of HNC leads to post-treatment sequela including lymphedema,
which can worsen and pose a great challenge for patients and clinicians to manage. Unfortunately, HNL has not been well studied nor documented. This article summarizes an evaluation protocol followed at the MUHC Lymphedema Clinic for patients with HNL. Our early experience using an objective evaluation and treatment protocol holds promise for a better understanding of HNL in patients treated for HNC. LP A full set of references can be found at www.lymphedemapathways.ca Acknowledgements I would like to extend my sincere gratitude to Marie-Eve Letellier and Angela Yung for their contribution to this article and continued support. A very special thank you to the head and neck patients with lymphedema as we strive to continue providing them with an improvement of their quality of life as they manage their HNL.
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Research Perspective
Rethinking the safety net
The case of public support for expanded lymphedema care By Yasser Almadani, Hedi Zhao, Anna Towers and Joshua Vorstenbosch
E
nsuring all members of society, including underserved and vulnerable communities, have access to needed healthcare is a central pillar of Canadian social policy. Yet in the current system, there are many population groups in which individuals have difficulty accessing comprehensive health services. Among these groups is lymphedema patients. A plethora of scientific approaches have been described to accurately capture the potential impact of a certain medical condition on the affected individual and broader society across numerous domains. The quantification of such impact has historically been a key driver of resource allocation in various national health care systems.1-3 However, when public perceptions of a disease empathize with the plight that patients experience, such as patients suffering from lymphedema, the case for additional health care funding
becomes even stronger. Our research group leveraged the power of crowdsourcing to assess whether the public accurately perceived the burden of lymphedema. Our group also assessed public support for additional funding for comprehensive lymphedema care. Crowdsourcing has emerged as a powerful tool for accumulating and analyzing data on a massive scale. In the broadest sense, crowdsourcing is a method of recruiting a large group of individuals to complete a specific task—in this case to accurately gauge public opinion on lymphedema. Anonymous crowd workers were recruited to provide assessments and collect responses on a secure platform. Crowd workers were aged at least 18 years and completed the entire lymphedema evaluation task presented that spanned multiple domains. Crowdsourcing presents an opportunity to study public preferences on a larger scale than has
been possible ever before. It has also been validated through a number of studies as a very accurate tool to assess presentations of various medical conditions and yielded results comparable to expert assessments.4,5 We integrated a detailed and piloted questionnaire with a crowdsourcing platform, yielding responses from over 1,000 American and Canadian individuals. Our research group found that the public believes that lack of access to comprehensive lymphedema care may lead to substantial reductions in quality of life due to both discomfort and pain. This has been demonstrated repeatedly across the various domains evaluated. The public also identifies with the monetary consequences for patients and also recognizes the financial burden of lymphedema on patients. This burden has been found not to be limited to productivity time lost only, but also includes significant
Yasser Almadani MD MSc is a plastic and reconstructive surgery resident at McGill University Health Centre (MUHC). Hedi Zhao BSc is a graduating fourth year medical student at McGill University with a strong interest in surgical research. Anna Towers MD, FCFP leads the multi-disciplinary team at the McGill University Health Clinic (MUHC) Lymphedema Clinic, Montreal, Canada. Joshua Vorstenbosch, MD PhD FRSCS is an attending plastic surgeon at the McGill University Health Centre (MUHC), an Assistant Professor of Surgery at McGill University and leads the surgical lymphedema program at the MUHC, providing cutting-edge surgical treatment to patients affected by lymphedema.
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Summer 2022
out-of-pocket expenses that may sum up to 10% of median Canadian income according to the public as identified by our research group. As many readers are aware, lymphedema affects more than one million Canadians, however, available provincial resources frequently fall short of what’s needed to address the existing resource gap6. The most important highlight from our group’s validated questionnaire was the broad public support for comprehensive lymphedema care. The large number of responders who participated were demographically comparable to the 2020 US census bureau results. The respondents clearly recognized the burden lymphedema poses on the quality of life of patients and this needs to be matched with public health policy reforms. It is of note that the majority of respondents where healthy members of the public. Our data also highlights the need for further awareness to build momentum for comprehensive lymphedema care. We found that members of the public who were familiar with lymphedema were more likely to support legally mandating comprehensive coverage for lymphedema
and statistically less likely to support current coverage models or not providing coverage for lymphedema care compared to participants who were not aware of lymphedema. Furthermore, our group uncovered the respondent’s impressive understanding of the psychosocial health and economic implications of lymphedema. Importantly, our group uncovered broad support amongst the public for a healthcare policy that provides comprehensive funding for lymphedema care given its significant burden. Our research group is actively gauging the public’s view, in addition to other stakeholders such as lymphedema patients and health care providers. With renewed interest in surgical management options for lymphedema, the disconnect becomes more apparent, with many patients needing to be connected to a multidisciplinary team of health care professionals to support them throughout their journey. In addition to public opinion research, our group has adopted a unique approach to starting a comprehensive multidisciplinary approach from the ground up. The aim was to connect all the dots and bridge
Our research group leveraged the power of crowdsourcing to assess whether the public accurately perceived the burden of lymphedema. gaps in a previously fragmented approach. The roles played by physiotherapists, specialist nurses, psychologists, basic science, and clinical researchers cannot be overstated, and adding lymphedema surgery as another option in their armamentarium can put more odds in favour of lymphedema patients. Our group has begun to establish our program by introducing a comprehensive lymphedema care clinic. We are working hand-in-hand with all other lymphedema experts to seamlessly add surgery into the longitudinal lymphedema treatment plan. We also identified the most common causes of lymphedema in our health care system and collaborated closely with the Breast Center Clinic to develop post-operative care/
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Summer 2022
Ly m p h e d e m a p a t h w a y s . c a 9
compression guidelines. This ensures multidisciplinary longitudinal follow-up on both ends, in addition to ensuring surgical indications for lymphedema surgery are made widely available. We believe provincial governments should take inspiration from other countries and start moving toward some form of comprehensive lymphedema coverage; in doing so they should also consider ways to integrate various health care providers to provide more competitive and efficient care. Policy initiatives along those lines could yield major payoffs, in terms of both equity and efficiency. A strong case can be made for an expanded government role in financing lymphedema care in Canada. The government programs that currently exist fall short of what’s needed, and while many Canadians have some access to lymphedema care, it tends to be limited in scope and fragmented in nature. Our research identified a reasonable level of support for income supplementation for eligible patients who face significant losses in their productivity
as a result of lymphedema. Many favoured a health care model that covers all costs associated with lymphedema and perceived it to be the most equitable coverage model. It’s a strange truth of Canadian public policy: the treatment of breast cancer is well covered by public funding, but lymphedema care remains limited and faces many shortcomings. This approach to lymphedema health care is a costly oversight for the public purse. A mounting body of evidence indicates that the costs associated with frequent emergency room visits, repeated infections, and clinic visits could certainly outweigh any added costs from adopting more comprehensive lymphedema care.7,8 There are welcome signs that the climate may be warming towards a greater public policy role in lymphedema care due to the great efforts of many advocacy groups. Our data indicate that the more the public knows about lymphedema, the higher the likelihood they would support comprehensive lymphedema care. Like many other countries around the
world, Canada faces challenges providing for the most vulnerable segments of its population (e.g. seniors, low-income populations, people with special needs, children, Indigenous peoples, new immigrants with refugee status, etc.) and the role of advocacy groups is integral to bringing these issues to the public’s view and improving their awareness. Our group work will continue to focus on furthering our understanding of the key drivers for support for lymphedema care amongst the general public, healthcare professionals, and patients. We believe intersections in views and opinions between these unique groups may provide fertile common ground that could pave the way for a better understanding of what “ideal” lymphedema care could be. Lymphedema is a lifelong, multifaceted challenge for patients and continued research into the various facets of this challenge will always be needed. LP A full set of references can be found at www.lymphedemapathways.ca
For more information about this particular research, visit https://www.mcgill.ca/plasticsurgery/joshua-vorstenbosch-md-phd-frcsc
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DECONGESTIVE THERAPY
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Ask The Expert
Lipedema management Tobias Bertsch MD is the Senior Consultant at the Foeldi Clinic in Germany, European Centre of Lymphology and founder of the European Lipoedema Forum who produced the International Consensus Document on Lipoedema.
Q
What would be the optimal protocol for the management of lipedema? The therapy for lipedema has to focus on the real complaints of the patients, which are: • pain in the fat tissue of the legs • psychological burdens such as depression, eating or anxiety disorders or chronic stress syndrome • obesity and weight gain • lack of self confidence because of our current beauty ideal which prefers thin legs For this reason the International Consensus Document suggests this therapeutic concept. 1 Physio- and movement therapy 2 Compression therapy 3 Psychosocial support 4 Weight management (including bariatric surgery for severely obese patients with lipedema) 5 Self-management 6 Liposuction, under certain circumstances. https://theila.net/fileadmin/user_upload/ ILA/JWC_Consensus_Lipoedema.pdf ____________________________________________
Q
How effective are compression garments in the reduction and maintenance of lipedema if a buildup of lymphatic fluid is in fact not the cause/issue? This is correct, there is no lymphatic insufficiency in patients with pure lipedema. But compression has an anti-inflammatory impact on the fat tissue of the legs (same as movement therapy) and therefore can reduce the complaints of the patients. Summer 2022
We know this from data from phlebology and from sports medicine. ____________________________________________
Q
Does MLD have a role for lipedema patients to stimulate the parasympathetic nervous system, thereby helping with pain control? This is a hypothesis, but indeed, we do not have any scientific evidence to support this statement. ____________________________________________
Q
Why do many lipedema patients not tolerate compression? In my experience (and in the experience of my colleagues at the Foeldi Clinic) the opposite is true. Patients with lipedema love their compression stockings. Some are willing to make the 8-hour drive to receive well-fitted compression stockings at the Foeldi Clinic. ____________________________________________
Q
If you do not want to use the term lipedema, how would you describe this disease? You are correct, there is no edema in lipedema, so the term is misleading. I would suggest “lipalgia syndrome”, because there is pain—and many other issues that our patients are suffering from. Currently an international renaming process has started. ____________________________________________
Q
So then what is lipedema— what is the cause of the pain? Is it majority mental based? What is the self-management? The two major criteria, according to the International Consensus Document are disproportional fat tissue in the legs (sometimes in the arms) plus complaints like pain in this fat tissue. Regarding the cause: there is a mild (and harmless) inflammation in this fat tissue, which causes a mild pain. But psychosocial issues like depression, chronic stress and others can increase this pain because of increased pain perception. We know this phenomenon very well from other diseases. Self-management means providing patients with the skills to transfer and maintain their therapeutic results and maximize function. ____________________________________________
Q
For a lipedema client, what compression do you recommend? Usually, I prescribe flat knit material and mostly two-piece garments, like Capri and knee stockings. Class 2 is perfect for lipedema patients, and never more if it is pure lipedema (meaning lipedema without any lymphedema). LP L y m p h e d e m a p a t h w a y s . c a 11
Advocacy
Inequities in garment funding across Canada Where are we in 2022? By Mona Al Onazi, Erica Park, Michelle Phung
I
n 2017, the Canadian Lymphedema Framework (CLF) published the results of a Canada-wide survey to provide insight on the reimbursement of lymphedema supplies and treatment services across Canadian provinces. At the time, considerable disparity was found, with some provinces providing full public funding for supplies and treatment, and others not providing any coverage at all. This article provides an update to the 2017 reimbursement document specific to the funding of compression garments, compression bandaging supplies, and nighttime compression systems to support self-management.
For many Canadians, access to funded lymphedema supplies can make the difference between having good control of their condition, or not. The problem It is estimated that over 1,000,000 Canadians live with lymphedema or chronic edema.1 Once lymphedema develops, the journey with this lifelong condition begins. To best control lymphedema, individuals with the condition require ongoing monitoring and adherence to self-management strategies such as skin care and compression therapy.2 If left untreated, lymphedema is a progressive condition.
Symptoms are common and include pain, fatigue, and limb tension and heaviness—symptoms FIGURE 1 that can further lead to psychological distress, and reduced self-esteem and quality of life.3,4 In advanced stages of lymphedema, the skin Basic supplies recommended for lymphedema management. becomes hardened and compression system) to daytime use of a has a leathery feel, and is more compression garment for individuals with prone to wounds and infection.5,6 Cellulitis breast cancer related lymphedema in the (a skin infection) is common, and may lead maintenance phase of treatment.11 to systemic (entire body) illness requiring Good adherence to a prescribed selfurgent medical treatment and even management routine is critical for long-term hospitalization.5,7,8 Given that there is no control of the swelling and to avoid episodes of cure for lymphedema, proper management is cellulitis.2,12 However, an individual’s ability to critical to prevent progression of the condition, adhere to self-management is also dependent and to lessen the impact on the individual’s on access to needed supplies such as daytime quality of life and overall health.2 compression garments, bandaging materials, Lymphedema management involves an and nighttime systems.12 The cost of these intensive treatment phase to reduce the items is not insignificant, and is a known swelling, followed by a maintenance phase of barrier to effective lymphedema care.13,14 For self-management.2 During the maintenance example, a single compression garment costs phase, best practice recommendations stress in the range of $150 to $600 CAD. Current a self-management regimen that includes clinical guidelines recommend provision of skin care, use of a daytime compression four garments per year;9 thus, the annual cost garment, application of multilayer bandaging of daytime garments alone, for a single limb, as needed, good weight management and can range from $600 to $3000. If not covered regular exercise.9,10 A recent Canadian study by the public health care system or private provided evidence to support the benefit insurance, the individual must pay out of of the addition of nighttime compression pocket, and this type of ongoing expense may (through self-bandaging or use of a nighttime
Mona Al Onazi BScPT, MSc, CLT, is a doctoral candidate in the faculty of Rehabilitation Medicine at the University of Alberta. Mona’s clinical practice and current research interests involve breast cancer related impairments, including lymphedema. Erica Park BSc is a recent Bachelor of Kinesiology graduate from the University of Alberta. She completed her practicum as an Exercise Specialist at the Cancer Rehabilitation Clinic. Michelle Phung BSc is an undergraduate kinesiology student at the University of Alberta.
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TABLE 1
REIMBURSEMENT ACROSS THE CANADIAN PROVINCES - 2022 Component
British Alberta Saskatchewan Manitoba Ontario Quebec New Nova PEI Newfoundland Columbia Brunswick Scotia & Labrador Daytime compression garments Inclusion
PostPrimary and Primary and Primary and Primary and Primary and mastectomy Secondary LE Secondary LE Secondary LE Secondary LE Secondary LE and lumpectomy
Coverage %
100% sleeves 75% of 100% 100% for low 75% of garment 75% adult up 100% for low 100% for low None 100% for low (based on income benchmark income only cost based on to a governincome only income only income only & annual price list of approved ment maximum based on PharmaCare garments and assessment limit prior to 100% for manufacturers 100% paediatric receiving full low-income and low-income coverage) only 100% for Glove/gauntlet low income $150 maximum for ready-made & $300 maximum for custom garment
Primary and Secondary LE
Primary and None Secondary LE
Primary and Secondary LE
Number 2 garments and 3 ready-made 4 daytime 6 garments per 3 per affected 2 ready-made 1 per year None 2 per year for per year gloves/gauntlets garments garments limb per year limb ready- those who qualify. (garment and made or custom Both upper and OR glove) per limb and lower, custom and non-custom 2 custom 6 for children compression garments per 3 standard or affected limb custom garments for the trunk Details
Annually: 1 VELCRO® garment per fastened limb can be devices are replaced with are also covered. a VELCRO® 2 per limb wrapped per year. system
Additional: 1 non-elastic compression garment (e.g. VELCRO® wrapped system)
Custom 2 set ups compression every garments and 2 years compression wrap should meet specific criteria
Paediatric patients assessed for eligibility and need
Accessories: garment glue or donner or rubber gloves (1 per limb)
Multilayer compression bandaging Compression No Yes Yes Yes No Yes Yes Yes No multilayer (if patients are (if patients are (unless patient (if patients are (if seen by bandaging seen at public seen by seen by seen at a public Homecare) hospital only) Homecare) Homecare. hospital only) Eligibility varies by region)
Yes (if seen by hospital or community based clinics)
Types of Coban 2; Bandaging Coban 2 Variable 1 set of Short stretch Coban 2 bandaging tubigrip/ supplies: provided if multilayer bandage and provided if supplies flexigrip/ foam, artiflex, treated by compression foam/cotton treated by surgigrip; short-stretch Homecare bandages padding Homecare edema wear: bandages, per limb foam; stockinet; swell spots moisturizers and scar pads Include: and cleansers Comprilan, Accessories/ Cellona, foam, 2 sets of supplies: stockinette, Comprilan with gel sheets, Coban 2, short- comfort layer adhesives, stretch bandages for patients who stocking self-bandage applicators, donning gloves
Coban 2 plus certain products related to wound care and edema covered through hospital or community based clinics Patients attending private clinics purchase their own bandaging supplies
Nighttime compression garments Nighttime No No Yes – for clients No Yes - can replace Yes compression with stage 2/3 one of the garments lymphedema set ups above Number and Not applicable 1 per limb Frequency every 2 years Summer 2022
Yes – can No No replace one of the set ups above
Based on clinical assessment and need
1 per limb 2 per year for per year those who qualify. 2 per child Both upper and per year lower, custom and Trunk and neck non-custom garments – if approved L y m p h e d e m a p a t h w a y s . c a 13
For more detailed explanations including wound care inclusions refer to references@pathways.ca
be prohibitive. For many Canadians, access to funded lymphedema supplies can make the difference between having good control of their condition, or not. Methods To update the CLF’s 2017 reimbursement document, we first searched websites for government funding programs and provincial lymphedema associations across Canada. We abstracted information related to provincial healthcare coverage of supplies and equipment provision for lymphedema. We then contacted provincial lymphedema associations and specialist lymphedema clinicians in each province to verify the data collected and to obtain further details. Findings Based on our updated data, there is still
significant variation in reimbursement of lymphedema garments and supplies across Canada (Table 1). For example, an individual with lymphedema who happens to live in Saskatchewan would receive full coverage for two compression garments every six months or four garments a year—a level consistent with best practice recommendations. On the other hand, an individual with lymphedema in Nova Scotia would receive coverage for two compression garments a year but only if they were classified as low-income residents on government assistance. Bandaging supplies are provided for individuals who reside in Alberta, Saskatchewan, Ontario and Quebec; however, access to supplies may be dependent on where the individual receives treatment. Nighttime compression systems are available to those living in Saskatchewan, Ontario and Quebec, and for those classified as low-income in
New Brunswick. The provinces of Quebec and Saskatchewan provide additional funding for accessories such as garment applicators and gloves to support proper donning of a compression garment. Figure 1 (page 12) lists the provision of basic supplies needed for lymphedema self-management and maintenance. Conclusion All Canadians with lymphedema need access to the necessary garments and supplies to support self-management, regardless of their location of residence. Identifying this type of inequity in reimbursement across the country supports advocacy efforts. LP A full set of references can be found at www.lymphedemapathways.ca
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Supporting Self-Care
There is a mobile app for everything– including lymphedema By Anna Kennedy
The use of mobile apps in general healthcare and eHealth has risen substantially in the past few years. We can assume that the number has increased even more since the Covid-19 pandemic. Restrictions forced health professionals to find creative ways to stay in touch with their patients and patients had an increased need for self-management.
U
nder the category of healthcare, there is mobile software that diagnoses, tracks or treats disease (typically used by health professionals) and there are wellness apps that enhance or track the overall health of the user and/or provides educational information to help manage overall health. Benefits of mobile apps Mobile healthcare apps provide the convenience that patients value and the opportunity to have more control over their health. In the digital age, we have (what feels like) the world at our fingertips. We have access to endless information. Patients are turning to their smartphones more than ever for health advice, video call examinations, prescriptions, and to track their overall health. Mobile healthcare apps for patients with chronic diseases such as diabetes, obesity, and heart disease provide
data that can change their lives for the better. Access to apps that track their daily numbers and progress allows patients and their healthcare providers to better identify treatments. This is only a small example of the list of benefits these apps have for users and healthcare providers alike. The use of apps for some diseases has become very readily available. However, the number of apps related to supporting lymphedema care are few and far between. We scoured the Internet to find those most relevant to patients and their healthcare providers. For the purpose of this article, we will concentrate on those that support either lymphedema therapists or patients. The Editorial board does not endorse the use of any specific apps and presents this article for reference only. The use of these apps should never replace the advice of a health
Anna Kennedy is the Editor of Pathways Magazine and lives with secondary lymphedema in her leg. In 2012 she was awarded the Queen’s Jubilee Award for her contributions to the lives of Canadians.
16 L y m p h e d e m a p a t h w a y s . c a
professional, but rather support the care provided by them. Targeted to patients Patients usually download healthcare apps to learn more about their condition and its causes, and to take action based on the available opportunities. It’s important that apps provide interactive tools to keep users engaged and feel that they are receiving individualized care. The following apps can be valuable tools in managing self-care for lymphedema by providing educational information tracking self-measurement and progress and accessing resources such as trained lymphedema therapists. Look4LE This mobile app, developed and funded by the American Lymphedema Framework Project (ALFP), is designed to help patients and families find therapists in their areas who are trained to treat lymphedema. The app, launched in 2012, currently features over 1400 LANA-certified therapists, Summer 2022
and therapists with a minimum of 135 hours of lymphedema training—and the list is constantly growing. Eligible therapists are encouraged to add their name to the list and provide their contact information, including phone number, email address, and website to be displayed on a personal profile page. In addition to providing links to a variety of resources about lymphedema, the app allows users to search by name or geographic location (using their current location, city or zip code) to identify certified lymphedema therapists in their area. Additionally, users can get directions
to the specialist or even add the information to the system address book. This application is a wonderful resource for patients looking for a specialist, traveling patients looking for treatment centers, or physicians and therapists looking to refer to a qualified therapist. Target audience: Patients Produced by: American Lymphedema Framework Project (ALFP) Availability: In English only. This app is free of charge and can be downloaded to an iPhone, iPad or Android from the APP store. Lymphatrack
Patients are turning to their smartphones more than ever for health advice, video call examinations, prescriptions, and to track their overall health. This app provides a platform for users to take an active role in managing their lymphedema by helping to track their lymphedema home treatment program. This app allows patients to record key lymphedema symptoms and treatments that create graphs and charts to monitor progress over time. Messaging applications allow patients to share their progress with their medical practitioner, family or friends. Customization allows users to select parameters that are relevant to them and that they wish to record. Options include: limb circumference, body weight, skin colour changes, pain, activity level, compression garment use, self-lymphatic drainage, pneumatic compression use, wound size,
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medical status change. Users can also customize the notifications reminding them to enter data on particular days. Target audience: Health professionals and patients Produced by: LymphaPress (Mego Afek – Israel Pharmacetical Company) Availability: Free app available in English, Spanish, German, French and Russian versions. Available on Apple iOS via the App Store and in an Android version via Google Play. LymEx
This app focuses on education, providing information organized into four key messages. 1. Skin care: how and why to care for skin and nails 2. Simple lymphatic drainage: arm, leg and head and neck massage sequences 3. Garment care: Tips for wear and care 4. E xercises: Reasons for exercises and examples of lymphatic circulation exercises Although never meant to replace the education provided by health professionals, this app can be useful to reinforce individualized education that would normally be provided by lymphedema therapists. Target audience: Patients Produced by: Lymphoedema Support Network and Lymphoedema Network Northern Ireland. Availability: In English only. Free app available eon Apple iOS via the App Store and Android via Google Play. Stanford lymphedema This application is designed specifically for patents who are preparing for lymphedema surgery. Award winning, nationally recognized, Dr. Dung Nguyen of the Division of Plastic 18 L y m p h e d e m a p a t h w a y s . c a
Surgery at Stanford, has created an all new experience to help patients get ready for their lymphedema surgery. Keeping track of upcoming tasks for the patient is a breeze. A customized timeline will help patients prepare and be notified if they have forgotten anything. There are tips and information cards that are designed to help understand and plan stress free for surgery. Target audience: Patients scheduled for lymphatic surgery Produced by: Stanford University Availability: In English. Available on Apple iOS via the App store. Sitting workout
This simply guided workout features exercises for legs that will tone quads, hamstrings, glutes and abs, but at the same time claims to make you sweat and burn calories. Ideal for patients who have difficulty performing regular exercise due to mobility problems etc. as they can participate in this workout from a chair. Target audience: Patients Produced by: unknown source Availability: In English. Free app available on Android only.
LymVol – Lymphedema Limb Volume Calculator LymVol has been specially designed and developed to help lymphedema professionals measure and calculate the limb volume of unilateral or bilateral limp lymphedema into a limb volume calculation. The method of calculation used in this application is a recognized mathematical and medical standard for measuring limb volume. It is calculated through the measure and addition of cylindrical 4cm sections of both the distal and proximal for each limb.
The app also includes a BMI calculator and a complete set of instructions on how to measure limbs accurately and effectively. Results of calculations include: distal, proximal and total volume(s) for each limb; total excess in mls and as a percentage for affected limb; difference in volume, as a ratio for both distal and proximal; distal/ proximal ratio. Target audience: Health professionals Produced by: Lymphoedema Training Academy Availability: $33.99 available on Android via Google Play. LymphaTech
Summer 2022
This app has received patent in the USA, Canada and Australia for its method of generating pre-fabricated compression garments. According to their website, this app provides fast, accurate and reliable 3D imaging and measurement to monitor the progression of geometric changes of limbs by detecting subtle changes in volume and circumference without the use of a tape measure. They claim their system is 99% accurate compared to water displacement for volume and tape measure for circumference. They also state that since no special training is required, this technology can provide easy scanning at home to increase the frequency of monitoring. Target audience: health professionals, fitters and patients Produced by: LymphaTech Inc. (Atlanta, Georgia) Availability: Contact the manufacturer noted on website www.lymphatechnology.com. Conclusion There are also a number of industry commercial applications designed to support patients and health professionals in lymphedema treatment. We also came across numerous mobile apps for wound care. With the growth of mobile phone usage, apps to support healthcare delivery to people living with lymphedema presents a huge opportunity to provide convenient and accessible methods for information delivery and self-management support of this chronic disease. The need to continually update their programs in order to comply with updated software and hardware releases however, presents challenges for developers. That affects the consistent availability of the apps and is likely the reason that a number of apps are unfortunately no longer accessible. It is disappointing that there are not more mobile apps available for lymphedema. We hope that both private and public funding will designate resources to create more mobile phone apps to support the lymphedema community in the future. We hope that innovative ways to make managing lymphedema from the comfort of your home will make all our lives easier. LP Acknowledgements Thanks to Rachel Li, CLF Communications Coordinator for contributing to this article by scouring the Internet to find relevant mobile applications. For a full list of the apps available and the link to their websites, please refer to: canadalymph.ca/pathways-references
Summer 2022
Letter to the Editor... _______________________________________________________________________________________________________________________________________
I would like to share my thoughts regarding an advertisement for Lymphatic Lifestyle Solutions in the Spring 2022 issue of Pathways (page 13).
_______________________________________________________________________________________________________________________________________
First of all, I totally agree that reducing one’s weight will significantly reduce the risks of having lymphedema. Obesity is one of the major _______________________________________________________________________________________________________________________________________ contributing factors of lymphedema, among other factors of course. _______________________________________________________________________________________________________________________________________ Some of your readers might be like me, with lymphedema _______________________________________________________________________________________________________________________________________ but had to live many years wondering what was wrong with one of their legs, _______________________________________________________________________________________________________________________________________ why was it so heavy when the rest of our body was ‘’normal.’’ I listened to my _______________________________________________________________________________________________________________________________________ doctors’ advice and started so many diets. A long history of a yoyo lifestyle, frustration, bigger and bigger leg and always, at the end of a ‘’diet’’ my weight _______________________________________________________________________________________________________________________________________ was higher than when I started. _______________________________________________________________________________________________________________________________________ In my early fifties, my gynecologist was able to have me accepted at _______________________________________________________________________________________________________________________________________ an obesity clinic and I was very happy to have a full team to help me with _______________________________________________________________________________________________________________________________________ nutrition, exercise, CPAP (life changing), weekly meetings, medical tests and _______________________________________________________________________________________________________________________________________ psychologists. Nothing was left for granted. I lost the first 40 pounds very _______________________________________________________________________________________________________________________________________ easily, but I was still battling my third summer with cellulitis episodes that made me, in a last effort, talk to my family doctor. I asked him what he could _______________________________________________________________________________________________________________________________________ do. I was losing weight everywhere on my body except my legs. Realizing _______________________________________________________________________________________________________________________________________ this, he consulted with a vascular surgeon: the next day I was diagnosed with _______________________________________________________________________________________________________________________________________ lymphedema, stage 4. _______________________________________________________________________________________________________________________________________ In the span of three days, I had met a certified lymphedema therapist, _______________________________________________________________________________________________________________________________________ had the shock of learning I had lymphedema tarda, trying to grasp what lymphedema was and realized I would have to wear compression for the _______________________________________________________________________________________________________________________________________ rest of my life. The light at the end of the tunnel was the end of my cellulitis. _______________________________________________________________________________________________________________________________________ After one week, I could wear almost normal shoes, had no more cellulitis and _______________________________________________________________________________________________________________________________________ was learning everyday self-management. _______________________________________________________________________________________________________________________________________ Fast-forward six years. I have lost 126 pounds to date and am still losing _______________________________________________________________________________________________________________________________________ more. I may still be overweight but my biggest victory is that I am continuing _______________________________________________________________________________________________________________________________________ to lose weight. No miracle drugs. No surgery. No fad diets. Simply good food bought at the supermarket, following the Canada Food Guide, follow-up _______________________________________________________________________________________________________________________________________ with a nutritionist, self-management with my lymphedema therapist and the _______________________________________________________________________________________________________________________________________ support of my provincial lymphedema association. _______________________________________________________________________________________________________________________________________ Be careful of any diets that may work for a certain time but are not easily _______________________________________________________________________________________________________________________________________ maintained for a long period. Having lymphedema is expensive so patients _______________________________________________________________________________________________________________________________________ should be careful about spending their money on diets and diet pills. I am happy for all your readers for whom those diets worked; more _______________________________________________________________________________________________________________________________________ power to you. But I deeply know that many of your readers are like me; they _______________________________________________________________________________________________________________________________________ simply tried everything, including Keto, and could not maintain it, until they _______________________________________________________________________________________________________________________________________ are taken in by an obesity clinic, and treated as obese patients. Obesity is a _______________________________________________________________________________________________________________________________________ disease and should be treated by specialists. Talk to your doctor; ask for a ______________________________________________________________________________________________________________________________________ consult at an obesity clinic. _______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Marie-Claude Gagnon, Executive Director Lymphedema Association of Quebec
_ _____________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________
L y m p h e d e m a p a t h w a y s . c a 19
Helpful Suggestions
Hints and Tips Protecting your compression garments Compression is the optimal intervention to manage lymphedema and for many patients, the costs associated to wearing compression represent a large investment. To maintain your compression garments for the longest period, follow these guidelines. 4 Frequency - Hand or machine wash (warm) daily to not only maximize the therapeutic effectiveness (by resetting the elastomer) but also prolong the life of your compression garments. 4 Temperature - Use the lowest temperature for hand washing, the washing machine and dryer. Follow the manufacturer’s recommendations about air-drying or using the dryer. A garment bag is recommended to prevent snags from zippers and other closures. 4 Soap - Use a mild detergent and AVOID bleach, chlorine, fabric softeners or other laundry additives, as these may damage your garment. Do not use fabric softeners.
4 Donning accessories - There are several donning devices that ease putting the stockings or sleeves on and off. These aids include specialized grip gloves, mechanical and steelframe aids, nylon and plastic slides, glide lotions and adhesives to hold garments in place. EDITOR’S NOTE A reminder from 22 years of personal experience living with lymphedema: in addition to wearing compression to stimulate lymphatic drainage, I also wear my compression stocking daily to protect my leg from sunburn, insect bites and any other injury that puts me at risk for cellulitis. It’s become as routine as brushing my teeth both morning and night and makes me feel that I am in control of my lymphedema through self-management. LP
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Did You Know?
Obesity-induced lymphedema
Lymphedema results from inadequate lymphatic function. Extreme obesity can cause lower extremity lymphedema, termed “obesityinduced lymphedema (OIL).” OIL is a form of secondary lymphedema that may occur once an individual’s body mass index (BMI) exceeds 40. The risk of lymphatic dysfunction increases with elevated BMI and is almost universal once BMI exceeds 60. Obesity has a negative impact on lymphatic density in subcutaneous tissue, lymphatic endothelial cell proliferation, lymphatic leakiness, collecting-vessel pumping capacity, and clearance of macromolecules. Lymphatic fluid unable to be taken up by lymphatic vessels results in increased subcutaneous adipose deposition, fibrosis, and worsening obesity. Individuals with OIL are in an unfavourable cycle of weight gain and lymphatic injury. The fundamental treatment for OIL is weight loss. SOURCE: Copyright © 2022 Cold Spring Harbor Laboratory Press; all rights reserved. PMID: 35074795 DOI: 10.1101/cshperspect.a041176
moderate-high quality) were included in the prevention and treatment aim, respectively. Relative risk of developing CRL for those in the exercise group compared with the non-exercise group was 0.90 (95% CI: 0.72, 1.13) overall, and 0.49 (95% CI: 0.28, 0.85) for those with 5 or more lymph nodes removed. For those with CRL in the exercise group, the standardised mean difference (SMD) pre- to post exercise of CRL was -0.11 (95% CI: -0.22, 0.01), and compared with usual care post-intervention the SMD was -0.10 (95% CI: -0.24, 0.04). Improvements post-intervention were observed for pain, upper-body function and strength, lower-body strength, fatigue and quality of life for those in the exercise group (SMD: 0.3-0.8; p < 0.05). CONCLUSIONS: Findings support the application of exercise guidelines for the wider cancer population to those with or at risk of CRL. This includes promotion of aerobic and resistance exercise, and not just resistance exercise alone, as well as unsupervised exercise guided by symptom response. Source: Med Sci Sports Exerc. 2022 Mar 22. Online ahead of print.
Exercise for prevention and treatment of cancer-related lymphedema
The purpose of this systematic review and meta-analysis was to evaluate the effects of exercise on (i) the prevention of cancer-related lymphedema (CRL), and (ii) the treatment of CRL, lymphedemaassociated symptoms, and other health outcomes among individuals with CRL. METHODS: An electronic search was undertaken for exercise studies measuring lymphedema and involving individuals at risk of developing or with CRL. The Effective Public Health Practice Project Quality scale was used to assess study quality and overall quality of evidence was assessed using the GRADE approach. Meta-analyses were performed to evaluate effects of exercise on CRL incidence, existing CRL status, lymphedema-associated symptoms and health outcomes. RESULTS: Twelve studies (n = 1,955; 75% moderatehigh quality) and 36 studies (n = 1,741; 58% Summer 2022
PMID:35320145 | DOI:10.1249/MSS.0000000000002918
Prophylactic use of compression reduces incidence of BCRL arm swelling
To determine whether prophylactic use of compression sleeves prevents arm swelling in women who had undergone axillary lymph node dissection for breast cancer surgery. METHODS: Women (n = 307) were randomly assigned to either a compression or control group. In addition to usual postoperative care, the compression group received two compression sleeves to wear postoperatively until 3 months after completing adjuvant treatments. Arm swelling was determined using bioimpedance spectroscopy (BIS) thresholds and relative arm volume increase (RAVI). Incidence and time free from arm swelling were compared using Kaplan-Meier analyses. Hazard ratios (HRs) were estimated from Cox regression models for BIS and RAVI thresholds independently. In addition, time to documentation
of the first minimally important difference (MID) in four scales of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the breast cancer-specific (BR23) questionnaire was analyzed. RESULTS: The HR for developing arm swelling in the compression group relative to the control group was 0.61 (95% CI, 0.43 to 0.85; P = .004) on the basis of BIS and 0.56 (95% CI, 0.33 to 0.96; P = .034) on the basis of RAVI. The estimated cumulative incidence of arm swelling at 1 year was lower in the compression group than the control group on the basis of BIS (42% v 52%) and RAVI (14% v 25%). HRs for time from baseline to the first change of the minimally important difference were not statistically significant for any of the four scales of EORTC QLQ-30 and BR23 questionnaires. CONCLUSION: Prophylactic use of compression sleeves compared with the control group reduced and delayed the occurrence of arm swelling in women at high risk for lymphedema in the first year after surgery for breast cancer. Source: J Clin Oncol. 2022 Feb 2:JCO2102567. doi: 10.1200/ JCO.21.02567. Online ahead of print. PMID:35108031 | DOI:10.1200/ JCO.21.02567
Management of lymphedema in presence of deep vein thrombosis There is some confusion surrounding the management of people with lymphedema in the presence of deep vein thrombosis (DVT). This may be in relation to the suitability of commencing compression therapy or regarding the continuation of compression therapy in those who develop DVT. The purpose of this British Lymphology Society position paper is to support evidence-based practice and debunk the myths surrounding the management of DVT and lymphedema. Source: Br J Community Nurs. 2022 Apr 1;27(Sup4):S24-S26. doi: 10.12968/bjcn.2022.27.Sup4.S24.
L y m p h e d e m a p a t h w a y s . c a 21
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Research Advances
Education Education
Canadian and International Events October 3-4, 2022 British Lymphology Society Staffordshire, UK The conference highlight will be a debate featuring lympedema experts panel on ‘Manual Lymphatic Drainage – is it time to come off the fence?’ n www.thebls.regfox. com/the-bls2022-conference
e-Learning Course for Healthcare Professionals
Lymphedema and Chronic Edema REHABILITATION MEDICINE Management FACULTY OF
Oct 13-16, 2022 American Vein & Lymphatic New Orleans, LA Society - 36th Annual Congress Theme: Veins and all that Jazz. Registration: In-person and at-home rates. n www.myavls.org/annual-congress-2022 November 17-20, 2022 NLN Cleveland Clinic Cleveland, OH Health professionals, who are currently practicing in lymphatic therapies, will have the option to obtain the NLN Expert Clinician certification during the first day of the conference. n www.lymphnet.org/conference 2022 Dates Canada and USA
Training and Certification Programs C ourses are offered by various educational schools for qualifying healthcare professionals. Some provincial lymphedema associations also organize or host educational courses. Refer to the Canadian Lymphedema Framework’s MARKETPLACE, where you can find links to all the schools and provincial associations. n www.canadalymph.ca/marketplace.
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PATIENTS: share your story CLINICIANS: help debunk myths for the Fall issue https://canadalymph.ca/feedback/ EVERYONE: help us plan for our 2023 conference canadalymph.ca/feedback The Canadian Lymphedema Framework (CLF) wishes to thank these partners for their support in making this magazine a reality.
Pathways is available by subscription either directly from the CLF or as a benefit of membership through one of our Provincial Association partners. www.canadalymph.ca/provincial-lymphedema-associations
CANADIAN LYMPHEDEMA FRAMEWORK
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ABOUT THE CLF: The CLF is an academic and patient collaboration, working to improve lymphedema management for lymphedema and related disorders in Canada. Charitable Registration 85160 1260 RR0001
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