Pathways Summer 2021 (Volume 10, Issue 3) (With Insert)

Canada’s Lymphedema Magazine

Pathways

Acc e Digit ss Edit al ion See p age 4

SUMMER 2021

Empowering patients and professionals

Lymphedema:

A lifelong risk

© GEMMA LEVINE LONDON

Lymphangiography

WHAT’S INSIDE:

Venous and lymphatic disease Awareness/Advocacy

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Hints and Tips

n

Research Advances

n

Patient Perspective

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Editor’s Message

Lymphatics become as natural as “AQUA”

O

ur cover photograph is by Gemma Levine, a world-renowned author and photographer living in London, England.

She has photographed many famous icons such as Anthony Hopkins and Golda Meir.

Her portrait of HRH Diana, Princess of Wales, was the official Palace photograph in 1995.

We appreciate Gemma’s generosity in letting us feature the cover of her new book AQUA as our magazine cover. Her lymphedema related photographs are a unique and abstract way of looking at the lymphatics

The provincial lymphedema associations spent March working on activities to promote lymphedema awareness in their communities. and in her own words…“make lymphatics less foreboding and clinical. It becomes as natural as “Aqua”. You can read about her photographs and where to purchase the book, on page 26 of this magazine. All proceeds benefit lymphedema research.

Studies show that lymphedema is a lifelong risk that increases with age. In a ZOOM interview, Dr. Chen explained this concept in the simplest terms for our readers.

Asymptomatic lymphatic insufficiency reinforces the need for better measurement and diagnosis. Once swelling is recognized, there has usually already been quite a delay from the onset of lymphedema. Earlier diagnosis impacts better treatment outcomes.

Diagnosis using lymphangiography is the focus of Dr. Weiss and Dr. Stilwell’s article.

This type of medical imagery provides insight and a clearer “picture” into how the lymphatics flow, although in Canada it is being used primarily in surgery, and not available to all clinicians. We hope that emerging imaging technologies such as Indocyanine Green (ICG) lymphangiography become more accessible Summer 2021

for lymphedema patients in Canada in the near future.

Chronic venous insufficiency is the leading underlying cause of lymphedema in many countries, including Canada. Dr. Hannah explains the connection between venous and lymphatic issues. Since lymphedema therapists would see patients with both co-morbidities in their practice, they are encouraged to recognize and understand this connection.

The Canadian Lymphedema Framework will have an interesting speaker on this topic at their national lymphedema conference (virtual) in December. Stay tuned.

During COVID, Wanda Guenther experienced new challenges of keeping her patients and herself safe while providing therapy on the front line. PPE, hand washing and so many extra precautions became the new norm. Wanda has since retired after a long career as a certified lymphedema therapist. We are glad she shared her story with us and wish her well in this new chapter of her life.

The provincial lymphedema associations spent March working on activities to promote lymphedema awareness in their communities.

The abundance of proclamations and teal-lit government buildings on March 6, World Lymphedema Day, just keeps growing each year in Canada. Congratulations to the Chairs of the various associations for championing this cause so well and “painting the country teal.”

As part of March awareness in 2020, the CLF targeted their education efforts on physicians. An information card entitled “5 Things Every Physician Should Know” was disseminated to 70,000 members of the College of Physicians and Surgeons through the Canadian Medical Association Journal. Plans were to distribute additional cards at conferences and events across Canada. Of course, COVID changed all that.

We have enclosed the Physician Card with this magazine and encourage everyone to share it with his or her family physician—to help raise awareness. Early diagnosis improves patient outcomes. You can each make a difference by passing it on. Every card counts. LP

Anna Kennedy

IN MEMORIAM: Helmut Dostal It is with a heavy heart that I let our readers know that, sadly, Helmut Dostal, President of BCS Communications Ltd, the publisher of Pathways, passed away on April 8, 2021. He will be sorely missed.

Helmut was by far one of the kindest, gentlest, generous and creative minds I have had the pleasure of working with. He was instrumental in the start of our Pathways magazine, meeting regularly to provide input and guidance; not only in the early days, but year over year, for the last ten years. He was always available for a quick call regarding a question, idea or suggestion. He was the epitome of integrity, honesty and respect. Helmut and his wife Caroline were always very eager to see our magazine grow. They participated in many strategy meetings over the years. His contribution to the Canadian Lymphedema Framework, the legacy he has left behind and the positive impact he had both professionally and personally on so many, will never be forgotten.

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Contents

Lymphedema is a lifelong risk

An interview with Dr. Wei Chen of the Cleveland Clinic.

Summer 2021 n Volume 10 Issue 3

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Publisher Pathways is published four times per year

by BCS Communications Ltd. on behalf of the Canadian Lymphedema Framework.

CANADIAN LYMPHEDEMA FRAMEWORK

Watching the flow

The role of lymphangiography.

..........................................

LANA’s place in the field of lymphology and related disorders

PARTENARIAT CANADIEN DU LYMPHOEDÈME

Editorial Board Angela Dunphy Mei Fu PhD RN FAAN Pamela Hodgson PT David Keast MD FCFP Lori Radke PT CLT Anna Towers MD FCFP Editor Anna Kennedy Editorial Assistants Catherine Andrew Nicole Boulet 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 Photos in this issue: Cover photo: GEMMA LEVINE LONDON Other photos: W. Guenther, CLF PhotoBank, Provincial Chairs, CanStock

Canadian Publications Mail Agreement 40065546 ISSN 1929-1418 Printed in Canada

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5 10

Setting industry-wide lymphedema training standards.

13 16 18

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Canada celebrates Lymphedema Awareness Month How provinces celebrated across the country.

Venous and lymphatic diseases Opportunities for improved care.

Servicing clients from the front-line

Transitioning during COVID-19.

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DEPARTMENTS: Letters to the Editor Hints and tips Did you know?

Canadian and International events

22 24 25 26

FOR SUBSCRIBERS The price of the annual subscription includes both a print and digital copy of Pathways.

Email: digitalpathways@canadalymph.ca

Stay informed digitally Now, when you subscribe to Pathways, either directly or through a provincial association, the digital edition is included FREE! Learn more about added benefits the digital copy offers by sending an email to digitalpathways@canadalymph.ca.

www.canadalymph.ca Summer 2021

Research Advances

Lymphedema is a lifelong risk

volunteers were tested for the peak or maximal lymphatic pressure they can generate in their lymphatic system and researchers found that this ability to generate pressure declines with age. The earliest drop they identified was in people in their 30s. Then in their fourth and fifth decade, this just continued to drop.

This means that for example, a patient with cervical cancer who underwent a hysterectomy, pelvic lymph node dissection and radiation while in her 30s, had no lymphedema or swelling in her 30s, 40s, or 50s—she may still develop swelling in her 60s.

Do we label that patient as having acquired

Photo: newsroom.clevelandclinic.org

Is lymphedema a lifelong risk for anyone who has had breast cancer, gynecological cancer etc.?

Based on our current understanding, particularly in a field as novel and rapidly advancing such as lymphedema treatment, the short answer is yes, lymphedema is a lifelong risk. Cancer surgery and radiation, or any direct traumatic injury that damages the lymphatic system, are all cumulative injuries that diminish our lymphatic reserve.1 Why? Because lymphatic function, like all bodily function, declines with age. Studies, including one from Japan2 prove this. Healthy

Dr. Wei Chen is a professor of plastic surgery at Cleveland Clinic and serves as the head of microsurgery and super microsurgery and co-director of Cleveland Clinic’s multidisciplinary lymphedema center. He is internationally renowned for his expertise in lymphatic super microsurgery, pioneering several procedures for lymphedema reconstruction.

Dr. Anna Towers runs the lymphedema program at McGill University Health Centre (Montreal, Quebec) and is on the Editorial Board of Pathways.

Anna Kennedy (Toronto, Ontario) is the Editor of Pathways magazine.

Summer 2021

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Anna Kennedy and Dr. Anna Towers recently interviewed Dr. Wei Chen, who kindly addressed some patient-related concerns and questions. We appreciate his perspective and enthusiasm to educate patients, therapists and physicians.

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An interview with Dr. Wei Chen of the Cleveland Clinic

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lymphedema (secondary lymphedema) or do we label this as so-called senile lymphedema as a result of progressive decline of lymphatic function with age? Based on our current understanding, it is both. If the patient had not had the cancer operation or radiation treatment, she might have at that age tolerated related decline completely fine and without symptoms, because our bodies have physiological reserve built in. On the other hand, if all she had sustained was cancer treatment-related compromise of lymphatic function, but without the age-related decrease in lymphatic function, she probably wouldn’t have developed lymphedema. So in that situation, based on our current understanding, it’s a mixture of both.

This age-related drop in lymphatic function happens to everyone, even in healthy individuals. We lose bone density, our stamina decreases, our facial skin or collagen decreases, and our metabolism slows down (the list goes on and on). Why would our lymphatic function be any different?

Would you say that this concept applies more to leg lymphedema than arm because of other factors that increase pressure on the legs as people age?

They might have comorbidities such as obesity and varicose veins and just the fact of standing?

Scientifically, we don’t know whether this age related decline is more so in any particular part of the body as this has not been studied. But in terms of the pathogenesis of lymphedema, the legs (compared to say, for example, arms or head and neck) definitely are disadvantaged Ly m p h e d e m a p a t h w a y s . c a 5

What influence does gender have on the lymphatic system?

In the same study2, with a fairly equal distribution of male and female participants, the drop in lymphatic function takes place a lot faster in females. In males, we also saw a drop starting at age 30, but this drop slows down significantly from the fourth decade to the sixth decade. And in females, the two curves become divergent by around age 40. So females continue to drop in almost a linear pattern, whereas the males’ lymphatic function decline slows down. We don’t know whether there are other factors at play, but this is at least one significant factor why we tend to see this female predominance in lymphedema.

Can you explain asymptomatic lymphatic deficiency in layman’s terms?

That’s a very important concept.

There’s a difference between having a detectable lymphatic defect versus having asymptomatic disease. And that’s why I 6 Ly m p h e d e m a p a t h w a y s . c a

That measurement will change depending on whether you measure first thing when the patient gets up, or at the end of the day, and what level of compression the patient is using etc. When did they remove their compression garment before you performed the measurement? Weather and diet etc. also have an impact. So there are too many things that negatively affect volume-based measurement.

But let’s say assuming volume-based measurement is reliable, even so, a key

concept is that swelling is a late symptom.

From the time when the patient developed a detectable lymphatic injury to the time when the patient becomes symptomatic, which has been defined as having swelling, it’s not uncommon that there is a significant lag time.

So the injury has been there for a while and our body starts to try to compensate. We can see that on indocyanine green lymphography.

Our body would sprout all these compensatory pathways, almost similar to peripheral vascular disease when there is a blockage in one of the main arteries, and our body sprouts all this compensatory neovascularization, trying to compensate. We only start to break down with an ulcer in the foot when the body decompensates, when the body has given up, saying, “this is it, this is beyond what I can do.”

The same thing happens with lymphedema.

So when we see swelling, we’ve already lost ground. This underlines the importance of LYMPHA or so-called prophylactic or preventative LVA surgery. Many lymphedema surgeons are objecting to the term prophylactic or preventative because the pathology is already there. It’s just that the patients don’t have symptoms yet; they’re not swollen yet—but that is the best time to intervene. Of course, the success of LYMPHA is dependent on lots of other factors like the experience of surgeons etc. But putting that aside, I think most surgeons would agree that the outcome of LVA at that time point is in general quite favourable

Lymphaticovenular Anastomoses: A) Marking the superficial veins of upper extremity with the Veinsite (VueTek Scientific®, Gray, ME). B) Vein marking with marking pen as viewed through the Veinsite. C) Upper extremity with veins (dotted lines) marked.

Summer 2021

Photo: scitemed.com

because of the legs’ dependent position.

Several other risk factors; weight and coexisting venous insufficiency, are all adverse factors that will further burden or directly injure the lymphatic system. And the effects on the legs are definitely more so compared to other parts of the body, again, because of the legs’ dependent position. So in terms of pathogenesis, I think the legs are hit harder.

But concerning age-related decline, whether it happens more so in the leg, that we don’t know and we can’t say. I would speculate, probably not. There is no reason to think that would be the case, although I think we all know that once the disease conditions are in place, lymphedema is a disease process that progresses and propels itself. I think the leg would advance faster for the reason we’ve just discussed.

Photo: Georgia Research Alliance

This age-related drop in lymphatic function happens to everyone, even in healthy individuals.

always discourage diagnosing lymphedema with circumference measurement or any volume-based measurement. Among volumebased measurements (3D scanning, water displacements, circumference measurements, etc.), the worst is circumference measurement because it has such a high inter and intra– rater error. But even the best volume based measurement, 3D scanning, provides you with only a snapshot of how the patients are doing at the exact time of measurement.

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From the time when the patient developed a detectable lymphatic injury to the time when the patient becomes symptomatic, which has been defined as having swelling, it’s not uncommon that there is a significant lag time.

compared to the therapeutic LVA, which when performed properly still has a very favourable outcome as well. Relatively speaking, LYMPHA, which is intervening at a much earlier time point, has a more favourable prognosis.

How is the process of lymphatic insufficiency different in primary versus secondary lymphedema?

There are several differences. The first difference is that in secondary lymphedema, there is no underdevelopment or hypoplasia.

There is a blockage, which based on our current understanding, causes backflow or lymphatic hypertension, similar to that of a garden hose being pinched. The elevated pressure in the “hose”, will in turn damage the lymph channels. And this damage in lymph channels results in loss of this pump function (or the peristalsis of the lymph vessels), and that further builds up a further increase in lymphatic pressure. It’s a vicious cycle. And from that point on, there is progressive loss in the lymphatic pump function causing further damage and pathogenesis.

Whereas in primary lymphedema, there is underdevelopment, with the degree of hypoplasia varying from patient to patient.

Conceptually, you can imagine that someone having 20% of their lymphatic system missing will have disease progression behave very differently compared to someone who has 60% missing. How they would respond to manual lymphatic drainage would also be very different. If you try to perform LVA in the ones with only 20% deficiency (meaning 80% of the lymphatics are developed), it would be

quite easy to find lymphatic vessels. Whereas someone, for example, who has only 10% of the lymphatic system developed has severe hypoplasia, and we’re going to have a very difficult time finding any lymphatic tissues for us to work with.

Another implication is that the current prevalence of asymptomatic primary lymphatic insufficiency is unknown. Most clinicians are unaware of asymptomatic primary lymphatic insufficiency but it is important for them to start recognizing this. How did we initially become aware of this entity? We have patients coming to our clinic with the diagnosis of acquired lymphedema, and when we asked them, “How did you acquire your lymphedema?” patients would say, “I sprained my ankle, and after that I developed lymphedema.”

Or “I developed lymphedema after my knee replacement”. But based on our understanding of lymphatic physiology, we know the lymphatic system is much more robust and such injury would be insufficient for pathogenesis.

Without predisposing conditions and by themselves, those mechanisms are insufficient

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What is the prevalence of primary lymphedema, as you understand it?

We don’t know. Textbooks are saying primary lymphedema is rare, but I can tell you from what I see, it’s not rare. Of course at the Cleveland Clinic I see a selected patient population and, therefore, my practice may not be representative. But in my practice, patients with primary lymphedema Summer 2021

I’ve heard you suggest that traditional classification of primary lymphedema be discarded.

That’s actually my personal opinion and shared by some others. Peter Mortimer’s group in England looks at different classification from a genetic testing standpoint; whether the primary lymphedema is syndromic, whether there is visceral involvement. But that really gets into another big topic. I think in general, they are in agreement with us in that the older classification really carries very little meaning and it reflects our lack of understanding in the past. Whether onset for primary lymphedema is around the age 35, before or after 35... is inconsequential because we are not treating the patient any differently.

While the age 35 specification is inconsequential, the age of onset in. does in fact have r ve de e e .r w meaning.

The timing ww Photo: of swelling has to do with the time when there is an imbalance between lymph production and lymph drainage. This means that if someone develops swelling in her 50s, it tells us that for 50 years, this patient has sufficient lymphatic drainage, compared to another patient who is swollen at birth and therefore already insufficient. How do these two patients compare? The one who was swollen at birth most likely had even less lymphatic function, more severe hypoplasia so that even at birth she had insufficient amount of drainage to meet the need.

Whereas someone who had a much later onset, she is fairly well developed in terms of the lymphatic function. So based on what we have seen, the age of onset does imply severity.

Most clinicians are unaware of asymptomatic primary lymphatic insufficiency but it is important for them to start recognizing this.

Photo: CLF PhotoBank

represent approximately 40% of my patients.

Breast cancer related lymphedema really isn’t the majority. It’s just that the breast cancer patient population in general is a more vocal group, which is a good thing, and they also tend to receive more attention from the media. That unfortunately results in underexposure of other patients.

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to cause lymphedema. So when we hear that history, we should always suspect primary lymphedema. Our subsequent protocol requires that we study all four limbs, both arms and both legs. For a patient who sprained her right ankle and developed right leg lymphedema, we would also study the left leg and both arms. And we consistently found in a patient with that type of history, not only that their right leg has lymphedema, their left leg and both arms were also abnormal, although they were without symptoms. So based on this consistent finding, we drew two conclusions.

First of all, primary lymphedema is a global hypoplasia—there’s no such a thing as primary lymphedema of the right leg. It’s primary lymphedema affecting the patient’s lymphatic system globally. The second conclusion is that now this patient is a “lymphedema time bomb” of her arms and her other leg. If, unfortunately this patient also develops breast cancer and has a sentinel lymph node dissection in which the breast surgeon removes two lymph nodes from say the right armpit, this would have been otherwise well tolerated by someone without this entity. But in this patient, she would develop lymphedema. She would likely be misdiagnosed as acquired (secondary) lymphedema. Why wouldn’t she? She had breast cancer and she had lymph node dissection, and she had radiation. But when in reality this patient had primary lymphedema and she probably would have developed lymphedema in the arm eventually anyway because of the age-related decline.

So how then do you suggest lymphedema be staged?

I tend not to focus too much on staging.

Staging systems were created so lymphedema professionals can communicate more effectively with each other. All staging systems describe the same disease. It’s more important to understand the disease process, the disease progression, the natural history of disease, and the pathogenesis than trying to artificially classify them, which is, in my opinion, missing the point. Instead, understand the disease process and think about how to best help the patient. LP References 1. Q in, Evelyn S., Mindy J. Bowen, and Wei F. Chen. “Is the risk of lymphedema life-long following treatment for gynecologic cancer? A case report.” Current problems in cancer 44.4 (2020): 100538.)

2. Unno, N., et al. “Influence of age and gender on human lymphatic pumping pressure in the leg.” Lymphology 44.3 (2011): 113-120.)

Editor’s Note: The second part of the transcribed interview with Dr. Chen will be featured in the Fall issue of Pathways. That article will focus on surgical perspectives including his LYMPHA surgical technique.

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Diagnostics

Watching the flow

The role of lymphangiography

By Elliott Weiss and Moira Stilwell raditionally, the diagnosis of lymphedema has been purely clinical, based on the clinical history and the findings on physical examination. Sometimes one is born with lymphedema (e.g., Milroy’s Disease), or it develops during the teenage years (e.g., Meige Disease), or later in life, (e.g., Lymphedema Tarda). It can also be seen in combination with other congenital conditions. In other cases, lymphedema occurs secondary to conditions such as malignancies (cancer) or infections (most commonly filariasis), among many others.

Originally this condition was considered to be due to a ‘blockage’ or other forms of lymphatic flow malfunction, limiting the transport of lymphatic fluid. With each new medical imaging technology, our understanding of lymphedema evolves.

With the advent of X-ray technology, the use of medical imaging allowed for investigations of the lymphatic system, primarily using a technique called lymphangiography with the procedure called a lymphangiogram. Started in 1952, the original version of this test involved injecting a dye under the skin to map out the lymphatic vessels. It was a very painful technique, using standard X-ray technology, but it was considered the gold standard of imaging and viewing lymphatic flow over the next 40 years.

During that time, nuclear medicine technology developed in parallel with traditional X-rays. Improvements in technology, safety and comfort, led to it replacing the traditional lymphangiogram. In the past, both methods

were seen as binary tests; either you had normal lymphatic flow or not. Nuclear medicine technology has become more sophisticated and is used to diagnose, measure and stage this condition. It is now used to follow the course of disease before and after treatment.

visualization of lymphatic flow over time.

The images may be obtained at various time intervals. This allows for an understanding of the lymphatic flow through the lymphatic vessels. Sentinel node biopsies such as in breast cancer management, use this technology

What is a nuclear medicine lymphangiogram, also known as a lymphangio-scintographic scan (LSG)?

A LSG involves an injection of a sterile medical grade tracer under the skin, typically sub-dermally or subcutaneously. The tracer, which is tagged with a radioisotope such as technetium-99m (99mTc), is picked up by the lymphatic system and normally travels up the lymphatic vessels to the lymph nodes.

A scanning device called a gamma-ray detector measures the radioactive tracer, as it is moves up the limb. The intensity and distribution of 99mTc is tracked and produces an outline of the lymphatic vessels, although typically it is measured in the superficial lymphatic system.

This technology is considered to be a functional imaging modality as it allows for

to stage patients with a known malignancy before surgery.

What was initially used as a static (yes-no) technology is now able to follow lymphatic flow in real time. This allows physicians and surgeons to have a much better understanding of lymphatic function and assist in decision-making.

Photo: centraloregonradiology.com

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Dr. Elliott Weiss, MD FRCPC is a specialist in Physical Medicine & Rehabilitation who is primarily based out of Providence Healthcare in Vancouver.

Dr. Weiss has been involved in the care of patients with lymphedema for over thirty years.

Dr. Moira Stilwell, MD FRCPC is a Radiologist and Nuclear Medicine physician. She practises Nuclear Medicine in Vancouver, British Columbia.

Drs. Erin Brown, Kathryn Issac and Weiss have established a provincial lymphedema clinic at Vancouver General Hospital.

10 L y m p h e d e m a p a t h w a y s . c a

What are the risks of LSG? There are three main concerns regarding a nuclear medicine lymphoscintigraphy: • t he effects of radiation • the possibility of infection •w hether the procedure might make lymphedema worse Radiation exposure is very low. Normally, the tracer passes from the lymphatics into the blood supply, then very quickly to the kidneys and the bladder. That is why the bladder is often visible in these scans. As well, 99mTc has a short half-life (six hours) and it is nearly completely decayed within a day, without any known long-term effects.

A sterile technique is used to minimize the risk of infection. Allergic reactions are rare.

People with a medical/contrast dye allergy are generally not allergic to this particular agent.

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How is lymphatic flow assessed using LSG? In a LSG, lymphatic flow is assessed based on the uptake of tracer from the injected area up the limb, which is usually compared to the other side. The assessment criteria include: • Lymph node uptake, typically in the groin or axilla (armpit) • Dermal backflow, as it applies to the appearance of stagnant tracer, which has difficulty travelling up a limb • Collateral lymphatic flow, if the lymphatics are not functioning normally • Appearance of the main lymphatic circulation • The speed of clearance of the radioisotope from the site of injection A normal LSG will demonstrate efficient

passage of the tracer through the limb from the injection site upward. With lymphedema, the tracer may move more slowly up the limb or there may be no movement. There may be dermal backflow with a specific pattern on imaging.

In the case of primary lymphedema, LSG is the best investigative tool to establish this diagnosis. LSG can demonstrate intact lymphatic flow and pathways, which allow for transport or document abnormal or no flow.

The role for LSG in secondary lymphedema is similar to the primary case. It allows for visualization of the damaged lymphatic system, including the lymphatic response to surgery or radiotherapy.

In the past 25 years, the role of surgical management of lymphedema has evolved.

Lymphangiography has played an important role during this time in that it assists in surgical planning and the evaluation of outcomes following surgical procedures such as lymphatico-venous anastomosis and lymph node transfers.

Images: https://line.17qq.com/articles/idpdeiehdz.html

It is unlikely a LSG will make lymphedema worse as the tracer is picked up by the usual lymphatic circulation. In a person with lymphedema, it may take longer for the tracer to leave the body but as noted above, it decays very quickly, even if it takes longer to pass through the body.

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angiograms demonstrate different conditions and the health of the lymphatics. It also has value in post-operative management.

Our understanding of conditions affecting the lymphatic system has evolved over the past 70 years, in good part due to evolving medical imaging technologies. The future looks very promising with emerging imaging technologies improving our understanding of disorders of the lymphatic system. These new approaches will continue to provide guidance and direction regarding treatments and interventions for the patient with lymphedema. LP As previously noted, the results following a LSG provide quantitative and qualitative information, which will assist the physician/ surgeon in advising the best management for lymphedema. Therapists performing lymphatic massage may also find the imaging results to be of value, as these results can provide valuable information regarding the distribution of lymphatic drainage and flow in an affected limb.

What’s new in lymphatic imaging?

Improvements in nuclear medicine scanning are beginning to be more accessible. This includes improvements with digital imaging. Newer

radioisotopes may offer better imaging quality.

Positron Emission Tomography (PET) lymphangiogram technology may eventually replace or complement more traditional techniques.

Fusion technologies such as the combination of Magnetic Resonance Imaging (MRI) with a lymphangiogram are emerging trends.

MRI-lymphangiography offers a new level of imaging of the lymphatics not seen before.

Finally, the use of indocyanine green (ICG) lymphangiography allows for clinicians to view the superficial lymphatics at the bedside without radiation exposure. It allows for staging of disease severity and assists in pre-operative assessment. ICG lymph-

A full set of references can be found at www.lymphedemapathways.ca

Editor’s Note: Despite advances in medical imaging for lymphedema, this technology is used mainly by surgeons and specialists assessing primary lymphedema. At this time it is not in widespread use in clinical practice, where diagnosis continues to rely primarily on clinical history and physical findings.

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CANADIAN LYMPHEDEMA FRAMEWORK

PARTENARIAT CANADIEN DU LYMPHOEDÈME

The course received educational grants from Essity and Juzo.

uab.ca/pd

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Summer 2021

Community Profile

LANA’s place in the field of lymphology and related disorders Setting industry-wide lymphedema training standards

By Kathy Weatherly

T

he Lymphology Association of North America (LANA) was advocated for and financially supported by the American Cancer Society as a primary outcome of the Lymphedema Summit meeting in 1998. As identified at the time, patients and healthcare providers had no way to judge the quality of the training programs and no standard to identify competent lymphedema treatment providers. Regardless of whether a lymphedema training program required 20 hours or 170 hours of training, all programs bestowed the credential—Certified Lymphedema Therapist (CLT), to the attendees. Given the range of preparedness amongst healthcare professionals treating lymphedema, stakeholders at the time expressed frustration in trying to find a qualified specialist. The American Cancer Society heard their frustrations and inspired the creation of LANA to set training standards, create and administer a certification exam and provide a reputable listing of therapists.

The founding LANA Board of Directors met with physicians, lymphedema training program directors, nurses, physical therapists, occupational therapists and massage therapists to develop a core knowledge outline that describes the foundational concepts necessary to evaluate and manage lymphedema and related disorders. This outline has been adopted by the majority of lymphedema training programs. As new training programs have emerged, they have contacted LANA to have their program reviewed prior to launching their continuing education.

The public and medical professionals are aware of and trust the credibility of the LANA

standards and credential which is accredited by the American National Standards Institute.

LANA has successfully set industry-wide lymphedema training standards and established minimum educational standards for an alliance of healthcare professionals identified as lymphedema specialists. In its 24-year history, LANA has stayed true to its originating belief that a collaborative, comprehensive and inclusive network of healthcare professionals is necessary to fully support the patient.

LANA’s alliance of medical professionals utilize their comprehensive knowledge of the lymphatic system to assess, plan, and provide therapeutic intervention to help restore or maximize function and improve the quality of life for people living with lymphedema. To be eligible for the LANA exam, a medical professional must: nP rovide proof of successful completion of qualified instructional course in Complete Decongestive Therapy (CDT) course work (consisting of 1/3 theoretical instruction and 2/3 practical lab work and documentation of 135-classroom hours) from no more than four consecutive or cumulative courses from one training program. nP ossess a current, unrestricted US or equivalent Canadian license as a Registered Nurse, Occupational Therapist, Certified Occupational Therapy Assistant, Physical Therapist, Physical Therapist Assistant, Medical Doctor, Doctor of Osteopathic Medicine, Doctor of Chiropractic, Massage Therapist, or Certified Athletic Trainer nP rovide proof of basic science requirement

Kathy Weatherly is a retired Occupational Therapist specializing in lymphedema since 1994 and has been actively involved on the LANA Board of Directors since 2000. She currently serves as the Vice-President of LANA.

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“ Since there are several lymphedema therapy schools that practice different philosophies and techniques, it is all the more important to have an independent entity such as LANA, that certifies and ensures the quality of training of our lymphedema therapists. I am fully supportive of LANA gaining a high level of recognition and regulating authority as the head of microsurgery and super microsurgery and co-director of Cleveland Clinic’s multidisciplinary lymphedema center.”

January, 2021 – Wei F. Chen, MD, FACS, Professor of Plastic Surgery,Head, Regional Microsurgery & Supermicrosurgery. Cleveland Clinic, Ohio, USA

completion consisting of 12 credit hours of college level human anatomy, physiology, and/or pathology from an accredited college or university.

Throughout the healthcare industry, specialty certification is required. LANA specialists demonstrate their commitment to lifelong learning through continuing education and recertification.

Peers recognize the significance of the CLT-LANA credential. Third party payors and employers are inquiring about certification status, which in turn increases employment opportunities for specialists possessing LANA board certification.

LANA will continue to advocate and support education and research in the field of lymphedema and related disorders on behalf of every person faced with the diagnosis of lymphedema and related disorders. Therapists from Europe, Asia and the Middle East are registering to take the LANA exam as it is now offered internationally.

When looking for a specialist, look for the CLT-LANA credential. LANA’s website provides a repository of continuously updated listings of medical professionals who have successfully passed the LANA examination. LP www.clt-lana.org L y m p h e d e m a p a t h w a y s . c a 13

Company Profiles

The Canadian Lymphedema Framework is pleased to present the profiles of organizations playing a role in the 2021 National Lymphedema Conference.

Co-host and Presenting Partner Wounds Canada is the voice for Canadians at risk of or living with wounds and their providers. Our vision is a Canada where preventable wounds do not occur and persons living with wounds receive the best possible care.

Established in 1995, Wounds Canada is a charitable organization dedicated to the advancement of wound prevention and management for all Canadians. We advocate for a population health approach that promotes best practices to support persons at risk for or living with wounds and their care givers, health decision makers and frontline clinicians. In addition, we support wound-related research to further advance a holistic risk-based approach to foster innovation in wound prevention and management.

Wounds Canada’s educational arm, Wounds Canada Institute (WCI) (https://www.woundscanada.ca/wci-home), provides educational programs and resources for health-care professionals from all disciplines as well as for unregulated care providers.

WCI offers excellent online programs and skills labs—including fully accredited programs—to improve wound-related knowledge and competencies.

Wounds Canada is pleased to foster relationships with interested individuals and organizations, such as the Canadian Lymphedema Framework, to expand and sustain a robust wound community that also has mutually beneficial goals such as developing best practices, providing education, improving public awareness and supporting research. Our advocacy work is strengthened by working with partners who share our aims in promoting effective wound prevention and management strategies.

Our website, woundscanada.ca, contains free downloadable resources for patients and their care partners, frontline health-care providers and decision makers as well as information about our cost-effective educational programs and virtual conferences.

Wounds Canada’s overall goal is to reduce the prevalence and incidence of wounds of all types and the negative consequences they bring—including patient suffering and wasted health-care dollars.

Essity is a leading global hygiene & health company dedicated to improving well-being through products and solutions. Essentials for everyday life. Essity’s sustainable business model creates value for people and nature.

Essity sells in approximately 150 countries under leading global brands TENA, JOBST, Leukoplast, Tork, and others. Essity’s global headquarters is in Sweden with Canadian manufacturing in Drummondville, Quebec.

Essity believes that to succeed, a multi-disciplinary approach is required to achieve lymphedema management. We are proud to be an integral part of the team and are committed to raising awareness on lymphedema through innovation, our education programs and our partnerships with community associations and healthcare providers.

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SP ON S

L&R CAN – passionate about delivering innovative wound care and compression solutions.

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OR

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L&R CAN provides you with effective compression solutions, including bandaging, the Solaris Collection™ of garments and wraps, and VENOSAN® compression stockings and support socks, to help you treat your lymphedema and edema patients.

When you use L&R CAN products, you know you are in good hands with trusted brands like TributeNight™, ReadyWrap®, Rosidal® K and VENOSAN® 4000.

SP ON S

www.jobstcanada.com or www.essity.com

L&R CAN is an affiliate of our global parent company Lohmann & Rauscher, which has a 160-year history as a well-recognized and respected global manufacturer and supplier of compression therapy solutions and innovative wound care products.

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National Lymphedema Conference “Moving Evidence into Practice”

Highly Interactive Sophisticated 3D Platform

December 3–4, 2021 VIRTUAL

Virtual Exhibit Hall Live Streaming Sessions On Demand Viewing Expert Q&A Forums Poster Presentations

KEY TOPICS

International Networking

x Diagnostics x Surgery x Obesity x Woundcare x Measurement x Lipedema x Research x Exercise x Oral and Poster Presentations

AND MORE!

Pre-Conference: 3 FREE WEBINARS

JUNE 1, 2021 REGISTRATION OPENS

AUGUST 1, 2021

Post-conference: On-demand viewing available until January 30, 2022

ABSTRACT SUBMISSION DEADLINE

CANADIAN LYMPHEDEMA FRAMEWORK

PARTENARIAT CANADIEN DU LYMPHOEDÈME

...in collaboration with...

With support from our industry sponsors:

www.canadalymph.ca/conference

Awareness and Advocacy

Canada promotes Lymphedema Awareness Month

How provinces celebrated across the country

By Anna Kennedy

Many diseases have been designated a specific day, week or month to raise awareness and better understanding of their impact and to promote support among the general public.

These events are organized by recognized health or community groups and give opportunity to celebrate successes. Such events also are meant to catch the attention of health advisors and decision makers by shedding a light on the disease and its impact on individuals and hopefully influence policy changes for increasing support for those living with the disease.

Initiated long ago by Saskia Thiadens (the long-time Executive Director, now retired) of the National Lymphedema Network in the USA, March is lymphedema’s designated month. This early movement has gained momentum across the world with March 6 now designated as World Lymphedema Day, since 2016. March awareness for lymphedema was celebrated across Canada in 2021, with many of the provincial lymphedema association’s busy working on several initiatives to support this important day.

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BC Lymphedema Association (BLCA) asked members to contact their local Member of the Legislative Assembly (MLA) to share their personal lymphedema story, as part of an advocacy campaign. A few members also managed to have articles published in community papers.

For the third year BCLA also achieved a province wide proclamation for World Lymphedema Day. And for the first time they arranged to have both the BC Legislative building (fountain & entry door) and the Bastion in Nanaimo, lit up in lymphedema teal colours.

On March 6, BCLA held a virtual zoom party with balloons and members wearing their BCLA blue & green shirts, and participating in a sing-along, led by a local entertainer.

The highlight of the party was the launch of six pre-recorded educational webinars, which constituted the BCLA 2021 Virtual Conference.

Recognition of World Lymphedema Day reached as far away as a remote Island in French Polynesia, with BCLA shirts being worn by grandchildren waiting out the pandemic on a sailboat with their parents.

Alberta Lymphedema Association (ALA) was proud to have the City Mayors of Airdrie, Calgary and Edmonton proclaim March 6, 2021 as World Lymphedema Day. The ALA was also successful in arranging for the Calgary Tower to light up the sky to raise awareness on March 6 and the association added a photo frame to be shared across Canada.

Lymphedema received local media coverage in Calgary to advocate on behalf of lymphedema patients through an interview on Global News Television that included interviews by Diane Martin, President of the ALA and Alicia Tocila, a mother of a child with primary lymphedema. Dr. James Kennedy, an Albertan surgeon performing lymphedema surgery was also quoted.

Lymphedema Association of Saskatchewan (LAS) celebrated Lymphedema March Awareness in 2021 virtually by hosting their Annual General Meeting for their association members on March 30, via ZOOM. They also organized some virtual

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.

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fundraising events and were successful in getting proclamations from major cities in Saskatchewan, including Regina, the province’s capital city.

Lymphedema Association of Manitoba (LAM) joined other organizations throughout Canada that moved to the virtual world for celebrations, education and fundraising during COVID. In conjunction with World Lymphedema Day, March 6th was officially proclaimed Lymphedema Awareness Day in Manitoba, by Bill 209 in 2014.

The LAM celebrated in 2021 with their first-ever virtual event. They were honoured to have Dr. Lesyln Keith speak on “Healthy Lifestyle for Lymphatic and Fat Disorders”.

An expert panel, (Karen Dobbin, Kim Radford and Dr. Keith) answered live, pre-submitted questions from the community. The event was well attended and very well received.

Another first was celebrated as one of the LAM’s professional members, Amanda Sobey arranged for the Manitoba Legislature building to be lit up in teal on the evening of March 6.

Lymphedema Association of Ontario (LAO) encouraged members to participate in an Advocacy Letter Campaign. Many city mayors and township councils officially proclaimed March 6 as World Lymphedema Day. These included the cities of Markham, Milton, Ottawa, Peterborough, Pickering and Toronto; the towns of Milton and Whitby; the municipality of Clarington, as well as the township of Scugog. The iconic CN Tower was also lit up in teal on March 6.

Dolores Steinwall, LAO’s President and Ann DiMenna, a certified lymphedema therapist and LAO Director, presented “Lets Talk Lymphedema” at a Canadian Cancer Summer 2021

Survivorship Network sponsored educational webinar on March 4. Participants learned about the causes and symptoms of lymphedema, what treatments are available and how to access the appropriate help and support.

The LAO thanks the volunteers who helped reach their communities on World Lymphedema Day 2021.

Lymphedema Association of Quebec (LAQ) has raised awareness for lymphedema as well as increasing their organization’s visibility among health professionals and patients with several initiatives. They launched their LAQ Resource Guide 2021 with 8,000 copies of this 32-page directory distributed free to health professionals, administrators and therapists in Quebec.

They collaborated with the Association of Orthopedic and Prosthesis Quebec (AOPQ) to create and distribute a reminder card for the renewal of compression garments and jointly produced a Lymphedema-Cancer poster explaining causes and treatments. They also created two new guidelines for self-measuring upper and lower limbs, in order to make the results of self-management more visible.

The directories and guidelines are available on their website (www.en.infolympho.ca) Finally, the LAQ created a photo frame for World Lymphedema Day generating over 300 downloads on Facebook. They continue to call on Québec’s government to make lymphedema treatments accessible to patients.

Lymphedema Association Nova Scotia (LANS) was busy celebrating Lymphedema Awareness Month by posting information about lymphedema, every day on Facebook. They also hosted their first (but definitely not their last) online event.

Sarah Brownlow During, a MLD therapist, provided a presentation on “Understanding Lymphedema and Lipedema—and how we can

Lymphedema awareness was celebrated across Canada in 2021, with many of the provincial lymphedema association’s busy working on several initiatives to support this important day. help ourselves”. LANS members also discussed ways to move forward as an Association.

Lymphedema Association of Newfoundland and Labrador (LANL) distributed laminated printed copies of two previous Pathways articles on practical exercises (Fall 2020 and Spring 2021) to all certified lymphedema therapists and compression garment fitters during the month of March, as part of their awareness campaign.

This sanitizable copy was intended to be a low contact activity during COVID, that those who already see lymphedema patients can review these important exercises with them.

LANL, through Martina Reddick and Erin Pennell, RN and LANL board member, gave presentations to members of the Newfoundland and Labrador Nurse Practitioner Association, the College of Registered Nurses of NL and College of Licensed Practical Nurses of NL. More than 50 healthcare practitioners attended.

March 6 was proclaimed as World Lymphedema Day in 15 Newfoundland and Labrador municipalities, and Government House and Mount Pearl City Hall buildings were lit. Terry Walsh Oakley, RMT, CLT and LANL Board members, gave a one-hour radio interview on VOCM’s On Target with Linda Swain on March 1st. LP A special thank you to the Chairs of the provincial lymphedema associations, who shared their activities and photographs for this article. It is through the hard work of their members and volunteers who help to raise awareness and advocacy efforts in Canada.

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Clinical Perspective

Venous and lymphatic diseases Opportunities for improved care

By Paul Hannah

L

ymphatic and venous disease share many commonalities, but there could be a lot more communication between lymphologists and phlebologists. Both professions are frustrated with the lack of understanding in the medical community of venous and lymphatic issues.

Venous disease is common, and for the most part curable, at least in the medium term. Varicose veins occur in about 30% of the population, of which only half are symptomatic, with such complaints as postural heaviness and swelling, relieved by rest and elevation. Venous ulcers occur in about 1% of the population, with another 1% having a healed ulcer. This number increases to 5% of Australians over 65 years of age.

New research continues to identify multiple genetic markers of venous disease, such as the FOX2 gene. The pathological mechanisms of venous disease remain elusive, but multiple lines of evidence point to a diffuse, chronic, inflammatory process with valve damage, venous reflux and venous hypertension leading to leucocyte and protein migration into the extracellular space. The end result of this is a disordered extracellular matrix and abnormal collagen and elastin. Initial phlebo-oedema from venous hypertension gradually blends into phlebolymphedema as the subcutaneous lymphatics become damaged in this process, resulting in skin damage called lipodermatosclerosis. The older theory of proximal valve failure, for example, at the saphenofemoral junction, leading to descending progressive valve failure and distal venous hypertension, has been replaced with a realisation that a diffuse process is damaging the valves of the veins.

Sequential examination with ultrasound has

shown that the progression of reflux is more likely to be from distally below the knee to proximally, with time. Asymptomatic children and young adults can be shown to have some refluxing valves, the extent of which usually progresses with the decades. Heredity is the single biggest risk factor for varicose veins, with pregnancy next, and prolonged standing a distant third.

Deep venous disease (below the superficial fascia) is uncommon and usually the result of deep vein thrombosis (DVT). If the clot does not dissolve quickly, it can damage the deep valves resulting in deep venous reflux or deep vein

obstruction. Such post-thrombotic syndrome can usually only be treated by lifelong compression and, rarely, stents for stenosis.

Artificial valve replacement has proved elusive so far. Congenital absence of valves is seen in the rare lymphedema-distichiasis syndrome.

Superficial (above the fascia) venous disease is easily diagnosed by its clinical appearance and the ultrasound presence of reflux (abnormal distal flow due to incompetent valves) during Valsalva or following a distal calf squeeze to augment venous return. These scans must be done while standing or at least with some body

Dr. Paul Hannah, Phlebologist has had a career divided between Family Practice, Emergency Physician and Phlebologist. He is currently National Director of Training of the Australian College of Phlebology and is actively involved in Medical student and GP education about venous and lymphatic diseases.

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tilt. DVT scans on the other hand are performed supine and the veins are compressed with the probe to see if there is a clot within them.

A reflux of greater than 0.5 seconds is typically used to diagnose venous incompetence.

The presence of chronic distal venous hypertension leads to progressive skin changes from the appearance of ankle telangiectases and venous eczema, through gravitational edema, then to the pigmentation of haemosiderin due to red cell extravasation and pale dermal infarcts called atrophie blanche. The typical pre-ulcerous changes of lipodermatosclerosis, or tight in-drawn hardened skin, are due to progressive fibrosis within the subcutaneous layer. Any minor trauma at this stage cannot be repaired and will lead to an ulcer. Venous ulcers are not usually as painful as arterial ulcers, and often wetter. They are typically found on the medial (great saphenous territory) or lateral ankle (short saphenous territory). Venous ulcers need all the usual wound care and debridement; however, healing will be expedited if the causative venous hypertension is controlled by treating the reflux. Traditional venous surgery was painful and had a five-year recurrence rate around 30%. All relevant worldwide vascular authorities these days recommend other methods of treatment, usually thermal ablation with laser or radiofrequency, but other options are available, such as adhesive superglue and ultrasound guided sclerotherapy.

What does the lymphatic therapist need to know about venous disease?

Patients do not come to us with diagnostic labels and, especially in the elderly, often have multiple pathologies. In someone with bilateral swollen legs, one needs to consider cardiac failure, liver and kidney disease, and drug side effects (especially calcium antagonists and steroids). With unilateral Summer 2021

swelling, venous disease is more common than primary lymphedema, although the history or presence of varicose veins will differentiate these often. Ask about previous DVTs and consider proximal obstruction causing either venous edema or lymphedema.

Proximal obstruction typically involves the nodes in the case of lymphedema but could be due to pelvic masses, anatomical compression (e.g. May-Thurner syndrome) or lymph nodes, in the case of venous obstruction. Stemmer’s sign may be positive in phlebolymphedema and may be negative if there are multiple pathologies, such as venous hypertension, as well as lymphedema.

Treatment of these other pathologies, such as heart failure and venous disease, will make the lymphatic therapists’ job a lot easier. If you see patients who may have venous disease, consider the following.

Firstly, do not just rely upon the diagnoses of the referring doctor. Venous disease, in particular, is under-appreciated or even worse, ignored, by the medical profession. Learn to look for the typical symptoms (gravitational

heaviness and swelling) and signs (eczema, pigmentation, lipodermatosclerosis, ulcers) of venous disease. If in doubt, an ultrasound scan looking for reflux is a simple test. Cardiac, renal and hepatic disease are mostly selfevident from the history.

Venous disease is usually easily treatable and will significantly reduce the fluid burden on any lymphedema or lipedema present.

Ultrasound machines are typically very expensive, but we are witnessing a revolution in technology with clever probes that plug into your smart phone or Ipad. I predict the current generation of doctors will be the last to not routinely use this ‘stethoscope of the 21st century’. Although complex to become a master of this technology, the basics are not difficult to learn. For instance, a GP can learn

to do a basic DVT scan in 30 minutes with 90% accuracy. I envisage that a lymphatic therapist could quickly ‘exclude significant venous reflux’ with some training, and professional sonographers would only be needed to elucidate subtle reflux and look for other pathologies, such as proximal obstruction and pelvic venous disease. Indeed, this is how I work with my current sonographers—their skills are at another level beyond mine, but I can make quick and convenient diagnoses by myself without fuss. My sonographers create beautiful venous ‘road maps’ with complex connections and diameters duly recorded.

In summary, lymphologists already have the knowledge base to easily understand phlebology. They need to accustom themselves to the visual signs of venous disease and know that venous disease is usually easily treatable and will significantly reduce the fluid burden on any lymphedema or lipedema present. LP

Reprinted with permission from Lymph Exchange (Feb 2020), a publication of the Australasian Lymphology Association.

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Personal Perspective

Servicing clients from the front-line

Transitioning during COVID -19

By Wanda Guenther

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s a registered massage therapist and manual lymph drainage therapist, I have been working out of my home clinic since 1993. Treatment I provide includes basic deep tissue massage, geriatric massage, neuro-proprioceptive taping, palliative care and lymphatic drainage.

I started lymphatic drainage at the Breast Health Centre, treating people post breast cancer treatment for arm/truncal lymphedema and post-surgical complications.

“Transitioning from working out of my home to doing home visits only.”

I’ve always enjoyed working out of my home and have had a busy practice. I am grateful for the clients that have come to see me over the years, for the flexibility it has afforded me and especially my ability to do the work that I love to do.

In March 2020, I closed my home clinic to comply with the mandated shut down due to COVID-19. On May 4, 2020, supported by the Massage Therapy of Manitoba (MTAM),

we were able to reopen with return to work protocol to stop the spread of COVID-19.

After serious consideration and discussion with my family, this seemed to be an appropriate time to make a change so I transitioned from working out of my home clinic to conducting client home visits only.

Over the years home visits had been a part of my practice. Some clients had difficulty with stairs, some were in hospital or long-term care and others simply did not have easily accessible transportation to my office. These clients made up approximately 15-20% of my total business. I wanted to create more balance in my life and ultimately chose to assist those who are housebound 100% of my time. It seemed like a good decision.

Working to support clients and at the same time manage the personal protection equipment (PPE) was my next challenge.

Where does one begin? Gloves, gowns, masks, face shields or goggles and disposable shoe covers (my latest addition to the list of requirements) seemed like a lot at first. On the other hand, if this is effective in protecting me, my clients, and the related community from the risk of spreading COVID-19, then I can continue to provide much needed

Wanda Guenther, RMT, CDT was a registered massage therapist since 1993 and certified manual lymph drainage therapist since 1999 in Winnipeg, Manitoba.

Wanda retired from her practice as of March 31, 2021. She continues to be an active member of the Lymphedema Association of Manitoba.

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services of care of post-surgical swelling, primary and secondary lymphedema, plus lipedema, with ease and less stress.

Therefore, changing shoes at the door or donning disposable shoe covers, using hand cleanser, wearing a mask and face shield, gowning and gloving and washing hands after treatment became the new routine. My shield and cell phone were wiped before and after each visit.

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Although the costs related to the PPE increased my expenses, I did not increase my charges to the client. Had I continued working, I feel it would have been a consideration.

I sent a questionnaire along with the appointment reminder one or two days before each visit. Questions asked at each visit were: How were they feeling? Did they have COVID-19 symptoms such as feeling unwell, unable to taste or smell, have a temperature?

Had they travelled or been with someone that had in the last 14 days? Were there other people living in the same house? Staying safe for ourselves and those around us, and not to be the carrier of this virus was number one on the agenda.

I never felt ill or fit in a category to be tested for COVID. However, I received my first and second vaccine shot as soon as it was available (January 2021) in Manitoba’s initial rollout to health care workers, nursing and community care providers. Being proactive

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and responsible to do my part, I was very excited and pleased to “get the shot”.

How am I feeling now compared to when we first learned about COVID-19?

The biggest fear for me personally is the possibility of spreading the virus to others.

Next, I want to recognize symptoms and provide the appropriate support to my clients, resuming treatment once the appropriate time has passed and/ or support has been received.

My clients and I shared the same feeling; we all wanted to be safe for ourselves and for each other.

Although rare, some declined treatment altogether and wanted to first wait for their vaccine.

Even with the changes and added protocol, home visits were my passion.

It was always different, and you never knew what lay ahead. I was always so grateful for the ability to be of service to my clients.

They were always happy to see me. They appreciated not having to leave home and still

Even with the changes and added protocol, home visits were my passion. It was always different, and you never knew what lay ahead. receive the much needed comfort and help.

On the other hand, I now have an extra room in my house. It has morphed into an office/sitting room where I watch the activity on the street as I catch up on my office work or read the paper in the early morning hours.

I continued to work during COVID, but just a bit differently!

I have since retired as of March 31, 2021.

I felt it was the right time to make the change in my life so I could enjoy new hobbies, sports, activities and time with my family. I look forward to the next step in my journey, which will hopefully include some travel as well. LP

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Letters to the Editor... ____ ______ ______ . I ______ _ _ _ _ _ ____ mu_c_h___ ______ __________ u v_e_r_y___ __ ______ e, _th_a_n__k_y_o___ tho_u_g_h_t______ ______________ __ _ __ _ __ _ __ _ __ __ _ _ __ _ I in _ _ __ _ z . _ __ __ _ _ a _ __ __ _ re _ __ g __ _ y _ __ _ __ a _ _ fo log __ _ __ _ _ xo ______ _____ fle__ Re__ d ___ __ t __ ou__ e be___ ab__ the__m___ ______________ _ __n__ ___a_n__ __tio a_g_a_z_in____ sio_n_H s to __es nd__ _in_ts c_e_iv__e_d___ th_is__m po__ __a__qu ______________ _ _ res __ re __ _ __ ely __ I __ __ Ne _ __ ___ __ __ _ ma Mc s _ __ __ __ _ de e __ __ __ _ he rgi d mp__________ _____ Ly__ ___ ere wh__ __________ __________ I_h_a_d____ n __ r re_a____ om_p_re __Ma ist__wi__th__the ____ rap__ ____ the __lum D Ex__pe__rt” __co ______________ the d_n__e_ve___ i’s_a_r_ti_c_le __(_C___ w_is_h_e_d__th__a_t _ ed__RL ____ sk a niz __ “A __ og h __ _ __ __ ur ___ rec __ yo __ _ _ a __ __ __ to the _ d I _ __ __ __ er an ing _ __ __ _ __ z . _ I nd er _ nd po________ mb__________ ty cie a me I am res__ er__So am ____________ ____ ona__A_l_O__n_a__ nc __(u ____ ). 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All the__ err__ ref__ e Ric Commun e __ Su __p_h_e_d_ sh__ ______________ __ d_o_n_’t__fi_n_d__th__ b_o_u__t _ly_m ______________ e Care, trained by es__ nc__ _ ______ ere__ ______________ _ _ ref __ _ _ __ the _ __ _ by _ __ _ ______________ Cancer Palliativ__ _ y a _ __ _ _ uir _ _ __ _ inq______________ _ __ s __ also __________ thi__ to__ ____ s are ed ns__e__ nc po g_e_a_b_le_ studie ______ va ______ ______ ______ _ e res _ __ Ad d _ es ’s _ __ __ _ Th _ ely __ _ le . __ _ _ __ Ne 17 __ _ _ w _ __ . __ _ ge Mc _ _ . __ o __ _ __ pa e _ _ _v ______ about Ms __________ 2 and 3 on __________ was quite surprised__ __k_n_ _____ _____ ms __ ____ as ite __________in__the __r_m_a__ti d owing I ______________ __________ limb an__ ______ ______ ed sh ___________ __ ______tio r_y__in_fo _ on __ _ __ _ e nti __ _ __ _ v _ _ id __ __ me _ _ _ flu __ __ _ es s _ _ of __ _ __ _ nc _ a n __ _ __ __ _ _ ere ______ reduc ________________ nths or the ref __________ er. I checked two of __ _____ _____w _____ n_____ s show__the ____________ th result __________ ______ to six mo answ _____________ _V_a_l _D_ic__k_in_s_o_ _ta .uk. Bo__ ______ __lym ______ _ up __ __ __ _ .co t _ _ __ __ __ ge _ las _ __ __ _ __ na to _ __ _ __ __ _ rai n __ _ __ __ _ ph _ ow __ __ _ _ sh gy ____ tion was ____________________ two studies __________own under www.reflexolo ____ __lb__er _____ _____ __________ e reduc__ bility. Th__ sh ________________________ ______ is was mentioned in the ______________________ __E_d_m__o_n_to__n_, A ___________ _ ______ and mo__ _ in __ _ __ pa _ _ _ _ the __ _ th _ __ wi _ __ _ __ d _ _ Th lpe ________________ _ earch. ____________________ ____ __________reduction of swelling he__ ______ ______ further res__ ______ _ _ __ _ for _ __ e _ __ _ __ nc _ __ _ _ __ __ __ a ide _ _ _ __ __ ev __ _ t _ __ _ __ _ ______ that there was sufficien __________________ ____ _____ ______at______ ________ ______ ______ctu ________mo oned __________________ ______ ______ ______ rer ______ re. It menti ____stu ______ ____________ ______ ____ nces. is a Senior Le ______ _ __ __ __ s, _ __ __ __ _ die __ __ _ __ _ __ __ __ _ _ __ se __ __ _ _ __ __ __ the _ __ __ _ __ ____ 2019, for refere __________________ ___ ________tha rs in both of __________________Bo t were used __ ______ ____ mentioned as one of the autho ____ LN), in ston__in________________________ ____ __ ____wh ______ ______ o is ma Network (N__ ____tio__na__l __ de __ __ he __ __ mp __ __ / Ly __ __ ____________ Ju eo __ __ dith Whatley,__ vid __ Na ______ imeo.com/ __________ __________ presented at the ______________ ______________at: https://player.v______________et. ____________ __is__ ____ in the UK. She__ ____ __ __ ________Ca __ available to watch______________ __D__ ____ rdiff University __ cardittm ac.uk ______ ____________ eo w. __ ____ vid __ ww a ____ __ at d e __ an sit __ ty __ ________ ________ rdiff Universi ________ effects of RL ______________ __________ ____ __ow __ __ __ __ ________sh __lymphnet.org. See also the Ca ____________o__ __ ing the promising ____________w. e is__recognized ha__ve__read your __________________________ __ sh__ ____ w __ __ ho d __I__ __ an __ __ __ inf __ ______ __ ww __ __ __________ex__tra y’s __ is __age. Sally Ka __ __ __ __ ite __ __ bs __ __ __ __ we __ __ __ N __ __ __ NL __or __ ain __ __ e __di__na __ed. rin__ __logy Lymph Dr __on __xo g __ __ry__Sp __nti __fle 20__21 ______ ________370012828. Th ____ m __e__me __on__Re ag __sit ______ __ az __eb __ in __ __ __ e __ __ __ in __ __ __ __ __ a __ __ __ __ on wa __ __ __ t w __ __ ati _____ itin __ __ __ __ firs __________ g __ ____ ro__ om__at __arc __________ ______ for ____ n under the __in a __ ow__ h for more inform __________ing __er ____________ Med __d__do __on __titi icu__s__ ____ a se __ __ ________an sto __ ____ co__ __ re______ __ m__ __ Prac __ __award winn __therapy is sh pr d __ __ __ __ es ve __ __ __ __ __ sio __ __ pro __ n. __ __ Ap __ __ __ al D I __ __ ha __ __ __ on RL __ _ __ ________ve__no __. I am an __16 t re__ad ____ __to__in__20 l and Internati ____ an__ na__ ____ yth tio__ firs__t ____ __________on ____ ____to__To__ ron s Na en__I__ __me thi__ wh__ ____ __ ________for br__ __ts, m__ __in__g__________ ea__ __en ____ fro__ ____ st__ __cli __en ca ce __ e __ __ llu __ sh __ __ __ liti __ __ my __ __ s __ wh __ an of __ __ __ y _ e __ __ __ d __ Ka __ On __ ents. ______lym ph__ ed__em __D__tre__atm ____ ____ under Sally d __ a of ____ ol________ __________br ine__ RL toc__ th__ I tra ____ __D__pro for__ e ______ y __ ea ____ all__ ____________ __ ____ ific__ ____ , on __ed ec__ the__RL __sts sp__ ____ __ I us __ly ___ a.__ __ar ____ __ me__to__me __m em__ __________ __ph __ co__ __s. ed__ o __ __ __I__wa s__gr__at__ ____ __r__lym __ wh__ __ __ __ ts __ __ __ __ ef en he __ ul __ cli __ __ __ for __ to ve __ __ __ __ ha re__ad __ I __ arm __ __ __ me . r __ __ __ __ yo tco he __ __ __ __ ur ou on __ __ __ r t __ m __ __ __ ________Canada he en __ ag __ __ __ at rm _________ az __ __ __ wh ga in __ t __ __ n e. __ __ __ ou __ sio __ __ If __ ab __ res __ yo __ __ __ us __ u __ __ mp __ xio __ ha __ __ co __ an __ a __ __ ve __ le __ ______in__ __s__ fo__ a litt g, wore rm__at__ cin__ I wa ____ cti__ ion ”, __ __bie ng________ __________br pra__ __ew ____ on________ d __ nti__ ____ rte__ wa__ __a__“n __ea he__r __ __st lym __ed ________sta ing m__ __d__ be__ fro__ __ll__ ____ ___ , an __ion t a__ca __em a__ ge__ ____ an__d__ to__ sess ______________ph t __ d__ __t __ ce__llu__liti__s__ firs__ hte__ ______ __ __ lig__ ____ __ __ tha de __ __ __ s in __ __ __ wa (n __ __ ing __ I ot , __ ell __ __ __ ju en __ __ nth sw __ __ __ st__________ r be ar __ __ __ __ mo __ ’t he __a __ __m__ dn__ s)__I__ __er ha__ __ov wo __e__ ________for __r__for __ul__d__ __he ere__sh ap__pr__ec__iat ____ __m _ wh __ __ __ fro gh __ __ __ ou __ ard __ __ en __ he __ __ e ’t __ __ it. __ wn __ __ dn __ __ __ do I lik s __ ha __ __ __ ed__re ____ wa en I ____ __ing Wh__ __ad __ell __in __is________ __________yo __re __g___________ __ the__sw ____ uld__be__. __ __ur ,__the d __ __ m ow an __ __ ag __ kn __ at __ u __ az __ __ ________wo gre yo __ in t __ __ e __ As fel __ __ be __ e n. __ __ ca__ ____ __ us__ __id__sh e __ e sa it is ________ __r__ga__rde Sh__ ____ __he ____ t in ____ se__ ____ __nt. ou__ rio__ me ng__ us__ int__ rki__ , an po__ t __________ ____ ap__ ____ d __________ __wo __un er__ ____ __ed joy ____ __fo __pis en__ __oth __rtu __era ____ na__ __d__ __y__Th te__ ly __ __log __d__ha ________an s an _ lym __xo ek__ n Re __fle __ph we dia __ ____ ____ ed __ six __ na __ t __ em __ __ Ca __ ou __ __ __ __ ed a ab __ __ __ is __ ter __ for __ __ __ no gis e __ __ __ __ __ ev t__ Re __ __ __ __ ta__ a sle __ __ __ __ ke r se __ __ __ __ n re he __ ca __ __ __ __ __ se mo ng __ __ __ __ my ___________ rio ari at __ __ __ __ in us we wh __ __ __ __ s, ; ly __ ____ __ ist life __ by __ y rap __ __ __ da m the __ __ __ ________ an ery __ as __ __ ev y. , __ __ __ ir It’ we __ __ __ if s the __ a __ to______ so____ pr__ a __ ck__ ______ of__ em__ ba__ es__ ____________ ed__ ty __ sio__ ali__ ph__ na__l __ rm__ no__ ____ m__ for__lym ag__ me re __ az__ cu__ ____ an ____ in__ k yo e. _____ __u__fo ______________ ______Th ____ ief__an __d__so__ rel__ __r__ th__ ________no e __ ____ rs m__ __me vo ag__ ______________ __so az__ __ __ __ survi in __ __ __ __ er e __ __ __ __ nc an __ __ __ __ __ ca __ d __ e __ __ __ yo __ __ __ __ giv __ __ ur__ n __ __ __ __I__ an ca __ __ __ __ __ sw __ __ __ T), the __ wi __ __ __ __ er CR to __ ll __ __ __ __ s. e (R ta __ __ __ _____ __ ns lk __ __ __ __ po to __ __ __ ot__ r __ the ________ ve__ pe__ ________ lie__ op__ __res be__ le__ th__ as__I __ ______________ at__yo__ur__m ____ he__ __ __ __ __ xt__iss __ag ____ __az __,__ __sh s ne __in so ______ __ue ay__ __ou ask__for __e_________ __ __?____________ ng __ thw we __ __ ini __ n Pa __ __ tra __ ld ca __ d __ __ __ the be __ __ ize __ __ in __ __ ial __ in __ ed __ ec __ __ ____ hosp __ sp ita__ ______ ____ l wa ________ __int itin__ __pr e thi ______ __ter g__ se__ ____ __is__a__________ ro__ olo__gis to__ __s!____________ ____ __is om __s__let e __ lex__ ____ __Th ref__ ____ __ts.

D __ uld__lik__ RL__ I wo __ ______ ______________ _____ ____ olo__gis ____ lex__ ref__ ____________ __ts__are all __ Je t __ an __ No __ . ______________ t fully research ne __ __ ed __ __ tte __ __ ______________ __ Co __ __ __ __ __ __ te __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ no __ s __ __ __ __ _________ __ __ wa __ __ . ______________ D__________ __ __ ing __ RL __ ad __ __ he __ __ e __ __ on r __ __ __ de __ __ __ M un__________ ______________ ontreal, __ ts __ ______ ____________ ____________ ebec all__ref ____Qu ______________ ____ ____ __gis __olo __lex ______________ __k__ you cann ______________ ________ ______ _ __ot__lin ____________ ______________ __ __ ______________ __ __ __ __ ______________ __ __ __ __ __ __ __ __ __ __ __ __ ____ __ __ __ ___________ __ __ __ __ __ __ __ __ P __ __ __ __ RN __ __ __ , __ __ __ __ RT __ __ __ __ __ RC __ __ __ e __ __ __ __ __ fus __ __ __ __ Ra __ __ __ __ ia __ __ __ __ tric __ __ __ ______________ ______ Pa ________ __ ______________ d ___________ a __________ oti__ Sc__ ____ ______________ ______________ scale randomi__ __va , No ____ __ish __nw __ee __ ze__________ ______________ ge __ __ lar __ __ ________Gr __ __ no __ __ are __ __ re __ __ __ __ __ the __ __ __ __ D, __ __ __ RL __ __ __ m __ __ __ fro __ __ __ ief is ____________ at__ d rel ______ ______ wh__ is __ is __ edema. Th__ __y__fin__________ lexology for lymph ______________ te: Although so__ me patients__ma __ types of ref________________________ ness of dif ferent__ No____________ ________ ing benefit from__ r’s ito ______________ Ed __ __ ak __ __ ow __ we __ sh d __ __ __ s __ ____ ____t remove an __ se s __ __ aly __ gth __ ______ an __ en __ ta__ str __ __ me __ the __ __ or t ls____________ tria__ ls tha ing abou __________ ________ ale__tria -sc__ controlled t. __Le__arn ge__ en__ lar__ ____ atm ______________ ______________al and why we need a__tre nd me We would love to __ __ __ ______________ to universally recom __ __ __ tic __ cri __ is __ __ evidence ____________ ______________ needed __________________ rstanding research de__________________________ ts). ____________________________ Un__ ec nt. eff ______________ rta ed po rat hear from you... im ge ry ag ve rch__is________________ en show ex ____________ resea__ s (that__oft studie aller__ ______________ sm __ th __ wi ____________bia __ ted __ cia If you would like to drop us so __ any s as ______________

____ ______________

a line, please do so at: pathways@canadalymph.ca

Thank you!

To all of the family caregivers, front-line and essential workers and health professionals who are working hard to care for us, feed us canadianabilities.org and keep us all safe.

22 L y m p h e d e m a p a t h w a y s . c a

Summer 2021

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Helpful Suggestions

Hints and Tips Lymphedema and your job Take special care if you’re in a job that puts your arm or hand at risk of cuts or exposure to harsh substances. Examples include chef, gardener, nurse, doctor or surgeon, chemist or researcher, and florist.

Protect your hands with gloves and minimize your risk of injury. You’ll also need to take precautions if your job requires active and heavy use of your arm, hand, and/or upper body—including repetitive or intense lifting, reaching, pushing, or pulling. Some examples include daycare teacher, nurse’s aide, cleaner, mail or package delivery person, assembly line worker, construction worker, and waitress.

Patience is key At least initially, treatment for lymphedema can be time-consuming, requiring frequent visits to your lymphedema therapist to bring symptoms under control. Talk to your employer and co-workers about your condition and why you may need to take time off during the day.

Educate your employer Many people have never heard of lymphedema. You may need to educate your employer about this, perhaps supported by a note from

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your doctor or therapist. Ask for temporary adjustments in your role until your therapist says it’s OK to return to your previous tasks.

You’ll need to ease up on tasks that involve the arm and upper body until you get your symptoms under control. Your therapist can help you figure out what’s safe.

Educate your colleagues If you do start wearing a compression sleeve to work, you may find that your colleagues are curious about it.

You might want to prepare a set answer you can use to respond to their questions.

LP

Source: breastcancer.org

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Lymphedema management ONLINE Level 1 Theory Available ~ Evidence-based ~ Easy learning modules with small class sizes ~ Interactive, live classroom instruction with physicians ~ Learn precise manual skills with expert, accredited instructors ~ ISO 29990: 2010 certified training ~ CE credit available

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Research Advances

Did You Know?

ICC compression questionnaire

There is no validated questionnaire evaluating the effect of compression and its acceptance by the patient. The aims of this study were to construct a questionnaire evaluating the effect of compression and its acceptance by the patient (the Dutch ICC Compression Questionnaire ICC-CQ), and to investigate its reliability and validity. Methods & Results: 11 experts in applying compression and 51 patients with experience of using compression participated. One part of the ICC-CQ is to be completed by the patient and the other part by the health care provider. Reliability and validity of the ICC-CQ was investigated in a group of 79 patients with lymphedema or chronic venous disease, wearing compression garments or bandages. 89% of the patients fully understood the questionnaire indicating good face validity, and 87% found it complete indicating good content validity. Conclusion: The ICC-CQ is the first reliable and valid questionnaire evaluating different kinds of compression and the experience by patients with lymphedema or chronic venous disease.

Source: Lymphat Res Biol. 2021 Mar 30. PMID:33781091 | DOI:10.1089/lrb.2020.0125

Surgical treatment review

Background: The goal of a consensus conference, sponsored by the American Association of Plastic Surgeons, was to perform a systematic review and meta-analysis of controlled trials to examine both the benefits and risks of surgical treatment and surgical prevention of upper and lower extremity lymphedema.

Methods: The panel met in Boston for a 3-day meeting in July 2017. After a review of the literature, the authors created consensus recommendations using the Grading of Recommendations, Assessment, Development and Evaluation criteria. Results: There is evidence to support that lymphovenous anastomosis can be effective in reducing severity of lymphedema (grade 1C). There is evidence to support that vascular lymph node transplantation can be effective in reducing severity of lymphedema (grade 1B). Currently, there is no consensus on which procedure (lymphovenous bypass versus vascular lymph node transplantation) is more effective (grade 2C). A few studies show that Summer 2021

prophylactic lymphovenous bypass in patients undergoing extremity lymphadenectomy may reduce the incidence of lymphedema (grade 1B). More studies with longer follow-up are required to confirm this benefit. Debulking procedures such as liposuction are effective in addressing a nonfluid component such as fat involving lymphedema (grade 1C). There is a role for liposuction combined with physiologic procedures although the timing of each procedure is currently unresolved (grade 1C). Conclusions: Many studies seem to support some efficacy of lymphovenous bypass and vascular lymph node transplantation. Many studies show the important role of lymphedema therapy and other procedures such as liposuction and debulking. The management of lymphedema is a challenging field with many promising advances. However, many questions remain unanswered.

Source: Plast Reconstr Surg. 2021 Mar 19. PMID:33761519 | DOI:10.1097/PRS.0000000000007783

Managing lymphedema remotely

COVID-19 accelerated adjustments in lymphedema service delivery, while ensuring effective and efficient care. Although clinicians need to comply with guidance from their own organizations, this document provides specific guidance and good practice in relation to lymphedema management. They have been used throughout NHS Wales, providing a standardized approach in supporting care for people with lymphedema. In light of the enduring nature

of COVID-19, it is imperative that lymphedema services have a means to provide suitable care for patients. Although face-to-face appointments are sometimes deemed necessary, many patients can be suitably supported via telehealth consultations. These guidelines may help lymphedema services restore and reset in a safe and acceptable manner.

Source: Br J Nurs. 2021 Feb 25;30(4):218-225. PMID:33641394| DOI:10.12968/bjon.2021.30.4.218

MEASURE VS. 3D SCANNER Reliability and validity of measurement

Measuring lymphedema with high accuracy is important. This study’s aim was to assess the reliability and validity of 3 routinely used methods to estimate limb volumes. Methods & Results: Inverse water displacement, girth measurements, and Perometer measurements were executed. Although standard techniques were used, extra precautions were taken to maximize accuracy within and between observers. Water displacement, and girth and Perometer measurements resulted in standard deviations of 0.7%-0.8%, 0.5%, and 0.4%1.0%, respectively. Conclusion: Measuring limb volumes using routine methods is not easy. Even under optimal conditions, the measurements are quite dependent on the observer. For practical situations, an easy, objective, and reliable method is lacking. LP Source: Lymphat Res Biol. 2021 Mar 22. doi: 10.1089/lrb.2019.0082.

Online ahead of print. PMID:33751914 | DOI:10.1089/lrb.2019.0082

International Lipoedema Association (ILA)

NE

W

The European Lipedema Forum, a group of renowned scientists and health professionals in the field of lymphedema and lipedema, published an International Consensus Document on Lipedema in 2020. This Consensus has led to a paradigm shift in how this disease is viewed and treated. Experts from 14 European countries, who are part of this forum, support and already apply the new treatment concept in their practice.

Because of strong interest from experts beyond Europe, the expert group decided to extend the forum and establish an International Lipoedema Association (ILA). This organization will consist of health professionals and researchers. The aim of ILA is to create and provide scientific based knowledge about lipedema, which will lead to better understanding and treatment of this disease. The physical, mental and social health of patients with lipedema is their driving force.

Health professionals and researchers who are interested in joining the ILA can contact: Tobias.Bertsch@foeldiklinik.de

!

L y m p h e d e m a p a t h w a y s . c a 25

Education Education

Canadian and International Events May 2021 and September 2021 – Online Learning Lymphedema and Chronic Edema Management – a course for health care professionals.

This series of online educational modules presents an in-depth, expert-facilitated overview of key topics in lymphedema and chronic edema management, across practice settings from pediatrics to elder care. A collaboration between the University of Alberta Faculty of Rehabilitation Medicine’s Continuing Professional Education office and the Canadian Lymphedema Framework. n www.uoa.ca/pd

“AQUA - A MEDIC AL MYST ERY” Lymphoedema is a chronic, debilitating and incurable swelling, that can be a result of damage to the lymphatic system due to surgery, cancer treatment, or injury. It can also be inherited.

An estimated 400,000 UK citizens suffer from Lymphoedema.

September 20-24, 2021 – Athens, Greece 28th World Congress Lymphology. Live your lymph dream in Greece. n isl2021lymphology.com October 1-3, 2021 – Boston, Massachusetts National Lymphedema Network Conference. This year’s conference theme will be “A Mysterious Experience of Lymphology”. n www.lymphnet.org October 21-24, 2021 – Virtual setting Wounds Canada National Conference. The largest wound-related conference in Canada, presented in a virtual setting. n www.woundscanada.ca Nov 18-20, 2021 – Copenhagen, Denmark 10th International Lymphoedema Framework Conference. The 2021 Symposium will highlight innovative ideas and research. n www.lympho.org

My current photographic book ‘Aqua’ is a unique illuminating concept for laymen to understand the lymphatic system. Each of my photographs are of different visions of water, which with the captions voiced by Professor Peter Mortimer, will show the lymphatics out of the realm of the invisible system and give readily comprehended ‘a visual smile’ in its place. This book, makes lymphatics less foreboding and clinical.

It becomes as natural as ‘Aqua’ Foreword by PROFESSOR PETER M ORTIMER MD FRCP Preface by DAME JUDI D EN CH CH D BE Letter from The Prime Minis ter BORIS JOHN SON Created and photographed by GEMMA LEVIN E FRSA

NEW DATES December 3-4, 2021 – Virtual Conference Canadian National Virtual Conference. Join fellow colleagues in this highly interactive, virtual conference; brought to you by the Canadian Lymphedema Framework, in collaboration with Wounds Canada. The theme is “Moving evidence into practice”. n www.canadalymph.ca

P urchase P rice: £15 p er cop y A ll procee d s go to Lymphoed e ma res earc h , in p ar tn ers h ip with St Georg e’s H ospital Cha r ity. (Re g is te red Ch arity n o : 1 1 7 1 19 5 )

Order online: http s :/ / s tgeorges hos p italc har ity.b igc ar tel.com/ prod uct/ gemma -levine

INTERNATIONAL RECOGNITION. The International Lymphoedema Framework (ILF) was announced as the winner of the Most Progressive Society Award at the Journal of Wound Care WUWHS Awards ceremony in February 2021. The award was a joint gold award together with the WCET® (World Council of Enterostomal Therapists).

CLF Industry Partners

Alberta Lymphedema Association

The Canadian Lymphedema Framework (CLF) wishes to thank our Industry Partners and Pathways Sponsors for their financial support in making this magazine a reality.

BC Lymphedema Association Lymphedema Association of Manitoba

Pathways Sponsors CANADIAN LYMPHEDEMA FRAMEWORK

PARTENARIAT CANADIEN DU LYMPHOEDÈME

About the CLF: The Canadian Lymphedema Framework is an academic and patient collaboration, working to improve lymphedema management for lymphedema and related disorders in Canada.

26 L y m p h e d e m a p a t h w a y s . c a

The CLF distributes Pathways through direct subscriptions and through its provincial partners.

Lymphedema Association of Newfoundland and Labrador Lymphedema Association of Nova Scotia Lymphedema Association of Ontario Lymphedema Association of Quebec Lymphedema Association of Saskatchewan Charitable Registration 85160 1260 RR0001

Summer 2021

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Lymphedema/Chronic Edema What Every

Physician Should Know

A progressive, chronic inflammatory condition that can affect any area of the body, most commonly the limbs. It is estimated that up to ONE MILLION CANADIANS suffer from this disease; yet most are undiagnosed and not treated.

Early diagnosis and adequate management are important.

1 CAUSES AND RISK FACTORS PRIMARY • Hereditary

• Congenital

SECONDARY •O besity • V enous disease •M any cancers and their treatments (lymph node dissection, radiation) • S urgical interventions • Trauma • I mmobility • Infection

2 COMPLICATIONS AND CONSEQUENCES OF INADEQUATE TREATMENT • Recurrent bacterial cellulitis in the affected limb, risk of septicemia • Skin and tissue changes e.g. papillomata, thickened skin (pachydermia), dermatitis • Chronic wounds, lymphorrhea, lymph cysts • Reduced function, work disability • Negative psychological/body image/social impact

3 ASSESSMENT AND INVESTIGATIONS • Edema (pitting or non-pitting) • S temmer sign • Rule out deep venous thrombosis, cancer, cardiac, renal, liver disease and hypoproteinemia • Identify causes of co-existing pain

4 TREATMENT Skin care

Compression

Exercise and Weight Control

Manual Lymph Drainage

Education

- cleansing - short-stretch bandage systems - moisturizing - compression garments and devices - avoiding trauma

- decongestive exercise regime - regular physical activity - healthy eating

- MLD as required - self lymphatic massage

Education in self-management

Surgical treatments for lymphedema are being piloted and investigated in Canada

Referral to a certified lymphedema therapist or knowledgable clinician for a therapeutic plan and support

5 PHARMACOTHERAPY • N o current effective drug treatments • D iuretics usually not effective unless there is concurrent fluid overload (CHF) • A ntibiotics for cellulitis, antifungals as required

Lymphedema Resources For more information on treating lymphedema and resources for your patients, contact: INTERNATIONAL Visit the International Lymphoedema Framework website (www.lympho.org) for access to International Best Practice Guidelines.

NATIONAL Visit www.canadalymph.ca for comprehensive information about lymphedema, assessment and educational tools for health professionals and how to subscribe to Pathways, Canada’s national lymphedema magazine.

2020 © Canadian Lymphedema Framework • www.canadalymph.ca Adapted with permission from the British Lymphology Society

REGIONAL Contact your provincial lymphedema association for local resources and information.

CANADIAN LYMPHEDEMA FRAMEWORK

PARTENARIAT CANADIEN DU LYMPHOEDÈME

Lymphedema/Chronic Edema What Every

Physician Should Know

Dear reader, More than one million Canadians suffer from lymphedema and/or chronic edema, a progressive, chronic inflammatory condition that can affect any area of the body, most commonly the limbs. Most of these Canadians remain undiagnosed and/or untreated.

Canadian physicians are primarily familiar with cancer-related lymphedema, however recent physiological research has shown that all excess interstitial fluid is handled by the lymphatic system, concluding that any chronic swelling may, in fact, lead to lymphedema or lymphatic failure. While some cases of lymphedema are mild and may resolve on their own, any edema lasting more than a few months causes permanent lymphatic damage. Lymphedema usually requires higher compression classes and specific decongestive approaches.

Early diagnosis and adequate management are critical to prevent complications such as recurrent bacterial cellulitis and wounds.

Prevalence in Canada 1 million* for 36 million population

Chronic venous insufficiency (Prevalence undetermined)

Canadian Lymphedema Framework 2018

Morbid obesity related 570,000

Mean incidence of cancer related lymphedema from systematic reviews

Cancer related 310,000

All cancers: 15% Breast cancer: 18% Melanoma: 18% lower extremity, 3% upper extremity Gynecological: 20% uterine, cervical, vulvar Genitourinary: 10% prostate, bladder, penile Sarcoma: 30% Head and neck: 4% Reference: Shaitelman et al 2015

Disabilities/chair-bound 83,000 Surgeries non-cancer 40,000

*USA up to 10 million LE (Stanford) extrapolated to Canada = 1 million

Primary lymphedema 20,000

We developed this reference card through the Canadian Lymphedema Framework (CLF) as an education tool to alert physicians regarding the latest best practice recommendations for the identification and treatment of this condition.

Regards, Dr. David Keast, MSc MD FCFP Co-Chair, Canadian Lymphedema Framework

CANADIAN LYMPHEDEMA FRAMEWORK

Dr. Anna Towers, MD FCFP Co-Founder, Canadian Lymphedema Framework

PARTENARIAT CANADIEN DU LYMPHOEDÈME