Download Lymphedema and its Treatment

www.mcgill.ca/lymphedema-research
2010 ANNUAL REPORT
(January -December 2010)
Dr. Anna Towers
Director
McGill Lymphedema Research Program
MUHC-Montreal General Hospital, L10-212
1650 Cedar Avenue
Montreal, Quebec
Canada H3G 1A4
Tel: (514) 934-1934 ext. 43964
Fax: (514) 934-8415
Email: [email protected]
Département d’oncologie l’université McGill/McGill Department of Oncology
Centre universitaire de santé McGill/McGill University Health Centre
Hôpital général juif-Sir Mortimer B. Davis-Jewish General Hospital
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
TABLE OF CONTENTS
Page
MESSAGE FROM THE DIRECTOR……………………………………………………... .3
BACKGROUND…………………………………………………………………………....... .6
McGILL LYMPHEDEMA RESEARCH PROGRAM…………………………………… .7
Organogram………………………………………………………………………..... .7
About the Program…………………………………………………………………. .7
Research Team………………………………………………………………………..8
Research Program…………………………………………………………………...12
Current Lymphedema-Related Research Grants………………………………… 16
Publications…………………………………………………………………………. 16
Invited Presentations……………………………………………………………….. 17
Other Presentations………………………………………………………………….19
Abstracts……………………………………………………………………………...19
OVERVIEW OF THE LYMPHEDEMA CLINICS………………………………………. 20
MUHC - Montreal General Hospital………………………………………………20
MUHC- Royal Victoria Hospital – Cedars Breast Centre………………………21
Jewish General Hospital – Segal Cancer Centre…………………………………22
MUHC LYMPHEDEMA EDUCATIONAL INITIATIVES………………………………23
Education for Health Care Professionals…………………………………………...23
Education for Lymphedema Therapists…………………………………………….23
FINANCIAL REPORT……………………………………………………………………… 24
2
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
MESSAGE FROM THE DIRECTOR
The past several years has seen increasing interest in survivorship programs within cancer
services. Although in Quebec and across Canada they are usually charitably funded, there is a
movement to offer the best medical and psychosocial support possible to those that suffer the
sequelae of cancer treatment. Lymphedema advocacy groups are being listened to, there is a
national and international organization to promote best practice guidelines and improved patient
care, and educational programs are being drafted. Buoyed by the cancer-related efforts, those
with lymphedema from other conditions are also beginning to have their needs discussed. The
McGill Lymphedema Research Program (MLRP) has played a leadership role in these efforts.
Nevertheless, at the time of this writing, lymphedema treatments are not covered by Medicare in
Quebec. Cancer survivors with this condition either must spend thousands of dollars of their
own funds yearly or go untreated. Because of lack of awareness amongst health care
professionals, diagnoses are often made late, if at all, and patients are not referred for the
physical treatments that are recommended for lymphedema and related disorders. Research
programs are rudimentary and many of the basic treatments and prevention strategies require
further clinical testing in randomized trials.
Our research is helping to document how even modern cancer treatments can have long-term,
negative effects on general and limb function, including pain, swelling (e.g., lymphedema),
heaviness, and reduced range of motion (ROM). Using breast cancer as an example, our CIHRfunded longitudinal research indicates 76% of our participants (n=719) experienced arm
morbidity in some form (i.e. pain, ROM restrictions, lymphedema) at 6-12 months post-surgery.
Twelve months later (18-24 months post-surgery), 62% (n=476) experienced arm morbidity.
Further, our results indicate that, survivors with some arm pain, 2½-3 years post-surgery, are
almost 8 times more likely to experience a loss in productivity, compared to those survivors
without pain. Women with some range of motion limitations are 4 times more likely to
experience productivity loss 2½-3 years post-surgery. The findings point to the importance of
rehabilitation services. These problems are not unique to breast cancer but are found with
melanoma, sarcoma, gynaecological, head and neck, prostate and colorectal cancer.
The McGill Lymphedema Research program is committed to lead in furthering the lymphedema
agenda until the injustices and lack of awareness issues are addressed and resolved. We are here
because of the lack of services, our passion for patients, and to advocate on their behalf, to act as
a team to change things. We are creating opportunities to do our own clinical research, as well as
influencing change in medical and allied health undergraduate curricula. We are forming
collaborative research partnerships and are accessing masters and doctoral students who may be
integrated into research.
Our overall long-term purpose is:
1. To advocate on behalf of lymphedema patients to improve clinical care and ensure that
lymphedema best practice standards are integrated within health policy
2. To integrate teaching of the lymphatic system, its pathologies and treatment into the
undergraduate medical and allied health curricula
3
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
3. To undertake interdisciplinary epidemiological and clinical research and to promote the
professional credibility of lymphedema therapy through improving the evidence base
This year has seen exciting developments for the McGill Lymphedema Research Program. We
are Canadian leaders in cancer-related lymphedema. Dr. Anna Towers is co-chair of the
Canadian Lymphedema Framework (CLF) with David Keast of the Lawson Research Institute in
Ontario, who represents non-cancer programs. The CLF charitable corporation promotes the
development of lymphedema research, education and clinical services in Canada and works with
the International Lymphoedema Framework (ILF) to promote development internationally. The
CLF co-chairs are on the organizing committee for the June 2011 ILF conference in Toronto.
Following the successful Canadian stakeholder meeting last year, the CLF has developed a
national strategy for the development of lymphedema clinical services and research, created an
advisory board and formed three active volunteer working committees in Research, Education
and Partnership Development.
The McGill program is expanding and is comprised of clinical staff, educators and researchers at
three different sites of the McGill University Health Centre (MUHC) and at the Jewish General
Hospital (JGH). Natasha Grant, Casi Shay and Dorit TIdhar are three physiotherapists who are
part of the program. Marie-Ève Letellier, a lymphedema therapist and McGill PhD candidate, is
pursuing her doctoral studies in lymphedema and arm morbidity research. This will make her
one of the few PhD lymphedema clinicians in Canada, augmenting research capacity in this area.
Pamela Hodgson is a Masters qualified therapist who provides clinical, administrative and
research support. The program has strong national and international links that will enable it to
pursue research on topics that have been deemed a priority by stakeholders. Research
involvement ranges from prevalence studies to studies on prevention and body tissue
composition, as well as participatory action research projects to help fuel development in
Canada.
Our educational involvement continues to be active at the international, national, provincial and
local levels. To fill a grossly unmet need training programs for nurses and for physiotherapists
have been developed and conducted by Dorit Tidhar PT, MSc, an international lymphedema
expert and trainer from Israel who is spending two years working with us in Montreal under
MLRP sponsorship. Dr. Anna Towers is a trainer in the Dr. Vodder School International, coleader of the CLF and active with the ILF scientific committee.
Throughout the world, lymphedema training programs have tended to develop in isolation and
separate from academic research centres. This needs to be corrected by ensuring that major
clinical and educational programs are university based. With ILF and CLF committees, we are
working to create standards of training and develop university curricula across Canada.
On the advocacy front, members of MLRP are very active in a Quebec Ministry of Health
committee that is advising on policy regarding reimbursement of compression garments for
lymphedema.
Securing adequate space for our programs remains an issue in this era of expanding health care
and educational activities in the McGill medical system – all within limited premises. Through a
4
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
grant that has recently been awarded to the MUHC for lymphedema program infrastructure
development by the Fondation Québécoise du Cancer du Sein, we hope to secure adequate
therapeutic and research space to expand our interdisciplinary lymphedema services, educational
programs and research activities.
We are proud to be Canadian and international leaders in the prevention and treatment of
lymphedema and related morbidity caused by cancer treatment. We will continue to develop our
young academic interdisciplinary programs to support those who suffer from lymphedema and
related conditions.
I would like to express my thanks to Dr. Gerald Batist for his encouragement and to Pamela
Hodgson of the MUHC Lymphedema Program and Dr. Gayle Shinder of the Department of
Oncology for their valuable administrative support. We appreciate the support of the McGill
teaching hospitals and their Foundations, and the general public in our endeavours.
Anna Towers MDCM, FCFP
5
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
BACKGROUND
Lymphedema and its Treatment
Chronic lymphedema, which is swelling caused by the lymphatic system’s failure to adequately
drain fluid and proteins from the interstitial space, is usually due to a complication of cancer
treatment. The incidence following breast cancer varies widely in different reports depending on
the definition used, differences in measurement techniques, extent of surgery, radiotherapy doses
and length of follow-up, but averages 15-25%. These problems are not unique to breast cancer
but are found with melanoma, sarcoma, gynaecological, head and neck, prostate and colorectal
cancer. As a result of swelling, the limb may feel tight and heavy, and pain may be present
because of associated nerve injuries, venous obstruction, and ligament strain. If left untreated,
loss of limb function and chronic infections may occur. Lymphedema can cause psychological
distress that can have a profound effect on quality of life.
The current recommended treatment for chronic lymphedema is Complete Decongestive Therapy
(CDT) which aims to improve lymph drainage through existing lymphatic vessels and to
encourage collateral circulation. It can be subdivided into two treatment phases: 1- an edema
reduction phase of approximately 1 month that involves specific massage techniques (manual
lymphatic drainage) and application of non-elasticized bandages, for 5 days per week. Electric
pneumatic compression machines may also be used in this stage of treatment. 2- a maintenance
phase, which is a life-long commitment to wearing a graduated pressure elastic garment during
the day and to performing daily specific remedial exercises. Additional manual lymph drainage
and bandaging can be performed as needed during the maintenance phase in those with more
severe degrees of lymphedema. Drug treatments are not effective for chronic lymphedema.
Therefore, research into physical treatments and methods of self-management are of primary
importance in this chronic life-long condition.
6
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
McGILL LYMPHEDEMA RESEARCH PROGRAM
About The Program
The mission of the McGill Lymphedema Research Program is to increase the quality of life of
individuals suffering from cancer-related lymphedema.
The specific goals of the Program are the following:
● Increase awareness of the morbidity associated with cancer treatments and of lymphedema
in particular, and advocate for the development of adequate rehabilitation programs to meet
the needs of the affected persons.
● Conduct research on cancer-related lymphedema with a multi-disciplinary group of local,
national and international researchers.
● Contribute to the development of international best practice guidelines and promote
treatment modalities that are based on current pathophysiological understanding of
lymphedema.
● Advocacy to obtain coverage of treatments for lymphedema and related conditions under
Medicare.
A variety of activities have been undertaken in order to achieve the above goals:
 Organization of educational programs for health care professionals, government agencies
and the public at large, in collaboration with the Lymphedema Association of Quebec.
 Clinical research on lymphedema prevalence, risk factors, morbidity and treatments, in
collaboration with Canadian and international colleagues.
 Provision of clinical and support services for the prevention, assessment and follow-up of
patients with cancer-related lymphedema.
7
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
The administrative base for these activities is the Vendôme site of the McGill University Health
Centre (MUHC), and the research sites are the MUHC, the Jewish General Hospital (Segal
Cancer Centre), and the Cedars Breast Clinic.
Research Team
The McGill Lymphedema Research Program operates within a multidisciplinary team of
clinicians and PhD researchers whose areas of expertise include medical, surgical and radiation
oncology, palliative care, sociology and physiotherapy.
A) McGill Co-Investigators
Anna Towers, MD is Associate Professor of Oncology and Director of the McGill Lymphedema
Research Program. She is a palliative care physician with a special interest in lymphoedema and
cancer rehabilitation. She trained in lymphedema management under Drs John and Judith
Casley-Smith in Australia in 1995. She has been co-ordinating the Lymphedema Program at the
McGill University Health Centre for the past 16 years. Since 2009 she is Medical Director of the
Dr. Vodder School International where she trains four cohorts of therapists per year in Canada
and the USA. She is the Founding Co-Chair of the Canadian Lymphedema Framework which
aims to improve access to care for lymphedema and related disorders. She was Director of the
Palliative Care Division, McGill University from 1999-2009. She is involved in international
palliative care development projects and, since 2004, has been chairing the biennial Montrealbased biennial Congress on Palliative Care. She is the author of numerous articles and book
chapters on lymphedema and is recognized as an advocate for the development of lymphedema
services in Canada.
Marie-Ève Letellier, PhD (Candidate) is a doctoral candidate in Rehabilitation Science where
the focus of her work is on lymphedema and other arm morbidity following breast cancer
treatment. She is supervised by Dr. Nancy Mayo, with Dr. Anna Towers on her thesis committee,
and was awarded the Richard and Edith Strauss Fellowship in Rehabilitation Science for 2009 and
2010 ($22 000) and the Recruitment Excellence Fellowship in 2007 ($5000). Ms. Letellier has
been trained in Manual Lymphatic Drainage and Combined Decongestive Therapy - Vodder
Method, Aqualymphatic Therapy (Tidhar Method) and Dance Exercise for Lymphedema
Treatment (Lebed Method). She pioneered the opening of the Cedars Breast Centre clinical
lymphedema assessment and treatment program, and is a Lymphedema Therapist at Physio Extra
in Montreal where she provides treatment to an at-risk cancer population and to people suffering
from lymphedema. Ms. Letellier has lectured on topics such as cancer and exercise (postgraduate
students at Université du Québec à Montréal, Agence de santé et services sociaux de l’Estrie), the
lymphatic system and lymphedema (postgraduate students at Université de Sherbrooke) and an
introduction to the lymphatic system (to undergraduate students at the Université de TroisRivières). She was also invited to present “Aqualymphatic exercises as an alternative therapy for
chronic breast cancer related lymphedema, a randomized controlled pilot study”.
Mary Ellen MacDonald PhD is a medical anthropologist who heads the MUHC Qualitative
Research Group and who is collaborating on projects related to the development of the Canadian
Lymphedema Framework.
8
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
Robin Cohen, PhD is an Associate Professor in the Department of Oncology at McGill, and the
Research Director for the Division of Palliative Care in the Department of Oncology. Her
research interests focus on quality of life issues in those with cancer-related problems. She
played a role in the design, data analysis and write-up of the study Aqualymphatic exercise as an
alternative therapy for lymphedema management following breast cancer: a randomized
controlled pilot study.
Franco Carnevale, RN, MSc, PhD, is an Associate Professor in the School of Nursing and the
Faculty of Medicine (Pediatrics). He is also an Adjunct Professor in Counseling Psychology and
an Affiliate Member of the Biomedical Ethics Unit. His research interests include ethics and
psychosocial issues in illness as well as qualitative research methodology. He played a role in the
design, data analysis and write-up of the study The Psychosocial Effects of Cancer-Related
Lymphedema.
Antonio Vigano, MD, MSc is Director of the McGill Nutrition and Performance Laboratory.
http://mnupal.mcgill.ca/index.php?option=com_content&view=category&layout=blog&id=16&I
temid=61&lang=en-GB
Leonard Rosenthall, MD is a professor of radiology at McGill University, erstwhile director of
Nuclear Medicine at McGill University Health Centre. Throughout his career, Dr. Rosenthall has
been involved in many interdisciplinary research projects inovlving the application of nuclear
medicine to many other specialities. He is now collaborating on projects involving DEXA and
bio-impedance spectroscopy as measurement tools to evaluate breast-cancer related
lymphedema.
B) Lymphedema Therapists
Natasha Grant, Pht is a physiotherapist specialized in cancer rehabilitation and lymphedema
management. Ms. Grant worked with the McGill Cancer Nutrition-Rehabilitation (CNR) program
from 2004 to 2007. She spearheaded the JGH Segal Cancer Centre Lymphedema Clinic in April
2007, which was the first hospital-based clinic in Montreal to offer both evaluation and treatment
for oncology-related lymphedema. She has training in Combined Decongestive Therapy (Vodder)
and Aqualymphatic Therapy (Tidhar method). Ms. Grant has given many lectures on cancer
rehabilitation and lymphedema management at the JGH Hope & Cope Wellness Centre, McGill
University Physiotherapy Cancer Rehabilitation course, and JGH surgical grand rounds and inservices to oncology clinicians. She will be collaborating with Dr. Mark Basik (JGH surgical
oncologist), the principal investigator on a project looking at the Axillary Reverse Mapping
(ARM) technique to reduce the incidence of breast cancer related lymphedema.
Marco Raffis, Pht is a physiotherapist and kinesiologist specializing in lymphedema treatments
and oncology rehabilitation since 2000. In 2000 he was trained in the Vodder method in Victoria
BC and obtained a diploma in manual therapy from St-Augustine University Florida. He was on
the medical review board of the first International Lymphedema Conference in Montreal in 2001
and has given multiple lectures on lymphedema treatments to medical professionals working in
hospitals throughout the province of Quebec and for the Lymphedema Association of Quebec.
Casi Shay, Pht is a physiotherapist with 37 years’ experience in both inpatient and outpatient
physiotherapy and specializing for the past ten years in lymphedema management and outpatient
9
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
breast cancer rehabilitation services. She is a member of the team in the MUHC Lymphedema
Clinic and has recently become interested in body composition and lymphedema. She is involved
in protocol development using dual-energy x-ray absorbimetry (DEXA) to assess fat mass in
breast-cancer lymphedema, with Dr Anna Towers and Dr Antonio Vigano as co-investigators. She
has training in Combined Decongestive Therapy (Klose Norton) and Aqualymphatic therapy
(Tidhar Method) and is certified with the Lymphedema Association of North America (LANA). In
addition to giving lectures at the McGill School of Physical and Occupational Therapy as well as
at community organizations, she coordinated educational and support group services for the
Lymphedema Association of Quebec since 2004.
Dorit Tidhar, MPt, Pt, is a physiotherapist and Casley-Smith trained therapist who co-ordinates
the lymphedema teaching program at the McGill University Health Centre in Montreal and
works in the MUHC Lymphedema Clinic. Her permanent lymphedema practice is in Israel,
where she has co-ordinated the lymphedema program for one of the four health networks and
been an active advocate for lymphedema development and research. She is the creator of Aqua
Lymphatic Therapy –Tidhar method. She teaches courses for therapists and is actively involved
in several lymphedema treatment-related research projects.
Pamela Hodgson, MSc, RMT is a lymphedema therapist trained in Complex Decongestive
Therapy (Dr. Vodder School). She is research assistant to Dr. Anna Towers and assists in the
McGill University Health Centre Lymphedema Program. She has designed and delivered
educational workshops on lymphedema to healthcare practitioners and to the public. She is
currently working with Dr. Towers and others to develop lymphedema-focused research projects
and is a founding member of the Canadian Lymphedema Framework.
C) Other University Co-investigators and Graduate students
Robert D. Kilgour, Ph.D., FACSM is a Professor and the Chair of the Department of Exercise
Science at Concordia University and Associate Director of the McGill Nutrition and
Performance Laboratory (MNUPAL). His primary research area examines the factors that
contribute to cancer-related fatigue. He is currently exploring how the neuromuscular system
influences fatigue in cancer. He is also interested in the assessment of breast cancer related
lymphedema (BCRL) and describing how specific therapeutic interventions could modify BCRL
by reducing swelling, inflammation, and fatigue, and ultimately enhancing the quality of life in
cancer patients.
Anne Newman, BSc, MSc (c) holds a Bachelor's degree in Exercise Science with a
specialization in Clinical Exercise Physiology and is currently enrolled in the Exercise Science
Master’s program at Concordia University under the supervision of Dr. Robert Kilgour. Her
research interests include segmental body composition assessment and investigating the efficacy
of treatments for women with breast cancer-related lymphedema. She works as a research
assistant for MNUPAL collecting data on the assessment of BCRL using Dual-energy X-ray
Absorptiometry and multi-frequency bioelectric impedence spectrometry. She has presented a
research poster of her thesis proposal Comparing the effectiveness of three differerent treatments
for women with breast cancer-related lymphedema. at the International Graduate Course
sponsored by Concordia University and the University of Copenhagen. Anne’s previous work
experience includes seventeen years as a shiatsu practitioner in which time she developed
10
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
lectures and taught in the clinic that she co-founded.
D) Program Annual Reports and Website
Gayle A. Shinder, PhD is the research grants coordinator for the McGill Department of
Oncology and also works on a wide range of special projects for the various Programs in the
department. She has worked with Dr. Towers on a number of projects since 2001 including the
development and management of the McGill Lymphedema Research Program (MLRP) website
(www.mcgill.ca/lymphedema-research), and the compilation of the 2005, 2007-2008 and 20082009 MLRP Annual Reports.
E) McGill Collaborators
Marc David, MD: McGill Department of Oncology, Radiation Oncology, MUHC
Marie Duclos, MD: McGill Department of Oncology, Radiation Oncology, MUHC
Segio Faria, MD: McGill Department of Oncology, Radiation Oncology, MUHC
David Fleiszer, MD: McGill Department of Oncology, Surgical Oncology, MUHC
Carolyn Freeman, MB, BS: McGill Department of Oncology, Radiation Oncology, MUHC
Christine Lambert, MD: McGill Department of Oncology, Radiation Oncology, MUHC
Antoine Loutfi, MD: McGill Department of Oncology, Surgical Oncology, MUHC
Catherine Milne, MD: McGill Department of Oncology, Surgical Oncology, MUHC
David Roberge, MD: McGIll Department of Oncology, Radiation Oncology, MUHC
Francine Tremblay, MD: McGill Department of Surgery, MUHC
F) Canadian and International Co-Investigators and Collaborators
Christine Moffatt, RN, PhD, University of Glasgow
Roanne Thomas-MacLean, PhD, University of Saskatchewan
Elizabeth Quinlan, PhD, University of Saskatchewan
Thomas Hack PhD, University of Manitoba
Winkle Kwan, MD, University of British Columbia
Baunkje Miedema, PhD, Dalhousie University
Sue Tatemichi MD, Dalhousie University
Andrea Tilley PT, Dalhousie University
Martina Reddick RN, St. John’s, Newfoundland
Research Program
Our main research development program initiative focuses on promoting a research strategy for
Canada through the Canadian Lymphedema Framework.
Ongoing research projects include:
1. Development of a Canada-wide collaboration of lymphedema stakeholders to promote
lymphedema awareness through improved education and research.
2. The development and assessment of interdisciplinary programs with educational tools and
strategies to prevent lymphedema in women after breast cancer treatment.
3. A pilot study looking at the role of an interdisciplinary lymphedema team in a tertiary referral
centre.
4. Assessment of the prevalence of and risk factors for developing lymphedema, pain and
functional problems following breast cancer treatment.
11
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
5. Research on various exercise treatments for lymphedema.
6. Research on body composition of patients with lymphedema.
7. Comparing three methods for treatment of breast cancer-related lymphedema.
At the present time, treatments for lymphedema are not covered under Medicare. The research
programs conducted by the McGill Lymphedema Research Program, and its Canadian and
international co-investigators and collaborators, will help provide a solid evidence base required
to convince policymakers that it is a priority to fund prevention and treatment programs for
lymphedema and related conditions.
Current Research Studies
1. Development of the Canadian Lymphedema Framework
The recently formed Canadian Lymphedema Framework (CLF), co-directed by Dr. Anna
Towers of McGill and Dr. David Keast of the Lawson Health Research Institute, London,
Ontario, is an academic and patient stakeholder collaboration, part of an international initiative to
promote research, best practice guidelines and lymphedema clinical development worldwide.
The CLF works closely with the International Lymphedema Framework (ILF) which is based in
the UK. The CLF is and incorporated charity, led by academic lymphedema experts and patient
advocates from the Lymphedema Association of Ontario and the Lymphedema Association of
Quebec. In 2010 the CLF appointed an Advisory Board with representatives from a variety of
stakeholders from across Canada and developed a strategic plan to define education, research and
awareness development strategy for Canada. Volunteers from across Canada and representing
different health care professions, researchers, industry and patient advocates met in November
2010 to organize working groups in Education, Research and Partnership Development to
implement the strategic plan with the long term goal of improved management for lymphedema
in Canada.
2. Long term disability after breast cancer: building an empirical foundation for education,
prevention and rehabilitation
CIHR-Funded Study, 2009-2014. This is a renewal of the 2004-2009 study entitled Arm morbidity
after breast cancer: Building a foundation for education, prevention and rehabilitation.
PI: Roanne Thomas-MacLean, University of Saskatchewan.
Co-Investigators: Anna Towers, McGill University; Thomas Hack, University of Manitoba;
Winkle Kwan, University of British Columbia; Baukje Miedema and Sue Tatemichi of Dalhousie
University; Andrea Tilley, St. Joseph’s Hospital, Atlantic Health Sciences Corporation
McGill Collaborators: Marc David, Marie Duclos, Sergio Faria, Carolyn Freeman, Christine
Lambert, Antoine Loutfi, Catherine Milne, David Roberge, Francine Tremblay, David Fleiszer
We are conducting a prospective cohort study with a sample size of 745 breast cancer patients
who are followed for 5 years. The project began in January 2005. Participant accrual concluded
in 2008, and data collection will end in September 2013. The purpose of this study is to create
interdisciplinary knowledge about the impact of arm morbidity after breast cancer treatment,
through the generation and testing of hypotheses about arm morbidity and its relationship to
overall health and psychosocial well-being.
12
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
Our original study, Charting the course of arm morbidity after breast cancer: A prospective,
longitudinal follow up (Phase I; 2005-2008) addressed 3 forms of arm morbidity affecting the
upper quadrant: lymphedema, pain, and limited ROM. Phase I data provided insight on the early
impact of arm morbidity, however the long-term impacts (i.e., 2-5 years post-surgery) are even
more important and understudied. Phase II (2009-2014) will examine women’s experiences of
arm morbidity using an interdisciplinary, mixed-methods approach, and will study etiology,
impact and disability. Our six objectives in Phase II are:
1. To continue to chart the course of lymphedema, pain, and ROM every 6 months, providing
rigorous documentation of the incidence of arm morbidity in breast cancer survivors;
2. To continue to identify possible triggers of arm morbidity;
3. To further document, measure, and analyze psychological and social impacts of arm
morbidity;
4. To compare provision of care and access to appropriate treatment across demographic
groupings;
5. To qualitatively explore the long-term impact of arm morbidity; and
6. To create a detailed model capturing the impact of arm morbidity.
Our study is the first to involve the collection of descriptive, longitudinal data on arm morbidity
following breast cancer treatment. Our findings show aspects of arm morbidity require a long
study period before the natural history and psychosocial impact can be fully documented and
analyzed. Longitudinal data demonstrating incidence rates, etiology, disability, psychosocial
impact, and access to treatment will aid policy makers in the development of multidisciplinary
rehabilitation programs to address problems in a holistic fashion and in a timely manner.
Furthermore, our findings are relevant for the majority of the cancer population, as breast,
prostate, gynecological, and head/neck cancer patients may experience treatment effects (from
lymph node dissection and radiotherapy) such as lymphedema, pain, and loss of function.
3. The role of an interdisciplinary lymphedema team in a tertiary referral centre: a pilot project
Funded by the Lymphedema Association of Quebec
Our vision is for adequate and well-timed lymphedema services to be available in Quebec and
for these services and rehabilitation aids to be covered by Medicare. This requires the awareness
and the support that will lead to the creation of interdisciplinary clinics that provide prevention,
assessment and treatment services as outlined in the International Best Practice Guidelines.
This present project focuses on: 1. developing appropriate interdisciplinary lymphedema
services at the MUHC, with outcomes that are transferable to other cancer centres; 2. developing
training programs for health professionals, and in particular for therapists and nurses who will
offer prevention information to all cancer patients at risk, and who will provide treatment
services to those in the palliative phase and to those who require home care.
The eventual outcome would be appropriate and well-timed information and rehabilitation
services to the cancer population living with lymphedema and related conditions.
13
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
4. Axillary Reverse Mapping in Breast Cancer (ARM)
PI: Dr. Mark Basik (Surgical Oncology JGH)
Collaborator: Natasha Grant
5. Aqualymphatic exercise as an alternative therapy for lymphedema management following
breast cancer: a randomized controlled pilot study
Marie-Ève Letellier, Anna Towers and Robin Cohen
(This is the research project entitled Evaluation of group remedial exercises for chronic breast
cancer related lymphedema. St. Pierre D, Towers A, Cohen R, Collet JP. which was funded by a
Canadian Cancer Society Feasibility Grant, 2005-2008.)
Background: Cancer rehabilitation is an understudied area in which palliative care programs are
taking an interest. Life-long lymphedema is a prevalent complication of breast cancer treatment,
producing significant morbidity. Drugs are not effective for lymphedema; therefore, research
into physical treatments and methods of self-management are important. Although case series
suggest a benefit with daily remedial exercises, and water-based exercises are theoretically
superior, no randomized controlled trials (RCTs) have been published in this area.
Objectives: To investigate the feasibility of conducting a larger RCT aimed at assessing the
effectiveness of water-based group remedial exercises.
Methodology: We conducted a randomized controlled single-blind pilot study in which 25
women with breast cancer related lymphedema – 24 mild stage (less than 25% difference) and
one moderate stage – from the McGill University Hospital Centre Lymphedema Clinic were
allocated into a standard treatment or standard treatment plus water-based exercise group, for 12
weeks. They were evaluated prior to and following a 12 week intervention period, and following
a further 12 week follow-up period. We measured changes in arm swelling using waterdisplacement volumetry and limb girth circumference. We assessed pain (SF-MPQ), upper
extremity function (DASH), range of motion, grip strength and quality of life (FACT-B).
Structured qualitative interviews were conducted regarding the impact of the water exercises.
Results: Weekly aqualymphatic exercises were acceptable to patients: of 13 participants, 8 (62%)
participated in at least 9 of 12 sessions. The qualitative data suggest that women find valuable
support in exercising with other women suffering from lymphedema. Some reported that they
experienced the aqualymphatic exercices as the equivalent of receiving manual lymph drainage.
The quantitative data suggest that there are no differences between the intervention and the
control groups. Further pilot studies, recruiting women with moderate lymphedema, are required
in order to justify a full scale RCT to assess the method’s effectiveness.
6. Assessing body composition in arms of women with breast-cancer related lymphedema: a pilot
study
Anna Towers, Antonio Vigano, Leonard Rosenthall, Anne Newman, Pamela Hodgson, Carol
Shay, Robert Kilgour
Chronic edema due to lymphatic insufficiency may occur in any body part as a result of different
disease states as well as surgical and therapeutic interventions. Breast cancer-related
14
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
lymphedema (BCRL) is a common form of swelling that occurs in approximately 25% of women
following surgical removal and/or radiation of axillary lymph nodes (Petrek et al., 2001).
Initially, the swelling is due primarily to the accumulation of extracellular fluid (ECF); however,
over time the composition of the ECF compartment can change and transform into fibrotic
lesions and abnormal fat deposition. As a result of this tissue transformation it is often difficult to
effectively treat later stages of lymphedema. Although decongestive therapies tend to eliminate
excess interstitial water and proteins from the ECF space, they have little impact on the
elimination of fat. Measurement devices that are both reliable and precise in assessing tissue
composition are urgently needed in order to develop more accurate staging, and effective
treatment for lymphedema.
Dual-energy X-ray Absorptiometry (DXA) and Multifrequency Bioelectric Impedance
Spectroscopy (BIS) are two measurement devices that have been shown to be relatively safe and
simple to assess tissue composition during the progressive development stages of lymphedema.
This observational pilot study aims to gather preliminary data regarding the feasibility of using
DXA and BIS to assess fat composition and fat/fluid ratio between dominant and non-dominant
arms of women with unilateral BCRL. Twenty women with BCRL and a clinical diagnosis of
stage 1 or stage 2 lymphedema will be recruited from the MGH Lymphedema Clinic. Using
DXA and BIS, a trained technician will measure participants in a test retest sequence. Our aim is
to use this pilot data to plan future studies to evaluate and predict the effect of different
lymphedema treatment modalities.
7. Comparison of the efficacy of three methods of treatment for women with breast cancerrelated lymphedema: a pilot study
Anna Towers, Anne Newman, Dorit Tidhar, Leonard Rosenthall, Antonio Vigano, Robert Kilgour,
Pamela Hodgson, Carol Shay
The incidence of breast cancer related lymphedema (BCRL) is estimated at 6-83% for women
who undergo mastectomy, axillary node dissection and/or radiation treatment. The resulting
physical (e.g., pain, numbness, and fatigue) and functional (e.g., strength and range of motion)
symptoms place a constant and significant burden on the quality of life of cancer survivors.
These negative outcomes create the need for effective treatments. The purpose of this pilot study
is to compare the efficacy of three treatments for women with breast cancer-related lymphedema
using 3 methods of volume measurements. Study Objectives: The study objectives are: 1) To
assess the immediate and short-term effects of three different treatments for BCRL (e.g., manual
lymphatic drainage (MLD), aqua lymphatic therapy (ALT), and a Casley-Smith based exercise
routine (CSER), 2) To determine which of the three treatments is most effective in maintaining
or reducing limb volume over a 24 hour period, 3) To record any changes in physical symptoms
after each treatment and, 4) To ascertain which of the three modalities the women prefer.
Methodology: This is a pilot study (n=15) where we will recruit women between the ages of 35
and 75 with Stage 1 or 2 lymphedema from the McGill University Health Center Lymphedema
Clinic. All women will be randomly assigned to complete all three interventions. Each
intervention will be completed once and will last approximately 45min. There will be a 2 week
“washout” period between interventions to eliminate any carry-over effects of the previous
treatment. Procedures: Bilateral limb measurements to estimate changes in limb volume will be
15
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
done using Dual-energy X-ray Absorptiometry (DXA), multi-frequency, bio-impedance
spectroscopy (MFBIS) and circumferential arm measures (CAM). The Lymphedema Breast
Cancer Questionnaire (LBCQ) will be used to subjectively gauge the degree of heaviness,
tightness, numbness, and aching experienced by the women. Measurements will be taken pretreatment, and 3-10min, 30min, 60 min and 20-24 hrs following treatment. After completion of
the final intervention a three question questionnaire on modality preference will be administered.
Current Lymphedema-Related Research Grants
Defining Research and Development Priorities for Lymphedema Care in Canada: Launching of
the Canadian Lymphedema Framework. Towers A, Keast D, MacDonald ME, Kennedy A,
Pritzker R. Canadian Breast Cancer Research Alliance CBCRA KT-link grant no. 020637.
$10,353. 2009-2010
Long-term disability after breast cancer: Expanding an empirical foundation for education,
prevention and rehabilitation. Thomas-MacLean R, , Kwan W, Hack T, Miedema B, Tatemichi
S, Tilley A. Towers A. CBCRA/CIHR operating grant. $587,852. 2009-2014
Evaluation of an interdisciplinary program for lymphedema prevention and treatment. Towers
A. Lymphedema Association of Quebec. $40,000. 2008-2010
Publications
Peer-Reviewed Journals
Thomas F. Hack, Winkle B. Kwan, Roanne L. Thomas-MacLean, Anna Towers, Baukje
Miedema, Andrea Tilley, and Dan Chateau. Predictors of arm morbidity following breast cancer
surgery Psycho-Oncology (2010) Psycho-Oncology, Psycho-Oncology 19: 1205–1212, Nov
2010.
Thomas-MacLean R, Towers A, Quinlan E, Hack T, Kwan W, Baukje Miedema, Andrea Tilley
& Paul Graham. “This is a kind of betrayal”: A Qualitative Study of Disability after Breast
Cancer. Current Oncology. 16 (3) 26-32, 2010.
Roanne Thomas-MacLean, Paul Spriggs, Elizabeth Quinlan, Anna Towers, Thomas F. Hack,
Sue Tatemichi, Baukje Miedema,Winkle Kwan, Andrea Tilley. Arm Morbidity and Disability:
Reporting the Current Status from Canada. Journal of Lymphoedema, 5(2):33-38, 2010.
Tidhar D., Katx-Leurer, M. Aqua lymphatic therapy in women who suffer from breast cancer
treatment-related lymphedema: a randomized controlled study. 2010. Support Care Cancer. 18,
383-92.
Towers A, Hodgson P, Shay C, Keeley V. Care of the palliative patient with cancer-related
lymphedema. Journal of Lymphedema, 5(1), 72-80, 2010
Other Publications
Norton S., Towers A. Adapting CDT in palliative patients. International Lymphedema
Framework, Palliative Care Template for Practice, March 2010
16
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
Kennedy, A and Hodgson, P. Moving towards Canadian standardization for training and are of
lymphedema. Rehab and Community Care. 2010. Vol 19. 3. 10-14
Book Chapters
Towers A. “Diagnosing dying”, Chapter in Rocker G, Puntillo K, Azoulay E and Judith Nelson J
book End of Life Care in the ICU, Oxford, Oxford University Press, 2010, p.1-3, ISBN 978-010-923924
Invited Presentations
Anna Towers
La compression médicale pour le lymphoedème et les problèmes veineux. Drummondville,
Département de médecine génerale CME, Jan 26, 2010
What do I say?: Communication in palliative patients with lymphedema. Plenary presentation. 2nd
International Lymphedema Framework Conference, Brighton UK 22-25 Mar 2010
An integrated approach to lymphedema prevention and management, CanSupport, McGill
University Health Centre, Montreal, April 13, 2010
New developments on disability, prevention and standards of care, Victoria BC Vodder School
Refresher Course, Victoria BC May 9, 2010
Supportive care for cancer patients at the MUHC: fostering interdisciplinary synergies between
clinical practice and research. Palliative Care Week presentation, McGill University, Montreal
Chair, Session on lymphedema and palliative care. 2nd International Lymphedema Framework
Conference Brighton UK 22-25 May 2010
New developments on disability, prevention and standards of care, Victoria BC Vodder School
Refresher Course, Stowe, Vermont USA, May 30, 2010
La compression médicale pour le lymphoedème et les problèmes veineux. St-Jean, Quebec,
Département de médecine génerale CME, Jun 17, 2010
Nouveaux développements en recherce sur le lymphoedème, Vodder Revision Course, Montréal,
Québec Aug 30, 2010
New Developments in Research on Compression and Lymphedema, Conference of the
Lymphedema Association of Quebec, Aug 30, 2010
Diagnosis and treatment of chronic edemas: the use of compression therapy. West Island
Palliative Care Residence, Quebec. Oct 26, 2010
Best practice guidelines and the role of the Canadian lymphedema Framework. Wound Care
Course for Nurses. University of Victoria, British Columbia, Nov 1, 2010
17
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
Implementing Best Practice Guideline for Lymphedema. Annual conference of the Lymphedema
Association of Ontario. Toronto Nov 20, 2010
Decongestive therapies for lymphedema and self-management strategies. Annual conference of
the Lym0hedema Association of Ontario. Toronto Nov 20, 2010
Therapy of malignant lymphedema. Annual conference of the Lymphedema Association of
Ontario. Toronto Nov 20, 2010
Expert panel on lymphedema management. Annual conference of the Lymphedema Association
of Ontario. Toronto Nov 20, 2010
Marie-Ève Letellier
Le cancer du sein: lymphoedème et activité physique. Agence de santé et services sociaux –
Estrie, April, 2010
Aqualymphatic exercises as an alternative therapy for chronic breast cancer related
lymphedema, a randomized controlled pilot study. Training session for lymphedema therapists in
Aqualymphatic Therapy, Montreal, October, 2010.
Dorit Tidhar
Exercise and lymphedema. Lecture at the Lymphedema Association of Quebec conference.
Montreal, April 2010
Aqualymphatic Therapy Research, Vodder School recertification, Vermont, USA. May 2010
Hydrotherapy for orthopedic swelling, Vodder School recertification, Montreal, August 2010
Clinical reasoning based on graphs in bandaging therapy for lymphedema, Lymphedema
association of Quebec, August 2010
Aqua Lymphatic therapy: Another way of managing your lymphedema. Lymphedema
Association of Ontario conference, Toronto, November 2010.
Clinical reasoning in the management of lymphedema therapy based on measurements graphs –
workshop for health care professionals. Lymphedema Association of Ontario conference,
Toronto, November 2010.
Aqua Lymphatic Therapy: An overview of the method, principles, examples and suggestions on
how to use this medium in lymphedema treatment. Workshop for health care professionals and
patients, Lymphedema Association of Ontario conference, Toronto, November 2010.
Pamela Hodgson
Self-bandaging workshop for Patients. Lecture demonstration. Lymphedema Association of
Quebec conference, Montreal, August 2010.
18
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
Anne Newman
Lymphedema. Third year pathophysiology course, Rehabilitation and Exercise Science Program,
Concordia University, October 2010
Other Presentations
Newman A, Towers A, Tidhar D, Hodgson P, Shay C, Rosenthall L, Vigano A, Kilgour R.
Comparing the effectiveness of three differerent limb volume reduction and maintenance
treatments for women with breast cancer-related lymphedema. International Intensive Graduate
Course in Exercise and Clinical Physiology, Concordia University, Montreal, Oct 25-29, 2010.
Tidhar, D Aqualymphatic therapy training for lymphedema therapists, Training session (7 days)
Lymphedema Association of Quebec, Montreal October 2010.
Tidhar, D. Rehabilitation after cancer treatments - minimizing the risk of developing
lymphedema. McGill University Physiotherapy Program October 2010
Tidhar, D. Measurement lab: Assessing lymphedema, McGill University Physiotherapy Program
October 2010
Abstracts
Dorit Tidhar. Aqualymphatic therapy in women with breast cancer related lymphedema. Oral
presentation at National Lymphedema Network 2010 Conference Orlando USA, September
2010.
19
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
OVERVIEW OF THE LYMPHEDEMA CLINICS
1. McGill University Health Centre (MUHC) - Montreal General Hospital: MUHC
Lymphedema Clinic
The MUHC Lymphedema Clinic, coordinated by Dr. Anna Towers, has been operational since
1994 and was integrated with the Palliative Care Hospital in 1999. In 2009 the clinic moved into
the research facility of the McGill Nutrition and Performance Laboratory (MNUPAL), Blvd de
Maisoneuve, next to the Vendome Metro station. The MUHC Lymphedema Clinic is the largest
medical referral centre for cancer-related lymphedema in Quebec. We help chronic lymphedema
patients manage the physical, psychosocial, and financial consequences of their problem on an
ongoing basis and facilitate the use of as many proven treatment modalities as possible. Since
January 2008, with the assistance of the Lymphedema Association of Quebec, the clinic has
expanded to include a varied interdisciplinary team. The team approach offers each patient an
opportunity to be seen by different health professionals all trained in lymphedema care. The clinic
emphasizes patient education and self-management.
Population served
Referrals come from throughout Quebec, across the four RUIS territories, and occasionally from
Ontario and the Maritimes. There are daily consultations via email and telephone with
lymphedema therapists and patients from all over Canada. The full MUHC clinic operates one
day per week, with a half day twice a month for follow-up and educational sessions. Over 800
patients with cancer treatment related lymphedema are followed. 50% of patients have
lymphedema following breast cancer, 10% melanoma, 8% sarcoma, 7% lung, 4% gynecological,
4% lymphoma and 16% other. This clinic is referred the more complex cases. 10 % of patients
have advanced metastatic disease and are seen conjointly with the palliative care staff in the Day
Hospital. Many of the patients have concurrent morbidity such as pain and functional problems.
Many also need support to be reintegrated into their previous work or they need help to find
different work or to get disability benefits. Dr. Towers also offers formal expertise in legal cases
involving lymphedema.
Staff and volunteers
Since January 2008 a team of volunteers, (two are members of the Lymphedema Association of
Quebec (LAQ)) and the third is a McGill kinesiology student) offer indispensable services,
welcoming patients, offering information, answering questions and providing psycho-social
support where necessary. Since April 2008 a physiotherapist trained in lymphedema treatment
and an exercise trainer have been funded through a grant from the Lymphedema Association of
Quebec. The physiotherapist assists Dr. Towers in evaluating and educating patients, using
clinical decision-making based on volumetric measurements. The exercise trainer provides
information about safe and effective exercise tailored to the needs of each individual patient. In
2010 a receptionist was a welcome addition to the clinic. Patients can now call a dedicated
number to make appointments.
Assessment and treatment process
The interdisciplinary team assesses and educates patients in self-bandaging, risk reduction,
lifestyle change, exercise and other self-care measures. Patients are diagnosed using the
20
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
International Society of Lymphology criteria and an individual treatment plan is developed for
each patient following international Best Practice Guidelines.1 Patients are referred to community
therapists and fitters for treatment and to various movement and exercise classes. Patients are
followed in the clinic according to need, usually quarterly in the first year and then yearly, if in
remission from their cancer.
In 2010 self-bandaging instruction was offered to patients but full lymphedema treatments were
not provided at the clinic because of lack of space and staff. Dr. Towers provides medical support
to community therapists for follow-up, often via telephone. Lack of resources does mean that
patients without financial means and/or private insurance do not receive the care that they require.
In 2011 the clinic will be augmented with a newly-trained lymphedema therapist from the MUHC
Physiotherapy Department and it is anticipated that some treatment services will be provided to
those who can attend three sessions a week and who would be unable to access treatment
otherwise.
Other services
Dr. Towers frequently is called to assess patients for lymphedema within the hospital and since
2008 one of the team has provided lymphedema care to patients and educated nurses in basic
lymphedema bandaging techniques and other aspects of lymphedema care.
At the MUHC Outpatient Wound Clinic, outpatients with lower extremity lymphedema or mixed
edema receive compression therapy from a nurse with a specialty in wound care. An estimated
200 patients are treated annually. Outpatients with post-breast cancer upper extremity
lymphedema can be referred for treatment with compression pump therapy. The Royal Victoria
Hospital has two pumps in use about 45 weeks of the year while the Montreal General Hospital
has one pump that is occasionally used. Pumps are less often used in modern lymphedema
therapy and alternative treatments involving compression bandaging are preferred, according to
international practice guidelines.
2. McGill University Health Centre (MUHC) - Royal Victoria Hospital-Cedars Breast
Centre
The Royal Victoria Hospital Lymphedema Clinic, located at the Cedars Breast Centre, began
seeing patients in September 2008 thanks to the generous support of the Montreal General
Hospital Foundation. The clinic is run by Marie-Ève Letellier, M.Sc. Kinanthropology, a
kinesiologist who has training in Combined Decongestive Therapy (Vodder), Aqualymphatic
Therapy (Tidhar), and Exercise Therapy following breast cancer (Lebed). The clinic sees
predominantly breast cancer patients, although patients with melanoma are also seen.
The mandate of this clinic is to see patients before and (if necessary) after surgery for breast
cancer and follow them over time, to screen for arm or shoulder problems. The clinic provides
Lymphoedema Framework: Best Practice for the Management of Lymphoedema. International
Consensus. London MEP Ltd, ISBN 0-9547669-4-6. 2006 (Dr. Towers was a member of the
international advisory board that drafted these practice guidelines.)
21
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
women with information about the possibility of developing arm morbidity (such as pain,
reduction of range of motion, loss of strength, and/or lymphedema) and encourages them to seek
treatment early should signs appear. If the patient experiences arm morbidity they are either
treated by Marie-Ève Letellier or are referred to a therapist or other health professional
depending on the problem. Those who require intensive therapy have access to two to three
sessions per week of Combined Decongestive Therapy for approximately two to four weeks. The
maintenance phase is then initiated where the patient is encouraged to continue with skin care, an
exercise program, and daily use of compression garments. Patients are also referred to the clinic
for prevention of arm and shoulder problems, and the appropriate risk-reduction practices are
given as well as a prescription for a compression garment for all exercise, repetitive activities
and air travel.
The clinic sees between 8 and 12 patients per week. More complex lymphedema cases/patients
are referred to Dr. Anna Towers at the Montreal General Hospital. Patients are encouraged to
participate in exercise groups offered by the community including Tai Chi/Qi Gong, AquaLymphatic Therapy (ALT), and the Lebed method, and can pursue further CDT management in
the private sector. The Lymphedema Association of Quebec publishes a list of resources.
3. Jewish General Hospital (JGH) - Segal Cancer Centre
The Jewish General Hospital Lymphedema Clinic, which began in April 2007 with funding from
the JGH’s Weekend to End Breast Cancer, is the first hospital-based clinic in Montreal to offer
both the evaluation and treatment of lymphedema secondary to cancer-related treatments. The
clinic is run by Natasha Grant, Pht, a physiotherapist who is specialized in cancer rehabilitation
and lymphedema management with training in Combined Decongestive Therapy (Vodder) and
Aqualymphatic therapy (Tidhar). Dr. Bertha Fuchsman, a palliative care physician, is available
as a consulting physician.
The mandate of this program is to serve oncology patients at the JGH. Referrals are made by the
patient’s medical, surgical and/or radio-oncologist. The patient population comprises those
treated for cancer of the breast (81.7%), gynecological cancer (14%), melanoma (2.6%), and
other (1.7%) The physiotherapist is able to consult directly with the treating physician, their
primary nurse and/or any health care professional that may be needed, such as a social worker
for psycho-social interventions. Each patient undergoes an initial evaluation with the
physiotherapist after which they are seen every 3 months for follow-up. Those for whom
intensive phase treatment is indicated, based on circumferential measurements and physical
impairment, are offered 2 sessions/week of CDT (Combined Decongestive Therapy) for
approximately 4-6 weeks. The maintenance phase is then initiated where the patient is
encouraged to continue with skin care, an exercise program, and daily use of compression
garments. There are a number of patients who are referred to the clinic for prophylaxis and the
appropriate risk-reduction practices are given as well as a prescription for a compression garment
for all exercise, repetitive activities and air travel. Patients are given a list of resources in the
community including the Lymphedema Association of Quebec and the JGH Hope & Cope
Wellness Centre. The Wellness Centre is an excellent opportunity for patients to exercise with
other oncology patients with adapted programs such as Yoga, Qi-Gong, and supervised gym
22
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
programs. Community exercise groups are promoted including Tai Chi/Qi Gong, AquaLymphatic Therapy (ALT), and the Lebed method. Since its inception, the clinic has grown and
now follows over 400 patients. It currently functions 3 days per week.
MUHC LYMPHEDEMA EDUCATIONAL INITIATIVES
Education for Health Care Professionals
In 2010, through the financial support of the Lymphedema Association of Quebec we have
begun implementation of phase 2 of our strategic plan to improve patient care through wider
education of health care professionals on lymphedema recognition, risk reduction, treatment and
self-management information. One hundred and four health care professionals (physiotherapists,
radiation oncology technicians and doctors) from the Jewish General Hospital, the Royal
Victoria Hospital and the Montreal General Hospital and in the McGill Physiotherapy Program
attended workshops in Risk Reduction and in Rehabilitation after Cancer. Thirty-two
physiotherapists in the private sector attended a rehabilitation workshop.
Response to the workshops was extremely positive: evaluations rated the workshops as excellent
or very good in relevance of content, quality of sessions, and overall rating. Many participants
requested that more time be available in future workshops and requested workshops in wound
care and lymphedema, lymphedema therapy and manual lymph drainage, lymphedema in
vascular disease, self-management.
The aim in the coming year is to develop and train a core team (6-10) of lymphedema specialisteducators who will conduct systematic education programs within the milieux hospitaliers de
Québec, the CSSS centres and soins domiciles and appropriate university programs. Workshops
will focus on understanding of the lymphatic system, recognition of lymphedema, evidence
based prevention education, and resource availability of treatment (referrals). Awareness and
education will also be promoted through presentations and workshops at conferences.
Education for Lymphedema Therapists
Lymphedema treatment continues to be primarily delivered through certified lymphedema
therapists in the community. It is important to provide up-to-date evidence-based workshops and
seminars for those lymphedema therapists working privately in the community, outside the
research and teaching resources of the university and hospital-based system.
Our goal over the next few years is to provide high quality continuing education programs for
certified lymphedema therapists. In 2010 three workshops were held in English on implementing
international best practices, clinical decision-making and minimizing the risk of developing
lymphedema, and one in French on implementing international best practices. Fifty certified
lymphedema therapists attended the workshops and evaluated them as excellent or very good in
terms of relevance of content, quality of sessions and overall rating. Therapists also asked for
workshops to be given in the future on wound care, garment fitting, risk reduction, exercise and
lymphedema, self-management, measurement and self-bandaging.
23
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
FINANCIAL REPORT
Funding requirements for MUHC Assessment and Treatment Facilities (2011-2013)
 The MUHC Clinic, presently housed at the Vendome site and open one day per week,
and a half day twice a month, requires permanent premises to house the interdisciplinary
team and to expand its services and research activities to five days per week.

The Cedars Breast Clinic at the Royal Victoria Hospital presently offers the services of a
lymphedema therapist 3 days per week. With funding this program could be expanded to
5 days per week to better serve this population as well as the melanoma and sarcoma
patients who develop lymphedema.
Staff training and cost of continuing education preparation and dissemination
2011-2012
4 therapists (RN, PT)@ $5000- 2-week $20,000
lymphedema course fee and expenses
2010-2012
Preparation of continuing education $25,000
courses for therapists, community nurses
inservice (to be given throughout
Quebec)
Annual costs
Membership fees international societies $2,200
Presentation and participation in $9,500
research conferences
$56,700
Total
Funding is required to develop pilot project studies in:
risk factors for lymphedema development
$15,000
assessment of lymphedema therapies
$15,000
Facilities for rehabilitation research within the McGill network of hospitals
Our program has been advocating for adequate rehabilitation facilities for a number of years.
With increasing competition for resources in tertiary-level institutions rehabilitation programs
are often not prioritized for funding in spite of the increasing rate of cancer survivorship and
treatment-related problems that require research and clinical services. Often, health care research
focuses on pharmaceutical treatments. There is no medication that can help lymphedema.
Physical treatments tend to be under-investigated and under-funded in our medical culture. One
of the aims of our program is to advocate for adequate facilities for research into physical
therapies.
The following facilities are required:
Rehabilitation pool
Lymphedema treatments include specific aquatic exercises which require access to a heated
rehabilitation pool. This could be shared with other rehabilitation programs. There are no pools
in the Montreal area that are available. The Lucie Bruneau Rehabilitation Centre has a pool that
they use during the day and rent at night but which is always completely booked. The Lethbridge
Centre pool is also fully utilized and not available to us.
24
McGill Lymphedema Research Program (MLRP)
Annual Report 2010
The pool that we require for lymphedema therapy and for research into aquatic exercise regimes
needs to be kept at a temperature of 31-33 degrees Celsius since the exercise movements are not
aerobic. This is considerably warmer than a standard pool. Dimensions of 13 by 8 metres would
allow us to run groups of 6-8 patients at a time. The ideal depth is from 1.2 to 1.4 metres. The
estimates for building a pool are very variable depending on dimensions, location and existing
building structure and range from $100,000 to $180,000
Rehabilitation gyms (MUHC and JGH)
There is presently no dedicated gym space for cancer rehabilitation programs.
In addition, the following equipment is needed for the research and education programs:
1 Multi-Frequency Bio-Impedance Spectrometer (MFBIS)
$18,400
1 Impedimed (impedance tissue measures)
$3,500
1 Tissue Tonometer
$1,000
3 Computers (with printers) 3 x $2,200
$6,600
Computer software
$2,000
Educational materials
$3,000
Total
$34, 500
This report was written by Pamela Hodgson, MSc, and reviewed and edited by Gayle A. Shinder, PhD, Research
Grants and Project Coordinator in the Department of Oncology, McGill University.
25