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淋巴水腫之物理治療

彰化基督教醫療財團法人

鹿港基督教醫院

黃睦升 MS,PT

衛生福利部國民健康署衛生福利部國民健康署衛生福利部國民健康署衛生福利部國民健康署2013201320132013年癌症復健相關人員培訓計畫年癌症復健相關人員培訓計畫年癌症復健相關人員培訓計畫年癌症復健相關人員培訓計畫

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Causes Lymphedema

� Primary lymphedema: present at birth or onset after puberty. Born without enough lymph nodes, or lymphatic collectors.

� Secondary Lymphedema: developed due to trauma, infection, surgery, tumors, and/ or radiation to the lymph node regions. Can be within days to several years later.

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：：：：↑↑↑↑2~3 times (Mortimer et al., 1997)

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BLOODBLOODBLOODBLOOD

LYMPHLYMPHLYMPHLYMPH

NormalNormalNormalNormalHighHighHighHigh----flowflowflowflowedemaedemaedemaedema

LowLowLowLow----flowflowflowflowedemaedemaedemaedema

====lymphoedemalymphoedemalymphoedemalymphoedema(high protein)(high protein)(high protein)(high protein)

Lymphatic Lymphatic loadload��������

TissueTissue��������

Lymphatic Lymphatic TransportTransport

CapacityCapacity��������

SafetySafetySafetySafety----valvevalvevalvevalveinsufficiencyinsufficiencyinsufficiencyinsufficiency

The Causation of EdemaThe Causation of Edema

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Lymphedema

� Definition：An abnormal accumulation of tissue proteins , causing edema and chronic inflammation within an extremity.

(Grabois M. Phys Med Rehab Rev 1994;8:267-77)

� Functional overload of the lymphatic system

� Lymph volume exceeds transport capacities

� Also occurs in the face, trunk and external genitalia.

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Stages of LymphedemaInternational Society for Lymphology (Casley-Smith et al. 1985)

Stage 1 : pits on pressure

reduced on elevation

no or mild fibrosis

Stage 2 : non-pitting on pressure

not reduced by elevation

moderate to severe fibrosis

brawny

Stage 3 : elephantiasis, warts

skin very thick and leathery

subcutaneous tissue hypertrophied

Stage 1

Stage 2

Stage 38

CTCAE: lymphedema(Common Terminology Criteria for Adverse Events v3.0)

� Includes both objective measures (interlimb discrepancy) and subjective assessments.� Grade 1: 5%~10% interlimb discrepancy in volume or

circumference at point of greatest visible difference; swelling or obscuration of anatomic architecture on close inspection; pitting edema.

� Grade 2: More than 10%~30% interlimb discrepancy in volume or circumference at point of greatest visible difference; readily apparent obscuration of anatomic architecture; obliteration of skin folds; readily apparent deviation from normal anatomic contour.

� Grade 3: More than 30% interlimb discrepancy in volume; lymphorrhea; gross deviation from normal anatomic contour; interfering with activities of daily living.

� Grade 4: Progression to malignancy (e.g., lymphangiosarcoma); amputation indicated; disabling lymphedema.

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Drug Therapy for Lymphedema

� Antibiotics: for acute or chronic infections(ex: cellulitis and lymphangitis)

----Preventive antibiotics for recurrent ALD (acute lymphatic Preventive antibiotics for recurrent ALD (acute lymphatic

dermatitis)dermatitis) (2005,20th International Congress of (2005,20th International Congress of LymphologyLymphology))

� Diuretics: no effect or even aggravated swelling

� Benzo-Pyrone (Coumarin):--Stimulate proteolysis by macrophages

--Increase the number of the macrophages over

edematous limb (N Engl J Med 329; 1158-63;1993)

－no effect and liver toxicity (N Engl J Med 340; 346-50;1999)

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Surgical Therapy for Lymphedema

� Debulking or reduction Surgery

� Liposuction--Destroy superficial & deeplymphatic pathways

--Main complication：：：：cellulitis

� Functional or physiological surgery

1. Microlymphatic-VenousAnastomosis (LVA)

2. lymphatic-venous-lymphatic-plasty

Limitation：

1. few long term good results2. failure after 2~3yrs

� Circumferential liposuction� Post-OP + compression

garment �� may sustained improvement in symptoms

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0.5mm collecting lymphatic

0.8mm subdermal venule

Lymphatic Venous Anastomosis (LVA)

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Circumferential Liposuction

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移植淋巴結 當抽水幫浦� 林口長庚醫院副院長鄭明輝：「嚴重水腫的患肢就像是正在淹水一樣，已經淹到了好幾層樓高，淋巴結就像是抽水機，經由顯微手術將抽水機往最低的一樓擺，開始抽水，就能逐漸解除淹水慘狀。」

� 淋巴結移植手術：從淋巴結較多的下頷處，將部分淋巴結移植到右腳背上。

� 移植後的淋巴結發揮「抽水幫浦」作用，將堆積的淋巴液慢慢往上輸送，過了一年多，右腿總算慢慢恢復原貌。

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In later stage, filled with fibrosis and adipose tissue � poor result

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In later stage, filled with fibrosis and adipose tissue � surgical intervention

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腹大網膜移植手術(Goldsmith HS, de los Santos R: Omental transposition for the treatment of chronic lymphedema.

Rev Surg 1966;23:303-304.)

�術後仍需配合復健治療，才能使患肢有機會恢復至接近正常之大小，時間約需六至八個月，甚至更久。

�有腎臟病、缺血性心臟病患者，通常不建議施行此一移植手術。

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早發型下肢淋巴水腫早發型下肢淋巴水腫早發型下肢淋巴水腫早發型下肢淋巴水腫((((lymphedemalymphedemalymphedemalymphedema praecox)praecox)praecox)praecox)的男性患者的男性患者的男性患者的男性患者：：：：((((許文憲許文憲許文憲許文憲,2008),2008),2008),2008)

術後術後術後術後7777個月後之追蹤結果個月後之追蹤結果個月後之追蹤結果個月後之追蹤結果：：：：其患肢體積其患肢體積其患肢體積其患肢體積、、、、彈性彈性彈性彈性、、、、膝踝關節可彎曲程度及膝踝關節可彎曲程度及膝踝關節可彎曲程度及膝踝關節可彎曲程度及足踝變形程度均恢復正常足踝變形程度均恢復正常足踝變形程度均恢復正常足踝變形程度均恢復正常，，，，但是下肢色素沉著並無顯著改善但是下肢色素沉著並無顯著改善但是下肢色素沉著並無顯著改善但是下肢色素沉著並無顯著改善。。。。

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腹大網膜移植腹大網膜移植腹大網膜移植腹大網膜移植((((許文憲許文憲許文憲許文憲,2008),2008),2008),2008)

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先天性兩下肢淋巴水腫先天性兩下肢淋巴水腫先天性兩下肢淋巴水腫先天性兩下肢淋巴水腫

� 32歲秘魯籍的女子，罹患先天性兩肢淋巴水腫20年，得長年臥床。

� 因為重複感染，造成兩肢嚴重「垂足」，趾骨併發骨髓炎。

� 動員18個科別、上百名醫護人員為她進行10餘次手術。

� 切除她雙腿共15公斤的淋巴纖維化組織，並且矯正垂足，全程腿部皮瓣移植。

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Surgical Therapy for Lymphedema

�� Supplement TSupplement T’’X for poor response to X for poor response to

D.L.T.D.L.T.

�� IndicationIndication：：conservative Tconservative T’’X failure.X failure.

�� Surgery+DLT Surgery+DLT �� good longgood long--term resultterm result

�� Life long D.L.T. is necessary to keep Life long D.L.T. is necessary to keep

satisfactory result. satisfactory result.

(2005,20th International Congress of (2005,20th International Congress of LymphologyLymphology))

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The most effective treatment?� Currently not enough evidence to draw conclusions

about the best physical therapy to use in the treatment of lymphoedema.

(Physical therapies for reducing and controlling lymphoedema of the limbs (Review). 2007 The Cochrane Collaboration)

� No evidence to suggest the most effective treatment for secondary lymphedema.

(Systematic review:conservative treatments for secondary lymphedema. Oremus et al. BMC Cancer 2012, 12:6)

(A Systematic Review of the Evidence for Complete Decongestive Therapy in the Treatment of Lymphedema From 2004 to 2011. Lasinski et al. PM R 2012;4:580-601)

� Insufficient evidence power:� Inconsistencies in defining and measuring lymphedema

� lack of enough RCT.

� Small sample sizes.

� Ethical questions.

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� The medicine-based evidence is undeniably strong that CDT is an effective way to treat lymphedema.

� Effective for various degrees of lymphedema:

� mild, moderate, or severe

� early or late onset

� recent or chronic

� active cancer or palliative situations(Lasinski et al. PM R 2012;4:580-601)

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� 15,16th century:lymphedema has been known.� 1936, Vodder:manual lymphatic drainage to treat lymphedema� 1950-1970, Kinmonth:D/D lymphedema & venous edema� 1981, Kubik:concept of lymphatic watersheds.� 1975-1980s, M. Foldi (Germany):

� put all techniques together� with his wife (E. Foldi) 1st modern clinic for T’x lymphedema� Complex Decongestive Physiotherapy (CDP)

� 1986, John Casley-Smith:Microcirculation� combine Kubik & Foldi methods� Complex Lymphatic Therapy (CLT)or Complex Physical Therapy (CPT)

� 1998, Foldi, Leduc, Vodder school and Casley-Smith et al. agreed:

����Decongestive Lymphatic Therapy (DLT)

History of Lymphedema

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SelfDrainage Exercise

Compression Therapy

Manual Lymphatic Drainage

Decongestive Lymphatic Therapy (DLT)

Skin Care

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�To maintain and even improve the results achieved in intensive phase.

�Loosen skin remodelling.

Maintain phase (6~9 months)

�Max. reduction in 7~10 times

�To mobilize the accumulated protein-rich fluid.

�To initiate the reduction of fibrosclerotic tissues.

Intensive phase

(2~4 weeks)

Goal

＊ Intensive phase: repeated after loose skin remodeling

(in maintain phase).

＊Each repeated DLT course:↓50% preserved

lymphedema

Decongestive Lymphatic Therapy (DLT)

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↓↓↓↓Lymphatic load

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Obstruction of lymph vessels

LYMPHOEDEMA

Excess protein in tissues

REPEATED INFECTIONS

Damaged blood vesselsSpasms & Thrombosis

of Lymphatics

Chronicinflammation

Cellular debrisIncreased Lymphatic Load

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Skin Care Education

� 1.Avoid infection and injury

� 2.Avoid pressure on the involved extremity

� 3.Avoid constrictive clothing

� 4.Avoid vigorous activity

� 重物不宜超過重物不宜超過重物不宜超過重物不宜超過15151515磅磅磅磅((((約約約約6.86.86.86.8公斤公斤公斤公斤))))

� 5.Avoid heat

� 6.Keep skin in good condition- moisture lotion

� 7.Avoid strong massage

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Skin complications of lymphedema

� Hyperkeratosis: thickening of the epidermis.

� Caused by overproliferation of the keratin layer and produces scaly brown or grey patches.

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� Lymphangiectasia(lymphangiomata): excessive dilatation of the lymphatics

� Treatment: compression with multi-layer short stretch bandage.

Skin complications of lymphoedema

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� Papillomatosis: multiple benign epidermal tumors� due to dilatation of lymphatic vessels and

fibrosis, and may be accompanied by hyperkeratosis.

� may be reversible with adequate compression.

Skin complications of lymphoedema

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� Lymphorrhoea: leakage of lymph from the skin.

� The surrounding skin should be protected with emollient, and nonadherent absorbent dressingsshould be applied.

� Bandages will reduce the underlying lymphoedema, but needs to be changed frequently to avoid maceration of the skin.

� In the palliative situation, light bandaging may be more appropriate.

Skin complications of lymphoedema

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↑↑↑↑Lymphatic transport capacity

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Vascular & Lymphatic System

� Initial lymphatic (2,3)

� Collecting lymphatic (5)

� 1-epidermis

� 6-deep fascia

� 8,9-two adjacent drainage regions

Lymphatic System

Lymphotome&

Watershed

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The Passage of Proteinin Normal Tissue

Blood capillary Blood capillary ��Tissue channel Tissue channel ��Lymphatic system Lymphatic system ��VeinVein

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Effect of MLD

� Open valves of collecting lymphatic that crossed watershed.

� Set up collateral pathway.

�Mechanically move fluid into initial lymphatic.

�Make initial lymphatic & collecting lymphatic pumping & being emptied repeatedly.

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MLD techniques

� Casley-Smith:

� The Strokes

� Nodal massage

� Clearing across the watersheds

� Blocking flow

� Clearance of deep trunk areas

� Vodder: four basic strokes

� Stationary circle: for lymph node

� Pump technique: for extremities

� Rotary technique: for trunk

� Scoop technique: for lower parts of extremities

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Massage Technique� Massage area should be exposed！

� Stroke pressure : <80 g/cm2 (60 mmHg).gentle, not redness or pain. � 壓力小於30mmHg即可使淋巴液通過微淋巴管，在動物實驗中，過大的力道(壓力大

於60mmHg)會使得微淋巴管塌陷。

� Slowly with control：with minimal friction by hands & fingers.

� Speed: the greater the amount of fluid, the slower the movement.

� 40 min : 30 (trunk)/10(affected limb) � Higher pressure over watershed, lymph node and fibrosis area.

� Watershed area：6cm (3cm from the midline and crossed over it 3cm)

＊Ulnar side of hand：vertical to watershed

＊Bil. thumbs encircle：for lateral trunk

20-40 µm in diameter

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Massage for fibrosis area

� 對於肢體或體表上很堅硬、纖維化的區域，可加重按摩力道，創造新的組織通道(tissue channel)，即使這些通道已經沒有瓣膜、也喪失推動淋巴液的功能，卻仍然能提供一個通向含有正常淋巴管的區域。

� 另外，外在的壓迫(compression)是必須的，以保持淋巴液在這些沒有瓣膜的組織通道能抵抗重力的往上回流。

� 然而在纖維化區域中，微淋巴管的內皮層可能會不正常的被打開或撕裂，造成更多的淋巴液從微淋巴管滲漏出來，因而需要馬上纏繞低壓力彈性繃帶。

� 若因為某種因素，而無法使用低壓力彈性繃帶，則必須省略纖省略纖省略纖省略纖省略纖省略纖省略纖省略纖維化區域的按摩維化區域的按摩維化區域的按摩維化區域的按摩維化區域的按摩維化區域的按摩維化區域的按摩維化區域的按摩，否則將造成淋巴液滲漏、組織間隙的蛋白質濃度升高、局部皮膚溫度上升、水腫加劇，甚至有感染的可能。

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Posterior TrunkAnterior Trunk

Drainage pathway & Sequence

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Drainage pathway & Sequence

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Face Lymph Pathways

1 2

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� A one-way drainage：remove protein and excessive fluid

� Initial lymphatic� pre-collector�collecting lymphatic� lymph node�

lymphatic trunk� collecting duct�thoracic duct� sub-clavian vein�

vena cava� R’t atrium

Lymphatic Drainage

Superficial pathway

Deep pathway

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Respiration

� Lymph flows into the sub-clavian veins most rapidly

at the peak of inspiration.

� The rate of flow of lymph into venous circulation is

proportional to the depth of inspiration.

� The mechanism of inspiration：

＊ Intra-thoracic pressure decreases� decreased

pressure of the thoracic duct in the thoracic portion.

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� M-breathing � Pelvic Scoop:� The fingers placed superior

the pubic symphsis.

� Toward the umbilicus.

� A really deep pressure.

教導患者做腹式呼吸(abdominal breathing)，吸氣到最飽最深的程度、接著吐氣時輔以治療師雙手給予往內往上的壓力，產生較大的腹壓。

Umbilicus

sub-costal sub-costal

Inside the pelvic rim Inside the pelvic rim

•若合併有腹水若合併有腹水若合併有腹水若合併有腹水(ascites)症狀症狀症狀症狀，，，，則不適合實施則不適合實施則不適合實施則不適合實施M-breathing。。。。 48

MLD practice: External genitaliaExternal genitalia

�When working on the legs�observe the pubis and the genitalia if became edematous, esp. scrotum.

�當下肢與生殖器的淋巴水腫合併存在時，需注意生殖器的皮膚照護、避免黴菌感染，若只治療下肢淋巴水腫(如淋巴引流或壓縮療法)，則可能會加重生殖器淋巴水腫症狀，因此軀幹淋巴區的清空則更加重要！

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Past hx：：：：R’t THR (+) 、、、、R’t drop footCervix Ca. S/P with R’t thigh and buttock lymphoedema PT for Post TRAM Procedure

� Evaluation：– Inspect the flap for color, temperature, capillary refill

– Signs of swelling on the involved side

– Signs of infection, decreased tissue perfusion, or edema

Rehabilitation Goals

� Prevent subdermal fibrosis and adhesions

� ↓↓↓↓lymphostasis

� Modulate abnormal sensation

� Restore trunk alignment

� ↓↓↓↓stress on the lumbar spine

� Optimize proprioceptive acuity in residual abdominal m.

� Encourage normal muscle recruitment patterns

To reduce stress on the sutures of the abdominal wound closure

� 1. Positioning the head of the bed at a 450

� 2. Lie on the uninvolved side in a fetal position

� 3. May also hug a pillow closely to the chest when coughing and avoid a Valsalva maneuver by exhaling during physical exertion.

� 4. Use "log-rolling" techniques without disrupting the abdominal sutures.

� 5. Maintain trunk flexion during transfers– supine to sitting

– sitting to standing

– ambulation for short distances

� 6. Ambulation generally begins the postoperative day 1.

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Post TRAM Exercise

� One week after：– active and active assistive exercises of upper extremities with

achieving full range of motion.

– General lower-extremity isometric exercises to prevent deconditioning.

� Several weeks after– Abdominal strengthening exercises.

– Lifting and sit-ups are not permitted until 6 weeks.

� This time frame will depend on healing and on an individual basis by the surgeon.

Trunk strengthening

� Exercises be for co-contraction of the oblique, transversus abdominis, and multifidus muscles.

� Examples of exercises：– hook lying with pelvic rotation against resistance at the knee

– sitting with isometric trunk rotation against resistance

– bridging with isometric pelvic rotation against resistance

� A home exercise program with self-resistance.

熱敷有助傷口復原及減少莢膜攣縮熱敷有助傷口復原及減少莢膜攣縮熱敷有助傷口復原及減少莢膜攣縮熱敷有助傷口復原及減少莢膜攣縮���� 「「「「低溫燙傷低溫燙傷低溫燙傷低溫燙傷」」」」

MLD practice: Breast reconstructionBreast reconstruction

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↑↑↑↑Lymphatic transport capacity

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Multiple channel pneumatic pump

� optimal pressure parameters are not been established

� little or no lasting beneficial effects

� fail to move lymph into different lymphticquadrant

� may damage remaining health lymph vessels

� need to combine self massage to the neck & trunk

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Compression garment

Multi-layer bandage

Compression Therapy

Suture line

& cuff effect

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Effects of compression

� Reduction in capillary filtration by enhanced tissue pressure

� Shift of fluid into non-compressed parts of the body

� Increase in lymphatic re-absorption and stimulation of lymphatic transport

� Improve rhythmic lymph pulsation

� Breakdown of fibrosclerotic tissue

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Short stretch bandages (in-elastic)

low resting pressure & high working pressure

Graded pressure：：：：decreasing from distal to proximal.

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Bandaging Principles

� Maintain slight tension on bandages, except for wrapping fingers or toes.

� The bandage should never be stretched to its maximum length.

� The first bandage is always “light”, then increase pressure slowly over a comfortable period of time.

� Use only tape to fix a bandage.(clamps are dangerous; they can injure the skin and cause serious infections).

� Check pressure gradient after completing the bandage.

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� Padding:� Protect the skin and tissue� preventing friction

and shearing.

� Reshape the limb to a cylindrical shape

� provides a smooth surface for an even distribution of cross-sectional sub-bandage pressures, with a decreasing pressure gradient from distal to proximal points.

Multi-Layer Bandage

Different radius���� different pressure.

��Even pressure by padding.Even pressure by padding.

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Cautions with Bandages

� Very high pressures may be achieved over pressure points.

� A joint bandage needs to provide adequate pressure to enable reshaping but reduce the potential for shearing and friction.

� Reducing slippage (may result in a tourniquet effect)

� Applied pressure should be with uniform tension over the limb.

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Addressing specific problems

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When to Remove Bandages

□ Limb distal part: soreness, numbness, more swelling, pain can’t relive by e’x

□Fingers nail: cyanosis, cold

※Bandages should always be adapted to the individual: age, diagnosis, and other condition-DM or peripheral neuropathy.

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Lymphoedema bandaging for

head, breast and genitalia

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Bandaging the Head and Facial area

� Pressure: � applied gently and low�to prevent paraesthesia or bruising in

irradiated regions.

� No compression on neck.

� The padding is placed within the tubular bandage.

� To increase local pressure: by placing several layers of foam.(fig2.)

A 12–16cm wide tubular bandage, folded in half

Hook-and-loop fasteners for

easy apply.

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Compression of the breast

� A cup shape thick foam(1.5-2.5cm): provide a micro-massage effect(Fig5)

� Gently squeezes the fibrosis.

(Fig6: L’t breast)

� Foam padding: extended to underneath the armpit and overlap the edges of the bra� prevent tourniquet effect.(Fig7)

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Bandaging the male genitalia-1� Cohesive bandage to prevent

slippage.

� Allow for urination.

� In severe lymphoedema, the penis and scrotum are also padded with 3-4cm thick foam.

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� Foam padding:

� at least 2cm thick

� anatomically contoured foam.

� Female genital lymphoedema:

� More complex

� at least 1cm thick of custom-made anatomically contoured foam

Bandaging the male genitalia-2

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Bandaging the male genitalia-3

� Primary genital lymphoedema with long-term compression and elevated temperatures in the testicles � can result in fertility problems.

� Begin with a low level of compression and depending on the severity and response.

� Patients or their care-givers must learn self-bandaging skills because excess fluid can rapidly accumulate in the external genitalia if treatment is interrupted.

� Attention to common cellulitis and fungal infection.

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Compression Garment

� Class I : 20-30 mmHg

hypertrophy scar, mild varicose vein

� Class II : 30-40mmHg

mild arm lymphoedema

� Class III : 40-50 mmHg

severe arm & mild leg lymphoedema

� Class IV : >50 mmHg.

severe leg lymphoedema.

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Contraindications to high compression

� Acute infection with local and/or systemic symptoms

� Untreated DVT

� Untreated cardiac failure or HTN

� Untreated genital oedema

� Proven arterial insufficiency (ABPI <0.5–0.8)

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↑↑↑↑Lymphatic transport capacity

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Self Drainage Exercise

� Improve muscular contractions and joint mobility.

� Reduce muscle atrophy.

� Muscular contractions along with the low-stretch bandages provide constant counter pressure to keep the lymph fluid moving.

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消腫運動的基本原則消腫運動的基本原則消腫運動的基本原則消腫運動的基本原則

� 要求自己每天做以達到最好的效果。

� 不要穿太緊的衣服，以免阻礙淋巴回流。

� 需先穿上彈性衣或綁著彈性繃帶時，做消腫運動才有效果。

� 一定要按照每項運動的順序，就像按照淋巴引流的順序一樣。

� 每項運動不要做太快，慢慢的數1.…2….3….。

� 運動不可以太累而讓肌肉酸痛，適量就好。

� 花費的時間：大約是30分鐘，但是一天若只做10分鐘也總比都沒有做的好。

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FAQ

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徒手淋巴引流是否加速癌症轉移徒手淋巴引流是否加速癌症轉移徒手淋巴引流是否加速癌症轉移徒手淋巴引流是否加速癌症轉移？？？？

� 一些學者認為徒手淋巴引流會將惡性癌細胞經由淋巴結傳輸到血管系統，最後使癌細胞散佈全身。然而當組織直接接觸到不同的癌細胞，必須視癌細胞的生物特性及免疫系統的狀況，並不一定會讓癌細胞散佈全身或形成轉移。

� 因此，不管患者的癌細胞仍存在或是復發，在先經過必要的醫療處置後，如化學治療或放射線治療等，都可接受去腫脹淋巴治療。

•Lawenda BD, Mondry TE, Johnstone PAS. Lymphedema: A primer on the identification and management of a chronic condition in oncologic treatment. CA: A Cancer Journal for Clinicians 2009;59(1):8-24. •Pinell XA, Kirkpatrick SH, Hawkins K, Mondry TE, Johnstone PAS. Manipulative therapy of secondary lymphedema in the presence of locoregional tumors. Cancer 2008;112(4):950-4.

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Avoid heavy lifting and resistance-training exercise for arm lymphoedema？？？？

� 即使文獻指出阻力式訓練或重量訓練可能使上肢淋巴水腫的症狀惡化，使得臨床上對運動強度的設定仍趨於保留、使得水腫肢體變的無力。(2006,Markes M)

� 但仍有學者以隨機控制實驗指出，6個月的重量訓練對上肢淋巴水腫肢體的周徑及主觀症狀並無影響。(2006, Ahmed RL)

� 甚至以持續13週、每週兩次、共90分鐘的舉重運動可有效緩解乳癌術後上肢淋巴水腫的症狀。(2009, Schmitz KH)

•Markes M, Brockow T, Resch KL. Exercise for women receiving adjuvant therapy for breast cancer. Cochrane database of systematic reviews (Online) 2006(4).•Ahmed RL, Thomas W, Yee D, Schmitz KH. Randomized controlled trial of weight training and lymphedema in breast cancer survivors. Journal of Clinical Oncology 2006;24(18):2765-72.•Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L et al. Weight lifting in women with breast-cancer-related lymphedema. The New England journal of medicine 2009;361(7):664-73.

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Predictive factors for DLT effect in

lymphedema

� Baseline PEV was the only predictor of PREV in our study. (including breast cancer related & lower extremity lymphoedema)

� a lower PEV would predict a better response to DLT.

� PEV=(baseline VL−VH)/VH×100%

� PEV: percent of excess volume

� PREV=100%×(post-treatment VL−baseline VL)/excess volume

� PREV: percent reduction in excess volume (DLT effect)

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Predictive factors for DLT effect in

lymphedema

� Duration of LE lymphedema was not associated with PREV (DLT effect).

� Studies on BCRL reported the opposite conclusion

� Longer duration of UE lymphedema would induce higher PEV and lead to worse DLT efficacy.

� �early intervention in patients with mild lymphedema would achieve better DLT efficacy.

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Treatment Goal

� A cure is not yet available.

� T’x is difficult, costly, and time consuming.

� Aims

-to reduce and control the amount

of swelling in an affected limb

-to restore the function and cosmetics.

Vicious Circles of Oedema

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Take Home Message

� DLT: skin care, MLD(<60mmHg), compression therapy, self drainage exercise.

� To reduce lymphatic load: skin care.

� To improve lymphatic transport capacity:

� MLD

� compression therapy

� self drainage exercise.