Rural Health Webinar – Contemporary Lymphoedema Education in Rural Health
Dimitri
My name is Dimitri and I will be hosting tonight's webinar. If you could just give me a moment and we will bring up the PowerPoint slides as well. Tonight's webinar, everyone, will focus on lymphoedema management in the context of rural practice, and we will also explore contemporary approaches to lymphoedema assessment and identify the early detection of lymphoedema in the community. Our presenters this evening are Madeleine Stockden and Ellen Gulin. Madeleine is an Australian Physiotherapy Association titled Cancer and Lymphoedema Physiotherapist. She has over 20 years of clinical experience in the areas of lymphoedema, chronic oedemas and cancer rehabilitation physiotherapy. Madeleine currently works in private practice near Fremantle in Western Australia and has completed a Masters of Manipulative Physiotherapy at Curtin University in 1998 and is currently enrolled at the Macquarie University undertaking a Master of Research looking at the effects of snakebite bandaging on superficial lymphatic transit in the lower limb using ICG lymphography. Ellen is a Registered Occupational Therapist with 20 years of clinical experience, predominantly in the areas of burns rehab, hand therapy and lymphoedema management. She has worked for Essity as a Clinical Specialist for eight years, and is the primary contact for product support and education for lymphoedema clinicians for Western Australia. We are in very good company this evening. Thank you for joining us, Madeleine and Ellen.
We would like to begin tonight's webinar by acknowledging the traditional owners of the lands on which we are coming together from and on the land on which this event is being broadcast. I would like to pay our respects to the elders, past and present, and would also like to acknowledge any Aboriginal and Torres Strait Islander people who have joined us this evening. RACGP Rural would also like to thank our sponsor, Medical Insurance Protection Society. MIPS membership includes comprehensive indemnity cover for the provision of healthcare to individuals. MIPS exists to promote honourable practice and protect the interests of its members. MIPS provides a range of benefits in addition to insurance covers such as a 24-hour medicolegal support and accredited risk education workshops. We greatly appreciate the support of this webinar series. Before I hand over to Ellen, just a few housekeeping things to cover. Participants, if you are not set on mute, then please set yourself on mute. This is just to ensure that we are not getting disrupted by any background noise. We do encourage you to use the chat function or the Q&A function to ask questions. When using the chat function, we do kindly ask you that you address your questions and your comments to all panellists and attendees, rather than just the panellists, so that everyone has the opportunity to see your questions and comments. Finally, this webinar has been accredited for one hour of educational activities CPD. To be eligible, you must be present for the duration of the webinar. We also kindly ask that you complete the short evaluation at the end of the webinar. This should only take you a couple of minutes to complete and will help us to improve the format and content of future webinars. By the end of this webinar, you will be able to identify the early detection of lymphoedema and raise awareness of lymphoedema in the community, identify precautions and alerts in the presence of lymphoedema, review contemporary approaches to lymphoedema assessment, discuss the management of lymphoedema in rural Australia, including access to treatment. For now, I am going to hand over to Ellen. Thanks, Ellen.
Ellen Gulin
I am passionate about optimising accessibility to compression, and Jobst is the leading compression brand globally. I am going to hand over to Madeleine now from the sunny shores of Fremantle.
Madeleine Stockden
Thanks, Ellen, and I am excited to have this opportunity to be able to talk about lymphoedema with you all. Please do put messages in the chat because this is a session for you all to find out whatever you can about lymphoedema from us and to make it relevant for you all. I cannot actually change the slides over because of the internet connection. Quick summary. Lymphoedema or chronic oedema, which means swelling for more than three months is when there' is an accumulation of a protein rich fluid in interstitial tissue. Notably, when our patients come to us and they are on fluid tablets, furosemide, and their lymphoedema is not getting any better, it is probably because we are not actually affecting the protein in their tissue caused by some sort of lymph drainage. The most common lymph drainage that we see is secondary lymphoedema or usually cancer related lymphoedema due to lymph nodes being removed, but not to forget that we also see patients with primary lymphoedema when there is a systemic problem or a problem with their actual lymphatic system or the structure of their lymphatic system or vessels that are not being formed correctly. As mentioned in the introduction, prevalence, we do not actually have accurate data on how many people have lymphoedema. The Cancer Counsel and organisations as such are often throwing out statistics that 30% of breast cancer patients develop lymphoedema, etc. Those stats actually have no data behind them. We do not follow patients long term, so there are only the patients that are being reported to having actually had lymphoedema or might have seen a doctor or might have seen their specialist, and so somebody has written it down. They are actually numbers that we have no current knowledge of how many people in Australia have lymphoedema. Also, as I said, there is a lifelong risk for onset. Patients do not always develop lymphoedema immediately postsurgery and I will talk a bit later about effects of radiotherapy. Often it is later effects of radiotherapy when we start seeing lymphoedema. Going back to those stats again, patients are living longer and surviving cancer. Therefore, if we are thinking only of five-year survival rate with cancer, and then we say, well patients did not get lymphoedema. Perhaps they are now because they are living longer and we are seeing more patients with lymphoedema later on in life.
Next slide please. A prospective surveillance model for early intervention model for care for lymphoedema has been proposed a couple of years ago. It has come out of Macquarie University Hospital part of a PhD. You will see and I do acknowledge the Macquarie University Hospital or some of their slides you will see with their names on the bottom and I thank them for actually giving me some information from them. We are aiming to detect subclinical or stage 0 or early stage 1 lymphoedema meaning lymphoedema that is not obvious. We have methods of being able to detect lymphoedema before it is clinically obvious before we can palpate and see obvious swelling. Obviously like any early intervention model, early intervention is much easier to manage if we see it early rather than waiting for these large chronic effects for the skin and tissue and fibrosis and potentially there is some reversibility if we can actually catch these patients early. We really want to aim for early knowledge, early detection, early diagnosis. Obviously, we are aiming to prevent any progression of lymphoedema. The early model is now recommended to have a prospective surveillance. Patients are getting seen over time and monitoring for the effects of their lymphoedema, and actually having a look at the tissue and seeing and palpating if there is tissue changes rather than just waiting to see someone swell or not fit their shirt on anymore.
Next slide please. Our risk factors for lymphoedema and certainly risk factors for our secondary lymphoedema, which is our larger group for people with lymphoedema. The more lymph nodes removed, the more likely the patient is going to develop lymphoedema. If someone has had a major lymph node dissection, auxiliary dissection for breast cancer, we can start thinking there is possibly a stronger risk of lymphoedema and radiation to the area increases that risk factor. I will show this slide again later on with this this picture. If we are looking at this this lady who has had all these chronic changes around her neck and under her jaw, we could start thinking about is there some potential lymphoedema proximal around the facial area or oral oedema not to be missed as what is going on inside? That patient actually had reported feeling like there is fluid in her ears that was her sign of lymphoedema. Just before we go to the next slide, obesity is another and increased BMI is another, increase greater than 25%, another risk factor for lymphoedema. Those first two are our most likely risk factors. If you have a patient that has had a large lymph node dissection, be it an inguinal dissection or auxiliary dissection and has had radiation to the area, we have got to start thinking that there is higher risk category for lymphoedema than any of the other groups that we see.
Next slide. Our model of care is now this is what we are suggesting and we are trying to teach across the country. How to model a care for our patients with lymphoedema is to screen pre and post operatively or pre-treatment. Again, we are talking secondary lymphoedema if it is a pre or postop. In my clinic and private practice, I rarely see people preoperatively. I mostly see them once they have had their surgery, but if we get an opportunity to educate and pre-screen and pre-measure, then we actually have some idea in giving patients awareness of what to look for and then it is recommended that someone is screening them and if they are going home to country areas then are someone is actually following up and screening what is happening. Are there any changes? Are there tissue changes? Are there any signs of symptoms of lymphoedema? We will talk about different assessment technologies. We can have access to fancy technologies, but the tape measure is still an accurate, reliable measurement tool for lymphoedema. We were at a conference today and there was a presentation comparing bioimpaedance spectroscopy, which we will talk about in a moment and a tape measure. The recommendation is probably both and both are good sources. They measure different things but they are still accurate measures. It is something to keep some sort of screening for our patients. Early intervention on education and skincare. The critical basics of skincare that our patients very much commonly overlook. Skincare more commonly particularly with our chronic leg oedemas that we see in the clinics all the time and then of course general education, cancer rehabilitation, health promotion for all the other factors.
Next screen please. The early intervention protocol for our secondary lymphoedema now and this is again what is being taught across the country as far as best practice for prevention of lymphoedema and early management is class 2 compression therapy, which is about 20 to 30 mmHg and to be worn for 10 to 12 hours in times when patients are most active. When they are up and moving around for the first four to weeks postoperatively and then to review, and review at four weeks, it may be then they go off and have radiotherapy at that time or their radiotherapy happens after their chemotherapy, ongoing education for risk minimisation. I am going to talk about all the myths that are out there shortly for lymphoedema. There is a lot of misinformation out there. Exercise prescription. I will present the closing statement Cancer Oncology Society of Australia statement on exercise. To really get the message across to avoid inactivity, there is again with our myths, a lot of misinformation that people cannot move their limb and they should not move their limb. We certainly want people to move. SOZO or bioimpaedance spectroscopy if it is available, if it is early intervention model. L-Dex is a lymphoedema index and it is how we can determine early screening for pre and postop for lymphoedema as well. I will show you some pictures of that in a moment.
Next slide. Early warning signs and this has been put out on a handout that just actually literally has been launched today at the Australasian Lymphology Conference here in Adelaide, which I will probably try and show you a link with. On their early warning signs are looking at transient swelling, feelings of heaviness, pain or tension which is sometimes talked about. I certainly have argued that I do not see that as an early sign in my clinic. Certainly feelings of heaviness, achiness, tightness, jewellery being tight, clothing being tight, uncomfortable and being aware that these early warning signs may be present for quite some time. Literature says three years prior to development of swelling. Thinking about what else is going on. If someone has had a radiated breast, they might not have had lymph nodes removed, but it is the breast feeling tight and hard or uncomfortable or painful and actually is there lymphoedema or chronic oedema going on inside that breast area or whatever area that has been radiated.
Next slide please. A busy slide for differential diagnosis. I just wanted to draw your attention to the picture in the right corner of those chronic oedema legs, which probably is renal disease or cardiac disease or chronic swollen legs that have that shiny look about them. We all know, we see those types of legs in our clinic all the time, palpably pitting oedema, sometimes a bit sticky because there is a little bit of lymphorrhoea and leakage coming out of the skin. We will also talk about what can we do about those legs. What simple measures can we manage them. There are obviously many reasons for swelling and chronic swelling in the legs. What we really want to pick up for our red flags, sudden acute onset of swelling, a measurement of L-Dex can spike. There is some good literature with lymph bioimpaedance spectroscopy, a sudden spike in L-Dex, it may not be lymphoedema per se, might be cancer recurrence, might be something else going on. Certainly, I have been referred several patients over the years for lymphoedema in a lymphoedema risk limb. Notably, there have been some collateral veins visible across the chest wall and they have had DVTs in their upper limb. Not to forget DVTs in the upper limb as well as lower limb DVTs. We see them mixed with lymphoedema, and again thinking about has that lymphoedema changed significantly quickly and knowing what the patient's lymphoedema is normally like to a sudden onset. I also just wanted to highlight cellulitis. People living with lymphoedema are significantly higher of developing cellulitis than the normal population. There is a lot of literature backing up if we treat lymphoedema early, we see a significant reduction in cellulitis. There was a big study done in the UK a number of years ago. It has been repeated in the ACT here a couple of years ago. If we can manage lymphoedema, we reduce the hospital admission and incidence of cellulitis. Lipoedema, mixed messages as to a fat disorder as opposed to being lymphoedema with chronic lipoedema or chronic problems with a fat disorder may start causing effects to our lymphatic system. Therefore, we may then see some lymphoedema, but they arguably are not the same disorder. They are two separate entities.
Next slide please. Cellulitis. I am not going to read these fine print. On the Australasian Lymphology website, lymphoedema.org.au, there is a consensus guideline that has been put together in conjunction with the British Lymphology Association and our doctors from the Australasian Lymphology Association and the British Lymphology Association have actually put this consensus guideline in for some reminders as to what is recommendation for management of cellulitis. Certainly, often we see more cellulitis than a lot of GPs because we see these patients all the time. I will admit that there is quite a lot of therapists out there, arguably, that are overdiagnosing cellulitis, but that is the other problem. Certainly, our awareness is because we see these patients with lymphoedema. That guideline can be downloaded and it is currently under review or has been just updated. They are in the process of updating it for us to make sure it is still as up to date as possible. Sometimes, our patients need long-term low dose antibiotics and we need to work well with you all and your GPs to manage that for us. Thank you.
Next slide. I am going to look at contemporary approaches to lymphoedema assessment and how we can actually look at assessment from simple ways to a little bit more complex ways, and certainly what is being done across the country now.
Next slide. Nothing wrong with the tape measure, still being shown to be a reliable and accurate measure of lymphoedema. Pitting test. Obviously, by the time patient has got pitting oedema, we are sort of beyond our early intervention model, but certainly we know there is swelling. The old-fashioned perometry we do not see so much. Simple questionnaires that you can have in your clinic, is patient feeling anything different? Have they felt any different signs and symptoms if you do not have other measuring tools. Has anything changed? Are they feeling any pain or discomfort? Bioimpaedance spectroscopy I will talk about in a moment. MRIs and I will show you some nice videos of MRIs and the differences, what we can see on MRI. Lymphoscintigraphy, I will show you again in a moment. ICG lymphography is our best diagnosis for lymphoedema. It is really becoming now the gold standard nationally and internationally now for measurement for true diagnosis for lymphoedema. We do not all have access to that. We certainly do not in Western Australia.
Next slide please. Bioimpaedance spectroscopy and more and more therapists are having these in their clinics. They may send you a message to say their L-Dex lymphoedema index is what is measured in units is xyz. A normal range according to the company, ImpediMed, who produce this SOZO machine will say +/- 10. Certainly, now across the country, if there are changes, +/- 6 or +/- 7, we start implementing therapy. It is a noninvasive test. It is very simple to do. It is a way of detecting fluid difference between one limb and the other limb, upper limb or lower limb. It does not tell us about the breast. It does not tell us about the neck yet. They are looking at doing further research currently and seeing if they can get measurements, but it is a measurement tool that picks up lymphoedema before it is clinically obvious. This is what is being used in our early intervention models wherever possible wherever available because it will show changes before we see a change on a tape measure or a visible change.
Next slide. Lymphoscintigraphy has been around since 1950s. It gives us some information, but it is only two injection sites and really only showing the anterior medial aspect of the limb as opposed to a bioimpaedance spectroscopy, which I think we will see on the next slide.
Next slide. On that right hand side, we can just see a whole lot more changes compared to just whether a lymphoscintigraphy.
Next slide. MRI. We will not be able to get this video to work. Sorry, everyone. I had a lovely little video, but technology is not allowing us. With MRI, we can see the changes throughout the limb. I will show you. If you have a look at this picture of this leg, it looks like it is quite fluidy in the thigh, gets a bit thinner as the leg goes down, but again, not just looking at the leg but actually feeling it and what is happening underneath it. When we have a look at the next slide, which we would have seen all the way down as we come down on the MR on the previous slide, we see increased thickening, increased tissue fibrosis, increased fluid. By the time we get down to the bottom of the leg, it actually looks quite thin. We actually are seeing significant changes in in tissues. Then we are thinking more high risk of cellulitis if that tissue is not treated and softened up.
Next slide. Sorry, you cannot see my lovely little videos. ICG lymphography has been around for some time now in surgical fields, in ophthalmology, in cardiac reviews and function tests. It is starting to become used in centres around Australia for mapping of lymphoedema.
If we go to the next slide please. The alert program Australian Lymphoedema Education Research and Training in Sydney University have written out protocols for use of ICG lymphography to find the best areas to inject directly into the lymphatic system. What they do is they inject the fluoroscopic dye, observe where it is going. Then they actually in real time do manual lymph drainage and see actually where that flow is and give a real time idea of where that patient has got a problem or obstruction with their lymphatic system and then photos are taken and then data is collected.
Onto the next slide please. This is the ICG camera. This is actually healthy legs that I have used in my study. In real time, they draw on the legs to show them where their obstruction is or is not. These are very healthy legs, as I said, and they get projected onto a TV screen so they can actually see where their lymph flow is. It is very exciting for the patient to actually have a good understanding and good adherence then with their treatment as to what is going on. Now in rural areas, obviously this is not happening and why am I talking about it in Western Australia when we do not actually have access to this method of assessment is because patients are starting to ask about it. Patients are hearing about it, they are hearing about it and they Zoom and they Google and they find all sorts of information and they are prepared to fly and travel. I have quite a few patients that have flown to Sydney to actually have assessment and diagnosis. Macquarie University is probably the only full centre of assessment where there are actually medical doctors to assess where the speciality and lymphology ICG mapping to be able to be done, prescription of garments and a full assessment and treatment. There are centres in South Australia starting up, here in South Australia and in Melbourne and the ACT, I know they are doing some work with head and neck lymphoedema.
Next slide please. This is the photo I wanted to show you the difference between in the middle the old lymphoscintigraphy where a little bit of information is going on about that leg. If we look to the right, we are getting a whole lot of information as to how that fluid is going. Instead of a nice linear direction that we expect to see with lymphoedema, we are seeing this starry look where all the fluid is just sitting in the superficial lymphatics and showing there is a massive backlog of fluid in that leg. We are getting a lot more information with ICG lymphography, the lymphoscintigraphy.
Next slide please. Normal lymphatics will get a less linear form. If we go to the next slide, we will see a posterior version. This is what we expect to see with normal healthy lymphatic function, not like what we saw in that previous slide.
Next slide please. This is how we see our staging with ICG. Healthy stage I lymphoedema, good linear direction of lymph flow and then progressively dermal backflow which is our true diagnosis now and our gold standard diagnosis for lymphoedema. The final slide that looks all black is actually the fluid is not going anywhere. It is stuck in the foot.
Next slide please. We have seen compensatory drainage regions. Now we have been mapping with secondary cancer related lymphoedema. This has really changed how we treat and how we massage when our lymphatic massage. Traditionally we used to think from the lower limb, we would massage up to the axilla. I think it is something like 1.5% of the population actually drained the axilla. Most people drain to the ipsilateral inguinal node. A few go to the abdominal region. Some go to contralateral inguinal nodes. Again, those sorts of patients we have got to think about genital oedema and how we are managing that genital oedema. We are just putting a thigh garment on and pushing it all into the groin, perhaps some shorts. We will talk about compression in a moment.
Next slide. That was a video which actually showed that contralateral flow but never mind. Next slide. Compensatory drainage in the upper limb and again how we have changed how we massage. This is why I really encourage you to make sure the therapists that you are using are actually staying up to date, attending conferences because there is a lot out on Google still, a lot of misinformation of how to massage, 70% of breast cancer related or axillary dissection related lymphoedema still drains to the axilla, even if it has had a lymph node dissection. The other 30% tends to drain either to the supraclavicular nodes, a little bit across the chest and very rarely around to the scapular node area. Nobody is draining around the back. People are wasting a lot of time massaging around the back. It might feel nice but does not actually move any fluid. Thinking 70% is still draining to the axilla.
Next slide please. How can we manage and access to treatment? Next slide please. First of all, the myths. What do we do? I have been working in the area of lymphoedema for about 20 years, and I have been saying compression and exercise is the best management. After all that new research that is coming out and monitoring and mapping lymphatics, exercise and compression is still the best management for lymphoedema. In that respect, nothing has changed. There are a lot of myths out there and a lot of misinformation out there. First of all, what can we do? What do we do? I have had a treating GP recently and she said I send you patients and I do not actually know what you do when you see them. Education is part of what we do, of actually dispelling the myths, explaining compression exercises is our best management. Awareness of lymphoedema, how to pick it up, how to be aware of changes. Is there pain, is there tightness, is there tissue changes. Actually picking that there are changes. A lot of people think if I have had a lymph node dissection and breast cancer population is so heavily researched but if they have not got swelling in their arm, they think "well, that's it" but they forget that the breast drains to the axilla as well and do not always pick up the fact that they have got breast oedema too. How we can restore their prior level to a function, making sure our patients are aware that they should be doing everything they were doing before. If they are not, perhaps we need to look at why they are not doing what they were doing before. Lymphoedema does not stop you doing all the exercise, all the activity, all the function that you were doing before. Also, being aware of how people move, how people walk. Someone has got a big swollen foot or a big swollen leg, they tend to turn their feet out. If they are slightly rotated out or if they cannot fit their shoes on, so often they come shuffling in in thongs or shuffling in in slippers because they cannot fit their shoes. Then they cannot get a decent heel to toe. If they are not getting a decent heel to toe propulsion with their calf propulsion, they are not getting any calf contraction on their vascular system and their lymphatic system to push the fluid up. Simple measures that we can teach our patients and be aware of is getting them into a decent pair of shoes, getting them into walking properly and feeling that they can function and walk properly and explain to them the importance of just a simple change of a heel to toe. It may be they need a walking frame so they are not shuffling anymore, so they can actually walk properly. The myths and legends. Our aim is to avoid unnecessary risk.
If you move on to the next slide, please. We get asked should we take blood pressures on an affected limb? There is no evidence that taking a blood pressure in the clinic will cause lymphoedema. Now we have patients that will not put their arm out. We talk about they will not. They are desperately afraid they are going to develop lymphoedema. There is no evidence that having venipuncture in that limb will cause lymphoedema. There is no evidence that having blood pressure needles, anything on that limb will cause lymphoedema. However, it will not pass an ethics committee to go and do a study to see if that will work. I have had enough trouble putting my research through an ethics committee recently, and that was injecting dye into healthy legs. Also, there actually was a study that was looked at in Sydney, but they could not get any participants to volunteer for the study either. We say try not to do it if there is a perfectly healthy other side because we do not want to put people at risk and we do not want to upset them and we do not want to cause potential unrest. If they are trying to have chemotherapy and treatment, they have got no vessels left on their contralateral side, we will have it on the ipsilateral side if there is a perfectly good vessel and it is really more about the blood pressure cuff coming off quickly and not leaving something on someone who is in ICU and the blood pressure cuff staying on for a long time that may affect their lymphoedema. However, we like to save their life first. With pressures again pain on elevation, exertion. If we are thinking more arterial problems, they do not tend to have swelling. They tend to be cold, pale, dry skin.
Next slide please. Tissue fibrosis. This is what I see a lot of in the clinic. Tight, hard swollen breasts. Sometimes they are smaller, sometimes they are bigger. Patients think that that is how it is meant to be. Please, if you can get the message across to your patients, if the breast is tight, hard and sore and swollen, it does not need to be like that just because it has had radiotherapy. Often as GPs, you are the only people seeing these patients. We do not see these patients commonly if they have not had a lymph node dissection and often they just get some radiotherapy, get discharged back to the community and we never see them again. Very simple measures, very gentle massage and learning to touch that tissue. Low level laser if it is available or photobiomodulation is fantastic at softening the breasts and sometimes as much as one session or just teaching people to gently start massaging their breast. Just getting some movement, getting some palpation on that area can actually make a massive difference to pain and function and a softening.
Next slide please. Head and neck. Same thing. What can we use. Raising awareness that these patients may develop lymphoedema. Having a look inside their mouth. Is their oral oedema? Is the tongue swollen? Have they got problems with speech and swallow? Can they do simple exercises. Range of motion of their mouth. Can they get their tongue and massage their inside of their teeth, cheek for a buccal oedema. This is a just a foam pad. It is called a Jovipak. It is actually a Jobst product, but they can buy these things. We will talk about how to get garments as well, but they could also just cut up a bit of foam and stick it together with some fixing oil, and there is a foam pad. This is a pressure garment, not to be worn during the day. That does not look nice, but perhaps they could wear it for some hours in the evening and making it work for the patients.
Next slide please. Skin breakdown. Those legs we saw in that earlier slide. Those legs that we see all the time. Light compression can help and compression wraps, which I will show you in a minute. If there is already a skin breakdown, we want to prevent the skin breakdown because obviously then we start getting greater risk of cellulitis and then we get ulcers and we get skin tears. It is a lot more work and a lot harder to manage. Teaching the patients good skincare, teaching the patients simple skincare soap, glycerine, moisturiser and some wraps or bandages I will show you in a moment.
Lymphoedema and bites. I thought I needed to put bites in there somewhere just to cover. If someone has suddenly developed lymphoedema, sometimes it is worth asking the question and have they been bitten by something? And we do see and we have seen patients with lymphoedema following leeches and spider bites. Sometimes it is transient, sometimes it is with the leech bites, they can cause local damage to the lymphatic system, so we might see some local area of lymphoedema from where the bites been. It is just worth highlighting that there we do see secondary lymphoedema from some of our bites and stings local West Australian spiders there.
Next slide please. Multilayer compression bandaging is still how we still manage lymphoedema. There are lots of different brands available. With two layer systems is becoming more common than the old fashioned, one on the left side because they tend to fall down. The soft layer is usually a bottom layer and then a compression layer of the top apart from the Urgo 2 in the bottom right hand corner, and then the bottom layer is actually the compression layer, which is a soft material with another layer over the top. Simple measures self-management patients might be able to anywhere just try and some bandaging to manage their lymphoedema.
Next slide please. Wraps. Very simple. Those legs that we saw earlier on, perfect case for compression wraps. Easy to don, easy to doff for variable lymphoedema for changing lymphoedema in sizes and shapes. Dressings can go underneath it. You can get wraps for the ankle. I argue that they are still hard to get the shoe on, often the Reps will say they are okay to put shoes on over the top, but really helpful for chronic oedemas, lower limb oedemas especially some of our older patients.
Next slide please. Here is an example with a Cutimed Sorbion which is just a cleaning the skin, moisturising the skin, compression wraps and ten weeks later the legs looking hugely better, not hard treatment. They can order the wraps through the wraps online.
Next slide please. Here again just looking at cleaning pad cleaning the skin and moisturising and how much better simple measures can manage for our patients.
Next slide please. Compression garments come in all sorts of shapes, sizes, costs and ugliness. I just want to draw your attention and expense to these. I have got some people in the room here. They are laughing at me now. These compression pants, so thinking about our genital oedema patients, bike shorts have got compression in them, might be send them off to the local target and try some of the like sporting compression garments to use sporting compression garments to create a little bit of support for their groin and genital oedema that is not too strong around the abdomen, and breast garments are forever a nightmare to try and get to fit properly.
Next slide please. Should I wear a garment for exercise? Generally, yes. If they need an exercise, if they are swimming in the pool, well, it is not break down expensive garments. Thinking about the recovery for exercise. Yes. That is an AFL footy player, and yes, I am a Fremantle supporter in the bottom left hand corner. They actually got two players in custom compression garments for recovery, for swelling. It is good enough for them. It is good enough for our patients, but thinking about what can they exercise in if they cannot wear their expensive custom made garments and perhaps some light to excuse must be skins they have gone out of business or custom made garments that are lighter that they can manage to work in, so yes, if they cannot wear it for exercise, immediately after exercise is to be recommended if the patient needs a compression.
Next slide. Compression pump therapy. There are just a couple of pictures of different pump therapies. Fantastic. Takes the place of massage in lots of cases, especially for our lower limbs when people cannot reach, we can get good pressures and really good results from pump therapy, and patients can order these and use them at home, especially if they are in a rural area and cannot get access to good hands on treatment regularly. It is certainly something to help and adjunct to treatment, but none of these take away from compression and exercise still being our best management shows a recommendation.
Next slide. For exercise, The COSA Recommendations are 150 minutes of cardio a week and two to three strength sessions a week. People ask me all the time what exercise should I do? And my answer is one that you like, and then the big Nike slogan "just do it". I spent a lot of time telling people to just do it and find something they like and do it for the rest of their life. I think I am running out of time.
Surgery options. I mentioned this again. We do not have much of this option in Western Australia. There is a tiny little bit of surgery being done intraoperatively immediately with mastectomies. There are some lymph venous anastomosis surgery being done, but mostly it has been done in the eastern states, starting to be done in South Australia, Melbourne, and Sydney, and I think in the ACT. Patients might ask what we can do for our lymphoedema, and in some cases, that have mild lymphoedema, surgery might be appropriate, a lymph node transfer might be appropriate, liposuction if fat has now settled in that area may be appropriate, and they will ask you for it does not stop them exercising and wearing their compression though.
Next slide, please. This patient actually had a debulking liposuction for a unilateral lymphoedema, and you can see the difference 12 months later, and that particular patient, her goal in life was to be able to wear boots, and she was absolutely delighted. She still wears her compression many years later.
Next slide. That is just a quick slide of the LVA surgery, thanks to Macquarie.
Next slide. Some unanswered questions as we finish off. Why do some patients develop lymphoedema, and some other patients do not? Is there a predisposition for lymphoedema? That is a good study to do and a very tricky study to find out, but probably yes, and certainly, we know there are those risk factors that we saw earlier. Why does initial fluid accumulation change to fat deposition? So why do we see fat in areas of lymphoedema limbs? Sometimes it is not just a swelling fluid oedema, sometimes it is fat oedema as well. Can we identify lymphoedema before the symptoms become evident? And we perhaps more so with Bioimpedance Spectroscopy. Can we can prevent lymphoedema with our within surgery procedures? And what are our future ways of treating lymphoedema?
Next slide, please. In summary, early detection via spectroscopy is one of those things, early diagnosis with our secondary, just please be aware our primary lymphoedema is our legs, but generally, legs I think are 80-90% of primary lymphoedema are in the lower limbs. You can take up to nine years from when symptoms start to when actually they are diagnosed. Can we pick up these patients early? Avoiding unnecessary risks, but lymphoedema should not stop you doing anything you want to do. If you have got a perfectly good non-lymphoedema limb or you use that limb rather than injecting the one that where there is swelling. Our exercise prescription following COSA statement which is great for everything for all our cardiac patients as well, preventing infections, simple measures of skin care, keeping the tissue soft with massage or pumps so we do not get progression to tissue fibrosis, and then get more swelling, potentially surgical options and finding options you can see from the Australasian Lymphology website for individual states and what they do or do not offer.
Final slide I think. Lymphoedema.org.au has a find a practitioner button. If you are looking for a therapist and remember zoom is a great way for therapists now. If the person has access to a telephone, they can talk to a therapist and make an appointment via zoom if they cannot get into the into a city area to have hands-on treatment, and certainly my patients that go to Sydney, they often have a zoom appointment before they think about having surgery over their lymphoedema.org.au. If the patients are on that find a practitioner button, at least we know they have done a certain level of education and professional development because we make sure to be a registered lymphoedema practitioner. They have to keep up with professional development. Hopefully keeping up to date with what messages we are sending out.
Ellen Gulin
This is just a slide showing the JOBST website, jobst.com.au. It has a whole host of education for both professionals and patients, and also product information, of course, and there is a little red button at the top there where to buy online, and just on the next slide, we will bring up a where you can put in your location so you can pop in a post code and then a kilometre radius and it will actually bring up a list of JOBST suppliers in your area. Then the next slide is just to show you that does city health and medical does have a skilled clinical team right across Australia and New Zealand. There are plenty of people to contact for help. Then just the next slide, is just to say thank you and to invite any questions, and if we in the interest of time, there is a QR code there if anyone would like to quickly scan that. If we do run out of time for questions or if there is anything that you would like to request in regards to follow up, just leaving a contact detail there and we will definitely get back to you.
Dimitri
Fantastic. Thank you so much, Madeleine and Ellen, considering that we started off a little bit bumpy, we were running a little bit behind, we actually stuck to times, so that was very good. Thank you so much. There are a couple of questions that have come through the webinar chat. We have got a few minutes to go still, so Madeleine, I am not too sure if you are able to view those questions on the chat.
Madeleine Stockden
Louise. Comfiwave garments working really well and easy for worker to apply. So Comfiwave garments are a Haddenham's product and they are soft, generally used for nighttime garment to help soften the tissue with very mild light compression, which is why patients love them because they are soft, they are comfy. They do not necessarily take the place of a daytime garment, but they are fantastic at breaking up tissue fibrosis and helping soften, so being aware that they often use more as a nighttime garment rather than a normal everyday stronger day garment, AND the other question is why is not a standard practice to have L-Dex or sozo before surgery? The reason is because not everyone has access to Sozo and not everyone has access to see a practitioner before surgery. I work in the private system, and my patients are generally do not have an opportunity to be seen preoperatively because they are seen by GP, straight to the surgeon, straight to theatre a few days later and often there is no time to see someone. It would be wonderful standard practice to have the L-Dex reading prior to surgery, and there is an argument having an L-Dex reading long before surgery because there may even be changes if the patient has already got cancer, that might already be affecting the lymphatics, but that would be the ideal world to see people preoperatively. Seiko products are quite good for clients, particularly older clients, wraps around not have to pull on. I use wraps for particularly for my chronic oedema legs and there are several makes and brands that do make the wraps and they are just slightly varied in how many wrap functions they have got around them. They all have their role, and again, I use them particularly for older patients who have got varying oedema. Very good in a nursing home population who need somebody to help slip them on or they can take them off if they have had an off enough time during the day. The only problem is they are not getting support around the ankle and the foot, but sometimes if we can get the oedema supported in the leg, then the ankle is not as a problem and the foot is not as such a problem. Thank you.
Dimitri
Fantastic. Thank you so much for those questions. We would like to just thank our sponsor again, MIPS, and also thank everyone for joining us this evening. Thank you, Madeleine and Ellen, that was a fantastic presentation. A reminder to please also complete the short evaluation that will pop up in the session or shortly after the session closes. It really does take no more than a minute to complete and just gives us a little bit of an idea on how we can improve future webinars. Be kind to us. With the technology, sometimes that is just completely out of our control, and of course, your CPD statements will also be updated. That will happen in the next couple of days. As I mentioned at the beginning, this webinar is accredited for one hour of educational activities, CPD. For any non-RACGP members in the audience today, if you would like a certificate, please email rural@racgp.org.au. Our webinar schedule for the rest of the year is available on our website. So do not forget to tune in to our other free monthly webinars held on the first Thursday of every month. And on that note, I will end the webinar for everyone. Have a wonderful evening and thank you and good night.