Sean Smith, MD
Physiatry in Oncology explores the benefits of cancer rehabilitation in oncology practice to screen survivors for physical and cognitive impairments along the care continuum to minimize survivors’ disability and maximize their quality of life. The column is guest edited by Sean Smith, MD, Director of the Cancer Rehabilitation Program at the University of Michigan Department of Physical Medicine and Rehabilitation in Ann Arbor.
A number of years ago, while attending a rehabilitation workshop, I received a handout of common dos and don’ts for individuals with or at risk of developing lymphedema. The format was a typed sheet with two columns of detailed advice, including the importance of avoiding hot tubs, blood draws/needle sticks, and pressure from purse straps, among others. I thought this was great information and distributed the list to many of my patients with breast cancer.
Over time, however, my enthusiasm waned, as I began to realize that while such precautions serve to protect individuals medically compromised by cancer or its treatment, often they are based on limited evidence of success and may unnecessarily complicate the daily routine of patients by reinforcing a sense of fragility and interfering with their quality of life.
For example, for many years, breast cancer survivors have been advised not to lift objects heavier than 5 or 10 pounds. However, research now shows that resistance exercise, albeit in careful, controlled fashion, is generally well tolerated and perhaps even helpful in controlling lymphedema.1
The bottom line is each patient must be prescribed an individual physical rehabilitation approach based on his or her symptoms and overall physical health.— Mary Vargo, MD
Blood draws and other needle sticks, such as electromyography, present another historical prohibition in the setting of lymphedema. Although blood draws are routinely performed for laboratory testing or blood-glucose monitoring, in the physical medicine and rehabilitation setting, needle procedures are commonly performed to provide therapeutic options, including intramuscular and joint or bursa injections to relieve pain; such procedures are also employed in diagnosis, especially needle electromyography. Should a patient with or at risk for developing lymphedema be deprived of such interventions?
A position statement released by the American Association of Neuromuscular and Electrodiagnosic Medicine in 2014 recommended caution when performing electrodiagnostic testing but not absolute prohibition against the practice.2 And a clinical practice guideline3 for breast cancer rehabilitation noted that although needle procedures have been contraindicated for upper extremity musculoskeletal impairments and lymphedema in breast cancer survivors, there is some evidence that such precautions can be relaxed.
A small survey of physiatrists4 found a wide range of consensus—from zero willingness to no precautionary strategies at all—in their practice of performing needle interventions in the setting of underlying lymphedema, with most favoring an intermediate approach, such as careful selection, needling the fewest possible sites, and a stepped-up lymphedema care regimen surrounding the procedure. In my own practice, I sometimes perform therapeutic needle procedures, but the clinical situation must be compelling and the procedure only utilized after I’ve had a full discussion with my patients about the procedure’s potential risks and benefits. I then monitor them for complications.
Determining the Best Course of Therapy
Patients with lymphedema are often advised to wear compression garments if they are planning on air travel to offset the effects of a decrease in air pressure, but are compression garments really necessary? The National Lymphedema Network’s statement5 on this issue recommends that individuals with lymphedema use some form of compression therapy during air travel and that individuals at risk for lymphedema understand the risk factors associated with air travel and make a personal decision.
However, a study by Kilbreath and colleagues prospectively assessed breast cancer survivors for a change in their extracellular fluid measured by a single-frequency bioimpedance device before and after air travel.6 Each of the women’s arms was measured separately to obtain the interlimb impedance ratio. The study found that 95% of the women experienced no significant change in bioimpedance in the at-risk limb. A more recent analysis of over 3,000 women with axillary nodal dissection found that the number and duration of air flights taken do not lead to limb volume increase when controlling for other risk factors.7
These studies underscore the confusion that often exists due to recommendations presented in guidelines and position papers but that are contrary to present or emerging study data. Oncology providers should be aware of this confusion, and if there is uncertainty about what to recommend to patients, a discussion with a rehabilitation provider may help clarify the issue.
Another Area of Controversy
The use of a lymphedema compression pump to decrease fluid buildup is another area of controversy, although there is no scientific evidence of harm with the device in the absence of contraindications, such as deep-vein thrombosis, severe arterial vascular disease, uncompensated heart failure, and recurrent cancer in the affected area. A systematic review of 13 studies evaluating compression pumps as an effective modality to reduce the volume of the lymphedematous limbs found no evidence of harm, beyond minor discomfort at the compression site.8 Concern has also been raised that pneumatic pumping, especially at higher pressures (above 50 mm Hg), might damage superficial lymphatics, but this concern, too, has not been substantiated.
It should be noted, however, that pumps are useful mainly in the adjuvant setting and not as front-line therapy. The historical prohibition to pumping over an area of active tumor can also be problematic. Malignant lymphedema tends to be more painful and severe than its “benign” posttreatment counterpart, with patients often in undeniable need of palliation, and in that context, an open mind should be kept toward all options. Still, careful discussion with patients is warranted prior to proceeding with this approach.
Separating Fact From Theory
Lymphedema care strategies are not the only areas of controversy in the physical rehabilitation of cancer survivors. Physical modalities, especially when applied over tumors, have raised concern. For example, therapeutic ultrasound, a deep heat modality used to treat pain syndromes, has been associated with increased tumor size in mice,9 although this heat intensity was much greater than that of ultrasound used in clinical applications.
Concern has also been raised about electrical modalities, such as the use of transcutaneous electrical nerve stimulation therapy, to manage acute and chronic pain, due to the potential effects of electricity in stimulating DNA synthesis and cell replication. The actual evidence against electrical therapies, however, is low, and some studies even show a benefit with these therapies in controlling tumor growth.10,11 A guideline on the use of electrophysical agents by Houghton et al12 provides a good resource for rehabilitation staff in their clinical decision-making for patients with cancer.
Physical activity is another area that patients may need to proceed with caution in some instances. Physical activity is strongly encouraged to help improve mobility, reduce pain, and increase bone density, and the benefits of exercise in increasing survivors’ overall fitness and long-term outcomes are well known. However, physical activity may require precautions in some situations, for example, for patients with bone metastases who may need surgery to prevent bone fractures. If surgery is not indicated, but the patient is at risk for bone fractures or injury due to a fall or simply needs improved pain control with mobility, assistive devices, such as walkers or canes, are often necessary. Modified physical activity that avoids high-impact and high-torque activities may be helpful in reducing patients’ pain and improving their mobility and physical function.
Finally, confusion also exists over how much exercise to recommend for patients with platelet counts below 50,000/mm3. Existing paradigms generally favor unrestricted activity with platelet counts greater than 50,000/mm3; avoidance of resistive exercise, which increases blood pressure when platelets are in the 20,000/mm3 to 50,000/mm3 range; and minimum essential functions when platelets are below 10,000/mm3 to 20,000/mm3, in which spontaneous bleeding is more likely.13 However, risk of bleeding is greatest in labile situations, such as with a fever or actively dropping platelet count. Most studies have borne out that exercise is generally safe when supervised.14
The bottom line is each patient must be prescribed an individual physical rehabilitation approach based on his or her symptoms and overall physical health. ■
Disclosure: Dr. Vargo reported no potential conflicts of interest.
Dr. Vargo is Associate Professor in Physical Medicine & Rehabilitation at Case Western Reserve University School of Medicine in Cleveland.
2. American Association of Neuromuscular & Electrodiagnostic Medicine Position Statement: Risks in Electrodiagnostic Medicine. July 2014. Available at http://www.aanem.org/getmedia/50f4dd83-835c-46cb-a832-930851440e9e/risksinEDX.pdf.aspx. Accessed December 2, 2016.
3. Harris SR, Schmitz KH, Campbell KL, et al: Clinical practice guidelines for breast cancer rehabilitation: Syntheses of guideline recommendations and qualitative appraisals. Cancer 118(8 suppl):2312-2324, 2012.
5. National Lymphedema Network: Position Paper: Lymphedema Risk Reduction Practices. Available at http://www.lymphnet.org/resources/position-paper-lymphedema-risk-reduction-practices. Accessed December 2, 2016.
7. Ferguson CM, Swaroop MN, Horick N, et al: Impact of ipsilateral blood draws, injections, blood pressure measurements, and air travel on the risk of lymphedema for patients treated for breast cancer. J Clin Oncol 34:691-698, 2016.
12. Houghton PE, Nussbaum EL, Hoens AM: Electrophysical agents—Contraindications and precautions: An evidence-based approach to clinical decision making in physical therapy. Physiother Can 62:1-80, 2010.