Did you know that MossRehab specializes in therapies for individuals recovering from breast cancer? In this episode of MossRehab Conversations: Therapy Edition, Trish Crane, PT, clinical manager MossRehab Plymouth Meeting, and Michele Moravec, PT, and board-certified clinical specialist in oncologic physical therapy and a certified lymphedema therapist discuss treatment options for breast cancer survivors.

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Welcome to MossRehab Conversations: Therapy Edition, where MossRehab clinicians come together to discuss their expertise. In this episode we join Trish Crane, clinical manager at MossRehab Plymouth Meeting and faculty member in the orthopedic PT residency program as she speaks with Michele Moravec, a physical therapist also at our Plymouth Meeting facility. In practice for 14 years, Moravec is a board certified clinical specialist in oncologic physical therapy and a certified lymphedema therapist.

Michelle, thank you so much for joining me today. I'm very excited to talk to you about the use of physical therapy to manage breast cancer related Conditions.

Thank you for having me. You know I've practiced in a wide range of physical therapy over the years, but oncology rehab, in particular the rehab of breast cancer survivors, is really an area that speaks to me.

How long have you been in practice and how long out of that time have you specialized in treating cancer patients?

So I've been in practice for over 14 years and I've spent about the last five years focusing on primarily cancer rehab in particular for breast cancer survivors.

What drew you to the cancer population?

Throughout my career I've met breast cancer survivors who come to therapy 10, 20 even 30 years later with arm and shoulder issues or swelling that they've just ignored and lived with. And they assume that a lower quality of life is expected with breast cancer and so they don't want to complain.

By not complaining do you mean they're not complaining because they just feel lucky to be alive?

Exactly. So this issue is actually being researched in the literature because so many caregivers and patients don't talk about their concerns and they're finding that exercise can help increase quality of life. And I feel really strongly that if we can improve quality of life, that rehab should be available to these people.

One aspect of breast cancer rehabilitation is managing lymphedema. Tell me a little bit about lymphedema.

Lymphedema is one of those topics in rehab that is finally getting the attention it needs. I could probably talk your ear off about it so without getting into like the anatomy and physiology of it all, breast cancer-related lymphedema is swelling in a specific portion of the body. It's usually in the arm on the same side as the breast cancer, but it could also be seen as swelling in that side of the trunk, in the hand, even the breast.

I notice that you call it breast cancer lymphedema. Can you describe exactly what that means?

Breast cancer-related lymphedema is swelling caused by breast cancer or cancer treatment. If you think about arteries and veins that move blood and fluids throughout your body, the lymphatic system is another type of vessel in our bodies that transports fluid. So a tumor for example could block that fluid flow almost like a dam across the river. And sometimes it's the cancer treatment itself that can contribute to swelling, either by surgical removal of lymph nodes or even radiation therapy to lymph nodes. However, I will say that getting lifesaving treatment outweighs the risk of developing swelling.

Are there other causes of lymphedema beyond breast cancer?

So in the United States, the number one cause of lymphedema is cancer. But worldwide the leading cause of lymphedema is actually a condition called filariasis which is a type of infection from a parasite that causes swelling. It comes from a bug bite found in the tropics. So most people who get that condition really live in tropical countries and some people have what's called primary lymphedema and that's based on genetics and tends to run in families. So people will often say something like, oh all the women in my family have big legs.

What function exactly does the lymph system provide to our body?

The role of the lymphatic system is really to move lymphatics fluids throughout the body and this lymph fluid really helps the body get rid of waste products from cells, get rid of toxins and helps our bodies fight infection and damage to these lymphatic pathways, either by cancer or treatments, can cause swelling.

What does physical therapy for lymphedema consist of?

The gold standard of lymphedema treatment is a process called complete decongestive therapy. A combination of good, meticulous skin care, specialized massage called manual lymph drainage, compression therapy and gentle exercise helps circulation.

Okay, can we take a step back and break down some of those components that you mentioned for complete decongestive therapy? You mentioned meticulous skin care. Why is that important in the treatment of lymphedema?

Swelling from lymphedema isn't just water. Like I mentioned before, it contains waste products from the body that can act like a breeding ground for bacteria in the skin. So meticulous skin care, making sure the skin stays clean, moisturized and avoiding cuts or other trauma is very important in preventing a bacterial infection and the infection in a swollen arm can spread quickly throughout the body and cause life threatening illness. So we want to avoid skin breakdown as much as possible.

You mentioned the lymphedema can occur as a result of an infection in the skin. If somebody has cancer treatment, can this happen years after they've had their cancer  treatment completed?

Yes. You know there's no timeline for developing lymphedema. Most people who develop lymphedema after breast cancer will often get it within the first couple years, but people who have either surgery to the lymph nodes or radiation therapy, they are at a lifetime risk.

You also mentioned that gentle exercise is a key part in the management of lymphedema. However, it's often said that breast cancer survivors should limit their exercise, they shouldn't lift more than 10 pounds. What should a physical therapist do in this case if they're using exercise to manage the lymphedema?

Nowadays, their finding the opposite is true. Staying physically active and doing a strengthening program may actually help with the swelling. Many studies are showing that a graded strengthening program does not cause swelling. The key of course is to not overdo it and go slowly. So the takeaway message for survivors is to stay as physically active as possible, and if a person does develop swelling or even the sensation of swelling, to encourage that person to get a script from their oncologist for a lymphedema therapy evaluation.

Another component of the complete decongestive therapy that you mentioned is compression. Can you describe how someone with lymphedema is able to get compression and what that looks like?

The most common garment a breast cancer survivor will see is an arm sleeve but any compression garment should be measured for proper fit. Poorly fitting garments may actually turn into a tourniquet and dig into people's skin almost like a rubber band. Also a swollen limb should be treated with complete decongestive therapy before getting an arm sleeve. That way the arm is at its smallest size, and the sleeve will help maintain that small size and measurement could be by a certified fitter at a garment store or by a certified lymphedema therapist but really a big barrier that a lot of people have is that a lot of insurance companies don't cover compression sleeves or they only cover a portion of the cost.

You mentioned that the garments themselves will help maintain the reduction in swelling or keep the person at a smaller size. So these compression garments are not intended to actually shrink the limb down is that correct?

 That's correct.

Does timing of physical therapy matter?

Regarding lymphedema, the sooner the better. Lymphedema is easier to manage when it's mild. When it's untreated, mild lymphedema can actually progress to more severe stages. Skin can change in either texture or appearance. One thing to think about is that a lot of breast cancer survivors go through a lot of physical, mental, emotional barriers and obstacles and cancer treatment itself is a really stressful process. So to develop swelling in the arm due to lymphedema can really add to a person's distress, so it is the sooner a  person is seen for symptoms the better.

I could imagine that that would be stressful. So, are there hallmark symptoms that a person who suspects they have lymphedema would notice to alert them to contact their medical providers or seek physical therapy?

Oh yes. Common early symptoms would include feeling tightness or heaviness in the arm. Noticing that even their jewelry or clothing doesn't feel quite right. It feels tighter and feeling swollen even if the swelling isn't visible. If someone develops these symptoms, I wouldn't ignore it. I would recommend talking to your oncologist about early stage lymphedema.

I noticed that you received a grant from the Albert Einstein Society for an innovative program to screen newly diagnosed breast cancer survivors for lymphedema.

And a lot of evidence is pointing to early detection for breast cancer related lymphedema, especially using technology that can detect swelling before it's visible. So the Einstein Grant was essential in helping us just kind of stay on the edge of that innovation. So we used the grant as seed money at MossRehab in Plymouth Meeting and we purchased the device called the L-Dex that detects swelling up to ten months before it's visible and it really gave us the ability to start treating patients sooner. And just like the emerging evidence is showing, we were able to prevent people from developing full blown swelling.

Are there other common conditions that breast cancer survivors encounter that can also be managed with physical therapy?

Breast cancer is similar to other types of cancer. Fatigue and the diagnosis of cancer related fatigue is the most common complaint that can be managed with physical therapy. Also there is research that breast cancer survivors are at risk for shoulder issues and shoulder pain, particularly decreased range of motion and tightness with radiation therapy and those issues are very treatable with physical therapy.

 What would be one piece of advice that you would give someone who's interested in specializing in cancer rehab?

I think that the advice I follow myself for all patients rings even more true for a patient with cancer. And that's really to remember the patient. A lot of survivors compare their cancer diagnosis to a journey and it's really our privilege to walk a little of that road with them. So aligning the goals of rehab and meet the patient wherever they are on that road is really important.

Is there anything that you have come across that is new and innovative in the treatment of breast cancer patients that you've begun to incorporate within your care?

They say that everything that comes around goes around sort of thing and what's old is new again and really the innovative thing that they're finding in cancer care for rehab specifically is exercise is so very important. Not only for long-term survivorship and long-term wellness, but in the short-term during active chemotherapy, during radiation therapy when people are actually actively receiving treatment. And that's really the edge of where we are right now where they're pushing exercise and physical activity sooner and having good benefits for patients.

Michele I can't thank you enough for being here and presenting your expertise on this patient population. You've done so much for the breast cancer survivors in our area so thank you again.

And thank you for having me.

That was Michele Moravec, a board certified clinical specialist in oncologic physical therapy and a certified lymphedema therapist at MossRehab Plymouth Meeting. Speaking with Trish Crane, clinical manager at our Plymouth Meeting facility on our new multi-part series MossRehab Conversations: Therapy Edition, where MossRehab therapists discuss their expertise in the various clinical fields and on the web at mossrehab.com/conversations. You can also listen in as we talk with pioneers in physical medicine from around the globe. Thanks for joining us. I'm Bill Fantini.