Faculty member Linda Koehler, PhD, PT, CLT-LANA (Certified Lymphedema Therapist - Lymphedema Association of North America), is one of the few researchers in the world studying AWS or axillary web syndrome.

AWS is the result of breast cancer surgery in which one or more lymph glands are removed. It causes painful upper extremity disability and range of motion issues due to a tight band of tissue that develops in the axilla [the space below the shoulder through which vessels and nerves enter and leave the upper arm]. During a previous observational investigation, Dr. Koehler discovered that, 90 percent of women, even without AWS, have some sort of impairment after breast cancer treatment. “Less than 36 percent receive rehabilitation to help reduce that impairment,” she added.

BIRCWH award
Being one of three 2020 BIRCWH* (Building Interdisciplinary Research Careers in Women's Health) program scholars at the U of M is enabling her to expand her knowledge about and test an intervention for the condition.

Dr. Linda Koehler

Dr. Koehler (pictured at left) was introduced to AWS just out of physical therapy school when she had an opportunity to work with Dr. Audrey Traub, a breast cancer surgeon at Unity Hospital in Fridley, MN. “She was far ahead of her time and sent all her patients to physical therapy right after surgery,” said Dr. Koehler. At that time, surgeons removed more lymph nodes than they do now, and impairment was not only more prevalent but more impactful on the women involved.

“I kept seeing this condition in Dr. Traub’s patients — an abnormal web of tissue in the axilla,” Dr. Koehler noted. “I remember calling and asking her what it was. She said she didn’t know but please help them get their range of motion back.”

Clinical trial
The BIRCWH grant is enabling Dr. Koehler to conduct a clinical trial comparing the effect of specialized physical therapy interventions to the usual care of breast cancer survivors with axillary web syndrome (AWS). “AWS develops about two to eight weeks after breast cancer surgery,” she explained. “My observational research showed that it occurs in up to 70 percent of these patients.”

Having worked with the same group of women after their breast cancer surgeries for five years, Dr. Koehler discovered that several of them had AWS at 18 months post-surgery; some even had the condition five years after surgery, which increased their risk of shoulder impairment and dysfunction. Those findings inspired her to follow up her initial work with a clinical intervention study. “It’s why developing an intervention is so important,” she said.

Dr. Koehler and her research team are enrolling 20 in each group to compare a group that receives intervention for AWS compared to a group that receives usual care for the BIRCWH-funded study. They use manual therapy, exercise, and education to address range of motion issues, lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), function, and pain.

Adapting to the pandemic
When the COVID-19 pandemic temporarily halted the use of manual therapy, Dr. Koehler’s team developed a unique telehealth approach. “We taught the patients to treat themselves,” she said. “While we are still refining how to deliver the intervention over telehealth, the patients have been amazing. They are taking complete responsibility for their care because they know they need to.”

When pandemic restrictions lift, Dr. Koehler plans to collaborate with Professor David Hunter, MD, Associate Professor Anil Chauhan, MD, and Assistant Professor Noelle Hoven, MD in the Department of Radiology. “We want to use advanced ultrasound to image AWS to gauge if it would be a good diagnostic tool and to see if it will give us some additional insight about the condition,” she said.

As Dr. Koehler looks to the future, she hopes that the work she is doing on the BIRCWH grant will change standard practice regarding the treatment of AWS. “If we can show the benefits of our intervention, it will lead to better management of the condition and far less impairment for these patients following their surgeries,” she said. In addition, Dr. Koehler wants to make the telehealth procedure available to breast cancer survivors living in rural/isolated areas.

*More about the BIRCWH program
According to the U’s BIRCWH website, the program is an internal K12 grant mechanism from the National Institutes of Health (NIH) Office of Research on Women’s Health. It fosters mentored research career development of junior faculty engaged in interdisciplinary women’s health or sex differences research. Dr. Koehler’s mentors include Douglas Yee, MD, Division of Hematology, Oncology and Transplantation; Todd Tuttle, MD, MS, Department of Surgery; Paula Ludewig, PhD, PT, FAPTA, Department of Rehabilitation Medicine; lymphedema expert Jane Armer, member of the faculty of the Sinclair School of Nursing in Columbia, MO; and biostatistician Jim Neaton from the Department of Public Health.

The aim of this training program is to place junior investigators on the path to being competitive for NIH independent K- or R- awards (more funding, longer time periods). On average, UMN BIRCWH Scholars receive about $850,000 in federal, internal, and other funding within the first five years post-award.

Receiving the award have been lifechanging for Dr. Koehler. “It’s a great honor to be among those who have won it before,” she said. “It enables me to focus on my research, collaborate with those who have shared interests, and gain advanced training.” Her BIRCHW work began in August 2019 and will run until August 2022.