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• January 22, 2015
• Joy C. Cohn PT, CLT-LANA
Lymphedema Team Leader – Penn Therapy and Fitness
Philadelphia, PA
What Do You Need to Know about Lymphedema?
Objectives
• Learn what Lymphedema is
• Learn about risk factors and how to reduce your risk
• Learn what treatments are available for Lymphedema
• Learn about new treatments
• Learn where you can find more information
Lymphedema
• Not all swelling is Lymphedema!
• A hi protein edema characterized by progressive swelling and tissue thickening due to inflammation
• Primary vs. Secondary
– Secondary is caused by known damage to lymphatics/nodes: surgery, radiation, or infection in Breast CA
Symptoms of Lymphedema
• Achiness
• Heaviness
• Fullness
• Trouble with fit of clothes or jewelry
• Odd sensations
• Obvious swelling
• Symptoms that last 7 days…..
Staging of Lymphedema
Stage Pathology Signs/Symptoms
0 Local tissue thickening Lymphatic damage
No edema, subjective complaints possible
I Hi Protein Edema Local tissue thickening
Pitting Edema, reduced by elevation, +/- ‘pain of congestion’
II Extensive thickening Fat proliferation
Brawny, hard swelling, no reduction with elevation
III As in Stage II Like Stage II with added skin changes- hyperkeratosis and papillomas
Foldi 2003
Breast Cancer Related Lymphedema
Breast Lymphedema
Lymphatic System
Lymphatic System
• A ‘sewer’ system separate from our blood flow
• Drains the tissues just under the skin
• Major functions:
– Recycles proteins (big molecules)
– Important part of immune system for fighting infection and cancer
– Helps with fat digestion (big molecules)
• Drains along with veins back to the heart
Lymph System- Regional Nodes
• Number 600-700 in body
• Widespread in body
• Concentrated at head/neck, in gut, and at ‘root’ of each limb-
– Armpit (axilla)
– Groin
Lymph Nodes
• Filter and adjust the amount of lymphatic fluid
• Monitor for foreign materials: cancer cells, bacteria and viruses, other debris
• Add immune cells to the lymphatic fluid and blood: T cells and other lymphocytes to fight infection and disease
What happens in Breast CA ?
• Surgery to Breast
– Lumpectomy
– Mastectomy
• Axillary Nodes are removed
– Axillary dissection (6-20 nodes)
– Sentinel Node biopsy (2-6 nodes)
• Radiation Therapy may be done
Axillary nodes
Lymphatic Damage
• Removal of nodes = less ‘plumbing’ to drain fluid from the tissues
• Radiation causes fibrosis = ‘thickening’ of the tissues surrounding the drainage system leading to less drainage from the tissues
What area of the body might swell?
• Breast on the same side
• Arm on the same side
• Front and Back of the chest on the same side
• No other area
Risk of Developing Lymphedema
• 6-20% of women treated for Breast CA
• Approximately 1 in 5 Breast CA survivors
• Likely to develop in first 1-3 years after surgery
• BUT- risk is lifelong
• Risk is lower with Sentinel Node Biopsy-
– Less nodes removed
Other Known Risk Factors
• Weight Gain after Diagnosis/Treatment
• Radiation
– Size of radiation field matters
• History of injury to at risk area
• History of infections after surgery/treatment
Risk Reduction
Lymphedema
Position Paper on Risk Reduction Practices for Lymphedema- ‘Live Smart’ advice
Source: www. lymphnet.org Accessed: 1/16/15
How can you reduce your risk of developing/worsening lymphedema?
• Lymphedema risk reduction practices include:
– Skin care
– Activity/lifestyle
– Avoiding limb constriction
– Compression garments (If appropriate)
– Avoiding extremes of temperature
Skin Care
• Avoid trauma/injury and reduce infection risk – Keep arm clean and dry – Apply moisturizer daily to prevent chapping/chafing of
skin – Attention to nail care; do not cut cuticles – Protect exposed skin with sunscreen and insect
repellent – Use care with razors to avoid nicks and skin irritation
(shave armpit with electric razor) – If possible, avoid punctures such as injections and
blood draws
Skin Care
• Wear gloves while doing activities that may cause skin injury
• If scratches/punctures to skin occur, wash with soap and water, apply antibiotics, and observe for signs of infection
• If a rash, itching, redness, pain, increased skin temperature and swelling, fever, or flu-like symptoms occur, contact your physician immediately
Activity/lifestyle
• Gradually build up the duration and intensity of any activity or exercise
• Take frequent rest periods during activity to allow for limb recovery
• Monitor the extremity during and after activity for any change in size, shape, tissue, texture, soreness, heaviness, or firmness
• Maintain a healthy weight
Avoid Limb Constriction
• If possible, never have blood pressure taken on the arm at risk
• Wear loose fitting clothing and jewelry
• Wear a well fitted bra- avoid underwires if possible and wear wide straps with pads if large breasted.
A well fitted bra!
• Wide, supportive sides
• No Underwire
• Padded straps
• Cup sizes up to N!
www.elilausa.com
Compression Garments
• Should be well fitting
• Support the limb with lymphedema for strenuous activity (e.g. weight lifting!)
• If you have lymphedema, wear a well fitting compression garment for air travel
Extremes of Temperature
• Avoid exposure to extreme cold, which can be associated with rebound swelling, or chapping of skin.
• Avoid prolonged (> 15 minutes) exposure to heat, particularly hot tubs and saunas
• Avoid immersing limb in water temperatures above 102 degrees
What should I do on a plane?
• If you have lymphedema: wear a well fitted compression sleeve AND glove or gauntlet
• If you do NOT have lymphedema: consult a therapist for advice
• NEVER wear just a sleeve on a plane- it can cause swelling in your hand!
• The risk of swelling starting during a plane flight is less an 0.5%
What can you do if you develop lymphedema?
• Get evaluated by your doctor or lymphedema therapist.
• Earlier treatment results in faster response to treatment thereby decreasing the length of therapy.
Training of Lymphedema Therapists
• See Position Paper from NLN
• Be sure your therapist meets these minimum requirements
“I haven’t lifted anything that weighs more than 5 pounds
since my surgery”
A MYTH!!!!!!
• A gallon of milk weighs 8 pounds
• What does you handbag weigh? ☺
• Absolutely NO research that supports avoiding exercise!
• A great deal of research supports exercise thru out cancer treatment and beyond
Why is Exercise Important?
• It can help you maintain your weight after Breast CA
• It can help you reduce the fatigue you feel during and after your treatments
• It can reduce the risk of injury/overload when you need to use your arm
• It can contribute to reducing your risk of recurrence of CA
Exercise Guidelines for Cancer Survivors
• “Avoid Inactivity”
• Survivorship timeframe: “from the time of diagnosis until the end of life” – National Coalition for Cancer Survivorship
• ACSM Roundtable on Exercise Guidelines for Cancer Survivors – Schmitz KH et al 2010
Why is exercise important?
• It can reduce your risk of developing lymphedema or having it get worse if you have lymphedema
Strength After Breast Cancer
• Based on a large clinical trial conducted at Penn – 154 survivors WITHOUT lymphedema
– 141 survivors WITH lymphedema
• Women who participated had these benefits: – 50% reduced likelihood of lymphedema worsening
– 70% reduced likelihood of lymphedema onset among women with 5 or more nodes removed
– Improved strength and energy
– Improved body image
– Reduced body fat
Strength After Breast Cancer Physical Therapy program based on
PAL Trial
• 5-6 sessions to learn:
– Exercises
– Correct Form
– How to Progress
– Learning about lymphedema
– Usually covered by insurance
– Physician Referral recommended
Guidelines for SAFE exercise From PAL Trial
• START Low, GO Slow
• Have a well rounded program
– Warm Up
– Flexibility Exs
– Core Exercises
– Upper Body Resistance Exs
– Lower Body Weightbearing Exs
Guidelines for SAFE exercise From PAL Trial
• Learn how to exercise with good form from an exercise professional to avoid injury
• Learn how to progress resistance exercise correctly
• Don’t ignore a symptom that lasts 7 days
How is Lymphedema Treated?
• Complete Decongestive Therapy (CDT)
• Compression Pumps
• Surgery
Treatment of Lymphedema
Lasinski BB et al: A Systematic Review of
the Evidence for Complete Decongestive
Therapy in the Treatment of Lymphedema
from 2004-2011. PM&R 4(8) 2012 p.580-
601.
Pub:2006
ALFP Review of CDT
• Conclusions:
– CDT improves overall QoL and is effective for various degrees of lymphedema
– Continued use of compression is usually needed
– MLD enhances the effect of compression and improves QoL and Sx
– Longer term follow-up studies are needed
Complete Decongestive Therapy
• PHASE 1: Decongestion • Meticulous Skin Care
• Manual Lymph Drainage
• Gradient Compression Bandaging
• Remedial Exercises
• Compression Garment
• PHASE 2: Maintenance • Meticulous Skin Care
• Day: Compression Garment
• Night: Gradient Compression Bandaging
• Self Manual Lymph Drainage
• Remedial Exercises
• Follow-up Assessment
Meticulous Skin & Nail Care
• Low pH, gentle soaps
• Moisturizer (Low pH also recommended)
• Do not cut cuticles in manicures
• Prevents infection
• Keep skin working optimally
Manual Lymph Drainage Expert Stretching of the Skin
Manual Lymphatic Drainage
Source: Foldi 2003
Manual Lymphatic Drainage
• Drains the congested areas
• Reduces the risk of infection
• Normalizes the size and pressure in the limb
• Reduces pain/discomfort
Compression Therapy
• Gradient, short-stretch bandaging
• Medical compression garment
Garment Measurement
Elastic Garments for Day Use
www.BSNMedical.com www. Lymphedivas.com
Bandage Alternatives
Appropriate for the maintenance
of reduction in volume
www.solarismed.com www.mediusa.com
Compression Pumps
www.flexitouch.com
Why NOT use a Pump for Lymphedema?
• Absorbing lymphatics are superficial, fragile, and low pressure
• Pumps cannot ‘remodel’ fibrotic areas
• Pumps can mobilize large fluid volumes, generally in those patients most at risk
• In the UEs – may cause truncal/breast swelling
• Pumps have not been proven to mobilize proteins
Adequate Conservative Care? • Inadequate treatment often seen
– CDT principles not followed by therapists
• Treatment not intensive (only 1-2 days/week)
• Multilayer bandaging poorly done and not tolerable by patient
• Inadequate MLD ( treated while clothed, incomplete sequencing)
• Poorly fit and (often) non-custom garments causing pain and/or swelling
• Nighttime bandage alternatives not offered or considered.
Adequate Self Care?
• Mistakes:
– Wearing elastic at night instead of during the day
– Taking a ‘vacation’ from regular self care
– Adherence to self care with chronic condition is hard!
New Approaches to Lymphedema
• Vascularized Lymph Node Transfer Surgery
– Pioneered in Europe and Asia
– Designed to ‘replace’ lost nodes
– Nodes harvested from another part of body
– New in US
• Results: – 1/3 smaller in size
– 1/3 ‘feel better’
– 1/3 No change
To Learn More: • Living Beyond Breast Cancer
– www.lbbc.org
• National Lymphedema Network
– www.lymphnet.org
• Oncolink- Univ of Penn
– www.oncolink.org
• BreastCancer.org
– www.breastcancer.org
