Lymphedema: A Breast Cancer Patient’s Guide to Prevention and Management Lindsay Davey, MScPT, MSc, CDT Registered Physiotherapist, Certified in Combined Decongestive Therapy, Owner/Clinic Director of Toronto Physiotherapy
The Lymphatic System: What Does It Do? Maintains a normal balance of fluid in our tissues and blood stream 20% of all tissue fluid returns to the heart via the lymphatic system (80% returns via veins) Monitors for foreign material and bacteria in the body Circulates immune cells for fighting infection
What is Lymphedema? The swelling of a body part due to the accumulation of lymphatic fluid Caused by an insufficiency of the lymphatic system to ‘drain’ fluid from the limb (or torso) Reasons for impaired drainage: ◦ Surgical removal of lymph nodes from the armpit ◦ Radiation to the lymph nodes in the armpit/chest Lymphedema can take weeks, months, or years to appear following cancer treatment
Who Gets Lymphedema? Incidence rate of lymphedema in breast cancer population: 6% - 30% Increased Risk*: ◦ Full mastectomy ◦ Higher number of nodes removed ◦ Radiation to armpit ◦ Tumour positive nodes ◦ Post-op complications ◦ Axillary Web Syndrome (Cording) ◦ Increased Body Mass ◦ Genetic predisposition? *Miaskowski C et al, PLoS One 2013: Apr 16; 8(4).
Symptoms of Lymphedema: Early Stage May not see swelling Sensation of heaviness, fullness, tightness, bursting sensation, aching pain, tingling May see swelling or puffiness after exercise or more vigorous use of the arm Elevating the arm may decrease swelling Swelling may be ‘pitting’ when pressure is applied
Symptoms of Lymphedema: Later Stage Swelling of the upper arm, forearm, hand, fingers and/or trunk Non-pitting Elevation has no effect Areas of ‘hardening’ of the tissue Skin changes Chronic condition (but can be well managed !)
How is Lymphedema Treated? Gold Standard Treatment Approach: Combined Decongestive Therapy (CDT) 1. Manual Lymphatic Drainage Massage 2. Compression 3. Infection Prevention / Skin Care 4. Exercise
Manual Lymphatic Drainage Massage NOT the same as a typical massage Specific pressure Specific strokes Specific sequence Re-routes fluid to bypass deficient pathways where nodes have been removed or exposed to radiation Self-massage is a KEY component in management. *VIDEO*
Compression TWO Phases: 1. Arm Volume Reduction Phase Short-stretch bandages (like tensor bandages) Usually takes 3 – 6 weeks 2. Maintenance Phase Compression garment, custom fit or off the shelf
Are These Garments Covered Under OHIP? The Assistive Devices Program (ADP) will pay for 75% of the cost of garments They cover 2 garments, 3 X per year ADP form must be signed by a Physician (the first time it must be a specialist ), a CDT-Authorizor (like myself), and a Fitter Some patients may also have coverage through extended health benefit plans
Infection Prevention & Skin Care The arm is at higher risk for infection Keep the skin well moisturized (glycerin-free products are best to prevent drying/cracking) Caution with things that could break the skin: ◦ Insect bites ◦ Animal scratches ◦ Cuticle trimming/manicures ◦ Paper cuts or larger cuts ◦ Shaving the armpit ◦ Minor burns Use antibiotic cream on all cuts/scrapes
Signs of Infection and What To Do Signs of Infection: Redness (Cellulitis) Streaking or Rash appearance (Lymphangitis) Heat Fever Generally feeling unwell What To Do: STOP heavy use of the arm STOP self-massage and compression Seek medical attention immediately (antibiotics)
Exercise: How Does It Help? For Breast Cancer Rehabilitation In General: Aerobic exercise (ex- walking) can decrease fatigue, stress, depression, body mass, and improve immune responses Strength exercises help battle deconditioning and generalized weakness Patients’ Quality of Life scores are significantly higher among those who exercise!
Exercise: How Does It Help? For Lymphedema Prevention & Management: Promotes fluid flow via pumping action of contracting muscles Strengthening makes limb less susceptible to repetitive strain or other injuries (which can cause inflammation) Stretching maintains tissue flexibility to promote flow through lymphatic channels Decreases risk of lymphedema* *Schmitz K et al, JAMA 2010: 304, 2699-2705
Exercise Principles for Lymphedema Patients: Wear compression during exercise Avoid wearing tight jewelry Pre- and Post-exercise self-massage promotes lymphatic flow Keep cool Include aerobic and resistance training Progress exercises for the arm at slower rate; delay pectoral exercises? Evidence supports lifting ‘heavy’ weights* *Cormie P et al, J Cancer Surviv 2013 Apr 20, epub
Scar, Radiation Damage, and Cording YES WE CAN HELP! Mastectomy, lumpectomy and/or node dissection scars Adherent/tight tissue in radiation zone Rope-like cord in armpit/arm Specialized massage techniques* Specific home exercises Improves range of motion, improves lymphatic flow, decreases pain
Do’s and Don’ts ! Avoid injections and IV’s on the affected side Avoid blood pressure cuffs on this side Avoid hot tubs and saunas Diuretics do not help lymphedema * * * Do wear some form of compression on flights Do learn self-massage of the arm, and neck! Do learn diaphragmatic breathing!
Summary: Lymphedema and CDT Incidence as high as 30% in breast cancer patients Chronic condition, but can be well managed! CDT effectively treats lymphedema CDT can help prevent lymphedema CDT therapists a great resource on topic of lymphedema, scar and radiation field tissue adhesions, cancer rehabilitation We’re here to help!
Resources Lists of CDT Therapists: ◦ Lymphovenous Association of Ontario www.lymphontario.ca ◦ Toronto Lymphocare Centre www.torontolymphocare.com
Resources Toronto Physiotherapy www.TorontoPhysiotherapy.ca On-line Resources: ◦ A copy of this talk ◦ Lymphedema educational material ◦ Self-Massage Video ◦ Lymphedema Blog: hot topics and latest research
Thank you! Lindsay Davey, MScPT, MSc, CDT www.TorontoPhysiotherapy.ca
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