Advanced certification: breast cancer related lymphedema management

       Breast cancer related lymphedema is the accumulation of high protein fluid in the upper extremity that stagnates due to impairment of the lymph vessels following removal of axillary lymph nodes and possibly exacerbated by subsequent radiation. The excess fluids represent an imbalance of arteriole flow entering the limb and the venous and lymph flow carrying fluid out of the limb and back to the heart. Fluid and protein ÒinÓ is greater than fluid and protein Òout.Ó

       Lymphedema occurs between the outer skin and the surface of the muscle in the interstitial space. The lymphatic system of the body is composed of a number of drainage areas or lymphotomes with watersheds or divisions between the lymphotomes. Successful treatment for lymphedema, based on this pathophysiology, depends on the proper blend of treatment modalities, and the tailoring of these modalities to the individual:

1. Manual lymphatic drainage is a manual technique using light and sequential strokes repeatedly performed in the direction of normal lymphatic flow. The technique uses the superficial lymphatic vessels of the skin to transport fluid from an area of congestion to an area of functioning lymphatics. The result is an increase transport capacity and an increase in collaterals adjacent to the congested area. Repeated lymphatic drainage can lead to anatomical changes that increase lymphatic flow away from compromised areas reducing the size of the extremity.
2. Compression garments (sleeve or bandage) provides external support to the skin. The gradient compressive forces push the lymphatic fluid from the interstitium into the lymph vessels aiding the fluid's movement out of the extremity into proximal drainage ports. The patient learns how and when to wrap with non-stretch compression bandages, and/or is fit with a garment and learns when to use it.
3. Exercise prescribed and monitored to each individual ranges from flexibility exercises to gentle strengthening exercises using free weights or therabands. By closely monitoring the edema, a safe home exercise program can be incorporated into the treatment program. If there is no increase in the edema for several sessions, the exercise can progress. Abdominal breathing exercises and an aerobic component to the program can also be beneficial. The increase in abdominal breathing alters the intrathoracic pressure creating a suction force that can facilitate lymphatic flow.

Determining the appropriate treatment will depend on the size of the limb, the firmness of the edema, the general condition, lifestyle, and personal goals of the person with lymphedema. These factors will also determine frequency and duration of treatment. The person with lymphedma is vulnerable to cellulitis-type infections. To reduce this risk, the goal of treatment is to move the high protein fluids, reduce the limb, improve its texture, and offer the person with lymphedema skills/knowledge for independent management. Copyright, Idelle Packer, 1999

Resource:

Smith JK, Miller LT. Management of patients with cancer-related lymphedema. Oncology Nursing Updates: 1998;5:1-12.

Physical Therapy following the Diagnosis of Breast Cancer
Physical Therapy when Postural, Orthopedic, or Neurologic Symptoms occur following Surgery
Physical Therapy at the Onset of Lymphedema
Lymphedema Management
Anatomy of Lymphatics
Kinesio Taping for lymphedema

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