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