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