· Physical Therapist's Guide to Lymphedema
Lymphedema is swelling generally in the arms or legs due to a blockage in your lymphatic system. It's estimated that about one third of women who undergo axillary lymph node dissection during breast cancer treatment will develop lymphedema. Identifying and treating lymphedema early helps ensure faster and better outcomes, but even treatment later on, during the chronic stages of the disease, can still help.
To determine if you have lymphedema, check with your physician or physical therapist immediately if you have swelling in one of your limbs and you:
o Have cancer or have been treated for cancer
o Have a cardiac, kidney, or liver condition
What is Lymphedema?
The lymphatic system collects lymph (excess fluid, proteins, and other substances) from the body tissues and carries them back to the bloodstream. Lymph is moved slowly through lymphatic vessels and is passed through the lymph nodes. Swelling ("edema") may occur when the lymph increases in the body tissues. Lymphedema occurs when the normal drainage of fluid is disrupted by a blockage or a cut in the lymph nodes in the groin area or the armpit. Lymphedema can be a hereditary condition, but it's most commonly the result of blockages caused by infection, cancer, and scar tissue from radiation therapy or the surgical removal of lymph nodes.
You're at greater risk for lymphedema if you:
o Had surgical removal of lymph nodes in the underarm, groin, or pelvic region
o Received radiation therapy to the underarm, groin, pelvic region, or neck
o Have scar tissue in the lymphatic ducts, veins, or under the collarbones caused by surgery or radiation therapy
o Have cancer that has spread to the lymph nodes in the neck, chest, underarm, pelvis, or abdomen
o Have tumors in the pelvis, abdomen, or chest that involve or put pressure on the lymphatic vessels and/or the large lymphatic duct thereby blocking lymph drainage
o Have inflammation of the arm or leg after surgery
o Are older
o Have an inadequate diet or are overweight, as these conditions may delay recovery from surgery and radiation therapy and may increase the risk for lymphedema
 Lymphedema |
Signs and Symptoms
With lymphedema, you may have:
o Swelling in your arms, legs, shoulders, hands, fingers, or chest
o Skin that feels tighter, harder, or thicker than normal in the affected area
o Aching or a feeling of heaviness in your arm or leg
o Weakness in your arm or leg
o Inability to move certain joints, such as your wrist or ankle, as freely as usual
o "Pitting" in the tissues of your limb (an indentation that is made by pressing a finger on the skin that takes time to “fill in” after the pressure is removed)
o Clothing, rings, bracelets, or shoes that fit tighter than before
o Repeated infections in your arm or leg
o Joint pain
o Difficulty doing your daily activities
If you have fever and chills, and your limb with lymphedema is red, swollen, or painful, and feels warm to the touch, you may have an infection.
How Is It Diagnosed?
Your physical therapist will review your medical history and medications and perform a thorough physical examination that includes the following information:
o Your actual weight compared with your ideal weight
o Measurements of your arms and legs
o How well you’re able to do activities of daily living
o History of edema, previous radiation therapy, or surgery
o The time between surgery and when you first noticed the swelling
o Other conditions such as diabetes, high blood pressure, kidney disease, heart disease, or phlebitis (inflammation of the veins)
How Can a Physical Therapist Help?
Your physical therapist will serve as an important member of your health care team and will work closely with you to design a treatment program to help control the swelling and meet your goals for returning to your activities.
In the early stages of lymphedema, when the swelling is mild, it can often be managed by compression garments, exercise, and elevation of the affected limb to encourage lymph flow. For more severe swelling, the physical therapist may use a treatment called "complete decongestive therapy." The initial step often includes manual lymphatic drainage, which feels like a light form of massage and helps improve the flow of lymph from your arm or leg. This is followed by compression bandaging that helps to reduce the swelling. Your therapist will carefully monitor the size of the limb throughout your treatment sessions.
Once the limb has decreased to the desired size, your physical therapist will help you begin to take over your own care by:
o Developing a safe and sensible exercise program that will increase your physical fitness without unnecessarily straining your affected arm or leg
o Updating your compression garments to ensure proper fitting, working with you to find the type of garment that best meets your needs
o Educating you about proper diet to decrease fluid buildup in your tissues and skin care to reduce the risk of infection
Can this Injury or Condition be Prevented?
Some risks, such as treatment for cancer, can’t be avoided. If you’ve had radiation therapy, or your lymph nodes have been removed but you don’t have lymphedema, your physical therapist will help you identify and manage the risks that you can control to avoid it.
Your physical therapist will:
o Design a safe and sensible home exercise program to improve your overall fitness and help you avoid the weight gain that can increase your risk of lymphedema
o Develop a safe and sensible exercise program that will avoid straining the affected limb and help you reduce the risk of developing lymphedema following surgery or infection
o Periodically assess the size of your limb and, if there is an increase in limb size, providing conservative, early intervention to help prevent the swelling from getting worse
o Help you maintain good skin care and hygiene
Poor drainage of the lymphatic system might make your arm or leg more susceptible to infection, and even a small infection could lead to serious lymphedema. You can help prevent lymphedema by avoiding cuts and abrasions, needle sticks and blood draws, burns, and insect bites on the affected limb.
What Kind of Physical Therapist Do I Need?
Although all physical therapists are prepared through education and experience to treat a variety of conditions, you may want to consider:
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
o Get recommendations from family and friends or from other health care providers.
o When you contact a physical therapist for an appointment, ask about his or her experience in helping people with lymphedema.
During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
Further Reading
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
APTA has determined that the following articles provide some of the best scientific evidence on how to treat lymphedema. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.
Bevilacqua JL, Kattan MW, Yu C, et al. Nomograms for predicting the risk of arm lymphedema after axillary dissection in breast cancer. Paper presented at: 2011 Breast Cancer Symposium; September 8-10, 2011; San Francisco, CA. Abstract 8. Abstract Summary.
Cohen MD. Complete decongestive physical therapy in a patient with secondary lymphedema due to orthopedic trauma and surgery of the lower extremity. Phys Ther. 2011. August 25 [Epub ahead of print]. Article Summary on PubMed.
Quirion E. Recognizing and treating upper extremity lymphedema in postmastectomy/lumpectomy patients: a guide for primary care providers. J Am Acad Nurse Pract. 2010;22:450–459. Article Summary on PubMed.
Gilchrist LS, Galantino ML, Wampler M, et al. A framework for assessment in oncology rehabilitation. Phys Ther. 2009;89:286–306. Free Article.
Acknowledgments: APTA’s Section on Women’s Health and Oncology Section; Patricia Ohtake, PT, PhD original article appeared on: http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=8fadc252-aa62-472d-9f22-977837a30acc
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