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Arm Lymphedema

Note:  This page has been updated, please see the page below for updated and complete information as of Jan. 14, 2012:

Arm Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=arm_lymphedema

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Discussion: 

Most arm lymphedema is a secondary condition caused by removal of lymph nodes for cancer biopsy or damage to thelymphatics from radiation.  Other causes can include burns, various infections, injury or trauma.

However, often overlooked and seldom mention is that you can also have primary lymphedema of the arm.

The dynamics of arm lymphedema are the same as leg lymphedema.  A damaged lymphatic system is unable remove lymph fluids adequately and the fluid begins to collect in the interstitial tissues.  This causes swelling of the affected limb.

Risk Factors for arm lymphedema:

Who is at risk for lymphedema? Anyone who has one or more of the following factors can acquire lymphedema.

1.) Lymph node removal for biopsies

2.) Serious infections that include lymphangitis, cellulitis or erysipelas.

3.) Deep invasive wounds that might tear, cut or damage the lymphatics

4.) Radiation treatments, especially ones that are focused in areas that might contain "clusters" of lymph nodes

5.) Morbid obesity can cause secondary lymphedema by "crushing" the lymphatics

6.) Serious burns, even intense sunburn 

7.) Infection of the microscopic parasite filarial larvae, though this is more common in tropical countries

8.) For primary lymphedema any person who has a family history of unknown swelling of a limb

Early Signs and symptoms of arm Lymphedema

If you are an at risk person for arm lymphedema there are early warning signs you should be aware of.  If you experience any or several of these symptoms, you should immediately make your physcian aware of them.

1.)  Unexplained aching, hurting or pain in the arm

2.)  Experiencing "fleeting lymphedema."  This is where the limb may swell, even slightly, then return to normal.  This may be a precursor to full blown arm lymphedema.

3.)  Localized swelling of any area.  Sometimes lymphedema may start as swelling in one area, for example the hand, or between the elbow and hand.  This is an indication of early lymphatic malfunction.

4.)  Any arm inflammation, redness or infection.

5.)  You may experience a feeling of tightness, heaviness or weakness of the arm.

Complications of arm lymphedema:

1.  Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immuno-deficient.

2.  Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.

3.  Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids.

4.  Loss of Function due to the swelling and limb changes.

5.  Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.

6.  Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections.

7.  Sepsis, Gangrene are possibilities as a result of the infections.

8.  Possible amputation of the limb.

9.  Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.

10. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections.

11. Chronic localized inflammations.

12. Angiosarcoma, a cancer of the soft tissues

13. Lymphangiosarcoma which is a rapidly progressive, non curable cancer of long term lymphedema      patients.

14. Lymphoma, new research indicates a possibility of this with hereditary lymphedema.  I have been diagnosed with two forms of lymphoma.

15. Septic arthritis

Stages of arm lymphedema

There are three basic stages active of lymphedema. The earlier lymphedema is recognized and diagnosed, the easier it is to successful treat it and to avoid many of the complications.

It is important as well to be aware that when you have lymphedema, even in one limb there is always the possibility of another limb being affected at some later time. This "inactive" period referred to as the latency stage. It is associated with hereditary forms of lymphedema.

LATENCY STAGE

Lymphatic transport capacity is reduced
No visible/palpable edema
Subjective complaints are possible

STAGE I

(Reversible Lymphedema)
Accumulation of protein rich edema fluid
Pitting edema
Reduces with elevation (no fibrosis)

STAGE II

(Spontaneously Irreversible Lymphedema)
Accumulation of protein rich edema fluid
Pitting becomes progressively more difficult
Connective tissue proliferation (fibrosis)

STAGE III

(Lymphostatic Elephantiasis)
Accumulation of protein rich edema fluid
Non pitting
Fibrosis and sclerosis (severe induration)
Skin changes (papillomas, hyperkeratosis, etc.)

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Treatment of Arm Lymphedema

The treatment for arm lymphedema is much the same as treatment for leg lymphedema.  The preferred treatment is decongestive therapy.  However, with arm lymphedema, it has been shown that a treatment protocol including sequential pump therapy  with manual decongestive therapy has obtained the best results.

During the course of treatment, the arm will be wrapped in compression bandages after the treatment session.  Upon completion of the treatment, compression sleeves and arm garments will be prescribed.    

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No Blood Tests, Blood Pressure, I.V. or Injections into this Arm!
By Pat O'Connor, Lymphedema People
Nov 1, 2004

Needles
Perhaps the foremost rationale for NOT allowing the use of needles in an arm with lymphedema is the threat of infection. Every break of the skin creates potential entry foci for bacteria. Because of the immunodeficient state of the arm any infection can and often does escalate quickly into cellulitis.  These infections cause further damage to the lymphatics, thereby increasing the severity of the lymphedema.

Lymphorrhea (which is the fluid in the arm) is a protein-rich substance that provides excellent nutrition to any bacteria that might gain a foot hold in the arm. Once an infection has begun the excess fluid and any fibrosis of the arm tissue makes it tremendously more difficult to eradicate the bacteria.

Injection of Medicines
The doseage strength of any medicine injected into the arm will be diminished for two reasons.  First, because of the fluid accumulation in the arm it is going to be immediately diluted. Following that, because of the impaired fluid outflow of the arm, the medicine will have a more difficult time reaching the remainder of the body system.

IV's
The first reason for not allowing an IV is simply the break in the skin - which would be a continous opening until the removal of the IV. Beyond that and even more important is the simple fact that lymphedema is caused by the inability of the arm to remove even the normal excess fluids of body dynamics. When you add the fluids that are present in the administration of an IV, you catastrophically overload the arm.  It simply is totally unable to rid itself of that extra fluid thereby causing a substantial increase in swelling.

Blood Pressure Tests
The danger of having a blood pressure test on an at-risk arm or an arm affected by lymphedema is that the squeeezing involved can cause possible further damage to already fragile lymphatics and blood vessels. If this occurs, it would cause worsening of the lymphedema.

These are common sense approaches that any physcian should be immediately aware of.   For more information, check out the Canadian Medical Association Journal at

http://www.cmaj.ca/cgi/content/full/164/2/191

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Light Arm Exercises That Can Help Prevent/Manage Lymphedema

Because light exercise after breast cancer surgery and lymph node removal can help reduce the chances of lymphedema, patients should discuss how and when to begin arm exercises. Some patients find that taking painkillers (analgesics) 30 minutes prior to exercising helps alleviate discomfort, although all medications should be approved by the patient’s physician.

The following are suggestions of exercises following breast cancer surgery from the Wessex Cancer Trust, an independent charity that provides information and support to patients with cancer. Each exercise may be performed five times in a row, three times a day (morning, afternoon, evening) with the physician’s approval.

• With palms up and elbows straight, stretch arms high above head, linking fingers together.
• Bend elbows and clasp hands at the back of the neck. Push elbows out as far as possible and then bring them together to touch in front of the body. Repeat.
• Place hands behind the back and lace fingers together. Slide hands as far as possible up the body toward the neck.
• Place hands on shoulders (on the same side of the body) and move elbows up and then down toward the sides of the body.
• Place hands on shoulders and make circular movements with the elbows. Circles should be as large as possible. Change directions periodically.
• After breast stitches have been removed, stand with one foot in front of the other. Hold on to a chair or table. Lean forward and swing the arm that was involved in the surgery backwards and forwards, and then from side to side as far as it will go. Hold a small weight to gain momentum. Increase movement until arm reaches shoulder height. Keep elbows straight.
• Stand with one foot in front of one another. Hold onto a chair or table for support. Lean forward and swing the arm on the side of the surgery in circles, first clockwise and then counter-clockwise. Keep elbows straight.
• Face toward a wall. Place hands on the wall and inch fingers up the wall. Try to go higher each day until arms are fully straight over head.

http://imaginis.com/breasthealth/lymphedema.asp

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Lymphedema Arm Self Massage

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Measuring the arm and hand

http://www.lymphoedemaonline.com/page5.html

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Preventing Arm Swelling after Breast Cancer Surgery and Radiation

Peer Review Status: Internally Reviewed by Cancer Center Staff
First Published: September 2003
Last Revised: November 2003

Swelling of the arm on the side of your breast cancer surgery can be due to the lymph nodes under the arm being disturbed by surgery and partial removal and also to radiation of the armpit.

After an injury anywhere in the body, lymph fluid will rush to the injured site to carry away bacteria and any foreign substances. If that injured area is a hand or arm on the side of armpit surgery and radiation, the lymph fluid will have a harder time being absorbed back normally because surgery has removed some of the channels that would have carried the fluid. Radiation has closed down some of those lymph channels also. Since surgery and radiation were life saving treatments, the focus now should be on preventing injury and stress to the affected hand, shoulder and arm to lessen the chance of lymph fluid causing swelling of the arm. If you are a person who has had armpit surgery to test lymph nodes for cancer cells, or if you have received radiation to the armpit, you may want to consider ways to prevent arm swelling.

Avoid Infection

• Treat even small injuries/hangnails with care. Wash the injury with soap and water, apply antibiotic ointment, then cover with a band-aid.
• Keep skin of the hand and arm clean and moisturized. Apply moisturizing lotion several times a day.

Avoid Injury

• Do not have blood drawn from the affected arm, unless absolutely necessary.
• Wear long oven mitts whenever putting hands in an oven. Have someone else get dishes out of the oven when feasible.
• Carefully cook foods in oil to avoid splashing of hot grease onto hands.
• Use rubber gloves when doing cleaning with harsh cleaners.
• Wear rubber gloves when doing dishes.
• Wear canvas gloves while gardening and doing yard work.
• Wear a thimble while sewing.
• Shave underarms with an electric razor. Avoid chemical hair removers.
• Use insect repellant to protect against bug bites or bee stings.
• Avoid sunburn by using sunscreen with SPF of at least 15. Reapply sunscreen after swimming and as directed on the sunscreen label.
• Don't allow injections, vaccinations on the affected arm.
• Do not have manicures on the affected hand. Do not cut cuticles or hangnails.
• Don't hold a cigarette in the affected hand.

Avoid Constriction

• Avoid clothing with elastic sleeve bands or with tight arms.
• Don't wear a watch or rings on affected arm.
• Avoid carrying a heavy purse or bag with the affected arm.
• Have blood pressure taken on the unaffected arm, if possible.
• Underclothing, such as bras, should not leave pressure marks.
• When traveling in a car or plane for long distances, keep the affected arm above the level of the heart, if at all possible.

Avoid Muscle Strain

• Avoid heavy lifting if your muscles are not used to heavy lifting.
• Avoid vigorous, repetitive movements such as scrubbing, pulling, hammering.
• Sports such as tennis, racquetball and golf have the potential to strain muscles because of sudden and forceful strokes.
• Begin any new exercise/activity involving the arms gradually and with caution.

http://www.vh.org/adult/patient/cancercenter/lymphedema/

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LYMPHEDEMA OF THE ARM AND CHEST

AFTER MASTECTOMY

1. WHAT IS LYMPHEDEMA?

Edema -- Lymph -- Lymph - obligatory load--

an accumulation of lymph fluid consists of lymph and other matter consists of fluids (water) + plasma proteins (albumin) debris cells (cells) + foreign matter + long chained fatty acids (fats)

2. WHAT CAUSES LYMPHEDEMA?
      CAN LYMPHEDMA GET WORSE?

The standard treatment for breast cancer is the partial or total resection (removal) of the breast with either a partial or total resection and/or radiation of the underarm lymph nodes.

25 PERCENT TO 50 PERCENT OF PATIENTS DEVELOP "SECONDARY
ARM LYMPHEDEMA" OR "SECONDARY CHEST LYMPHEDEMA:"

The anatomy of the lymphatic system provides an explanatiion of what causes lymphedema following surgical treatment or radiation therapy for breast cancer.

The removal of the axillary or underarm lymph nodes brings about a disruption of the superficial and deeper lymph drainage pathways of the arm and the body quadrant on that side. This results in a predisposition to or the immediate formation of a condition of lymphedema on that side.

Although lymphedema of the arm or body after mastectomy is not life-threate- ning, it is according to Stillwell "...often the source of considerable physical and mental discomfort and occasionally even disabling."

If left untreated, lymphedema will become worse with time. There is a hardening of tissues as fibrosis or slerosis occurs. Long-term lymphedema of the arm that remains untreated can turn into a form of cancer (angiosarcoma).

http://www.wittlinger-therapiezentrum.at/englisch-2000/lymphedema.htm

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Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema

CMAJ*JAMC  -  JANUARY 23, 2001

Susan R. Harris, Maria R. Hugi, Ivo A. Olivotto, Mark Levine and The Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer

Dr. Harris is Professor in the School of Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC; Dr. Hugi is with Providence Health Care, Vancouver, BC; Dr. Olivotto is Clinical Professor in the Division of Radiation Oncology, BC Cancer Agency-Vancouver Island Cancer Centre and the University of British Columbia, Victoria, BC; and Dr. Levine is with the Cancer Care Ontario Hamilton Regional Cancer Centre, and the Departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, and is the Buffett Taylor Chair in Breast Cancer Research, McMaster University, Hamilton, Ont.*The steering committee is part of Health Canada's Canadian Breast Cancer Initiative. A list of committee members appears in Appendix 1.

ABSTRACT

Objective: To provide information and recommendations for women and their physicians when making decisions about the management of lymphedema related to breast cancer.

Options: Compression garments, pneumatic compression pumps, massage and physical therapies, other physical therapy modalities, pharmaceutical treatments.

Outcomes: Symptom control, quality of life, cosmetic results.

Evidence: Systematic review of English-language literature retrieved primarily from MEDLINE (1966 to April 2000) and CANCERLIT (1985 to April 2000). Nonsystematic review of breast cancer literature published to October 2000.

Recommendations: · Pre- and postoperative measurements of both arms are useful in the assessment and diagnosis of lymphedema. Circumferential measurements should be taken at 4 points: the metacarpal-phalangeal joints, the wrists, 10 cm distal to the lateral epicondyles and 15 cm proximal to the lateral epicondyles. · Clinicians should elicit symptoms of heaviness, tightness or swelling in the affected arm. A difference of more than 2.0 cm at any of the 4 measurement points may warrant treatment of the lymphedema, provided that tumour involvement of the axilla or brachial plexus, infection and axillary vein thrombosis have been ruled out. · Practitioners may want to encourage long-term and consistent use of compression garments by women with lymphedema. · One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone. · Complex physical therapy, also called complex decongestive physiotherapy, requires further evaluation in randomized trials. In one randomized trial no difference in outcomes was detected between compression garments plus manual lymph drainage versus compression garments alone. · Clinical experience supports encouraging patients to consider some practical advice regarding skin care, exercise and body weight. [A patient version of these guidelines appears in Appendix 2.]

Validation: An initial draft of this document was developed by a task force sponsored by the BC Cancer Agency. It was updated and revised substantially by a writing committee and then submitted for further review, revision and approval by the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer.

Sponsor: The steering committee was convened by Health Canada.

Completion date: October 2000.

Lymphedema in women treated for breast cancer is an accumulation of protein-rich fluid in the arm that occurs when axillary lymphatic drainage from the arm is interrupted because of axillary lymph node dissection or axillary radiation, or both. Lymphedema remains a problem even with modern treatment modalities. Affected women can experience pain, swelling of the arm, tightness and heaviness in the arm and recurrent skin infections. Three stages of lymphedema have been described.^1,2,3 Stage I presents with pitting and is considered reversible; some women with this stage have no increased arm girth or heaviness and no signs of pitting edema. As the edema progresses, it becomes brawny, fibrotic, nonpitting and irreversible (stage II). In advanced lymphedema (stage III), which rarely occurs following breast cancer treatments, cartilaginous hardening occurs, with papillomatous outgrowths and hyperkeratosis of the skin. In this guideline, we provide an evidence-based approach to the management of this difficult problem.

METHOD

This guideline document is based on a systematic review of English-language literature retrieved from MEDLINE (1966 to April 2000) and CANCERLIT (1985 to April 2000). Medical subject headings used were "breast," "breast neoplasms," "lymph node excision," "mastectomy" and "lymphedema." Randomized controlled trials comparing different modalities would provide the strongest evidence for recommending best treatments for lymphedema. However, given the lack of data from such studies, a broader strategy without limits set by methodological search criteria was used. Review articles and textbook chapters were also consulted, primarily to provide background information and to secure additional references. A nonsystematic review of the breast cancer literature to October 2000 also took place. Rules of evidence as described by Sackett⁴ were used for grading the levels of experimental studies.

An initial draft of this guideline document was developed by a task force sponsored by the BC Cancer Agency that was convened in March 1997. The task force comprised physical therapists, breast surgeons, radiation and medical oncologists, and breast cancer patients living with lymphedema. The draft was reviewed by clinical practitioners and by representatives of the British Columbia College of Physicians and Surgeons, the Registered Nurses' Association of British Columbia, the College of Physical Therapists of British Columbia and the British Columbia Council on Clinical Practice Guidelines. The Breast Tumour Group at the BC Cancer Agency then approved the guideline in October 1997. The initial draft was updated and revised substantially by a writing committee and then submitted for further review, revision and approval by the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer, sponsored by Health Canada

RECOMMENDATIONS (INCLUDING EVIDENCE AND RATIONALE)

Measurement

· Pre- and postoperative measurements of both arms are useful in the assessment and diagnosis of lymphedema. Circumferential measurements should be taken at 4 points: the metacarpal-phalangeal joints, the wrists, 10 cm distal to the lateral epicondyles and 15 cm proximal to the lateral epicondyles.

There is no consistent operational definition of "clinically significant lymphedema" in the literature. The lack of a consistent definition leads to confusion regarding the incidence of lymphedema after breast cancer treatment. The following criteria have been used in the literature to measure lymphedema: absolute increase in volume or percentage increase in volume as determined by water displacement, circumferential measurements and patient symptoms.^5,6 Results of studies comparing differences in arm circumferences with volume differences are conflicting.^7,8 In a recent study Megens⁸ reported that both circumferential measurements and water displacement volumetry in women with breast cancer had excellent interrater and test-retest reliability, although the 2 methods had poor agreement with each other.

Circumferential measurements are widely used because tape measures are readily available and because volumetric measurement is logistically difficult. One common approach involves measuring the circumferences of both arms at points 13 to15 cm proximal and 10 cm distal to the lateral epicondyle of the humerus.⁹ Differences greater than 2.0 cm at any point are defined by some as "clinically significant,"^5,10 whereas others classify this degree of lymphedema as mild.^11,12 Other methods for assessing lymphedema, including lymphoscintigraphy, MRI, CT scanning and ultrasound, are being evaluated in research settings.¹³

· Clinicians should elicit symptoms of heaviness, tightness or swelling in the affected arm. A difference of greater than 2.0 cm at any of the 4 measurement points may warrant treatment of the lymphedema, provided that tumour involvement of the axilla or brachial plexus, infection and axillary vein thrombosis have been ruled out.

Incidence of lymphedema

Given the variation of criteria used to define lymphedema and the variety of assessment techniques, it is not surprising to see wide variation in the reported incidence of lymphedema following breast cancer treatment. Lymphedema rates of 6% to 70% among patients with breast cancer have been reported.^{5,14,15,16,17,18} Petrek and Heelan¹⁹ reported on the incidence of lymphedema after breast cancer treatment in a review of 7 studies published since 1990. These studies were all retrospective, differed in patient populations, used different criteria to measure lymphedema and had varying degrees of follow-up. The incidence of lymphedema ranged from 2% to 24%.

Transient lymphedema occurs in a number of patients following axillary dissection. In a study involving 282 women who underwent breast-conserving surgery including axillary dissection, Werner and colleagues¹⁰ reported that transient edema occurred in 21 (7%) of the women and persistent edema in 24 (12%). The median time to development of persistent edema was 14 months (range 2-92 months).

Irradiation of the axilla increases the risk of lymphedema. In a randomized controlled trial conducted in British Columbia, chemotherapy alone was compared with chemotherapy plus regional radiation therapy in women with node-positive breast cancer after modified radical mastectomy.²⁰ The reported rate of lymphedema was 9.1% among the irradiated subjects and 3.2% among those who received chemotherapy alone. Although the risk of lymphedema increases with irradiation of the axilla, this risk is also influenced by the extent of axillary dissection.^21,22,23,24 Other factors that have been implicated in the development of lymphedema are obesity,¹⁰ extensive axillary disease²² and recurrent cancer in the axillary lymph nodes.²⁵

Chronic and severe lymphedema may very rarely give rise to lymphangiosarcoma. The incidence of this complication is rarely reported among lymphedema patients; in unselected patients the risk is less than 1%.²⁵ In a population-based Swedish study involving 122 991 women treated for breast cancer between 1958 and 1992, angiosarcoma developed in only 35 women.²⁶ However, 26 (74%) of the 35 women had lymphedema.

Management

Before any type of lymphedema treatment is started, tumour involvement of the axilla or brachial plexus, infection and axillary vein thrombosis should be looked for and treated if present. The systematic review of literature on the management of lymphedema was limited by the lack of prospective randomized trials evaluating different treatment options.

Compression garments

· Practitioners may want to encourage long-term and consistent use of compression garments by women with lymphedema.

Graded compression garments that deliver pressures of 20 to 60 mm Hg are the mainstay of lymphedema therapy and can be used as primary therapy.^1,27,28 Some clinicians recommend the use of a compression garment for up to 24 hours per day, while others recommend its use only during waking hours or exercise.^{9,12,29,30,31,32} Compression garments may also protect the extremity from injuries such as burns, lacerations and insect bites.

Collins and colleagues³³ used CT scanning to assess the effect of compression garment therapy in 27 women with unilateral lymphedema. They found significant decreases in the cross-sectional area of subcutaneous compartments: the mean decrease was 9% in the proximal portion and 26% in the distal portion of the limb (level V evidence).

In one of the few randomized controlled trials of lymphedema, the use of a compression sleeve plus electrically stimulated lymphatic drainage was compared with the use of a compression sleeve alone.⁹ Both modalities reduced limb girth by 17%, which suggested that compression sleeve therapy alone is effective (level II evidence).

Good compression garments can be custom-made or prefabricated, and ideally they should be fitted by trained personnel.^12,34 Some sleeves start at the wrist and end at the upper arm. Others incorporate the shoulder and fasten with a strap around the upper torso. A compression gauntlet, especially one incorporating the wrist, can be used if the hand is swollen.¹ Compression garments should be replaced every 4 to 6 months, or when they begin to lose their elasticity.^1,32

Patients may be noncompliant with using compression garments because the garments are unsightly, uncomfortable, difficult to put on and expensive.¹ Customized, lightweight and colourful garments may be an option for comfort and wear.

Pneumatic compression pumps

· One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone.

There has been only one randomized trial that has evaluated pneumatic compression pumps for the treatment of lymphedema. Dini and colleagues³⁵ assigned 80 women with postmastectomy lymphedema to either intermittent pneumatic compression or no treatment. Women in the treatment group underwent a 2-week cycle of 5 pump sessions per week, each session lasting 2 hours, followed by a 5-week break, and then another 2-week treatment cycle. Although the mean decrease in arm circumference in the treatment group was nearly 4 times that in the control group (1.9 cm v. 0.5 cm), the post-test differences between the 2 groups failed to reach statistical significance (p = 0.084), possibly because of the small sample and the large variability in both the initial arm measurements and the circumferential changes within each group (level II evidence).

The experience with lymphedema pumps has also been reported in a number of level V studies.^{36,37,38,39,40,41,42} The results have been mixed. These studies were limited by their small samples, mixed populations (arm and leg edema), lack of control groups and lack of outcome measures that assessed symptoms such as pain and heaviness. In one study pneumatic compression produced a reduction in lymphedema volume that was 18% greater than the reduction produced by elastic compression;⁴¹ in another study no difference was detected between elastic compression and pneumatic compression.³⁶

No comparative studies have been published to determine the most effective pumping time, pressure levels or kind of pump. There is a suggestion,⁴⁴ but not unanimous agreement,⁴³ that sequential, multichambered pumps are more effective than monochambered pumps. The former produce a linear pressure wave from distal to proximal portions of the limb that reduces the tendency of fluid to collect in the hand. There are several commercially available pumps, ranging in complexity and cost. Most pumps used by therapists, clinics and consumers are complex and cost several thousand dollars. Pump therapy is contraindicated in the presence of active infection or deep vein thrombosis in the limb.

Massage and physical therapies

· Complex physical therapy, also called complex decongestive physiotherapy, requires further evaluation in randomized trials. In one randomized trial no difference in outcomes was detected between compression garments plus manual lymph drainage versus compression garments alone.

Complex physical therapy, also called complex decongestive physiotherapy, is a treatment regimen that includes meticulous skin hygiene, manual lymph drainage, bandaging, exercises and support garments. Manual lymph drainage is a massage technique that involves the skin surface only and follows the anatomic lymphatic pathways of the body. A session of manual lymph drainage starts centrally in the neck and trunk to clear out the main lymphatic pathways, thereby facilitating drainage from the arm.^45,46,47

A recently published randomized trial involving 42 women with modest stage I or II lymphedema compared standard therapy alone with standard therapy plus manual lymph drainage and training in self-massage (level I evidence).⁴⁸ Standard therapy included use of a custom-made sleeve-and-glove compression garment worn during the day, instruction in physical exercises, education in skin care, and information and recommendations about lymphedema. Both groups obtained a significant reduction in limb volume, a decrease in discomfort and increased joint mobility over time. However, no significant differences in objective measures of change in arm volume or subjective measures of symptoms related to lymphedema were found between the 2 groups.

In a cohort study involving 35 women, compression bandaging plus manual lymph drainage was compared with compression bandaging alone (level III evidence).⁴⁹ There was a trend in mean volume reduction and a statistically significant difference between the 2 groups in the percentage reduction in volume in favour of the combined treatment. Symptoms did not differ statistically significantly between the 2 groups. A number of case series have reported on the use of these modalities. Some reported alleviation of lymphedema (level V evidence).^{50,51,52,53,54,55,56,57} However, interpretation of the results is limited by the methodology of the studies. In another trial, manual lymph drainage plus compression garment use was compared with sequential pneumatic compression plus compression garment use; no difference was detected between the treatment groups (level II evidence).⁵⁸ In another study, involving 6 months of compression garment use by 120 women, no additional benefit was shown by adding electrically stimulated lymphatic drainage or pneumatic pump therapy (level V evidence).³⁶

Other physical therapy modalities

Other physical therapy modalities, such as laser treatment, electrical stimulation, transcutaneous electrical nerve stimulation (TENS), cryotherapy, microwave therapy and thermal therapy, have been used for lymphedema in breast cancer patients (level V evidence).^{9,59,60,61,62} However, these modalities need further, rigorous evaluation before recommendations can be made.

A 1993 Italian study compared ultrasonography and pump therapy with a monochambered pump.⁶³ There was no significant reduction in lymphedema with either therapy. In fact, therapeutic ultrasound to areas of potential metastatic disease is contraindicated. A randomized study involving 71 mice showed enhanced tumour growth when high-intensity, continuous ultrasound was applied directly over the tumour.⁶⁴ Low-intensity, continuous ultrasound and pulsed ultrasound also increased tumour weight and volume, although not as significantly as high-intensity ultrasound.⁶⁵ Therapeutic ultrasound should not be used over areas of active or potential breast cancer metastases, such as the hips, lumbar area, ribs, chest wall or axillae.

Pain management

Pain and discomfort associated with lymphedema are common^66,67 and should be managed primarily by controlling the lymphedema. Refractory pain can be managed with non-narcotic and narcotic analgesics, with the use of adjuvant analgesics (e.g., tricyclic antidepressants, corticosteroids, anticonvulsants or local anesthetics) when necessary.⁶⁸ Aggravating conditions, such as infection and recurrence of cancer in the axillary lymph nodes or brachial plexus, should be looked for and treated.

Psychosocial issues

Because of the psychological morbidity associated with lymphedema, psychosocial issues should be promptly recognized and addressed. Women with lymphedema have been shown to have greater psychiatric morbidity and greater functional disability.^69,70,71,72

Surgery, diuretics and benzopyrones

Surgery (e.g., microsurgical lymphovenous anastomoses, creation of a myocutaneous flap with latissimus dorsi muscle, omental transposition, grafting of lymphatic vessels with tubes or threads) has produced disappointing, inconsistent results and should be avoided.^{2,73,74,75,76,77,78} Diuretics, which have been recommended in the past, may temporarily mobilize water, but the increased interstitial oncotic pressure exerted by the high protein concentration of lymph fluid will cause rapid recurrence of edema.³ The diuretic effect in the rest of the body may cause adverse side effects, such as hypotension, dehydration and electrolyte imbalance.

Benzopyrones were promoted for use in lymphedema because they were felt to stimulate macrophage-induced proteolysis.^79,80 Subsequently, a large randomized, placebo-controlled trial of coumarin, a benzopyrone, in 140 women failed to show any benefit (level I evidence).⁸¹ These products are no longer recommended.

Practical tips

· Clinical experience supports encouraging patients to consider some practical advice regarding skin care, exercise and body weight.

The following suggestions make clinical sense to the authors of this guideline, even though the evidence that supports the suggestions is limited and primarily anecdotal.

· Scrupulous skin care should be encouraged. Women should avoid cuts, pin pricks, hangnails, insect bites, contact allergens or irritants, pet scratches and burns to the affected extremity. Whenever possible patients should avoid medical procedures such as vaccination, blood drawing, intravenous access, blood pressure monitoring, acupuncture, venography and lymphangiography in the affected arm.

· Lymphedema may be exacerbated if women use saunas, steam baths or hot tubs, spend time in hot climates or travel. Many patients report worsening of their lymphedema during flight,^12,82 which suggests that patients who use compression sleeves should probably use them during air travel.

· Exercise involving the affected arm may be beneficial in controlling lymphedema. Although some clinicians have recommended avoidance of rowing, tennis, golf, skiing, squash, racquetball or any vigorous, repetitive movements against resistance, there is no published evidence to suggest that these activities promote or worsen lymphedema. No exacerbation of existing lymphedema or development of new cases of lymphedema occurred in 20 women with breast cancer who competed in the strenuous sport of dragon boat racing.³¹ Some experts have recommended that women with lymphedema wear a compression sleeve during arm exercises.³⁰

· Maintenance of ideal body weight should be encouraged. Obesity is a contributing factor for the development of lymphedema^10,21 and may limit the effectiveness of compression pumps or sleeves.³⁶

· Skin infection, which is often streptococcal, or on rare occasions staphylococcal, should be promptly treated with antibiotics such as a penicillin, a cephalosporin or a macrolide.^{83,84,85,86,87} For recurrent infections, prophylaxis with oral antibiotics or monthly injections of penicillin should be considered.⁸⁷ It may be prudent to provide the patient who has recurrent infections with an emergency home supply of an antistreptococcal antibiotic, to be taken at the first sign of infection. A patient travelling to a remote area should be encouraged to take along a supply of antibiotics

FUTURE RESEARCH

The management of lymphedema in breast cancer patients is based primarily on results from case studies, clinical experience and anecdotal information. The natural history and most effective therapies for lymphedema are poorly understood and need further study. Accurate assessment requires agreement on a standardized and reliable system of measurement.⁸⁸ Randomized controlled trials to answer these questions should be encouraged and funded whenever possible.

FOOTNOTES

A patient version of these guidelines appears in Appendix 2.

This article has been peer reviewed.

Contributors: There are 4 principal authors of this guideline article. The Steering Committee for Clinical Practice Guidelines for the Care and Management of Breast Cancer provided scientific and editorial comments, which led to multiple revisions of the manuscript.

Competing interests: None declared.

Reprint requests to: Dr. Mark Levine, c/o Ms. Humaira Khan, Faculty of Health Sciences, McMaster University Health Sciences Centre, Rm. 2C6, 1200 Main St. W, Hamilton ON L8N 3Z5; fax 905 577-0017

Top
Abstract
Method
Recommendations (including...
Future research
Appendix 1-17
Appendix 2A-17
Appendix 2B-17
References

http://www.cmaj.ca/cgi/content/full/164/2/191#ABS

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Factors associated with the development of arm lymphedema following breast cancer treatment: a match pair case-control study.

Johansson K, Ohlsson K, Ingvar C, Albertsson M, Ekdahl C.

Department of Physical Therapy, Lund University, Sweden. karin.johansson@skane.se

We examined factors that may influence the development of arm lymphedema following breast cancer treatment including the specific mode of therapy, patient occupation and life style. Medical record data and a questionnaire were used to collect information after surgery concerning such issues as wound seroma, infection, adjuvant treatment, vessel string (phlebitis), body mass index, smoking habits and stress. Occupational workload was assessed after surgery whereas housework, exercise, hobbies and body weight were assessed both before and after surgery. Seventy-one breast cancer treated women with arm lymphedema lasting more than 6 months but less than 2 years were matched to women similarly treated for breast cancer but without arm lymphedema (controls). The matching factors included axillary node status, time after axillary dissection, and age. In the lymphedema group, there was a higher body mass index at time of surgery (p=0.03) as well at time of study (p=0.04). No differences were found in occupational workload (n=38) or housework, but the lymphedema group reduced their spare time activities including exercise after surgery compared with the controls (p<0.01). In conclusion, women treated for breast cancer with axillary node dissection with or without adjuvant radiotherapy could maintain their level of physical activity and occupational workload after treatment without an added risk of developing arm lymphedema. On the other hand, a higher BMI before and after operation increases the lymphedema risk.

PMID: 12081053 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12081053&dopt=Abstract

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Effects of compression bandaging with or without manual lymph drainage treatment in patients with postoperative arm lymphedema.

Johansson K, Albertsson M, Ingvar C, Ekdahl C.

Department of Physical Therapy, Lund University Hospital, Sweden.

We examined the effects of low stretch compression bandaging (CB) alone or in combination with manual lymph drainage (MLD) in 38 female patients with arm lymphedema after treatment for breast cancer. After CB therapy for 2 weeks (Part I), the patients were allocated to either CB or CB + MLD for 1 week (Part II). Arm volume and subjective assessments of pain, heaviness and tension were measured. The mean lymphedema volume reduction for the total group during Part I was 188 ml (p < 0.001), a mean reduction of 26% (p < 0.001). During Part II the volume reduction in the CB + MLD group was 47 ml (p < 0.001) and in CB group 20 ml. These differences were not significant (p = 0.07). A percentage reduction of 11% (p < 0.001) in the CB + MLD group and 4% in the CB group was significantly different (p = 0.04). In both the CB and the CB + MLD group, a decrease of feeling of heaviness (p < 0.006 and p < 0.001, respectively) and tension (p < 0.001 for both) in the arm was found, but only the CB + MLD group showed decreased pain (p < 0.03). Low stretch compression bandaging is an effective treatment giving volume reduction of slight or moderate arm lymphedema in women treated for breast cancer. Manual lymph drainage adds a positive effect.

Publication Types:

• Clinical Trial
• Controlled Clinical Trial

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10494522&itool=iconabstr

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Sentinel lymph node biopsy lowers the rate of lymphedema when compared with standard axillary lymph node dissection.

Golshan M, Martin WJ, Dowlatshahi K.

Department of Surgery, Rush University, Rush Presbyterian St. Luke's Medical Center, Chicago, Illinois, USA.

Arm edema occurs in 20 to 30 per cent of patients who undergo axillary lymph node dissection (ALND) for carcinoma of the breast. Sentinel lymph node biopsy (SLNB) in lieu of ALND for staging of breast cancer significantly lowers this morbidity. We hypothesized that SLNB would have a lower lymphedema rate than conventional axillary dissection. Patients who underwent SLNB were compared with those who underwent level I and II axillary node dissection. A total of 125 patients were evaluated with 77 patients who underwent SLNB and 48 patients who underwent ALND. The arm circumference 10 cm above and 10 cm below the olecranon process was measured on both arms. In this series a difference in arm circumference greater than 3 cm between the operated and nonoperated side was defined as significant for lymphedema. Lymphedema was seen in two of 77 (2.6%) patients in the SLNB group as compared with 13 of 48 (27%) ALND patients. Given the above data patients who underwent sentinel lymph node biopsy show a significantly lower rate of lymphedema than those who had axillary lymph node dissection. This has an important impact on long-term postoperative management of patients with breast cancer.

Publication Types:

• Case Reports

PMID: 12678476 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12678476&itool=iconabstr

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Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study.

McKenzie DC, Kalda AL.

Division of Sports Medicine and School of Human Kinetics, University of British Columbia, Vancouver, British Columbia, Canada. kari@interchange.ubc.ca

PURPOSE: To examine the effect of a progressive upper-body exercise program on lymphedema secondary to breast cancer treatment. METHODS: Fourteen breast cancer survivors with unilateral upper extremity lymphedema were randomly assigned to an exercise (n = 7) or control group (n = 7). The exercise group followed a progressive, 8-week upper-body exercise program consisting of resistance training plus aerobic exercise using a Monark Rehab Trainer arm ergometer. Lymphedema was assessed by arm circumference and measurement of arm volume by water displacement. Patients were evaluated on five occasions over the experimental period. The Medical Outcomes Trust Short-Form 36 Survey was used to measure quality of life before and after the intervention. Significance was set at alpha < or = 0.01. RESULTS: No changes were found in arm circumference or arm volume as a result of the exercise program. Three of the quality-of-life domains showed trends toward increases in the exercise group: physical functioning (P =.050), general health (P =.048), and vitality (P =.023). Mental health increased, although not significantly, for all subjects (P =.019). Arm volume measured by water displacement was correlated with calculated arm volume (r =.973, P <.001), although the exercise and control group means were significantly different (P <.001). CONCLUSIONS: Participation in an upper-body exercise program caused no changes in arm circumference or arm volume in women with lymphedema after breast cancer, and they may have experienced an increase in quality of life. Additional studies should be done in this area to determine the optimum training program.

Publication Types:

• Clinical Trial
• Randomized Controlled Trial

PMID: 12560436 [PubMed - indexed for MEDLINE]

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A new method for treatment of chronic lymphedema of the arm after a radical mastectomy.

DEPARTMENT OF PLASTIC AND RECONSTRUCTIVE SURGERY

MALMÖ UNIVERSITY HOSPITAL

S-205 02 MALMÖ

Head: Professor Henry Svensson, M.D., Ph.D.

Lymphedema Unit: Håkan Brorson, M.D., Ph.D.

Telephone: +46 40 33 10 00 Fax: +46 40 33 62 71

e-mail: brorson@plasticsurg.nu

Lymph is produced as the result of hydrostatic filtration of blood in the smaller blood vessels. Normally lymph is removed from the extracellular space via small lymph vessels and is then carried to the lymph glands. From these glands the lymph finally empties into the blood stream.

At the time of a radical mastectomy, the axillary lymph glands are removed to prevent any spread of the cancer. Many of these patients develop lymphedema of the arm due to the impaired lymph drainage, which is further exacerbated by post-operative irradiation. The accumulating lymph and the thickened subcutaneous fat leads to chronic lymphedema. After some time subcutaneous fibrosis can develop. Common symptoms of chronic lymphedema are pain, a feeling of heaviness and decreased mobility of the arm.

Conservative therapies (manual lymph therapy according to Foldi, compression garments), if used early, can remove the edema, but in long-standing cases this is not always possible. To date there has not been a surgical procedure that completely removes the edema after breast cancer treatment. At the Department of Plastic and Reconstructive Surgery, Malmˆ University Hospital, Malmˆ, Sweden, a new and unique method of complete removal of cronic lymphedema has been developed using a special liposuction technique. The edema and the increased subcutaneous fat are removed via some 30 small incisions along the arm. This results in disappearance of pain and feeling of heaviness as well as an increased mobility of the arm.

A prerequisite to the success after the operation is a vigilant use of a custom-made compression garment. This garment has to be used at all time or lymphedema inevitably recurs.

We have operated on 85 patients to date using this technique. The mean volume of the lymphoedema was 1.9 liters. The edema reduction is complete, and no recurrence of the edema has been seen at 10 years follow-up.

References:Brorson H, Svensson H. Complete reduction of lymphoedema of the arm by liposuction after breast cancer. Scand J Plast Rec Surg Hand Surg 1997; 31: 137-143.
Abstract
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Brorson H, Svensson H. Skin blood flow of the lymphedematous arm before and after liposuction. Lymphology 1997; 30: 165-172.
Abstract
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Brorson H, Svensson H. Liposuction reduces arm lymphedema without significantly altering the already impaired lymph transport. Lymphology 1998; 31:156-172.
Abstract
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Brorson H, Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema significantly better than controlled compression therapy alone. Plast Reconstr Surg 1998; 102: 1058-1067.
Abstract
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Thesis: Brorson, H. Liposuction and controlled compression therapy in the treatment of arm lymphedema following breast cancer
Abstract
List: Articles
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Brorson H. Liposuction gives complete reduction of chronic large arm lymphedema after breast cancer. Acta Oncologica 2000; 39: 407-420.
Abstract
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Brorson H. Fettabsaugung des Lymphödems am Arm. Handchir Mikrochir Plast Chir 2003; 35: 225-232.
Abstract
Download full text

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Frequency of lymphedema of the upper limb after treatment of breast cancer. Risk factors. Apropos of 683 cases

Ferrandez JC, Serin D, Bouges S.

Unite de reeducation main-membre superieur et unite de reeducation vasculaire, Avignon, France.

Lymphoedema of the upper limb after breast cancer treated with axillary clearance is a well known sequels. But its real rate is not precise. The retrospective study of 683 patients approaches this reality. When clinic criteria are selected with centimetric measures, its general rate is 41%; 65% out of them have a difference smaller than 3 cm. We noticed three different kinds of lymphoedemas which occur on the arm, the forearm or the complete upper limb. Their volumes are different, the more voluminous ones occur when the upper limb is touched completely (P = 0.0001). The different factors which increase the risk of lymphoedema are described. The role of the infection is noticed (x 1.7). The rate is independent of the surgery, of the importance of axillary clearance and of the shoulder joint function. The lymphoedema size is more important when it occurs secondary to mastectomy then conservative treatment (P = 0.0078). Parietal fibrosis increases lymphoedema risk to 54% (P = 0.005) and lymphoedemas are more voluminous (P = 0.009).

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9116379&itool=iconabstr

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The Role of Pneumatic Compression Pumps:
preliminary results from a current study

Andrzej Szuba, researcher with the Stanford/Aurora Centre for Lymphatic and Venous Disorders, Stanford University School of Medicine, Stanford, CA U.S.A. has made a number of presentations documenting this centre's experiences in using pneumatic extremity pumps on patients with post-mastectomy lymphedema.

Sept. 14-17, 2000 The Role of Pneumatic Compression Pumps, a presentation at the 4th National Lymphedema Network Conference in Orlando, Florida. Szuba suggested that intermittent penumatic compression with single or multi-compression with single or multi-chamber pumps effectively removed access fluid from the extremity. He reported that they were conducting two studies on the application of pneumatic compression in combination with decongestive lymphatic therapy (DLT) in patients with arm lymphedema secondary to breast cancer therapy.

Preliminary results of the first study involving 22 women showed an average arm volume reduction of 51% in the group using the compression pump with DLT vs.35% volume reduction in the group treated with DLT alone. The second study of 23 which assessed the usefulness of daily sequential compression for maintenance of arm volume by patients with post mastectomy arm edema also found beneficial effects.

Sept. 2002 at the Internation Congress of Lymphology, Genoa, Italy, Szuba, R. Achalu and S.G. Rockson reported on their continued research in this area.

They investigated the safety and efficacy of adjunctive intermittent pneumatic compression (IPC) for the acute decongestive therapy of post-mastectomy lymphedema. 23 patients were randomized into two groups: the first which received decongestive lymphatic therapy (DLT) which included manual lymph drainage, bandaging and exercise daily and IP; and the second which received IPC 30 minutes daily at 40-50 mm. In group 1, 11 patients received a 25% acute arm volume reduction; in group II 12 patients received a mean volume of 45.3% mean volume reduction.

These preliminary results appear to show positive affects for some patients which use this form of treatment.

http://www.healthquest-nf.com/CompressonPumpsInfo.htm

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EVALUATION OF INTERMITTENT PNEUMATIC COMPRESSION AS ADJUNCTIVE MAINTENANCE THERAPY IN POSTMASTECTORMY LYMPHEDEMA
A. Szuba, R. Achalu, S.G. Rockson
Stanford Center for Lymphatic and Venous Disorders,
Stanford Univerity School of Medicine, Stanford, CA USA
Srockson@cvmed.stanford.edu

We studied the safety and efficacy of intermittent pneumatic compression therapy as an adjunct to standard decongestive lymphatic therapy in patients with stable post-mastectomy arm lymphedema.
Study design: Randomized, cross-over, 2 month study with 6 month follow-up
Patients and methods: 29 patients with postmastectomy arm lymphedema and without evidence of active cancer were enrolled. Patients were randomized into two groups.
Patients assigned to Group I were asked to continue their routine maintenance therapy with use of a Class II compression garment and self–applied manual lymphatic drainage (MLD); patients assigned to Group II were asked to use the intermittent pneumatic compression (IPC) pump for 1 hour daily (40-50mmHg) in addition to conventional therapy (garments + MLD). All patients crossed over to the alternate therapy after one month. Patients who elected to continue chronic use of the pump were evaluated after 6 months. Clinical evaluation was performed at the beginning of
the study, after the first and the second month and after six month follow-up. The evaluation included tank volumetry, skin tonometry, and measurement of range of motion.
Results: 27 patients completed the study. Two patients voluntarily withdrew.

There was a mean volume reduction of 89.5 ml during the month with IPC and volume increase of 32.7 ml during the month of routine maintenance therapy.

The difference was statistically significant (p<0.05). There was no difference in tonometry results. Of the 21 patients who completed chronic use of IPC, 19 were available for analysis. After 6 months, there was a further average volume reduction of 29.1 ml (not statistically significant). No adverse effects of IPC were observed.

Conclusion: Intermittent pneumatic compression is safe and well tolerated and may offer additional benefit for patients with postmastectomy lymphedema.

http://elitelymphedema.com/clinicalstudies.html#duke

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Liposuction in arm lymphedema treatment.

Brorson H.

The Lymphedema Unit, Department of Plastic and Reconstructive Surgery, Lund University, Malmo University Hospital, Malmo, Sweden. hakan.brorson@plastsurg.mas.lu.se

Breast cancer is the most common disease in women, and up to 38% develop lymphedema of the arm following mastectomy, standard axillary node dissection and postoperative irradiation. Limb reductions have been reported utilizing various conservative therapies such as manual lymph and pressure therapy. Some patients with long-standing pronounced lymphedema do not respond to these conservative treatments because slow or absent lymph flow causes the formation of excess subcutaneous adipose tissue. Previous surgical regimes utilizing bridging procedures, total excision with skin grafting or reduction plasty seldom achieved acceptable cosmetic and functional results. Microsurgical reconstruction involving lympho-venous shunts or transplantation of lymph vessels has also been investigated. Although attractive in concept, the common failure of microsurgery to provide complete reduction is due to the persistence of newly formed subcutaneous adipose tissue, which is not removed in patients with chronic non-pitting lymphedema. Liposuction removes the hypertrophied adipose tissue and is a prerequisite to achieve complete reduction. The new equilibrium is maintained through constant (24-hour) use of compression garments postoperatively. Long-term follow up (7 years) does not show any recurrence of the edema.

Publication Types:

• Review
• Review, Tutorial

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14758919&dopt=Abstract

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Horse chestnut seed extract for the treatment of arm lymphedema. P. R. Hutson, R. R. Love, J. F. Cleary, S. A. Anderson, L. Vanummersen, S. L. Morgan-Meadows, E. A. Doran; UW School of Pharmacy, Madison, WI; UW Comprehensive Cancer Center, Madison, WI; UW Dept Biostat Med Informatics, Madison, WI Abstract: Background: Lymphedema of the arm occurs frequently as a consequence of surgical and radiation damage to the major lymphatics during lymph node dissection (LND) and adjuvant treatment of breast cancer. Usual lymphedema treatments are massage, compression sleeves and wraps; there are no drug treatments currently available in the USA. This is an interim report of our use of Horse chestnut seed extract (HCSE) for the treatment of arm lymphedema in breast cancer survivors. HCSE is widely used in Europe for venous and lymphatic disorders, and is postulated to act by decreasing capillary and interstitial permeability. Methods: In this double-blind, randomized, and placebo-controlled study, eligible subjects with stable arm lymphedema receive placebo or HCSE (50mg escins) twice daily PO for three months, followed by a 1 month washout. Eligible subjects have affected : unaffected arm edema ratios of ¡Ý 1.1 to 1 by bioelectric impedance, and significant response was empirically set as a 15% decrease in arm ratios. Arm edema is measured concurrently with serial tape measurements, water displacement, and bioelectric impedance. Subjective assessments include the FACT-B QOL instrument and a 16-item experimental lymphedema questionnaire. Results: 25 subjects (of 68 sought) are evaluable at 3 months. 24 patients are at intermediate assessment points and accrual continues. One patient developed progression of known breast cancer metastases; one developed minor, reversible dizziness and tolerated 50% dose reduction. There are no statistically significant differences in the amount of lymphedema at 3 months by any of the measurement techniques. Small changes in arm volume are not reflected by correlative changes in the scores of the QOL instruments. Conclusions: HCSE at doses commonly used for treating CVI or varicose veins is well tolerated in breast cancer survivors with lymphedema. This interim analysis does not demonstrate significant objective or subjective benefit of HCSE in reducing arm lymphedema. QOL questionnaires need improvement to identify issues that more specifically reflect the impact of lymphedema. Funded by the Susan G. Komen Breast Cancer Research Foundation (BCTR 0100506). Abstract No: 8095

http://www.annieappleseedproject.org/horchesseede.html

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Exercise and Arm Lymphedema

Nicole L. Gergich MPT, MLD/CDT Lymphedema Specialist, Penn Therapy and Fitness Posting Date: May 6, 2001 Last Modified: January 3, 2002

Why Should I Exercise? One very important component of a comprehensive treatment plan for cancer-related lymphedema is exercise. A program consisting of flexibility, strengthening and aerobic exercise is beneficial in reducing lymphedema when administered under the correct conditions. Exercise also allows cancer survivors a more active role in their own lymphedema management. Recent studies have shown no significant increase in the incidence of lymphedema after breast cancer, between women participating in an exercise program when compared to women who did not exercise. What Type of Exercises are Helpful To Someone with Lymphedema? Flexibility exercises help to maintain joint range of motion and allow for elongation or stretching of tissues. Flexibility exercises also help to prevent joint stiffness and postural changes after cancer surgeries or treatments. Muscle tightness may further complicate lymphedema. Strengthening exercises are also important in reducing lymphedema when done at low intensity levels with the extremity wrapped (see below). These exercises often help increase lymphatic and venous flow, aiding in the removal of fluid from the involved extremity. Aerobic exercise enhances the lymphatic and venous flow, further reducing swelling in the extremity. Aerobic exercise also combats fatigue, which plagues so many people during and after cancer treatment. Finally, deep abdominal breathing or diaphragmatic breathing is important with all exercise, but especially so in people with lymphedema. When deep breathing is carried out, the pressure inside the chest and abdomen is altered and creates a pumping activity within the lymphatic system. The central thoracic duct, which carries lymph fluid from the abdomen and legs, travels through the chest cavity. Pumping action around the duct helps to increase lymphatic flow throughout the body. Deep breathing is also important to deliver adequate oxygen supplies to the working muscles so that they may work efficiently. Exercises should be initiated by a physical or occupational therapist that specializes in lymphedema treatment. As with all exercise, you should discuss beginning a program with your physician. How Much Weight Can I Lift? There has been little research to date regarding the intensity of exercise in people with lymphedema and what is a safe level. Previously, intensive exercise was viewed as contraindicated, or not advisable. Currently, exercise and progressive weight lifting activities are used to assist in the removal of lymphedema from the affected areas. Therapists can guide clients in a weight lifting program that is tailored to their present fitness levels. How much you can lift depends on the stage of treatment and most importantly, you previous and present fitness levels. It is important to continuously monitor the limb for swelling or redness, which can be an indication that the exercise was too intense. A weight lifting program should be initiated by a therapist who specializes in the treatment of lymphedema. Should I Wrap My Arm With Exercise? It is recommended that the affected limb (arm or leg) be wrapped with compression bandages during exercise to aide the muscle pump force on the venous and lymphatic systems. Wrapping also prevents further fluid from accumulating in the extremity. The bandages used for lymphedema treatment are short-stretch bandages. The short stretch bandages used in lymphedema treatment do not stretch much when applied to the arm or leg. When you exercise the wrapped limb, the muscles and the bandages place a force on the lymphatics that help move fluid out of the arm. ACE bandages stretch too much and are ineffective in the treatment of lymphedema. Do NOT USE Ace wraps when wrapping for lymphedema. What Exercises Can I do After Breast Surgery? Following a mastectomy it is important to maintain range of motion or flexibility in the shoulder. Frequently, women decrease the use of the shoulder and arm on the side of the body where surgery was performed due to pain or fear of hurting the incision. Protecting the arm may lead to stiffness and tightness in the shoulder which can make it difficult to move the arm. This is often followed by a loss of muscle strength and stability around the shoulder. Since the shoulder and neck are closely related, it is also important to maintain neck mobility to prevent further complications. Ask your doctor or physical therapist if you have questions about which shoulder exercises are right for you. If you have recently undergone a mastectomy accompanied by a breast reconstruction REFER TO YOUR SURGEON FOR INFORMATION REGARDING SHOULDER EXERCISE. It is important to discuss beginning an exercise program with your physician.

http://www.oncolink.com/coping/article.cfm?c=5&s=23&ss=39&id=536

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Vascular Web - MD

http://www.vascularweb.org

This illustration will give you an idea on the

correct way to wrap your arm. You can also

find sleeves and garments at the

suppliers listed below.

==================================

Lymphedema Arm Sleeves Gauntlets, and Gloves Designed to treat primary or secondary lymphedema of the hand and arm.  Arm sleeves are an effective treatment for primary lymphedema patients, as well as those experiencing lymphedema following mastectomy, radiotherapy, cellulitis, trauma or surgery. http://healthylegs.com/

http://www.jovipak.com/newprod.shtml

UE-P-AH arm sleeve and UE-P-AH with JoVi Jacket
Made-to-Order shoulder extention contours over the rotator cuff with a Jovi Jacket to match. (order UE-P-AH) Available with elastic cross strap. See Made-to-Order products page for more information.

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Suppliers of arm wraps, compression garments and sleeves

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Juzo

http://www.juzousa.com/

........

JoviPak

http://www.jovipak.com/

........

CircAid® Measure-Up™ Arm Sleeve

http://www.lymphedema.biz/products/measureup2001.htm

........

Lympha Press "Lymphedema" Garments

http://www.lympha-press.com/medical4.htm

================================================

Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

http://health.groups.yahoo.com/group/AdvocatesforLymphedema/

Subscribe:

AdvocatesforLymphedema-subscribe@yahoogroups.com

Pat O'Connor

Lymphedema People / Advocates for Lymphedema

=======================================================

For information about Lymphedema

http://www.lymphedemapeople.com/thesite/all_about_lymphedema.htm

For Information about Lymphedema Complications

http://www.lymphedemapeople.com/thesite/lymphedema_complications.htm

For Lymphedema Personal Stories

http://www.lymphedemapeople.com/forum/forum.asp?FORUM_ID=7

For information about Lymphedema Wounds

http://www.lymphedemapeople.com/thesite/lymphedema_wound_care_revised.htm

For information about Lymphedema Treatment Options

http://www.lymphedemapeople.com/thesite/lymphedema_treatment_options_revised.htm

For information about Children's Lymphedema

http://www.lymphedemapeople.com/thesite/lymphedema_childrens_pediatric.htm

=======================================================

Lymphedema Glossary

http://www.lymphedemapeople.com/forum/topic.asp?TOPIC_ID=247

=======================================================

Lymphedema People

Support Groups

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Children with Lymphedema

The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.

http://health.groups.yahoo.com/group/childrenwithlymphedema/

Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com

......................

Lipedema Lipodema Lipoedema

No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.

Come join, be a part of the family!

http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515

Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com

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MEN WITH LYMPHEDEMA

If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.

http://health.groups.yahoo.com/group/menwithlymphedema/

Subscribe: menwithlymphedema-subscribe@yahoogroups.com

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All About Lymphangiectasia

Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.

http://health.groups.yahoo.com/group/allaboutlymphangiectasia/

Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com

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Lymphatic Disorders Support Group @ Yahoo Groups

While we have a number of support groups for lymphedema... there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.

DISCRIPTION

Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People.

http://health.groups.yahoo.com/group/lymphaticdisorders/

Subscribe: lymphaticdisorders-subscribe@yahoogroups.com

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All About Lymphedema

For our Google fans, we have just created this online support group in Google Groups:

Homepage: http://groups-beta.google.com/group/All-About-Lymphedema

Group email: All-About-Lymphedema@googlegroups.com

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Lymphedema Friends

http://groups.aol.com/lymphedemafriend

If you an AOL fan and looking for a support group in AOL Groups, come and join us there.

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At our home page we have 18 categories with 218 articles

on lymphedema, edema, and related conditions:

                     The Forums

                      Lymphedema Information

                      Lymphedema and Edema Related Conditions

                      Hereditary Conditions of the Lymphatics

                      Related Medical Conditions

                      Complications of Lymphedema

                       Lymphedema Treatment Options

                      Complete Listings of Therapists and Links

                      Cellulitis and Related Infections

                      Wound Information, Care, Treatment

                      Skin Care, Conditions and Complications

                      Exercise, Diets, Nutrition

                      Miscellaneous Interesting Articles section

                      Resources, Organizations, Support Groups

                      Government Resources

                      Advocacy and Lobbying Resources

                      Resources for the Medical Community

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Our Home Page:  Lymphedema People

http://www.lymphedemapeople.com

Reviewed Jan. 14, 2012