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ARM LYMPHEDEMA

Discussion

Most arm lymphedema is a secondary condition caused by removal of lymph nodes for cancer biopsy, damage to the lymphatics from radiation or even chemotherapy for breast cancer. 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.

Lymphedema can be devestating emotionally, but I believe that despite lymphedema, you can experience a full and rich life, here's a page that offers some tips Your Emotions and Self Image with Lymphedema

For arm lymphedema in children

Risk Factors for arm 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 immunodeficient and the protein rich fluid provides an excellent nuturing invironment for bacteria.

2. Draining wounds that leak lymphorrhea 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. See also Thrombophlebitis

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.)

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. See also manual lymphatic drainage mld complex decongestive therapy cdt

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.

There is one final and critical area pertaining to the treatment, control and management of lymphedema, and that is exercise. Not only is it vital for our over all health, it helps in weight control and is important for the movement of lymph fluid through our body. No matter the stage of lymphedema, underlying medical conditions or age, everyone of us should have a plan for exercises for lymphedema.

Sometimes too, the process we must go through to get our treatment covered is maddening to say the least. You made need to learn how_to_file_a_health_insurance_appeal to reverse a coverage or treatment denial and you may even have to learn the process how to file a complaint against your insurance company with your state commissioner.

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 immunocompromised 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, see our page lymphedema

Primary upper-limb lymphedema.

August 2012

Vignes S, Arrault M, Yannoutsos A, Blanchard M.

Source

Department of Lymphology, Centre National de Référence des Maladies Vasculaires Rares (lymphœdèmes primaires), Hôpital Cognacq-Jay, 75015 Paris, France.

Abstract

Background:  Lymphedema is a general term applied to designate pathological regional accumulation of protein-rich fluid. It can be either primary or secondary, mainly after cancer treatment.

Objective:  To analyze clinical and lymphoscintigraphic characteristics of primary upper-limb lymphedema.

Method:  All patients with upper-limb lymphedema (January 2007-December 2011) recruited in a single Department of Lymphology were included.

Results:  Sixty patients (33 females, 27 males) were enrolled. For the 54 noncongenital lymphedemas, mean age at onset was 38.5 (3-82) years. Lymphedema was unilateral in 51 (85%) patients. It always affected the hand, but less often the forearm (55%) or upper arm (23%). Eleven (18%) patients developed cellulitis after lymphedema onset. Twenty-one (35%) patients had associated lower-limb lymphedema. Forty-six patients (with 49 lymphedematous limbs) underwent lymphoscintigraphy: axillary lymph-node uptake was diminished in 18 (37%), absent in 24 (49%) and normal in 7 limbs (14%). Among the 43 patients with unilateral lymphedema and lymphoscintigraphy, 28 had epitrochlear node visualization, suggesting a re-routing through the deep lymphatic system, 15 only on the lymphedematous limb and 22 on the contralateral nonlymphedematous limb. Median follow-up was 103 months and 57/60 (95%) patients considered their lymphedema stable.

Conclusion:  Primary upper-limb lymphedema appears later in life than lower-limb lymphedema without sex predominance. Infectious complications are rare and patients considered the lymphedema volume stable throughout life.

PubMed

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

Lymphedema Arm Self Massage

You can do a simplified version of MLD yourself at home, called simple lymphatic drainage (SLD). SLD is done by using your fingers very gently to move the skin in a particular direction. If you find that the skin is red when you have finished, then the movement is too hard. It is often easier if your partner or a friend also learns the technique, so that they can help you in any areas you cannot reach. Your physiotherapist or nurse will be able to show you or your partner the technique. The diagrams and explanations on the following pages should also help.

Massage 1 - for both arm and leg swelling

Place your fingers, relaxed, on either side of your neck at position 1. Gently move the skin in a downwards direction, towards the back of your neck. Repeat 10 times at position 1, 2 and 3. At position 4 (on the top of your shoulder) use a gentle inward scooping movement down towards the top of your breast bone (where the collarbones meet) Repeat 5 times.

Massage 2 - for swelling of one arm

The aim of this massage is to stimulate the lymph channels on the trunk to clear the way ahead so excess fluid can drain away.

The skin is always moved towards the non-swollen side. You will find it easier to start with one hand, and then swap to the other as you move across the body.

Starting in the armpit on the non-swollen side (position 1), use light pressure to gently stretch the skin up into the armpit. Your hand should be flat and not slide over the skin. Repeat 10 times. Next, at position 2, use a light push to stretch the skin towards the non-swollen side, with a slow and gentle rhythm. Repeat 5 times.

Repeat the same movements at position 3. Swap hands, and repeat the movements 5 more times at position 3 with your other hand, as this position is very important for lymphatic drainage. This time, the movement with your fingers is a slight pull to move the skin to the non-swollen armpit. Repeat movements 5 times at position 4, then 5.

Hand-held massagers

Hand-held massagers can be useful for people who have restricted movement of their hands, perhaps due to arthritis. They are available at most large chemists and some electrical shops. As with all SLD techniques, a light touch is necessary. Massagers should never be used to press down on the skin. If you do this, you will obstruct your lymphatic channels and so the massage will not help lymph drainage. Hand-held massagers can be quite heavy to hold so try to hold it in the non-swollen hand. You may need your partner or a friend to help you.

Talk to your doctor or lymphoedema specialist before using a massager. It can be used to apply gentle pressure in the same sequence of movements as the exercises on the previous pages. Here are some guidelines for using a hand-held massager:

Use it for at least 15 minutes a day. Use the lowest setting and a dimpled head. Do not use oils or creams with the massager. Do not use the heat setting. If possible, get a massager without a heat pad, as these are lighter and easier to use. Use a gentle, circular movement, following the sequences of movement described earlier. Avoid massaging abnormal or broken skin.

Deep breathing exercises

Before and after SLD, breathing exercises can help to stimulate lymphatic drainage. Use the following simple exercises:

Sit in a comfortable chair or lie on your bed with your knees slightly bent. Rest your hands on your abdomen. Take deep breaths to relax. As you breathe in – direct the air down to your abdomen, which you will feel rising under your hands. Breathe out slowly by `sighing' the air out. While breathing out let your abdomen relax in again. Do the deep breathing exercises five times and then have a short rest before getting up.

http://www.cancerbacup.org.uk/Resourcessupport/Controllingsymptoms/Lymphoedema/Massage#9023

Cancer BACUP UK

“One of the truely most comprehensive and best sites I have seen.”

**Special Note for Bi-Lateral Mastectomy Patients or Bi-Lateral Surgeries**

At special risk are patients who have gone through a bi-lateral mastectomy or a single mastectomy with surgery also on the opposite side. Remember that both sides of the chest are at risk for lymphedema, so it is important not to move the fluids from one side to the other.

Instead, per several lymphedema therapists I asked, the fluid should be directed to the neck and groin lymphatics, as well as the intercostals and abdominals, and away from the left axilla, or right axilla nodes just as part of the “normal” pattern for left upper extremity lymphedema, per the Vodder technique.

Thanx Cassie and Carol;-) who are also members of BreastCancer.org. This is one of my favorite breast cancers sites and they also have a wonderful forums section with one specifically for breast cancers survivors with lymphedema.

See also: Patient Self-Massage for Breast Cancer Related Lymphedema

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.

Oconolink

Physical activity for the affected limb and arm lymphedema after breast cancer surgery. A prospective, randomized controlled trial with two years follow-up

Acta Oncol. 2009 Jun

Sagen A, Kåresen R, Risberg MA. Department of Breast and Endocrine Surgery, Oslo University Hospital, Ullevaal, Norway.

Background The influence of physical activity on the development of arm lymphedema (ALE) after breast cancer surgery with axillary node dissection has been debated. We evaluated the development of ALE in two different rehabilitation programs: a no activity restrictions (NAR) in daily living combined with a moderate resistance exercise program and an activity restrictions (AR) program combined with a usual care program. The risk factors associated with the development of ALE 2 years after surgery were also evaluated.

Material and methods Women (n=204) with a mean age of 55+/-10 years who had axillary node dissection were randomized into two different rehabilitation programs that lasted for 6 months: NAR (n=104) or AR (n=100). The primary outcomes were the difference in arm volume between the affected and control arms (Voldiff, in ml) and the development of ALE. Baseline (before surgery) and follow-up tests were performed 3 months, 6 months, and 2 years after surgery. Data were analyzed using ANCOVA and regression analysis.

Results Voldiff did not differ significantly between the two treatment groups. Arm volume increased significantly over time in both the affected and the control arms. The development of ALE from baseline to 2 years increased significantly in both groups (p<0.001). The only risk factor for ALE was BMI > 25 kg/m(2).

Conclusion Patients that undergo breast cancer surgery with axillary lymph node dissection should be encouraged to maintain physical activity in their daily lives without restrictions and without fear of developing ALE.

InformaWorld

Exercise Information Articles

Prevention of Arm Lymphedema

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.

Prospective evaluation of a prevention protocol for lymphedema following surgery for breast cancer

Lymphology. 2009 Mar

Boccardo FM, Ansaldi F, Bellini C, Accogli S, Taddei G, Murdaca G, Campisi CC, Villa G, Icardi G, Durando P, Puppo F, Campisi C. Department of Surgery, Unit of Lymphatic Surgery and Microsurgery, S. Martino Hospital, University of Genoa, Italy. francesco.boccardo@unige.it

Lymphedema is a common complication of axillary dissection and thus emphasis should be placed on prevention. Fifty-five women who had breast-conserving surgery or modified radical mastectomy for breast cancer with axillary dissection were randomly assigned to either the preventive protocol (PG) or control group (CG) and assessments were made preoperatively and at 1, 3, 6, 12 and 24 months postoperatively. Arm volume (VOL) was used as measurement of arm lymphedema. Clinically significant lymphedema was confirmed by an increase of at least 200 ml from the preoperative difference between the two arms. The preventive protocol for the PG women included preoperative upper limb lymphscintigraphy (LS), principles for lymphedema risk minimization, and early management of this condition when it was identified. Assessments at 2 years postoperatively were completed for 89% of the 55 women who were randomly assigned to either PG or CG. Of the 49 women with unilateral breast cancer surgery who were measured at 24 months, 10 (21%) were identified with secondary lymphedema using VOL with an incidence of 8% in PG women and 33% in CG women. These prophylactic strategies appear to reduce the development of secondary lymphedema and alter its progression in comparison to the CG women.

PubMed

Lymphology. 2009 Dec

Szolnoky G, Lakatos B, Keskeny T, Varga E, Varga M, Dobozy A, Kemény L.

Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary. [szolnoky@dermall.hu]

The application of intermittent pneumatic compression (IPC) as a part of complex decongestive physiotherapy (CDP) remains controversial. The aim of this study was to investigate whether the combination of IPC with manual lymph drainage (MLD) could improve CDP treatment outcomes in women with secondary lymphedema after breast cancer treatment. A randomized study was undertaken with 13 subjects receiving MLD (60 min) and 14 receiving MLD (30 min) plus IPC (30 min) followed by standardized components of CDP including multilayered compression bandaging, physical exercise, and skin care 10 times in a 2-week-period.

Efficacy of treatment was evaluated by limb volume reduction and a subjective symptom questionnaire at end of the treatment, and one and two months after beginning treatment. The two groups had similar demographic and clinical characteristics. Mean reductions in limb volumes for each group at the end of therapy, and at one and two months were 7.93% and 3.06%, 9.02% and 2.9%, and 9.62% and 3.6%, respectively (p < 0.05 from baseline for each group and also between groups at each measurement).

Although a significant decrease in the subjective symptom survey was found for both groups compared to baseline, no significant difference between the groups was found at any time point. The application of IPC with MLD provides a synergistic enhancement of the effect of CDP in arm volume reduction.

PubMed

Lymphedema Arm Sleeves, Gauntlets, and Gloves

These are garments that are designed to help control the swelling and should be utilized after you have undergone treatment to reduce to the size of your arm. They are also used inconjunction with compression bandage wrapping.

PROPER FITTING OF AND CARE FOR SLEEVES AND GLOVES/GAUNTLETS

For an excellent page on how garments should fit, illustrations of arm garments and other general information, please see this page:

PROPER FITTING OF AND CARE FOR SLEEVES AND GLOVES/GAUNTLETS

PROPER FITTING OF AND CARE FOR SLEEVES AND GLOVES/GAUNTLETS

This is from the website Step Up - Speak Out. This wonderful site was started by breast cancer survivors with lymphedema and in my personal opinion is one of the best there is available. Pat

Suppliers of arm wraps, compression garments and sleeves

DIAGNOSTIC ICD-9 CODES and PROCEDURE CODES

ICD-9 Codes

Covered ICD-9-CM Edema or Lymphedema Codes

   125.0-125.9      Filarial lymphedema
   457.0                Post-mastectomy lymphedema syndrome
   457.1                Other lymphedema (praecox, secondary, acquired/chronic,    elephantiasis)
   457.2                Lymphangitis
   457.8                Other noninfectious disorders of lymphatic channels (chylous disorders)
   624.8                Vulvar lymphedema
   729.81              Swelling of limb
   757.0                Congenital lymphedema (of legs), chronic hereditary, ideopathic hereditary
   782.3                Edema of Legs-Acute traumatic edema

HCPCS Procedure Codes

Procedure A manipulation of the body to give a treatment or perform a test; more broadly, any distinct service a doctor renders to a patient. All distinct physician services have ‘procedure codes’ in various payment schemes.

   97001 or 97003 initial evaluation by a physical or an occupational therapist, or an   Evaluation and Management CPT Code for physicians.
   97002 or 97004 re-evaluation by a physical or an occupational therapist,  or an     E valuation and Management CPT Code for physicians.
   97110  Therapeutic exercises
   97016  Vasopneumatic Pump
   97124  Massage therapy for edema of an extremity
   97140  Manual therapy, manual lymphatic drainage (15 minute units)
   97150  Group therapy
   97504  Orthotic training/fitting
   97530  Therapeutic activities, restoration of impaired function
   97535  Self-care home management training, instruction on bandaging,  exercises, and   self-care
   97703  Checkout for orthotic or prosthetic use

Item Codes

The items and supplies listed below are considered “incident to” a physician service and are not separately reimbursable. However, if these supplies are given to a patient as a take home supply, the claim should be submitted to the DMERC.

Code Description

  
   A4454               Tape
  A4460               Elastic bandage (e.g. compression bandage). Use this code to report compression bandages associated with lymphatic drainage
                            (CIM 60-9, MCM 2133, ASC)
   A4465               Non-elastic binder for extremity. Use for Reid, CircAid, ArmAssist, etc                               manually-adjustable sleeves and leggings. Medicare jurisdiction DME                               regional carrier (CIM 60-9, MCM 2133, ASC)
   A4490-4510   Surgical Stockings
   A4490          Surgical Stockings above knee length (each)
   A4495          Surgical Stockings thigh length (each)
   A4500          Surgical Stockings below knee length (each)
   A4510          Surgical Stockings full length (each)
   A4649          Miscellaneous Surgical Supplies, Compression bandaging kit
   E0650-0652     Pneumatic Compressor and Appliances
   E0650               Pneumatic Compressor, non-segmental home model
   E0651          Pneumatic Compressor, segmental home model, without calibrated                                         gradient pressure
   E0652          Pneumatic Compressor, segmental home model, with calibrated                                         gradient pressure
   E0655-0673     Arm and Leg Appliances used with Pneumatic Compressor
   L0100-L4398      Orthotics
   L2999          Lower Limb Orthosis, not otherwise specified
   L3999          Upper Limb Orthosis, not otherwise specified
   L4205          Repair of orthotic device, labor, per 15 minutes
   L4210          Repair of orthotic device, repair or replace minor parts
   L5000-L5999   Lower Limb
   L6000-L7499   Upper Limb
   L8000-8490     Prosthetics
   L8010              Mastectomy Sleeve, Ready-Made
   L8100-L8239   Elastic supports
   L8100-8195     Elastic Supports, elastic stockings various lengths & weights
   L8210             Gradient compression stocking, custom made
   L8220             Gradient compression stocking/sleeve, Lymphedema, Custom
   L8239             Gradient stocking, not otherwise specified. Carrier discretion.

ARM LYMPHEDEMA RELATED ARTICLES

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ABSTRACTS ON ARM LYMPHEDEMA

2012 Jun 19

Ancukiewicz M, Miller CL, Skolny MN, O'Toole J, Warren LE, Jammallo LS, Specht MC, Taghian AG.

Source

Department of Radiation Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.

Abstract

The purpose of this article is to evaluate arm measurements of breast cancer patients to critically assess absolute change in arm size compared to relative arm volume change as criteria for quantifying breast cancer-related lymphedema (BCRL). We used pre-operative measurements of 677 patients screened for BCRL before and following treatment of unilateral breast cancer at Massachusetts General Hospital between 2005 and 2008 to model the effect of an absolute change in arm size of 200 mL or 2 cm compared to relative arm volume change. We also used sequential measurements to analyze temporal variation in unaffected arm volume. Pre-operative arm volumes ranged from 1,270 to 6,873 mL and correlated strongly (Kendall's τ = 0.55) with body mass index (BMI). An absolute arm volume change of 200 mL corresponded to relative arm volume changes ranging from 2.9 to 15.7 %. In a subset of 45 patients, modeling of a 2-cm change in arm circumference predicted relative arm volume changes ranging from 6.0 to 9.8 %. Sequential measurements of 124 patients with >6 measurements demonstrated remarkable temporal variation in unaffected arm volume (median within-patient change 10.5 %). The magnitude of such fluctuations correlated (τ = 0.36, P < 0.0001) with pre-operative arm volume, patient weight, and BMI when quantified as absolute volume change, but was independent of these variables when quantified as relative arm volume change (P > .05). Absolute changes in arm size used as criteria for BCRL are correlated with pre-operative and temporal changes in body size. Therefore, utilization of absolute volume or circumference change in clinical trials is flawed because specificity depends strongly on patient body size. Relative arm volume change is independent of body size and should thus be used as the standard criterion for diagnosis of BCRL.

Springerlink

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]

PubMed

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 PubMed

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]

PubMed

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]

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

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).

NIH

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.

Healthquest

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.

Link no longer available

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 PubMed

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