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Lymphedema

Overview

Lymphedema is a chronic progressive regional swelling that often results from breast cancer treatments such as lymph node removal or radiation. It affects 5%–42% of women with breast cancer and may result in pain, changes in physical appearance, and functional Imitations.  

OTPs utilize exercise and relaxation techniques, in addition to massage therapy, to positively impact the physical and emotional well-being of women with lymphedema. 

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Lymphedema Symptoms: 

  • Heavy limbs

  • Intermittent swelling

  • Limited range of motion

  • Pain

  • Scar mobility issues. 

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OTPs managing an exercise and relaxation program (in addition to their given role of massage therapy) can have a positive impact on both the physical and emotional aspects of a woman with lymphedema. These types of therapies are a convenient and cost-effective approach to help reduce extracellular fluid in arms and improve a woman's emotional well-being (McClure et al., 2010).

 

Professional Insights 


Stefania Falvo - MS OTR/L, CLT, Baystate Medical Center  â€‹

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Overview

  • Finding a new normal: 

    • During lymphedema therapy sessions, patients struggle with body image, fear of cancer recurrence, and reintegrating into social and leisure activities

    • Facilitate emotional discussions as trust builds and encourage engaging in meaningful activities to 

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Clinical Interactions

  • Common challenges:

    • Determining the stage of lymphedema and proper course of action (manual lymphatic drainage vs compression garment - is a common intervention challenge)

    • It is difficult for many women to move forward because cancer is all consuming. Women experience discomfort in their own skin and it takes time to find joy in previous social activities  

  • Nutrition

    • Low sodium is best - high sodium causes swelling 

    • Regular exercise + compression garments during exercise is beneficial 

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Click below to learn more from Stefania Falvo: 

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Jyo Supnekar - Occupational Therapist and Certified Lymphedema Therapist, Johns Hopkins Hospital 

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Overview

  • Patients should be referred to an OT before surgery for lymphedema education: symptoms to watch for, expections post surgery, and preventative measures. The sooner the patient is referred the better the outcome

  • Targeted radiation and chemotherapy has reduced the instances of lymphedema over the past 15-20 years

  • Patients with history of axillary lymph node excision and radiation should take precautions when flying, even if no significant lymphedema is present (especially if traveling for long periods of time) - the lowest level of compression garment should be used, consisting of a sleeve and glove (both are needed while traveling)

  • Potential impact of lymphedema is based on the number of treatments a woman is receivieng. A full radical mastectomy +  axillary lymph nodes + radiation, is compounded, resulting in a higher risk of lymphedema

 

Clinical Interactions

 

 The following is the lymphedema comprehensive assessment process:

  • Ask patient about their goals for therapy

  • ADL and IADL factors 

  • client factors such as wound healing or scars (is the scar adherent?)

  • range of motion measurements

  • postural assessment

  • evaluate tight muscle groups (circumferential measurements for both limbs to compare the difference) 

  • Provide 2-3 exercises and a home exercise program to begin progress  

  • If there is time, begin soft tissue management 

 

Prehabilitation

  • During prehabilitation, measurements are taken of both limbs, so any changes can be compared

  • OT is needed for early range of motion - patients need to be able to hold up their arms for an extended period of time for specific treatments

  • Patient education includes information on warning signs, important dos and don'ts, and the possibility that lymphedema may still occur years later   

  • Therapists should be cautious about how information is presented  - information should be provided in a manner that does not overwhelm a patient 

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Click below to learn more from Jyo Supnekar

OT Insights

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  • Clinicians should recommend clients engage in meaningful activities to reduce focus on cancer diagnosis   

  • Current protocol is to put high risk patients in therapy prior to surgery, take baseline measurements, and determine current functional capabilities

  • Educate patients on healthy habits prior to surgery and encourage implementation strategies  

  • Involve family/loved ones in the session to garner support (with client approval) donning compression garments and practicing soft tissue mobilization techniques 

  • Consider recommending low sodium nutritional habits  (with approval of the physician) 

  • Encourage exercise with compression garments on - Muscle pump created while exercising, pushies against the compression garment and will help with getting fluid out of the swollen limb 

  • Connect individuals to local resources (exercise groups, dieticians, massage or other traditional and non traditional ways to support a client and family)

  • Patients with history of axillary lymph node excision and radiation should take precautions when flying, even if no significant lymphedema is present (especially if traveling for long periods of time) - the lowest level of compression garment should be used, consisting of a sleeve and glove (both are needed while traveling)

  • Upon initial evaluation, a comprehensive home exercise program should be provided so patients can begin progress at week 1 

  • Therapists should be cautious about how information is presented  - information should be provided in a manner that does not overwhelm a patient 

References:

McClure, M. K., McClure, R. J., Day, R., & Brufsky, A. M. (2010). Randomized controlled trial of the Breast Cancer Recovery Program for women with breast cancer–related lymphedema. The American Journal of Occupational Therapy, 64(1), 59–72. https://doi.org/10.5014/ajot.64.1.59 

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