Lymphedema Management Part II Post Breast Cancer

Lymphedema can occur to individuals who have had breast cancer treatment with radiation and/or surgical intervention with or without lymph nodes removal usually in the arm pit. Lymphedema is a special type of swelling that occurs when there is excessive build of fluid that is rich in protein that is to become lymph due to an impairment in the transport of this fluid anywhere enroute to its final drainage site in the neck. Lymphedema management is divided into two phases: Phase I Congestive/acute phase whose goal is to achieve the greatest decrease in volume of lymphedema and Phase II Maintenance phase, whose purpose is long term maintenance to ensure sustenance of goals achieved in Phase I. Components of Phase I are, a) patient education about the condition, self management strategies. The patient will be advised to avoid certain medical procedures to be done on the affected side, e.g. blood pressure readings, pricking to withdraw blood. These procedures especially the pricking will result in minor injury which in a normal functioning system is insignificant. The normal bodily response is that the body will respond as there is injury with insignificant swelling. In the case of someone with risk to lymphedema this can be a trigger to full blown swelling, b) Meticulous skin and nail care to keep fungal infections and cellulitis at bay, c)Manual Lymphatic Drainage (MLD). This is specialised manual (hands-on) technique whose purpose is to improve fluid removal from congested (swollen) areas where there is impediment of flow to using alternative routes to de-congest the areas. For example, if there is lymphedema in the right arm from right partial mastectomy (breast tissue removal) with eight lymph nodes removal in the right arm pit. The alternative routes to drain) the right swollen hand/arm is to re-direct fluid to drain into the left armpit, right groin and maybe right breast bone areas. Following this during a treatment session, d)multi-layered Compression Bandaging is used. Here special bandages are used which come in different sizes. Which technique to use when bandaging is influenced by the degree of swelling and staging of lymphedema. The bandage system is tighter at the wrist and progressively becomes looser towards the arm. This creates graduated compression which facilitates fluid to flow from the wrist towards the armpit. Initially the bandages are worn 24hrs/day at a time. If there are wounds which is not as common when compared to the leg(s) preference is to co-treat with nursing care for them to manage the wounds while I manage the swelling concurrently. Immediately the patient does, e) therapeutic exercises to further drainage of fluid from the wrist to the armpit. This phase I duration can be anywhere from three weeks to eight weeks and more if needs be. During this time the patient is taught to self bandage, gentle self manual lymphatic drainage, prepared for wearing and taking off of compression garments. Phase II: Maintenance phase, this is initiated when there has been maximal limb (arm size) reduction in Phase I. The patient is fitted into a compression garment. This can either be custom made or off the shelf. Compression garment may be arm sleeve, glove with or without fingers. The compression garments come in a variety of compression (Class I to IV). The therapist advicss on the compression garment class. Most patients use compression Class II and III. Ideally the patient is encouraged to wear the compression garment all the time. From time to time there will be a relapse, that is, swelling starts and Phase I will need to be initiated. There are a number of treatment approaches that can be taken. Factors influencing choice include cancer disease stage, type of cancer, location of lymphedema, patient mental status. It is not just lymphedema that needs to be treated. Other things to treat include scarring, pain and decreased function. If you suspect you have lymphedema bring it to the attention of your oncologist who will refer you to someone trained to manage this condition.