IPMR: Lymphedema Risk

Progress Report Proctor Hospital

Lymphedema: Could You Be At Risk?

By Molly Nettles, OTR/L, CLT

Gina is a 63 year-old woman who is a breast cancer survivor. She underwent a mastectomy and radiotherapy five years ago. She is happy to have beaten cancer, but lately she has noticed some puffiness in her arm and tightness of the rings on her fingers.

Ray is a 35 year-old male who has had swelling in his legs since he was an adolescent. It did not bother him too much in the past, and doctors told him not to worry about it. But over the past seven years, his legs have swelled to an unusual size and walking has become difficult.

George is a 70 year-old male who has had circulatory problems in his legs for some time. He has developed wounds and swelling in his legs that do not go away. His socks and shoes leave indentations on his feet. One leg appears more swollen than the other.

What do all of the above individuals have in common? Along with 400,000 other individuals in the United States, they are suffering from a condition called LYMPHEDEMA.

WHAT IS LYMPHEDEMA?

Lymphedema is a chronic swelling, usually in the arms or legs, that occurs as a result of an impaired lymphatic system. Lymphedema can occur in anyone--men, women, and children. The lymphatic system is part of the circulatory system along with veins and arteries. It has several important functions:

It collects excess fluid from tissues in all parts of the body, and returns the fluid to the heart.
It removes impurities including bacteria, proteins, and waste cells from the circulatory system.
It aids in creating disease fighting cells, or antibodies, called lymphocytes for the immune system.

If the lymphatic system has been impaired, the fluid can become backed up. Swelling occurs when the amount of fluid in an area is greater than the capacity of the lymphatic system to carry it away.

WHAT ARE THE TYPES AND CAUSES OF LYMPHEDEMA?

There are two types of lymphedema -- Primary and Secondary.

Primary Lymphedema is caused by an abnormality of the lymphatic system that can be present at birth, develop at or around the onset of puberty (lymphedema praecox), or develop after the age of thirty-five (lymphedema tarda).

Secondary Lymphedema, the most common type, has many causes including:

Surgery, in particular when lymph nodes are removed after treatment of cancer: breast, prostate, gynecological, head or neck, or melanoma. Lymphedema may develop soon after surgery or many years later.
Radiotherapy which kills cancer cells but can also damage the normal flow of the lymphatic system.
Trauma that damages the nearest area of lymph nodes.
Infections, lymphangitis.
Paralysis or immobility.
Chronic venous insufficiency.

WHY SHOULD LYMPHEDEMA BE TREATED?

Lymphedema is a serious condition. If left untreated, lymphedema creates an environment of stagnant, protein-rich fluid which increases the potential for bacteria to cause recurrent infection. Lymphedema may increase limb girth size. Lymphedema often interferes with wound healing and may cause skin changes and tissue thickening (fibrosis). There are less common life threatening complications as well, such as the development of lymphangiosarcoma (a rare type of cancer).

Lymphedema may worsen with time if left untreated. It may result in loss of range of motion and strength. It may cause fatigue due to heavy limb size, weight, and pain. Due to the possible cosmetic deformities, lymphedema can also have large psychological, social, and emotional effects on the person who develops it.

HOW DO I KNOW IF I HAVE LYMPHEDEMA?

Several signs may indicate the initial onset of lymphedema. A feeling of pressure or soreness may occur first. The sensation of swelling may be present even before swelling is detected. Puffiness or an increase in the size of the limb or any quadrant closest to the surgical site or site of radiotherapy may be detected. Numbness and tingling sensations may occur. A feeling of heat or aching may develop. The skin and tissue may pit. Pitting can be tested by pressing in the skin and holding it for a moment to see whether the skin and tissue bounce back readily or not.

If experiencing any of these early signs or symptoms, the individual should contact a doctor. It is not uncommon for lymphedema to occur several years after having finished regular and frequent appointments with the physician. Usually, a diagnosis of lymphedema can be made through a complete history and physical examination. However, other diagnostic tests exist which can aid in the diagnosis.

WHAT TREATMENTS ARE AVAILABLE?

Unfortunately, there is no cure. However, with early intervention and proper treatment, the condition can be controlled and minimized, allowing the individual to lead a full and normal life.

Treatment begins with a physician’s referral to a specially trained Occupational or Physical Therapist. The therapist performs a thorough evaluation to determine a baseline of the individual’s sensation, pain, range of motion, strength, skin integrity, and extent of swelling.

A treatment plan to decrease the swelling and improve the individual’s ability to function may include:

Lymphatic manual drainage, a specialized lymphatic "massage", to move the extra lymph fluid through intact lymphatics and create new pathways for the lymph fluid to flow.
Compression bandaging to reduce swelling.
Exercise to improve functioning of the lymphatic system, range of motion, and strength.
Establishment of a good skin care program to decrease the chances of infection.
Recommendation of a compression garment and instruction for wear and care.
Thorough patient education regarding all of the above to promote independence with self-management of lymphedema.

Not all therapists have received special training to treat lymphedema, so it is important to select an occupational or physical therapist that is qualified to treat individuals suffering with the condition. The Institute of Physical Medicine and Rehabilitation employs several qualified therapists who have been trained and certified to treat lymphedema at many of their outpatient sites. For more information, please call (309) 692-8670.

Women who have undergone breast cancer surgery and/or radiotherapy are particularly at risk for developing lymphedema. An individual who has had any type of breast cancer surgery or therapy is at risk of developing lymphedema. The National Lymphedema Network’s 10 Precautions for Women at Risk of Lymphedema include the following:

Do not ignore any slight increase of swelling in the arm, hand, fingers, neck, or chest. Call your doctor. The sooner treatment begins, the more effective it will be.

Never allow an injection, needle stick, or blood pressure cuff in the affected arm. Breaks in the skin allow infection causing bacteria to enter. Pressure on the arm may damage existing lymphatics.

Avoid heavy lifting with the affected arm. Never carry heavy handbags with over-the-shoulder straps. Be especially careful lifting children and groceries. Do not lift more than 15 pounds at a time as excessive weight lifting can place a burden on the lymphatic system.

Do not wear tight jewelry or elastic bands on the affected arm/hand as these may obstruct the lymphatics.

Avoid injuries to the arm such as cat scratches, cuts, sunburn, insect bites as these may serve as a portal for bacteria to enter and cause infection.

Avoid extreme temperature changes when bathing, washing dishes. Stay out of the sauna and hot tub. Keep the arm protected from the sun. Temperature changes may lead to increased swelling.

Wear gloves while performing gardening or housework. This will prevent any type of minor injury that could result in increased swelling.

Maintain a healthy diet and lifestyle. Light exercise is beneficial.

Wear well-fitted supportive bras that are not too tight and without wires. Avoid a heavy prosthesis. These may put extra pressure on the collarbone and shoulders.

Wear a compression sleeve in airplanes, as the change in pressure may increase the risk of swelling. Remember to drink plenty of water.

Molly Nettles, OTR/L, CLT is program coordinator of the Lymphedema Program through the Institute of Physical Medicine and Rehabilitation.