Society for Oncology Massage
Uncommon Interest, Training, Compassion


Lymphedema

Reducing the Risk of Lymphedema During and After Breast Cancer Treatment
(NB Also Applies to Abdominal Cancer Treatments.)


An article published on the Step-Up, Speak-Out website draws on a 2008 report in the Journal of Nursing Scholarship[1] to make the case that everyone who has had breast cancer is at risk for lymphedema and that everyone can proactively minimize that risk or, if lymphedema has occurred, minimize the severity.  This discussion extends the concepts for oncology massage therapists and their clients.  (Material quoted directly from the article is highlighted in maroon.)

"If you've been treated for breast cancer, you are at risk for lymphedema of the hand, arm, back, and chest or breast on the affected side. If your surgery was bilateral, then both sides are at risk. The risk remains for the rest of your life. The good news is that you can reduce that risk by understanding a few important principles and the safe practices that follow from them."

The study reports that just 57% of the participating patients had received adequate lymphedema information prior to the study.  Oncology massage therapists can play an important role in encouraging their breast cancer clients to ask for, think about and act on their physicians' and nurses' advice about this very important subject.  We can then reinforce its importance by discussing massage restrictions intelligently and firmly - explaining our reasons by drawing on articles like this for medical concerns (saunas, BP cuffs, overuse, sleep position, ...) that are equivalent to our massage concerns (friction, pressure, overstretch, poor positioning, ...).


Lymphedema Suggestions for Breast Cancer Patients

The lymphatic system is often referred to as the body's "second" circulatory system.  It collects and filters the body's intercellular fluids, trapping and destroying protein molecules, fats, cellular debris, bacteria and viruses. 

A healthy lymphatic system at rest uses only about 10% of its total capacity.  The other 90% is functional reserve.  Increased demand and/or damage to the system decrease the reserve.  When the reserve is gone, the system backs-up, resulting in swelling, discomfort and sometimes infection.  That is lymphedema. 

The capacity of the lymphatic system in your chest and arm is reduced by:

The demands placed on the system are increased by:

You cannot change the first three factors.  You do have some control over the second three. Talk the following suggestions over with your healthcare providers.

Be Alert
Learn what your new "normal" looks like so you can detect changes.  Look for normal dimples and creases in your skin on the affected side and on the unaffected side.  Place your hands together in "the prayer position".  Study the soft tissue between the base of your thumbs and your hands.  Extend both arms straight ahead and turn your fingers straight up.  (The "No-No" position)  Study the hollows on the back of your hands.  Lymphedema often fills these spots first - they may be your earliest warning system.

Learn what your new "normal" feels like.  Experience how the affected body parts feel - be alert for heaviness, aching, firmness and swelling.  Compare the feelings to unaffected body parts.  Changes in these sensations may be your next warning system.

The medical standard for lymphedema is an increase of 2 cm. in the diameter of your arm.  This is the least sensitive warning system.

Wear a Medic-Alert bracelet or pendant so others will be alerted in an emergency.

Using the following pointers, consider the impact your normal activities may have on your lymphatic system.  The necessary adjustments may be a nuisance at first but you will soon internalize them.

"Two words summarize all the risk reduction practices and make them easy to remember: "Promote" and "Protect." That means you will promote the lymph flow in your affected arm/chest or other affected area, and protect the area from injury or infection."

Prevent Infection
Keep the skin clean
Keep your arm pits and the area under your breasts dry to avoid fungal infection
Keep your skin intact
Moisturize your skin daily to prevent microscopic cracks
Keep nails clean and avoid cutting cuticles
Avoid commercial manicures
Use sunscreen or protective clothing to prevent sunburn
Use an insect repellent on any exposed skin
Avoid razor nicks and burns
Wear gloves when handling household cleaners and other chemicals
Wear rubber gloves when washing dishes
Where sturdy work gloves when gardening or using tools
Wear a thimble when sewing to avoid needle and pin pricks to your fingers
Use extra caution to prevent even moderate burns
Avoid skin punctures from IV's, injections and blood tests
Discuss with your doctor the use of prophylactic oral antibiotics with any medical procedures that involve the affected parts of your body

In case of nicks, scratches, burns, insect bites, abrasions or any skin break, wash the area well and apply a topical antibiotic. Watch for redness, itching, sudden swelling, warmth to the touch, rash, or fever, which may indicate an infection, and get medical help promptly.

Stay Active, but be Watchful
Exercise is good for both prevention and control of lymphedema.
Build up very gradually to your former activity level.
With any new activity, start slowly and increase very gradually.
Take frequent rests, or switch activities to avoid overuse or constant repetition.
Use your legs, not your back, to lift things (or kids!) off the floor.
Use both arms rather than one to carry heavy objects, such as milk bottles.
Keep your arms close to your body when lifting loads.
Stay well hydrated
- drink plenty of water, avoid caffeine, avoid alcohol.
Avoid any activity which reddens the skin in the affected area.
If you have massage, be sure your therapist is trained in oncology work.
Avoid becoming generally run down.

Stop at once if you experience heaviness, aching, firmness, or swelling. Rest and elevate your arm. You may want to try the activity again the next day, but stop earlier and plan to proceed more slowly.

Avoid Constriction
Except in an emergency, do not allow blood pressure to be taken on an at-risk arm.
Make sure bracelets, rings, watches, clothing and bandages are not tight.
Keep bags and purses light so they don't dig into your shoulders or fingers.
Bras should have wide straps that do not cut into the shoulders.
Avoid under-wire bras that can limit lymph drainage below the breast.

Bras should be sufficiently relaxed fit that they do not leave red marks or creases.
Do not sleep on an affected arm.
Do not hang an affected arm off a bed, couch or massage table.

Avoid Temperature Extremes
Extreme cold may cause rebound swelling that can overwhelm the lymph system.
If an ice pack is needed, pad it with a towel and use it for no longer than 10 minutes at a time.
Heat can draw lymph fluid to the affected areas and overwhelm the lymph system.
Avoid water temperatures of more than 102 degrees in hot tubs, saunas, baths or showers.
If moist heat is needed, moderate the temperature and use it for no longer than 10 minutes at a time.
In warm climates, limit outdoor activities to the cooler morning hours.

Control Your Weight
Studies have shown that maintaining your ideal weight, or losing weight if you are overweight, can make a significant difference in controlling lymphedema. Weight loss may curb cancer-related arm swelling.
If you are overweight, weight loss can significantly reduce your lymphedema risk.
Try to avoid weight gain following your cancer surgery.
Get help from a dietician if necessary.

Use Compression Garments
Always "promote" your lymph flow with manual lymph drainage massage before donning your compression garments.
Garments should fit well and be checked for fit by a knowledgeable professional.
Always wear a glove or gauntlet with a compression sleeve to avoid trapping any excess fluid in your hand.
If you have had bilateral surgeries, wear garments on both arms.
Wear your garments when you exercise or for any strenuous or unusual activities, or if your arm feels achy or heavy after exercise.
Wear your garments for air travel, and for an hour or two after you land while your arm recovers from the pressure changes.
If you choose to travel without wearing compression garments, take a well-fitted sleeve and glove with you in your carry-on luggage in case you develop heaviness or swelling.


Footnote
[1] Cancer-related lymphedema: information, symptoms, and risk-reduction behaviors
Fu, Mei R.; Axelrod, Deborah; Haber, Judith
Journal of Nursing Scholarship, Vol 40, No 4, Dec 2008 , 341-348

Other References
Understanding Breast Cancer Related Lymphoedema
Britton TMB, Purushotham AD
The Surgeon, 2009 Vol7 No2

Medicine Hands: Massage Therapy for People with Cancer
Gayle MacDonald MS LMT
2nd Ed, 240 pages
Findhorn Press, 2007
p96-102

Traditional Massage Therapy in the Treatment and Management of Lymphedema
Joachim Zuther, MT, PT
Massage Today
June, 2002, Vol. 02, Issue 06

Exercise and secondary lymphedema: safety, potential benefits, and research issues.
Hayes SC, Reul-Hirche H, Turner J.
Med Sci Sports Exerc. 2009 Mar;41(3):483-9.

For more information on careful training, vigorous exercise and lymphedema
search PubMed on "dragon boat cancer" .

 


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