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Intermittent pneumatic compression acts synergistically with manual lymphatic drainage in complex decongestive physiotherapy for breast cancer treatment-related lymphedema. Comparison of relative versus absolute arm size change as criteria for quantifying breast cancer-related lymphedema: the flaws in current studies and need for universal methodology. Factors associated with the development of arm lymphedema following breast cancer treatment: a match pair case-control study. Effects of compression bandaging with or without manual lymph drainage treatment in patients with postoperative arm lymphedema.
Sentinel lymph node biopsy lowers the rate of lymphedema when compared with standard axillary lymph node dissection. Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study.
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. However, often overlooked and seldom mention is that you can also have primary lymphedema of the arm.
If you are an at risk person for arm lymphedema there are early warning signs you should be aware of. 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.
During the course of treatment, the arm will be wrapped in compression bandages after the treatment session. There is one final and critical area pertaining to the treatment, control and management of lymphedema, and that is exercise. Sometimes too, the process we must go through to get our treatment covered is maddening to say the least. Perhaps the foremost rationale for NOT allowing the use of needles in an arm with lymphedema is the threat of infection. 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.
The doseage strength of any medicine injected into the arm will be diminished for two reasons. 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.
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.
Department of Lymphology, Centre National de Reference des Maladies Vasculaires Rares (lymph?demes primaires), Hopital Cognacq-Jay, 75015 Paris, France. Background:? Lymphedema is a general term applied to designate pathological regional accumulation of protein-rich fluid. 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. Conclusion:? Primary upper-limb lymphedema appears later in life than lower-limb lymphedema without sex predominance. 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. 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. Place hands on shoulders (on the same side of the body) and move elbows up and then down toward the sides of the body.
You can do a simplified version of MLD yourself at home, called simple lymphatic drainage (SLD). 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. Starting in the armpit on the non-swollen side (position 1), use light pressure to gently stretch the skin up into the armpit.
Next, at position 2, use a light push to stretch the skin towards the non-swollen side, with a slow and gentle rhythm. 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. Hand-held massagers can be useful for people who have restricted movement of their hands, perhaps due to arthritis. As you breathe in – direct the air down to your abdomen, which you will feel rising under your hands. At special risk are patients who have gone through a bi-lateral mastectomy or a single mastectomy with surgery also on the opposite side. 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. One very important component of a comprehensive treatment plan for cancer-related lymphedema is exercise.
Flexibility exercises help to maintain joint range of motion and allow for elongation or stretching of tissues.
Strengthening exercises are also important in reducing lymphedema when done at low intensity levels with the extremity wrapped (see below).
Aerobic exercise enhances the lymphatic and venous flow, further reducing swelling in the extremity. Finally, deep abdominal breathing or diaphragmatic breathing is important with all exercise, but especially so in people with lymphedema.
Exercises should be initiated by a physical or occupational therapist that specializes in lymphedema treatment.
There has been little research to date regarding the intensity of exercise in people with lymphedema and what is a safe level. 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. Following a mastectomy it is important to maintain range of motion or flexibility in the shoulder.
The influence of physical activity on the development of arm lymphedema (ALE) after breast cancer surgery with axillary node dissection has been debated.
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.
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. When traveling in a car or plane for long distances, keep the affected arm above the level of the heart, if at all possible.
Sports such as tennis, racquetball and golf have the potential to strain muscles because of sudden and forceful strokes. Boccardo FM, Ansaldi F, Bellini C, Accogli S, Taddei G, Murdaca G, Campisi CC, Villa G, Icardi G, Durando P, Puppo F, Campisi C. Lymphedema is a common complication of axillary dissection and thus emphasis should be placed on prevention. The application of intermittent pneumatic compression (IPC) as a part of complex decongestive physiotherapy (CDP) remains controversial.
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. 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. 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. 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.

The items and supplies listed below are considered “incident to” a physician service and are not separately reimbursable. Synergic effect of compression therapy and controlled active exercises using a facilitating device in the treatment of arm lymphedema. Microvascular Breast Reconstruction and Lymph Node Transfer for Postmastectomy Lymphedema Patients. Distribution of axillary lymph node metastases in different levels and groups in breast cancer, a pathological study. Factors Associated with the Development of Breast Cancer-Related Lymphedema After Whole-Breast Irradiation. Manual lymph drainage when added to advice and exercise may not be effective in preventing lymphoedema after surgery for breast cancer. Comparison between one day and two days protocols for sentinel node mapping of breast cancer patients. Ancukiewicz M, Miller CL, Skolny MN, O'Toole J, Warren LE, Jammallo LS, Specht MC, Taghian AG. Department of Radiation Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA. 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 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. 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. Arm edema occurs in 20 to 30 per cent of patients who undergo axillary lymph node dissection (ALND) for carcinoma of the breast.
Division of Sports Medicine and School of Human Kinetics, University of British Columbia, Vancouver, British Columbia, Canada.
PURPOSE: To examine the effect of a progressive upper-body exercise program on lymphedema secondary to breast cancer treatment. Lymph is produced as the result of hydrostatic filtration of blood in the smaller blood vessels. At the time of a radical mastectomy, the axillary lymph glands are removed to prevent any spread of the cancer. 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.
A prerequisite to the success after the operation is a vigilant use of a custom-made compression garment.
Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections. Lymphangiosarcoma which is a rapidly progressive, non curable cancer of long term lymphedema patients.
The earlier lymphedema is recognized and diagnosed, the easier it is to successful treat it and to avoid many of the complications. Once an infection has begun the excess fluid and any fibrosis of the arm tissue makes it tremendously more difficult to eradicate the bacteria. 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.
Infectious complications are rare and patients considered the lymphedema volume stable throughout life. 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.
Each exercise may be performed five times in a row, three times a day (morning, afternoon, evening) with the physician’s approval. Push elbows out as far as possible and then bring them together to touch in front of the body. You will find it easier to start with one hand, and then swap to the other as you move across the body. This time, the movement with your fingers is a slight pull to move the skin to the non-swollen armpit. It can be used to apply gentle pressure in the same sequence of movements as the exercises on the previous pages. A program consisting of flexibility, strengthening and aerobic exercise is beneficial in reducing lymphedema when administered under the correct conditions. Flexibility exercises also help to prevent joint stiffness and postural changes after cancer surgeries or treatments. These exercises often help increase lymphatic and venous flow, aiding in the removal of fluid from the involved extremity.
Aerobic exercise also combats fatigue, which plagues so many people during and after cancer treatment. When deep breathing is carried out, the pressure inside the chest and abdomen is altered and creates a pumping activity within the lymphatic system. 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. 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 primary outcomes were the difference in arm volume between the affected and control arms (Voldiff, in ml) and the development of ALE.
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.
Wash the injury with soap and water, apply antibiotic ointment, then cover with a band-aid.
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.
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.
The application of IPC with MLD provides a synergistic enhancement of the effect of CDP in arm volume reduction.
However, if these supplies are given to a patient as a take home supply, the claim should be submitted to the DMERC. Use for Reid, CircAid, ArmAssist, etc manually-adjustable sleeves and leggings. 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.
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.
After CB therapy for 2 weeks (Part I), the patients were allocated to either CB or CB + MLD for 1 week (Part II). Sentinel lymph node biopsy (SLNB) in lieu of ALND for staging of breast cancer significantly lowers this morbidity. METHODS: Fourteen breast cancer survivors with unilateral upper extremity lymphedema were randomly assigned to an exercise (n = 7) or control group (n = 7). Normally lymph is removed from the extracellular space via small lymph vessels and is then carried to the lymph glands.
Many of these patients develop lymphedema of the arm due to the impaired lymph drainage, which is further exacerbated by post-operative irradiation. To date there has not been a surgical procedure that completely removes the edema after breast cancer treatment. Because of the immunocompromised state of the arm any infection can and often does escalate quickly into cellulitis. When you add the fluids that are present in the administration of an IV, you catastrophically overload the arm. 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. Lean forward and swing the arm on the side of the surgery in circles, first clockwise and then counter-clockwise.

Exercise also allows cancer survivors a more active role in their own lymphedema management. The central thoracic duct, which carries lymph fluid from the abdomen and legs, travels through the chest cavity.
Currently, exercise and progressive weight lifting activities are used to assist in the removal of lymphedema from the affected areas.
Protecting the arm may lead to stiffness and tightness in the shoulder which can make it difficult to move the arm.
The risk factors associated with the development of ALE 2 years after surgery were also evaluated. Baseline (before surgery) and follow-up tests were performed 3 months, 6 months, and 2 years after surgery.
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. 2012 Editors note I am posting this for basic information, I do not agree nor do I support the use of lymph node transfers. We also used sequential measurements to analyze temporal variation in unaffected arm volume. Occupational workload was assessed after surgery whereas housework, exercise, hobbies and body weight were assessed both before and after surgery. We hypothesized that SLNB would have a lower lymphedema rate than conventional axillary dissection. 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. At the Department of Plastic and Reconstructive Surgery, Malm? University Hospital, Malm?, Sweden, a new and unique method of complete removal of cronic lymphedema has been developed using a special liposuction technique. 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.
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. Therapists can guide clients in a weight lifting program that is tailored to their present fitness levels. The short stretch bandages used in lymphedema treatment do not stretch much when applied to the arm or leg.
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. Clinically significant lymphedema was confirmed by an increase of at least 200 ml from the preoperative difference between the two arms.
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). Patients who underwent SLNB were compared with those who underwent level I and II axillary node dissection. Lymphedema was assessed by arm circumference and measurement of arm volume by water displacement.
The edema and the increased subcutaneous fat are removed via some 30 small incisions along the arm. If you do this, you will obstruct your lymphatic channels and so the massage will not help lymph drainage. Deep breathing is also important to deliver adequate oxygen supplies to the working muscles so that they may work efficiently.
How much you can lift depends on the stage of treatment and most importantly, you previous and present fitness levels. 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. Since the shoulder and neck are closely related, it is also important to maintain neck mobility to prevent further complications. 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.
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. The matching factors included axillary node status, time after axillary dissection, and age.
A total of 125 patients were evaluated with 77 patients who underwent SLNB and 48 patients who underwent ALND. Common symptoms of chronic lymphedema are pain, a feeling of heaviness and decreased mobility of the arm. This results in disappearance of pain and feeling of heaviness as well as an increased mobility of the arm. It is important to continuously monitor the limb for swelling or redness, which can be an indication that the exercise was too intense.
Ask your doctor or physical therapist if you have questions about which shoulder exercises are right for you. Assessments at 2 years postoperatively were completed for 89% of the 55 women who were randomly assigned to either PG or CG.
The arm circumference 10 cm above and 10 cm below the olecranon process was measured on both arms. The Medical Outcomes Trust Short-Form 36 Survey was used to measure quality of life before and after the intervention. 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%). A weight lifting program should be initiated by a therapist who specializes in the treatment of lymphedema. If you have recently undergone a mastectomy accompanied by a breast reconstruction REFER TO YOUR SURGEON FOR INFORMATION REGARDING SHOULDER EXERCISE. 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. In this series a difference in arm circumference greater than 3 cm between the operated and nonoperated side was defined as significant for lymphedema. 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. These prophylactic strategies appear to reduce the development of secondary lymphedema and alter its progression in comparison to the CG women.
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.
Lymphedema was seen in two of 77 (2.6%) patients in the SLNB group as compared with 13 of 48 (27%) ALND patients. RESULTS: No changes were found in arm circumference or arm volume as a result of the exercise program.
Absolute changes in arm size used as criteria for BCRL are correlated with pre-operative and temporal changes in body size. Low stretch compression bandaging is an effective treatment giving volume reduction of slight or moderate arm lymphedema in women treated for breast cancer. 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. Therefore, utilization of absolute volume or circumference change in clinical trials is flawed because specificity depends strongly on patient body size.
This has an important impact on long-term postoperative management of patients with breast cancer. Relative arm volume change is independent of body size and should thus be used as the standard criterion for diagnosis of BCRL.
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.

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