Hi. My name is Peg Maas and I'm a Physical Therapist here at Swedish Medical Center.
The purpose of this podcast is to help you understand what lymphedema is, how it is managed,
and some things you can do to reduce your chances of developing it. Lymphedema is a
condition that is commonly discussed in the course of care for women who have been treated
for breast cancer. It is not unique to this population and it is not caused by the cancer
itself. Anyone with insufficient lymph transport abilities, either because we were born that
way or because we've been through medical procedures that compromise them, is at risk
for lymphedema, The way cancer is treated, the radiation and surgeries, puts women with
breast cancer more at risk for developing lymphedema. Lymphedema is easy to understand
if you think of it in terms of a traffic control issue. It's essentially the result of impaired
transport of the contents of the lymphatic vessels. To understand what we mean by this,
let me start by giving you a sense of the important anatomy. Our heart pumps blood away
from itself through the arteries. The arteries closest to the heart are large and the blood
starts there and then the vessels get smaller and smaller as you go further from the heart.
Eventually the tiniest arteries meet up with the very tiny veins and the blood travels
through progressively larger and larger veins until it arrives back at the heart after passing
through the lungs to pick up more oxygen. This system is a bit leaky by design. White
blood cells can escape so they can do their clean up duty in the body and then they reenter
the system. If they get too full or engorged though, they can't reenter the blood vessels.
That's where the lymphatic system comes in. The lymphatic system is a network of vessels
into which the engorged white blood cells can easily enter. The vessels of the lymphatic
system transport the body's cellular waste and along the lymphatic pathways there are
nodes which act like colanders straining out the big particles. There are cells within
the nodes that break down the clumps. And so what leaves the nodes is a cleaner version
of what came in. Eventually the lymphatic vessels meet back up with the heart and the
fluid reenters the bloodstream. There are a couple of fascinating to know about the
lymphatic system. One is that it has its own pulse, independent of the heartbeat. The vessels
gently contract and relax to move the material through them. This will be something to keep
in mind when we talk about treatment of lymphedema. The second unusual thing about the lymphatic
system is that it has the capability to remodel itself in response to injury. When nodes are
removed or damaged, as may be the case during breast surgery or radiation, the vessels that
lead to them can create new pathways and connect up the vessels that have intact nodes. This
is great news in the case of people who have had nodes surgically removed or damaged by
radiation. The special massage techniques used in lymphedema care specifically help
to regenerate the vessels. Now lets talk about how lymphedema occurs. Lymphedema occurs when
the fluid travelling up through the lymphatic vessels gets trapped because of insufficient
pathways. It's similar to when our local highways get overloaded with traffic. The fluid stops,
backs up, and just as cars on the highway may exit and spill over on to the surface
streets, the fluid seeps out into the nearby tissues causing swelling. The fluid that travels
in the lymphatic system is very high in protein. Protein likes to make matrices. If you think
of what happens to egg whites, they are runny until you expose them to heat and then they
begin to more solid. That's a matrix forming. The protein in our tissues forms matrices
and firms up in the same way if it is allowed to stay still. In difficult lymphedema scenarios,
the hardening of the tissues impairs adequate circulation and the tissue is not able to
heal itself or clear out infections. Not everyone who has surgery that involves the nodes will
develop lymphedema. Most people will not. It turns out that we cannot predict accurately
that those who have had more nodes removed will have lymphedema. Part of the issue is
not how many nodes you have removed but what percentage of your total number of nodes is
removed and that is not identified when surgical choices are made. The number of lymph nodes
a woman may have in her under arm area ranges from six to a hundred and twenty-five. So
the news of how many were removed is not a piece of data to worry about. The list of
risk factors, besides the surgical removal or damage to lymph nodes, includes radiation
treatment, failure to regain shoulder movement, obesity, and sedentary lifestyle. Additionally,
lymphedema may be triggered by sunburn, bug bites or other trauma to the limb. When lymphedema
occurs it's usually recognizable by swelling, especially in the hand of forearm. Some people
feel a heaviness or dull aching in their limb. This is not an emergency, unless it's also
accompanied by redness, fever or any other signs of being ill. Even though it's not an
emergency, promptly informing your health care provider will make it easier to address
and begin to manage the situation. Please understand this, lymphedema is not a sign
of cancer. It is a result of the treatments we currently use for eliminating cancer.
How is lymphedema treated? People who treat lymphedema have had special training in how to evaluate and treat the condition.
Currently there is no nationally recognized certification process
though many institutes that train therapists issue a certificate.
The people who might market themselves as lymphedema therapists are physical
therapists, occupational therapists, and occasionallly massage therapists.
Massage therapists are generally not covered by insurance for treating this
diagnosis and they're not licensed to assess for range of motion deficits or
giving any exercise prescriptions.
When it comes to arm and torso lymphedema, physical therapists and occupational
therapist have overlapping skills and training.
Whom you choose to see may depend partly on your insurance benefit for one
discipline or the other
and who you have access to.
At Swedish Medical Center our team of lymphedema therapists includes both
physical and occupational therapists.
A visit to a lymphedema therapist includes a thorough discussion of your history
including your exercise habits,
past orthopedic injuries, recent surgeries and treatments,
and what your lifestyle is like in terms of hobies, job activities and other elements.
We assess the movement of the limb,
feel for and measure swelling, and check healing of the surgical incision.
Depending on what we find
we may teach a patient how to care for herself independently
or we may recommend treatment in the clinic.
Sometimes treatment in the clinic means just a few visits
and sometimes it means a few visits per week for several weeks.
We work with the patient
to figure out what their goals are
and what it will take to achieve them.
The three major elements of lymphedema treatment are lymphatic drainage massage,
compression, and exercise.
The massage is a unique method that's
different from what people are typically accustomed to.
It's a very light technique 0:08:03.979,0:08:06.559. just deep enough to stretch the skin.
It's not deep like swedish massage
and it's not painful at all.
The technique is
performed rhythmically to support the natural rhythmic function
of the lymphatic system.
Strokes of performed in a very structured order
beginning on the torso and ending on the arm and hand.
Therapists can teach you to perform a version of this yourself
as a home program.
In this podcast you'll learn some basic elements of this.
The role of massage is to mobilize the lymphatic system to move the fluid
and also to promote the development of new lymphatic connections.
Blocked vessels can actually form new cross connections
and may then be able to transport fluids unimpeded.
The effect of the massage will be enhanced by compression,
which in essence creates an environment that is less able to accommodate extra fluid.
People with lymphedema are generally encouraged
to wear sleeves that provide some pressure
on the tissue sorta like a girdle.
There's a wide variety of products and levels of compression.
The choices of compression garments are best made with the advice of the
therapist who evaluates you.
There are also electric pumps that patients can purchase which are designed
to perform compression and massage.
Determining whether to obtain one should be done
with the advice of a physical or occupational therapist with legitimate
expertise.
The other essential component of treatment is exercise.
Regaining full motion in your shoulder and normalizing your posture
helps you lymphatic flow.
Cardiovascular exercise also assists with lymphatic flow.
Some women find that exercise creates a bit of swelling in their arm and others find
it's a great tool to reduce swelling.
Some women need to wear compression garments for their exercise activities and others do not.
Again because of the individual scenarios exercise choices are best made
with the advice of a therapist
and based on your particular valuation findings and preferences.
Can lymphedema human be prevented?
There are many questions about whether lymphedema be prevented.
At this time we do not have definitive research do guide us with this.
There is some indication that doing self massage as taught by a therapist
may reduce the chance developing lymphedema
by promoting good flow and connections for damaged vessels.
Certainly learning the precautions such as avoiding sunburn and cuts is likely
to help prevent lymphatic problems
and research is revealing that keeping fit is a key part.
We do not recommend wearing compression garments as a form of prevention.
There is preliminary research to suggest that this may actually cause an adverse
lymphatic response.
Now I'm going to teach you a few strokes of lymphatic massage that are
quite generic and suitable for all patients
and also a breathing technique that promotes healthy lymphatic function.
Before we do that though I want to recap some of the most important points we
have discussed.
First, the appearance of lymphedema does not mean anything about the cancer.
Second, lymphedema is not a life-threatening condition.
And third,
lymphedema can be successfully managed.
There many scary stories out there but rest assured that if you address
lymphedema promptly and with the correct information
it is very unlikely to cause you much trouble.
Lets move into learning a breathing technique
that is good for all of us but especially those with lymphatic flow issues.
We are designed to be able to breathe in two quite different ways.
One way is with the diaphragm, which is a muscle attached to the bottom of the rib cage.
When we breathe with our diaphragm the belly expands on the in breath
and flattens on the out breath.
The second method is using the muscles
of the neck and rib cage.
Breathing this way makes the chest rise and fall.
Take a moment to rest one of your hands on your abdomen
and one on your chest
as you breathe.
Notice which hand moves more.
Often the effects of stress and habits we develop over time transform our
daytime breathing into chest breathing.
One value of diaphragmatic breathing is that it massages some of the large
vessels of the lymphatic system and promotes lymphatic transportation.
Children and and pets breathe with their diaphragm
when they sleep.
Observing them can help you learn how to breathe this way.
Crying and laughing also promote lymphatic transportation because of the
abdominal activity involved.
Taking at least a few minutes everyday to breathe in this deep abdominal way
is something you can do to help your lymphatics function at their best.
In addition to the breathing technique there are two very basic lymphatic massage
strokes that you can start to do.
First, find the indentation behind your collarbone.
Put the flat part of your fingers there and make small circles
pressing only with enough pressure to stretch the skin.
Do five to ten repetitions.
Second, apply the palm of your hand to your underarm area.
This is best done directly on your skin and not through clothes.
Create a large area of contact as if you were
using a washcloth and making circular movements.
Again taking the skin
as you make the circles
stretching it
and releasing it as you circle
repeating five to ten times.
These are just two of the steps of the self massage of lymphatic drainage.
The other steps for a complete program would be selected based on your
assessment by a trained lymphedema therapist.
You can begin doing those
and it will support your lymphatic flow.
If you want to learn a complete routine ask your physician to refer you to a
lymphedema therapist.
Understanding the basics of lymphedema
helps you make informed choices for your own care.
There are many providers in the Swedish Medical Center system who can guide you. Take care.