- Question from Kate: Is massage beneficial in treating lymphedema?
- Answers - Sara Cohen, OTR/L, CLT-LANA One of the main treatments for lymphedema is a massage-like technique that helps to stimulate the lymphatic vessels. However, massage, the way people generally think of massage, is a vigorous technique that can cause an increase in fluid production. The type of massage that is used to treat lymphedema is a very gentle technique. Lymphatic massage is directed towards the heart from the fingertips, up the arm, towards the shoulder, and there are very specific directions and strokes that are used in this particular massage.
- Marisa Weiss, M.D. Inside the tiny little lymphatic channels, there are valves. The valves keep the lymphatic fluid flowing in one direction, towards the heart. So when you massage up along the arm towards the heart, the valves help keep the fluid going in the right direction: out of the arm, and back into circulation.
- Saskia Thiadens It also is extremely important to remember that a certified lymphedema therapist needs to either perform the treatment or educate the patient and/or family members in self-care techniques, once the patient has gone through an intensive treatment program. The therapist will design the treatment plan based on the severity of the lymphedema. It can also depend on the type of reimbursement patients can get from their health plans. In my practice, for example, we would treat a patient with a mild upper extremity lymphedema for a five-day period, including two sessions of manual lymphatic drainage (MLD), bandaging, exercise, and also education in self-care. So by the end of the five days, usually the patient is able to manually drain the limb and follow a home program.
- Sara Cohen, OTR/L, CLT-LANA Manual lymph drainage, or decongestive lymphatic therapy, involves the massage-like technique followed by using special bandages and low-stretch bandages, which are different from Ace bandages, and the bandages are applied in layers over different kinds of padding material. The goal of the bandaging is to reshape the limb, support the skin, and to prevent re-accumulation. The compression garment is used at the conclusion of treatment. Patients often use a compression sleeve during the day, and they sometimes use bandages at night after the intensive part of the treatment.
- Marisa Weiss, M.D. An elasticized sleeve is one piece that covers the arm, and may also include an additional garment that covers the hand. These sleeves are made to order for you; they come in sizes.
- Sara Cohen, OTR/L, CLT-LANA There are many different brands of lymphedema garments, and it would be helpful for women looking for a garment to try different brands and see which one works best for them. They should never use a garment that causes any kind of skin irritation, allergy, or constriction at one area that causes swelling below that point.
- Saskia Thiadens The person needs to be measured by a certified fitter.
Marisa Weiss, M.D.
It's not a good idea to walk into a medical supply store and ask the person behind the counter for a sleeve. If these garments do not fit properly, they can cause you more problems than they solve. Likewise, the application of a specialized bandage requires a lot of instruction and guidance. It needs to be applied in an even way, where a little bit more pressure is exerted towards the hand, and a little bit less towards the shoulder, in order to move the fluid in the right direction. If there are pockets where the pressure of the bandage is uneven, you can get pockets of swelling. This is a technique that you can learn to master with the guidance of a trained specialist.
From a practical point of view, I've learned from treating many hundreds of women with breast cancer that summertime is a difficult time for lymphedema patients, because with the extra heat, there tends to be extra swelling of the arm. It's also a lot less comfortable to wear a hot, elasticized, tight garment along your arm during the summertime. There are other ways to manage lymphedema besides wearing a sleeve all day. Many of my patients prefer the practical nature of a specialized pump.
I'd like to hear from our speakers about how they approach the use of a specialized pump that involves the placement of the affected arm into a sleeve that exerts a pumping action, pumping the fluid from the fingertips up to the shoulder.
- Saskia Thiadens I do not recommend the sequential gradient pump, but if people do use the pump, it is important that a certified lymphedema therapist monitor them and that the pressure does not go above 40mmHg. They should not stay on the pump for more than an hour, and they should watch the arm really closely once they come off the pump. And most important, do the manual lymphatic drainage before and ideally after the pump treatment as well. The reason we are concerned is because if we do not open the pathways in the proximal shoulder area, you can congest the area and worsen the condition, or, potentially, it could lead into irreversible lymphedema.
- Marisa Weiss, M.D. By sequential, we mean that the pump creates a sequence of pressure starting from the hand up to the shoulder. And by gradient, we mean that the amount of pressure applied tends to be greatest at the lowest part of the arm, and it decreases as it moves up the arm. The pressure is lower by the time it reaches the shoulder.
- Sara Cohen, OTR/L, CLT-LANA Historically, pumps were used before the European lymph drainage techniques were brought to this country. Pumps were the prescribed treatment whenever anybody had edema, and part of the problem now is that some physical or occupational therapists or doctors may not be aware of current treatments for lymphedema and prescribe a pump. There are many schools of lymphedema therapy, and some schools recommend using a pump in conjunction with lymphatic massage, and there are many studies that show pumps are effective, and some show they are not effective.
Marisa Weiss, M.D.
Lymphedema is a chronic problem that may be mild in nature, or may be really significant to an individual person, and, in addition, it can vary over time. Sometimes it's okay, and sometimes you get flare-ups. For many women that I take care of who have lymphedema, it's important to incorporate a regular approach to managing it on a daily basis. Their insurance may not cover a professional MLD (manual lymphatic drainage) person, or they may be working during the day and be unable to get to such an expert. I have plenty of patients who go to a very capable pump expert, and they use their pumps each evening, or at least several times a week in the privacy of their homes, after work, when they're relaxing, to decompress the arm. They're carefully monitored so they get the benefit without the side effects of a pump.
Each woman has to find what works for her. What works for you now may continue to work for you, or it may not work as well over time. If you work closely with a physical therapist, occupational therapist, and doctor, you can ask for extra help and be monitored for this problem over time. Often women use a combination of treatments to help ease this ongoing problem.
On Wednesday, July 17, 2002, our Ask-the-Expert Online Conference was called Arm Lymphedema Prevention and Management. Sara Cohen, O.T.R./L., C.L.T.-L.A.N.A., Saska Thiadens, R.N. and Marisa Weiss, M.D. answered your questions about preventing and managing arm lymphedema.
The materials presented in these conferences do not necessarily reflect the views of Breastcancer.org. A qualified healthcare professional should be consulted before using any therapeutic product or regimen discussed. All readers should verify all information and data before employing any therapies described here.
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