Whitehair, CL Chapter Nine v.6
Author-1: Curtis L. Whitehair, MD
Associate Medical Director, MedStar National Rehabilitation Network
Director, Cancer Rehabilitation
MedStar National Rehabilitation Hospital
Author-2: Yvonne Francis, PT
MedStar NRH Network, Irving Street
Chapter Nine
Managing Lymphedema
Key Points
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Lymphedema is a lifelong condition
Although lymphedema is incurable, it is controllable
The risk of developing lymphedema increases with the amount of different types
of cancer treatment
Maintaining proper exercise and a rehabilitation program by a lymphedema
expert is the best way to control lymphedema
“After my breast cancer treatment, I felt like I was home free. My oncologist said my cancer was gone
and the likelihood of recurrence was low. I felt like I didn’t have much to be concerned about. However,
6 months after my surgery, I began to notice swelling in my arm. My first thought was: Is the cancer
coming back so soon? I was so scared. Luckily, my oncologist referred me to a physiatrist – a specialist
in physical medicine and rehabilitation. This physiatrist was an expert in problems caused by cancer and
its treatment. The physiatrist told me I had lymphedema. While the bad news was that I will always be
at risk for lymphedema, the good news was that it is treatable and manageable. The physiatrist referred
me to a physical therapist with specialized training in lymphedema management. After just 6 weeks
working with the therapist twice a week, my lymphedema was practically gone. I finished outpatient
therapy and was given exercises and massage techniques to do at home on my own. I also have to wear
a compression sleeve to keep the lymphedema away. This can be annoying, but it’s worth doing to keep
my arm healthy. I am very thankful for my rehabilitation treatments.”
Mary H.
1
1
INTRODUCTION
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Lymphedema is a specific type of swelling that can be related to cancer treatment. As Mary
3
H.’s experience illustrates, lymphedema is both scary and challenging. This chapter will help
4
alleviate those fears by first providing an understanding of how the body works, what causes
5
lymphedema, and the risk involved in developing lymphedema. Furthermore, it will provide an
6
understanding of the complications that can occur with lymphedema if not treated. Lastly it will
7
discuss the different treatment options available to minimize or control lymphedema.
8
SECTION I: WHAT IS LYMPHEDEMA
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How the body is constructed
10
The lymphatic system is composed of lymphatic channels or vessels which are located in every
11
part of the body (Figure 9.1). This system complements the circulatory system and runs along
12
the arteries and veins in what is known as the extracellular space. The circulatory system
13
carries the blood to and from the cells in the body, however, this system is somewhat leaky and
14
about 3 liters of a protein-rich fluid per day may leak out into the extracellular space. The
15
lymphatic system filters this fluid (known as lymphatic fluid) through lymph nodes to trap
16
bacteria, viruses and debris which help the immune system. It travels to places where the
17
circulatory system does not go and provides protection against illness. Part of the job of the
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lymphatic system is to pick up any extra fluid that then gets deposited back into the circulatory
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system. The right side of the head and neck, the right arm and that side of the upper body
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drain into one particular lymphatic vessel known as the right lymphatic duct. The left side of the
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head, neck, left arm, left side of trunk and both legs drain into the left side of the circulatory
22
system through the thoracic duct. Because this network is so extensive through the whole body
23
it, unfortunately, provides excellent routes for cancer cells to migrate to other locations resulting
24
in metastases of the primary tumor. Typically the cancer cells that loosen from the primary
2
25
tumor will be trapped by the lymph nodes thus becoming a secondary cancer site. This is why
26
lymph nodes are often biopsied or removed as part of cancer treatment.
27
28
29
[Figure 9.1] The Lymphatic System
30
What causes lymphedema
31
Most lymphedema associated with breast cancer is caused by an injured lymphatic system
32
leading to a buildup of protein-rich fluid in the extracellular space typically called lymphatic
33
fluid. This may be referred to as secondary lymphedema because it is cause by a known
34
problem. Primary lymphedema causes are unknown and are usually from birth. There are two
35
main ways in which this occurs.
36
The most common is when parts of the lymphatic system are removed either during
37
diagnosis, staging or during removal of the cancerous tumor and effected lymph nodes. Less
38
commonly, but just as problematic, is an obstruction due to scarring of the lymphatic system
39
which may occur with some treatments such as radiation or from the tumor itself. When the
40
system does not drain the extra fluid, two things occur. First, the fluid that leaked out of the
41
circulatory system is unable to get back in. Secondly, the proteins in the extracellular space
42
cause more fluid to come to that area than what would have normally leaked out.
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The effects of lymphedema
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In breast cancer, an abnormal lymphatic system may cause edema or swelling of the arm,
45
breast, chest wall or neck. The swelling may be extremely large or very minimal. Even if
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lymphedema is kept under good control, there is a lifelong risk of developing a return of
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increased lymphedema.
48
The complications due to lymphedema
49
Untreated lymphedema may result in an increased size of the affected limb or body part and
50
also create several risk factors for other medical problems. Cellulitis, which is a skin infection, is
51
a common complication that left untreated could result in a serious medical condition. The
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protein rich fluid buildup is an excellent place for bacteria to grow. In addition, there may be
53
significant problems such as openings in the skin with leaking wounds and failure of these
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wounds to heal.
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How lymphedema is diagnosed
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The typical diagnosis is made by a physician or lymphedema specialist using girth
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measurements of the affected extremity with a comparison to the unaffected side. If there is
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greater than a 2 cm difference at the measurement sites this is typically considered due to
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lymphedema. There can be normal physiological swelling which makes one side of everyone’s
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body larger than the other side, but there is rarely more than a 2 cm difference. The
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lymphedema specialist should take the measurements from the same location each time during
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an evaluation. If there is an increase of 2 cm from prior measurements this would then be
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considered an exacerbation of the lymphedema.
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New research is emerging about bio-impedance machines that may be used to diagnose
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lymphedema. These machines measure the resistance of an electrical current in the
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extracellular space. The electrical current is not felt during the test. If there is lymphedema this
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electrical current will move faster to the recording site. The advantage of this new technology is
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the ability to diagnose lymphedema prior to the girth size of the arm changing. One of the first
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signs of lymphedema that a patient will notice is heaviness in the arm. A good example to think
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of is the following: if two towels are lying on the floor and one is dry and one is wet, the
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measurement around the towels would be the same, however, when lifting up the two towels the
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one which is wet will feel heavier. This is the same concept that occurs within one's arm. More
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lymph fluid results in a sense of heaviness. Bio-impedance may diagnose lymphedema even
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before the heaviness is noted. Recent studies suggest that early treatment will help contain
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lymphedema.
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There are other potential causes of swelling in the arm that are related to the circulatory
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system. If the veins are not pumping blood well, fluid can back up and cause swelling. One
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potential cause of this would be a blood clot, which needs to be ruled out if suspected. In this
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case the lymphatic system may be removing fluid at its normal rate but there is more fluid than
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the lymphatic system can remove. An analogy would be a sink running over. Either the faucet is
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turned on so much so the sink fills faster than it drains or the faucet is okay, but the drain is
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clogged. Your doctor may request a special test called Lymphoscintigraphy. This involves
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injecting a small amount of radioactive material between the webspace of the fingers. The arm
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is then scanned as the radioactive fluid is absorbed and flows through the lymphatic
85
system. This is the only way to accurately determine whether there is a circulatory system or
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lymphatic system problem.
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The chances of getting lymphedema
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The risk of developing lymphedema is directly related to how much of the lymphatic system is
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damaged either by the cancer itself or the treatment to eradicate it. Almost 80% of all patients
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that develop lymphedema do so within the first 3 years after cancer treatment, however, it has
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been reported to occur as far as 30 years after treatment. All treatments to battle cancer can
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have significant side effects. Therefore it is very important to have a frank conversation with the
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oncologist or breast surgeon to examine the risk versus the benefit of each treatment.
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Cancer has the lowest risk of causing lymphedema. In the past, the biggest risk factor
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was related to the number of lymph nodes removed during surgery. The surgeons now use
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sentinel lymph node biopsy to identify how far the cancer may have spread without need of
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exploring or removing a large portion of the lymphatic system. This has significantly reduced the
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risk of lymphedema in today's treatment.
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During the removal of the tumors and or the lymphatic system the risk increases with
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each lymph node that is removed. The surgeon will report how many lymph nodes were
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removed during the surgery. There are approximately 35 to 45 in the region of the breast and
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armpit. Additionally, radiation causes scarring of all of the vessels that are within the radiation
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field. This may cause obstruction of the lymphatic drainage even if no lymph nodes have been
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removed.
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The National Lymphedema Network (www.lymphnet.org) publishes a position paper on
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risk reduction practices. Most of these recommendations are based on health care provider
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expertise as there is little research or data on this subject. Refer to the website for up-to-date
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recommendations. In general, however, the following guidelines are recommended:
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110
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risk for lymphedema periodically.
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Maintain regular medical checkups to include an evaluation of the arm at
Report any increased size or heaviness in the arm as well as changes in
sensation, color, temperature or skin conditions.
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Maintain a proper diet and body weight. This is critical as a close
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correlation between body weight and lymphedema has been
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demonstrated.
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Proper exercise has been shown to improve lymphedema. CAUTION:
incorrect or unsafe exercise may worsen lymphedema

Use compression garments. Follow the manufacturer's recommendations
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as well as your healthcare provider's instructions. Wear the garment
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during air travel, exercise and extreme exertion.
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Treat all skin infections or cellulitis urgently. More than three episodes of
cellulitis in the year may require the use of preventive antibiotics.

Appropriate skin care is extremely important.

Use regular moisturizer to maintain good skin health and avoid
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skin breakdown and cracking, especially during dry or cold
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weather..
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When you go outside, wear protective clothing as well as bug
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repellent and sunscreen on exposed skin. Avoid trauma to the
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affected area.
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Wear gloves when performing any activity that can injure the skin
(such as gardening).
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Burns, broken bones or any kind of trauma may increase the risk
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of lymphedema.
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It is recommended regular venous puncture blood draws and
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blood pressure readings should not be done on the affected side
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if it all possible. However, in an emergency situation use that
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arm if needed.
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139
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Avoid wearing constrictive clothing, this may cause additional
swelling.

Avoid extreme heat and cold temperature.
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There is considerable controversy among healthcare
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providers relating to heat and cold
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recommendations. Specifically, these concern the use of
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saunas and hot tubs. If one feels the need to get into a hot
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tub, do not submerge the affected limb.
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Running hot water over the affected limb in a shower is
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allowed, however, it is not recommend to let do not let hot
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water run over the arm long enough for it to turn red.
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150
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Your healthcare provider managing the lymphedema should be
contacted before any surgery on the affected limb.
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Air travel: There is an increased risk of developing or making
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lymphedema worse while flying. The low pressure in the airplane
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cabin promotes swelling. In addition, the flow of lymph fluid slows
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down during the flight which can contribute to increased
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swelling. Moving the arm frequently can reduce this
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risk. Regardless of other risk factors, it is recommended to wear
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a compression garment (Figure 9.2). It should be placed on your
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arm at least 30 minutes before the flight. The compression
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garment should remain on after the flight for 1 to 3 hours based on
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the length the flight. The rule of thumb is 1 hour of wearing for up
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to 2 hours of flying time, 2 hours of wearing for 3-5 hours of flying
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time and 3 hours of wearing for any flight over 5 hours.
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SECTION II: TREATMENT OPTIONS
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Overview
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There are many effective treatments for lymphedema such as manual lymphatic drainage,
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multilayer bandages, vasopneumatic sequential gradient pumps, compression garments and
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exercise.
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lymphedema. However, several treatments in combination are even more helpful. When these
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treatments are combined together, it is called Complete Decongestive Therapy (CDT.) The
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individual components of CDT are described below.
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Manual lymphatic drainage
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Manual lymphatic drainage (MLD) is a light massage that helps to decongest an area and move
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lymph fluid to healthy lymph vessels. MLD should be performed by a lymphedema specialist
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who has received specialized training and certification. The arm is placed in a relaxed position
Each of these treatments alone has been shown to be helpful to combat
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while the specialist begins to drain proximal (closest to the shoulder) to distal (closest to the
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hand). The massage strokes are performed to facilitate the movement of tissue fluid and
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stimulate lymph nodes. Patients can be taught by the lymphedema specialist how to perform the
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manual lymphatic drainage at home. Home maintenance of MLD will help to maintain the results
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achieved in the clinic.
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When performing MLD, It is important to avoid deep pressure to minimize the risk of a
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backflow of fluid which can damage lymph vessels. Extra care should be taken when performing
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MLD near radiated tissue to avoid further skin injury. Manual lymphatic drainage should be
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performed prior to multilayer bandaging or to the vasopneumatic sequential gradient pump
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treatment.
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Multilayer bandages
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Multilayer bandages (MLB) are a special type of short stretch bandages which are distinct from
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typical ace-wrap bandaging. They are applied to the arm to assist with re-absorption of lymph
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fluid and provide external support to the arm. A pressure gradient (tighter at the distal end and
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looser at the proximal end) is created to facilitate a flow of fluid up the arm. The lymphatic
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channels will begin to transport fluid away from the congested area. MLB will assist in breaking
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up fibrosis or hardening areas of skin. MLB are wrapped along the arm to form a cone shape,
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with greater pressure distal than proximal. The lymphedema specialist will inspect the skin prior
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to applying the MLB for any breaks in the skin, infections, discolorations or increase in swelling
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in the arm. Multilayer bandages will affect tissue texture changes which will reduce the size of
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the arm.
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Guidelines for multilayer bandages include:
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Apply at the end of therapy treatment.
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Don’t re-apply if they become undone between treatment sessions.
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Continue to participate in activities of daily living with bandaging on.
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If bandaging becomes too tight, remove outer most layers one at a time
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until relief is experienced instead of removing entire wrap.
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Keep bandaging dry.
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Be aware of bandaging located around hand region when cooking with an
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open flame.
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The goal is to wear bandaging for 24 hours. A caregiver can be trained by a
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lymphedema specialist how to apply MLB for home maintenance. Typically, a patient with
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congestive heart failure should not have MLB applied unless cleared by a cardiologist.
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Vasopneumatic sequential gradient pump
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The vasopneumatic sequential gradient pump is a mechanical device sometimes used in
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conjunction with MLB, and/or MLD, education and skin care. The pump is designed to move
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fluid from the distal to the proximal arm. The, amount of pressure is usually pre-set on home
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units at 30-40 mmHg. The treatment time should not be greater than 60 minutes per
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session. The lymphedema specialist will place the arm in a sleeve and the flow of intermittent
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air will move through multiple chambers causing a sequential squeezing effect. Conscientious
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use of a home pump is critical for the reduction and long term maintenance of arm swelling..
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Patients with congestive heart failure or kidney problems should not receive pump therapy to
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avoid pushing extra fluid to the heart and kidney which has impaired function. There are many
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types of vasopneumatic sequential gradient pumps on the market. The lymphedema specialist
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will help decide which machine is best to use which may also include a consideration of the cost
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and
how
much
is
covered
by
insurance.
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[Figure 9.2] Home compression pump. Copyright Lymphapress, reprinted with permission
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Compression garments
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After a lymphedema specialist provides the first phase of lymphedema treatment (discussed
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above), a compression garment will need to be worn to maintain these improvements. A
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compression sleeve provides external pressure and is worn during the day to maintain reduction
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of lymphedema received in treatment. Compression garments are not worn to reduce swelling,
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but to maintain the swelling reduced by other treatments. The garments are designed to have
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greater pressure distally than proximally and to be worn in compliance with the lymphedema
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specialist’s recommendations. The pressure in the sleeve is based on the amount of swelling in
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the arm: the pressure for mild swelling should be 20-30 mmHg, mild-moderate 30-40 mmHg,
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mod-severe 40-50 mmHg. For hand swelling, a gauntlet (a glove without fingers) can be worn.
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For breast edema and fibrosis, a compression bra is useful fibrosis and breast edema. Custom
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compression garments can be measured by a garment fitter when the size of the arm is too
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large for a Pre-Fabricated sleeve.
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It is important to wear compression garments during the day when doing regular
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activities and exercising. The lymphedema specialist may also recommend a night time
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compression garment while sleeping. There are many different brands of these garments
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available. As discussed earlier, it is highly recommended to wear a compression sleeve and
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gauntlet while flying.
241
Guidelines for the compression garments:
242

They typically last for 6 months before needing to be replaced.
243

Hand wash and air dry instead of putting in the washing machine and
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dryer.

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When experiencing difficulty adjusting to the garment, start by wearing it
246
two hours the first day, four hours the second day and six hours the third
247
day, etc.

248
249
Any time there is increased swelling and or pain the lymphedema
specialist should be contacted immediately.
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Exercise
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It is essential for breast cancer patients with lymphedema to participate in some form of physical
252
activity to enhance lymph flow and maximize their quality of life. Muscles and joints can often
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become stiff and hard to move after surgery or radiation. Exercise encourages a pumping
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action of muscles to stimulate lymph fluid to flow. The lymphedema specialist will recommend a
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specific exercise regimen based on individual impairments. There are three types of exercise:
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flexibility, strength and aerobic (cardiovascular exercise). If pain is experienced during any of
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these types of exercise, the exercise should be stopped immediately and the lymphedema
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specialist should be notified.
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Flexibility exercises consist of gentle stretches and range of motion which can be
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performed postoperative Day 1. Deep breathing should be performed in conjunction with
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flexibility exercises. MLB or a compression garment worn during exercise will support the arm,
262
serve as a protective measure and help to decrease swelling. It is important to follow the
263
exercise guidelines provided by the lymphedema specialist and progress gradually to avoid
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overuse of the arm. Flexibility exercises can help with scar management, increase range of
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motion and prevent joint tightness. These exercises are performed slowly to allow muscles to
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stretch over a period of time.
267
Strengthening exercises are integral to rehabilitation management by providing physical
268
and emotional benefits. Muscle contractions help promote the flow of lymphatic fluid out of the
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swollen region. It is important to gradually increase repetitions and resistance over a period of
270
time. Various equipment can be used safely to strengthen muscles in the arm including
271
dumbbells, weight machines, theraband and swimming (pool should be cool temperature) used
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Some exercise principles consist of:
273

Exercise daily to achieve full symmetrical movement of the arm.
274

Deep breathing for relaxation and to increase venous blood and lymph fluid
275
return to the heart.
276

When using weights, begin with less than 10 pounds for the first six weeks.
277

Don’t wrap cuff weights on the arm.
278

Increase the amount of weight lifted at gradual intervals, as tolerated. Weight
279
lifting should never be more than “a little bit difficult”.
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For aerobic exercise to be effective, it is recommended that the heart rate should reach
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60—70% of the maximal heart rate. A person’s maximal heart rate is calculated by taking 220
282
minus their age. Some examples of aerobic exercise include; jogging, walking, cycling and
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swimming. These activities will help maintain your weight, improve endurance and
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cardiovascular fitness. It is important to drink plenty of water and take rest breaks while
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exercising. While performing aerobic exercise, the intensity, speed and duration should not be
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increased at the same time. Bowling, tennis and golf should be discussed with the lymphedema
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specialist prior to returning to these activities due to the repetitive movements and stress on the
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arm.
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Deep Breathing exercises
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Breathing deeply is a great contributor to good health. Among its many virtues, it helps get more
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oxygen to all of the tissues and is a great stress reliever. Moreover, deep breathing exercises
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are helpful to stimulate lymphatic pathways to healthy lymph nodes and the circulatory
293
system. This can be accomplished by diaphragmatic or abdominal breathing and lateral
294
expansion.
295

Diaphragmatic breathing is most easily done while lying on one’s back with your hand on
296
the abdomen. Breathe out (exhale) as much of the air as possible while pushing on the
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abdomen with the hand. Next, breathe in (inhale), as much as possible. The hand should
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be pushed up by the abdomen. Once comfortable with the lying position, try the exercise
299
sitting and standing.
300

Lateral expansion is most easily learned when sitting or standing in front of a mirror with
301
one’s hands on each side of the ribs. Exhale using the hands to squeeze in the ribs and
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then inhale, flaring the rib cage so that the hands are pushed outward. Don’t let the
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shoulders rise during this exercise.
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Wellness
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Wellness is your ability to maintain a healthy lifestyle, good nutrition and life-affirming habits. A
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physically fit body decreases musculoskeletal problems, prevents strain on the affected arm and
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reduces the chances of getting lymphedema. Gradual conditioning of the body is
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best. Maintaining an ideal body weight is important to control obesity which increases the risk of
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lymphedema. Lifestyle changes consist of minimizing alcohol, caffeine, unhealthy and salty
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foods. Smoking can cause serious health issues for breast cancer patients; therefore quitting is
311
highly encouraged.
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CONCLUSION
313
Everyone’s risk for developing lymphedema is different and therefore the treatments
314
vary. Maintaining a consistent relationship with a lymphedema specialist combined with
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following the guidelines and recommendations in this chapter will help provide decreased risk of
316
developing or making lymphedema worse and provide the best possible treatment outcomes.
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Glossary
318
319
Bio-impedance – a measurement utilizing a small and slow electrical current which records the
time it takes to move through the body or specific tissues.
320
Biopsy – a small piece of tissue taken from the body for diagnostic purposes.
321
CDT – an abbreviation for Complete Decongestive Therapy.
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Cellulitis – a bacterial infection of the skin and subcutaneous tissue.
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Distal – near the end of a limb or body part such as an arm.
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Edema – a term for swelling of any type.
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Extracellular space – the space outside of the cells and the circulatory system.
326
Fibrosis –connective tissue that loses its normal elastic properties and becomes hardened..
327
Gradient – going from a lower pressure area to one of higher pressure or vice versus.
328
Gauntlet – a glove like garment without the fingers that only covers the hand.
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Interstitial space – same as extracellular space.
330
331
Lymph node – a place where several lymph vessels join together. These nodes contain lymph
tissue which support the immune system.
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333
Lymphedema – involves blockage of the lymph vessels, with a resulting accumulation of
lymphatic fluid in the interstitial tissues of the body.
334
335
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Lymphoscintigraphy – a test done in a Nuclear Medicine Department where a radio-active
isotope is injected and then followed under a scanner as the isotope moves through the
lymphatic system.
337
MLD – is an abbreviation for manual lymphatic drainage
338
mmHg– is an abbreviation for “millimeters of Mercury” , a measurement unit for pressure.
339
MLB – is an abbreviation for multilayer bandages
340
Physiological swelling – swelling that normally occurs and is not considered a problem.
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Primary lymphedema – lymphedema that occurs when a person is born with a deficient
lymphatic system. There is no known cause.
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Primary tumor – the site of the original tumor. Proximal-- near the beginning of a body part such
as an arm.
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Secondary lymphedema – lymphedema that occurs after the lymphatic system was working
normally. This may be due to trauma or illness .
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350
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Sentinel lymph node – the first lymphnode in a branch of lymphnodes. Biopsies are often done
on this node as if it is clean than all that drain into it are considered cancer free.
Vasopneumatic sequential gradient pump – a pump that causes pressure starting at one end
and slowly moves it in a particular direction.
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Symptom Index
353
Hardness
354
Heaviness
355
Leaking
356
Opening
357
Redness
358
Stiffness
359
Swelling
360
Weeping
361
Wound
362
[Figure 9-1] The Lymphatic System
363
[Figure 9-2] Home compression pump. Copyright Lymphapress, reprinted with permission