Lymphedema is an accumulation of protein-rich lymphatic fluid in the tissues that contributes to swelling. Lymphedema occurs most frequently when lymph nodes are removed or damaged due to cancer surgery.
There are three stages of lymphedema. In stage 1, lymph fluid begins to fill in the interstitium, and with treatment it can be reversed with elevation. Stage 2 involves the development of fibrotic tissues with skin changes and is not easily reversed. Stage 3 is known as “elephantiasis” with severe thickening of the tissues, papillomatosis and nail mycosis.
Signs and symptoms of lymphedema include swelling, heaviness, achiness, fatigue, numbness and tingling of the extremity. Venous insufficiency and obesity can contribute to lymphedema.
Treatment of lymphedema should be performed by a certified lymphedema therapist. The therapist will perform a comprehensive evaluation of upper- or lower-extremity range of motion, strength and quality of edema (pitting vs. non-pitting), girth measurements, skin inspection to assess scars and temperature,lo sensation testing, Stemmer’s sign (a test to identify lymphedema) and evaluation of posture and functional limitations.
Treatment will include manual lymphatic drainage – light massage to decongest the extremity and direct lymphatic fluid toward healthy lymph nodes. For example, when treating a breast cancer patient, the arm is placed in a relaxed position while the lymphedema specialist drains fluid from proximal (closest to the shoulder) to distal (closest to the hand). Patients can be taught to perform manual lymphatic drainage at home.
Multilayer bandages are short-stretch bandages that are different than typical compression bandaging. They are applied to the upper or lower extremity to assist with re-absorption of lymph fluid and to provide external support. These bandages can break up fibrosis or hardening areas of the skin. Patients are advised to wear the multilayered bandages for 24 hours, then remove them to wash the skin and apply moisturizer.
Physical activity, flexibility, range-of-motion and strengthening exercises are prescribed to contract muscles to stimulate lymph flow into the circulatory system. Strengthening exercises are integral to rehabilitation management, providing physical and emotional benefits.
A vasopneumatic sequential pump is a mechanical device sometimes used in conjunction with treatment. The pump is designed to move fluid from distal to proximal.
Patients with congestive heart failure and kidney problems should receive medical clearance prior to pump therapy to avoid pushing extra fluid to the heart and kidneys, which could impair function. The lymphedema specialist may educate the patient on skin care, the importance of avoiding excessive exposure to the sun and heat, not having blood pressure taken on the affected arm and the importance of maintaining a proper diet.
Once the lymphedema therapist has completed the treatment, a compression garment can be ordered to provide external pressure. It is worn during the day to maintain reduction of lymphedema. The garments are designed to have greater pressure distally vs. proximally.
SEE ALSO: Decongestive Therapy for Wound Healing
New compression garments must be ordered every six months. Some insurance plans will cover the cost of garments (a patient will need to verify insurance benefits). Treatment for lymphedema is individualized and can last several months, depending on the stage. If left untreated, complications can arise, such as infections, loss of mobility, pain, cosmetic problems and ulcers.
The MedStar Program
The Cancer Rehabilitation Program at MedStar National Rehabilitation Network was established 10 years ago. The program consists of a multidisciplinary team approach under the leadership of physiatrist Eric Wisotzky, MD, as well as surgeons, medical oncologists, radiation oncologists, pain management specialists, nurses, physical and occupational therapists, speech-language pathologists, dietitians and patient navigators.
The MedStar NRH Rehabilitation Network has outpatient facilities in Washington D.C., Maryland, Northern Virginia and Delaware. The oncology rehabilitation physical therapy specialist receives referrals from physiatrists, surgeons, medical oncologists, radiation oncologists, primary care physicians and nurse practitioners for lymphedema treatment and oncology rehabilitation.
Many patients are treated for upper- and lower-extremity lymphedema due to cancer surgeries, radiation and vascular insufficiencies throughout MedStar NRH Network’s outpatient facilities. Patients can be treated for cancer diagnoses such as breast, bronchus, Hodgkin’s lymphoma, bone, gynecological, head and neck, multiple myeloma, gastric, lung, melanoma, colorectal, liver, central nervous system, leukemia, oral, ovarian, sarcoma, thyroid and prostate.
Lymphedema patients are evaluated by physical and occupational therapists. Evaluations include inspection of the skin, limb temperature, pitting edema, color of skin, girth measurements, range of motion, sensation, scar condition, assessment for cording (scarring of lymphatic system), strength and gait and balance with lower-extremity evaluations.
Therapeutic interventions for oncology patients often consist of balance training, endurance training, energy conservation, gait training, manual therapy, pain management, peripheral neuropathy management, modalities, visceral manipulation, adaptive equipment, post-mastectomy management, craniosacral therapy and therapeutic exercise.
Outcomes for upper-extremity lymphedema patients are tracked with the AMPAC-Every Day Activity measure, circumferential measurement sheet, and the QuickDASH. Circumferential measurements are taken with a tape measure 2-3 times weekly. The Neck Disability Scale and temporomandibular measurements are used for head and neck cancer patients. Specific measurements are taken with a tape measure for head and neck lymphedema patients.
The Six-minute Walk Test, Timed Up and Go (TUG) and the Dynamic Gait Index are outcome measures used for cancer patients with fatigue issues. The outcome measures are assessed at initial evaluations, re-evaluations and discharge.
Markers of Success
Physical therapists and speech-language pathologists work closely with head and neck cancer patients. Physical therapists are trained in manual therapy and soft-tissue mobilization techniques to minimize radiation fibrosis, increase extensibility of tissues, and improve jaw and cervical range of motion. This will allow the speech-language pathologist to improve swallowing and communication.
Occupational therapists assist patients with energy conservation and activities of daily living. As endurance improves, physical therapists are able to progress patients with ambulation. Physiatrists and pain management specialists often use injections and medications to mitigate pain.
Patients are prepared for discharge by receiving updated upper- and lower-extremity home exercise programs, written instruction on self-manual lymphatic drainage and compression garments. Some patients may receive a home compression pump to maintain results received in the clinic.
We have developed a Cancer Rehabilitation Fellowship Program for physiatrists, which includes participation in cancer surgeries, medical rounds, research projects, journal clubs and observation of physical and occupational therapy treatment sessions.
Our cancer rehabilitation program has created a cancer fatigue protocol and a cancer rehabilitation course for PTs and OTs. The team collaborated to write Managing Breast Cancer: A Guide to Living Well through Physical Medicine and Rehabilitation. Clinicians perform community outreach for cancer advocacy and lecture about cancer rehabilitation.
Role of Rehab
At MedStar National Rehabilitation Network, cancer rehabilitation is vital to improving function, safety and rehabilitation potential. Best practices and collaborating as a team maximize quality of life.
The role of rehabilitation begins early in the patient’s care to address functional limitations as well as other complications from chemotherapy and radiation. Rehabilitation specialists maximize a patient’s ability to gain endurance and mobility, and improve activities of daily living.
There is no cure for lymphedema, and it is a life-long condition. A multimodal treatment approach by a certified lymphedema therapist can play a significant role to rehabilitate and educate lymphedema patients to improve their quality of life.
Yvonne Francis is physical therapy clinic coordinator at MedStar National Rehabilitation Hospital in Washington, D.C.