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1. Rehabilitation of lymphedema By Dr. Mostafa Ahmed Lecturer at faculty of physical therapy

2. Lymphedema Is a condition in which protein-rich fluid accumulates in the tissues due to a failure of the lymphatic system. In cancer care it is most often associated with lymph node dissection and radiation therapy to lymph nodes. It can develop at any time between a few months and up to twenty years after treatment.

3. It is one of the most significant long-term complications following surgery for breast cancer. discomfort, a decrease in the functional ability of the arm, cosmetic disfigurement, and can lead to cellulitis, lymphangitis, and lymphangiosarcoma.

4. The physiology of lymph drainage: The lymph system is a one-way drainage route designed to rid the "tissues" of unwanted material and excess fluid. Two types of lymphatic vessel exist: first, the lymphatic, capillary and the larger precollector vessel, and, second, the collecting lymphatics vessels into which the precollectors drain. The collecting lymphatics are the main limb lymphatic vessels that provide the afferent flow to the lymph nodes. They behave like a series of smooth muscle hearts that are responsible mainly for the propulsion of lymph centripetally.

5. Causes of lymph drainage failure: The etiologic factors implicated in the development of lymphedema are reported as chronic insufficiency of lymphatic drainage as a result of blockage of lymphatic trunks, compression or obstruction of the lymphatic trunks , compression or obstruction of the lymphatics by neoplasm , inflammatory or scar tissue insufficient muscle contraction and prolonged dependency of the extremity Incidence

6. Incidence is defined as the number of new cases of a disease occurring in the population during a specified period of time Although lymphedema of the upper extremity has been identified by women experiencing it as one of the most distressing long-term consequences of breast cancer treatment. There are inadequate data about the incidence of lymphedema or about the like hood of mild, moderate, or sever lymphedema The overall reported incidence of postmastectomy lymphedema ranges from a low of 5.5% to high of 80%..

7. Most patients appear to have some degree of swelling following radical mastectomy , especially in the early postoperative period, when a 2 cm discrepancy between extremities may be inevitable. Patients who receive postoperative radiation therapy appear to have a higher incidence of lymphedema than do nonradiated mastectomy patient.

8. Types Lymphedema is lymphedema, associated with developmental abnormalities of lymphatic system , may be manifested in neonates ( congenital ), adolescents ( praecox ), or patients older than 35 years ( tarda ). The most common form of lymphedema is secondary lymphedema. This usually occurs after oncologic surgery or radiation therapy.

9. Degree The degree of lymphedema can be categorized as either mild, moderate, or severe depending of actual swelling present.

10. Tracy Classification: Absolute Volume Insignificant 0-150 ml > normal extremity Slight 150-400 ml > normal extremity Moderate 400-700 ml > normal extremity Severe More than 750 ml > normal extremity

11. Stillwell Classification : Percentage-Based Criteria Insignificant 0%-10% ml > normal arm Slight 11%-20% ml > normal arm Moderate 21%-40% ml > normal arm Marked 41%-80% ml > normal arm Severe More than 80% ml > normal arm

12. Complications: Full joint range of motion about the elbow, wrist, and hand requires distensible sub cutaneous tissue about the joint. With increasing lymphedema, this capacity of subcutaneous tissue to distend is lost and movements of the joints in the involved area become stiff and their overall range decrease .

13. Joint range of motion is also negatively affected by the shear increase in the mass . This lost range, coupled with the increased fluid tension in the subcutaneous tissue , can cause symptoms ranging from discomfort to outright pain in the lymphedematous arm. The decreased range and the pain can affect arm use in functional activities of self-care and work.

14. Signs and symptoms : The most consistently described ways in which women noticed a problem related to size were: swelling, sometimes involving the whole upper extremity and sometimes limited to the hand of fingers. 2) Watches, rings, bracelets, or clothing becoming too tight on one side Puffiness, Difficulty in seeing knuckles or veins on one side Noticing that one upper extremity was larger than the other upper extremity, Pain and changes in tissue texture . 7) Changes in the size may occur gradually or suddenly.

15. Table (1). Symptoms of lymphedema

16. Methods to assess lymphedema are: Volumetric measurements To measure the volume of the entire arm, the same upper extremity was then lowered into the volumeter with the elbow straight , and the palm and volar surface of the arm held flush against the inside of the cylinder. Once the subject's arm was sufficiently lowered so that the water level reached 15 cm proximal to the lateral epicondyle , the arm was held there until water flowed at rate of less than 1 drop per second. The arm was then removed and dried.

17. Circumferential measurements Were taken at the center of the ulnar styloid process, and every 3 cm along the length of the upper extremity, ending 15 cm proximal to the lateral epicondyle . Calculating volume, An indirect method which was used to calculate limb volume, is called the frustum sign method. In this calculation, the limb is visualized to be in the shape of a truncated cone. The circumference of the extremity at the proximal and distal limits of the segment, together with the length between them, are used to calculated the volume of the segment By using the following formula = 1/12 x h (C2 +Cc +c2), where V =volume, h = height, C= proximal circumference, and c = distal circumference.

18. Fig (1). upper and lower limbs measurements .

19. Fig (2) volumetric measures.

20. Physical therapy to prevent and control postmastectomy lymphedema: On the 1" day) postoperatively: (a) Application of an arm band on the involved side with instructions to avoid taking blood pressure, administrating injections, Ivs or withdrawing blood from that arm. (b) Review of hand and arm care to prevent infection and minimize edema . (c) Instructions in elevation and proper positioning, with the shoulder at 65 ° of flexion, 45° to 65° of abduction , 45° to 65° of internal rotation , and the forearm resting on a pillow . (d) Gentle, active hand and elbow range of motion. (e) Activities of daily living.

21. The following measures should be of help in the prevention and reduction of edema in the upper extremity after mastectomy: Avoidance of dependent positioning as much as possible. 2. Elevation of the arm above the level of the heart during rest as much as possible, but not with the shoulder widely abducted . 3. Isometric contraction of the upper extremity muscles with the arm elevated . 4. Avoidance of excessive use of the limb, particularly in a warm environment . 5. Avoidance of injury to the limb . 6. Decongestive milking massage to decrease edema (infection must be eliminated before this). 7. Use of a pneumatic pumping device. 8. Use of elasticized bandaging (to inhibit redevelopment of the swelling between treatments while the edema is being diminished) and of custom- made elastic sleeve to maintain improvement after the condition has stabilized

22. Management of Lymphedema:

23. Compression therapy : Compression therapy is considered a key component of the CDT, both in reducing the limb volume during Phase I and in helping to control the condition during Phase II. Compression helps to resolve lymphoedema by reducing capillary filtration , increasing lymphatic flow , shifting fluid to uncompressed fields , and breaking down fibrosclerotic tissue.

24. Multilayer low stretch bandages can be left on the affected field overnight for 24 hours in Phase I . One layer bandage is applied during the day only in Phase II . The multilayer lymphoedema bandaging consists of a single protection layer of cotton tubular bandage next to the skin and a soft synthetic wool or foam under-padding. Short stretch bandages have a high working pressure and compressive forces are maximal when the underlying muscles contract.

25. In Phase II , various compression garments and bandages can be utilized. Compression garments and bandages are categorized according to the type of fabric they are manufactured from. The severity of lymphoedema determines the grade of compression needed from the garment (I–IV grades). Phase I can last between two and eight weeks , depending on how long it takes to reduce swelling and improve any other symptoms. 

26. They can be custom-fit or purchased over the counter in standard sizes. It is important to use the low pressure-short stretch bandages instead of higher pressure-long bandages , leading to the collapse of lymphatics due to excessive compression. Custom-knitted garments offer greater support and are recommended in advanced lymphedema.

27. The requirement for custom garments must be determined individually; general indications include irregular limb contour and extensive fibrosis . Compression garments should be replaced every 6 months.

28. Compression bandaging and compression garments demonstrate effectiveness in various stages of the treatment of lymphoedema . There are only a few studies directly comparing the effectiveness of these two compression tools.

29. Compression bandaging can result in greater volumetric effect in the initial treatment phase , but compression garments can result in fewer symptoms and better functional status .

30. 2)Intermittent pneumatic compression: (IPC) IPC therapy is widely used in the treatment of lymphoedema as an adjunct to CDT. It is particularly useful in cases that are treated with passive physical therapy (i.e., elderly patients , immobile patients , and patients with serious disabilities ) in whom spontaneous/isotonic physical exercise is compromised or not possible. The inflation and deflation of IPC requires pressure that mimics the action of the muscle pump, which is an important mechanism in lymph transport. IPC reduces lymphoedema by decreasing capillary filtration and lymph formation .

31. However, nowadays, the use of IPC with pump devices is controversial due to its adverse effects . These devices extract water from the interstitial space with the help of pressure, but the proteins remain on the same field. Although oedema reduces after application, it can reappear or increase further because the residual proteins in the interstitial space retract the water . Another adverse effect is that it damages lymphatic structures when it is applied with high pressure .

32. The most suitable patients for IPC treatment are those who finish phase 1 of CDT but still have oedema or patients with oedema due to venous insufficiency. In selected patients, the use of IPC may provide an acceptable home-based treatment modality . Nowadays, specialised lymphatic pump devices that work with a much lower pressures and slower sequences have been developed, which are compared with widely used venous or less commonly used arterial pumps. These new generation pump devices may be more beneficial for patients with lymphoedema without adverse effects.

33. Fig (3).upper and lower limb garments

34. Fig (4).pneumatic therapy

35. 3) Massage and physical therapies: Complex physical therapy, also called complex decongestive physiotherapy, Complex physical therapy, also called complex decongestive physiotherapy, is a treatment regimen that includes : meticulous skin hygiene, manual lymph drainage, bandaging, Exercises and support garments.

36. Manual lymphatic drainage (MLD) Manual lymphatic drainage is not the same as massage ; it consists of intermittent , gentle pressure applied directly on the skin to stretch the very small initial lymphatics , increasing lymphatic vessel contraction , and lymph drainage of the affected field . It has four essential hand strokes which must be circular or spiral in character and with a slow frequency .

37. The central fields are treated first , and then the drainage continues peripherally . A session of MLD begins centrally at the neck and the trunk to clear out the main lymphatic pathways . MLD takes 45 – 60 minutes and is applied in a descending manner to facilitate the flow of lymph from affected areas to those that are not affected. It has been shown to stimulate lympholymphatic and lymphovenous anastomoses .

38. The results of numerous studies demonstrated the value of MLD when combined with compression in the treatment of lymphoedema . These results did not support using MLD alone for the aim of limb volume reduction independent from the CDT. However, in a systematic review, it was reported that MLD alone contributed to an improvement in self-reported symptoms when used in the palliative care setting.

39. Exercise is one of the fundamental components of care for patients with lymphoedema. Exercise increases the activity of muscle pump to encourage venous and lymphatic drainage in addition to maintaining or improving a range of movement. The group activity is being increasingly used to assist with compliance, motivation and to increase self-esteem. Exercise programs such as healthy steps and yoga have proven successful for patients with lymphoedema , improving their quality of life.

40. 4) Other physical therapy modalities: Other physical therapy modalities, such as laser treatment, electrical stimulation, transcutaneous electrical nerve stimulation (TENS), cryotherapy, microwave therapy and thermal therapy, have been used for lymphedema in breast cancer patients However, these modalities need further, rigorous evaluation before recommendations can be made. Therapeutic ultrasound should not be used over areas of active or potential breast cancer metastases, such as the hips , lumbar area, ribs , chest wall or axilla .

41. 5) Pain management: Pain and discomfort associated with lymphedema are common and should be managed primarily by controlling the lymphedema. Refractory pain can be managed with non-narcotic and narcotic analgesics, with the use of adjuvant analgesics (e.g., tricyclic antidepressants, corticosteroids, anticonvulsants or local anesthetics) when necessary. Aggravating conditions, such as infection and recurrence of cancer in the axillary lymph nodes or brachial plexus, should be looked for and treated.