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Risk Reduction in the News – Response from the NLN Medical Advisory Committee
2012 Conference featured in Oncology Times
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NLN Position Papers: Risk Reduction, Risk Reduction Summary, Diagnosis and Treatment, Exercise, Training, Breast Cancer-Related Lymphedema, Supplement BC-Related LE
Q: Is it true that stress aggravates lymphedema?
A: Stress is the plague of our modern, fast-track world. The state of being "stressed out" is an all too common complaint of adults and, more recently, children and teens. Too much to do in not enough time, the increasing demands of 10- and 12-hour workdays while still trying to maintain a balanced life, handling the discomfort of being a child that does not "fit in" - these are just a few of the many causes of stress.
A number of studies have been done highlighting the negative effects of stress on the major organ systems - blood pressure, heart rate, blood vessel dilation/constriction, increased sympathetic nervous system stimulation triggering the "fight or flight" response, changes in respiration, muscle tone, etc. All of the above directly or indirectly influence the function of the lymphatic system. Gentle, rhythmic, reciprocal exercises enhance the pumping of the lymphatics. Muscle tension/spasm will block or impede lymph flow, thereby increasing lymphedema. Deep abdominal breathing exercises are crucial to enhance the flow of fluid through the thoracic duct and back into the central circulatory system. Shallow, irregular breathing or holding one's breath when anxious or upset will impair that flow. All this is assuming that you have the time to actually do your exercise and skin care program, if pressed for time and feeling overwhelmed. In times of stress, the things that usually suffer the most are rest, diet, proper exercise and self-care activities such as skin care and self-massage. Unfortunately, without proper attention to these activities, the individual with lymphedema will, most likely, experience an exacerbation of their lymphedema. Try to make every effort to maintain your self-care activities, asking for help when needed. Sometimes, you just have to say "no" to some things in order to avoid a downward spiral of decreasing self-care, increasing lymphedema and eventual inability to continue one's daily activities. This may necessitate a gradual lifestyle adjustment. Of course, there are always emergency situations that leave you with no choice. In that event, try to prioritize your individual self-care program to insure that the essential steps are still possible, even in the event of an emergency.
Q: I have swelling in both legs from cancer surgery. I always had large thighs and have great difficulty keeping up my bandages. I am aware of the great benefits of walking with the bandages on, but am embarrassed when they fall down to my ankles. Any suggestions would be wonderful.
A: You are not alone! I am certain that many people (both men and women) reading this question are so happy that you brought it up. It is a challenge and there are many ways to look at this problem. The most positive is that if your bandages fall down after prolonged walking, maybe you are reducing your legs so much that it is causing the slippage! If that is not the case and they are slipping right away, you may want to try several things:
Good luck and hope this helps.
Q: I am a compliant patient and follow all instructions from my therapist, but am terribly frustrated. Two months ago, I had a lumpectomy followed by radiation. Two weeks later, my hand became swollen. I was taught how to do self-manual lymphatic drainage and bandaging, and I wear my sleeve and glove every day. My arm is doing well, but the back of my hand is very stubborn. Often it looks like a pin cushion. Please help me.
A: You are fortunate to have had early intervention with your lymphedema. However, lymphedema of the hand is often difficult to reduce and finding a compression sleeve and glove combination that works can be tricky. You do not say how your hand responds after being bandaged at night. If it is flat/flatter in the morning, then you might need to look at the sleeve and glove you are wearing during the day and ask your therapist for some suggestions regarding alternative garments - maybe a different compression class or higher gram-strength (lower-stretch) fabric. I prefer custom garments to ready-made, particularly for the hand. Individual contours can be fitted better, achieving a more even compression gradient and minimizing back flow into the hand.
Perhaps a review of your self-manual lymphatic drainage and bandaging is in order, as well; check that you are being careful not to increase layers/pressure at the wrist or forearm which could force fluid back into the hand. If you have not had an intensive course of CDP/CPT/CLT to reduce your lymphedema, but have only been instructed in self-massage and bandaging and see no improvement in your hand, perhaps you should consider a course of treatment.
Also, do you have a dense foam "chip pad" for the back of your hand that you can bandage over at night? My patients find these very helpful to soften that area and help break through new tissue channels, increasing lymph flow through the hand. There is also a company with a line of products called Legacy that makes a glove of sturdy cotton material with foam chips sewn between the layers of fabric. The glove is shaped like an oven mitt with webbed fingers and is comfortable to wear at night with a compression bandage wrapped over it. Try not to become frustrated; there is no single easy answer and it may take a combination of things to improve your hand. Take it one step at a time so you can evaluate what improves the hand.
Q: My skin is very dry. I have used many different creams and lotions to keep the skin soft and supple, but it does not last very long and I worry about infections. Any suggestions? Also, does the chlorine in swimming pools affect lymphedema? My legs feel much better after I come out of the pool, but I worry about the chlorine. Thank you.
A: My first question is, what kind of soap do you use? A cleansing lotion (not soap) such as Cetaphyl, or a mild soap, such as Dove unscented or glycerin soaps, are better choices than antibacterial or deodorant soaps that have too high of a pH (too alkaline). The acidic pH of our skin acts as a natural waterproof barrier that helps protect our skin. The stronger soaps are more alkaline and will destroy the acidic pH, leaving the skin more prone to infection and injury. Fragrant "body washes" that are applied with a "buff puff" can dry the skin too. Also, minimize your shower/bath time and keep water temperature moderately warm (sorry, not hot!). Be sure to change your compression garments after 12 hours of wear, wash them inside out and rinse them well. This is very important, as is moisturizing the skin before you put on your garments.
Many of my patients swim in pools with no ill effect to their skin from the chlorine, and I have not seen any documentation reporting skin damage from chlorine diluted in a pool. Swimming is actually the best exercise for lymphedema, so go for it! Just remember to rinse the chlorine from your body thoroughly after your swim and moisturize your limbs as soon as possible after leaving the pool. One last thought: sometimes fungal infection of the toes and feet causes excessive dryness and scaling of the skin. Make sure that this is not a part of the problem. Your physician may be able to prescribe some anti-fungal creme, or a prescription moisturizer like Lac-Hydrin, that may improve your skin.
Please address questions to: Editor c/o NLN, 116 New Montgomery Street, Suite 235, San Francisco, CA 94105 or e-mail: nln@lymphnet.org. Deadline for submissions is first day of the month prior to publication.
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