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April-June 2013: Cording


Lymphlink Question Corner - Archived From April-June 2013

By:  Jodi Winicour, PT, CMT, CLT-LANA Klose Training and Consulting, Lafayette, CO

Q: What is the “popping” that I hear during the course of stretching or soft tissue mobilization for the treatment of axillary webbing?

A: This is an excellent question. Honestly, there is no definitive answer, but in my opinion there are two possibilities:

One possibility is that the popping sound is the fibrotic lymphatic vessel “unsticking” itself from the surrounding fatty tissues it is adhered to.  You may have noticed that even in thin women, the cords create a “cellulite” appearance of the arm when they are placed on stretch. This “cellulite” appearance of the fatty tissues instantly resolves when a release is heard, which results in immediate improvement of movement and pain.

Another possibility is that the fibrotic lymphatic vessel actually tears during a stretch or soft tissue technique. I compare this to pulling hard enough on a thread to break it. Gentle techniques that avoid pain and inflammation during treatment are advised to try to prevent “popping” during soft tissue techniques and stretching. 

Q: Why is using moist heat on a cord suggested for some patients? I thought that we should never use heat on someone who is at risk for lymphedema, isn’t that right? Can’t we trigger lymphedema by adding heat to an at risk limb?

A: You are correct to be concerned that too much heat can influence fluid dynamics negatively in an affected limb through the process of active hyperemia, but the other side of the coin is that it can also be very helpful. Moist heat is only prescribed on 2 specific occasions:

The cording is so acutely painful that providing therapy is not possible. In these cases, I recommend the application of a moist heat pad for 5-10 minutes directly on the painful cord before therapy begins and several other times throughout the day at home to decrease pain and inflammation. The heat improves the elasticity of the cords and the surrounding tissues and decreases tissue adherence so that the patient can tolerate gentle soft tissue mobilization and stretching. It is important to note that the duration and intensity of the heat is limited and the region of erythema is localized. Applying heat to the axillary region is generally not recommended due to the reduced sensation that is common after axillary surgery.

Phlebitic cording of the forearm is causing a localized pain and pitting edema of the anterior/medial forearm due to inflammation of the veins in this region. Although counterintuitive, the application of heat to this area improves blood flow out of the limb by decreasing the inflammation of the veins, which decreases the lymphatic load and reduces the edema. Some physicians may prescribe NSAIDS several times/day in addition to moist heat.  Generally, this local edema and pain caused by the phlebitis cord will resolve within 2 weeks in most cases.  The application of heat to the at risk/lymphedematous limb remains controversial and is recommended on a case-by-case basis.

Q: But doesn’t the risk of triggering lymphedema outweigh the benefits of the heat?

A: This certainly is a concern, but consider that ruling out an almost exclusively safe and effective treatment that is prescribed on a case by case basis does not serve our patient population well. The NLN precautions guidelines are becoming more and more patient specific as our specialty moves into a more individualized care philosophy. I encourage you to try moist heat, when appropriate, for acutely painful AWS and phlebitis cording.

In the unlikely event of an exacerbation of edema due to heat application, discontinue the heat and initiate your CDT treatments, as needed.