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April - June 2015 Q&A - Cancer (Non-breast)-Related Lymphedema

By Laurie Kilmartin, PT, DPT, WCS, CLT-LANA, CSCS
New York University Langone Medical Center, New York, NY

Q: I have had lymphedema in my leg for several years following a surgery for endometrial cancer, which included removing lymph nodes. I want to be more active and start an exercise program to make my legs stronger, but am worried about making the swelling worse. How would I start an exercise program after not exercising for a few years?

A: If you haven’t exercised in a while, it is important to obtain medical clearance before starting an exercise program. Your physician would be able to give you parameters for exercise that are specific to you and your medical needs.

If you have lymphedema, it is important to stay as active as you can and move your swollen limb as normally as possible. Studies have shown that the movement of lymph through the lymph vessels is increased during exercise.1 One of the primary goals of an exercise program for someone with lymphedema is to engage the pumping mechanism of muscles in and around the swollen area to help promote lymphatic circulation. In your case, this would involve not only active movement of the muscles in the leg, but also in the trunk and the rest of the body to promote an overall increase in pumping of the lymph fluid.

Most of the studies on exercise and lymphedema have been with individuals who have lymphedema of the arm following breast cancer. These studies have shown that appropriate exercise and physical activity, including resistance training, do not worsen symptoms of lymphedema in individuals who are already diagnosed with it.2 However, there are few studies that have looked at the effect of exercise on leg lymphedema.3,4

Appropriate exercise for someone with lymphedema would ideally be performed in a safe and conservative manner. Movements of the affected area should be performed throughout the available range of motion at regular intervals throughout the day5 and should not be painful or tiring. Exercise should be progressed slowly and carefully to avoid strain and trauma to the muscles and an exacerbation of swelling. Diaphragmatic breathing is frequently incorporated into an exercise program for an individual with lymphedema, as the deep breathing helps stimulate movement of the lymphatic system.6 You should monitor the leg regularly to ensure that there is no damage to the skin or muscles and choose modes of exercise that will not put you at risk for infection or trauma.

A nice way to start exercising is to begin a daily walking program—either in the gym, the park, or just around the neighborhood. Walking a little bit further and at a slightly faster pace than you normally do can be the first step toward beginning an exercise program. 

A comprehensive exercise program should include the following: strength training, aerobics, and flexibility training. An exercise program for someone with lymphedema should be customized for each individual based on a host of factors including the location of the lymphedema, the stage and type of lymphedema, and co-existing medical conditions. 

Guidance by a trained lymphedema therapist to help design a proper exercise regime and assist with a safe and appropriate progression of exercise is recommended. Compression garments or short-stretch bandages as prescribed by your therapist should be worn during exercise.

Q: I was diagnosed with throat and tonsil cancer, and recently developed lymphedema in my neck after surgery and radiation in the area. My insurance company denied approval for physical therapy visits for treatment of the swelling, stating that there is no evidence to support physical therapy treatment for lymphedema of the neck.  Is this a common condition, and is there anything I can do to get treatment for this problem?

A: Studies have reported that lymphedema is a relatively common condition in patients with head and neck cancer,7,8 however, there is little documented research on this topic. 

Complete decongestive therapy (CDT) is currently recognized as the “gold standard” of treatment for lymphedema in most instances. It includes four components:

  • manual lymphatic drainage: a specialized type of massage that helps to mobilize the lymph fluid out of the swollen and congested areas
  • compression therapy: the application of an external garment or device to help mobilize the lymph fluid out of the tissues and back into the bloodstream. It may include one or more of the following: multi-layer bandages, compression garments, compression pump
  • exercise: uses the pumping mechanism of muscles in and around the affected area to help promote lymphatic circulation, and to help keep the muscles in the area strong and flexible
  • meticulous skin care and hygiene: will help decrease your risk for infection and prevent exacerbation of swelling

Each of these components would be customized to address the particular area of the body that is swollen. A certified lymphedema therapist would be able to assess the area and come up with an individualized treatment strategy to help reduce swelling and educate you on a lymphedema self-management plan. Education and early treatment are recommended to effectively manage this condition.

Evidence in the literature supports the use of CDT for head and neck lymphedema,8,9 and a study by Piso et al10 also provides support for treatment of head and neck edema utilizing two components of CDT (manual lymphatic drainage and compression garments) in early treatment for patients with postoperative head-neck edema following
surgery for orofacial tumors.

A study by Smith & Lewin11 provides a model, based on the available evidence, for evaluation and treatment of patients with lymphedema of the head and neck utilizing a foundation that is based on the traditional methods of CDT.

While there is limited evidence to support the use of CDT as an effective treatment option for head and neck lymphedema, the literature available should be adequate to guide current lymphedema treatment interventions in this population.

Your healthcare team can help you advocate for authorization for physical therapy visits for your condition. Your doctor and your physical therapist can speak with the medical director at your insurance company and educate them about the benefits of CDT for head and neck lymphedema. You can also provide the insurance company with studies that support the effectiveness of physical therapy intervention for this condition. 

Q: I just finished four weeks of physical therapy for lymphedema in my leg, resulting from surgery to remove a melanoma. While my leg is much better and I am happy about the results of my treatment, I am worried that the swelling will get worse and I will not be able to take care of it on my own. What would you recommend to help me manage the swelling at home?

A: Congratulations on the success with your physical therapy treatment to help manage your swelling! At this point, you probably know many of the important aspects of lymphedema treatment and have already been doing a good job with helping to manage the leg during the treatment sessions. Because there is no cure for this condition, you want to remember that taking care of this area will continue to be an important part of each day. Here are some recommendations to guide you following discharge from physical therapy:

  • It is important to monitor the area daily to ensure that the swelling is well managed and the tissue is healthy. Make sure you are able to recognize signs of infection and take extra precautions to decrease the risk of trauma or injury to the affected areas. 
  • Maintain proper circulation in the area by using and moving the arm/leg normally.
  • If you notice changes in the leg, including increased swelling, pain, skin changes, difficulty with using/moving the leg, please see your doctor immediately.
  • Maintain a healthy, active lifestyle that includes: proper nutrition and weight management, regular and appropriate exercise (avoidance of exercises that may strain or injure the affected area), and regular follow-up appointments with your physician.
  • Take care of your compression garments (including bandages). Ensure that they are properly fitted, regularly cleaned, and replaced approximately every 4-6 months.
  • A short course of physical therapy every year can help keep you on track. A therapist certified in lymphedema treatment and management can help monitor the area, make appropriate recommendations regarding use of compression garments or bandages, and will help design an appropriately progressive exercise program. They can also help you update your self-management plan in the event that there are new strategies, techniques, or garments that may make your self-management program easier and more effective.

References:

  1. Lane K, Worsley D, McKenzie D.  Exercise and the Lymphatic System: Implications for breast-cancer survivors.  Sports Med 2005; 35(6):  461-471.
  2. Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan CJ, Williams-Smith CT, Greene QP.  Weight-lifting in Women with Breast-cancer-related lymphedema.  New England Journal of Medicine.  2009; 361(7): 664-73
  3. Katz E, Dugan NL, Cohn JC, Chu C, Smith RG, Schmitz KH. Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study. Arch Phys Med Rehabil. 2010 Jul;91(7):1070-6.
  4. Brown JC, John GM, Segal S, Chu CS, Schmitz KH. Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study. Arch Phys Med Rehabil. 2010 Jul;91(7):1070-6.
  5. Lawenda BD, Mondry TE, Johnstone PAS. Lymphedema: A primer on the identification and management of a chronic condition in oncologic treatment. CA: A Cancer Journal for Clinicians. 2009; 59: 8–24. doi: 10.3322/caac.20001
  6. Moseley AL, Piller NB, Carati CJ.  The effect of gentle arm exercise and deep breathing on 741140secondary arm lymphedema. Lymphology 2005;38: 136-145.
  7. Deng J, Ridner SH, Dietrich MS, Wells N, Wallston KA, Sinard RJ, Cmelak AJ, Murphy BA. Prevalence of secondary lymphedema in patients with head and neck cancer. J Pain Symptom Manage. 2012 Feb;43(2):244-52. doi: 10.1016/j.jpainsymman.2011.03.019. Epub 2011 Jul 30.
  8. Smith BG, Little LG, Skoracki RJ, Rosenthal DI, Lai SY, Lewin JS. Lymphedema Outcomes in Patients with Head and Neck Cancer.  Otolaryngol Head Neck Surg. 2014
  9. Tacani PM, Franceschini JP, Tacani RE, Machado AF, Montezello D, Góes JC, Marx A. Retrospective study of the physical therapy modalities applied in head and neck lymphedema treatment.  Head Neck. 2014 Oct 21. doi: 10.1002/hed.23899. [Epub ahead of print]
  10. Piso DU, Eckardt A, Liebermann A, Gutenbrunner C, Schäfer P, Gehrke A. Early rehabilitation of head-neck edema after curative surgery for orofacial tumors. Am J Phys Med Rehabil. 2001 Apr;80(4):261-9.
  11. Smith BG, Lewin JS.  The Role of Lymphedema Management in Head and Neck Cancer. Curr Opin Otolaryngol Head Neck Surg. 2010 June ; 18(3): 153–158. doi:10.1097/MOO. 0b013e32833aac21.