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July - Sept 2014: Assessment and Risk Reduction

By: Jan Weiss, PT, DHS,CLT-LANA

Cox Health Outpatient Rehabilitation, Springfield, MO

Q: I have recently been diagnosed with lymphedema in my left arm after breast cancer treatment last year. My doctor referred me to a local lymphedema clinic for treatment. I know people with terrible swelling who tell me that treatment doesn’t help. How will I know that the practitioner I see will know how to best treat my lymphedema?

A: It is always best if you can receive treatment from a certified lymphedema therapist (CLT).1 CLTs are specialists in treating lymphedema to provide the optimal care for your lymphedema. You may inquire as to whether your therapist is a CLT. Regardless of whether your practitioner has CLT training, you should expect them to perform a thorough examination and provide educational and clinical interventions for your lymphedema.2 At a minimum, your examination should include a review of your medical history and inspection of your swollen limb and adjacent area of the trunk. Following the examination, your therapist should inform you of treatment recommendations designed to reduce and then control your swelling. Lymphedema is considered a chronic disease, so it will always require some amount of self-care. A very important part of your treatment should include education in self-care management to reduce the risk of complications such as infection, diminished function, and impaired quality of life.

Q: I have swelling in my legs that has gotten worse over the past two years. My doctors tell me it is lymphedema and to elevate my legs more. The problem is that it is interfering with being able to wear shoes and move around. I thought lymphedema only happened after cancer surgery and I haven’t had cancer. What should I do?

A: Ask your physician to perform medical tests to help determine why you have leg swelling. Swelling (edema) can be caused by a multitude of problems, and not all swelling is truly lymphedema. It is important to receive an accurate diagnosis as to the cause of the edema, since this will determine whether it can be appropriately treated with conservative therapy such as Complete Decongestive Therapy (CDT), or if the edema is an indicator of serious disease requiring medication or physician intervention. Your physician and therapist should conduct medical screening and examination to determine the cause of your swelling.3 This will include a thorough medical history, discerning if the symptoms are in one or both legs, and evaluating how long the symptoms have been present. In addition, your physician may obtain lab tests or imaging to help determine the source of the swelling. Your lymphedema therapist will perform a detailed examination of your legs, including measurements, skin assessment, and a functional assessment. Once the cause of the edema is known, the appropriate treatment can be provided. Often combined interventions, such as CDT, medications, and lifestyle changes may be necessary to best control the swelling.

Q: I am a breast cancer survivor and worried that I could develop lymphedema. I have heard about the importance of being very careful with my arm to prevent lymphedema. My doctor assures me that I won’t get lymphedema because I only had two lymph nodes removed. Do I need to worry about taking precautions with my arm?

A: This is a very good question, for which you would likely get different answers, even from those practitioners educated in the management of lymphedema. There is considerable debate over what is referred to as risk reduction. At the heart of it, there is not enough good evidence-based research and every individual is different. You should educate yourself in risk reduction practices and discuss your risk of developing lymphedema with a certified lymphedema therapist (CLT). The National Lymphedema Network provides an excellent overview of risk reduction on their website.4 Unfortunately, there is not a “one size fits all” recommendation for all breast cancer survivors. There are known risk factors, such as being overweight, or having had radiation, which may increase the likelihood of developing lymphedema. Your therapist can educate you about your level of risk and discuss precautions that may apply to your particular situation.

Weissfour [at] sbcglobal [dot] net

References:

  1. www.lymphnet.org/pdfDocs/nlntraining.pdf
  2. www.lymphnet.org/resources/nln-position-paper-the-diagnosis-and-treatment-of-lymphedema 
  3. Ely JW, Osheroff JA, Chambliss ML, Ebell MH. Approach to Leg Edema of Unclear Etiology. JABFM. 2006;19(2):148-160.
  4. www.lymphnet.org/resources/lymphedema-risk-reduction-practices