Here at the NLN, we receive hundreds of e-mails, phone calls and letters every month asking similar questions about the controversial topic of lymphedema prevention. In this issue's Question Corner, Bonnie Lasinski addresses a detailed e-mail received from Joyce Clateman. We hope this will be of help to those of you with similar concerns - Ed.
First of all, let me begin by saying that there are no absolutes in medicine. Each person is an individual. The NLN 18 Steps to Prevention are guidelines, not absolutes.
One important function of the lymphatic system is that it helps maintain fluid balance in the body, so that we are not dehydrated, nor are we swollen. As long as lymph load is less than the lymphatic transport capacity (in other words, as long as the amount of fluid in the tissues to be transported does not exceed the capacity of the vessels/ nodes to drain the fluid), there is fluid balance and no edema. When there is an impairment of the lymph transport system, i.e. from surgical cutting of nodes/vessels or radiation scarring of the nodes and tissues surrounding vessels, then a limb is considered "at risk." If lymph load is less than lymph transport capacity, then there is no edema. If, however, due to injury, infection or change in tissue pressure via mechanical or atmospheric pressure changes, lymph load can exceed lymph transport capacity and lymphedema can develop. It is a simple mathematical equation; the myriad of forces/factors influencing the equation, some within our control, some not, is extremely complex.
Physical activity requires oxygen for the muscles to do their work. When you increase physical activity, you increase blood flow to supply the increased oxygen demand. The more blood flow to an area, the more lymph fluid (essentially the water component of blood at the venous end of the capillary loop) is left behind in the tissue spaces, which increases the lymphatic load to be drained. If your lymphatic transport capacity is decreased from the removal of nodes and vessels (or if it is insufficient from a congenital lack/malformation of vessels/ nodes as in primary lymphedema), you may experience a failure of your lymph transport system by lymph load exceeding lymph transport capacity. The more rigorous the physical activity, the more stress is put on the lymphatic system. No one knows what their individual threshold transport capacity is. You can learn your limits by proceeding with activity slowly and listening' to your affected limb and its adjacent the quadrant closely. Do you feel "congested/full/achy" in your chest/axilla/shoulder/upper arm during or after the specific activity? That could be a warning sign that the lymph load is exceeding lymph transport. You need to judge for yourself and weigh the risk of the activity with your desire to perform it. Only you can make that decision.
Q: Can I row a boat? Can I use a Nordic Track (a repetitive pulling motion)? I was told "yes," but start with lower tension on the affected arm and work up to pre-operative strength."
A: Rowing a boat is much more strenuous than using the Nordic Track. I agree with what you say you were told - that you should start with low tension and build up to pre-op level slowly.
Q: I was told that I may go back to weight-lifting, but not to lift more than two or three pounds. I should not lift the weights above my head, but keep my elbows at my side. I was also told that the heavier the weights I can eventually lift, the stronger my arm would become and the better to prevent lymphedema.
A: I believe you can work up to 5-10 pounds slowly. If your mobility in your shoulder and tissue flexibility in your axilla (armpit) is good, I see no reason why you should not lift the weight over your head. It is true that the stronger your muscles are and the more flexible your tissues are, the less likely you are to have a sprain/strain which can trigger lymphedema. Avoiding inflammation (which will cause increased lymph load in the affected area) helps to avoid lymphedema. Another interesting point to remember is that holding even five or ten pounds in your hand at your side can cause compression of the vein in your arm pit, causing venous insufficiency in the arm which will increase fluid load in the tissues, causing an increased lymphatic load. That is why you should avoid carrying packages/bags with the affected arm, or weight bearing on the affected arm while bike riding. Perhaps you could change the handlebars on your bike to those that are more upright to lessen the downward pressure on the affected arm.
Q: I was told it is not necessary to wear a compression bandage/garment for prevention of lymphedema when flying; the bandage/garment is worn only if lymphedema already exists.
A: Compression for air flight is a controversial issue. There is no data to "prove" that wearing compression anytime can "prevent" lymphedema. However, going back to the principles of fluid balance I mentioned earlier, it makes sense that external compression can help decrease the amount of fluid in the tissues by creating an increase in tissue pressure which will force fluid into the lymphatic vessels. Poorly applied compression, whether by proper bandaging or from an ill-fitting compression garment, can most assuredly cause edema, so one must be careful. Compression bandaging is an art and a skill; care must be taken to learn the proper technique for each individual case from someone trained and experienced in compression bandaging for lymphedema. The Casley-Smiths in Australia, our group at Lymphedema Therapy in New York and others have anecdotal reports that an individual's first onset of lymphedema occurred during or immediately after an air flight. The change in pressure on the tissues of the limb at risk from the changes in cabin pressure during flight, especially at take-off and landing, can be enough to cause an increase in lymph load that can exceed an individual's threshold capacity. Not everyone is affected. The problem is that we do not know who will be at greater risk.
Q: May I lie on my affected side with my arm stretched out above my head, flat along the mat with my ear on my shoulder, to do side leg lifts (similar to sleeping on my side)?
A: Why look for trouble? Why not leave the affected shoulder at a 90-degree angle to the body and decrease the chance of your body weight over-stretching structures in the affected axilla, possibly impinging functioning lymphatic vessels and causing a further decrease in lymph transport capacity?
Q: Since I was told not to lift anything heavier than 3-4 pounds (groceries, handbag, etc.), is it potentially a problem to pour water from a pitcher weighing six pounds?
A: Again, the 3- or 4-pound number is an arbitrary one. The rationale behind the limit is to avoid stress or strain which can cause bleeding/inflammation in areas which can increase lymph load, etc. You should make it a habit to try to lift heavy loads using both arms together, thereby shifting more of the weight onto the trunk/shoulder girdle muscles. As to the six pound water pitcher, use both hands for support. Better yet, get a smaller, lighter pitcher!
Q: When hiking up a steep hill, may I use the affected arm to pull myself up by grabbing a tree or rock above me?
A: As previously stated, use both arms together. Again, this may be a high risk activity for you. Only you can be the judge.
Q: May I pull myself up onto the side of a pool, this time using two arms, but leaning on the affected arm?
A: You can, but why not avoid the risk by using the ladder? Again, you are going to weigh the risk with the desire for the activity and decide for yourself what is important for you.
Q: Is it all right to lean forward in a sitting position, elbows on thighs, reading or watching something intensely, sometimes with chin in hand?
A: From a biomechanical point of view, this position is very stressful on the spine. The neck is hyperextended, while the mid and low back are overstretched. Abdominal and pelvic lymph drainage is impaired by the forward flexed position and breathing/changes in thoracic (chest) pressure is impaired, as well. Natural collateral lymphatic drainage exists from the upper chest area to the inguinal (groin) area on the side at risk and will be impaired by this position. So, no, it is not good lymphatically or biomechanically.
In conclusion, think of your body as system in flux - always trying to maintain balance (homeostasis). The more balanced our fluid system is, the greater the chance of avoiding lymphedema. Surgical removal of lymph nodes/vessels shifts the balance toward the unbalanced side; the margin for error is less. You need to "weigh" your activities to try to limit further shifting of the balance to the negative side, limiting increased lymph load and forces that would further decrease lymph transport capacity. I've given you a lot to think about. Thanks for the great questions.
Bonnie B. Lasinski, MA, PT, CLT is Assistant Clinical Director at Lymphedema Therapy Center in Woodbury, New York, and a member of the NLN Board of Directors and Medical Advisory Committee.
Please address questions to: Editor c/o NLN, 116 New Montgomery Street, Suite 235, San Francisco, CA 94105 or e-mail: firstname.lastname@example.org. Deadline for submissions is first day of the month prior to publication.