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Treating a person with lymphedema of the breast using CLT and a compressive garment

Presented at the
National Lymphedema Network 2002 Conference
Chicago, Illinois

Kristi C. Johnson, MSPT
Timberlane Physical Therapy
South Burlington, Vermont

Secondary Lymphedema may be a complication from breast cancer treatment. Lymphedema treatment in the upper and lower extremities has been well documented. (2,4,5,7,8,9) Less commonly documented is chronic edema of the breast or trunk. Patients with lymphedema may experience functional impairments such as reduced motion and functional mobility, psychosocial morbidity, pain, joint stiffness, and paresthesia. (7) Effective long-term management and self-care is necessary for the best clinical outcomes. Clinical experience has shown this therapist that breast and trunk edema exists and warrants treatment as well as further study.

Lymphedema has been defined as a high protein edema caused by a decreased lymphatic transport or increased lymphatic load. (3) Treatment for lymphedema has been shown to be effective using complete lymphedema therapy, (CLT). (1) CLT consists of the following: lymph drainage massage to reroute the high protein lymph fluid to uninvolved adjacent areas (lymphotomes); extensive patient education including meticulous skin care, precautions, and self-massage; remedial therapeutic exercise that compliments the self-massage program; and compression. Compression can include compressive bandaging and/or a compressive garment. Garments are most commonly measured for the extremities. There is a paucity of research and documentation for measurement of trunk/breast edema and fitting for compression garments.

There are two phases of compression therapy. Compression with bandages assists in the reduction of the edema, versus compression with garments to maintain the reduction achieved during CLT as well as prevent further leakage (1). Compression of the limbs consists of gradient compression in which the highest compression is distal and gradually decreases as it ascends proximally up the limb. In essence, the garment is attempting to reverse gravity. Compression of the trunk would lack this gradient effect but it is hypothesized that a firm external force would enhance the muscle pump to improve lymphatic flow and prevent further leakage.

Compression increases total tissue pressure. Combined with exercise or movement, compression will increase lymphatic drainage. (2,4,6,10) Muscle contraction against increased external resistance increases tissue pressures to mobilize lymph flow. (6) Compressive garments can decrease capillary leakage/filtration secondary to increased external pressure. Compression compensates for the loss of tissue elasticity. A high working pressure increases total tissue pressure when muscles contract with lymphatics compressed between muscles and a firm external support. (20) Leduc demonstrated an increase in resorption of proteins with pressure therapy and muscle contractions in edematous arms (10). Decreased protein concentrations in the interstitial space also decrease the body's water content in that space, as fluid moves to dilute the protein concentration.

It is important for a compressive garment to fit appropriately to avoid tourniquet areas, which may prevent or block lymphatic flow. Patients with odd contours may require custom measurement for their garment to fit appropriately (2). Persons with lymphedema are educated to limit tight-fitting waistbands, brassiere straps, jewelry, (NLN — Dos and Don'ts), as these may limit lymph flow by acting as a tourniquet. Therefore, a compression garment of the trunk must not create constriction around the shoulder, axilla, chest, or waist, and attempt to accommodate any unusual body or breast tissue contours.

One of the primary goals of CLT is teaching the patient self-care and long-term management. Patients are taught the following: a home program of self-massage to keep collateral drainage open; exercises that compliment the massage; continuation of skin care to prevent infection and limit skin irritation; and to be consistent with compression therapy. When patient compliance is good, patients require fewer repeated courses of intensive CLT (2). In my clinical experience, an educated and compliant patient has better outcomes, less supervision from the therapist, and fewer repeated therapies.

Examination:

Patient History:

The patient was a 71-year-old female status post left breast lumpectomy with sentinel node biopsy and radiation therapy. She had a history of repeated infections in her breast during radiation. One month after completing radiation, she was referred to physical therapy with a primary complaint of breast pain and edema. The patient complained of extreme breast pain, rated at 8-9/10, as well as upper arm pain. She complained of decreased left shoulder mobility and inability to wear a bra. Her medical history is significant for rheumatoid arthritis, costochondritis, and degenerative joint disease in her lumbar spine. She is a retired business owner, has a supportive husband, and is active with local community groups. She enjoys walking for exercise. She is independent with community and home activities but feels limited due to fear of use and fear of infection. Her goals are to manage pain and edema and to increase activity.

Tests and measures:

The patient presented with limited bilateral upper extremity flexion at 130 degrees on the left with symptoms and 140 degrees on the right. Her left breast was significantly larger (photos taken). Her left breast was pink, had a mild increase in temperature, and mild fibrosis was present medially and inferiorly. She had a palpable fullness in her lateral scapula. Arm circumferences were not significantly different from left to right. She had a negative upper extremity Stemmer's sign and no pitting edema.

Trunk measurements:

Hemi-circumferential measurements of the trunk were taken from the midline of the sternum anteriorly to the midline of the thoracic spine posteriorly for left and right sides individually. Specific intervals were at the axillary fold and inferiorly every inch for 5 inches. (Five inches inferiorly was estimated to be at the abdominal watershed.) Measurements were taken at the end of exhalation. (Table 1) The measurements were complimented by photographs due to the absence of any reliable and valid trunk edema measurement methods.

Arm:

Circumferential bilateral upper extremity measurements were recorded regularly to keep track of changes in arm size. No noted changes were observed. Nonetheless, the patient was fitted for a class I UE sleeve and glove to wear for flying.

Diagnosis:

The patient presented with mild grade II breast and trunk edema. It was recommended that she participate in a CLT program twice a week for four weeks. Daily protocol was modified since bandaging was unrealistic for edema in the location. It was anticipated that the patient would benefit from some type of compression garment. Goals were to minimize edema in her (L) breast, minimize risk for infections, increase ability to reach overhead without symptoms, demonstrate knowledge of skin care, demonstrate self-massage, (I) with therapeutic exercises, and (I) with garment wear and care.

CLT Outcomes:

The patient responded to lymph drainage massage with decreased subjective complaints, no recurrent infections, improved skin coloring, and softening of her breast. It was still apparent that she would require some sort of compression for long term self-care and to wean from supervised physical therapy services. It was difficult to find appropriate compression secondary to her naturally large breast size and her decreased trunk mobility from costo-chondritis and RA. The patient was unsuccessful in attempts to wear a commercial “sports bra” or and in wearing inserts and ready-made garments that are available to assist in compression of the breast. For long-term management and self-care, the patient was finally measured for a custom compressive vest.

Compressive Vest:

The vest was designed to disperse forces in the strap area at the shoulder, have compression as superiorly as possible in the axillary region, and allow for changes in girth with eyelet attachments. Frontal opening allowed for easier donning and doffing. It was made of standard compression material at the trunk for stiffness, and a softer material at the arms for comfort and to decrease chafing.

Patient follow-up/ Re-examination:

The patient was discharged, as she was independent with self-massage and garment wear. She followed up in three months, reporting intermittent use of the garment as needed for sedentary periods and partial day use as she could not tolerate continuous use. Two years later the patient reports that she continues to wear the vest as needed, “when I feel as if I am filling up.” She can only tolerate three hours of wear time, as “it is my straight jacket.” She reports that she does the self-massage, yet not on the recommended daily basis. Her symptoms are rated as a 2-3/10 and described as a full and aching sensation. She has not had any infections in the last two years. Visually, her breast size looks more symmetrical with the right and the color matches bilaterally.

Discussion:

Unlike compression therapies where garments are worn 24 hours a day, this patient is able to control her symptoms with intermittent use. It may be postulated that continuous compression is not indicated in the trunk secondary to the central location of edema. Trunk compression of the chest lymphotomes also does not have a compressive gradient such as in the limbs to reverse gravity. In this case the chest lymphotome is already in the superior position to follow gravity and empty into the collateral drainage of the abdominal lymphotome. The compressive garment would facilitate flow inferiorly as well as prevent increased accumulation. It could also be hypothesized that the trunk might receive a massage effect, with the natural movement of the rib cage from respiration moving against an external support would assist to mobilize lymph flow. Perhaps this type of central compression would facilitate a “vacuum effect” for the trunk lymphatics. Careful massage to reroute the edema and careful garment fit is also needed to prevent backflow of edema into the upper extremity.

References

1. Lasinski, B (instructor), Complete Lymphedema Therapy Certification Course, (The Casley-Smith Method), 1999; Burlington, VT.
2. Casley-Smith, JR: Treatment for Lymphedema of the Arm — The Casley-Smith Method. American Cancer Society Lymphedema Workshop, New York, New York, Feb. 1998; 2843-2860.
3. O'Brien, P; Lymphedema. Principles & Practice of Supportive Oncology Updates, 2. 1999:1-11.
4. Leduc, A: “Lymhpatic Drainage of the Upper Limb”. The European Journal of Lymphology, 4. 1993: 11-18.
5. Mortimer, PS: “Therapy Approaches for Lymphedema”. Angiology, 48. 1997; 87-91.
6. Casley, Smith JR: Casley, SmithJR.: Modern Treatment for Lymphedema. 5th ed. Malvern. The Lymphedema Association of Australia, Inc. 1997.
7. Hwang,: “Changes in Lymph function after Complex Physical Therapy for Lymphedema”. Lymphology, 32. 1991: 15-21. Tunkel, RS: “Lymphedema of the Limb”. Postgraduate Medicine, 104. Oct 1995; 131-144.
8. Dicken, S. “Effective Treatment of Lymphedema of the Extremities”. Arch Surg. 1998; 1333: 452-458.
9. Leduc, O, Peters A, Bourgeiois P. “Bandages: Scintigraphic demonstration of its efficacy on colloidal protein reabsorption during muscle activity”. Lymphology, 12. 1990; 421-423.

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