For some women, physical therapy is needed for guidance with postoperative exercises for recovering shoulder mobility and returning to their normal activities. Patients who are unable to lift the arm overhead or put their arm behind their head at follow-up visits are candidates for physical therapy. Physical therapy may also be needed for treatment of persistent pain or postoperative swelling of the breast, arm, or trunk.
We also offer a new, noninvasive therapy that has been highly successful for a condition which principally affects women called lymphedema. Lymphedema occurs when there is an accumulation of protein-rich fluid caused by the removal of lymph nodes during surgery or by damage to the lymph-collecting vessels during surgery or radiation. This new massage therapy offered through DHMC's Department of Rehabilitation Medicine has been primarily used to treat women with arm lymphedema.
Arm lymphedema is a complication of breast cancer treatment which many women fear. This condition, which results in painful swelling, may happen shortly after surgery or years later and may produce pain, restricted movement of the shoulder and arm, and increased susceptibility to infection. Arm lymphedema is usually a result of surgery which removes the lymph nodes (axillary node dissection) or from radiation therapy. Although surgery for breast cancer has become more conservative, the removal of lymph nodes is thought to be a key factor in disrupting lymphatic flow. Hopefully, sentinel node biopsy will eliminate the need for axillary node dissection for many women. Lymphedema can also be due to treatment of other types of cancer. Lymphedema of the legs, lower trunk, or genitalia can develop after surgery or radiation of the groin lymph nodes for treatment of lymphoma, bladder cancer or vulvar cancer.
In very few cases, the onset of lymphedema is related to the cancer progressing. In these cases, the swelling usually appears suddenly and is painful. For most women, however, the swelling progresses gradually over weeks or months and is due to interruption of lymphatic pathways.
It is estimated that 15-45% of women who have had breast cancer surgery will develop lymphedema, and it is impossible to predict in advance which women will experience this condition. Lymphedema is not related to the degree of swelling after surgery or during radiation therapy, and women who have more collateral lymph vessels bypassing the axilla are probably less susceptible. Occasionally, swelling can develop 15-30 years after the surgery.
Left untreated, lymphedema tends to worsen over time and can increase the risk of skin infection, which can spread rapidly. For women with arm lymphedema who have had axillary node dissection, needle sticks and blood pressures should be done on the unaffected arm. Precautions should also be taken against sunburn, insect bites, and minor cuts.
The best strategy to prevent lymphedema before it occurs is with the arm and hand exercises prescribed following surgery and early detection of the signs of swelling. Treatments used in the past for lymphedema have involved using special sleeves designed to reduce the swelling; or a different sleeve hooked to a compression pump to manually remove the accumulated fluid; or, in extreme cases, performing "debulking" surgery. None of these treatments have been very successful.
In Europe, a type of massage called "Manual Lymphatic Drainage" (MLD) has been used for many years to treat lymphedema. Using light manual pressure, the therapist redirects fluid toward areas with normal lymphatic flow. During the 1980's, the use of low-stretch compression bandages was added to this therapy to maintain the progress made with massage. Meticulous skin care and exercise are also part of this approach, which is called "Complete Decongestive Physical Therapy (CDP).
This combined MLD/CDP therapy has proven to be very effective, even with many severe cases, and is now available at DHMC. On average, intensive treatment includes treatment for a couple of hours each day for two to four weeks. Then patients begin a maintenance phase - they are fitted with a compression garment, taught self-massage, and reevaluated periodically. Treatment for mild lymphedema is less intensive, but still requires considerable commitment and compliance on the part of the patient. Results have shown that it is worth it!
For more information about these programs or to schedule an appointment, call (603) 650-5978.
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