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Hello, my name is Loraine Lovejoy-Evans, and I am honored to be with you today. My website ITPTclinic.com will have a copy of this transcript as well as some handouts about the information I am providing today.

I earned my Doctorate and Masters Degree from the University of Puget Sound in Tacoma, WA. My undergraduate degree is in Music Therapy which I earned from Willamette University in Salem, OR. I have been a practicing physical therapist since 1993.

I have been treating lymphedema since 1997. I received my first training here in the U.S. from Dr. Marisa Perdomo who now teaches at the University of Southern, California.

I then spent 4 weeks training in Hinterzarten, Germany with Drs. Michael and Ethyl Foeldi.

After completing this training I was certified in the Foeldi method as a lymphedema therapist. I prefer to call myself a swelling specialist because there are so many different swelling problems I treat in addition to lymphedema.

I own a small private practice in Sequim, WA, called Independence Through Physical Therapy. I specialize in teaching patients to learn strategies to manage their symptoms.

My preference is to help patients understand what they can do for themselves to prevent problems from worsening.

Over the years I have developed a swelling spectrum. On the left side are those without any obvious signs of swelling but who are at risk. On the right side are those with significant swelling. I like to catch people on the left side of the spectrum and help prevent them moving to the right side. Once they move to the right side of this spectrum they require more treatment but the swelling can be reduced.

I have been trying different methods with my patients in the clinic to find the best treatment tools to help minimize or prevent lymphedema.

I have been able to go around the country and share these findings with my lymphedema colleagues.

I performed my doctoral research on controlling knee pain by using the methods I learned from treating breast cancer patients. The outcomes were very exciting and I hope to do more research on this at a later date.

But today I want to share with you what I have learned about lymphedema in those individuals being treated for breast cancer.

I would like to first tell you that lymphedema is not life threatening, but can be life frustrating. The earlier you act on seeking treatment the less intense treatment you will need.

An article published in the International Journal of Radiation Oncology, Biology, and Physics on September 22, 2011 titled: Breast Cancer-Related Arm Lymphedema: Incidence Rates, Diagnostic Techniques, Optimal Management and Risk Reduction Strategies was done By Shah C, and Vicini FA.

This article showed Published incidence rates for Breast Cancer Related Lymphedema vary substantially with a range of 2-65% based on surgical technique, axillary sampling method, radiation therapy fields, and the use of chemotherapy.

Unfortunately Breast Cancer Related Lymphedema therefore is a risk for all patients undergoing cancer treatments. So we need to find measures to reduce these risks and ideally prevent this problem.

I am going to present what I would do with a new patient who comes in at each stage of cancer care: before surgery, after surgery, during chemotherapy, during radiation, and after all cancer treatments are completed.

So no matter where you are in your cancer treatments, I hope to be able to share something with you today to help you.

There are still significant differences in the care for breast cancer patients after surgery across the country. I am sharing today the information I have collected from my studies with the Foeldi’s in Germany as well as the care I have provided for my patients in trying new standards of care. As I saw better outcomes, I kept those practices and dismissed the ones that were not as helpful.

I urge you to not panic if you received different care from what I am describing. This field is so new the research is not conclusive and it will take us awhile to find the best treatments to provide the best outcomes.

I am simply providing my findings that I have been working on since 1997.

Let’s begin with a new patient who has yet to undergo surgery. I am going to give you the discussion I give them preoperatively on how to prevent lymphedema.

I start with an evaluation of their strength, range of motion, any signs of overuse tendinitis or limitations of the shoulder or neck prior to surgery. I also take measurements of the chest and both arms so we have a baseline to compare after surgery.

I like to start educating my patients with a brief description of what lymphedema is and why people get it. This is best done by describing the anatomy of the system and how it works.

The circulatory system of the body starts at the heart which pumps the fluid out into the body through a series of arteries which are vessels or tube-like structures.

The arteries get smaller as they get farther away from the heart. The smallest arteries connect with the smallest veins which bring the blood back up to the heart.

The lymphatic system starts near the veins. The lymphatic vessels are tiny tube-like structures that help carry some of the blood products back to the heart. These tube-like structures, or collecting vessels, increase in size as they come back to the heart just like the veins.

The primary job of the lymphatic system is to carry the protein molecules from the blood back to the heart.

These protein molecules are too big to fit into the holes of the veins. The lymphatic collecting vessels have a really wide flap that opens at the end to allow the large protein inside.

In a normal situation the amount of protein going out of the arteries is equal to the amount coming back through the lymphatic system.

Lymphedema develops when the lymphatic system is damaged and goes on strike. With enough damage to the lymphatic system through surgery or trauma or several other reasons, they stop working in that part of the body.

The protein molecules keep coming out through the arteries but they fail to return to the heart and start building up in the tissue spaces.

When the protein molecules are left in the tissue spaces outside of the lymphatic collecting vessels they start attracting water to them.

If you have seen dried beans soaking in water, overnight they swell up with the water that the proteins have attracted.

This is where the edema comes from. It is the protein attracting the water and not allowing it to go back to the heart.

The proteins over time can cause the area to turn hard and thickened just like a plate of refried beans left out on the counter overnight getting hard and crunchy. This hardening of the tissues is called fibrosis. It can get as hard as a brick at times.

These proteins are normal to have in the blood stream and in the body. So the protein moving out into the tissue spaces from the arteries is not the problem. The problem occurs when the lymphatic structures are damaged.

The lymphatic structures are damaged when lymph nodes are removed through surgery, or even cutting the lymphatic collecting vessels, or tubes, during surgery.

The skin is filled with small lymphatic vessels so any surgery or cuts to the skin put that area of the body at risk for developing lymphedema.

Anything that damages the skin can be a risk factor for developing lymphedema.

Other causes of lymphedema include radiation, burns, infections, or being born with fewer lymph nodes. This list is not exhaustive, there are several other things that can cause lymphedema.

Lymphedema is the abnormal accumulation of protein-rich fluid.

With the preoperative patient the next thing I explain is the behavior that can help prevent lymphedema after the surgery.

To prevent lymphedema one of the most important things is to allow the cut lymphatic vessels to reconnect with each other. When the lymph nodes are removed the lymphatic collecting vessels surrounding the lymph nodes are severed. There is now empty space between those two vessels. So we want them to grow back together to carry fluid out of this area.

Specialized cells come to the area of inflammation after injury. Fibroblasts are one of the specialized cells that help knit the cut ends of the lymphatic vessels back together. This knitting process takes 8 days.

This is according to an article titled "The Regeneration of Lymphatics" printed in the Archives of Surgery volume 13 in 1926 by Reichert, FL. This article states that the deep vessels take 8 days to regenerate while the superficial vessels-those closest to the skin only take 4 days.

However, this is 8 days of the vessels being left in close proximity to each other. If they keep getting pulled apart they are less likely to heal and the fluid in the vessels coming to the armpit will start to pool and can cause a seroma.

A seroma is pooling of the liquid in the armpit region which causes a blockage of fluid from moving out of this area and this can cause lymphedema.

• Seroma formation and post-surgical infection have been associated with development of lymphedema in the ipsilateral-same side- trunk quadrant and extremity

According to an article done by Foldi E, Foldi M, Clodius L. The lymphedema chaos: a lancet. Annals of Plastic Surgery done in 1989; vol 22: pages 505-515

• A 40% reduction in the incidence of seroma was found in patients for whom arm exercises were delayed

– K, Simonite V, Beardshaw A. Delayed versus immediate exercises following surgery for breast cancer: a systematic review. Breast Cancer Research and Treatment in 2005; vol 90: page 263-271

One of the major things I learned from Dr. Foeldi which I recommend to my patients after surgery is to keep the arm next to the body so this knitting process can take place.

Putting a safety pin from a shirt sleeve to the trunk of the body can help remind you to not move the arm. The arm is kept at rest at the side of the body until the drains are removed. After waiting 5 more days it is OK to start moving the arm to gain range of motion.

Avoiding too much activity or exercise is also important. Because the more you move around the more fluid you pump out of the heart into the area of injury.

Since the area of injury is already having difficulty moving fluid out of the area this extra exercise or activity simply adds more fluid and causes more edema.

There are several research articles that looked at those patients who moved and exercised the arm early versus those who waited 7 days or longer after the surgery. One of those articles was done by Flew TJ. Titled Wound drainage following radical mastectomy: the effect of restriction of shoulder movement in the British Journal of Surgery done in 1979, volume 66, pages 302-305.

In this research they compared two groups-those who moved the arm right after surgery and those who were put into a bandage to tie the arm to the body for 7 days.

They found in their conclusion that by limiting shoulder movement for 7 days postoperatively, the amount of fluid drained from a radical mastectomy wound can be reduced by an average of 40% while the length of time until fluid formation ceases is reduced by about 29%

This article also compared aspirations between the two groups. An aspiration is a needle put into the armpit region or side of the chest wall to pull out accumulating fluid. The group that moved the arm required 33 aspirations compared with only 4 in those that did not move the arm. This is one of the articles that proved Dr. Foeldi’s recommendation of keeping the arm by the body.

When I am working with patients who are about to undergo surgery I encourage them to correlate their drain output with their activity level.

They have reported to me that the days they were more physically quiet they had less drainage output. On the more active days, even something as simple as riding in a car, or walking the dog, their drainage output was higher.

The drain stays in place until the drain is putting out 20-25 cc a day for 2 days in a row. Then it is removed. Patients who have followed my recommendations have typically had the drain out in less than one week.

However, those who were more active, I have seen the drains stay in place up to 8 weeks which increases the risk of infections.

It is important to learn how to recognize an infection and what to do if noted. Losing lymph nodes is losing part of your immune system so the body is less capable of fighting off infections in the area where the nodes were removed.

Having armpit lymph nodes removed puts that side of the chest and that arm at risk for infections. You need to watch for infections the rest of your life.

Signs of infection include skin that is red, warm, swollen and painful (which is normal after surgery) however if you add fever, chills, aching or headache this is more likely a systemic infection.

This is called cellulitis. Often people think I am saying cellulite which is the globby fat on the legs-but it is different.

Cellulitis is a dangerous infection that can spread and require hospitalizations for IV antibiotics. This infection if left untreated can even spread to the heart. So recognizing infections is important.

If you suspect you have an infection take your temperature and call the doctor. If it is after hours then go to the emergency room.

According to Dr. Foeldi if you start antibiotics within hours of developing the infection you can prevent the hospitalization.

If you have an infection or do not feel good-feeling sick in anyway such as your heart is not working right, then do not perform the massage technique or you can spread the infection to the heart.

Because of this great risk of infection, after surgery we work really hard to get the drain out as fast as possible. Getting the drain out sooner helps to prevent the risk of infections and gets you feeling better on the road to recovery faster.

Another hint I give patients who are about to undergo surgery is to learn about nutrition in the role of healing the body. Eating a lot of protein can help heal the wound much faster.

Typically after surgery we don’t feel like eating a lot, however, eating protein helps build muscle. Without adequate protein or calories the wound will not heal properly.

A wound the size of a silver dollar takes about 1000 calories per day to heal it adequately. So I recommend that they not worry about dieting but instead really push the protein.

I also try to look out for their psychosocial welfare and recommend that they tell their friends that their "evil physical therapist" does not want them to have visitors. Understanding

Visitors bring in their germs which you don’t need and they often tell you horror stories of what happened to someone else they knew with breast cancer.

I have found that when they have visitors they feel like they have to get up and put on nice clothes and even do their hair and makeup. They will even make tea for their company. So all of those calories that should be working on healing the wound are now being spent on other activities.

The extra activity is now pushing more fluid out throughout the system and leaves more fluid in the area of injury which puts more fluid out in the drain and can cause more discomfort or pain.

I recall one patient telling me she thought I was crazy for telling her not to have visitors. But then she was grateful to have a medical personnel she could blame to be able to rest.

When healing from surgery or radiation or other traumas, it is the edema pushing on the nerves that causes the pain. So anything you can do to get edema out of an area can help reduce pain.

Removing the edema from the area can also help promote healing of the tissues. It reduces the forces putting pressure which is pushing on the inside of the skin that is trying to knit back together.

One of the ways to help encourage fluid to go back inside the vessels is by using compression. After the surgery commonly the doctor prescribes a pressure garment-which is good to use. Once the drain is out often a good fitting bra will provide the same pressure.

The main problem with the bra is that on the side of the chest it often is too low as more pressure is needed up to the armpit. I recommend patients sew a panel into the bra to provide this pressure up to the armpit.

There is a technique which is very helpful at removing fluid from the area of injury and returning it back to the heart.

I teach patients to perform self Manual Lymphatic Drainage Massage. This is a simple massage to do frequently, ideally every hour or any time you notice increased pain or discomfort.

An article titled Primary Prevention of Upper Limb Lymphedema in Breast Cancer: How, Why and What Kind of Results? This research was done by A.P. Pecking, et al and published in English in Progress in Lymphology 16, Lymphology, vol 31, pages 532-537, in 1998.

• 60 women with breast cancer treated by surgery and radiation therapy were included in a prospective randomized study (1982-1983) and followed for at least 10 years.

• Three days after surgery patients were randomly assigned to a physical treatment:

• 1: Bandaging

• 2: Manual lymphatic drainage (MLD)

• 3: No physiotherapeutic treatment as a control group

• Bandages and MLD were applied for 4 weeks and stopped before beginning radiation therapy

• Clinical Results: Only patients with a clinical sign and limb circumference up to 4 cm compared to normal limb were considered as lymphedemas

• They concluded:

• Immediately after surgery 85% of the patients have lymphatic disturbances and after radiation therapy the rate reaches 98%

• Post surgical physiotherapeutic cares could be of interest to minimize the therapeutic induced lymphatic insufficiency

• The bandages as used for venous disease is not able to protect the patient against the lymphatic disturbances and the short and long term results obtained are worse than in the control group where no physical treatment was applied

• Using MLD as a post-surgical physical care, the rate of lymphatic troubles is significantly less either in clinical or pre-clinical edemas or lymphatic insufficiency

• The ideal should be to use new methods to localize the first involved node to minimize or avoid the lymphatic dissection and to apply MLD systematically during the first line therapy (surgery + radiation therapy)

• In the next future, the frequency of upper limb edemas occurring after a breast cancer treatment should decrease significantly

This article is the reason that I teach patients to do MLD as soon as possible because it showed significantly less lymphedema in those who received MLD compared to the control group or the bandaging group.

To do lymphatic drainage properly, imagine a river system that is flooded.

You want to start at the mouth of the river and make sure there are no beaver dams or blocks to the fluid moving out of the mouth of the river to the ocean. This Manual Lymphatic Drainage or MLD massage technique works to open the river system in reverse direction.

Rather than starting at the flood plain by starting at the mouth of the river and working backwards opens a path for the fluid to move more easily.

With Manual Lymphatic Drainage Massage the mouth of the river is the heart-all of the fluid of the body ends up back at the heart.

Neck exercises open this part of the lymphatics by moving the collar bone in different directions they put pressure on the lymphatic collecting vessels and lymph nodes in this region.

To perform Manual Lymphatic Drainage for breast cancer swelling start with 4 different neck exercises: Bring chin to chest and say "Yes" with your head 10 times.

Next turn head from side to side saying "No" with your head 10 times.

Then do shoulder circles pulling shoulders backwards and down 10 times-I call this saying "Maybe" with your shoulders.

Finally finish neck exercises by bringing ear down toward shoulder while pulling shoulders down and then repeat ear to the other shoulder-repeat 10 times. This is called "I don’t know".

Neck exercises are made up of 10 of each of these: "Yes, No, Maybe, and I don’t know".

After doing the neck exercises move to the next big river which is in the trunk or the middle of the body.

This is done with deep breathing exercises. Breathe in through the nose and let the belly expand with air as if blowing up a balloon.

Blow the air out through the mouth and tighten the belly as if a balloon were deflating. Blowing out should last twice as long as breathing in. Repeat 10 deep breaths.

If it is too difficult to coordinate tightening the tummy at the same time as the deep breathing you can split those two apart. 10 deep breaths and 10 tummy tightening.

You are now ready to move the fluid away from the injured armpit. Find a place to move the fluid away from the armpit and chest wall by picking the front of the groin on the same side as the surgery. Use only enough pressure to wrinkle the skin.

Put your hand at the front of the groin and hold tight on this skin while pulling the skin at the front of the groin up and out to the side. Release the pressure and let it pull your hand back to the starting place. Repeat this pumping motion 10 times.

Now start as close to the armpit as you can get-this may be under the drain and dressings. Then stretch the skin down the side and front of the body to the front of the groin.

Repeat this skin stretching from the armpit down to the groin 10 x. Perform this on the front of the body and on the side as well, 10 reps each place.

Another possible place to take the fluid is to the opposite armpit-if there are no problems with that armpit. This is done by stretching the skin of the opposite armpit and then stretching the skin across the front of the body from the involved armpit to the opposite armpit.

This is repeated across the back of the body or can be done against a door jamb or with a towel stretching the skin from the involved armpit to the opposite armpit.

According to Dr. Michael Foeldi the most powerful pathway is moving from the armpit down to the front of the same groin. So I encourage patients to do this pathway only rather than across the front or back of the body on a frequent basis during the day. But I do recommend that they do the opposite armpit and the front and back of the body when they shower and towel off from showering.

Finish by stretching the skin of the arm-start at the elbow and wrinkle the skin up to the collar bone. Repeat 10 times and perform it on the under side of the arm ending in the armpit.

If the arm is not swelling you do not necessarily need to move down the arm but it is not a problem if you do. The next section of the arm is the elbow crease.

Lay the hand on the elbow crease and gently lift this skin up toward the shoulder making sure you create a wrinkle. Repeat 10 times on each side.

Finally start on the back of the hand and create a wrinkle moving up to the elbow. After 10 repetitions repeat this on the underneath side of the forearm.

Pay attention to how you feel before you perform the MLD. Pay attention to how you feel after the MLD and use this as often as needed to keep any symptoms under control.

Ideally do this at least once an hour in order to keep edema under control and help promote healing.

If you are lucky enough to have a helpful partner or caregiver please ask them to help you by performing the MLD massage. As long as a wrinkle is present in the skin and they are going the right direction it will be beneficial.

To recap what I do with a patient who is preoperative: I perform an evaluation, then I instruct them in behaviors to minimize lymphedema risk: No visitors, eat a lot of protein, avoid moving the arm away from the body by using a safety pin until 5 days after drain is out, avoid extra activity or exercise, observe for signs of infection and actions necessary if noted, and use of the Manual Lymphatic Drainage to help reduce drain output and get the drain out sooner.

Now I would like to describe what I do with a patient who has had surgery and comes to see me in the clinic.

I start with a post-operative examination and evaluation only I do not test range of motion. I do take the measurements and make a notation if they are a returning patient that they have now had surgery as the breast may be missing which will really change the numbers on the chest wall. I look at the incision for any signs of infection.

If they are a new patient I explain to them the anatomy of the lymphatic system and what lymphedema is and why we want to prevent it. I teach them or review their self MLD massage.

My office manager has fibrosis in her arm and will let the new patients feel her arm. She does a great job helping them understand that she wishes she had learned these strategies earlier in hopes that she would not have to wear her sleeve now.

I teach them about recognizing infections and what to do if noted-get antibiotics right away and stop doing the MLD massage.

I like to see patients in the clinic starting about a week after surgery so I can perform clinical Manual Lymphatic Drainage on them in order to help get the drain out faster. There are other manual techniques I can use as well to help reduce discomfort and promote relaxation.

While I am working on the patient on the treatment table I review their drainage output and how their activity level affects this. I review how well they are keeping their arm to their side. I also ask about any other issues that are coming up that I might be able to help with such as pain in the rib cage or discomfort.

I have other treatment tools that I use to help if they have rib cage pain or even back, neck and shoulder pain. We try to treat patients holistically in our office and use the different treatments we know to help solve as many problems as we can.

Commonly I find in the medical world that patients are told to put up with pain but I respectfully disagree with that. I find that the manual lymphatic drainage massage can be very helpful for all patients who have had surgery and are feeling pain.

There are other techniques we use in our office to help improve alignment of the skeleton which can commonly cause discomfort.

We are working to help patients restore their normal quality of life.

A complication of not moving the arm until the drain comes out is the risk of developing adhesions, axillary web syndrome, or tightness through the layers just below the skin in the armpit, chest or even down the arm. I have seen adhesions down to the wrist on the arm and down to the belly button on the trunk.

These adhesions also seem to block fluid from moving and can trap edema in the chest wall or in the arm. So it is important to release them as soon as possible.

Once the drain has been out we wait an additional 5 days and then I instruct the patient in a series of stretches to be performed 3-4 times a day.

I like a snow angel stretch with the hand pulled back, elbow straight then raise the arm out to the side as high as you can go. Another good addition to this is to use your opposite hand to pull downward in the armpit to pull both sides of the armpit away from each other. Hold for 30 seconds and repeat 3 times.

I also like using a door jamb stretch. When they step through the door way I want them to reach the arm as high up on the door jamb as possible. They can put a piece of painters tape to see where they reached and every day try to make this go higher and higher. It is great if they will also use the other hand and do a downward pull on the armpit at the same time.

Each of these stretches: snow angel stretch and door jamb stretch are best if done more frequently throughout the day.

During this time I am seeing the patient in the clinic 2 times a week where I use moist heat on that armpit and then perform a technique called Myofascial Release.

This Myofascial Release helps to release the adhesions that are in the fascia. The fascia is the shiny stuff you can see when you pull the skin off of chicken. It is sort of like saran wrap that covers the meat.

When you have inflammation in an area it causes this fascia to act like glue and get stuck-pulling the skin and not allowing it to move in a normal fashion. The myofascial release technique can help release these adhesions and gain the range of motion back.

I continue working with patients until they have close to full range of motion back in the arm and they are able to maintain it on their own with their home program. Understanding

I recommend that they find reasons to raise the arm overhead throughout the day even if it is touching a specific top of a door every time they walk through that door.

Once the adhesions are resolved and no signs of swelling are occurring then I instruct the patient in a gradual progression of an exercise program. I usually have them start by walking to their mailbox a few times a day. As they do well with this then I have them add a few mailboxes to their neighbors and back.

They keep building adding more mailboxes until it is clear that they have the strength to make it all the way around the block.

The exercise is carefully monitored to make sure it does not cause the adhesions to return or any swelling to increase. I always think of tomorrow as your report card for today. If you did too much today you will see swelling, stiffness, or discomfort the next day.

If no worsening the next day in swelling or adhesions then the amount of exercise done the day before was good and ready to progress more.

I am a big fan of teaching patients to change only one variable at a time to see what makes the difference. So when progressing strengthening I do not want to start them on walking and arm strengthening exercises at the same time. But once the walking is going well then I teach them arm strengthening exercises.

Very commonly people come to me with a history of a home program of yoga or strengthening exercises they were doing prior to the surgery and I observe them doing those.

I make any corrections to form but otherwise I encourage them to go back to the workout they enjoy just start slow and build gradually to prevent overuse injuries.

One of the main things I instruct in exercise is the use of the pelvic floor to stabilize by using the inner core muscles. When exercising lifting weights or lifting the body parts it is important to keep the trunk of the body steady and still. This is done by contracting the pelvic floor muscles as if holding back urine or gas-or doing a Kegel exercise.

By firing this inner core using the pelvic floor it will kill two birds with one stone. This helps keep the back stable so people do not lose their good alignment of the skeleton.

It also helps with any problems with incontinence such as urgency to go to the bathroom more often or wake at night to use the bathroom.

I know this seems to not have anything to do with lymphedema, however, one of the main things that people notice when doing the Manual lymphatic Drainage massage technique is that they have to go to the bathroom much more often. So learning about the pelvic floor can be a big benefit.

Once the patient shows no signs of swelling, or at least the ability to control any swelling with their home program of self massage, they have good range of motion, and they are doing a good cardiovascular exercise program as well as a strengthening program, I usually have them work on their own. Some people prefer exercising in a group and then I encourage them to find one in the community.

Once they are managing symptoms on their own I discharge them from the clinic to their home program. I always invite them to contact me if they are having any difficulty-the sooner they contact me the better.

To recap what I do with a patient who comes after the operation: I perform an evaluation, I perform clinical Manual Lymphatic Drainage and teach them self MLD, use of tennis ball and channel foam if fibrosis is noted, teach them to avoid extra activity or exercise, observe for signs of infection and actions necessary if noted, use of compression, 5 days after surgery they start range of motion stretches and I perform clinical myofascial release. Once they show no signs of swelling and adhesions are resolved they start progressing to strengthening exercises and cardiovascular exercise. Once they are controlling symptoms and know how to progress their strengthening programs while preventing overuse they are discharged to their home program.

Moving on let’s talk about patients who come to see me during chemotherapy treatments. Chemotherapy can take place before or after surgery but is usually done before radiation therapy.

While undergoing chemotherapy treatments I start the patient with an evaluation of their range of motion, strength, observe for any signs of infection, take measurements and observe for any signs of swelling or fibrosis.

I educate them about observing lifelong for infections and actions necessary if noted including calling the doctor and getting in for antibiotics and not performing the self MLD.

I teach them how to perform self MLD technique and to do this often enough to keep any symptoms or swelling under control. When they first start I recommend every hour for a few days and then start peeling it off to determine how often they need to do the MLD massage.

If they are not having any symptoms 2 times a day is usually plenty. I also go over using compression of the chest with a bra if needed.

I also educate them in a cardiovascular and strengthening program building slowly and gradually to prevent overuse injuries.

However, when they are feeling poorly after chemotherapy I encourage them to do what feels best for their body even avoiding the MLD massage if they want. Asking a partner to help perform this technique for them helps save their energy.

After a few days when they are feeling OK again it is OK to resume the MLD and exercises and walking program.

If any adhesions are noted these are treated with Myofascial Release technique and self stretches.

They are discharged to their home program when they are controlling symptoms on their own and know how to watch for a problem of worsening that requires further assistance.

To recap what I do with a patient who comes during chemotherapy: I perform an evaluation, I teach them self MLD, use of tennis ball and channel foam if fibrosis is noted, teach them to observe for signs of infection and actions necessary if noted, use of compression, range of motion stretches and I perform clinical myofascial release. Once they show no signs of swelling and adhesions are resolved they start progressing to strengthening exercises and cardiovascular exercise.

Once they are controlling symptoms and know how to progress their strengthening programs while preventing overuse they are discharged to their home program.

Next I would like to talk about patients who come to me before or during radiation therapy. I do an evaluation/examination including measurements of range of motion, strength and circumferential girth measurements. I look for any signs of infection or adhesions.

I teach them about the lymphatic system anatomy and tell them what lymphedema is and why people get it. I go over signs and symptoms of infections and actions necessary.

If they do not have good range of motion we work on stretches. If their strength is not up to par we work on strengthening programs. I like to make sure they have a good cardiovascular or walking program in place to help with the fatigue.

Then I teach them how to perform self manual lymphatic drainage massage using the abbreviated version I described above. The neck exercises: yes, no, maybe and I don’t know; deep breathing; front of the groin.

And then I change it and put their operated hand on their head. Next they start with their hand on the inside of their elbow and pull up the inner arm through the armpit and down the front of the chest all the way to the front of the groin.

After 10 reps of this they put their hand at the back of the elbow and pull up the back of the arm to the shoulder then down the side of the trunk to the front of the groin.

I show them how to do the rest of the arm at the elbow crease and the forearm as well if needed.

What I have found with radiation is that there are far fewer breaks in the skin and therefore fewer breaks from radiation needed with self Manual Lymphatic Drainage massage that is performed quite frequently. Typically I have seen that patients who do it at least 8 times a day seem to get through radiation faster and do not see signs of swelling problems.

I can tell you about a patient who had quite large breasts and was overweight. The reason I mention being overweight is that the more weight a person has on them the greater the risk for developing lymphedema.

This patient was undergoing radiation when I first met her. I recall one session she had been doing the MLD massage 4 times a day but she complained about having nipple pain.

We use the pain scale of 0 is no pain and 10 is the worst imagineable. Her nipple pain was 6-7/10. I reviewed her MLD massage with her and had her perform 10 of each of the neck exercises, deep breathing, front of the groin, inside elbow down the front of the body including the breast, and outside of elbow down the side of the body to the front of the groin.

After 10 of each of these she noted the pain level reduced to 3/10. So I asked her to repeat the entire sequence. After 1 more sequence of the abbreviated MLD version the pain was down to 1/10. She repeated the sequence one more time and the pain was 0/10.

So I encouraged her to do her MLD massage 3-4 times in a row or as often as needed to resolve the symptoms. After this, she usually did the MLD 10-12 times a day. She did quite well except one day when she drove up on our mountains which is a 45 minute drive up to significantly higher elevation and she did not do any of her MLD massage.

When she got home she could see significant swelling in the side of her trunk above her bra. She started doing her MLD 20 times a day 3-4 reps each time and within 1-2 days the swelling was gone.

This sounds like a lot of MLD massage and it is but the abbreviated version she was doing took her only about 3-5 minutes to perform. She was also desperate to not develop lymphedema.

She was able to finish radiation with very minimal discoloration of the breast. With her increased weight I would have anticipated seeing her have more burning and more difficulty so I was quite thrilled to see her doing the MLD massage so often.

I was more excited to see her skin resulting in ability to heal from the radiation each day. Her arm size has remained the same and shown no increase in size through radiation and her chest has actually reduced quite well with the massage technique.

This patient was also recommended to wear a good fitting bra to give her compression. When she was in the bra I could lift it far away from her breast so I asked her to find a more snug fitting bra that would help push the fluid back inside the vessels so the massage would be even more effective.

If along the way the patient develops fibrosis or hardening of the tissues in the breast-I have them wear specialized foam made into small channels called Komprex II. This is available from NorthAmericanrehab.com. They wear this channel foam inside the bra to help break up the fibrosis.

I also instruct them to use a tennis ball to roll with fairly firm pressure around the hard areas to break them up and then perform their self MLD massage. Then wear the bra with the channel foam over the top of it to help keep it soft.

Once the patient is done with radiation I see them back to make sure I see no signs of lymphedema-increased girth, signs of swelling, or signs of fibrosis. Then I have them reduce their frequency of MLD down to 4 times a day.

After 1 month I have them reduce down to 2 times a day. If they notice any problems when they reduce frequency of MLD massage then they rev it back up.

I always recommend that they perform their full MLD massage technique every time they shower or bath using the soap or washcloth and repeating it when they towel off.

By retraining themselves in how they bathe this will have them doing their MLD at least 1 time a day the rest of their life.

The patient is also instructed to watch for signs of infection and know what to do if noted-stop MLD and get to doctor to get antibiotics. If they continue to have infections then I recommend that they talk with their GP about having antibiotics on hand but they have to be able to tell the doctor when they would take them specifically for cellulitis and not for a cold.

We don’t want them compromising their immune system anymore than it has to be. With an overuse of antibiotics we are growing super bugs that are resistant to our antibiotics.

So we have to be careful to use them only when they are needed.

Before I have the radiation patient work on their own I make sure they know how to maintain their range of motion, continue to progress strengthening and cardiovascular programs, perform self MLD frequently enough to keep symptoms under control, watch for infections, and observe for signs that a sleeve is needed.

If the MLD frequency is needed too much and the arm swells without it then a sleeve is required. Then they contact my office.

To recap what I do with a patient who comes during or before radiation treatments: I perform an evaluation, teach them self MLD, use of tennis ball and channel foam if fibrosis is noted, use of compression, observe for signs of infection and actions necessary if noted, range of motion stretches and I perform clinical myofascial release if needed. Once they show no signs of swelling and adhesions are resolved they start progressing to strengthening exercises and cardiovascular exercise. Once they are controlling symptoms and know how to progress their strengthening programs while preventing overuse they are discharged to their home program.

The last group of patients I want to talk about is those that come to me after they have completed all of their cancer treatments.

If they have no obvious signs of swelling or fibrosis they are still in a preventative mode and I teach them to maintain their range of motion, strength, cardiovascular conditioning, observing for infections, use of compression with a bra if needed, and then teach them self Manual Lymphatic Drainage massage to be done 1-2 times a day especially in the shower or while going to the bathroom.

If they later notice a problem developing then I instruct them to contact my office for further assistance.

Those who come in after all of their cancer treatments are completed, or even those who were seen during cancer treatment who have swelling in their arm are likely going to require use of a compression sleeve. The sleeve looks like a long evening gown glove only without the hand.

Some people need to wear a compression glove as well as the sleeve if their hand is also swollen.

To treat significant arm swelling I teach patients self care strategies of observing for infections, self manual lymphatic drainage massage, and self bandaging. We use specialized compression bandages that are quite stiff like cotton without much stretch in them.

Underneath these we use specialized foams to help protect the skin and joint structures and to help break up the fibrosis. These bandaging supplies can be quite expensive about 150$ for one arm but the extra expense reduces the length of the time wearing them dramatically.

When I first came back from Germany I had patients in bandages for 3-4 weeks to reduce the girth. Now they are in bandages only a few days but less than one week.

The main difference is that patients now do all of the manual lymphatic drainage 10 times a day or every hour they are awake. The other change is that I am using the specialized foams and am much stiffer in my bandaging technique.

To improve the stiffness I have increased to using 3 layers of the stiff brown bandages that look like ace wraps but are less stretchy. I used to only use one layer but by adding extra layers it helps force the fluid back inside the vessels so it comes back to the heart even faster.

When the patient comes back into the clinic each day we remeasure and continue bandaging until the arm is soft and the girth is stable or we feel the bone and it will get no smaller.

At that point, I order them a custom-fit compression sleeve. I typically have found that the custom-fit sleeves work better than over-the-counter, but if a patient wants to try one of the cheaper sleeves we start there.

However, I take the measurements for the custom-fit sleeve when they come out of the bandages so if they swell back up we do not need to bandage again before we order the sleeve.

When the sleeve arrives in the office I measure the patient and if they have kept the arm small enough with self MLD massage or bandaging then I give them the sleeve.

Otherwise I put them back into bandaging usually only for 24 hours. They rev their MLD massage back up to every hour.

The next day they have usually lost enough again to try fitting into the sleeve.

I like to see them back after wearing the sleeve for a few days and washing it each night. Then I remeasure to make sure this sleeve is working well to keep the arm swelling down and the fibrosis soft.

If they are bigger and harder then they either need to try more MLD massage or we progress up to the next tighter sleeve.

Once the sleeve is working well I make sure the patient is maintaining their Range of motion, progressing their strengthening program, performing a cardiovascular program, and knows what to do if they develop cellulitis.

I also make sure they know how to care for their compression garment including when it is time to order a new garment. Ideally by getting a new garment early enough every 6 months to a year the less likely you have to go back into bandages.

To recap what I do with a patient who comes after cancer treatments have been completed: I perform an evaluation, I teach them self MLD, use of tennis ball and channel foam if fibrosis is noted, observe for signs of infection and actions necessary if noted, use of compression, range of motion stretches. They are also taught strengthening exercises and cardiovascular exercise. If needed, they are placed into compression bandaging and a custom-fit sleeve is obtained. Once they are controlling symptoms and know how to progress their strengthening programs while preventing overuse they are discharged to their home program.

With all groups of patients I make sure they know how to control symptoms if they worsen.

Lymphedema can be treated at any point along the swelling spectrum, however, the best time is to learn about strategies such as self MLD technique to prevent lymphedema.

People with swelling can be helped at any point across the spectrum.

I want to make a point about my evaluation about someone with swelling. Typically lymphedema comes on slowly. So if someone has a history of lymphedema that develops very rapidly I typically send them back to the doctor to make sure there is not an infection, blood clot, or an active cancer such as a recurrence.

When treatment is performed by a skilled therapist but no reduction of the swelling occurs this can be from something such as a blood clot or a tumor blocking the ability of the fluid to move. So if they do not respond well to treatment I send them back to the doctor for more workup.

If a person has cancer and swelling we can try our techniques to see if we can help them get any pain relief or reduction of the swelling. But it is not correct to start treating the swelling until the cancer is ruled out. If the person has a history that the lymphedema took a long time to develop then I am less likely to be suspicious of something like an active cancer being present.

I have found that most patients with lymphedema have had a history of cancer but do not have an active cancer. I did want to point this out though that it is something that I keep in the back of my head at all times while treating breast cancer patients and those with lymphedema.

My website ITPTclinic.com (ITPT stands for Independence Through Physical Therapy) is new but I am asking my webmaster to post a copy of the transcript of this lecture as well as some handouts. I have provided handouts on how to do the MLD-it is demonstrated for both sides but you only need the one side that is involved. I have provided the snow angel stretch.

There are handouts about preventative strategies before surgery as well as during radiation. There is a handout about what lymphedema is and why people get it. I have also provided a handout on hints for healing after surgery or trauma.

last handout I have posted is about energy tokens and how to be smart in progressing exercise and prevent overuse injuries.

I am working on writing a book for patients to be able to do their own care and to know how to do all of the strategies I have presented to you today. It will take me awhile to get this done but once I am finished it will be available on my website at ITPTclinic.com.

I have also done a DVD on self care including how to perform self Manual Lymphatic Drainage Massage and self bandaging. This is available through North American Rehab.com. Their phone number is 1-800-845-6050.

It has been an honor speaking to you today. I am ready to answer any questions you have.