Before one can properly and effectively treat shoulder impairment secondary to breast cancer-related lymphedema (BCRL), it's vital to treat the lymphedema itself. After all, the effects of lymphedema (e.g., heaviness, tightness, fatigue, strain on the shoulder girdle) are a large contributing factor to impaired shoulder mobility on the same side.
Lymphedema is treated via Complete Decongestive Therapy (CDT). This consists of a combination of manual lymphatic drainage (MLD), skin care, decongestive exercises, and compression use.
CDT is typically performed by a Certified Lymphedema Therapist (CLT).
Manual Lymphatic Drainage:
MLD is a light, hands-on manual therapy technique meant to assist in moving the static lymph fluid.
This technique is different from massage, as massage is technically a deep tissue pressure. MLD, again, uses a very light pressure. Using excessive pressure depth has the potential to overstimulate the lymphatics, increasing the workload, and subsequently further congesting the area that is already struggling.
MLD uses re-routing pathways in healthy areas of the lymphatic system to detour the static lymph fluid past the affected area into unaffected regions that are able to assist with drainage.
Self-MLD is a common technique taught as part of the home program to manage lymphedema.
Skin Care:
It is important to maintain healthy skin with lymphedema. This condition tends to leave the skin more prone for dryness. This dryness, if not cared for properly, can create the potential for open, cracked areas of skin to develop. These then become possible entryways for germs and bacteria, creating susceptibility for infection.
If lymphedema is not addressed promptly, additional skin changes can occur. This usually involves hardening and thickening of the skin, along with possible lymphatic blisters or warty growths. Common terms to describe these changes include fibrosis, hyperkeratosis, papillomatosis, and peau d’ orange.
In more severe cases, wounds can develop on the affected area. This may require medical treatment from a wound care facility in conjunction with treatment from a CLT.
Treatment can still help to reduce these skin changes, but it is always better to take appropriate measures to treat the lymphedema before the skin reaches this point.
Decongestive Exercise:
Light exercise is absolutely beneficial to help reduce and best manage lymphedema. The natural muscle pumping mechanism aids with promoting blood flow and circulation.
It was previously thought that those at risk or who developed lymphedema should not use the affected limb, let alone exercise with it. This idea has since been found to have no basis to it. There has been no consistent research or evidence found that would conclude exercise creates or worsens lymphedema.
You should use the arm, not only to help with encouraging lymphatic flow, but also to prevent and treat associated shoulder dysfunction; however, research has found that the best type of exercise for those at risk or who have developed lymphedema can include light aerobic activity and a gradually progressive weight training program. These types of exercise regimens will help to encourage lymphatic flow without overwhelming the system.
Exercise is found most beneficial and helpful for lymphedema when a compression garment is being worn concurrently, such as with a compression sleeve and glove. A medical grade compression garment is made with a sequential gradient of compression, with the greatest compressive forces at the most distal end of the limb, where gravity tends to pull the lymphatic fluid, and sequentially lessens as it moves up the limb. These assist in pumping the fluid in an upward direction.
An important note with exercise and lymphedema is that if while exercising you begin feeling excessive fatigue, heaviness, or tightness in the lymphedematous limb, you may be exercising too aggressively. This is a sign from your body to lessen the activity level.
Just like with utilizing excessive deep pressure, such as with massage, can overload the congested portion of the lymphatic system, being too aggressive with your exercise routine can increase this workload as well. It’s all about balance.
Compression:
Compression is a vital component of treating lymphedema. If the swelling has become advanced enough, then more aggressive measures are needed to treat it. This normally involves bandaging with layers of padding underneath.
If there is concern for the functional ability to maintain and re-create the effects of bandaging, compression wraps are a successful alternative. These are Velcro compression wraps, which offer a similar adjustable compression option for attempts at reducing the swelling.
If you are in the early stages of lymphedema, it may be possible to transition into a compression sleeve. If you also are experiencing swelling into the hand and fingers, then concurrent use of a compression gauntlet or glove would be recommended, respectively.
While there are mixed opinions regarding the use of a light compression garment option for prevention of lymphedema, it is worth it to consider use of an item like this in certain scenarios.
Specific situations and activities have been found to potentially increase risk of lymphedema onset. This includes travel, vigorous exercise, extended outdoor activities such as gardening, and any task that requires repetitive use of the arm. In such situations, there is the option of using a lighter compression garment for additional efforts to prevent lymphedema, as long as your medical history provides no reason for you to avoid using an item like this.
Reference:
- Rockson, M.D. SG. Lymphedema after Breast Cancer Treatment. Solomon, M.D., M.P.H. CG, ed. N Engl J Med 2018; 379:1937-1944. doi: 10.1056/NEJMcp1803290. Accessed September 24, 2022.
