MLD (manual therapy) for lymphedema should begin with someone specially trained in treating lymphedema.

• In this type of massage, the soft tissues of the body are lightly rubbed, tapped, and stroked.
• It is a very light touch, almost like a brushing.
• MLD may help move lymph out of the swollen area into an area with working lymph vessels.
• Patients can be taught to do this type of massage therapy themselves by a certified lymphatic therapist. (NCI)

Effects:

• Increases reabsorption of protein rich fluid
• Increases lymphatic activity
• Promotes relaxation
• Creates and analgesic effect (Klose Education)

When done correctly, massage therapy does not cause medical problems.

• Massage should not be done on any of the following:
  • Open wounds, bruises, or areas of broken skin.
  • Tumors that can be seen on the skin surface.
  • Areas with deep vein thrombosis (blood clot in a vein).
  • Sensitive soft tissue where the skin was treated with radiation therapy. (NCI)

Contraindications:

• Acute infections, such as cellulitis
• Untreated congestive heart failure (CHF)
• Malignant disease – cancer
• Renal dysfunction
• Acute undiagnosed DVT (Klose Education)

• Once the lymph fluid is moved out of a swollen limb, bandaging (wrapping) can help prevent the area from refilling with fluid.
• Bandages also increase the ability of the lymph vessels to move lymph along.
• Lymphedema that has not improved with other treatments is sometimes helped with bandaging. (NIH)

INDICATIONS:

• Lymphedema
• Chronic venous insufficiency (CVI )
• Combination venous and lymphatic edema
• Lipedema
• Post‐traumatic edema
• Post‐surgical edema
• Acute DVT (with physician dx)

CONTRAINDICATION:

• Acute infections (MD must clear patient)
• Arterial wounds
• Arterial disease (ABI 0.8 or below)
• Acute DVT (without physician dx)
• Cardiac edema (untreated CHF)
• Acute trauma without diagnosis

PRECAUTIONS:

• Sensory deficits
• Malignancy
• Diabetes – Small vessel (arteriole) and sensory deficits
  • Toe bandaging may be contraindicated
• Paralysis
• Poor cognition or altered mental status
• Sensitivity to the products used for bandaging (Klose Education)

Pressure garments are made of fabric that puts a controlled amount of pressure on different parts of the arm or leg to help move fluid and keep it from building up.

• Some patients may need to have these garments custom-made for a correct fit.
• Wearing a pressure garment during exercise may help prevent more swelling in an affected limb.
• It is important to use pressure garments during air travel, because lymphedema can become worse at high altitudes.
• Pressure garments are also called compression sleeves and lymphedema sleeves or stockings. (NIH)

Compression devices are pumps connected to a sleeve that wraps around the arm or leg and applies pressure on and off.

• • The sleeve is inflated and deflated on a timed cycle.
• This pumping action may help move fluid through lymph vessels and veins and keep fluid from building up in the arm or leg.
• Compression devices may be helpful when added to complete decongestive therapy.
• The use of these devices should be supervised by a trained professional because too much pressure can damage lymph vessels near the surface of the skin. (NIH)

Weight loss

• In patients who are overweight, lymphedema related to breast cancer may improve with weight loss.

Laser therapy

• Laser therapy may help decrease lymphedema swelling and skin hardness after a mastectomy.
• A hand-held, battery-powered device is used to aim low-level laser beams at the area with lymphedema.

Drug therapy

• Lymphedema is not usually treated with drugs.
• Antibiotics may be used to treat and prevent infections.
• Other types of drugs, such as diuretics or anticoagulants (blood thinners), is usually not helpful and may make the lymphedema worse.

Surgery

• Lymphedema caused by cancer is rarely treated with surgery. NIH

The axillary reverse mapping (ARM) technique has been developed to map and preserve arm lymphatic drainage during ALND and/or SLNB, thereby minimizing arm lymphedema.

• However, the success of ARM in reducing lymphedema has not been exactly determined.
• If ARM can be confirmed to be both effective and oncologically safe in preventing lymphedema, this technique should be recommended in the management of breast cancer treatment. (NIH) – National Library of Medicine.

Axillary Reverse Mapping (ARM): Where to Go

• Lymphedema is a major chronic morbidity that occurs in patients undergoing treatment for breast cancer (BC). Surgery for BC includes axillary surgery with either sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND).
• Lymphedema occurs due to removal or disruption of lymphatic drainage of the arm that overlaps with drainage of the breast.
• The risk of lymphedema increases significantly with adjuvant radiation.
• Axillary reverse mapping (ARM) is a technique where blue dye is injected into the upper arm at surgery, allowing direct visualization of arm lymphatics and nodes during either SLNB or ALND.
  • This allows preservation of arm lymphatics unless there is suspicion of metastatic disease in ARM lymphatics or if the ARM node is/are also the sentinel lymph node.
• Studies to date have largely been observational cohort studies, and mainly with low risk patients undergoing SLNB only.
  • There is only one published randomized controlled trial, and this included only patients undergoing modified radical mastectomy. 
  • (NIH) – National Library of Medicine.

 Axillary Reverse Mapping (ARM) Technique (ARM)

• Traditionally, the rates of arm swelling after sentinel node biopsy range from 3‐8%1 and from 13‐40%2 after axillary dissection surgery.
  • The studies that looked at ARM show a lymphedema rate that is lower, around 1‐3% for the sentinel node surgery and 4‐9%3 for the axillary dissection surgery.
• Sometimes, it is not always possible to do ARM, and the surgeon needs to inject the blue dye in the breast to help identify the correct lymph nodes.
  • This may be the case if you have had previous chemotherapy in the breast, or if the lymph nodes are not accurately found with other methods.
• Additionally, it is possible that the blue lymph nodes and the channels that are identified to drain the arm need to be removed to treat your cancer safely.
  • If this is the case, you may be placed in a special group to watch your arm swelling closely, or even have the option of having these channels reconnected.
  • This is usually done by surgeons well experienced in lymphatic surgery, and may include plastic surgeons also. Summit Education: Oncology Rehab Dec 12, 2019