Prevention
Treatment
        Compression garments
        Drug therapy
        Dietary Management
        Pain Management
        Complications
Psychosocial considerations

Prevention

Patients at risk for lymphedema should be identified early, monitored, and taught self-care. A patient may be more likely to develop lymphedema if he or she eats an inadequate diet, is overweight, is inactive, or has other medical problems. To detect the condition early, the following should be examined:

• Comparison of actual weight to ideal weight.
• Measurements of the arms and legs.
• Protein levels in the blood.
• Ability to perform activities of daily living.
• History of edema, previous radiation therapy, or surgery.
• Other medical illnesses such as diabetes, high blood pressure, kidney disease, heart disease, or phlebitis (inflammation of the veins).

It is important that the patient know about his or her disease and the risk of developing lymphedema. Poor drainage of the lymphatic system due to surgical removal of the lymph nodes or to radiation therapy may make the affected arm or leg more susceptible to serious infection. Even a small infection may lead to serious lymphedema. Patients should be taught about arm, leg, and skin care after surgery and/or radiation (see Considerations for Teaching Patients Prevention and Control of Lymphedema below). It is important that patients take precautions to prevent injury and infection in the affected arm or leg because lymphedema can occur 30 or more years after surgery. Breast cancer patients who follow instructions about skin care and proper exercise after mastectomy are less likely to experience lymphedema.

Lymphatic drainage is improved during exercise; therefore, exercise is important in preventing lymphedema. Breast cancer patients should do hand and arm exercises as instructed after mastectomy. Patients who have surgery that affects pelvic lymph node drainage should do leg and foot exercises as instructed. The doctor decides how soon after surgery the patient should start exercising. Physiatrists (doctors who specialize in physical medicine and rehabilitation) or physical therapists should develop an individualized exercise program for the patient.

Better recovery occurs when lymphedema is discovered early, so patients should be taught to recognize the early signs of edema and to tell the doctor about any of the following symptoms:

• Feelings of tightness in the arm or leg.
• Rings or shoes that become tight.
• Weakness in the arm or leg.
• Pain, aching, or heaviness in the arm or leg.
• Redness, swelling, or signs of infection.

Considerations for Teaching Patients Prevention and Control of Lymphedema

1. Keep the arm or leg raised above the level of the heart, when possible. Avoid making rapid circles with the arm or leg to keep blood from collecting in the lower part of the limb.



2. Clean the skin of the arm or leg daily and moisten with lotion.



3. Avoid injury and infection of the arm or leg.
   • Arms:
     • Use an electric razor for shaving.
     • Wear gardening and cooking gloves.
     • Use thimbles for sewing.
     • Take care of fingernails; do not cut cuticles.
   • Legs:
     • Keep the feet covered when outdoors.
     • Keep the feet clean and dry; wear cotton socks.
     • Cut toenails straight across; see a podiatrist as needed to prevent ingrown nails and infections.
   • Either arms or legs:
     • Suntan gradually; use sunscreen.
     • Clean cuts with soap and water, then use antibacterial ointment.
     • Use gauze wrapping instead of tape; do not wrap so tight that circulation is cut off.
     • Talk to the doctor about any rashes.
     • Avoid needle sticks of any type in the affected arm or leg.
     • Avoid extreme hot or cold such as ice packs or heating pads.
     • Do not overwork the affected arm or leg.



4. Do not put too much pressure on the arm or leg.
   • Do not cross legs while sitting.
   • Wear loose jewelry; wear clothes without tight bands.
   • Carry a handbag on the unaffected arm.
   • Do not use blood pressure cuffs on the affected arm.
   • Do not use elastic bandages or stockings with tight bands.
   • Do not sit in one position for more than 30 minutes.



5. Watch for signs of infection, such as redness, pain, heat, swelling, and fever. Call the doctor immediately if any of these signs appear.



6. Do prescribed exercises regularly as instructed by the doctor or therapist.



7. Keep regular follow-up appointments with the doctor.



8. Check all areas of the arms and legs every day for signs of problems.
   • Measure around the arm or leg at regular intervals as suggested by the doctor or therapist.
   • Measure the arm or leg at the same two places each time.
   • Tell the doctor if the limb suddenly gets larger.



9. The ability to feel sensations such as touch, temperature, or pain in the affected arm or leg may be lessened. Use the unaffected limb to test temperatures for bath water or cooking.

Lymphedema is treated by physical methods and with medication. Physical methods include supporting the arm or leg in a raised position, manual lymphatic drainage (a specialized form of very light massage that helps to move fluid from the end of the limb toward the trunk of the body), wearing bandages or custom-fitted clothing, such as stockings, that apply controlled pressure around the affected limb, and cleaning the skin carefully to prevent infection. Lymphedema may be treated by combining several of these physical methods. This is known as complex physical therapy (or complex decongestive therapy). which consists of manual lymphedema treatment, compression wrapping, individualized exercises, and skin care followed by a maintenance program. Complex physical therapy must be performed by a professional trained in the techniques.

Surgery for treating lymphedema usually results in complications and is seldom recommended for cancer patients.

When pressure garments are used, they should cover the entire area of edema. For example, a stocking that reaches only to the knee tends to become tight and block the lymphatic vessels and veins if there is edema in the thigh. Pumps connected to cuffs that wrap around the arm or leg and apply pressure on and off may be helpful; however, some physicians and therapists feel these pumps are not effective and may make the edema worse. The cuff is inflated and deflated according to a controlled time cycle. This pumping action is believed to increase the movement of fluid in the veins and lymphatic vessels and keeps fluid from collecting in the arm or leg. Compression pumps should be used only under the supervision of a trained health care professional because high external pressure can damage the lymphatic vessels near the skin surface.

Antibiotics may be used to treat and prevent infections. Other types of drugs such as diuretics or anticoagulants (blood thinners) are generally not helpful, and may make the problem worse.

Finding the exact cause of the swelling and treating it correctly is important. Edema often leads to infection, which then increases fluid and protein deposits in the tissues. If an infection is diagnosed, appropriate antibiotics should be given. Blood clots should be ruled out because massage and other therapy techniques to encourage drainage may cause the clots to move through the bloodstream and cause more serious heart or lung problems. If blood clots are found, they should be treated with anticoagulants.

Coumarin is a dietary supplement that has been studied as a treatment for lymphedema. In the United States, dietary supplements are regulated as foods, not drugs. Supplements are not required to be approved by the Food and Drug Administration (FDA) before being put on the market. Because there are no standards for manufacturing consistency, dose, or purity, one lot of dietary supplements may differ considerably from the next.

Coumarin was once used in some foods and medications in the United States. It was found to cause liver damage, and its use in foods and medications in the United States has been banned since the 1950s. Coumarin is available in several countries, but has not been approved for use in the United States or Canada.

The nutritional status of the patient should be evaluated and appropriate dietary recommendations should be made. Blood protein levels and weight should be monitored regularly, and patients should be encouraged to eat protein-rich foods.

Patients with lymphedema may experience pain caused by the swelling and pressure on nerves; loss of muscle tissue and function; or scar tissue causing shortening of muscles and less movement at joints. Pain may be treated with medications, relaxation techniques, and/or transcutaneous electrical nerve stimulation (TENS); however, the most successful treatment is to decrease the lymphedema.

Edema can make tissues less able to take in nutrients and more likely to be damaged if the affected limb is not moved for long periods. Therefore, patients with lymphedema should be monitored for areas of skin breakdown, especially over areas with very little tissue between the skin and bone (i.e., hips, knees, and elbows).

Bladder emptying problems can develop from lymphedema in the pelvic or groin areas. Patients with lymphedema who are also taking opioids may develop bowel problems. Bowel and bladder status should be monitored regularly for any signs of urine retention or constipation.

Because lymphedema is disfiguring and sometimes painful and disabling, it can create mental, physical, and sexual problems. Several studies have noted that women who develop lymphedema after treatment for breast cancer have more mental, physical, and sexual difficulties than women who do not develop lymphedema. The added stresses associated with lymphedema may interfere with treatment that is often painful, difficult, and time-consuming.

Coping with lymphedema in the arm after breast cancer treatment is especially difficult for patients who have little social support. Some patients may react to the problem by withdrawing. Coping is also difficult for patients with painful lymphedema. Patients with lymphedema may be helped by group and individual counseling that provides information about ways to prevent lymphedema, the role of diet and exercise, advice for picking comfortable and flattering clothes, and emotional support.

(See the PDQ summaries on Normal Adjustment and the Adjustment Disorders and Sexuality and Reproductive Issues for more information.

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