Anne Williams gives a guide to patient self massage in the management of lymphedema. Anne F. Williams RGN, MSc, DN, RNT, Onc Cert, is a Lymphoedema Specialist Practitioner Dalkeith, Scotland.
Article accepted for publication: November 2005
Keywords: Lymphoedema Lymphatic system; Simple lymphatic drainage (SLD) Manual lymphatic drainage (MLD); Decongestive Lymphatic Therapy (DLT); Lymphedema
The incidence of lymphoedema following breast cancer treatment is around 21 per cent (Clark et al., 2005) with reported prevalence rates as high as 38 per cent (Kissen et al., 1996; Mortimer et al., 1996). In most cases lymphoedema may remain relatively mild but is usually a chronic condition requiring lifelong treatment and care. Self-management practices therefore play a crucial role in maximising long-term independence in people with lymphoedema. This paper will overview the problem of breast cancer-related lymphoedema, discuss the principles and evidence base underlying the use of massage in lymphoedema and describe the practical application of a patient self-massage method for breast cancer-related lymphoedema.
Breast cancer-related lymphedema Lymphoedema presents as swelling of the arm and/or trunk and may affect the whole limb or be confined to the breast, hand, forearm or upper arm. Surgery and radiotherapy, particularly the level of axillary lymph node intervention, is widely acknowledged as impacting on lymphoedema incidence. Recently, specific risk factors including hospital skin puncture, mastectomy and BMI Ž 26 have been found to be significant (Clark et al., 2005). As the arm and adjacent trunk quadrant share lymph drainage routes via the axilla, trunk edema may occur, particularly posterior to the axilla. Since the advent of breast conservation surgery, breast oedema is also more common (Mondry & Johnstone, 2002) although this problem is rarely acknowledged in the literature.
The management of breast cancer-related lymphoedema requires a partnership between the patient and practitioner. Intensive treatment by the practitioner including daily manual lymphatic drainage massage and multi-layer bandaging, may be required to reduce limb volume, reshape the limb and improve skin and tissue condition. In the maintenance phase treatment is undertaken by the patient who develops significant expertise in self-care measures including skin care, exercises, wearing of hosiery garments and a type of self-massage often referred to as simple lymphatic drainage (SLD), a modified form of manual lymphatic drainage (MLD).
Manual lymphatic drainage is a specialised type of massage developed in the 1930's by Dr Emil Vodder, a Danish physical therapist who realised that gentle but very specific hand movements on the skin could influence the lymphatic system (Table 1). Several schools of MLD now exist worldwide including the Vodder, Földi, Casley-Smith and Leduc, although all follow similar principles in relation to lymphoedema treatment (Table 2).
Effectively, MLD moves the skin in specific directions to provide variations in tissue pressure that encourage the uptake of fluid and proteins into the initial lymphatics, without increasing capillary filtration. The movements also enhance the natural contraction of pre-collector and collector lymphatics and can be applied to influence drainage through lymph node groups.
MLD is most effective when used in combination with compression therapy, skin care and appropriate exercise and may be applied daily for a course of 2-4 weeks (Table 3). Treatment usually takes 30-60 minutes and begins centrally and proximally, often with clearance of the neck lymphatics and breathing exercises. The healthy, unaffected lymph nodes and trunk are then treated prior to treatment of the affected trunk and limb. MLD is used on the anterior and posterior trunk where possible. In a patient with a right-sided arm lymphoedema, the direction of drainage is usually towards the healthy lymph nodes in the left axilla and right inguinal areas.
Application of self-massage techniques to lymphoedema practice began in the UK in the late 1980's partly due to limited accessibility to MLD at this time (Badger et al., 1988). The British Lymphology Society later described this approach as 'simple lymphatic drainage' (SLD), based on the principles of MLD and designed to be easily accessible to patients and their relatives (British Lymphology Society, 1999). The main focus of SLD is treatment of the trunk, using simple hand movements and breathing exercises.
et al., 1988). The British Lymphology Society later described this approach as 'simple lymphatic drainage' (SLD), based on the principles of MLD and designed to be easily accessible to patients and their relatives (British Lymphology Society, 1999). The main focus of SLD is treatment of the trunk, using simple hand movements and breathing exercises.
There is a limited evidence base related to the use of manual lymphatic drainage, mainly in breast cancer-related lymphoedema. Various studies have highlighted the efficacy of MLD in reducing limb volume and improving aspects of quality of life (Sitzia et al., 2000; Williams et al., 2002). Johansson et al. (1999) also reported a significant reduction in excess limb volume and pain following MLD and compression bandaging, as compared to compression bandaging alone. Other studies have suggested that MLD does not contribute to limb volume reduction (Anderson et al., 2000) or is more effective in certain groups such as those with mild lymphoedema (McNeeley et al., 2004). However, many studies are limited by small samples, short study periods and unreliable or insufficient outcome measures, such as no measurement of trunk oedema.
Similarly, studies of SLD have failed to provide longitudinal data on the effect of long term self-massage and to date there is no empirical evidence to support the use of SLD despite its wide use in clinical practice. Much of the literature on self-massage is from the UK and Australia, describing a variety of techniques (Gillham, 1994; Bellhouse, 2000). Most information leaflets on lymphoedema also contain a section on SLD and videos from organisations such as the Lymphoedema Support Network provide useful instructions on SLD.
Studies of self-management practices have highlighted the difficulties for patients in adhering to treatment routines (Rose et al., 1991; Bunce et al., 1994). Piller et al. (1994) have described the importance of self-massage in maintaining and improving results of intensive treatments and discuss the use of massage at a focal point of the day, such as during showering, to improve adherence. The use of partners or carers in providing the massage has been described (Casley-Smith & Casley-Smith, 1997; Forchuk et al., 2004) and the fact that patients who have experienced MLD appear to be more confident using SLD has also been identified (Williams et al., 2002).
No definitive method of SLD exists and the method taught will depend on the individual needs of the patient and the type of MLD used by the lymphoedema practitioner. Table 4 provides an example of an SLD sequence for treatment of right sided breast cancer-related lymphoedema.
Breathing exercises are important as they enable clearance of the central lymphatics and influence lymph flow up the thoracic duct and into the venous system (Vaqas & Ryan, 2003). Treatment of the neck and shoulder aims to enhance drainage towards the lymph nodes at the neck and supraclavicular fossa, adjacent to the area where the lymphatics drain into the venous circulation. Massage to the unaffected lymph nodes and trunk clears the way ahead, encouraging fluid to drain away from the oedematous areas. The treatment of the midline watershed areas is probably important in opening the collateral pathways that are required in the longer term although the scientific and functional changes produced by MLD or SLD have not been fully established. SLD treatment of the arm and shoulder is useful in some patients, following trunk clearance although not included here.
SLD is a specialised technique requiring a very gentle touch, slow pace and many repetitions, as with MLD. This can be difficult to achieve and patients need to be advised to avoid firm pressures, using talc if necessary to prevent friction and skin reddening. A clear description of the lymphatic system along with explanation and rationale for the treatment is important to enable patients to understand why and how it is used. Several other points should be considered when teaching SLD:
Patients should be encouraged to fit SLD in with their lifestyle, finding a suitable time of the day with minimal distractions.
Adhering to a prolonged course of SLD may be daunting for some patients and one option is to suggest using SLD for a given period of time such as 6-8 weeks. At this point the frequency of treatment may be reduced, with SLD used at particular times, after a long car journey for example, when the limb has become more swollen.
Simple lymphatic drainage is used to supplement and complement MLD treatments. Further research is however required to inform practice in this area and evaluate the role and use of SLD over the longer term. Consideration should be given to how and when SLD is taught to exploring the use of information and teaching resources for this patient group.
Table 1: The lymphatic system
The lymphatic system consists of a complex network of lymph vessels and approximately 700 lymph nodes, many of which are situated in groups in the neck, axilla, inguinal area and deep in the abdomen. Variation in tissue pressures encourages interstitical fluid to move into the plexus of thin walled lymph capillaries in the dermis and through a series of pre-collector and collector lymphatics that gradually increase in size. It is then filtered through the lymph nodes before being returned to the blood circulation. One of the largest lymph vessels, the thoracic duct runs alongside the aorta and drains the lymph from the legs and left side of the body. The right lymphatic duct drains the right upper body. These large vessels drain into the venous blood circulation near the subclavian vein.
The lymphatic system has various functions:
The superficial lymph drainage routes of the skin are divided into skin territories or lymphotomes according to the direction of flow into regional lymph node groups. The division between these territories is often referred to as the 'watershed'.
Table 2: Principles of MLD and SLD in lymphoedema
Table 3: Indications and contraindications for MLD and SLD in lymphoedema
Useful in the maintenance phase when patients are undertaking self treatment (daily use).
- Sit or lie down with shoulders relaxed and hands resting below ribs. - Breathe in and feel your abdomen rising (imagine a balloon inflating under your hands). - Slowly breathe out and press gently inwards with your hands. - Repeat 5 times.
- Place your relaxed hands on your neck below your ears. - Gently stretch or stroke the skin down towards your shoulders and release. - Repeat this 5 times.
- Place your relaxed hands on your shoulders and stroke inwards to the hollow behind your collarbone. - Use your finger pads to make gentle pressures into the hollow behind your collarbone. - Repeat this 5-10 times.
- Place your right hand in your left armpit. - Massage upwards into your armpit and release (10 times). - Ensure the direction is always upwards.
- Place relaxed hand on your chest. - Stroke the skin across towards your left armpit. - Repeat from position 1 x 10 times. - Repeat from position 2 x 10. - Repeat from position 3 x 10. - Always stroke in the direction towards the left armpit
- Place relaxed hand below your waist on the right side. - Stroke the skin downwards over the hip. - Repeat from position 1 x 10 times. - Repeat from position 2 x 10. - Repeat from position 3 x 10. - Always stroke down away from the affected area.
- Sitting or lying. - Massage upwards into the left armpit and release (10 times). - Ensure the direction is always up.
- Place relaxed hand/s on the back. - Stroke the skin across towards the left armpit. - Repeat from position 1 x 10 times. - Repeat from position 2 x 10. - Repeat from position 3 x 10. - Always stroke in the direction towards the left armpit.
Internet Credit: JCN Online
A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema.
Standard Treatment of Lymphedema–Patient Education–Self-Management
Axillary Web Syndrome (Cording)
These are garments that are designed to help control the swelling and should be utilized after you have undergone treatment to reduce to the size of your arm. They are also used inconjunction with compression bandage wrapping.