Chapter 25: Management of Lymphatic Disorders

Impairments of the lymphatic system can lead to lymphatic insufficiencies that can result in significant physical impairments and subsequent loss of function of either the upper or lower extremities. Disturbances in structure or function can lead to accumulation of lymphatic fluids in the tissue of the body that affect the physiological health of the tissue, impair joint mobility, and impact daily functioning. Lymphatic dysfunction can be a result of a congenital or hereditary abnormality or can be caused by trauma, infection, or treatment for a cancer.

To contribute to the effective management of patients with lymphatic disorders, a therapist must possess a sound understanding of the underlying pathologies and the clinical manifestations of many types of lymphatic disorders, as well as the interplay between the lymphatic and venous systems. A therapist must also be aware of the use, effectiveness, and limitations of therapeutic exercise in the comprehensive management and rehabilitation of patients with lymphatic insufficiencies.

Structure and Function of the Lymphatic System

The primary function of the lymphatic system is to collect and transport fluid from the interstitial spaces back to the venous circulation (Fig. 25.1).^{30,35,47,52,105,107} This is accomplished with a series of lymph vessels and lymph nodes.^30,35,107 The lymphatic system also has a role in the body's immune function.^30,105,107 When the lymphatic system is compromised either by impairment of lymphatic structures or by an overload of lymphatic fluid, the result is swelling in the tissue spaces. Edema is a natural consequence of trauma to and subsequent healing of soft tissues. If the lymphatic system is compromised and does not function efficiently, lymphedema develops and impedes wound healing.

Lymphedema is an excessive and persistent accumulation of extravascular and extracellular fluid and proteins in tissue spaces.^{11,18,26,47,61,107} It occurs when lymph volume exceeds the capacity of the lymph transport system, and it is associated with a disturbance of the water and protein balance across the capillary membrane. An increased concentration of proteins draws larger amounts of water into interstitial spaces, leading to lymphedema.^26,41,107 Furthermore, many disorders of the cardiopulmonary system can cause the load on lymphatic vessels to exceed their transport capacity and subsequently cause lymphedema.^41,61

Anatomy of the Lymphatic System

The lymphatic system is an open system.^30,57,107 The lymphatic capillaries are situated close to the blood capillaries and are responsible for pulling the fluid into the lymphatic circulation (Fig. 25.2).^{30,47,57,105,107} Once inside the lymphatic vessels, the fluid is transported from lymph nodes to lymphatic trunks.^{30,57,105,107} The end result is the collection of the lymphatic fluid at the venous angles. In total, the body has 600 to 700 lymph nodes with the largest grouping found in the head and neck, around the intestines, and in the axilla and groin.^30,107

Physiology of the Lymphatic System

The main components of lymphatic fluid are water and protein found in the extracellular spaces.^26,30,41,57 In a normal state, the lymphatic system transports this fluid back to the venous circulation. The amount of fluid transported is the lymphatic load, and the amount of fluid the lymphatic system can transport is the transport capacity.^30,107 When the balance in the interstitium is disrupted, whether by an increased lymphatic load or a decreased transport capacity, lymphedema can develop.^26,30,41,107 Lymphatic load is increased when the venous system is unable to transport the required amount of fluid, which can occur in a patient with a venous insufficiency. Transport capacity is affected when the structures of the lymphatic system are impaired, for example, following surgery to remove lymph nodes in a patient with cancer.

Types of Lymphedema

Lymphedema can be classified as primary, meaning there is an inherent problem with the structures of the lymphatic system, or secondary, meaning there is an injury to lymphatic structures.^30,41,107 This injury may be in the form of surgery, radiation, trauma, or infection. Lymphedema can also be caused by a combination of lymphatic-venous dysfunction commonly seen in patients with chronic venous insufficiency. Remember, lymphedema is not a disease but rather a symptom of a malfunctioning lymphatic system.

Primary Lymphedema

Primary lymphedema, although uncommon, is the result of insufficient development (dysplasia) and congenital malformation of the lymphatic system.^35,40

Primary lymphedema can be divided into the age of presentation.^30,41

• Congenital: presents at birth and is sometimes known as Milroy's disease

• Praecox (early): develops prior to 35 years of age

• Tarda: develops after 35 years of age

Primary lymphedema typically affects more females than males and presents more often in the extremities, more so in the lower than upper extremities. However, it can be seen in other areas of the body as well.^30,41,57,107 If not managed properly, this type of lymphedema can progress over time and present with skin changes (hyperkeratosis) and increased skin folds and skin creases.^{30,41,52,98,102}

Secondary Lymphedema

Most of the patients seen by healthcare practitioners for management of lymphedema have secondary lymphedema.⁸³ By far, the most common causes of secondary lymphedema are related to the comprehensive management of cancers of the breast, pelvis, and abdomen.^{3,10,11,35,40,41,83,84} Secondary lymphedema is classified by the cause of the injury to the lymphatic structures including:

• Surgery

• Inflammation and infection

• Obstruction or fibrosis

• Combined venous-lymphatic dysfunction (chronic venous insufficiency)

Surgical Dissection of Lymph Nodes

Lymph nodes and vessels often are surgically removed (lymphadenectomy) as an aspect of treatment of a primary malignancy or metastatic disease. For example, axillary lymph node dissection is performed in most types of breast cancer surgeries to determine the extent and progression of breast cancer.^12,15,35,49 Likewise, pelvic or inguinal lymph node excision often is necessary for the treatment of pelvic or abdominal cancers.^3,83,84

Infection and Inflammation

Inflammation of the lymph vessels (lymphangitis) or lymph nodes (lymphadenitis) and enlargement of lymph nodes (lymphadenopathy) can occur as the result of a systemic infection or local trauma. Any of these conditions can cause disruption of lymph circulation.^35,40,41,107

Obstruction or Fibrosis

Trauma, surgery, and neoplasms can block or impair the lymphatic circulation.^35,41,97 Radiation therapy associated with treatment of malignant tumors also can cause fibrosis of vessels.^3,12

Combined Venous-Lymphatic Dysfunction

Although not a primary disorder of the lymphatic system, chronic venous insufficiency and varicose veins are associated with venous stasis and accumulation of edema in the extremities.^35,40,55,107 Dependent, peripheral edema occurring with long periods of standing or sitting is a common manifestation of chronic venous dysfunction. Edema decreases if the limb is elevated. Patients often report dull aching or tiredness in the affected extremity.^{27,35,40,55,79,107} If the insufficiency is associated with varicose veins, venous distention (bulging) also is notable. When edema persists, the skin becomes less supple over time and takes on a brownish pigmentation.

With time, a continued increase in the lymphatic work load imposed by the venous system causes a combined venous-lymphatic dysfunction. The lymphatic system begins to lose efficiency with the increased workload imposed over time, and a mixed edema results.¹⁰⁷ A venous-lymphatic dysfunction has a mixture of low protein edema from the venous system and a high protein edema from the lymphatic system.

Clinical Manifestations of Lymphatic Disorders

Lymphedema

Location. When lymphedema develops, it is most often apparent in the distal extremities, particularly over the dorsum of the foot or hand.^26,41 The term dependent edema describes the accumulation of fluids in the peripheral aspects of the limbs, particularly when the distal segments are lower than the heart. In contrast, lymphedema can manifest more centrally, for example, in the axilla, groin, or even the trunk.^26,35,40,107 Thorough assessment of the entire limb and regional area is important to define the extent of swelling.

Severity. The severity of lymphedema may be described quantitatively or qualitatively. Lymphedema is described by the severity of changes that occur in skin and subcutaneous tissues. The three categories—pitting, brawny, and weeping edema—are described in Box 25.1. Although all three types reflect a significant degree of lymphedema, they are listed in order of severity, from least severe to most severe.^{15,18,35,40,90}

Another common way to define the severity of lymphedema is through staging. Staging refers to the physical condition of the limb only.⁵² The stages are described in Box 25.2.^30,52,57,107 Stage 0 or the latency stage might present with the greatest possibility for reducing the onset of worsening lymphedema. This is especially true in the patient with secondary lymphedema from cancer surgery.

Increased Size of the Limb

As the volume of interstitial fluid in the limb increases, so does the size of the limb (weight and girth).^14,41,55,107 Increased volume, in turn, causes tautness of the skin and susceptibility to skin breakdown.^15,35

Descriptors, such as mild, moderate, and severe, sometimes are based on how much larger the size of the edematous limb is compared to the noninvolved limb.⁶¹ However, there are no standard definitions associated with size and severity.

Sensory Disturbances

Paresthesia (tingling, itching, or numbness) or occasionally a mild, aching pain may be felt, particularly in the fingers or toes. In many instances the condition is painless, and the patient perceives only a sense of heaviness of the limb. Fine finger coordination also may be impaired as the result of the sensory disturbances.^15,41,77,90

Stiffness and Limited Range of Motion

Range of motion (ROM) decreases in the fingers and wrist or toes and ankle or even in the more proximal joints, leading to decreased functional mobility of the involved segments.^15,69

Decreased Resistance to Infection

Wound healing is delayed; and frequent infections (e.g., cellulitis) may occur.^41,53,55,107 Early recognition and treatment of cellulitis has shown to be important in reducing further tissue damage.^24,103

Examination and Evaluation of Lymphatic Function

A patient's history, a systems review, and specific tests and measures provide information to determine impairments and functional limitations that can arise from lymphatic disorders and the presence of lymphedema. Key components in the examination process that are particularly relevant when lymphatic dysfunction is suspected or lymphedema is present are summarized in this section.^{16,27,55,69,93,107} Other tests and measurements, such as vital signs, ROM, strength, posture, and sensory, functional, and cardiopulmonary testing, are also appropriate.

History and Systems Review

Note any history of infection, trauma, surgery, or radiation therapy. If a patient has a history of cancer and received chemotherapy, a review of the treatment and duration of the chemotherapy treatment is also important. The onset and duration of lymphedema, delayed wound healing, or previous treatment of lymphedema are pertinent pieces of information. Identify the occupation or daily activities of the patient, and determine if long periods of standing or sitting are required. Specific questioning to determine a pattern to the swelling can also aid in treatment planning.

Examination of Skin Integrity

Visual inspection and palpation of the skin provide information about the integrity of the skin. The location of the edema should be noted. When the limb is in a dependent position, palpate the skin to determine the type and severity of lymphedema and changes in skin and subcutaneous tissues. Describe the thickness and density of the tissue in each area of the limb. Areas of pitting, brawny, or weeping edema should be noted.

The presence of wounds or scars and the color and appearance of the skin, which is often shiny and red in the edematous limb, should be noted. Document any papillomas, hyperkeratosis, or darkening of the skin, especially in the lower extremities. Photographic documentation is convenient in the clinical or home setting and provides visual evidence of changes in skin integrity. If a wound or scar is identified, its size should be noted, as should scar mobility or the presence of inflammation or infection in a wound.

A positive Stemmer sign, an indication of Stage II or III lymphedema, may be identified during palpation (Fig. 25.3). It is considered positive if the skin on the dorsal surface of the fingers or toes cannot be pinched or is difficult to pinch compared with the uninvolved limb.^{30,57,82,99,107} A positive Stemmer sign can be indicative of a worsening condition.

Girth Measurements

Circumferential measurements of the involved limb should be taken and compared with the noninvolved limb if the problem is unilateral.^14,77 Identify specific intervals or landmarks at which measurements are taken so measurements during subsequent examinations are reliable. Use of circumferential measurements at anatomical landmarks has been shown to be a valid and reliable method of calculating limb volume.^2,93

Volumetric Measurements

An alternative method of measuring limb size is to immerse the limb in a tank of water to a predetermined anatomical landmark and measure the volume of water displaced.^14,93 Although this method also has been shown to be valid and reliable, for routine clinical use, it is more cumbersome and less practical than girth measurements.^2,93

Bioimpedance Measurements

Bioimpedance measurements involve the use of a low-level, alternating electrical current to measure the resistance to the flow through the extracellular fluid in the upper extremities.^25,81,96 The higher the resistance to flow, the more extracellular fluid present. Testing is fairly easy to perform, requiring only placement of skin electrodes.

For any bioimpedance value to be meaningful, initial testing must take place prior to surgery.⁶⁵ Testing can then be performed at set intervals throughout the treatment continuum. This affords the opportunity for intervention at an earlier stage in the development of lymphedema. Other factors that affect volume in the body can theoretically affect the bioimpedance reading; therefore, this must be considered.^{25,65,81,82,96} There is still much to be learned about bioimpedance testing and how this correlates to lymphedema.

Lymphedema Risk Reduction

If a patient is at risk of developing lymphedema secondary to infection, inflammation, obstruction, surgical removal of lymphatic structures, or chronic venous insufficiency, reducing the risk of lymphedema should be the priority of patient management. In some situations, such as after removal of lymph nodes or vessels, risk-reducing measures may be needed for a lifetime. Even when a patient takes every measure to reduce the risk of edema, it still may develop at some time, particularly after trauma to or surgical removal of lymph vessels. Box 25.3 summarizes precautions and measures to reduce the risk of lymphedema.^* The education of patients in the importance of risk eduction has been shown to be effective in lowering lymphedema symptoms.^32,39,65 The effect of an increased body mass index (BMI) has shown mixed effect on the risk of developing lymphedema.^43,45,65,68

Management of Lymphedema

Background and Rationale

Comprehensive management of lymphedema involves a combination of appropriate medical management and direct therapeutic intervention by a therapist combined with self-management by the patient. Treatment also includes appropriate pharmacological management for infection control and prevention or removal of excessive fluid and proteins.^11,35,40

Because there is no cure for lymphedema, the main goal of treatment is to minimize the lymphedema as much as possible or return the lymphedema to a latency stage. In addition, the health of the tissue is important. Other goals include reducing risk of infection and softening of fibrotic tissue.^30,107

The overall objective of management when lymphedema has developed is to improve drainage of obstructed areas and, theoretically, to channel fluids into more centrally located lymph structures that carry the fluid to the venous system. In order to affect the reduction of lymphatic and/or venous edema, the following should be considered.

• Interstitial pressure is increased by external forces. These external forces can be from manual lymphatic drainage or compression therapy. An increased interstitial pressure causes an increased uptake of fluid. There is an increase of lymph production as more fluid enters the lymphatic system as well as an increase resorption of fluid by the venous system.^30,65,107

• Elevation can assist fluid return in stage I lymphedema or in venous edema. If elevation produces reduction, then a mild compression therapy (i.e., compression garment) may be indicated.^{26,35,52,57,97}

• Dynamic pressure changes within the body can assist lymphatic flow. Pressure changes can be in the form of diaphragmatic breathing or with muscle contractions. Breathing changes intrathoracic pressure and causes an increased uptake of lymph fluid in lymphatic trunks and ducts. Active muscle contractions change pressure in a localized area, enhancing the movement of lymph within lymph vessels. A muscle contraction combined with external forces from a bandage or compression garment can be even more effective in the movement of fluid.^30,57,86,107

Comprehensive Regimens and Components

A comprehensive approach to the management of lymphedema is referred to in the literature by a variety of terms, including complex lymphedema therapy, complete or complex decongestive therapy (CDT), or decongestive lymphatic therapy.^* Treatment typically is divided into two phases. Phase I is the intensive treatment phase; Phase II is the maintenance phase. The goal of Phase I treatment is reduction, whereas the goal of Phase II treatment is long-term management.^15,52,57,107 Therapist-directed care is replaced by patient-directed care as treatment moves from Phase I to Phase II. Box 25.4 summarizes the components of these programs.

Manual lymphatic drainage. Manual lymphatic drainage (MLD) involves slow, very light repetitive stroking and circular massage movements done in a specific sequence with the involved extremity elevated whenever possible.^{7,8,19,20,23,56,92,106,107} Proximal congestion in the trunk, groin, buttock, or axilla is cleared first to make room for fluid from the more distal areas. The direction of the massage is toward specific lymph nodes and usually involves distal-to-proximal stroking. Fluid in the involved extremity is then cleared, first in the proximal portion and then in the distal portion of the limb. Because manual lymphatic drainage is extremely labor- and time-intensive, methods of self-massage are taught to the patient as soon as possible in a treatment program.

Exercise. Active ROM, stretching, and low-intensity resistance exercises are integrated with manual drainage techniques.^{5,11,15,19,21,22,67,70,71,107} Exercises are performed while wearing a compressive garment or bandages and in a specific sequence. A low-intensity cardiovascular/pulmonary endurance activity, such as bicycling, often follows ROM and strengthening exercises. Specific exercises and a suggested sequence for the upper and lower extremities, compiled from several sources, are described and illustrated in the last section of this chapter.

Compression therapy. The type of compression used depends on the phase of treatment. During Phase I of treatment, only low-stretch bandages are used, which provide a low resting pressure on a limb but a high working pressure.^30,107 High-stretch sports bandages, such as Ace^TM wraps, are not recommended for treating lymphedema.^8,11,15,97 Given that a low-stretch bandage has a low resting pressure, the bandage can be worn during the day and at night. During the active reduction phase of treatment, it is recommended that compression be applied in the form of low-stretch bandaging at all times except for bathing.^30,87,107 Under the low-stretch bandage, nonwoven padding is used and can be combined with foam pads to aid in the softening and reduction of fibrotic tissue (Fig. 25.4).

As a patient moves from Phase I to a maintenance phase of treatment, compression is transitioned from low-stretch bandaging at all times to a compression garment during the day. A compression garment has a high resting pressure and low working pressure.^30,107 Therefore, the use of a garment is not recommended during long periods of inactivity (night rest). The garment should be viewed as a method to maintain limb size during the day, giving a patient a more cosmetic appearance and ease of wearing clothing. During Phase II, it is still recommended that a patient wear the low-stretch bandages at night.^15,87 In summary, the bandages are used for continued limb reduction, and a garment keeps the size of the extremity stable.

Compression garments are made in specific compression categories or classes (Table 25.1).^15,87,107 Patients can most often be fit with a premade garment, but custom garments are available. For patients with lymphedema of the trunk, genital area, or face, custom garments can be fabricated.

Another form of compression therapy is a pneumatic compression pump.⁶⁶ The use of compression pumps, however, has been controversial over the years. Studies have shown that a compression pump can be a positive adjuvant therapy to CDT but should not be the sole therapeutic modality in the treatment of lymphedema.^64,69,91 The main criticism of pump compression is the pumping of fluid in a distal to proximal sequence, which is opposite of the principles of MLD. There is also the potential to cause swelling in adjoining areas of the body, mainly the genital area, for a patient with lower extremity edema.⁹ When used correctly, a pneumatic compression pump can be a positive therapeutic intervention, especially in severe or refractory cases. More advanced pumps are now available that follow the sequence of MLD more closely, treating the trunk first and then the extremity in a proximal-to-distal sequence.

Skin care and hygiene. Lymphedema predisposes the patient to skin breakdown, infection, and delayed wound healing. Meticulous attention to skin care and protection of the edematous limb are essential elements of self-management of lymphedema.^11,20,69,97

Use of Community Resources

A valuable resource for patients and healthcare professionals is the National Lymphedema Network (www.lymphnet.org). This nonprofit organization provides education and guidance about lymphedema. Other resources include the Peninsula Medical, Inc. website (www.lymphedema.org) and Lymph Notes (www.lymphnotes.com).

Background

Breast cancer-related dysfunction of the lymphatic system and subsequent lymphedema of the upper extremity is a somewhat common and potentially serious complication of the treatment for breast cancer. The incidence of lymphedema following surgical intervention for breast cancer varies widely in the literature.^* Much of the variation is related to how lymphedema is diagnosed and defined. Some studies quantify lymphedema in the upper extremity only, whereas other studies define breast cancer-related lymphedema as including the remaining breast or chest wall and trunk. Other factors contributing to the variation in incidence of lymphedema reported are the use of sentinel lymph node biopsy versus axillary dissection.

Current treatment for breast cancer involves a multimodality approach. Surgery, chemotherapy or hormonal therapy, and radiation may be employed. The type of surgery performed, the extent of axillary nodes removed, and the use of radiation all affect the incidence of lymphedema in a patient with breast cancer.

Axillary dissection and removal of lymph nodes interrupt and slow the circulation of lymph, which in turn can lead to lymphedema.^5,12,15,29 Radiation therapy can cause fibrosis of tissues in the area of the axilla, which obstructs the lymphatic vessels and contributes to pooling of lymph in the arm and hand.^5,12,15,29 The extent of the axillary dissection and exposure to radiation is associated with the degree of risk for lymphedema to develop. In addition, shoulder motion can become impaired as the result of incisional pain, delayed wound healing, and skin ulcerations (associated with radiation therapy), and postoperative weakness of the muscles of the shoulder girdle.^15,69

A comprehensive approach to postoperative management that emphasizes patient education and includes therapeutic exercise and other direct interventions to reduce the risk of or to treat lymphedema and other impairments or functional limitations are key to successful outcomes.^{3,6,11,15,69,80}

As with most cancers, the diagnosis of breast cancer and the ensuing treatments have an enormous emotional impact on patients and their families.^15,90 The advent of breast cancer-related lymphedema not only has an impact on a breast cancer survivor's physical function but is known to have a significantly adverse effect on health-related quality of life, making prevention—and if it develops, aggressive treatment—of lymphedema high priorities for management.^59,78,84

Surgical Procedures

Surgical treatment of breast cancer falls into two broad categories—mastectomy and breast-conserving surgery, both of which are coupled with either sentinel lymph node biopsy and/or axillary lymph node dissection. Differences in surgical procedures are related to the extent of removal of breast tissue and surrounding or underlying soft tissues.^1,7,46 A course of radiation therapy routinely follows surgery to decrease the risk of regional recurrence of the disease in patients who undergo breast-conserving surgeries. Chemotherapy also may be initiated preoperatively or postoperatively to reduce the risk of systemic spread of the disease.

Mastectomy

Mastectomy involves removing the entire breast. In addition, a mastectomy may involve removing the fascia over the chest muscle. With late-stage, invasive disease, a radical mastectomy in which the pectoralis muscles also are excised may be required, leading to significant muscle weakness and impaired shoulder function.

Breast-Conserving Surgery

Options for resecting the tumor and preserving a portion of the breast include lumpectomy, which involves excision of the mass and a margin of healthy surrounding breast tissue, or segmental mastectomy (also known as quadrectomy), which is excision of the affected quadrant of the breast. Rather than mastectomy, these procedures are being used increasingly in combination with adjuvant therapy for patients with stage I or II tumors.^1,46

There are now multiple randomized clinical trials that show that the 10- to 20-year survival rate for patients with stage I or II disease who underwent breast-conserving surgery combined with radiation therapy is equivalent to that achieved by patients who underwent mastectomy alone or mastectomy with adjuvant therapy.¹

Patients who undergo breast-conserving procedures without removal of lymph nodes are still at risk for developing postoperative lymphedema and impaired shoulder mobility because of potential complications from radiation therapy and biopsy of at least one lymph node.^15,69

Evaluation of Lymph Node Involvement

In the past, axillary lymph node dissection was a standard part of mastectomy and breast-conserving surgery.^1,46 A minimum of a level I and, most often, a level II axillary dissection was performed. Currently, the sentinel lymph node biopsy is used to determine disease presence in the axilla, therefore sparing removal of uninvolved lymph nodes when possible.

Sentinel lymph node biopsy is used with patients who present with no clinically evident disease in the axilla. With a radiosensitive substance, the specific lymph nodes that a tumor first drains into are identified and removed.¹⁰⁷ If clear, research has shown that an axillary dissection is not required and risk of disease in further lymph node is low.¹³ If the sentinel lymph nodes show signs of disease, then axillary lymph nodes are removed. More extensive dissection for metastatic or regional bulky disease removes the nodes under the pectoralis minor muscle or around the clavicle.

Radiation Therapy

Radiation therapy is rarely used as the sole treatment intervention for breast cancer. Most often radiation is employed following breast-conserving surgery as an adjuvant treatment modality.⁵⁸ Radiation delivered to the whole breast is standard following breast-conserving therapy. The parameters of the radiation field include the tissue from the clavicle to 2 cm below the inframammary line and from the mid-sternum to the mid-axillary line laterally.⁷⁵ Radiation typically is delivered over a course of 5 to 6 weeks with effects not felt until 2 to 3 weeks into treatment. In patients who undergo mastectomy, depending on the disease presentation, radiation may be offered. The radiation field usually includes the surgical scar, chest wall, and sometimes the regional lymphatics.

Radiation causes changes in most types of soft tissue and can be categorized as having acute or chronic effects.⁵⁸ Acute effects of radiation include acute dermatitis or skin burn. Chronic or late effects of radiation involve tissue fibrosis and changes to the lymphatic vessel function. It is important to note that the chronic effects of radiation can extend for many years following the end of the radiation therapy.⁹⁵

Impairments and Complications Related to Breast Cancer Treatment

The following impairments and complications may occur in association with treatment of breast cancer. Many of these problems are interrelated and must be considered jointly when a comprehensive postoperative rehabilitation program is developed for the patient.^*

Postoperative Pain

Incisional pain. A transverse incision across the chest wall is made to remove the breast tissue and underlying fascia on the chest musculature. The incision extends into the axilla for lymph node dissection. Postoperatively, the sutured skin over the breast area may feel tight along the incision. Movement of the arm pulls on the incision and is uncomfortable for the patient. Healing of the incision may be delayed as the result of radiation therapy. Delayed wound healing, in turn, prolongs pain in the area of the incision.

Posterior cervical and shoulder girdle pain. Pain and muscle spasm may occur in the neck and shoulder region as a result of muscle guarding. The levator scapulae, teres major and minor, and infraspinatus often are tender to palpation and can restrict active shoulder motion. Decreased use of the involved upper extremity after surgery due to pain sets the stage for the patient to develop a chronic frozen shoulder and increases the likelihood of lymphedema in the hand and arm.

Postoperative Vascular and Pulmonary Complications

Decreased activity and extended time in bed increase venous stasis and the risk of DVT. Risk of pulmonary complications, such as pneumonia, also is higher because of the patient's reduced activity level. Incisional pain may make the patient reluctant to cough or breathe deeply, both of which are necessary postoperatively to keep the airways clear of fluid accumulation.

Lymphedema

As noted previously, patients who undergo any level of lymph node dissection or whose treatment regimen includes radiation therapy remain at risk throughout life for developing ipsilateral upper extremity lymphedema.^5,15,69,107 Lymphedema can occur almost immediately after lymph node dissection, during the course of radiation therapy, or many months or even years after treatment has been completed. It is typically evident in the hand and arm but occasionally develops in the anterior chest wall, remaining breast, or back area.^{5,12,15,69,77,107} In turn, lymphedema leads to impaired upper extremity function, poor cosmesis, and emotional distress.^15,33,77,90

Chest Wall Adhesions

Restrictive scarring of underlying tissues on the chest wall can develop as the result of surgery, radiation fibrosis, or wound infection. Chest wall adhesions can lead to increased risk of postoperative pulmonary complications, restricted mobility of the shoulder, postural asymmetry and dysfunction, and discomfort in the neck, shoulder girdle, and upper back.

Decreased Shoulder Mobility

It is well documented that patients may experience temporary and sometimes long-term loss of shoulder mobility after surgery or radiation therapy for treatment of breast cancer.^{5,38,49,59,69,80,89,100,101,104} Factors contributing to impaired shoulder mobility after surgery are listed in Box 25.5.

One of these factors, lymphatic cording, or axillary web syndrome (AWS), is a fairly new term for a condition that is quite common in patients treated for breast cancer. The incidence varies in the literature, and onset can be as soon as one week following surgery to years later.^15,72 AWS is thought to be caused by the interruption of the lymphatics in the axilla following a sentinel lymph node biopsy or axillary dissection, with resulting thrombosis of lymphatic channels.^54,72 Visually, AWS can be described as a web of skin covering "cords" that are more visible with shoulder abduction (Fig. 25.5).^54,72 These cords can extend from the axilla distally to the antecubital space and into the forearm. Lymphatic cording can be painful and limit movement of the entire upper extremity.^15,54 Treatment for AWS typically includes gentle stretching and soft tissue release of the lymphatic cord.⁵⁴

Weakness of the Involved Upper Extremity

Shoulder weakness. If the long thoracic nerve is traumatized during axillary dissection and removal of lymph nodes, this results in weakness of the serratus anterior and compromised stability of the scapula, limiting active flexion and abduction of the arm. Faulty shoulder mechanics and use of substitute motions with the upper trapezius and levator scapulae during overhead reaching can cause subacromial impingement and shoulder pain. Shoulder impingement, in turn, can be a precursor to a frozen shoulder. If the pectoralis muscles were disturbed, which occurs with a radical mastectomy for advanced disease, weakness is evident in horizontal adduction.

Decreased grip strength. Grip strength is often diminished as the result of lymphedema and secondary stiffness of the fingers.

Postural Malalignment

The patient may sit or stand with rounded shoulders and kyphosis because of pain, skin tightness, or psychological reasons. An increase in thoracic kyphosis associated with aging is commonly seen in the older patient.³⁷ This contributes to faulty shoulder mechanics and eventually restricts active use of the involved upper extremity. Asymmetry of the trunk and abnormal scapular alignment may occur as the result of a subtle lateral weight shift, particularly in a large-breasted woman.

Fatigue and Decreased Endurance

Patients undergoing radiation therapy or chemotherapy often experience debilitating fatigue.^1,35,59 Fatigue has been reported by more than 60% of patients undergoing cancer treatment.^17,73 Anemia may develop as a result of chemotherapy. Nutritional intake and subsequent energy stores may be diminished, particularly if a patient is experiencing nausea for several days after a cycle of chemotherapy.

Fatigue also is associated with depression. As a result, exercise tolerance and endurance during functional activities are markedly reduced. Multiple studies support the initiation of an exercise program as one of the most effective methods to combat fatigue related to cancer treatment.^17,73,74

Psychological Considerations

A patient undergoing treatment for breast cancer experiences a wide range of emotional and social issues.⁹⁰ The needs and concerns of both the patient and the family must be considered. The patient and family members must cope with the potentially life-threatening nature of the disease and a difficult treatment regimen. It is common for a patient to feel anxiety, agitation, anger, depression, a sense of loss, and significant mood swings during treatment of and recovery from breast cancer.

In addition to the obvious physical disfigurement and altered body image associated with mastectomy, medications such as immunosuppressants and corticosteroids can affect the emotional state of a patient. Psychological manifestations affect physical well-being and can contribute to general fatigue, the patient's perception of functional disability, and motivation during treatment.

Guidelines for Management Following Breast Cancer Surgery

Guidelines for postoperative management for the patient who has undergone a mastectomy or breast-conserving surgery and who may currently be receiving adjuvant therapy are outlined in Box 25.6. The guidelines identify therapeutic interventions for common impairments during the early postoperative period and those that could develop at a later time.

NOTE: The guidelines outlined in Box 25.6 also can be modified to prevent or manage problems that can develop in the trunk and lower extremities after surgery for abdominal or pelvic cancers and accompanying inguinal lymph node dissection.

Special Considerations

Patient education. The length of an in-hospital stay following surgery for breast cancer is short. Ideally, intervention by the therapist is initiated preoperatively with an emphasis on patient education for reducing the risk of postoperative complications and impairments, including pulmonary complications, thromboemboli, lymphedema, and loss of shoulder mobility. Recommendations for reducing the risk of lymphedema or for self-management if it develops is reviewed with the patient (see Box 25.3). Following surgery, once the drains are removed, an exercise program can then be individualized based on a patient's surgical procedure and anticipated adjuvant treatments.

Exercise. The postoperative exercise program focuses on three main areas: improving shoulder function, regaining an overall level of fitness, and reducing the risk of or managing lymphedema. Early, but protected, assisted or active ROM of the shoulder is the key to restoring shoulder mobility. Postoperative risks that contribute to restricted shoulder mobility were summarized previously (see Box 25.5).^{1,15,46,69,71} These risks are highest during the early postoperative period until drains have been removed and the incision has healed.

Although strengthening exercises and aerobic conditioning are important for upper extremity function and total body fitness, considerations should be taken in an exercise program. Programming considerations may include the type of chemotherapy given and the specific side effects of the drugs. For example, some chemotherapy can cause peripheral neuropathy, proximal muscle weakness, and differing fatigue patterns.^51,73 Exercises must be progressed gradually, excessive fatigue must be avoided, and energy conservation must be emphasized. Exercise precautions for a patient undergoing treatment are noted in Box 25.7.^{5,15,59,71,73,80}

Early intervention for reducing the risk of lymphedema and upper extremity mobility impairments is often advocated by therapists and suggested in descriptive articles in the literature. However, patients often are not referred for postoperative rehabilitation until after impairments and functional limitations have developed. This may be due to concerns raised in the literature²⁹ that early postoperative ROM could delay wound healing or that exercises, if performed too vigorously, could initiate or exacerbate lymphedema. In addition, few studies have rigorously investigated the efficacy of specific interventions or rehabilitation protocols.^69,100 A recent review of the literature on exercise and cancer-related lymphedema revealed, however, that exercise neither worsened preexisting lymphedema nor was associated with a significant increase in the occurrence of lymphedema.⁵

From the information available in the literature, the following recommendations for exercise are made.^*

• Integrate ROM, flexibility, and strengthening exercises into a patient's comprehensive plan of care.

• Implement posture-awareness training and exercise early in a postoperative program to prevent postural malalignment and muscle imbalance, especially following mastectomy.

• Include moderate-intensity aerobic conditioning exercises to improve fitness and quality of life and to reduce chemotherapy-related fatigue.

• Progress all forms of exercise gradually, and teach the patients individualized exercise parameters based on specific surgical interventions and adjuvant therapies.

Community resources. Reach to Recovery is a one-to-one patient education program sponsored by the American Cancer Society (www.cancer.org). Representatives of this program, most of whom are breast cancer survivors, provide emotional support to the patient and family, as well as current information on breast prostheses and reconstructive surgery. The National Lymphedema Network (www.lymphnet.org) is another valuable source of information for patients at risk for or who have developed lymphedema.

Background and Rationale

As noted previously in this chapter, exercise is just one aspect of a decongestive lymphatic therapy program. The rationale for including exercise in the comprehensive treatment of patients with upper or lower extremity lymphedema is to move and drain lymph fluid to reduce the edema and to improve the functional use of the involved limb or limbs. Principles on which exercises for lymphatic drainage are based are summarized in Box 25.8.^5,70,107

The exercises employed in lymph drainage regimens cover a wide spectrum of therapeutic exercise interventions, specifically deep breathing, relaxation, flexibility, strengthening, cardiovascular conditioning exercises, and a sequence of lymphatic drainage exercises as well. Exercise regimens have been described in an extensive number of publications.^†

No particular combination or sequence of exercises has been shown to be superior to another. Although a critical review of the literature a decade ago⁶² indicated that the effectiveness of exercise regimens for lymph drainage was based primarily on clinical observations and opinions of experienced practitioners or case reports, there is now an emerging body of evidence documenting the efficacy of specific components of these programs.^{5,50,67,69,91}

Components of Exercise Regimens for Management of Lymphedema

Deep Breathing and Relaxation Exercises

• Deep breathing is interwoven throughout exercise regimens for the management of lymphedema. It has been suggested that the use of abdominal-diaphragmatic breathing assists in the movement of lymphatic fluid as the diaphragm descends during a deep inspiration and the abdominals contract during a controlled, maximum expiration.¹⁵ Changes in intra-abdominal and intrathoracic pressures create a gentle, continual pumping action that moves fluids in the central lymphatic vessels, which run superiorly in the chest cavity and drain into the venous system in the neck (see Fig. 25.1).

• Progressive, total body relaxation exercises²⁸ (described in Chapter 4) are performed at the beginning of each exercise session to decrease muscle tension, which may contribute to restricted mobility and lymph congestion.^15,19,22,107 Deep breathing is an integral component of the sequence of relaxation exercises.

Flexibility Exercises

Gentle, self-stretching exercises are used to minimize soft tissue and joint hypomobility, particularly in proximal areas of the body that may contribute to static postures and lymph congestion.

Strengthening and Muscular Endurance Exercises

Both isometric and dynamic exercises using self-resistance, elastic resistance, and weights or weight machines are appropriate if done against light resistance (initially, 1 to 2 lb) and by progressing resistance and repetitions gradually. Regardless of whether lymphedema has developed, it is important to monitor the circumferential size and the skin texture of the involved limb closely to determine whether an appropriate intensity of exercise has been established. Emphasis is placed on improving endurance and strength of central and peripheral muscle groups that enhance an erect posture and minimize fatigue in muscles that contribute to the efficiency of the lymphatic pump mechanism.

Cardiovascular Conditioning Exercises

Activities such as upper extremity ergometry, swimming, cycling, and walking increase circulation and stimulate lymphatic flow.¹⁵ Thirty minutes of aerobic endurance exercises complement lymph drainage exercises. Conditioning exercises are done at low-intensity (at 40% to 50% of the target heart rate) when lymphedema is present and at higher intensities (as high as an 80% level) when the lymphedema has been reduced and exercise is otherwise safe.^15,70

Lymphatic Drainage Exercises

Lymphatic drainage exercises, often referred to as pumping exercises, move fluids through lymphatic channels. Active, repetitive ROM exercises are performed throughout each session. The exercises follow a specific sequence to move lymph away from congested areas.^{15,19,21,22,107} It is similar to the sequence of massage applied during manual lymph drainage.^56,92 In general, the exercises first focus on proximal areas of the body to clear central collecting vessels and then involve distal muscle groups to begin to move peripheral edema in a centripetal direction to the central lymph vessels. The affected upper or lower extremity or extremities are held in an elevated position during many of the exercises. Static, dependent postures are avoided. Self-massage also is interspersed throughout the exercise sequence to further enhance drainage. These exercises also maintain mobility of the involved limbs.

Guidelines for Lymphatic Drainage Exercises

The patient should follow these guidelines when performing a sequence of lymphatic drainage exercises. These guidelines apply to management of upper or lower extremity lymphedema and reflect the combined opinions of several authors and experts in the field.^{15,19,20,21,70,107}

Preparation for Lymphatic Drainage Exercises

• Set aside approximately 20 to 30 minutes for each exercise session.

• Perform exercises twice daily every day.

• Have needed equipment at hand, such as a foam roll, wedge, or exercise wand.

During Lymphatic Drainage Exercises

• Wear compression bandages or a customized compression garment if the patient has lymphedema.

• Precede lymphatic drainage exercises with total body relaxation activities.

• Follow a specified order of exercises.

• Perform active, repetitive movements slowly, about 1 to 2 seconds per repetition.

• Elevate the involved limb above the heart during distal pumping exercises.

• Combine deep-breathing exercises with active movements of the head, neck, trunk, and limbs.

• Initially, perform a low number of repetitions. Increase repetitions gradually to avoid excessive fatigue.

• Do not exercise to the point at which the edematous limb aches.

• Incorporate self-massage into the exercise sequence to further enhance lymph drainage.

• Maintain good posture during exercises.

• When strengthening exercises are added to the lymph drainage sequence, use light resistance and avoid excessive muscle fatigue.

After Lymphatic Drainage Exercises

• If possible, rest with the involved extremity elevated for 30 minutes.

• Set aside time several times per week for low-intensity aerobic exercise activities, such as walking or bicycling for 30 minutes.

• Carefully check for signs of redness or increased swelling or reports of aching or throbbing in the edematous limb, any of which could indicate that the level of exercise was excessive.

Selected Exercises for Lymphatic Drainage: Upper and Lower Extremity Sequences

The selection and sequences of exercises described in this section and summarized in Box 25.9 are designed to assist in the drainage of upper or lower extremity lymphedema. Many of the individual exercises suggested in lymphedema protocols, such as ROM of the cervical spine and some of the shoulder girdle or upper extremity exercises, are not exclusively used for lymph drainage. They also are used to improve mobility and strength. Several of the exercises highlighted in this section already have been described in previous chapters in this text. Only those exercises or variations of exercises that are somewhat unique or not previously addressed are described or illustrated in this section.

Sequence of Exercises

• Total body relaxation exercises are implemented prior to lymphatic drainage exercises.

• Exercises for lymphatic drainage should follow a particular sequence to assist lymph flow. The central and proximal lymphatic vessels, such as the abdominal, inguinal, and cervical nodes (see Fig. 25.1), are cleared first with trunk, pelvic, hip, and cervical exercises. Then, for the most part, exercises proceed distally from shoulders to fingers or from hips to toes. If lymph nodes have been surgically removed (e.g., with a unilateral axillary node dissection for breast cancer or a bilateral inguinal node dissection for cancers of the abdominal or pelvic organs), lymph must be channeled to the remaining nodes in the body.

NOTE: Because no single sequence of exercises has been shown to be more effective than another, the upper and lower extremity sequences of exercises outlined in this section do not reflect the exercises included in any one specific protocol. Rather, the exercise sequences are based on the recommendations of several authors.^{15,19,20,21,50,67,69,70,91,107} Sequences of exercises for upper or lower extremity lymphedema are summarized in the remaining portion of this chapter. Therapists are encouraged to modify or add other exercises to the sequences in this chapter as they see fit to meet the individual needs of their patients.

Exercises Common to Upper and Lower Extremity Sequences

These initial exercises should be included in programs for unilateral or bilateral upper or lower extremity lymphedema. They are designed to help the patient relax and then to clear the central channels and nodes.

• Total body relaxation

  • Have the patient assume a comfortable supine position and begin deep breathing. Then isometrically contract and relax the muscles of the lower trunk (abdominals and erector spinae), followed by the hips, lower legs, feet, and toes.

  • Then contract and relax the muscles of the upper back, shoulders, upper arms, forearms, wrist, and fingers.

  • Finally, contract and relax the muscles of the neck and face.

  • Relax the whole body for at least 1 minute.

  • Perform diaphragmatic breathing throughout the entire sequence. Avoid breath-holding and Valsalva's maneuver.

• Posterior pelvic tilts and partial curl-ups

  • Perform these exercises with hips and knees flexed, in the supine position.

• Unilateral knee-to-chest movements. These exercises are designed to target the inguinal nodes. This is important even for upper extremity lymphedema

  • In the supine position, flex one hip and knee and grasp the lower leg. Pull the knee to the chest. Gently press or bounce the thigh against the abdomen and chest about 15 times.

  • Repeat the procedure with the opposite lower extremity.

  • If lymphedema is present in only one lower extremity, initiate the knee-to-chest exercises with the uninvolved lower extremity.

• Cervical ROM. Perform each motion for a count of five for five repetitions.

  • Rotation

  • Lateral flexion

• Scapular exercises. Perform exercise for a count of five for five repetitions.

  • Active elevation and depression (shoulder shrugs)

  • Active shoulder rolls

  • Active scapular retraction and protraction. With arms at sides and elbows flexed, bilaterally retract the scapulae, pointing elbows posteriorly and medially. Then protract the scapulae.

Exercises Specifically for Upper Extremity Lymphedema Clearance

The following sequence of exercises is performed after the general, total body exercises just described. The exercises, which are performed in a proximal-to-distal sequence, are done specifically for upper extremity lymph clearance.

• Active circumduction of the arm (Fig. 25.6). While lying supine, flex the involved arm to 90° (reach toward the ceiling) and perform active circular movements of the arm about 6 to 12 in. in diameter. Do this clockwise and counterclockwise, five repetitions in each direction.

PRECAUTION: Avoid pendular motions or circumduction of the edematous upper extremity with the arm in a dependent position.

• Exercises on a foam roll (Fig. 25.7). While lying supine on a firm foam roll (approximately 6 in. in diameter), perform horizontal abduction and adduction, as well as flexion and extension of the shoulder. These movements target congested axillary nodes and are done unilaterally. For home exercises, if special equipment such as an Ethyfoam^® roller is not available, have the patient perform these exercises on a foam pool "noodle." Although the diameter is smaller, a towel or folded sheet can be wrapped around the foam "noodle" to increase the diameter of the roll.

• Bilateral hand press. With arms elevated to shoulder level or higher and with the elbows flexed, place the palms of the hands together in front of the chest or head. Press the palms together (for an isometric contraction of the pectoralis major muscles) while breathing in for a count of five. Relax, and then repeat as many as five times.

• Wand exercise, doorway or corner stretch, and towel stretch. Incorporate several exercises to increase shoulder mobility and to decrease congestion and assist lymph flow in the upper extremity. Hold the position of stretch for several seconds with each repetition. These exercises have been described and are illustrated in Chapter 17.

• Unilateral arm exercises with the arm elevated. The following exercises are done with the patient seated and the arm supported at shoulder level on a tabletop or counter-top or with the patient supine and the arm supported on a wedge or elevated overhead.

  • Shoulder rotation with the elbow extended. Turn the palm up, then down, by rotating the shoulder, not simply pronating and supinating the forearm.

  • Elbow flexion and extension

  • Circumduction of the wrist

  • Hand opening and closing

• Bilateral horizontal abduction and horizontal adduction. While standing or sitting, place both hands behind the head. Horizontally adduct and abduct the shoulders by bringing the elbows together and then pointing them laterally.

• Overhead wall press. Face a wall; place one or both palms on the wall with the hands above shoulder level. Gently press the palms into the wall for several seconds without moving the body. Relax, and repeat approximately five times.

• Wrist and finger exercises. If swelling is present in the wrist and hand, repetitive active finger movements are indicated with the arm elevated.

  • After performing the overhead wall press as just described, keep the heel of the hand on the wall and alternatively move all of the fingers away from and back to the wall (Fig. 25.8).

  • In the same position as just described, alternately press individual fingers into the wall, as if playing a piano, while keeping the heel of the hand in contact with the wall.

  • Place the palms of both hands together with the hands overhead or at least above shoulder level. One finger at a time, press matching fingers together and then pull them away from each other.

• Partial curl-ups. To complete the exercise sequence, perform additional curl-ups (about five repetitions) with hands sliding on the thighs.

• Rest. Rest in a supine position with the involved arm elevated on pillows for about 30 minutes after completing the exercise sequence.

Exercises Specifically for Lower Extremity Lymphedema Clearance

NOTE: After completing the general lower body, neck, and shoulder exercises previously described, have the patient perform self-massage first to the axillary lymph nodes on the involved side of the body. Then massage the lower abdominal area superiorly to the waist and then laterally and superiorly to the axillary area of the involved side. This sequence is repeated periodically throughout the lower extremity exercise sequence.

• Unilateral knee-to-chest movements. In the supine position, repeat this exercise for another 15 repetitions. If lymphedema is present in only one lower extremity, perform repeated knee-to-chest movements with the uninvolved leg first and then the involved leg.

• Bilateral knees to chest. In the supine position, flex both hips and knees, grasp both thighs, and gently pull them to the abdomen and chest. Repeat 10 to 15 times.

• Gluteal setting and posterior pelvic tilts. Repeat five times, holding each contraction for several seconds and then slowly releasing.

• External rotation of the hips (Fig. 25.9). Lie in the supine position with the legs elevated and resting against a wall or on a wedge. Externally rotate the hips, pressing the buttocks together and holding the outwardly rotated position. Repeat several times.

• Knee flexion to clear the popliteal area. While lying in the supine position and keeping the uninvolved lower extremity extended, flex the involved hip and knee enough to clear the foot from the mat table. Actively flex the knee as far as possible by quickly moving the heel to the buttocks. Repeat approximately 15 times.

• Active ankle movements. With both legs elevated and propped against a wall, or with just the involved leg propped against a door frame and the uninvolved leg resting on the floor, actively plantarflex the ankle and curl the toes; then dorsiflex the ankle and extend the toes as far as possible for multiple repetitions. Lastly, actively circumduct the foot clockwise and counterclockwise for several repetitions.

• Wall slides in external rotation (Fig. 25.10). With the feet propped up against the wall, legs externally rotated, and heels touching, slide both feet down the wall as far as possible and then back up the wall for several repetitions.

• Leg movements in the air (Fig. 25.11). With both hips flexed and the back flat on the floor and both feet pointed to the ceiling, alternately move the legs, simulating cycling, walking, and scissoring motions.

• Hip adduction across the midline (Fig. 25.12). Lie in the supine position with the uninvolved leg extended. Flex the hip and knee of the involved leg. Grasp the lateral aspect of the knee with the contralateral hand; pull the involved knee repeatedly across the midline in a rocking motion.

NOTE: If lymphedema is bilateral, repeat this exercise with the other lower extremity.

• Bilateral knee to chest. Repeat bilateral gentle, bouncing movements of the legs previously described.

• Partial curl-ups. To complete the exercise sequence, perform additional partial curl-ups, about five repetitions.

• Rest. With feet elevated and legs propped up against the wall, rest in this position for several minutes after completing exercises. Then rest the legs partially elevated on a wedge, and remain in this position for another 30 minutes.

Critical Thinking and Discussion

1. You have been asked to participate in a patient education program at your community's cancer society for patients who have undergone treatment for breast cancer. Your responsibility in this program is to help these breast cancer survivors reduce the risk of physical impairments and functional limitations associated with their surgery and any related adjuvant therapies. Outline the components of such a program, and explain the rationale for the activities you have chosen to include.

2. A patient has developed lymphedema as a result of a modified radical mastectomy 5 years ago. She presents to physical therapy with finger and hand swelling extending proximally to the upper arm. Elevation is not effective. The tissue is pitting in the hand but hard to palpation in the forearm. Stage this lymphedema, and outline a proposed treatment plan, including the elements of a home management program.

3. Describe the anatomy of the lymphatic system. Explain the terms transport capacity and lymphatic load.

4. Outline the components comprehensive decongestive therapy (CDT) and the relationship between each component.

Laboratory Practice

Perform the sequence of exercises and suggested repetitions for the exercise plan you have designed for Case 1 and Case 2.

Case Studies

Case 1

Ms. L underwent surgery for metastatic pelvic cancer and lymphadenectomy (lymph node dissection) 3 months ago. She also received a series of radiation therapy treatments as part of her comprehensive oncological management. About 2 weeks ago, she began to notice bilateral swelling in her legs, most notably in her feet and ankles.

She has been referred by her oncologist to the outpatient facility where you work to "evaluate and treat" her for her lymphedema. Describe the examination procedures you would use in your evaluation, and then develop a plan of care, including a program of exercise, to help her manage and reduce her lymphedema and prevent potential complications related to the lymphedema.

Case 2

Mrs. B is a 50-year-old female who recently underwent a lumpectomy and axillary lymph node dissection. She is referred to physical therapy following the removal of her surgical drain. She will be starting chemotherapy shortly, followed by a course of radiation therapy. She reports that prior to her diagnosis and surgery, she was an active individual who enjoyed a variety of recreational activities, including swimming, doubles tennis, and camping, and would like to return to those activities as soon as possible. Design a postoperative exercise program taking into consideration the upcoming chemotherapy and radiation therapy.