WHAT CAUSES LYMPHEDEMA AND HOW IS IT TREATED?

Lymphedema means swelling in the arm. It can occur if you have had lymph nodes removed in the surgical procedure (lumpectomy, modified radical/radical mastectomy), and/or from radiation therapy which can lead to the formation of scar tissue in the axilla (underarm). The lymphatic vessels can become obstructed and the lymph fluid won't drain as readily, so the arm will swell. Lymphedema was more common when more extensive surgery was done, but it is estimated to occur only in 5% of mastectomy procedures today because less tissue is removed. It is important to note that it can range from mild to severe, it can be temporary or permanent and it can happen immediately or several years after the operation.

In moderate to severe cases of lymphedema there can be increased size of the extremity, stiffness and decreased range of motion in the fingers, decreased sensation in the fingers and decreased function of the upper extremity. If it does develop it can be difficult and frustrating to manage. Elevation of the arm above the level of the heart is beneficial and physical therapy should include massage and range of motion of the entire extremity as tolerated. You should avoid heavy lifting with the arm and the arm should not dangle in dependent positions. Support gloves and compression pumps are also of value should lymphedema persist.

WHAT CAUSES WEAKNESS AND HOW IS IT ADDRESSED?

Weakness of the involved upper extremity can develop as a result of disuse or as a complication of the surgery that was performed. In a radical mastectomy the pectoral muscles are removed and this results in decreased strength in the shoulder. In procedures that remove axillary lymph nodes the long thoracic nerve can be temporarily traumatized. 'As a result a muscle called the serratus anterior may become weak causing the shoulder blade to wing limiting shoulder motion. A physical therapist will evaluate muscle strength in both upper extremities and scapular muscles, and provide a strengthening program to meet your individual needs.

WHAT PROBLEMS ARE ASSOCIATED WITH SCARRING?

Adhesions and scarring may develop around the, incision as a result of the surgery and/or radiation. Soft tissue restrictions in the anterior (front) chest wall, particularly in the pectoralis group is common. Tightness in these muscles will interfere with shoulder motion and also contribute to poor postural habits. As a result of this tightness, the muscles in back and around the shoulder blade often become over stretched and weak. Physical therapy will help to decrease adhesions and restore soft tissue mobility and muscular balance between the anterior and posterior (back) chest musculature. It will also help to reinforce good postural habits for activities of daily living.

HOW DOES ONE GET REFERRED TO PHYSICAL THERAPY?

Most patients are typically referred to physical therapy on an outpatient basis approximately two weeks post surgery. Your surgeon will typically be the one to refer you to physical therapy, however in some instances you might be referred to a physiatrist first, who is a doctor that specializes in rehabilitation medicine. At your initial evaluation with the physical therapist it is important for her to know what type of surgical procedure was performed (simple mastectomy, modified mastectomy, etc.), if any cosmetic procedures were done at the time of surgery (breast reconstruction, implants, or expanders), and if you are having any concurrent chemotherapy or radiation therapy. The therapist will want to know about any significant past medical history including conditions such as rheumatoid or osteoarthritis that may limit range of motion or strength in your arms. She will also establish hand dominance; inquire about your occupation, activities of daily living and your recreational hobbies.