Lymphedema Risk: A Hidden Massage Therapy Contraindication

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1 Lymphedema Risk: A Hidden Massage Therapy Contraindication A Webinar with Tracy Walton, MS, LMT Part 2 of the More about Cancer Care and Massage Webinar Series Background Tracy Walton Author Educator Researcher Massage Therapist Specialist in massage therapy and cancer care Things to Think about What questions can help you assess a client s lymphedema risk? How do you describe lymphedema? Which massage elements are likely or unlikely to trigger lymphedema? Describe the safest work with the arm of a person with lymphedema history How do we handle lymphedema risk + undiagnosed swelling? List lymphedema triggers encountered in everyday life 1

2 Highlights of this Webinar Why lymphedema risk is as important to assess as lymphedema history before beginning any massage How an initial lymphedema episode becomes a chronic, permanent health problem How to adapt massage in order to avoid provoking a lymphedema episode Questions to ask every client with a cancer history even decades later Breast cancer presents differently in different people Breast cancer Advanced (mets to brain, bone, liver) Strong chemo side effects Treatment poorly tolerated Lymphedema history in left arm Meds for anxiety, sleep, seizures, etc. Breast cancer Successful treatment 7 years survivorship Minor chemo side effects Treatment well tolerated No lymphedema (risk remains) No meds Breast cancer presents differently in different people Breast cancer Advanced (mets to brain, bone, liver) Strong chemo side effects Treatment poorly tolerated Lymphedema history in left arm Meds for anxiety, sleep, seizures, etc. Breast cancer Successful treatment 7 years survivorship Minor chemo side effects Treatment well tolerated No lymphedema (risk remains) No meds 2

3 Breast cancer presents differently in different people Breast cancer Advanced (mets to brain, bone, liver) Strong chemo side effects Treatment poorly tolerated Lymphedema history in left arm Meds for anxiety, sleep, seizures, etc. Breast cancer Successful treatment 7 years survivorship Minor chemo side effects Treatment well tolerated No lymphedema (risk remains) No meds Lymphedema Different from natural swelling Can occur decades later 3

4 Lymphedema Disfiguring Chronic Painful Risk of infection Lymphedema Disfiguring Chronic Painful Risk of infection Irreversible Cause trigger (1 st episode) (chronic) 4

5 Lymphedema Caused by impairment in the lymphatic system due to Surgery Radiation therapy Triggered by a later event 22 Surgery with lymph node removal Cancer Cells Pass through Lymph Nodes 24 5

6 Radiation Therapy Lymph node injury and scarring Nodes are Removed in Cancer Surgery Cervical Axillary Inguinal Lymph Node Dissection (LND) = some number removed 26 Nodes are Removed in Cancer Surgery Sentinel Node Biopsy (SNB) = specific nodes removed (first in drainage pathway for tissue containing tumor) 27 6

7 Nodes are often within a Radiation Treatment Field Radiation treatment can injure lymph nodes and vessels Scarring of lymphatic structures 28 Lymphedema Statistics 5-40% of women experience lymphedema after axillary lymph node dissection (ALND) Removing fewer nodes may reduce risk (3.7%- 13% develop lymphedema after SNB) Other factors may increase risk (chemotherapy, obesity, smoking, diabetes) 29 Lymphedema Statistics 5-40% of women experience lymphedema after breast cancer surgery Removing fewer nodes may reduce risk (3.7%-13% develop lymphedema after just SNB) Other factors may increase risk (radiation, obesity, chemotherapy) It is impossible to predict who will develop lymphedema and who won t! 30 7

8 Lymphedema is Unique Not garden variety swelling Can be profound, painful, disfiguring, heavy Can lead to complications (infection) Irreversible No curative treatment 31 Lymphedema is Unique Only specialized lymph drainage techniques help control - Manual lymph drainage by a lymphedema specialist - Compression bandaging Refer to lymphedema clinic National Lymphedema Network 32 Lymphedema is a Plumbing Problem Lymphedema starts as a Plumbing Problem! Mechanical problem Fluid in tissues > Transport capacity Nowhere for fluid to go 33 8

9 Lymphedema starts as a Plumbing Problem! Mechanical problem Fluid in tissues exceeds transport capacity Nowhere for fluid to go It backs up in the tissues -> SWELLING 34 Lymphedema is a Plumbing Problem Lymphedema becomes a Chemical Problem! Proteins collect in tissues Proteins draw more water into tissues 35 Lymphedema is a Plumbing Problem Lymphedema becomes a Chemical Problem! Proteins collect in tissues Proteins draw more water into tissues Swelling worsens Protein-rich edema 36 9

10 Which body parts are affected or at risk? The drainage field (Anything that drains into missing or injured lymphatic structures) 37 Face/neck (cervical nodes drain) Which areas at risk? Upper extremity/trunk (axillary nodes drain) Lower extremity/trunk (inguinal nodes drain) 38 Each Area Includes a Quadrant Face/neck (cervical nodes drain) Upper extremity/trunk (axillary nodes drain) Lower extremity/trunk (inguinal nodes drain) 39 10

11 Lymphedema caused by an underlying (hidden) weakness Lymphedema triggered by a small event in the at-risk area (quadrant and limb) Lymphedema arises cause trigger 11

12 Lymphedema triggers Trauma/inflammation -injury -cuts -pressure -overstretch -overuse Infection Heat anything that increases circulation! 43 Precautions: Triggers to Avoid for People with Lymphedema/Lymphedema Risk No blood pressure on that side No needle sticks on that side Avoid burns, cuts, heat, insect bites, sunburn No heavy bags/luggage No restrictive clothing No overexertion (5 lb. lift limit?) 44 Precautions (avoid triggers ) for people with Lymphedema/Lymphedema Risk Excellent skin care in affected/at-risk area (If arm) Wear gloves while gardening (If arm) Wear gloves while doing dishes Do not expose affected/at-risk area to hot showers Do not immerse in hot bath or hot tub 45 12

13 Small triggers can have huge effects When Does Lymphedema Occur? Can be at any point after cancer treatment Right away Years, decades later Risk is lifelong 48 13

14 What about massage? 49 Think in terms of ingredients. What should be left out? What is left in? 14

15 Cancer How Cancer Affects Client Where? Massage Guidelines Elements of Massage To Adjust Signs, Symptoms Effects on Organ Function Tissue Instability Medical Treatments Side Effects Contact Lubricant Pressure Joint Movement Friction Position Site of massage Draping Speed Rhythm Session length Session timing Session intent Medical consultation Medical referral Cancer Where? Elements of Massage To Adjust Signs, Symptoms Effects on Organ Function Tissue Instability Medical Treatments Removal or radiation of lymph nodes Side Effects Lymphedema Contact Lubricant Pressure Joint Movement Friction Position Site of massage Draping Speed Rhythm Session length Session timing Session intent Medical consultation Medical referral Elements of Massage To Adjust Trauma/inflammation -injury -cuts -pressure -overstretch -overuse Infection Heat Contact Lubricant? Pressure Joint Movement Friction Position Site of massage Draping Speed Rhythm Session length Session timing Session intent Medical consultation Medical referral 15

16 Cancer Where? Elements of Massage To Adjust Signs, Symptoms Effects on Organ Function Tissue Instability Medical Treatments Removal or radiation of lymph nodes Side Effects Lymphedema risk Contact Lubricant Pressure Joint Movement Friction Position Site of massage Draping Speed Rhythm Session length Session timing Session intent Medical consultation Medical referral Modify pressure 56 The Massage Therapy Pressure Scale* *Gratitude to Gayle MacDonald and Dawn Nelson for describing lotioning 57 16

17 No heat 58 Care with Position 59 Care with joint movemen 17

18 Massage and Lymphedema ( lymphedema history ) NEVER attempt to treat lymphedema with massage Conventional massage techniques can aggravate Refer lymphedema (or undiagnosed swelling) to physician and lymphedema specialist 61 Massage and Lymphedema ( lymphedema history ) In drainage field (limb + quadrant) ONLY hold with soft hands (Pressure = 1) and Position to elevate extremity and minimize pressure on it and Follow any additional instructions from the physician or lymphedema specialist 62 Massage and Lymphedema ( lymphedema history ) In other quadrants Limit pressure to level 2 and Refer client for lymphedema care 63 18

19 Massage and Lymphedema RISK Use care with anyone at risk of lymphedema Who is at risk of lymphedema? What is the minimum number of nodes removed that can put someone at risk of lymphedema? 64 Massage and Lymphedema RISK Use care with anyone at risk of lymphedema Who is at risk of lymphedema? (Anyone with history of lymph node removal or radiation in which areas?) 66 19

20 Massage and Lymphedema RISK Use care with anyone at risk of lymphedema Who is at risk of lymphedema? (Anyone with history of lymph node removal or radiation in cervical, axillary, inguinal area) 67 Massage and Lymphedema RISK In drainage field (limb + quadrant) Don t try to raise circulation Avoid heat treatments Never redden the skin Avoid strong joint movement 68 Massage and Lymphedema RISK In drainage field (limb + quadrant) Limit time to a few min. Pressure level 2 max safest for most people Thoughtful positioning 69 20

21 Massage of the Arm (Pressure level 2 max) Massage of the Arm (Pressure level 2 max) Massage of the Arm (Pressure level 2 max) 21

22 Massage of the Back (Pressure level 2 max) Massage of the Back (Pressure level 2 max) 2 Different Massage Protocols Lymphedema Hx In affected quadrant, hold with soft hands only In other quadrants, pressure max = 2 Position to elevate extremity No increase in circulation With heat With ice With friction With joint movement With strokes Refer to MD or lymphedema specialist Lymphedema Risk In at-risk quadrant, limit pressure to level 2 max Limit time to a few min. In other quadrants, limit pressure to level 3 for most people Thoughtful positioning No friction or strong joint mvt. On at-risk extremity, don t aim strokes directly at missing/injured nodes Work at-risk extremity in segments from proximal to distal strokes toward On back, sweep strokes from at-risk quadrant to other intact quadrants 75 22

23 Lymphedema HISTORY or RISK? Lymph node removal or radiation (RISK) + Undiagnosed swelling 76 Lymphedema HISTORY or RISK? Lymph node removal or radiation (RISK) + Undiagnosed swelling = Lymphedema history 77 Massage and Lymphedema Read up on lymphedema/lymphedema risk in resources - MacDonald, Medicine Hands - MacDonald, Massage for the Hospital Patient - Walton, Medical Conditions and Massage Therapy - Chapman, Cheryl - Breastcancer.org - National Lymphedema Network at lymphnet.org 78 23

24 Questions to Ask about Lymphedema/Risk Did you have any lymph nodes removed? If so, where? If not, why wasn t it necessary? Any removed that were negative? Any radiation therapy? Where? 79 Questions to Ask about Lymphedema/Risk Any swelling or tendency to swell? Any puffiness anywhere? Any lymphedema history? Did your doctor or nurse talk with you about lymphedema risk? Did they urge you to not get your BP taken in certain places, or avoid needle sticks? 80 Language to Use We recognize that the risk of lymphedema is always there, whenever one or more nodes have been removed or treated with radiation. Because of this risk, we work gently in the area drained by the missing/injured lymph node(s). This includes [list areas] Did your nurse or doctor talk with you about lymphedema risk? Did they tell you anything about blood pressure readings or needles on that side? I am borrowing the concern about lymphedema from standard medical and nursing practice. Because they are concerned about blood pressure, I will take care with massage pressure. Because they are concerned about circulation to the skin, I will take care with my strokes

25 82 References Aetna Intelihealth, Inc. Lymphedema. Health A to Z. Copyright Available at: ~st,24479 ~r,wsihw000 ~b,*. Accessed May Ahmed RL, Thomas W, Yee D, et al: Randomized controlled trial of weight training and lymphedema in breast cancer survivors. J Clin Oncol 24: , Anderson RT, Kimmick GG, McCoy TP, Hopkins J, Levine E, Miller G, Ribisl P, Mihalko SL A randomized trial of exercise on well-being and function following breast cancer surgery: the RESTORE trial. J Cancer Surviv Dec 10. [Epub ahead of print] Beers MH, ed. Lymphedema. Merck Manual of Medical Information, 2 nd home ed., online version. Copyright , Merck & Co., Inc. Available at: Accessed May Beesley V, Janda M, Eakin E, Obermair A, Battistutta D. Lymphedema after gynecological cancer treatment: prevalence, correlates, and supportive care needs. Cancer 2007;109: Available at: Accessed October Bicego D, Brown K, Ruddick M, et at: Exercise for women with or at risk for breast cancer-related lymphedema. Phys Ther 86: , Brennan MJ, Weitz J, Lymphedema 30 years after radical mastectomy. Am J Phys Med Rehabil Feb;71(1):12-4. Curties D. Breast Massage. New Brunswick, Canada: Curties-Overzet Publications, Inc., Dana-farber.org. Symptom management: lymphedema. Copyright , Dana-Farber Cancer Institute. Available at: Accessed May Eliska O, Eliskova M. Are peripheral lymphatics damaged by high pressure manual massage? Lymphology Mar;28(1):1-3. Mayo Foundation for Medical Education and Research. Lymphedema. Copyright , Mayo Foundation for Medical Education and Research. Available at: Accessed May Gautam AP, Maiya AG, Vidyasagar MS. Effect of home-based exercise program on lymphedema and quality of life in female postmastectomy patients: pre-post intervention study. J Rehabil Res Dev. 2011;48(10): Johansson K, Tibe K, Weibull A, et al: Low intensity resistance exercise for breast cancer patients with arm lymphedema with or without compression sleeve. Lymphology 38:167-80, Kwan ML, Cohn JC, Armer JM, Stewart BR, Cormier JN. Exercise in patients with lymphedema: a systematic review of the contemporary literature. J Cancer Surviv Dec;5(4): Epub 2011 Oct 16. References, Mayo Foundation for Medical Education and Research. Available at: Accessed May Johansson K, Tibe K, Weibull A, et al: Low intensity resistance exercise for breast cancer patients with arm lymphedema with or without compression sleeve. Lymphology 38:167-80, Lasinski BB. Exercise, lymphedema and the limb at risk. National Lymphedema Network LYMPH Link Article Reprint, McLaughlin SA, Wright MJ, Morris KT, Giron GL, Sampson MR, Brockway JP, Hurley KE, Riedel ER, Van Zee KJ. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. J Clin Oncol, 2008 Nov 10;26(32): Epub 2008 Oct 6. MedicineNet.com. Breast cancer: side effects of cancer: lymphedema. Copyright, , MedicineNet, Inc. Available at: Accessed May Medline Plus Medical Encyclopedia. Lymphatic obstruction. US National Library of Medicine, National Institutes of Health. Copyright Available at: Accessed May Moseley AL, Piller NB, Carati CJ: The effect of gentle arm exercise and deep breathing on secondary arm lymphedema. Cancer Control 38: , Preston NJ, Seers K, Mortimer PS. Physical therapies for reducing and controlling lymphoedema of the limbs. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD DOI: / CD pub2. Revis, DR. Medscape.com. Lymphedema. Copyright , Medscape. Available at: Accessed May Schmitz K, Ahmed R, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan CJ, Williams-Smith C, Greene Q. Weight lifting in women with breast-cancer related lymphedema. New England Journal of Medicine. August 13, 2009; 361(7): Abstract available at: Accessed October Tsai RJ, Dennis LK, Lynch CF, Snetselaar LG, Zamba GK, Scott-Conner C. The risk of developing arm lymphedema among breast cancer survivors: a meta-analysis of treatment factors. Ann Surg Oncol, 2009 Apr 14. Zuther J. Lymphedema Management: The Comprehensive Guide For Practitioners Copyright 2005; New York, Thieme Medical Publishers,Inc. Zuther J. Traditional massage therapy in the treatment and management of lymphedema. Massage Today June 2002:2(6). 25

26 Resources in Cancer and Massage Articles in massage publications DVD Collinge, W. Touch, Caring & Cancer: Simple Instruction for Family and Friends View trailers at complete description at Society for Oncology Massage 85 Resources in Cancer and Massage MacDonald, G. Medicine Hands: Massage Therapy for People with Cancer. Available at MacDonald, G. Massage for the Hospital Patient and Medical Frail Client. Available at Wible, J. Curties, D. Massage Therapy & Drug Handbook Cancer. for Massage Therapists Available at Resources in Cancer and Massage Walton, T. Medical Conditions and Massage Therapy: A Decision Tree Approach. Philadelphia: LWW,

27 The Society for Oncology Massage Thank you! Questions? Walton, T. Medical Conditions and Massage Therapy: A Decision Tree Approach. Philadelphia: LWW,

28 CONTEST How to enter: Write a review of a More About Cancer Care and Massage webinar on Facebook ( You re eligible for one entry per webinar What you can win: Autographed copy of Medical Conditions and Massage Therapy A complete set of the More About Cancer Care and Massage webinar series to give to a friend or colleague Webinars Available On Demand Dr. Ben Benjamin Unraveling the Mystery Series: Low Back Pain Cervical Pain Shoulder Pain Knee Pain Ankle Pain Hip & Thigh Pain Tom Myers Anatomy Trains: Clinical Applications of Myofascial Meridians And Many More Whitney Lowe Orthopedic Approaches to Upper Body Disorders New Series Title Carole Osborne Pregnancy Massage 101 Tracy Walton Massage in Cancer Care Cardiovascular Conditions & Massage All Webinars Available at Join Tom Myers & Ben Benjamin in Costa Rica Two Integrated Approaches to Shoulder Pain: Anatomy Trains & Orthopedic Massage Optional Ethics Course: Managing Challenging Conversations in Your Professional Life January 5-12,

29 Title of Webinar Title of Webinar Date of Webinar Question 1 Possible Answer Options Question 2 Possible Answer Options JOIN The Benjamin Institute ing List & Receive a FREE Ebook on the Low Back 29

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