Lymphedema

Goals of manual lymph drainage

Manual lymph drainage (MLD) is one part of complete decongestive therapy (CDT), the standard treatment approach for lymphedema, which also includes compression, exercise, and skin care. CDT has two phases: an intensive phase of daily treatment to reduce limb volume, and a maintenance phase where the patient self-manages with garments and exercise. The PTA carries out the PT’s plan of care, collects data such as limb girth, and reports changes back to the PT rather than modifying the plan independently.

• Peristalsis of lymph fluid
• Increase lymph volume in lymph vessels
• Decrease congestion in the interstitium

Basic principles

Decongestion always begins proximally, clearing the nodes closest to the trunk before moving to the affected lymphotome, since clearing proximal nodes first opens a path for fluid to drain. Treatment starts with deep breathing, then AROM exercises in a proximal-to-distal progression. Massage is then directed toward the cleared nodes in a distal-to-proximal direction, using very light pressure so the lymphatic vessels aren’t collapsed.

Data collection

• Measure circumferential girth at standardized points (for example, every 4 cm from a bony landmark) and compare with the unaffected limb
• Water-displacement volumetry gives a more precise measure of limb volume when it’s available
• Assess pitting depth and rebound time, and check for the Stemmer sign
• Inspect the skin and tissue for fibrosis, peau d’orange, and open wounds
• After axillary lymph node surgery, measure shoulder flexion and abduction against the other side, and note any compensation the patient uses to reach overhead
• Look for axillary web syndrome (cording): tight, rope-like cords from the axilla down the medial arm, sometimes to the forearm or base of the thumb, that limit shoulder abduction. It usually appears within 8 weeks of surgery and often resolves within 12 weeks; cords that aren’t visible may appear when the shoulder is taken into full abduction. Report new cording or lost shoulder motion to the PT

Contraindications

Contraindications fall into two categories: absolute contraindications mean treatment stops and the PT is notified, while relative contraindications mean treatment continues only with PT-directed modification.

Absolute contraindications

• Acute infection or cellulitis
• Acute or decompensated congestive heart failure
• Acute deep vein thrombosis
• Acute renal failure
• Acute pulmonary edema

Relative contraindications

• Malignancy
• Arterial disease (compression is contraindicated in severe arterial insufficiency)
• Sensation deficits
• Low blood counts
• Areas of local inflammation

Precautions

Precautions require caution, not a treatment stop:

• Avoid direct treatment over open wounds; adjust technique as directed by the PT
• Perform exercise only with compression in place
• Avoid heat sources, such as saunas and hot tubs, on the affected limb
• Avoid blood pressure readings, injections, and blood draws on the affected limb
• Monitor the affected limb closely and treat any skin breaks promptly to prevent infection
• Protect an at-risk limb (after lymph node removal or radiation, even with no swelling yet) when the patient is treated for something else: no saunas, hot tubs, or heat modalities on that limb; nothing constricting it, such as tight clothing or a compression garment or bandage that rolls or pinches; and care to avoid burns and other skin injury, since heat, constriction, and injury can each overload the lymphatic system

Example: Recognizing an adverse response

You’re treating a patient six weeks after a mastectomy with axillary lymph node dissection. During today’s visit, you notice the patient’s forearm is newly red and warm, and the patient mentions feeling feverish.

Answer: These findings point to cellulitis, not ordinary lymphedema swelling. You stop MLD and compression for the session, document the skin changes, and notify the PT so the patient can be evaluated before treatment continues.

Bandaging techniques

Short-stretch bandaging

• Use short-stretch (low-stretch) bandages rather than long-stretch elastic wraps: they provide low pressure at rest and a high working pressure during muscle contraction
• Apply in multiple layers with padding, using a pressure gradient that is firmest distally and decreases moving proximally
• Worn nearly 24 hours a day during the intensive phase of CDT
• Check distal circulation and sensation after application

Compression garments

• Maintains the reduction gained during therapy
• Transition to garments when reduction plateaus
• Garments for daytime wear, options for nighttime
• Insurance coverage varies greatly
• In stage 0 or 1 lymphedema, self-care education, infection prevention and compression garments may be enough; in stage 2 and 3, intensive clinical care (manual lymph drainage with multilayer short-stretch bandaging) is essential, and garments are used in the maintenance phase

Therapeutic exercise

• Exercises facilitate muscle pumping
• Should be done with compression
• Progress from proximally to distally
• Resistance starts light and progresses slowly, with the compression garment on; slowly progressive resistance training does not worsen lymphedema and reduced flare-ups in breast cancer-related lymphedema

Patient education

• Home exercise
• Self-massage
• Skin care
• Precautions
• Compression garments