LymphLink Question Corner - Archived from January 1999
Saskia R.J. Thiadens, R.N. and Judith Casley-Smith, Ph.D.
Q: My wife believes that MLD and heart conditions do not mix well. She has a long-standing history of heart problems in her family and, therefore, this has been a concern for her. Now that she recently experienced a heart attack, she and I are both very concerned about continuing her MLD treatments. Is there something about MLD that causes further complications, something perhaps about lymph movement and compression garments, etc., being hard on an already "taxed" heart condition?
A: Please allow me to reassure you that there is, in my mind, no connection between the heart attack that has occurred and lymphedema, or the MLD therapy. Furthermore, there is no contraindication to proceeding with MLD after the heart attack, provided that your wife avoids prolonged use of her arm in an elevated position above the level of her heart as this is a strenuous position. The one consideration that arises in the interplay between these two medical problems is in the area of potential need for cardiac surgery. In that circumstance, there is the finite risk that the intrathoracic manipulations could worsen the pre-existing lymphatic insufficiency. However, since cardiac surgery is often recommended for life-saving or preserving indications, the primary decision should involve the heart and not the lymphedema. MLD certainly can be performed to good effect after coronary bypass surgery, so I would proceed along whatever lines the cardiologist thinks have merit in this case.
Stanley G. Rockson, MD
Stanford University Lymphedema Clinic
Q: I am an avid backpacker and mountaineered for many years, as high as 20,000 feet. Recently, I had a modified radical mastectomy (MRM) with positive lymph nodes involved and finished my six months of chemotherapy and radiation with minimal complications, except losing my hair. I continued to work full time as a legal secretary and do low impact aerobics, including pushups. My concern: what are the odds of developing LE from carrying a heavy backpack (45 lbs. or more)?
A: I can understand your concerns, especially after reading in all the literature that carrying heavy bags over the shoulder is contraindicated. First of all, you seem to be in superb condition, which certainly was in your favor going through your surgery and follow-up treatment. The question again arises, why does one and not the next person develop LE? Despite living the same healthy lifestyle, there are people who already have a compromised lymphatic system and who develop lymphedema shortly after surgery. It is often unpredictable, but if you really want to know, there is a diagnostic procedure called Lymphangioscintigraphy which can visualize the lymphatics and determine if your lymphatic system shows normal drainage capacity; if this is the case, you have little to worry about. My recommendation is that whatever you do, always wear a compression sleeve while exercising, especially in high altitude (simply going to a ski resort in low range mountains, for example, without a sleeve has caused the onset of lymphedema in some patients). Slowly build up your weight training and the weight of the backpacks you wear.
Make sure that you have soft, padded shoulder straps. Always ask one of your fellow climbers to lift the pack onto your back to avoid the extra strain on your arm and shoulder. And something good to know: in February of 1995, 17 women who survived breast cancer climbed Aconcagua, the highest mountain in the western hemisphere, located in Argentina. None of them developed, or have developed, any problems or signs of lymphedema.
Q: I have always been curious if there is a link between high blood pressure (and treatment of HBP) and lymphedema. Also, I would like to hear more about hand use and lymphedema in the arm and hand.
A: As far as we know, there is no direct relationship between high blood pressure and lymphedema. I should mention that diuretics are frequently used in the treatment of both conditions and, while they are very effective as antihypertensive agents, diuretics generally have little effect in the treatment of LE. In fact, they serve to mask some of the effects of the edema, but usually do not provide any long-term benefit. Treatment with MLD would be favorable, as it would make blood vessels work better, help the BP and provide some relaxation during treatment. Our dominant arm is always slightly larger, often misleading for a person who has had axillary node dissection. IMPORTANT: Measure your arm before or shortly after surgery to create a baseline. Then you can continue to monitor on a regular basis. Some people use the arm normally and exercising makes it better; for others, exercise makes it worse. Unfortunately, it is the enigma of the lymphatic system.
Q: I am concerned that manual lymphatic drainage is pushed as the "cure-all" for management. I have spent two weeks at a famous lymphedema clinic. They finally dismissed me because the MLD did not improve my leg at all. I went back to my old regimen, the pump, which immediately gave me some relief.
A: I am sorry to hear of your poor results, but I have a few questions. (1.) My immediate question and concern is whether you were checked for possible recurrent cancer? (2.) Did they bandage your leg and have you exercise with the bandages on? (3.) Also, was your leg bandaged at night? And, when you use your pump, what pressure do you use? FYI: Treatment for lymphedema is not set in stone and there are a number of variations, as well as different products we use (such as Circaid legging, Reid sleeve, Legacy legging, bandaging only, etc.). Clearly, patients' responses will vary. Most important, whatever you do, become educated in self-manual lymphatic drainage which helps open the pathways to move and redirect lymph. You and your therapist are the judges and know what works best for you. You might try the Legacy legging underneath the pump sleeve as this has shown some wonderful reduction in patients using it with very low pump pressure applied.
Q: Is it true that those of us with lymphedema who need teeth cleaning are at a higher risk of developing an infection in our limb(s)? Should we take antibiotics beforehand?
A: This question has yet to be answered by any clinical studies, however, it is common knowledge that the mouth is an ideal environment for bacteria. Even during such routine work as teeth cleaning, the gums often do bleed and bacteria can then enter the blood stream and, subsequently, the lymphatics. This can adversely affect a weakened lymphatic system which may be more prone to developing an infection. For those with sensitive gums, a very soft toothbrush is advised and if your gums bleed after brushing, it may be helpful to use an anti-bacterial mouth rinse on a regular basis. Consult with your dentist.
Q: I am very concerned. Since my wife developed lymphedema in her arm, she not only does not want to go out anymore, but she is very depressed. I have tried everything to cheer her up. Please help me.
A: Many women experience similar feelings, and justifiably. The cancer diagnosis is hard enough, but to look at a swollen arm every day is very difficult. My first recommendation is for you to become educated in self-manual lymph drainage (there is a self-care for patients video available through the NLN that may be useful) and offer, as her husband, to participate, which may make her feel less fragile. Secondly, find a lymphedema support group in your area and see if she would like to attend. If you like, you might accompany her. It helps a great deal to know you are not alone. Also, if you and your wife are NLN members, you can place a free PenPal/NetPal advertisement in the Newsletter and on our website. Connecting with others often does wonders for the spirit. If symptoms worsen, I would recommend seeing a psychologist (or other licensed mental health professional), who may put her on anti-depressants temporarily to give her a positive edge and help her through this rough time.
Q: I just finished my four-week treatment and am amazed at all the daily self-care I have to do! I'm curious how people work full time and still have time to exercise, bandage, do MLD and have time to live and sleep!
A: From my own experience working with many patients, this often is the first reaction, or people tell me "I will, but I cannot do this every day." Each person has a different lifestyle - some busier then others, especially women who work all day and come home to cook and take care of a family. The key is to spend as little time as possible by streamlining your home program. Some patients now are experimenting with wearing a garment at night rather than bandaging, or alternating this every other night. Some are reporting good results. Be sure to wear a clean garment each night. Self-MLD can actually be done while clothed. While at work, take a few minutes here and there to walk around (for lower) or do your exercises (for upper), so that by the time you get home, you already have completed some of your daily routine. Of course, you are responsible for yourself and need to create your own self-care schedule. Soon, the self-care will become just another part of your life and, as your family gets used to your routine, they may be likely to help you (rolling bandages, etc.) and go for a walk/swim with you, as well.
In Your Opinion:
ATTENTION CLINICIANS: The following challenging questions are in need of answers. What is your opinion? Please send e-mail or fax your input to:E-mail nln [at] lymphnet [dot] org. Fax 415-921-4284.
Q1: I am an ergonomist in training and am searching for a chair solution for my client who has lymphedema of the lower extremity. He is trying to find a way to remain in his career as a computer programmer. He needs to get set up in a home office so that he can keep his leg elevated above heart level while working at the computer. Can anyone refer me to a resource that will help me find a chair adaptable to his needs?
Please address questions to: Editor c/o NLN, 116 New Montgomery Street, Suite 235, San Francisco, CA 94105 or e-mail: nln [at] lymphnet.org (firstname.lastname@example.org). Deadline for submissions is first day of the month prior to publication.