Dear OncoLink "Ask The Experts,"
I have had a radical hysterectomy for gyn-related cancer. I am experiencing severe abdominal swelling. My doctor has recommended complete decongestive therapy. Can you explain what is involved with that?
Linda McGrath Boyle PT, DPT CLT-LANA, Cancer Rehab Specialist and OncoLink Lymphedema Team Editor, responds:
Accumulation of swelling in the abdomen is not an uncommon problem for persons who have undergone a radical hysterectomy. This is especially true if radiation therapy to the pelvic lymph nodes was performed. However, the solution to this problem is the same, whether radiation was part of the treatment or not.
The international association that is very active in lymphedema research is called the International Society of Lymphology (ISL). The International Society of Lymphology published a consensus statement in 2003 that states that complete decongestive therapy is the accepted standard of care for persons with lymphedema.
Complete Decongestive Therapy consists of two phases.
Phase I- The Intensive Phase
In the United States, this treatment consists of at least one-hour-long sessions 4 to 5 days per week, including manual lymphatic drainage, bandaging with foam, short stretch bandages, exercises, and extensive education concerning the disease of lymphedema. The intensive phase lasts anywhere from 2 to 8 weeks, depending on the amount of swelling present, the firmness of the swollen tissue, and the ability of the person to participate in this intense program.
Manual Lymphatic Drainage (MLD) is a very light skin-mobilizing technique performed to help move the lymphatic fluid (which causes the swelling) out of areas of the body with damaged lymph nodes and into parts of the body with healthy lymph nodes. MLD sessions last approximately 50 minutes, and the techniques require excellent skill on the part of the lymphedema therapist in order to be most effective. It is important to begin manual lymphatic drainage gently in the area below the front of the neck. This is where the fluid dumps into the blood circulation. Persons with lymphedema develop a ?traffic jam? in the lymph system that must be unclogged at the beginning of the system (neck and trunk), before the legs are addressed. At least 25 minutes of the MLD session must be allotted to work on the trunk. The MLD must be performed on the FRONT AND BACK of the body. MLD performed properly does not leave skin red and will reduce much of the discomfort persons with lymphedema may feel. If performed by an excellent certified lymphedema therapist, it will also reduce fullness in the abdomen.
Bandaging with layers of short stretch bandages and foam is used to remove excess fluid from the legs and soften the swollen tissue. There are several brands of cotton short stretch bandages on the market. Two of the products are called Comprilan and Rosidal. These bandages are brown and look like elastic bandages (ace bandages), but do not stretch as much (only stretch to 30% of their length). The short stretch bandages have a low resting pressure so that they can be comfortably and safely worn 23 hours per day during phase I of complete decongestive therapy. The short stretch bandages, together with custom cut foam pieces underneath, create a container for the swollen area. The foam will soften the firm swollen tissues and make the bandage more comfortable. When applied properly, the bandage feels firm like a cast on the outside, but is flexible enough to allow for movement. Bandaging also requires a great deal of skill on the part of the lymphedema therapist. Bandaging is removed for showering.
Exercises are important to help evacuate the swelling out of the affected area. The bandage with foam presses against the swollen body part. Your muscles contract, pressing against the inside of the bandage. This muscle contraction forces fluid away from the bandaged area. Lymphedema exercises are simple, but must be performed several times each day in order to promote volume reduction and to soften the affected tissues. Lymphedema therapists encourage patients to participate in their normal daily activities while bandaged whenever possible. Movement is important to the success of phase I, and will reduce the number of days the person needs to continue with this phase.
Lymphedema education consists of daily attention to excellent skin care and an understanding of the disease of lymphedema. Persons with lymphedema are more apt to develop infection in the area of their body that has lymphedema, because the lymph system is damaged and cannot filter germs effectively. Skin needs to be protected from injury and sun using sunscreens and protective clothing. For example, persons with leg edema should not go barefoot and need to wear socks to prevent blisters on their feet. Skin must be cleansed daily, with special attention to washing between each toe. This is followed by application of a low pH, fragrance-free lotion such as Eucerin. This will help prevent cracks in the skin that can result in germ entry and infection (cellulitis). Cuts, burns, or insect bites need to be cleansed immediately, an antibiotic cream needs to be applied, and a non-latex bandage used to cover the area. Care must be taken to avoid injury while cutting the toenails. Tight clothing or pants/socks with elastic bands must be avoided. Shoes need to fit well and breathe to avoid injury or athlete's foot. Leather or canvas shoes are preferable to those made of plastic materials. Avoiding hot tubs or very hot weather helps to avoid sudden increases in the lymph load. Regular exercise is important, with gradually increasing activity. A 5-minute warm-up and cool down during the exercise session is important to avoid sudden changes in lymphatic load. Recognizing the signs of infection and obtaining immediate care with antibiotics is emphasized. The signs of infection include redness, pain, increased swelling, fever of 100.5 degrees F or higher, and possibly a rash. Excellent care and treatment will help to avoid the progression of lymphedema.
Phase II- Maintenance
During phase II, the limb size stabilizes and the person is measured for appropriate elastic compression garments to wear during the day. Most people will need to continue to bandages with foam at night, because the elastic garments do not maintain the size of the limb as well. Elastic compression garments may not be worn at night because they could slip down creating a tourniquet. This could result in injury to the limb. Some people invest several hundred dollars on garments that are non-elastic and padded to wear at night instead of wrapping with bandages and foam. Bandaging with foam remains the most effective way to keep the involved area from increasing in size.
Exercises and lymphedema precautions continue as taught during phase I in order to minimize the progression of lymphedema.
Every 6 months, persons with lymphedema return to their lymphedema therapist for re-evaluation and measurement for new elastic compression garments. Recommendations are made and re-instruction in self care activities occurs during this visit. I sometimes refer to this visit as a ?fifty-thousand mile check-up.? If the person is having trouble maintaining the size of the limb, the lymphedema therapist can offer problem solving ideas. Occasionally the person with lymphedema will need a week or two of intensive therapy (phase I) again to get back on track. These check-ups should also take place after the person has had a cellulitic infection. Active treatment is sometimes needed following an infection. It is important to be sure that all garments continue to fit properly after having an infection.
Lymphedema therapists have long-term relationships with their patients because there is no cure for lymphedema.
A helpful website for persons with lymphedema is the National Lymphedema Network. Here persons with lymphedema can find reliable information about lymphedema.
National Lymphedema Network www.lymphnet.org.
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