Lymphatic Learning

October is breast cancer awareness month.  As a Certified Lymphedema Therapist, I have decided to blog about lymphedema, a potential complication of certain breast cancer treatments.

By way of introduction, allow me to share some background information. In western societies, breast cancer is the most commonly diagnosed tumor among women.  In fact, 27% of tumors diagnosed among women are breast tumors. Fortunately, minimally invasive surgeries (including sentinel or axillary lymph node dissection) have become extremely popular.  However, as with any surgical procedure, internal scarring and adhesions may develop which may affect upper extremity joint and muscle function.  Furthermore, removal of lymph nodes may result in dysfunction of the lymphatic system, as will be discussed below.

Approximately 10% of water that exits the circulatory system at the cellular level does not return at the venous end of capillaries due to pressure related factors.  This excess water is called the lymphatic load.  It enters the lymphatic system at lymphatic capillaries, and it is returned to the circulatory system at the venous angle (the junction of the left subclavian vein and the internal jugular vein).  The lymphatic system also allows for transport of certain particles (including fats from the digestive system and certain large proteins) that are too large to travel through the circulatory system.

Lymph nodes are small oval shaped organs that contain white blood cells, T cells, and B cells (which are responsible for fighting infection and are a component of the immune system).  Lymph fluid travels through a series of lymph nodes, where filtration of the load occurs.  There are approximately 600 lymph nodes in the average adult human body.

Dysfunction of the lymphatic system can result in lymphedema, swelling of the upper or lower extremities due to an impaired lymphatic system.  Lymphedema can also develop in the trunk, head, neck, or genitals.  It is a chronic disease and treatment involves lifetime management of the condition.

Primary lymphedema involves a congenital malformation of the lymphatic system (ex. the vessels are too large or small) resulting in lymphedema.  Secondary lymphedema is when an initially healthy lymphatic system can develop problems through infection, obstruction, or damage.  Globally, the most common cause of lymphedema is filariasis, a parasitic disease that is caused by thread-like roundworms which occupy the lymphatic system.  The worms enter the lymphatic system through blood feeding mosquitoes and black flies in certain tropical countries.

In the United States, the most common cause of lymphedema is breast cancer-related surgeries that involve removal of affected axillary lymph nodes.  Removal of lymph nodes disrupts the normal return of fluid to the venous angles.  This can result in swelling of the involved upper extremity.  Similarly, lower extremity lymphedema can develop after removal of pelvic and or inguinal lymph nodes (ex. due to prostate or gynecological cancer surgeries).

Lymphedema can develop days, weeks, months, or even years after surgical node removal.  Therefore, individuals who have undergone these types of surgeries should be aware of their predisposition towards developing the disease. Any abnormal swelling or changes should be reported to one’s physician immediately, because the prognosis is better if the disease is detected and treated as soon as possible. The gold standard of care to treat lymphedema is complete decongestive therapy (CDT).  CDT consists of four components:

  1. Manual Lymphatic Drainage (MLD)
  2. Compression
  3. Exercises
  4. Skin Care

MLD was pioneered by Dr. Emil Vodder in the early 1900s, and it is series of manual techniques (including “pump,” “rotaries,” “scoop,” “and pump-push”) which promote mobilization of excess lymph fluid from the distal extremities towards proximal, healthy open lymph channels.  Another way to think about lymphedema due to lymph node removal is that there is congestion on one “road”.  Therefore, the certified lymphedema therapist (CLT) seeks to create new channels on uncongested “roads,” thereby creating detours for the lymph to return to the venous system through alternate routes.  MLD allows the CLT to direct the lymph along healthy, open lymphatic pathways.

Revitalize Physical Therapy recognizes that the breast cancer fight might not fully end after surgery.  As a therapist trained in CDT and MLD, it would be an honor and privilege to help address lymphedema experienced by you or a loved one. Please contact us if there is anything we can do to help.

A St-APP in the Right Direction

Smartphone Technology Meets Women’s Health

While many of us in the United States of America take advantage of our smartphone apps for conveniences which include online banking, social networking, and reading our favorite blogs, women in Uganda have recently started utilizing their smartphones for more basic healthcare related functions- testing for vaginal infections.  Thanks to Vaginosis Her Health/BVkit, women who cannot easily afford or who do not have easy access to gynecologists can perform an at home urine test which measures the pH level of their urine.  If the pH measured is too high or too low, the Vaginosis App will advise the individual to seek medical attention and provide physician recommendations.

This app enhances the women’s health progress that has already been made in Uganda in recent years.  In 2006, Dr. Ian Jacobs, Dean and Head of the School of Medicine at the University of Manchester, established the Uganda Women’s Health Initiative (UWHI), a collaborative project between Britain and Uganda with the goal of improving screening and treatment for women in Uganda.  Poor detection of infection, such as bacterial vaginosis, may result in pelvic inflammatory disease, miscarriages, and cervical cancer.  Cervical cancer is the leading cause of cancer related deaths amongst women in Uganda.  Prior to UWHI, approximately 2,464 of the 3,577 women diagnosed with cervical cancer annually in Uganda died from the disease.  Thanks to the efforts of Dr. Jacobs, improved screening techniques have enabled earlier detection and treatment of cancer.  In addition, postpartum hemorrhage (PPH), defined as loss of more than 500 ml of blood within the first 24 hours following childbirth, is a common and often fatal condition in Uganda.  PPH is often treated with oxytocic medications, and UWHI has increased the availability of misoprostol, a similar drug that can be self-administered.  Finally, UWHI has helped reduce brain damage in newborns through innovative brain cooling techniques, and it has empowered more women to seek medical attention in general.

While progress has clearly been made, nevertheless we still have a ways to go.  For starters, the entire premise of the BVkit app involves owning a smartphone, and at present only approximately 5% of women in Uganda own smartphones.  The apps designers hope and expect that these numbers will increase in the near future.  In the meantime, they are trying to share their app with women in other countries such as Nigeria and South Africa, where approximately 30% of women own smartphones.  Who knows what creative concepts are in technological store for women in the future?  I encourage you to share your ideas and suggestions…and if you end up winning a Nobel Prize someday, feel free to give me a shout out.

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