How to treat lymphedema after breast cancer surgery?

Author: You Miaoning, deputy chief nurse, Peking University Cancer Hospital

Reviewer: Duan Hua, Chief Physician, Beijing Obstetrics and Gynecology Hospital, Capital Medical University

Comprehensive swelling reduction treatment after breast cancer surgery is currently the international gold standard for treating lymphedema and a standard nursing method. In Europe, the implementation rate can reach more than 95%.

Comprehensive detumescence treatment, abbreviated as CDT treatment, is divided into two stages and four parts.

Two stages:

The first stage needs to be carried out in the hospital, and treatment needs to be carried out under the guidance of professional medical staff, with family members and patients learning.

The second stage is that after the patient has finished the treatment in the hospital, he or she will go home to continue the treatment. Because lymphedema is an incurable disease and a disease that requires lifelong care, after the patient has learned this skill in the hospital, he or she needs to go home for lifelong maintenance.

The treatment phase in the hospital is also called the shrinking phase or intensive treatment phase. Because the swelling is very severe at this time, the edema will shrink after professional treatment by medical staff. After shrinking, you need to maintain the treatment effect when you return home, and even use the techniques you have learned to continue shrinking and recovering the lymphedema while maintaining the effect. You can't just ignore it when she returns home because the edema has shrunk after treatment in the hospital, and the edema will slowly come back.

Comprehensive detumescence treatment includes:

The first is skin care, the second is manual drainage, the third is pressure therapy, and the fourth is functional exercise.

① Skin care

Some patients may develop tissue fibrosis as their lymphedema worsens, which means that the tissue becomes hard and feels stiff when pressed. Many grooves may even form at this time, and there are a lot of dirt hidden in the grooves, such as soil and bacteria. At this time, we need to wash her arms first. When washing her arms, check if there are any broken parts on the skin. If there are any broken parts, we need to deal with them first and then do skin care.

In addition, in daily life, because the pores of the skin after breast cancer surgery will be enlarged and thickened, some patients' skin will lose elasticity. During the treatment, her skin will be very astringent, or the patient's skin will desquamate and peel. At this time, some moisturizing lotion can be used to moisturize and lubricate the skin.

② Manual drainage

Manual drainage is divided into 4 actions:

The most basic movement is static rotation. That is, place your hands on the skin and rotate them. This rotation can be clockwise or counterclockwise, depending on personal preference. Pay attention to the fit, and then massage for about 15 seconds, and the number of massages is about 7-8 times. After massaging one part, move up and massage another part. This static rotation movement can promote local fibrosis and softening, and promote the return of lymph fluid to the venous system through the jugular angle.

The second action is circular push forward. Circular push forward is to hold the thumb and palm of the hand in a circular shape, and the circular shape is tightly attached to the skin of the patient's forearm on the affected side. When pushing forward in a circular shape, there is a slight downward pressure, but the force should not be too strong. At this time, remember not to rub the skin, but to drive the muscles under the skin and push forward. At the same time, our hands can move forward a little, just like a pump, constantly squeezing forward.

The third movement is to push forward with rotation. What is rotation? We know that after surgery, the patient's axillary lymph nodes are cleared, and the normal lymphatic vessels are cut off here. If we continue to push forward in a circular motion, when we push to this point, the lymph fluid will not be able to pass through, and it will stagnate here, causing edema. So we have to change the route. When it reaches the top of the elbow, we don't continue to push forward, but when it is on the inner part, the hand should be rotated, that is, to rotate the inner lymph fluid to the outside and push forward at the same time.

The fourth action is the emptying action. There is a large chyle pool deep in the human body, about three horizontal fingers above the navel. We will drive some lymph fluid from the surrounding abdomen into the chyle pool, and the lymph fluid in the chyle pool will flow back up along the thoracic duct. That is, we surround the chyle pool and drive the lymph fluid below and above toward the chyle pool, so that the lymph fluid can quickly pass through the chyle pool, through the thoracic duct, and enter the vein for return.

Generally, this drainage method can be performed once a day, and each time usually takes 40 minutes to complete.

Figure 1 Original copyright image, no permission to reprint

③Pressure therapy

Pressure therapy is the use of pressure tools to act on the affected limb to promote lymphatic return.

There are two main types of pressure tools, one is a pressure bandage and the other is a pressure suit.

There are low-elastic and high-elastic pressure bandages, which are mainly based on the circumference of the affected limb. They are tied from the fingers to the shoulder of the affected side. The pressure bandage will form a pressure gradient on the affected arm, and the pressure gradually decreases from bottom to top, which can squeeze the lymph fluid upward and promote its return.

Generally, patients with mild lymphedema can directly use pressure suits. For patients above grade II, especially those with moderate to severe grade II and grade III, it is recommended to use bandages first, and then gradually switch to pressure suits after the symptoms are relieved to a certain extent.

Why do you choose this way? For example, bandage therapy is equivalent to tailoring. The bandage is wrapped around your hand according to your hand shape, so it fits the patient better. The pressure suit is basically a piece of clothing you buy in different sizes. Maybe the M size is a little too small for you, but the L size is a little too big for you. It's just a little bit different.

Therefore, for serious patients, we recommend that they undergo bandage treatment first, and then switch to arm sleeve treatment after the condition has been relieved to a certain extent.

④ Functional exercise

Functional exercise is performed by patients after pressure therapy, with the affected limb wearing a pressure arm sleeve or bandage.

This exercise includes 7 movements and is relatively simple:

The first movement is to stretch your hand and move your wrist up and down. This movement is also relatively soothing and has a slower rhythm. The second movement is to abduct your arm and then move it upward. The third movement is to reach forward to the opposite hand. The fourth movement is to flip backward. The movement must be done in place, with a larger amplitude and slower. The fifth movement is to exercise the shoulder joint. The sixth movement is to exercise the elbow joint. The last movement is to do the ball-stroking movement to exercise the flexibility of the hand.

Figure 2 Original copyright image, no permission to reprint

The intensity of exercise should be selected according to the patient's physical condition. For example, some patients are in good physical condition and can do it two or three times a day, 20-30 minutes each time. Some patients are weaker and can do it for 10 minutes each time, maybe once or twice a day, as long as they don't get tired.

Why do we need to do exercises? Because the vertical pressure generated by the pressure bandage acts on the superficial lymphatic vessels, promoting the superficial lymphatic return. However, in addition to the superficial lymphatic vessels, people also have deep lymphatic vessels. The deep lymphatic vessels are deeper and the pressure bandage cannot reach them. Therefore, functional exercises are needed to promote lymphatic return. When exercising, the muscles will stretch and contract. The muscles are like a shuttle. They will become longer and shorter, and they will also generate power, which just acts on the deep lymphatic vessels and promotes the deep lymphatic return.

Therefore, the functional exercises in the fourth part of comprehensive treatment will only be effective if they are performed while wearing the pressure bandage or pressure suit in the third part.

Otherwise it will have the opposite effect. Because exercise will produce lymph fluid, if you don't wear a pressure bandage or pressure suit, the return flow will not be good, and it will cause swelling.