Monthly Topics

Laser Therapy on lymphoedema

Dr. Neil B Piller
MD, President of Flinders Surgical Oncology Clinic
Flinders Medical Center
PHOTO:Sunrise in Australia

Post-Mastectomy Lymphoedema (PML)

Chronic lymphoedema of the arm is a frequent and distressing complication of breast cancer treatment and is unrelated to tumor type or progression. The condition usually develops rapidly after a latent period of weeks, or even years; the limb swells to 150-200% of normal limb volume. In Australia low level laser therapy has been applied for this illness  successfully since 7 years ago. This is a report by Dr. NB. Piller who started this new treatment.

Strategy for management of upper limb problems arising from surgery and or radio therapy or other damage to the axilla and breast tissues and their associated lymphatic structures

Background

All parts of the body have a deep and a superficial lymphatic system.  It is important to consider this in any management or treatment program.

For each arm there are 6 major lymphatic territories, three in the forearm and three in the upper arm. The territories are drained by a series of lymph collectors.  These are generally found lying above the layer of connective tissue overlying the muscles of your body. These vessels, in the main, drain into the lymph nodes in the armpit region. There are some however, which bypass this area. 
For the left arm the arm and breast draining vessels drain into the left subclavian vein. For the right arm and right breast the drainage is via the right subclavian vein.

The surgical removal of the lymph nodes in the armpit destroys or damages some of the lymphatic collectors that drain the arm. Adjunctive radiotherapy can cause additional damage to these collectors and also can damage the smaller lymph capillary network. Radiotherapy may also slow the rate of regeneration of new capillaries and the formation of alternate pathways for lymph drainage due to the fibrotic induration it causes.  Radiotherapy to the chest wall, over the areas where the lymph drains into the subclavian veins, may compromise drainage into these vessels and needs to be considered during therapy.

Whether the tissues are free of abnormally accumulated fluid and in a healthy state or not depends on the balance point between the Lymphatic Load (the amount of fluid that is waiting in the tissues to be taken away) and the Lymphatic Transport Capacity (the ability of the system to clear the waiting fluid).

When load exceeds transport, lymph accumulates in the tissues and a localised swelling occurs. This is associated with discomfort and feelings of heaviness, tension, loss of range of movement etc. Some of these problems, especially those of feelings of numbness, tingling and mobility may also be linked with the radiotherapy and surgery.

However if the arm (and other affected tissues) are left untreated or poorly managed the area affected by the poor drainage (which may also include the breast) may spread from a single lymphatic territory to most or all of them. 

If the fluid remains in the tissues for any length of time there is a chronic inflammatory process in which fibre is laid down in the interstitium, usually through the over activity of fibroblasts and under activity of macrophages. There are many other events that may influence this process which are currently under experimental investigation.

For fluids to accumulate the surgery/radiotherapy and the progressive fibrotic induration of the tissues must have reduced lymphatic transport capacity to a level where it is unable to equal the lymph load. Remember, since the lymphatic system has a large reserve capacity (up to 90% of a normal resting load) the destruction or damage to the system must be quite significant before any serious lymphoedema becomes manifest.

The patient must realise that they can have a significant effect on lymphatic load through careful home management strategies. Education, awareness and treatment programs go hand in hand.

Management

This is what the patient can do.  Ideally these aspects should be attended to prior to treating since it makes the treatment more effective

Weight management is very important.  Overweight persons should receive diet advice.  BMI is a good indicator of whether weight management is needed.

Skin care is crucial  - infection entering through the skin (particularly if it is allowed to become dry and cracked) is the main source of an increased lymph load.

Wound care is crucial ? any infection will immediately result in an increase in lymph load and worsen the condition of lymphoedema.

Diet management is important ? this means is a normal well-balanced health diet with a good intake of fluid and one low in salt and moderate in alcohol. Elimination of long-chain fats from the diet is also important.

Isometric and isotonic exercise of the limbs should be performed regularly.  Some of the simplest exercises seem to be the best.  For instance a stretching yawn in which the arms are gently raised overhead and the muscles tightened while inhaling deeply. Another good exercise is the lotus flower opening which is part of the tai chi exercise program.

Both of these work in the following manner: The deep inspiration creates a negative pressure in the thoracic area, lymph will flow along the collectors and thoracic ducts to this area from others due to the pressure gradient. The muscular contraction will increase tissue pressure, helping to force the fluids into the small initial lymphatics,  once here the inherent pumping action of the lymphatics will transport the lymph proximally, with the lymph finally draining back into the vascular system at the junction of the subclavian veins.

Swimming is also good due to the external pressure on the limb which helps the lymph move into the collecting vessels and due to the variation in tissue pressure caused by the movement of the muscles. 

Treatment

It is very important to facilitate halt fibre deposition and to encourage removal of existing fibre. The fibre may be associated with surgery and/or radiotherapy as well as occurring as a result of the continuing subclinical inflammatory processes in  the tissues.

Low Level Laser Therapy has been shown in many occasions to do this well. 

Protocol for the arms

Clear as much residual fluid from the area as possible by elevation of the limb(s) and or isotonic or isometric exercises (as described above) while the limb is slightly elevated.

Self or partner massage prior to the laser use may be beneficial to help clear the lymphatic territories, although this has not been proven as yet. It is also likely to be useful afterwards as the fibre and scar tissue should be softened, allowing easier flow of lymph fluid.

Apply spot laser to areas of surgical scarring and cover the areas for the nominated time. (bilaterally or unilaterally as necessary).  These will generally be localised areas which have become heavily indurated. It is unclear whether itfs best to laser along or across the scar.

Apply spot laser over the area(s) treated by radiotherapy (consult with the patients about exactly where this occurred, although in the main it will be obvious from a change in skin texture). The laser to this area can be for a lesser time but care should be taken to cover the whole area.

Run laser over the medial line of the chest to help open the connections between the lymphatics of the right and left sides of the body.

Run laser over the anterior upper and lower parts of the limb where the major lymphatic collectors of the limb are found. This action may increase lymphatic motoricity although this is not proven and does not seem to occur in normally functioning vessels ? however laser is shown to affect non-functioning tissues differently to functioning tissues and the matter of lymphatic motoricity remains in debate.

After the laser treatment, encourage the patient to undertake gentle exercise while the arm is/are elevated or suggest the partner, professional, or even the patient to perform gentle manual lymphatic drainage. Ensure this follows the principles of lymphatic drainage with lymph only being moved into areas which already have been drained of lymphatic fluid. This means draining lymph first from areas furthest away from the affected limb and any other affected area. It is wise to have this demonstrated by a professional prior to its use.

How much laser and how long?

At the moment we are not sure of this.  There is some evidence of a dose-response relationship.  I.e. the more laser given the better the result (to a peek point after which the response will start to decrease with further treatment). There are others who say that the laser turns on a switch and once the switch is on it is on and more laser will make no difference.  Not with standing this, there is no doubt that laser works well to improve the size, feel and composition of the lymphoedematous limb. 

For patients taking the Laser Therapy Unit home we recommend twice daily use of the laser for the first two days if very significant fibrosis  is evident and daily there after. The laser needs to be used the most in the most severely indurated areas and least over other areas of the limb. 

Its also important to ensure that factors such as high blood pressure and thyroid aberrations have been attended to before treatment. If left unattended these will be likely to reduce the effectiveness of the therapy. It is also important to do everything possible to reduce lymphatic load. Information on how to best do this is indicated in a booklet titled gRecognition, treatment and management of a lymphoedema armh by Neil B Piller, and which is available from the Flinders Surgical Oncology Clinic at Flinders Medical Center.

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