Lymphastim and breathing exercises in breast cancer-related lymphedema: a path to improved lung function and quality of life – a case report

INTRODUCTION

Breast cancer is the commonest malignancy in India, with a prevalence of about 14% amongst the females. The incidence of breast cancer starts usually in women in their early thirties till late fifties and it continues as the age increases.¹ Due to evolution in the advances in the treatment of cancer, the numbers of cancer survivors are also now increasing drastically. Consequently, the complications from the treatment of breast cancer are gaining more importance. Secondary lymphedema accounts for about 2-40% cases reported as a complication post the treatment of breast cancer either by chemotherapy, surgery or radiation therapy.² Approximately 1 in 5 patients experience secondary lymphedema, as a complication post-surgery, post axillary lymph node dissection or chemotherapy or local lymph node radiation resulting in swelling and deformity of skin. The prevalence of breast cancer related lymphedema rising to about 19.9% and 24% at two and seven years post breast cancer respectively, with majority of patients reporting lymphedema in upper arm than trunk. This risk is comparatively more in women who have undergone lymph node dissection as well as radiation.

Breast cancer related lymphedema (BCRL) is a potential morbidity that has detrimental effects on the patients functional and psychological aspects of quality of life.³ Lymphedema, apart from being a reminder of the cancer is also painful and is psychologically distressing for the patients as it starts affecting their quality of life. Upper limb Lymphedema is a chronic progressive pathological complication characterized by accumulation of protein rich fluid in the interstitial spaces due to disruption of the lymphatic system, post mastectomy surgery or radiation to the upper limb. Lymphedema can be diagnosed with various subjective findings like painless swelling due to increase in the arm volume and circumference, which affects the upper extremity movement, strength and thus affecting the overall functional and day to day activities. A holistic approach needs to be directed in order to improve the functional activities and reduce the psychosocial impact of the condition.⁴

Complete decongestion therapy is a traditional treatment, with manual lymphatic drainage, faradism under pressure, elevation, crepe bandage as components as a part of the therapy.⁵ Intermittent pneumatic compressions, is a non-invasive device that has been used to treat venous thromboembolism in venous ulcers.

Lymphastim is a mechanical compression device, based on pneumatic pressotherapy principle helps to facilitate the movement of lymphatic fluid. The present case highlights the complex treatment program planned using lymphastim, breathing exercises and active upper extremity exercises for rehabilitation of breast cancer related lymphedema.

CASE REPORT

A 76-year-old female, a known and treated case of breast carcinoma, operated for radical mastectomy, 5 years ago presented with painless, swelling over the left arm extending up to the fingers, which was gradually progressing for 30 days.

She initially observed the swelling in the fingers and wrist and experienced difficulty in lifting and grasping objects. The swelling gradually progressed to the proximal areas due to which she was unable to do her functional activities and experienced discomfort.

She also started experiencing discomfort in breathing while doing strenuous activities, which gradually progressed to breathlessness in her day-to-day activities like stair climbing, walking and changing clothes. The patient visited her oncologist for the swelling in the left arm and the breathing dysfunction for which she was recommended to the physiotherapist for further treatment. For assessment, several clinical examination and investigations were conducted such as arm circumference/girth measurement, modified medical research council scale, pulmonary function test, and lymphedema quality of life arm questionnaire (Table 1).

A complete decompression protocol was planned for the patient which included lymphatism (intermittent pneumatic compression therapy), upper extremity exercises and breathing exercises. Table 2 discussed the protocol for 4 weeks (Figure 1).

Assessment tests were repeated after a month, which showed tremendous improvement in the swelling of left arm, functional abilities, breathing capacity and overall, in her quality of life (Table 3).

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DISCUSSION

Lymphedema is a swelling in the tissue spaces that develops due to an interruption in the lymphatic system.⁶ Apart from swelling due to accumulation of lymphatic fluid in the upper limb, it also affects the QoL in all concerns including physical concerns like heaviness, inability to complete full range of movement, muscle weakness, psychological concerns like social embarrassment and functional concerns like not able to do daily routine activities independently. Lymphedema when detected early and treated with palliative rehabilitation is easy to resolve with functional improvement.

World Health Organization (WHO) has released morbidity, management and disability prevention (MMDP) guidelines for lymphedema and have highlighted use of various physiotherapeutic interventions like manual lymphatic drainage, faradism under pressure, bandaging, kinesio taping, compression bandaging and exercises.⁷

In the above case presented, lymphastim along with breathing exercises showed significant effects in treatment of lymphedema. According to Leduc, lymphastism which is intermittent pneumatic compression works on the principle of pressotherapy.

Lymphastism is a mechanical decompression therapy where the cuff applied along the length of arm causes compression and relaxation initially in the proximal and later in distal areas, thus helping the accumulated fluid to drain in the lymphatic vessels.

Along with lymphastism, shoulder exercises showed tremendous improvement in the range of motion, muscle strength and helped in reduction of arm circumference, whereas breathing exercises improved the lung capacity.

Breathing exercises including thoracic expansion exercises, segmental breathing, diaphragmatic breathing exercises improved lung capacity, lung volume and helped in the drainage of lymph in the lymphatic vessels. Diaphragmatic breathing exercises which facilitate the abdominal excursion aid in the direction of lymph into the thoracic duct, resulting in lymphatic drainage.⁸

CONCLUSION

This study reports a patient case report for breast cancer-related lymphedema, where she was stage zero post-treatment. Changes were slow and gradual as reported by the patient which she took lightly and didn’t report to the medical professional and no intervention was followed. After three months it led to stage 2, with the development of the heavy limb and higher circumferential measurements. This study provided the data assessment of the patient concluding that leniency can lead to severe issues, making the condition less manageable and negatively affecting the QoL.

ACKNOWLEDGEMENTS

Authors would like to thank the patient for her co-operation and consent. They would also like to extend gratitude to the faculty and colleagues for their timely guidance and support in completing this case report.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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