This post was written by H&W instructor Susannah Haarmann, PT, WCS, CLT, who authored and instructs the course,Rehabilitation for the Breast Oncology Patient.
One year ago I received a phone call from my father on behalf of a friend, named Lynne,* from Oregon who was navigating her way through cancer treatment and jumping many medical and personal hurdles. “Susannah,” my father said, “Lynne is having terrible pain in her breast and arm and is unable to move it above her head. It started a couple of weeks after her surgery and months later it is still bothering her. She is a very active lady and this is really getting her down. Nobody can tell her what it is. Do you know what could be causing this?”
“Yes, dad, it sounds like lymphatic cording,” I said. I contacted Lynne and was able to speak with her physical therapist. Within a few weeks of treatment Lynne’s pain was gone, she had regained full range of motion in her shoulder and was back to paddling.
Lymphatic cording is a relatively common phenomenon occurring in approximately 43% of patients status post axillary lymph node dissection and 20% of patients after sentinel lymph node biopsy (Torres Lacomba et al, 2009) (McNeely et al, 2012). Not only are most therapists not familiar with this phenomenon, but many doctors are unable to identify a reason for the acute loss of shoulder range of motion and pain that can occur after axillary node dissection or mastectomy. Lymphatic cording does not only cause physical dysfunction and discomfort, it can also impede necessary medical treatments. In order to receive radiation to the axilla, a patient must be able to hold their arm in a cradle which requires maintaining a position of shoulder flexion and abduction.
But there is hope. Manual releases for lymphatic cording are one of the most efficient and effective methods of decreasing pain and restoring range of motion. Significant improvements in pain and range of motion are possible after one treatment and often resolve in as little as three sessions. These techniques require skilled assessment from a rehabilitation practitioner who understands basic anatomy and function of the lymphatic system and can provide progressive manual therapy treatment. The therapist must be able to identify the different types of lymphatic cording in order to determine functional prognosis and provide the most effective treatment.
Lymphatic cording has been described as ‘self-limiting,’ explaining that in most cases it resolves within 2-3 months, however, a cascade of physical dysfunction may occur from even the presence of this ‘temporary’ impairment. Within two months, an individual may develop compensatory mechanisms of movement which may lead to postural deficits and pain related to muscular trigger points, chronic headaches or shoulder impingement syndromes. Impairments such as this may also prevent a person from performing employment tasks or fulfilling family responsibilities; this can be detrimental to self-worth and affect quality of life. It is important to note, however, that the presence of lymphatic cording in clinical practice has been noted for months or even years after surgery (Kepics, 2007).
We as rehabilitation professionals are acutely aware that a patient’s investment is therapy is often based upon the reward of function and body restoration. In my opinion, lymphatic cording is a rewarding condition to treat because of its often quick response to manual release techniques and exercise. Lymphatic cording is a common and misunderstood phenomenon; I hope that one day every community in America will have a confident and skilled therapist at hand who is able to treat this often times perplexing condition.
*Permission granted for use of first name
Join Susannah this February in Phoenix where she will be teaching Physical Therapy Treatment for the Breast Oncology Patient
References:
Kepics, J., Treatment of axillary web syndrome: a case report using manual techniques. 2007; University of Scranton, case report.
McNeely, M., Binkley, J., Pusic, A., Campbell, K., Gabram, S., Soballe, P., A prospective model of care for breast cancer rehabilitation: postoperative and post reconstruction issues. Cancer. 2012. 188 (8) 2226-2236.
Torres Lacomba, M., Mayoral Del Moral O., Copariias Zazo J., et al. Axillary web syndrome after axillary dissection in breast cancer: a prospective study. Breast Cancer Res Treat 2009; 117: 625-630.