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Joachim Zuther, Lymphedema Specialist. Read more
Lohmann Rauscher
MediUSA

Tactile Medical

Treatment of RIBP in the Presence of Lymphedema

 

This is the second part of  Radiation-Induced Brachial Plexopathy (RIBP) and Lymphedema. The last blog entry covered the causes and symptoms. This entry covers the treatment and how it relates to the presence of lymphedema.

How is RIBP treated?

Although surgical procedures to decompress the brachial plexus and re-vascularize the nerves and surrounding tissues have been described in the literature, the results are often unsatisfactory.
Unfortunately, RIBP is essentially an incurable condition and with the absence of satisfactory treatment, emphasis is placed on symptom control and therapeutic exercises specifically addressing the maintenance of movement in the paralyzed extremity for as long as possible. Physical and Occupational therapists work as part of a multi-professional team to address loss of function and flexibility, weakness, pain and lymphedema. Special adaptive equipment and techniques address basic functions of daily living and suggest ways to modify the home and workplace.

Special considerations to address RIBP in the presence of lymphedema:

Lymphedema management in patients with RIBP is more challenging, but absolutely necessary to help control pain and to decrease the volume of the extremity. Volume reduction lessens the impact of excess weight on the shoulder joint, prevents the build-up of additional fibrotic (scar) tissue and significantly lowers the risk of infections commonly associated with lymphedema. It is often necessary to adapt compression and exercise protocols to accommodate the special circumstances associated with RIBP.

Compression Bandaging: Many patients affected by RIBP experience impaired sensation on the skin and are often unable to provide accurate feedback related to their individual tolerance to pressure. Therapists applying compression bandages to the affected extremity during the initial sessions of Complete Decongestive Therapy should be very conservative with application pressure and use ample padding to avoid pressure sores; application pressure may be gradually increased in the absence of side effects.

Effective compression therapy for lymphedema partially depends on the extent of the interaction between the bandage layers and the musculature working against the resistance of the bandages; this is also known as the working pressure. With partial or complete loss of muscle activity, the working pressure of the bandage is reduced, making the bandage less effective. However, even if compression bandages are applied with less pressure and the day-to-day results of these bandages are not as noticeable, they are still effective in promoting lymphatic return by increasing the pressure in the tissues.

It is also important to consider that some RIBP patients wear arm slings to reduce the degree of subluxation and discomfort of the shoulder joint. In these cases, the elbow should be kept in 90 degrees of flexion during the application of compression bandages.

The possible presence of joint contractures caused by muscular atrophy and immobilization should be addressed with special bandage application techniques.

Compression Garments: The wearing of compression garments is essential to prevent lymphatic fluid from accumulating in the tissues and conserves the results achieved with Manual Lymphatic Drainage.

Compression sleeves and gauntlets are available in a number of compression classes. The level of compression within the different classes is determined by the value of pressure the garments produce on the skin; these pressure values are measured in units of millimeters of mercury (mmHg). For a compression garment to work effectively, the pressure needs to gradually decrease from the wrist to the shoulder. This gradient is necessary to avoid tourniquet effects and subsequent obstruction of lymph flow.

In general, compression levels provided by class 2 garments (30-40 mm/Hg) will be sufficient to prevent swelling in most patients affected by

Donning Device

lymphedema of the upper extremity. However, if lymphedema is combined with RIBP and partial or complete immobility with subsequent loss of normal muscle tone, a lower compression may be required in order to avoid tourniquet effects.
Patients need to be thoroughly educated in the use of donning devices for compression sleeves and alternatives for night bandaging (Solaris, CircAid, etc).

Exercises: Immobility is detrimental to the lymphatic return. In addition to support the return of lymph fluid, the main goal of the exercise protocol is to focus on mobility. Modifications to the usual decongestive exercise program may be necessary to address impaired motor function.

Arm Bike

Exercise protocols for RIBPwith partial or complete loss of mobility are geared towards the development of strategies that compensate for lost muscle function by using those muscles that still have function. Specific exercises also help to maintain and develop any strength and control that remain in the affected musculature. This also helps to prevent further shortening of muscle fibers (contracture) and to maintain and regain range of motion in the arm. Elevating the arm as often as possible to promote lymphatic return is even more important in patients affected by RIBP.

Therapists and doctors may also suggest adaptive equipment that helps the patient to maintain a normal life. For a very comprehensive list if adaptive devices and coping tips, I would like to refer you to the RIBP page of the “Step Up – Speak Out” website.

Additional Resources:
BreastCancer.org Discussion Forum
Step Up – Speak Out
Medscape
Lymphedema People

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12 comments to Treatment of RIBP in the Presence of Lymphedema

  • Caryl Miilu

    I am a breast cancer survivor of almost 32 years and have been dealing with lymphedema for most of that time. It is reassuring to hear I am not alone in this problem and that the RIBP is also more prevalent than I knew–I do not have anyone in my area who has this condition. It took years and many MRIs and other tests with many doctors before I had a name for my weird symptoms. My left hand is almost completely useless and my left lung is also affected. Thank you for the work being done in this area…can I help?

  • Cindy Graeff

    Thank you Joachim for your writings and sharing your knowledge. RIBP has taken a huge toll on my quality of life after radiation treatments in the 80’s and again in 2006. Also, CIPN has also been a factor for me from chemotherapy, including vincrestine and taxotere. Surviving survivorship can indeed be difficult, and greatly change the quality of life for the patient. I am striving and advocating for more attention by the medical field, for research and funding aimed at reducing future incidents of these side effects. And for those of us already suffering, some relief and treatment. I have started a forum at http://apps.komen.org/Forums/tm.aspx?m=322106 to help others as best I can, sharing experiences and information, along with various websites that are beneficial, such as your two articles. Once again, I want to thank you Joachim, we need many more like you on this side of survivorship!
    Stay strong,
    Cindy

  • Jodi Orner, MSPT, CLT

    Recently referred a pt with L breast swelling (no cancer hx)however pt with hx of AV fistula in L arm. Any info on treating someone with a shunt? Or signs to look for other possible diagnosis vs lymphedema in this region?

    • Joachim Zuther

      Dear Jodi: Shunts only present a local contraindication for MLD and CDT. Manual techniques should not be directed toward the shunt, and lymph fluid should be directed arond the area

  • Wendy

    Thank you, thank you, thank you…..I am an OT working in homecare who has been treating a patient s/p biopsy and radiation for breast ca. She stated the lymphedema began before she was diagnosed,then became worse after the surgery and tx. She went to post-acute rehab with a lymphedema trained OT who tried wrapping and unfortunately she could not tolerate due to sensory involvement and per my patient, the OT just gave up and did nothing else for the lymphedema the entire time she was there !!!Needless to say, the lymphedema became worse and the arm more painful. I am not lymphedema trained,and unfortunately we do not have a trained therapist on staff. I am happy to say that we have made tremendous gains, with ‘modalities’ she can tolerate.(I can tell you later some of my tricks). From an arm that she could not lift off the table, she now has full shoulder flexion against gravity, full elbow flexion/extension, also against gravity.What has been baffling me is that she has strong wrist extension towards radial deviation. Trace wrist flexion. Minimal MP flexion, no PIP or DIP flexion and no finger extension. Minimal thumb adduction, no opposition/extension, with flattening of webspace noted. I have worked with many post tx breast ca patients with lymphedema over the past 20 years but none that I recall that have such good proximal return and sporadic distal return. There is nothing in her chart referring to RIBP but from what I have found in your writings, I think I have found my answers !!! Thanks !! Wendy–Green Lane, PA.

  • Jennifer Sanders

    Thank you so much for keeping us informed. Although I’ve not been officially dx with RIBP it does sound similar to my symptoms. I was hoping you could answer a question for me. Is it possible that RIBP would effect the neck, jaw and tongue. I’m having a burning, numbness, pain & heaviness that radiates across collarbone, up side of neck underneath jaw line, toward ear and occasionally side of tongue. It does come and go and has been warm to touch at times. LE has been ruled out and MRI was clear. Thanks again for all you do for us.

  • anu

    My mom with ribp nd lymphedema
    Can i use lymphedema pump…
    There are no treatment available in here…how effective are
    Bandages how can i get them to india

  • AmySamples

    I have suffered over a year with RIBP symptoms but finally met w/a neurologist that diagnosed me this March. I am a nearly 9 yr breast cancer survivor. I have had lymphedema for almost 8 years. I was diagnosed at age 28 & it’s my understanding that RIBP is more likely to occur in younger women.

    I currently am on pain medications for nerve & other arm pain (muscle), a muscle relaxer (although my muscles seem to draw/tighten even with them) & a daily antibiotic (as I am prone to infection in my arm–was hospitalized twice w/in 9 months w/severe infection in my arm).

    My family Dr did not take an initiative to “get to the bottom of” my pain. I waited for many months before I agreed to take pain meds that he had offered. My oncologist referred me & eventually I met w/the neurologist. My pain became severe in my arm & at times is almost unbearable. I suffer lymphedema pain which feels like an arthritic pain or like what you feel after a bee sting, swollen & fevered. I suffer muscle pain from constant drawing or pulling of my muscles. It also is a dull pain. I find myself having to manually twist my arm as it feels like my muscles are twisted up since my arm is immobile except for my shoulder. I suffer nerve pain which can be sharp sudden pains, severe burning sensations or wronged. I always have pain whether it be 1 pain or a combination of pain.

    I’ve been told the only treatment plan is to maintain range of motion through physical therapy & pain management. My hope is there is more help available than this. I am right handed & it is my right arm that is affected. My entire life has changed both personally & professionally. Constant pain effects my concentration & my abilities to perform my duties. My pain sometimes will only decrease if I lie down w/pillows under my arm for support. There are times that I may sleep a lot.

    Can you advise treatment options or specialists in RIBP? Thanks.

    • Joachim Zuther

      Dear Amy: the main goal of treatment is management of related pain and to increase range of motion. Any Physical Therapist will be able to advise you personally.

  • Laura

    Does RIBP also cause issues with excess swelling in the fingers when bandaging or increased swelling after wearing bandages for several hours? I’ve been seeing lymphedema therapists for over a month due to a sudden flare up, but every attempt to bandage results in a misshapen hand and increased swelling of my arm (causing me to lose the feeling in my hand) that then requires me to remove the bandages. One therapist mentioned that she suspected it may be due to nerve damage. It sounds like she may have been referring to RIBP.