Class Recordings

Okay, great. Thank you.

Great. Welcome.

My name is Michelle Larson. I know most of you new acquaintance.

Yes. I’m a physical therapist here at Tahoe Forest and have worked here for a very long time.

I’ve been here for over 30 years and I have been fortunate to specialize in the treatment of cancer patients and survivors.

Which has been wonderful for me personally and a big segment of my population is people with Lymphedema. So that’s what we’re going to talk about tonight.

I am board certified with the American Physical Therapy Association in oncology physical therapy and I’m also a certified Lymphedema therapist. So we’re going to talk about Lymphedema tonight.

My other great passion in what I do is teaching people about exercise and cancer, but that’s a whole another talk. And if you have interest in that, feel free to email me later.

So, what is Lymphedema? Lymphedema is a chronic condition which is an accumulation of fluid in the tissues of an at risk area and it happens because of either pre-existing damage to the lymphatic system or lymphatic damage because of external forces such as surgery, radiation, infection.

It is unfortunately a progressive disorder and there is no cure. And because of those factors is why it’s really important to learn about it, to learn about the onset, what it looks like, and then what you can do to try to prevent it.

When we think of Lymphedema most of the patients we think about are those with breast cancer. But it certainly affects other cancers as well.

We see it with head and neck cancers, with gynological cancers, sometimes melanomas. Again, most of the patients we’ll see are with breast cancer but it can happen with other cancers as well.

And the lymphatic system that gets damaged is part of our circulation system. Which helps with fluid balance and also with our immune response to different bacteria and viruses that might strike our bodies.

So in 2025, there’s actually 4.3 million breast cancer survivors in the United States. And we’re getting better and better at the treatment of cancer.

So there’s more and more survivors and unfortunately with that comes the side effects from chemo, radiation, surgery, all those side effects including Lymphedema. So people are surviving but they’re surviving with some of these more unfortunate risk factors.

The survival rate for breast cancer now is 90 to 91%. And then of those people 20 to 30% grossly get breast cancer related Lymphedema.

In the United States though if you look at the other patients including breast cancer there’s actually 10 million Americans right now living with some sort of Lymphedema. Welcome Jay.

I put that statistic up there, 20 to 30%. If you read the literature though, it varies greatly depending on the type of study that’s done.

From six to actually 77%. So there’s a lot of discrepancies in the research.

Hi Glenn, how are you? So again, 10 million people.

So that’s a big issue in our country. That’s unfortunately fairly poorly understood even by a lot of medical professionals.

So there’s actually two types of Lymphedema. There’s primary Lymphedema and then secondary Lymphedema.

Primary Lymphedema is something that is genetic and actually only happens in about 1% of Lymphedema cases. It’s a very small number compared to secondary Lymphedema.

Primary Lymphedema is something you’re born with. Your lymphatic system is malfunctioned at birth and you develop Lymphedema sometimes as a child and sometimes as a teen and sometimes in later years.

But again it’s a very small percentage. So secondary Lymphedema, that’s going to be 99% of the cases that we see.

And again that’s triggered by external damage to the lymphatic system again by surgery, chemo, radiation, these common things that happen with the treatment of cancer. So if we look at the lymphatic system it’s a network of vessels and lymph nodes throughout the whole body and again it’s responsible for fluid drainage and it helps with immune function.

A lot of the vessels are within the skin. The majority of the vessels of the lymphatic system are actually within the skin.

And when we talk about treatment, we’re going to talk about the skin in a few slides. The largest vessel within this system is called the thoracic duct.

It actually runs right through the center of your body through your diaphragm. This is a diagram of some of the lymphatics.

I often describe it as it’s again part of your circulation system. If you think about your arteries take the blood and fluid to your tissues with oxygen and nutrients and then your veins bring that fluid back.

So it’s this big circle. Well, the arteries take 100% of the fluid out and the veins bring 90% back.

So it’s that remainder of that 10% of fluid that is picked up by the lymphatic system to get back into that circulation. So it picks up that extra 10%.

It also picks up big molecules like viruses, bacteria, proteins. They’re too big to fit into the venous system.

So the lymphatic system helps carry those bigger molecules back up. I actually did a class online just a couple days ago about some new research about the lymphatic system because most patients don’t get it, which is the great news.

But there’s still a fair percentage that do. And why is that? And for decades, we’ve been trying to understand why this is.

And what they’re discovering is, you know, we have these main pathways that carry the fluid on a day-to-day basis. But what we’re learning is they’re discovering some alternative pathways that are essentially awakened and used when the main system is down.

So we’re thinking that that is why most people don’t get it because when the main system gets damaged, the backup system kicks in. Which is a great thing for most of us.

But those of us that aren’t born with these backup systems, those are the ones of us that will get the Lymphedema. So interesting, when we talk about the onset of Lymphedema the average onset is 18 months after surgery.

It’s a long time. Which is kind of weird because you know you’re going through all this stuff and you think it’s all going to happen now.

But this is something that it’s important to learn about early so you can watch for it later. I’ve seen it as early as 3 months and I’ve seen it as late as 15 years.

Once you have surgery, chemo, radiation, any damage to your lymphatic system, unfortunately, that lives with you as part of your medical history going forward. Just like if you broke your ankle, that lives with you as your medical history moving forward.

So, that risk is always going to be with you. And then there’s this variability of when it can start.

So average is 18 months. Most people if they’re going to get it will get it within the first 3 to 5 years following surgery.

So most people are going to get it in that earlier window. It also begins near the center of the body and moves outward.

So if someone comes to me with what they think is Lymphedema in their hand, unfortunately it’s probably been there for a while because it starts if we’re talking the upper body, it’s going to start at the shoulders and work its way down to the hand. For the legs, it’s going to start in the buttock hip area and work its way down to the feet as it progresses.

So it’s important to watch for it. If we’re talking arms in the shoulder, upper arm area, same thing in the legs, in the groin and thigh area.

The most common word I hear when people come to me saying, I think I have Lymphedema, the most common word I hear is, my arm or my leg feels heavy. And that’s because it is because it’s got extra fluid it’s carrying around.

It feels heavy. It’s usually not painful.

But it’s heavy. That’s the most common word that we get.

Yeah. So, because of this later onset, surveillance is really important, to learn about it early and then get to know a Lymphedema therapist in your area.

There’s actually three of us here in Truckee. And check in with them when there’s changes in your health.

If you’ve gained a lot of weight, if you’ve lost a lot of weight, if you’ve had a lot of change in medication, if you’ve had a change in your cancer care, if your cancer’s come back. Changes like that can affect or possibly trigger the start of Lymphedema.

And if you have someone you can connect with to help with that surveillance, that’s going to help us catch it early. It’s identified by history and patient report.

So you have to have this history for us to even think about it. But then the patient’s going to come into us and say, “My arm feels heavy. My arm’s achy. I’m not able to use my arm like I used to” or leg.

Sorry, I’m using most of my examples from arms. And that history combined with the patient report takes us to the next step, which is going to be a measurement of that limb, the leg or the arm.

Here we use a tape measure to measure volume. Which is still a gold standard.

I brought a tape measure, but I don’t know where it is. So I have an Excel spreadsheet and I do about 10 or 12 measurements on your arm or leg.

I put them in the spreadsheet and it produces a volume with high level mass. And in the arm it’s nice because you have a dominant arm and a non-dominant arm and I’m able to calculate the volume of both.

Your dominant arm should be 3 to 5% bigger than your non-dominant arm. So that’s one quick way for me to see if you’re within normal ranges.

Legs are a little bit different. You don’t really have that much of a dominant leg.

Most of us don’t. So, they should be more similar in volume.

There’s also bio impedance measurements. You can use something called lymphoscintigraphy.

MRIs can be used in perimetry. Those are available at bigger institutions like UC Davis, UCSF, Stanford — those bigger institutions will have those ways to measure, but tape measure is still a gold standard as well.

So the incidence ranges again, we see some pretty wide variations in our statistics again, but this is really related to how big a surgery you’re going to have or have had and how many lymph nodes you’ve had taken out. A lot of surgeries now use what we refer to as a sentinel lymph node biopsy as part of the surgery.

And that’s when they take the tumor out and they inject dye and see where the dye goes and they’re going to pull those first one or two, sometimes three lymph nodes and test them for cancer. And if they’re negative, they’re not going to do anything else, which is wonderful because you’re only losing one to three nodes with that sentinel lymph node biopsy.

So the rates of Lymphedema with that are on average about 6%. So definitely much lower with that sentinel lymph node biopsy.

If they inject the dye and they discover there is cancer in those first couple lymph nodes, then that tells them they need to do a bigger surgery. And again, you know, we’re talking about one of the unfortunate side effects of cancer care.

Our ultimate goal, of course, is to get rid of your cancer, right? So it’s a bummer that you might have to have a bigger surgery, but if they can get rid of the cancer, of course, that’s number one.

So again, if they find more cancer in the lymph nodes, they’re going to take more lymph nodes. And they usually do what’s called a node dissection.

If it’s in the arm, it’s going to be an axillary node dissection. If it’s in the leg, we refer to it as an inguinal lymph node dissection.

And they’re going to take actually a cluster of lymph nodes. And that’s where we definitely see a jump in the risk, on average of 22% with that procedure are going to have Lymphedema.

So, we usually talk about the legs and the arms, but it can also happen in the trunk. And it’s not talked about as much and it’s much harder to measure.

But it can happen there as well. With the axillary lymph node dissection and inguinal would be similar — you’re running around 25% to 30% risk of that Lymphedema happening in the chest, trunk, genital area in addition to the limbs.

It almost fortunately almost never happens with the sentinel lymph node biopsy, which is good news. So there’s some unmodifiable risk factors for Lymphedema and there’s some modifiable risk factors for Lymphedema.

So if we talk about the unmodifiable ones, here is the list — again the main risk factor is the number of lymph nodes taken out, which we just talked about with those surgeries. History of radiation is a major risk factor.

Everything within the field of radiation becomes hardened and stiff. Those tissues get hardened and stiff.

And if you think of any of your arteries, veins, and you harden them, they’re just not going to work as well. And that damages the lymphatic system.

Again, adding another level of risk. Some chemotherapies also increase risk because some side effects of some chemotherapies are increased swelling.

And then your body weight at the time that you were diagnosed with cancer is also an unmodifiable risk factor because you can’t change the past. So if you had a BMI of over 30 at the time of your diagnosis, that is another risk factor.

And then other factors include large tumor size, if you had positive lymph nodes, estrogen receptor negative breast cancer, history of infection or seroma, as well as advanced age. There are some modifiable risk factors.

That’s the good news. Back to weight.

Again, weight is a risk factor. So, if you’re able to control your weight, that will help reduce your risk.

We often talk about body mass index. So, we want to try to drop that into that normal range.

But even if you’re in obese or overweight range, even if you can bring that down some numbers, that’s going to help reduce your risk. And then part of the education we do is avoiding infection, having really good skin care of that involved body part that’s at risk to help reduce the risk of infections, cuts, that could lead to swelling.

We want to avoid injury or trauma as well as overuse. That’s going to be part of the prevention strategies we use to reduce our risk.

In the past there was information out there not to get blood draws or blood pressures on your limb that you’re concerned about. Those are not true anymore.

You can get blood draws and blood pressures on that limb. If you have two arms, which you all do, and one’s at risk and one is not, I would always offer the non-risk arm.

It’s your body, so tell them what you want. But if you’re trying to get a blood draw and they can’t find a vein, don’t panic if they have to take it at the one that’s at risk because that is not a risk factor.

The one medical procedure though that would possibly cause swelling in that arm or leg would be a vaccine. So I don’t recommend vaccines in the at risk arm or buttock.

Because we know vaccines can cause swelling and we don’t want to introduce swelling into that body part. So again it’s your body.

Tell them to use the other arm or some other body part. Similarly with blood pressure and blood draws, there was information on air travel that air travel was thought to cause Lymphedema and that has also been disproven.

So travel freely. Okay.

When we diagnose someone with Lymphedema, there’s actually four stages of Lymphedema starting at stage zero up to stage three. I mostly deal with patients in stage one and two.

Stage zero is what we call latency where there’s increased risk and no visible swelling. Some of the machines like the bio impedance can actually detect that latent swelling where I would not detect that with my tape measure because it’s not that perceptible.

That’s stage zero. Stage one they do refer to as reversible with elevation.

So, this is someone that’s been diagnosed with Lymphedema. They’ve come in with a bigger arm or leg.

We’ve taught them how to manage it and we’re able to get them into normal ranges, but they have to learn how to manage it going forward. It’s not like it’s just gone and they can forget about it.

Bless you. But they need to manage it.

And so that’s stage one. Stage two, they come in with Lymphedema and we can’t get it back to that normal range and their arm is bigger and, sometimes a lot bigger.

And we’ll work with them to get it as small as we can and teach them how to manage it and keep it as small as they can and as healthy as they can. It also says skin changes.

Often with stage two we get what we call a fibrosis. So because of that stagnant fluid in your tissues, your tissues actually get hard and unhealthy.

So that’s also an identifier of stage two. And then stage three is also called elephantiasis.

We really don’t see that in our country. Fortunately very rare in the United States.

So there’s a lot of effects of Lymphedema. It has a lot of physical effects.

Again, we talked about that heaviness of the arm. Sometimes when your arm is heavy, you’re not going to use it as much.

You’re going to get weak. That may impair your function.

And it might look big compared to your other arm. And clothes might be tight.

So there’s definitely some physical impairments with it, but there’s also decreased quality of life when you have a limb that’s larger than another. Decreased self-esteem, poor body image, decreased strength and function, and then also depression and anxiety.

So, it’s important to treat it for the physical reasons, but it’s also very important to treat it for the other psychological reasons. So the education again is really important — we’ve talked about kind of the onset and now I’m going to talk more about the prevention of it.

And I encourage anyone that is at risk. I’m so glad you guys are all here getting this education.

They’ve shown actually a statistical difference in patients that get education from a physical therapist really about prevention and management versus someone that’s just given a handout or maybe read something online. Big differences in the incidence of Lymphedema.

I think the statistics I had in one study showed patients that met with the physical therapists educated by them shown how to avoid it only had a 7% incidence of Lymphedema where the people that were just given a piece of paper had a 25% incidence. So again, come see us and we’ll help you.

Unfortunately nationwide only 25% of people get referred to physical therapy to learn about it. So that’s a big bummer.

I don’t know what our statistics are here, but I’m sure they’re higher. We have a very integrated system.

So I don’t know what it is, but I know it’s higher. And best practice is early referral to us, especially if somebody’s at higher risk.

If you’ve had an axillary lymph node dissection, if you’ve had some of these other unmodifiable risk factors, early referral is good and important and even pre-operative referrals are good to get some baseline measurements. Get some baseline education pre-operatively.

That is also very helpful. So, if you’re here and you haven’t had any of that, you want it, just tell your doctor and they’re always happy to refer.

So prevention — I hope if you take one thing away this is it — the take-home message on prevention is I want you to avoid swelling of your affected body part. Period.

Okay, you can lay down now. I want you to avoid swelling of the affected body part.

So, we want to avoid injury. I want you to 100% live a normal life.

I want you to hike the Alps, bike the Alps, whatever you’re going to do in the Alps. I want you to live life to its fullest.

Do what you love to do, but try to avoid injury. Because don’t fall off the bike — if I’m worried about my arm and I fall off and I sprain my wrist, that’s going to swell.

And again, the take-home message is avoid swelling. So, but live life, okay?

But if you fall off your bike and sprain your wrist, treat it. Maybe in the past you would just ignore it and just hope it gets better fast because it’s annoying, right?

But now treat it like you’re treating your child. Rest it, elevate it, compress it, ice it, see your doctor.

Be aggressive in your management if you get swelling to quickly reduce it and get rid of it. We want to avoid infection.

So if you love to garden, wear long sleeves and gloves. Avoid blackberry bushes.

Same thing if you like to hike. We want to avoid getting scratches and cuts.

If you have a cat that scratches you, we want to avoid scratches and cuts because of the risk of infection in that arm. Same thing with insect bites.

I unfortunately see too many people that develop Lymphedema after a spider bite here. Spider bites are fairly common here and that can quickly lead to swelling and an infection and sometimes Lymphedema.

Sunburn we want to avoid. Excessive heat.

I get asked a lot about hot tubs. Hot tubs are kind of a no-no if you’re worried about your legs.

Because if you submerge your legs in hot water for a long time, they’re going to swell. If it’s your arm, I’m a little more lenient.

Because with an arm, you can kind of dip your arm in and out of the hot water and elevate it in between dips. And you can also turn the temperature down and not be in that hot tub quite so long.

We talked about vaccinations. We also want to avoid overuse of the limb that’s involved.

Where we live, our sports tend to be six months on, six months off. Based on our weather this year, it’s a little odd.

We’re going to have eight months on, four months off, something like that. But for example, if you’re an avid paddleboarder in the summer, if that’s your sport of choice, paddleboarding is a lot of arm, right?

And if I haven’t done that in six months or eight months, I don’t want to go paddle around on a lake the first time I go out. I want to gradually reintroduce that activity so my arm doesn’t swell.

Same thing with maybe cross-country skiing in the winter. That’s a big arm workout.

If I’m worried about my arm, I want you to cross-country ski, but I want you to go into that season gradually so that you don’t get swelling. If you decide to paint your house one weekend — don’t — but delegate, and don’t for hours on end do repetitive motion because again, that could cause swelling in that limb.

Exercise. I started this talk saying I love to talk about exercise.

Exercise has actually been shown to reduce the risk of Lymphedema. The recommended exercise is 150 minutes a week of cardio, two to three times a week of stretching and strengthening.

People that do that have lower incidence of Lymphedema. So, if you’re not doing that already, I encourage you to start.

If you don’t know how, call me later and I’ll help you get started. We talked about body weight.

The other thing I do recommend for surveillance is monthly measurements. I’ll tell people to measure at home, usually like three different places on their arms.

And usually find like a crease or a freckle so you have the consistent spots to measure. If you measure at home, it’s really important you’re consistent.

So, you want to use the same tape measure, same time a day, same position, and then I tell people to do that once a month and then just toss it in a drawer. And then you can just keep an eye on those measurements and watch for change.

So if you do get diagnosed with Lymphedema, in addition to the education on prevention, we’re going to talk to you about treatment and we’re going to treat you. The phrase we use for the treatment of Lymphedema is referred to as combined decongestive therapy.

And what that term refers to is a combination of manual lymph drainage which is a type of lymphatic massage, compression, exercises, and again education — that all falls under that umbrella of combined decongestive therapy. It’s a mouthful.

That’s the basics. That’s what we start with.

Some other tools I’ll pull in occasionally based on how somebody’s doing or not doing. I have a laser that I occasionally use on patients.

I use kinesio tape. It’s the tape you see athletes wearing that can sometimes be effective.

We teach people abdominal breathing. And then I actually haven’t seen the research on vibration plates, but I’ve talked to a rep.

I don’t think it can hurt, but I’m working on that. There’s also research on rebounders.

Walking on a rebounder or a little trampoline. What are vibration plates?

They’re kind of the new craze. They’re probably about as big as this table and they literally vibrate and you stand on them or sit on them or do different things on them and you can exercise with them.

Check it out. Laura’s probably seen it.

Again, I haven’t seen the research on those yet, but I don’t think they can do harm yet. So again, we start with the basics, the combined decongestive therapy.

We’re going to add some of these other things if people aren’t progressing with just that. What’s your thought on compression as like preventative?

Great question. I was going to talk about compression, right, G?

Okay, so there we go. Yeah, that’s all.

I didn’t tell her to ask that. There’s actually been a study done that has shown for those more at risk people, if they wear a compression garment for three months after their surgery prophylactically, that has been shown to help reduce the incidence of Lymphedema.

So, why not? Again, it’s not going to hurt you.

Did that answer your question? Yes.

Okay. So, compression again is a gold standard of treatment.

It’s the main part of what we use to treat Lymphedema. 95% of my patients tolerate compression.

5% don’t. And those are really tricky patients, but we won’t talk about those.

So compression can be done with bandaging. We used to start with that initially with wraps that look like ace wraps and foam and you get these layers and this massive mummy looking arm or leg.

It’s effective but it’s hard to do. It’s very hard to do on yourself and it’s terrible in the summer here.

So I typically go right to a sleeve or a sock for patients. Sleeves and socks are available off the shelf, small, medium, large.

So, they do fit most people. Sometimes if off-the-shelf don’t work, we will order people custom sleeves or socks or pantyhose, whatever they need for that body part.

I did bring one sleeve with me right here. If you haven’t — looks so small, doesn’t it?

This is actually a size small sleeve. This is an off-the-shelf compression sleeve.

There’s also night garments that look like very large oven mitts for the leg or the arm. There’s swell spots.

And you guys can come look at this later. These swell spots are really effective.

If you have a lot of swelling, maybe in your forearm, we can put this underneath a wrap or underneath a sleeve. Or different body parts.

There’s all sorts of shapes and sizes of these swell spots. There’s things called reduction kits.

Reduction kits are sleeves with Velcro that you can tighten to help get an arm or leg smaller. There are lymphatic pumps.

I brought some brochures on some lymphatic pumps as well. The best ones actually compress your trunk first and then the limb at risk.

So if I’m going to put someone in a lymphatic pump, I always try to get the best one. Unfortunately, a lot of insurance companies make you fail the one that doesn’t work before you can get the one that works.

Welcome to our world of insurance. Fortunately, I think it’s been two years now.

Congress finally passed the Lymphedema act. Which means most of these things are being paid for now by insurance companies where they weren’t prior to that, which was a terrible disservice.

So most of the things we can get paid for with most insurance companies with proper documentation. Oh, and there’s that thing about the compression sleeve.

Exciting. There’s actually two new surgical techniques for Lymphedema.

And when I first heard about these, I was so skeptical because surgery would cause swelling, right? So why would you do surgery on that arm or leg?

But I’ve seen both of these procedures done on patients locally and they are very effective. The first one is lymphovenous bypass where they identify one of the green lymphatic vessels that’s not working, actually just cut it off and attach it to a vein and so it allows that area to drain into the vein which is working fine.

Those are effective and it works pretty fast. There’s restrictions for about 6 weeks after that surgery just so we don’t tug on that bypass.

But after that it’s pretty exciting how quickly those bypasses work. The second one is a lymph node transplant where they actually take lymph nodes from usually from your abdomen and put them in different places that need them to help the lymphatic drainage.

This also works very well for severe cases of Lymphedema, but it’s a much bigger time commitment for the patient. You’re in compression 24/7 for months.

You can’t even get up for a couple weeks. So it works and it’s effective for those really severe cases, but it’s something you definitely want to know about before you go into it.

UC Davis just started doing these probably a year and a half ago. Stanford and UCSF have been doing them longer.

But if it’s something you’re interested in, I encourage you to call them. Like any healthcare, even getting your ankle looked at, it takes a few months to get in and then just get a consultation and then if you’re a candidate, you have to get insurance approval and then you get scheduled, right?

So, it’s not a fast process, but if it’s something that you’re interested in, these centers are nearby. So, Lymphedema is something you don’t want to ignore.

Which I get why you’d want to ignore it because it’s not fun, but there are risks if you ignore it. And the number one risk is cellulitis.

Again, if you ignore it and leave fluid sitting untreated in an arm or a leg or a breast or abdomen, the tissue is going to get hard and it’s going to get unhealthy. And if you get a spider bite, if you get a cut from a blackberry bush, the chances of infection and cellulitis are high and you’re going to end up in the emergency room.

And let’s avoid that if we can. Again, it does progress.

So if you’re in stage zero or stage one, and you ignore it, it’s going to progress to stage two. It rarely goes to stage three, but you don’t want to be in two if you don’t have to be.

Because with stage two, again, you’re going to get that hardening, that hard tissue, and that arm is just not going to change sizes. I did bring some of these stoplight handouts too, if you’d like to take one.

Green is just that time for education, awareness of when it comes on and then prevention with avoiding swelling. Yellow’s when we’re actually doing the treatment.

We’re educating. We’re doing massage, compression, exercise.

It’s the treatment and management phase. And then red light is my hand is swollen red hot.

I need to go to the emergency room because I think I have an infection. So again, there’s three Lymphedema therapists in Tahoe Forest Hospital system.

There’s two of us here in Truckee, one in Tahoe City. We’re working on getting one in Incline.

There are some at Barton as well as Renown. And most major hospitals are going to have certified Lymphedema therapists.

It’s important to see someone that knows what they’re doing. So again, be advocates for your health and if they don’t have the certified Lymphedema therapist designation, ask them what their experience is, ask them what training they’ve done.

I’ve seen patients go to unqualified people and have had poor results that increase their Lymphedema and that’s absolutely what you don’t want. So, continue to be good advocates for yourself and the care that you’re getting.

As we all know, there’s a lot of stuff on the internet. There’s three references here that have good information on Lymphedema.

You could take a picture of it or this slideshow will be available online if you want to go back and look at those resources. But these have good solid information on resources and things like that.

The Lana — I think the Lymphology Association and the National Lymphedema Network also can link you to therapists in your area. You can just search for people to help you.

And the LEARN — they actually have a lot of education and research. So you’re going to see new and up and coming things with Lymphedema research, maybe clinical trials that you might be able to participate in on that third site.

Okay, questions. You guys have any questions?

Well, I do in that I just had breast cancer. Okay.

And on the left side and had both sides removed. Okay.

And all lymph nodes in my left arm. Okay.

When you say repetitive, I swim. Okay.

That’s a constant motion. Is that — So, what I would ask you is — I’m not — How long have you been swimming?

Pretty much all my life. Great.

So, your body’s used to swimming. Okay.

Right. Is that true?

Yes. Did you take a break from swimming?

Well, right now I’ve taken a break. Okay.

And how long has the break been? Probably about three months.

Three months. Yes.

Okay. So, great question.

So, for those of you online, again, the question is, someone here is a swimmer and she’s swam her whole life, but she’s had a three-month break from swimming. Can she go back to swimming?

So, absolutely, you can go back to swimming. If you have a port, you’d want to check with your doctor or if you have any surgical sites, you’d want to check with your doctor before you go swimming.

But if all that’s clear, you could resume swimming. But because it’s been 3 months, I would say resume gradually.

Okay. With your speed, your distance — a sleeve at that time — you don’t have to wear a sleeve when you are swimming.

Actually the sleeves and compression work best when you’re active. Swimming, however, when you’re in water, it’s a beautiful place to be because you’re in an environment that the water temperature is lower than body temperature.

So, it’s cooler, but you also have the compressive forces of the water. You can wear a sleeve in the water, but you don’t have to.

So I would just say yes — when you get cleared by your medical team just gradually resume your swimming. Okay.

Yeah. Okay.

So that it just was concerning because it is negative. Yes.

So your time swimming, your speed swimming, your effort swimming — just ramp all that up gradually. Yeah.

But go back to swimming. Okay.

Yeah. Sure.

Yes. So my leg started getting — you know, this leg was swelling up maybe five months ago.

Okay. Maybe a year ago.

Okay. And first thing I went to the cardiologist.

Yes. First thing they gave me is a diuretic.

Yes. 18 pounds in one day.

Wow. And then went to the hospital.

Everything was cramping though. Wow.

But it worked. Okay.

And his great thing was he couldn’t want to lose 50 pounds. Did the swelling come back or has it stayed away?

Yeah. No, it’s come back.

Okay. Gradually, but the basic —

Well, not that. But now I used to be very active now and I can’t be.

Can that create this like no sweating? I don’t drink water because I don’t sweat basically.

Don’t need thirst. So, no — no sweating won’t cause it, but inactivity —

Yeah. Won’t help prevent it.

An interesting thing on diuretics — if it is truly a swelling, usually in the legs, when we’re talking about diuretics, the diuretics will pull the water off. And they pull the water off.

What gets left in the tissues when you take a diuretic if your lymphatic system is not working is your proteins get left in your tissues and proteins attract water. You get where I’m going?

Yeah. So if — kind of like the hamster —

Yes. So if you truly have a damaged lymphatic system and you take the water off with a diuretic, it’ll be great for a short amount of time, but the swelling will likely go back because the proteins haven’t left the tissues because the lymphatic system is damaged.

Does that make sense? That captures the proteins.

Yeah. Yes.

So, we want the lymphatic system to work better with the compression, with the exercise, with the massage, because if the lymphatic system works better, it’s going to pick up those proteins and get rid of them and then not attract the water. Now sometimes the legs are a little tricky because if you have a cardiac situation going on, that can cause swelling in the legs.

So, sometimes we don’t know if it’s a combination cardiac issue and or Lymphedema issue. If it’s bilateral, if it’s both legs, it’s usually cardiac.

If it’s one leg, it may be more Lymphedema if you have that history. Okay.

But I did have radiation treatment. And yeah, then you have some history.

Yeah, you got some history. What kind of massage are you talking?

Another great question. So, I referred to manual lymph drainage as the type of massage.

It is a very different massage. It involves stretching the skin.

So if you just put one hand on either — maybe even on the back of your hand — and use the traction of one hand to stretch the skin of the other hand. That’s the amount of pressure we’re actually looking for.

And people think I’m crazy all the time because it’s so light, but the lymphatics are in the skin. So when you stretch the skin, you’re stretching those small vessels which helps them pick up the fluid better.

If you do, you know, like a deep Swedish or sports massage, that actually crushes those vessels and doesn’t help them work any better. And actually an aggressive sports or Swedish massage in the at risk area can actually cause Lymphedema because it can cause swelling.

So, don’t let anyone be aggressive in that area. And that’s the other reason you want to have somebody that’s trained in it.

Who knows the technique that is again a technique to stretch the skin and not push super hard. Did you have another question?

Just a simple — like it says avoid excessive heat and swelling. And I don’t know about others, but all my life like hiking and such, my feet and hands swell.

Like even today on our hike, it was warm out so my hands and feet swell. Yeah.

Pretty substantially. I mean they’re pretty big at the end of the hike.

Is that a problem or is that — Yeah, another great question because that does happen especially in heat.

And I just told you I really want you to exercise. Yeah.

So it’s kind of a balance. Again, if you’re diagnosed with Lymphedema, then you’re probably going to be wearing a sleeve or a glove while you’re hiking, which is going to provide some compression and help manage that swelling.

If you’re not diagnosed and you’re at risk, then I would keep an eye on it. If hiking is your thing and that’s what you like to do though, just like her swimming, do it.

But just keep an eye on it and know that activity causes swelling. And then when you’re done, get yourself into a maybe air conditioned room or car, elevate.

Just be aware of it and manage it more. But don’t stop hiking.

Exactly. No.

No. I can drink a lot of water and notice that people were starting to drink too much water because that creates something like that.

But a lot of people drinking way too much water. Too much water.

I — I can’t answer that. I was going to say, I mean, I remember from like way back years ago, but you know, like one particular hike, we were coming off Mount Whitney.

Wow. And we did the whole descent in a day.

I have to tell you, I was totally whipped by the time I got — Yeah.

But yeah, your hands and your feet are dependent. Yep.

It’s warm and they swell and I can tell you the cold water in the creek at the bottom. Lovely.

I bet. I bet.

But yeah, I was in my 20s or 30s. But yeah, you know, a long trip like that, you’re gonna —

Yeah, you’re going to get swelling. So again, if you’re at risk, keep being active and manage it and watch it.

Is there a risk for people who have family history of primary Lymphedema to more likely get — like my sister had surgery for the primary —

Oops. And it totally worked.

It actually — what you were describing — she had done and it’s amazing the impact on her legs. But is that more of a risk factor for secondary or family members or is there no real research within that that you know?

If you have primary Lymphedema, you have Lymphedema. If you have a relative with primary Lymphedema, that’s a good question.

I’ve never been asked that. You know, you could —

It’s a small percentage. Yeah, it’s a small percentage, but it is genetic.

I would maybe go to one of the big centers like Stanford and ask them for the big test to look at your lymphatic system and see if it looks normal. Yeah.

To give you that information, especially if you get diagnosed with cancer and you’re going to be undergoing — Yeah.

These things. Triple negative.

Yeah. It’s all —

Yeah. Yeah.

My computer just kicked me out. I’m glad it didn’t kick us out up there.

Other questions? Brandy, are there any questions online?

None. Okay.

I have my contact information here. Yes.

Okay. Question.

Yes. I am —

Okay. I’ve had my surgery and started with chemo and then surgery and now I’m supposed to do radiation.

Yep. Is that good or bad?

I mean, is that going to cause issues? Hopefully not.

Okay. So, you’ve said they took a bunch of nodes out.

They took all the nodes out. You’ve had chemo and you’ve had radiation.

So you have three of the big four risk factors. So you have some risk.

So you’ve just educated yourself. Yes.

I would be happy to see you and we could do some measurements to get some baseline information on your arms right now. And then do surveillance to make sure you don’t get it.

Why not, with the endocrine therapies and all that? Yes.

Your current indication is you probably will have to have radiation. That’s good.

Yeah. I mean again you have to do what you have to do but hopefully you don’t.

Yeah. Second opinion.

That’s great. That’s great.

But that’s — Yeah.

Some recent studies that have shown — Yeah.

But you’re still at risk, so still come see me. Okay.

Yeah. Yeah.

Yeah. Other questions?

If you think of something later, feel free to call me, email me. I work right down the street.

I’m happy to help you however I can help you. Yeah.

Thanks for coming. Thank you.