Self manual lymph drainage (MLD) for arm

Lymph massage requires gentle pressure that does not involve muscles. A "stroke" is a circular movement that stretches the skin without the hand sliding, and then the pressure is released, and the hand is moved to the next starting position.

This can be done twice a day, e.g. mornings and evenings (about 10 minutes). The description is for a seated position.

Each stroke is repeated 5-7 times, usually by the hand of the unaffected side.

Step 1: Activate the lymph drainage in neck, under arm, and in groin.
1. Place hand with fingers at collarbone, so that pressure is directed toward the neck.
2. Place hand of the affected arm with fingers directly under the axial of the unaffected arm, the pressure is directed downward.
3. Place hand of the affected arm on thigh with fingers point toward the groin. Circular movements with pressure towards the belly.

Step 2: Redirect lymph flow from affected to unaffected axilla
4. Use hand of unaffected arm and softly stroke with from affected armpit to the other side.
5. Place hand on chest and use circular movements from one side to the other in several placements

Step 3: redirect lymph flow from axilla to groin
6. Lift affected arm and place hand behind head. Use unaffected arm to make circles form armpit to groin in several placements

Step 4: redirect lymph flow from forearm to shoulder
7. Place arm on pillow. Soft stokes covering the entire arm from back of hand to shoulders directing towards the neck
8. Lift arm to side and sue hand to stroke from inside upper arm to outside
9. Place arm on pillow and turn palm of hand upward. Use circular motion towards the upper arm.
10. Repeat outside portion of arm (#7)

Strength training for shoulder and chest muscles

Since muscle fascia is removed during mastectomy and the surgical scars need time to heal, the upper body strength needs to be built up again, and the nervous system may need to rebuild some pathways.

Some useful exercises with light dumbbells are:
1.  Standing: straight arm lifts up in  front then move to side and lower. Reverse the movement.
2.  Bend forward: straight arm lifts from hanging position to side of shoulders
3.  Standing: dumbbells in front of body. Pull arms up, staying close to body, by bending the elbows.
4.  Standing:  dumbbells at the side of the body. Shrug shoulders up, keeping shoulders and neck straight
5.  Supine on a bench: lifting dumbbells to the side and up ("pec flys")
A "light" weight is relative. I use 8 pounds. 2-3 sets with 10 repetitions. Start slow with less weight and less repetitions.

A digital massage gadget can be used by attaching patches with electrodes to the skin, and different programs can be selected for massage or nerve stimulation. If the level is set too high, the muscles contract. With four electrodes both sides of the chest can be stimulated (two electrodes on each side) to see whether there are any differences. In my case, the right side, where the sentinel lymph nodes were removed, can be painful, so a lower level is better.

Yoga

There are many styles of yoga, my own practice encompasses both Iyengar yoga (with yoga props and focus on alignment) and Kundalini yoga (with physical postures and movement, breathing exercises, and meditation).

Stretching exercises by the American Cancer Society advises not to stretch too soon or too aggressively to avoid seroma formation. However I have found stretches to be helpful when fluid built up after drain removal. One possibility are passive stretches, for example placing the arm overhead on a pillow.  The fish pose is a nice chest opener, when it gets uncomfortable to lie on the back for much of the time, and it stretches the scar.

Restorative yoga has been very helpful immediately after surgery and it is still part of my daily practice,  both for relaxation and stretches [ref: Lasater JH]. There are some earlier blog posts with photos: restorative yoga.

For about 3 months after surgery I avoided yoga poses that are static with arms lifted and held (e.g warrior pose)  or weight bearing exercises on arms (e.g. downward dog, sun salutation, planks) due to the lymphedema risk as discussed in the guidelines by Step up, Speak out. Since I continue to get swelling under one arm (site of the sentinel lymph node excision and site of a fine needle aspiration of one of the lymph nodes before surgery) when doing arm weight bearing exercises, I continue to be cautious. Two studies that motivated my choices:

• A Pilates study with 15 women who were at least 6 weeks post surgery mentions the lymphedema risk, since the DVD provided had statically held arm exercises [ref: Stan et al]. Thus I preferred to focus on moving exercises. 
• A yoga study after breast cancer diagnosis with 30 women showed positive effects (relaxation, feeling of wellness, stress reduction) [ref: Pruthi et al]. Participating women had positive comments about the breathing exercises during their initial meetings with a yoga therapist. There are many yoga breathing meditations that may be helpful. A previous blog post describes a breathing meditation from the Japanese system of Reiki.

Kundalini yoga is the yoga of awareness. It should not be confused with weird things written about "Kundalini" on the internet which is a generic term. I restarted my practice 3 months after mastectomy, since it can be vigorous, and I wanted to focus on other exercises and meditations first. My favorite yoga set is the basic spinal energy series. The number of times or length of time for each exercise can be reduced. For example, 26 or 52 instead of 108 repetitions is fine or doing each exercise for 1 minute.  This yoga set includes spinal flexes and shoulder shrugs that are also mentioned in an article for cancer patients to reduce fatigue [ref: Shannahoff-Khalsa DS]. The article includes breathing meditations, but it would be best to find a Kundalini yoga teacher, if you don't have experience with this style of yoga.

References:

1. Judith H Lasater. Relax and Renew. Shambala 2005.
2. Stan DL et al. Pilates for breast cancer survivors. Clin J Oncol Nurs. 2012 Apr;16(2):131-41.
3. Pruthi S, et al. A Randomized Controlled Pilot Study Assessing Feasibility and Impact of Yoga Practice on Quality of Life, Mood, and Perceived Stress in Women With Newly Diagnosed Breast Cancer. Global Advances in Health and Medicine. 2012;1(5):30-35. [link]
4. Shannahoff-Khalsa DS.  Patient perspectives: Kundalini yoga meditation techniques for psycho-oncology and as potential therapies for cancer. Integr Cancer Ther. 2005 Mar;4(1):87-100. [link]

Scar management

"It is easier to prevent a scar than to reduce it once it is formed. [...] Scars can take longer to heal if not managed." (Kase et al)
This is interesting.  After sleeping or resting in one position for a longer period of time post surgery, it felt like the wound/scar is "glued on wrongly". This is likely the effect of collagen formation. Doing something that aligns the collagen properly may help the healing so that the scar integrates well with the skin and prevents future contracting. An example, of a scar not integrating well with the skin is a hypertrophic scar, that has a raised, red appearance.

A few approaches (more here: scar minimization):

• Scar massage means using fingers to stretch the skin/scar vertical, diagonal, and pulling the skin in opposite directions to either side of the scar. This can be done after the surgical wound has healed anywhere between 3 and 6 weeks depending on sources.
• Mechanical pressure means applying pressure on the scar such as using a silicon gel strip,  using a spoon to push down on the safer and pull along, or using kineseo taping.
• Acupuncture
• Stretching exercises to retain the range of motion.
• Hydration means applying oils or creams, often with Vitamin E to the skin.

Scientific evidence: There is anecdotal evidence for these treatments. But does this apply in general? Scientific studies indicate that scar massage has no effect on scars (Shin et al).  Furthermore, the skin is a very efficient barrier, so creams may not be helpful either. There is a discussion on the importance of relaxation and breathing and complementary therapy approaches to scar healing, but more evidence based research is needed (Zanier et al).

There are no medical protocols for scar management. So it will come down to individual preferences.

What I liked: I have stretched from the very beginning and believe this helped the wound to heal in a way so as not to restrict movements when scar tissue is formed. Acupuncture was part of my recovery, so this may have helped. In particular, there are places where there is NO scar. The acupuncture therapists says this is along the stomach, bladder, and kidney meridians.  I exercise a lot and sweat. It is gratifying that initially numb areas produce sweat after while. I take it as a good sign for healing.
What may help:
I did not know about scar massage until 11 weeks after surgery. However I have not noticed a difference 5 weeks later. But it is something that is easy to do at no cost and won't hurt. Possibly it is helpful to start earlier after surgery. Small Kinesology taping strips vertical or diagonal feel good.
What may not help:
I am not convinced that silicon strips or creams or other commercial products are helpful. The strips cause itching when left on a few hours. They are pricey, using it daily for months and getting new strips every 2 or 3 weeks. I would not buy them again.

Appearance at 3.5 months post surgery: some small stretches where the scar disappeared (along the meridians, see above),  raised and red at other places. I am not overly bothered about the appearance as long as the scar tissue is flexible enough for exercising and stretching. They look good and I wear them proudly. There is beauty in scars!


References:
Kase et al  Kineseotaping for Lymphoedema and Chronic Swelling. Kineseo IP, LLC 2014
Shin et al.  The role of massage in scar management: a literature review. Dermatol. Surg.  2012 Mar;38(3):414-23.
Zanier et al. A multidisciplinary approach to scars: a narrative review. J. Multidisciplinary Healthcare 2015; 8: 359-363