Treating post-mastectomy swelling with massage
New addition for chronic lymphedema
Have you heard questions from your patients about a new way to control the swelling that sets in after mastectomy? If not, expect to hear them soon. Massage therapy is an effective way to manage the lymphedema (swelling of the lymphatic tissues) that affects at least 13% of women after breast cancer surgery. (See graph on breast cancer complications, p. 103.)
Contrary to what you might predict, insurance plans weigh in with moderate to high coverage of the therapy. Physicians, the primary referral source for lymphedema treatment programs, require education about the technique.
In the past two years, several women’s health facilities have initiated the service because patients called to say they needed it. It’s a promising addition to the standbys of arm pump and elevation therapies that don’t work in every case.
Women with excessive swelling are sitting ducks for complications such as infections and reduced limb use. Lori Bowler, PT, team leader for the women’s programs at Brookwood Medical Center’s Outpatient Rehabilitation Services in Birmingham, AL, says Brookwood’s program is a godsend to patients who spend months looking for more effective treatments.
As a stand-alone therapy, manual lymph drainage through massage doesn’t produce maximum results. It belongs with a program delivered by an interdisciplinary team in which medical history, lifestyle, and patient education play into designing a treatment program, notes Sandra Kirchner, PT, physical therapist at the Cancer Rehabilitation Service of Legacy Good Samaritan Hospital in Portland, OR. The reason, Kirchner says, is "patients often don’t appreciate the lifelong nature of the condition. We look at how each patient will use the treatment and manage the condition in her own life."
Post-mastectomy patients often don’t understand that they’ll probably have a 1-11¼2 cm of swelling in the affected arm for the rest of their lives, she adds.
The best lymphedema massage therapies are part of a four-pronged package:
1. Patient assessment, including a medical history, ruling out of current infection, and baseline arm measurements.
2. Data about the home environment, including the demands of the patient’s daily routine and accommodations for elevating, bandaging, and exercising the arm.
3. Therapy sessions of about one hour. The fees average $100 to $150 a session. Included are arm massage, application of an arm pump that gently milks lymphatic fluid out of the tissues into the body for absorption, and bandaging to keep the fluid from settling back into the limb. Courses of treatment range from two to four visits a week over three to six weeks.
4. Patient teaching for self-care. Topics are skin care to reduce the risk of infection and diet guidelines for controlling sodium, which aggravates edema. (For further patient teaching points, see the inserts 18 Steps to Prevention for Upper Extremities and Lymphangitis (Infection): A Constant Fear.)
Women’s health providers who spoke to Women’s Health Care Management about their programs counted physicians among their top referral sources. Before they began sending patients to these programs, however, those physicians needed a better understanding of the benefits.
In Pittsburgh, Kathleen Cutler, RN, certified manual lymphatic drainage therapist, conducts inservices for residents of the teaching hospitals. She targets oncologists and surgeons and arranges through the chief residents to be a presenter at the hospitals’ regular resident seminars. She is president of the Lymphedema Connection, a facility specializing in massage therapy for lymphedema and wounds (diabetic type) that resist treatment. Since she and her partner, a physical therapist, started the center in fall 1996, they have enjoyed a growing number of physician referrals. Their current roll count is 150 patients.
While insurers aren’t exactly volunteering to cover the costs of lymphatic massage, they do respond to detailed treatment plans and documented outcomes. "They need to know where their dollars are going," Cutler says.
She and her partner cooperate by presenting a plan including physical therapy evaluation and the number of sessions necessary. Medicare allows only nine visits, so they stretch treatments over a three-week period to give the patient maximum benefit. "HMOs, I’m not happy to report, put us through a case-by-case ordeal," Cutler says. Although they’ve received individual patient coverage, they haven’t secured contracts for patient groups with HMOs.
Bowler’s HMO experience is similar to Cutler’s. She’s approaching the matter through direct contacts with the plans to get pre-authorized visits case by case. Additionally, she arms the patients with supportive articles to present to their HMOs. (Those articles, as well as information on training programs, are available from the San Francisco-based National Lymphedema Network. See source box, p. 103.)
In her area, it’s easiest for physical therapists to get reimbursement. Massage therapists and nurses have more trouble. She notes that coverage for occupational therapists varies by state. "People need to understand there’s a lot more to lymphedema treatment than doing massage," Kirchner says. ß
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