Cording and Preventing Lymphoedema
Breast or skin cancer surgery or any cancer surgery involving the arm, shoulder or chest Final Cording Blog Image 1sometimes requires removal of the regional lymph nodes located in the axilla or armpit. This is called a lymph node dissection or lymph node clearance. As a result patients may develop lymphatic cording or Axillary Web Syndrome (AWS).
What is cording?
There are several theories explaining how the hardened lymphatic vessels or tight cord(s) develop. For example the researcher Koehler in 2013, proposed that new healing lymph vessel(s) scar up to the neighboring tissue at both ends, which is indeed how cords present.
To diagnose cording your Physiotherapist will gently position your post surgical arm into maximum abduction so the cord(s) when present will be palpable and visible. They may or may not be painful and may or may not limit shoulder movement. Although in many cases after breast cancer for example, women with cording have less than 90 degrees of shoulder abduction.
Examples of cording.
Cords may present as single cords, as double cords as in the image provided, they may extend past the elbow into the forearm, or from the axilla towards the breast. Although much less common, cording may also occur after a sentinel lymph node biopsy. Cording is generally self-limiting or may be resolved with Physiotherapy, however there are cases that persist for years.
Who is more at risk for developing cording?
The incidence of cording or Axillary Web Syndrome ranges between 62% and 85% of people who have axillary lymph node clearance surgery. Those who are younger and who have a lower BMI seem to get it more. There is no link between cording and whether lymph nodes are positive or negative.
How does cording develop?
Cording does not usually appear right away, more often within 1 to 9 weeks post surgery and often disappears within 2 to 3 months post surgery.
What is the problem with cording?
Cording or Axillary Web Syndrome (AWS) is linked to reduced arm function and secondary lymphedema, both of which can be managed by your cancer rehabilitation physiotherapist.
The benefits of early physiotherapy for cording
#1. Early ID. Early identification of cording allows you to learn about lymphoedema prevention strategies and how to help yourself to reduce your risks of developing full-blown lymphoedema.
#2. MLD. Early Manual Lymph Drainage (MLD) or MLD is a specialized technique that diverts accumulating lymph fluid out of the limb, past the surgical site and into the neighbouring healthy lymphatic system, helping your body develop its adaptive drainage strategy.
#3. Differential diagnosis. Your Physiotherapist can differentially diagnose your shoulder problem by moving the arm up into abduction in elbow flexion and extension. This exam clarifies if limited range of shoulder motion is due to tight lymphatic cords or due to a shoulder problem and he/she can then treat you accordingly.
#4. Scars, cords and tissue tightness. Your Physiotherapist will assess the mobility of the soft tissue of the whole area i.e. the shoulder girdle, the chest wall and neck to see how the scar tissue from the surgery is affecting your movement as well as looking at the cord. Specifically she/he will identify the different surgical scars, cords and areas of tissue tightness.
For example, the dermis and superficial fascia around the surgical scars may be affected and tight in all directions. The surgical drain scars may be adhered to the underlying deep structures and there may be both adherent scars and lymphatic cords in the axilla, upper arm and/or past the elbow into forearm. Your Physiotherapist will use specific manual therapy techniques to address each specific restriction to help you regain full range of movement.
#5. Lymphoedema screen. Your Physiotherapist will also screen for lymphoedema by recording and comparing circumferential measurements of both arms, from the wrists to the axillae at various time points post treatment. This data will allow your Physiotherapist to pick up small changes in your limb volume and early signs of lymphoedema. This data will serve as a baseline for comparison over the coming years, which is important as a lymphatic node clearance is linked with a lifelong risk of developing lymphedema, and no matter when you may develop it, early intervention will benefit you most.
#6. Compression. Finally your Physiotherapist if needed may fit you with a compression sleeve and prescribe exercises to enhance your lymphatic drainage.
These 6 points serve only as guidance notes for you. Your Physiotherapist works in an individualized way with each patient referred to him/her for cancer rehabilitation. Each one of us heals in our own individual way, depending on our cancer type, what treatment we have had, our previous history, our general health, our age, diet, education and support system. Your Physiotherapist will take all of these factors into account during your physiotherapy assessment and treatment planning.
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