INTEGUMENTARY PHYSIOTHERAPY SKIN CANCER SKIN CANCER CAUSES

MRS. DAISY LOPEZ (BOOK)

SKIN CANCER ▪ Skin cancer, of which the risk factors are family history, race, scar,
and burns, can occur when one is exposed to sunlight.
OVERVIEW
Malignant skin cancers are divided into squamous cell carcinoma, skin cancer,
▪ Skin cancer occurs when one is exposed to ultraviolet rays, one of and basal cell carcinoma.
the sunlight, in general.
▪ It is divided into melanoma and nonmelanoma SQUAMOUS CELL CARCINOMA FACTORS
 nonmelanoma skin cancer occurs in 90% of skin cancers  most important factor of squamous cell carcinoma (squamous cell
▪ A 5-year survival rate of nonmelanoma cases is very high – more than carcinoma) among them is long-term exposure to ultraviolet ray
99 % – while melanoma cases have very high fatality rate, 22nd  the risk of skin cancer may increase if DNA is damaged by ultraviolet
highest fatality in all cancers, provided that its survival rate depends ray without DNA repair after the damages
on therapy methods.  another occurrence case is that one’s immunity is depressed
▪ Skin cancer, one of the skin tumors, is the most common and chronically after an organ transplant
fastest-growing cancer described by the American Cancer Society,  for precancer-period lesions (such as accumulated ultraviolet ray
affecting almost all Caucasians. exposure, burn, keratoma senile, and Bowen’s disease), skin cancer
▪ Skin cancer, mostly occurring due to sunlight irradiation, is found to be can result from radiation therapy, inhalation of herbicide including
significantly decreased by sunlight exposure prevention for 20 years arsenic, chronic skin irritation and inflammation, exposure to local
after birth. carcinogen (tar and oil), and hereditary problems (such as
▪ Among skin cancers, melanomas are found to occur in high-income xeroderma pigmentosum and albinism)
countries, where Caucasians live. The incidence rate is ten times
higher than that of low and middle-income countries. BASAL CELL CARCINOMA FACTORS

MAJOR FEATURES OF SKIN CANCER  Accumulated sunlight exposure and intermittent sunlight
exposure are the most common causes of basal cell carcinoma
1. Incidence Rate  Immunosuppression, hereditary vulnerability, and immunization
 Basal cell carcinoma or squamous cell carcinoma, most of which have sites are rare causes
high complete recovery rate, occurs more than one million times  likely to occur more frequently in adults infected by HIV; especially, it
annually. occurs on the neck or face of workers, who work outside, because
 The most fatal cancer (skin cancer) is rare, and total 62,000 cases they are exposed more.
have been reported annually. SKIN CANCER (MALIGNANT MELANOMA)
2. Fatality Rate  can occur in the race that has blonde hair, red hair, fair skin color, and
 Total death recorded was 11,200 in 2008; of that, 8420 died from skin blue eyes
cancer and 2780 died from other skin cancers  those people who are exposed to burn and belong to Celtic and
Scandinavia act as risk factors
3. Risk Factor  gene is related to gene mutation that produces melanin pigment to
protect the skin from ultraviolet ray
 An excessive ultraviolet exposure by sunlight, clean skin, coal tar,  occurs more in Caucasians, especially, more often to those who has
resin, creosote, arsenical, radium, chronic immunosuppression, and a risk of being exposed to long-term sunlight
heavy skin pigment (for the melanoderm) skin cancer in dark-skinned  skin tanning business can be regarded as a risk factor of generating
people are ignored due to their dark skin pigments skin cancer.
 for the pilot and flight attendants, the exposure to ionizing radiation
4. Warning Signal
from the space is a factor that increases the incidence of malignant
 Abnormal skin state, especially proliferation of the nevus or other dark melanoma
pigments and change of mole size and color  in other words, most of the malignant melanoma is associated with
its intensity rather than the time of exposure to sunlight, which is
5. Prevention and Initial Check because most of the people suffering from melanoma work inside but
are exposed to intense, however limited, sunlight in weekends or
 Avoid the sun (10:00 am to 04:00 pm) when ultraviolet ray is high during the vacation
 Use sunscreen
 Skin basal cell carcinoma and squamous cell carcinoma often make Inducing risk factor of Malignant Melanoma
macule with red prominent boundaries, or pale waxlike pearly knot is
formed ✓ Family History
 Melanoma generally seems dark-brown or dark, which multiplies like ✓ Race – Celts and Scandinavian
small nevus, changes its size and color, and then becomes ulcerating ✓ Hair (blonde or red)
and bleeds when experiencing slight attractive ✓ Striking Freckles over the back
 They begin to proliferate from the size of a small nevus, become ✓ Past History
bigger, change their color, become ulcer, and cause hemorrhage even  More than three times of bullous burn medical history
with the mild damage (before the age of twenty)
 In the case that exposure to sunlight while working
6. Medical Handling outdoors during adolescent summer for 3 years
 Existence of keratoma senile (horn-shaped growth)
4 Ways in Medical Handling:
CLASSIFICATIONS
A. Operation
B. Electricity Cauterization – tissue damage caused by heat ▪ Based on the tumor tissue initiating sites, skin cancers can be
C. Radiation Therapy classified as primary skin cancer and metastatic skin cancer
D. Cryotherapy – tissue damage caused by cooling ▪ most common malignant tumors are squamous cell carcinoma, basal
 Malignant melanoma requires wide and deep excision and removal cell carcinoma, and malignant melanoma
of surrounding lymph nodes  among them, squamous cell carcinoma occurs in the
7. Survival Rate epithelium, and it can be detected in the skin with hair

 Basal cell carcinoma or squamous cell carcinoma is almost completely PRIMARY SKIN CANCER
cured through initial checking or treatment. ­ the tumor (glot) that begins in the skin
 However, skin cancer causes metastasis quickly. • skin cancer frequently means the primary skin cancer resulting from
 Because of this, Caucasian shows low 5-year survival rate due to this
the skin.
disease

C.A.M.| I
METASTATIC SKIN CANCER MALIGNANT MELANOMA (SKIN CANCER)

­ the cases where cancer tissues, resulted from other organs, are ­ a malignant tumor of melanocytes that a melanin cell or nevus cell
metastasized into various parts of the body or recurred on the skin (spot) becomes malignant
• metastatic skin cancer, which occurs in other organs but develops ­ it is a malignant tumor that spreads very rapidly and deeply through
into skin cancer, is rare blood and may be exacerbated by sunlight irritation or stimulation of
the nevus
SQUAMOUS CELL CARCINOMA • occurs in any part of the body where melanin cell exists especially in
the skin
­ occurred by long-term exposure to sunlight and chemical substances
­ a skin cancer often found in elders and middle-aged population, • is a skin disease with the highest mortality rate
showing the incidence rate in male twice higher than that of in women
­ is characterized by locally invasive and higher metastatic rate
• has higher incidence rate than other skin cancers, especially in elders
• one of the malignant tumors, originated from the keratinocyte of the
epidermis, and appears in the scalp, lower lips, external ear, and
hands
• its biological characteristics (e.g., causes, size and depth of cancer,
anatomical position, and metastasis by histological properties) are
more complicated than those of basal cell carcinoma SYMPTOMS AND COMPLICATIONS
• among the skin cancers in Korea, squamous cell carcinoma and basal
cell carcinoma account for the highest percentage  male can suffer from skin cancer in the head and neck
• 90% of it occurs in the lips and particularly the regions that were  female can contact it in the leg or back during the exposure to
exposed to chronic ulcer, scar, and tar. excessive ultraviolet ray
• when detected earlier, it may have positive prognosis  results from previous nevus more than 70 %
 factors affecting the therapeutic prognosis of skin cancer change by
the depth of the tumor, shifting term, race, age, sex, and histological
form

KERATOMA SENILE

­ also called as ACTINIC KERATOSIS

­ is the precancer stage of skin cancer
which appears in damaged part of the
skin exposed to long-term sunlight
• those who are over 50–60 years of
SYMPTOMS AND COMPLICATIONS
age – particularly Caucasians who
 can occur in a form of an ulcer become red ripe and have freckle when
 flat red part, epidermis keratin, protuberance valve, and module, and exposed to sunlight – have high
its sarcode seems red and is surrounded by scale tissue incidence rate
 more than 80% occurs in the head, neck, lower lips, and ears • forms of keratoma senile lesion are
 systemic symptoms are pain, fatigue, malaise, weakness, and small but rough and keratinized skin
anorexia • it is red in color with unclear boundary or brown keratinized lesions
• lesion is usually multicentric, and its form comes a little uplifted or flat
BASAL CELL CARCINOMA • also, the diameter of its keratinous papule or red to gray verrucous
­ is a malignant tumor disease of the cell mass formed by the follicle, shape is 1–10 mm
bottom of the epidermis – i.e., basal layer (basal cell) • as highly fixed in the surface, the scale is difficult to remove and its
­ It is called rodent ulcer and basal cell lesion surrounds an erythema
• accounts for 65 % of the entire skin cancers • cutaneous horn occurs if hyperkeratosis is severe.
 it often appears after subsiding for weeks or months, and
• it results from skin cancer of Caucasian, showing relatively low
even it can quite occur even if keratin is removed
malignancy
• often occurs in the lower lips, and it is called actinic cheilitis
• basal cell carcinoma and squamous cell carcinoma are the most
common nonmelanoma skin cancers with low metastatic rate • is reported that less than 1–20 % of keratoma senile develops into
flat epithelium cell cancer; however, it can grow into
• originated from scar and burn scar and particularly developed in
nonmelanoma skin cancer
damaged parts with chronic exposure to sunlight
• as is relatively rare, its metastasis is infiltrated locally; if not properly TEST AND ASSESSMEBNT
treated, it is metastasized into the bone, lung, and brain leading to
death DIAGNOSIS OF SKIN CANCER

▪ melanoma is a skin cancer which requires a rapid recognition and

monthly self-examination
▪ by histological examination, it is necessary to test and determine the
depth of tumor as well as to assign the stage in order to distinguish
skin cancer from other lesions
▪ the diagnosis stage of skin cancer is systemized for the progress of
skin cancer by skin-layer infiltration
o 1ST STAGE - it infiltrates only into the epidermis
o 2ND STAGE - into the dermis
SYMPTOMS AND COMPLICATIONS o 3RD STAGE - into most of the upper dermis
o 4TH STAGE - into the lower dermis
 its form is classic pearl or ivory shape o 5TH STAGE - into the hypoderm
 it, whose boundaries are round and slightly elevated than other skins, ▪ higher the stage becomes, the higher the metastasis occurs
has small blood vessels on its surfaces. ▪ biopsy or histological test is taken
 generally, its nodules cause no pain and gradually grow to become ▪ assessment and diagnosis of cancer depend on the types of cancers,
ulcer in the center. using:
 more than 65 % of the basal cell carcinoma occurs in the head, face, o hematological test
and neck, followed by the body, especially the upper back and chest o X‐ray test, ultrasonic diagnosi
o CT (computed tomography)
o MRI (magnetic resonance imaging)
o etc.

C.A.M.| II
STAGES OF SKIN CANCER MEDICAL TREATMENT

 during the diagnosis and prognosis, the depth and skin-infiltration Therapeutic Goals
degree of tumor are most important, divided into the depth of
“infiltration degree of Clark” and “Breslow.” ▪ medical approach of skin cancer depends on the depth, size, and
 first, INFILTRATION DEGREE OF CLARK - how far the depth of the location of the lesion
tumor infiltrates ▪ consists of:
 second, BRESLOW LAW - measurement method to check the depth o dissection (excochleation, abrasion)
of melanoma o electrocauterization (cauterization)
o thinner melanoma = better prognosis o chemotherapy
 third, layers of infiltrated skin by melanoma are measure o surgical operation
 fourth, COMPUTED TOMOGRAPHY is essential to confirm o radiation therapy
basic pathological laboratory test, metastasis of bone scan, ▪ which means abrasive materials or tissues by abnormal mechanical
chest part, abdominal part, CNS, and metastasis of cerebellar procedure
tract ▪ it is important to take the approach within required time because
metastasis into other parts can occur if the approach for cancer is not
Diagnosis of Skin Cancer using Clark Stage taken sufficiently

Surgical Treatments

▪ surgical approaches of skin cancer have been developed safely and

efficiently as surgery evolved with proper early tests
▪ surgical approach is composed of radical operation and
conventional operation
▪ in case of cancer operation, radicality (complete remove), safety,
functional preservation, etc., are applied
▪ surgical approaches show good or complete recovery by local incision
or non-incision thalamotomy because the early test makes tumors
found rapidly

① radical operation

­ it means completely removing cancer tissues, which consists of

operation, radiation, carcinostatic chemotherapy, etc.
• among them, radiation therapy is a representative skin cancer therapy
applied to those suffering from skin cancer and difficult to
incision-operate.
• it is accompanied by radiation therapy secondary to incision-operate
Skin Cancer Stages and then remove completely the tissue of those who are suffering from
skin cancer
Period Proceeding Aspects
Stage 0 Although exists cancer cells, it is surrounded by epidermis. It ② conventional operation
is right before the cancer stage and called ‘intraepithelial
carcinoma’. ­ it, although impossible to remove tumor tissues completely, focuses
Stage 1 The size of cancer exists in the dermis below 2 cm or is on improving the symptom of those suffering from the cancer
surrounded by the hypoderm in the dermis • it does not remove cancer tissues completely, but lessens the degree
Stage 2 The size of cancer exists only in the dermis over 2 cm or is of symptoms
surrounded by the hypoderm (loose connective tissue,
blood vessel, fat cell) in the dermis. ③ radiation therapy
Stage 3 The depth of cancer progresses to deep inner region
(muscle, cartilage, bone, and so forth) or metastasizes from ­ concentrating on more radiation ray than measurement ray on the
the region that initial tumor occurs to the nearest lymph cancer, it can cure human bodies from the cancer
node • divided into outer radiation therapy and close radiation therapy
Stage 4 Pass from the region where cancer occurred at early stages • mainly its period and number vary according to the type and size of
to the nearest lymph node and remotely metastasizes to
cancer, and it is recommended to drink sufficient amount of water and
internal organs.
to eat food to increase the therapeutic effects during the therapy
• its methods depend on the type of cancer; especially, the radiation
INTERVENTION
therapy of basal cell carcinoma is not allowed to those who are below
INTERVENTIONAL APPROACH 50 years old
• the risk of the secondary skin cancer occurs by radiation ray, let alone
▪ therapeutic approach of skin cancer depends on age its recurrence risk
 thus, the small cancer of old patients can be removed by
simple operation or radiation therapy while their ④ medicine treatment
aesthetically important parts, such as a face, have high re-
a. vaccine therapy
occurrence possibility, which should be recovered by
­ its aim is to prevent tissue damage and remove cancer tissues by self-
minimal incision
immune system of the normal human body
 for America, physical therapists massage them, and
• vaccine produced in the patients’ own cancer cells is used to stimulate
therapeutic intervention is needed to resolve the
the immune system
contraction or stiffness of the face after the cancer of
• it has been considered much because it has a few side effects but
aesthetic face parts is operated.
shows clinical effects
▪ therefore, it is necessary to take manual therapy by a physical
therapist after the operation b. chemotherapy
­ followed by operation and radiation therapy
­ it is taken using anticancer drugs to remove the cancer cells of the
tissue
• it managed to minimize them and thus has contributed to locally
removing cancers through continuous studies and clinical tests
although its side effects are prominently destructive previously
• whereas radiation therapy is applied only to local parts, it can show
systemic effects, and thus those suffering from cancers select it the
most.

C.A.M.| III
PHYSICAL THERAPY INTERVENTION  types of resistance exercises applying the active exercise of
concentric and eccentric shape need balanced exercise between the
POSITIONING upper limb and lower limb
 its intensity is 50–80 % of 1RM, its repetition is 6–12 times, and its
▪ those suffering from skin cancer should try to maintain a balanced frequency is one to three times a week
body and to exercise stretching so as to prevent the side effect  after the exercise, take sufficient rest, provided that the exercise is
occurring in cancers. continuously taken for 20–30 min.
▪ switch off multimedia devices (such as notebook, a computer, a smart
phone, etc.), and take a rest once or twice a week to reduce mental Aerobic Exercise
stress.
▪ also, read a book, take meditation, or walk outside for mental rest  light walking exercise, needed to improve systemic strength through
while not using electric devices. blood circulation, should be taken by patients to stimulate
cardiovascular system.
EXERCISE THERAPY  programs to take aerobic exercise effect are fixed bicycle exercise
using big muscle, rowing, treadmill walking, and gradual stair climb
▪ Like other cancers, skin cancer results in decreasing physical  its intensity is set against 50–70 % VO2 max or 50~75% HRR
abilities and causing daily lethargy by insomnia, fatigue, (maximum heart rate reserve) and 60~80% HRmax (heart rate
depression, pain, and helplessness of those suffering from other maximum)
cancers  its frequency is at a minimum of three to five times a week by low
▪ Accordingly, those suffering from these cancers can be taken by intensity within a short period of time many times
exercise therapy to improve their depressed physical functions,  it is needed to exercise continuously for 20–30 min in order to take
which involve joint exercise, strength exercise, aerobic exercise, and effects
endurance exercise.
▪ The best benefit of exercise effects is to advance the maximum Aerobic Exercises Program Resistance Exercise Program
amount of oxygen intake and to improve whole body function as Variable recommended to incipient incipient cancer patients and
well as minimize the side effect of treatments for cancer if the cancer patients and healthy those who received cancer
aerobic exercise programs for those suffering from the cancer are people who underwent treatment is recommended
cancer treatment
offered
Type of exercise using large muscle dynamic resistance exercise
▪ Benefits of exercise therapies are the following: Exercise group (example – walking, of concentric, eccentric
o increase of strength by muscle contraction stationary exercise bicycles, exercise form, balanced
o increase of blood circulation and so on) exercise of the upper limbs or
o rise of blood return to the heart (means the whole strength lower limbs
of the heart) Frequency At least 3 to 5x per week, low At least one to three times
o resistance to muscular fatigue intensity, short time; those per week, break at proper
who have good physical interval
Joint Mobilization Exercises fitness are recommended to
exercise every day
 active joint mobility exercise is taken many times a day after the Intensity 50~70 % VO2 max or 50~75 % 50~80 % of 1RM, repeat up to
patient becomes conscious or can move HRR, 60~80 % HRmax 6~12 times
 skin cancer patient must be able to take an active joint mobilization Time Continual exercise for at least 20 to 30 min; those who have
bad physical fitness are recommended to exercise in sections
exercise on undamaged upper limbs and lower limbs as well as the
Degree of Progress considering physical fitness levels. Consider individual
body
Progress conditions.
 at first, must have stage by stage, it takes soften ROM initially and, if
required, active movement and passive movement are acquired at first MANUAL THERAPY
 exercise of the neck, arm, and shoulder near the proximal is taken,
and then the exercise to promote the mobility of the whole body is ▪ the skin can have scars resulting from the incision of skin cancer and
applied the surgical operation
 if patients cannot take an active movement efficiently, an active ▪ they become factors of which the adhesion to surrounding tissues
assistance movement and manual movement are taken at first. makes it difficult to move the epidermis and hypodermis; even it
causes intense pain and mobility restrain.
▪ therefore, physical therapists cannot only take skin rolling and skin
relaxation technique but have the mobility of the skin and the benefit
of pain solution while recognizing the recurrence risk of skin cancer.
▪ when interfering with skin cancer, the lymph massage should be
applied carefully, which significantly improves the blood circulation.
▪ that is because it results in aggravating skin cancer.

PHYSICAL AGENT MODALITIES

The therapy using physical factors includes:

✓ those using cold and warmth

✓ those suffering from tumor and skin cancer can be prescribed to
pressure treatment methods (e.g., pressure stocking and pneumatic
compression treatment)
✓ also, the laser therapies for them are lower-intensity laser therapy or
so
✓ for skin cancer patients, the physical factor therapy should be applied
carefully, which contributes to increase blood stream, due to the active
Strength Exercise circulation in tissues

 if skin cancer patients are recovered rapidly, strength exercise can PREVENTION AND MANAGEMENT
be taken as a part of rehabilitation program in stage
 skin cancer patients show the decrease of weight and muscle mass PREVENTION OF SKIN CANCER
 resistance exercise for strengthening can prevent the strength loss
• all cancers have high recurrence rate and their metastasis can move
of non-infiltrated parts, and strength exercise is taken using isokinetic
into each part of the body, so it is important to prevent the cancer by
devices, isotonic devices, other resistance exercise devices and limbs
regular medical examination.
of patients
• in addition, a small number of malignant tumors show poor prognosis,
 to prevent excessive exercise, physical therapists can block sudden
so the advanced management and prevention are necessary.
accident by checking the pulse, blood pressure, and respiratory rate
during, before, and after the exercise

C.A.M.| IV
Guidelines for Skin Cancer • physical therapists should pay attention to acquire physical therapy
intervention methods by the symptom and sign, evaluation of
▪ avoid exposure when sunlight is peak (11 am to 3 pm) lymphedema and to prevent the secondary infection or complications
▪ put on clothes made of fabric to avoid sunlight when going out of lymphedema
▪ use sunblock cream (PA++) which is higher than 15 SPF to protect
sunlight CAUSES OF LYMPHEDEMA
▪ inform children of sunlight protection
▪ avoid artificial tanning by sunlight Lymphedema resulted from various causes
▪ take regular skin examination
▪ consult experts as soon as possible if recognizing abnormal symptom  lymph fluid occurs because it does not circulate through lymphatic
of the body and skin vessels
 lymphatic glands are blocked or removed
MANAGEMENT OF SKIN CANCER  circulation of lymph fluid is not taken
 it is accumulated into the body tissue, and edema occurs
• because skin cancer, if detected early, can be almost fully recovered, ▪ in other words, it means the edema resulted from the abnormally
the examination by a medical team is taken periodically accumulated tissues on the upper limbs and lower limbs due to the
• also, those suffering from skin cancer show good prognosis as the damage of the lymph system.
therapy method for skin cancer is varied and its therapeutic effect ▪ although lymphedema has natural causes, it generally resulted from
becomes high infection, malignant tumor (cancer), venous disease, scar and
• it’s coming to the fore that self-management of in terms of therapy as wound by radiation therapy, and incision operation
well as diet ▪ those obese or old are likely to have the possibility of lymphedema
• avoid an excessive sunlight exposure
• try to prevent the direct sunlight CLASSIFICATION OF LYMPHEDEMA.
• avoid going out from 10:00 am to 14:00 pm when ultraviolet ray
becomes strong BASED ON ITS CAUSE OF OCCURENCE
• use the sunblock against ultraviolet ray, if owing to an unavoidable PRIMARY (FIRST) LYMPHEDEMA
engagement
• furthermore, wear long-sleeved clothes or hats ­ it means the edema created from birth
­ results from the loss of lymph circulation by the aplasia and
PATIENT/CAREGIVER EDUCATION hyperplasia of natural lymphatic vessel as well as no absorption of
lymph fluid
• for those suffering from skin cancer, it is difficult for them to care for
• 75% of the first lymphedema is premature lymphedema and occurs in
themselves, which means they need a caregiver for them
young women, especially after their puberty
• the training for a caregiver is essential in terms of prevention, so that
• it has been reported that the disease is caused by abnormal genes of
the training of a caregiver for children should be taken exhaustively,
FOXC2 and VEGFC
which has been supported by the researches that severe burn by
sunlight occurs mostly during the childhood and more aged group • although the 3rd gene has doubt but not clearly identified
causing the higher possibility of skin cancer. SECONDARY (SECOND) LYMPHEDEMA
LYMPHEDEMA ­ it means the second or acquired lymphedema
­ showing the complications after cancer operation and radiation
OVERVIEW
therapy
▪ in terms of anatomical composition, the lymph system, which • specifically, its 15–20 % occurs during breast cancer surgery and
originally develops in the vein, consists of deep lymphatic glands and uterus cancer surgery with lymphatic gland removal
lymphatic vessels as well as shallow lymphatic glands and lymphatic • its 50–70 % occurs when lymphatic vessel removal operation and
vessels. radiation therapy are taken
 it includes the thymus glands, marrow, spleen, tonsil, and
BASED ON ITS SYMPTOMS
Peyer’s patches of the small intestine as lymphatic organs
from International Society of Lymphology
and tissues.
 role of the lymph system is immunity function, body fluid INCUBATION PERIOD
balance, and infection control
 in general, 18L of the tissue fluid is removed inside the ✓ show the decrease of the ability to move lymph fluid
interstitium of the body, most of which is absorbed from 80 ✓ reveal little clinical symptoms and feel simply heavy
to 90%
FIRST STAGE
 the rest (10–20 %) is removed in shallow lymphatic vessels
and deep lymphatic vessels ✓ it means reversible stage
▪ lymph disease - caused by the disease of blood vessel, meaning the ✓ edema occurs; however, skin is still flexible
disease which affects significantly the functional loss of the upper ✓ it takes longer to remain a little pressed than in normal state if edema
limbs and lower limbs due to the limb circulatory disturbances part is pressed by the finger
▪ the disturbance results from acute or chronic medical conditions of ✓ it returns to its abnormal state if an edema part is located higher
peripheral blood vessel diseases (PVD), causing a severe blood than heart for long
vessel disease in artery, vein, and especially lymph circulatory ✓ fibrosis has not yet occurred in lymphatic vessel, and it can be cured
system.
 for example, it is unavoidable to take the radiation test or SECOND STAGE
surgical incision of chronic lymphedema in the upper limbs,
which can have physical effects on mental status in daily ✓ protein accumulates in tissue, and resultant fibrosclerosis makes
life. skin not pressed if the therapy period is missed in the first stage
✓ it has low change of improving
✓ it has very high risk of infecting
LYMPHEDEMA
THIRD STAGE
­ results from the circulatory system disorder of lymph
­ the unbalance between the amounts of body fluid, needed to remove ✓ irreversible stage
in interstitium, and the transportation ability ✓ skin becomes very swollen and abnormal change occurs in the skin
✓ functional loss takes longer with complications
• this secondarily results from the lymphedema by side effects and
✓ known as elephantiasis; it shows that skin becomes rough and its
complications after cancer therapy, operation, and radiation therapy
surface turns uneven, so body fluid release outside the skin
• it is the disease which changes tissue and skin as well as increases
✓ infection incidence rate is very high, and one’s life hangs in the
edema in the upper limbs and lower limbs
balance without active therapy
• means chronic inflammation when edema is accumulated by abnormal
✓ because of its long state of fibrosis, there is rarely chance of
accumulation of tissue protein
returning to normal tissue

C.A.M.| V
SYMPTOMS AND COMPLICATIONS ④ compare its value when measuring those with swelling and those without
swelling.
the symptoms of edema vary in the upper limbs and lower limbs generally ⑤ confirm how far their measurement difference is
 distribution of edema shows local condition and edema occurs in
the other or both upper limbs and lower limbs
 the lymphedema of the upper limbs occurs in the incision part of
armpit lymphatic gland and below the radiation therapy part
 the tissue and skin with edema tend to become soft and then too hard
to press during palpation
 also, patients feel heavy and tight in the part with edema and suffer SKIN EDEMA VOLUME MEASUREMENT
from the pain in the part with lymphedema, and the restrain of
• to measure edema, fill consistently 28,000 ml with left and right legs
mobility after edema extended into the joints
by their cubiti anterior, put overflowing amount of water into a beaker,
 secondarily, lymphedema has high frequency of skin infection
and calculate the average after measuring it
occurrence and causes exothermic reaction, rubor, etc.
 the damage to the lymph system, resulting from the secondary BODY COMPOSITION ANALYSIS (INBODY)
causes, has the risk of keeping up lymphedema and generating
recurrence • a body composition analyzer is characterized by
a simple measurement using the property that
residual resistance occurs in water, fat, and
muscle when a little current passes, recognizing
weight, body fluid, intracellular fluid, extracellular
fluid, body fat, and edema degree.
• placed foot at the heel part of sole shape on
body composition analyzer (inbody) and always
reach it on the same part, spread the upper
limbs by about 15° and examine with the eyes
straight

IDENFICATION OF PRODOME
TEST AND ASSESSMENT
• the pre-symptoms include feeling height, feeling
▪ check those with abnormal lymph system suffering from injury, sullen, feeling one or the other of upper limbs or lower limbs, feel a
malignant tumor, lymphatic gland clearing surgery, and radiation stinging sensation, hot flush, rubor, hot flush, etc.
therapy in past medical history
▪ confirm whether they had blood clot in their medical history, and then Self-Reported Diagnosis of Lymphedema
set and take therapeutic intervention with the prevention of
 legs feel cramping
lymphedema before the examination
 legs feel tight when wearing shoes
RADIOLOGIC EXAMINATION  legs often feel weak
 legs often feel sore and aching or heavy
• for the exact diagnosis, check the increased number of leukocytes  skin of legs easily becomes red or edema occurs
using the blood test, and check the state of lymphatic glands and  there is an infection symptom such as hot flush, pain
lymph nodes as well as the location and aspect of lymphedema using  pitting edema - symptom that pressed marker maintains for seconds if
the ultrasonic test, doppler test, lymphography, computed skin is pressed by finger end
tomography, magnetic resonance imaging (MRI), etc.
ASSESSMENT OF SYMPTOMS AND SEVERITY
PHYSICAL THERAPY EXAMINATION
• those suffering from lymphedema can feel pricky, heavy, bulky, weak,
• test and measure the sensibility evaluation of the skin, muscular etc., in the affected parts
contraction, strength, the restrain of articulation exercise, the range • for the severity of lymphedema, the international society of lymphology
of movement, etc. classifies into four stages, including the incubation period which shows
• besides, assess differently various measurement and evaluation abnormal lymphedema in the lymph system without clinical symptom
methods by the type of cancer and the damage extent of patients
Diagnosis Requirement of Lymphedema
SELF-MARKING TAPE MEASURE
 there is edema without one or both upper limbs and lower limbs
• measure the other part of the upper limbs and lower limbs with  earlier indentation edema is changed to non-indentation edema
lymphedema, using tapeline  pigmentation, created by ulcer, varix, and stasis does not occur;
• measuring the edema of the upper limbs and lower limbs is shown however, lymphedema is diagnosed when lymphangitis or phlegmon
below is detected
• stand with patient feet shoulder length apart using tapeline, stand
Step Classification by International Society of Lymphology
above the ground, and measure not only the bottom of the left and
right metatarsal and the bottom of saber shin but also the 0 STAGE (INCUBATION PERIOD)
circumference of the front of metatarsal in the largest part of the calf
muscle and that of the upper end of the anklebone in calf bone.  it is the state that the mobility of lymph fluid is damaged without
edema
 in reality, it can last for certain months or years before edema occurs

FIRST STAGE

 it is the stage that edema naturally decreases

 if pressed, pitting edema, which lasts the state, occurs, while if
maintained high, edema decreases

SECOND STAGE

 it is the stage that edema rarely occurs naturally

 in this stage, the fibrosclerosis of tissue becomes prominent
① measure it regularly in every week or every day.  pitting edema occurs in the earlier second period, while pitting edema
② measure it at the same time zone (mainly morning) with the same posture. does not occur because of the fibrosclerosis of tissue, and, if edema
③ wind tape line horizontally and measure it with appropriate pulling. part is maintained high, the edema of tissue decreases in the last
second period

C.A.M.| VI
THIRD STAGE

 this stage is that edema is very severe, as is known as “elephant

skin disease” which changes skin
 although the skin is pressed, hypertrophic skin change occurs such as
pitting edema acanthosis, fat deposition, overgrowth of verruciformis,
etc.

INTERVENTION

INTERVENTIONAL APPROACH

▪ lymphedema occurs due to poor circulation of the lymphatic system

and local or overall edema
▪ this disease is different from edema that occurs because of problems
of metabolism or the kidney
▪ therefore, safe and affordable management methods and treatment
intervention that are suitable for lymphedema are necessary
▪ physical therapists should prohibit methods that negatively affect
lymphedema patients in applying physical therapy intervention and be
informed of precautions to ease patients’ lymphedema and practice to
increase flow of lymph
▪ in general, a limb should be higher than the heart, and by putting
overpressure on a limb, blood flow should not be drastically increased

MEDICAL MANAGEMENT

▪ if there is inflammation by the primary and secondary damage

resulting from cancer, there is likely to be injury or acute inflammation
▪ at this moment, care is required for excessive amount of intervention
and care, and in severe cases, a quick wound dressing care and A. Maintaining Posture and Movement Program
administration of antibiotics are required ▪ through movement of the parts where edema occurred and proper
joint position, edema can be prevented.
PHYSICAL THERAPY INTERVENTIONS
▪ especially, conservative methods that lift the arms and legs may
POSTURES induce emission of intercellular interstitial fluid by gravity and reduce
hydrostatic pressure resulting from the blood vessel.
 physical therapists should be informed of posture which exacerbates
lymphedema and preventable posture B. Exercise of the Whole Body
 they should have patients informed about it and manage them
▪ there is a good point that through exercise of the whole body, pump
 especially, patients should not be exposed to risk factors (sauna,
muscle and at part of edema move lymph fluid to a region where there
fomentation, acupuncture, vacuum cupping therapy, injection,
is no edema, and by increasing joint working range, blood circulation
excessive exercise, wearing tight underwear, bruise)
can be facilitated; thereby functions of overall body improve.
 should be prescribed with regular range and intensity of training
▪ generally, 30 min of exercise 3 to 4x a week is proper, intensity of
 supervise patients to not adopt a posture that interrupts blood
exercise slowly increases, and maximum heart rate should be
circulation.
increased up to 60~80% step by step.
EXERCISE THERAPY
C. Breathing Exercise
 as a way of increasing limited joint range, union, and immobilization
▪ abdominal breathing using deep breath facilitates flow of lymph fluid
resulting from cancer, exercise treatment should be carried out
and is used for treatment of lymphedema.
 passive and active joint motion exercises and extensional movements
 through abdominal breathing, the ventral muscle is
may affect on fluid diffusion and flow of lymph circulation
stimulated, and by continual pumping to central lymph
 to improve weakened muscles and myatrophy, by the gradual strength
vessel, flow of lymph fluid is more facilitated.
exercise, lymph and blood circulation can be improved
▪ the order of intervention of diaphragmatic respiration is that you
 also, this kind of exercise treatments of cancer affects in weight loss
have patients raise their hands over the center of the stomach, slowly
and in lymphedema and is preventive measures
breathe, and feel the stomach rising and swelling.
 promoting mobility exercise of the neck, your own exercise regime for
▪ and, have them breathe out and feel the stomach down again.
improving pain, raising a shoulder blade and forearm over a head
▪ next, when patients breathe in, therapists should press the stomach,
lying for stretching, and butterfly-shaped stretching methods apply to
and when they breathe out, they should have them smoothly exhale
exercise treatment for cancer patients
by slowly relaxing.
▪ at first, start from one to three times, and when getting used to it
enough, increase to about ten times.

MANUAL THERAPY

 as a manual therapy, lymph massage (manual lymph drainage

massage) and lymph effleurage increase blood circulation and
lymph circulation where lymphedema occurs and act as reducing
edema.
 that is a way of excreting exudates occurring within the
tissues far away from the tissues.
 to excrete accumulated body fluid, physical therapists
massage with soft, slow, repetitive, and low pressure.
 through effects resulting from this, blood within the vein returns to the
heart without troubles, and there are sedation, reduction in pain, and
relaxation effects, reduction and maintenance of edema, and so forth.
 also, there is increment of lymph formation, increment of lymph blood
vessel mobility, formation of collateral circulation pathways, reduction
in nervous system stimulation during parasympathetic reaction
stimulation, and so on.

C.A.M.| VII
  the types of lymph massage are as follows, and detailed procedures
about massage order are indicated in lymph effleurage

A. Manual Lymph Drainage Massage (MLD)

▪ during manual lymph drainage massage, with lymph vessel as center,

increase to two directions, and through soft pressure, prevent acute
muscular contraction by a reflex, and slowly massage.
▪ in general, the order of massage application starts from the top
region, neck, and chest and to a distance, and when massaging the
abnormal part, start from the neck and chest or the center of the
body to the arms or legs and go down to a distance.
▪ treatment time is about 30–90 min.

B. Lymph Effleurage

- carried out for sedation of the skin and relaxation of tension

▪ massage to the direction of body of lymph vessel as if stroking and
hands’ pressure should be low and soft if possible, and move body
fluids to forward direction.
▪ stroking also follows lymph fluid emission order, and application order
starts from the chest and moves from the near part of the body to the
arms and legs and goes down. TIP
▪ however, application direction should be carried out from the arms
① pressure: hand pressure should be 30~40 mmHg and massage lightly
and legs to the near part of the chest and body
and softly not to increase hemofiltration from blood vessel.
▪ treatment time is about from 1 to 2 h
② direction: all directions of the massage should be toward the heart.
③ rhythm: therapists should use their wrist properly and their hands should
be light, soft, and rhythmic. therapists’ hands should not be separated
from the contact surface.
④ sequence: therapists should maintain their contact time for about 5 s per
each activity, and it should be repeated within 7 to 10 times

SKIN CARE

 because the tissue of skin edema region has been weakened due to a
cancer cell, it is a good place for germs to grow.
ways to apply lymph massage
 therefore, through proper skin care to reduce inflammation, it is
① neck and arms. necessary to prevent damage of lymph vessel.
 as a general method, it is important to prevent the skin from being dry
a. massage from the neck to downward. and keep the skin glossy by applying body lotion or cream to the skin
b. massage from the armpit of the edema region to the opposite armpit after a bath.
direction.
c. massage from the armpit of the edema region to the same direction of PHYSICAL AGENT MODALITIES
the groin region.
A. Iontophoresis
d. massage the back region from the armpit of the edema region to the
opposite armpit. - is a direct current of the positive and negative poles, and through skin
e. massage the upper arms from the elbow to the armpit. semi permeability, it permeates free ion to the skin edema region.
f. massage the forearm from the wrist to the elbow. • iontophoresis using copper medicine at both poles can help us
g. massage the back of one’s hand upward. prevent inflammation of weakened skin, give us sterilizing action,
and reduce edema by salicylate.
② legs
B. Compressive Treatment
a. massage the neck from the top to the bottom.
b. massage from the inside of the thigh of the edema region to the - can maintain hydrostatic pressure of tissue and facilitate fluidity of the
direction of the inside of the thigh lacking edema. vein and lymph fluid
c. massage from the inside of the thigh of the edema region to the same • in case of severe lymphedema, using continual pressure stocking,
direction of the armpit. elastic bandages, and a pneumatic compression device after the first
d. massage the back from the inside of the thigh of the edema region to stage, edema can be reduced, and circulation of blood and lymph
the opposite inside of the thigh. increased by giving direct pressure on edema tissue.
e. massage the thigh from the knee to the inside of the thigh.
f. massage the leg below the knee from the ankle to the direction of the pneumatic therapy
knee.
• when carrying out pneumatic treatment, it is important to know
g. massage top of the foot upward
that due to hypersensitiveness of sense that tumor patients,
especially skin cancer patients have, there may be pain.
• the intensity of pressure of pneumatic treatment for reducing skin
edema is important.
• the pressure of pneumatic compression for this is about 0~40
mmHg and it is recommended not to exceed 30–40 min

C.A.M.| VIII
 ▪ in addition, through lymph massage, compressive treatment, and
exercise treatment, lymph circulation should be increased by
contracting and relaxing muscles.
▪ lymphedema can be prevented by relaxing the region of edema in
the daytime with pressure stocking or elastic bandages worn in terms
of simple prevention.

PREVENTION OF LYMPHEDEMA

1. Maintain the arms and legs higher than heart (use a cushion or a
compress bandage therapy pillow).
2. Avoid increasing blood circulation of the arms and legs (do not use hot
• when applying elastic bandages for compression, the intensity pack and hot water).
of compression, direction of bandage, types of bandages 3. Keep the skin of the arms and legs clean and maintain skin moisture
should be checked. (however, keep the feet dry).
• compressive treatment is good right after lymph massage. 4. Be careful of inflammation and injury of the arms and leg(do not inject
• the method of compress bandage is easily applied with large to the region of edema).
bandages, sponge bandages, finger bandages, hands, and so 5. Do not give excessive pressure on the arms and legs(do not sit with
on. legs crossed).
• compress bandage using bandages should be bound softly 6. Regularly measure the circumference of the arms and legs.
and securely, and to prevent inhibition of blood circulation, it is 7. Maintain appropriate weight with moderate amount of exercise.
desirable to use spiral or figure-of- 8 bandage that binds the 8. Meet medical staff regularly, and in case of severe edema, inform
limbs from a distance to a body. them of it immediately.
• when binding compress bandage, bind the end point region in
layers since pressure of the region of the bottom end should be MANAGEMENT OF LYMPHEDEMA
higher than the top end. 1. Lymphedema patients should care for lymphedema after learning
• at this moment, there is caution that when pressure is high and treatment methods.
applied to not sensitive patients, there is likely to be dermolysis 2. Using low-elastic bandages or pressure stocking helps body fluid
and stasis of blood circulation, so the amount of pressure reabsorbed (if there is erythema or itching on the skin, ask the medical
should be adjusted. staff).
• check regularly if the fingertip becomes excessively blue or 3. Symptom of inflammation such as hot flush or pain exacerbates
white. edema, so treat it right away.
• and by bending the arms, the thumb should contact the nose. 4. The region where lymphedema is severe results in pain if there is a
sense of skin being hard and wrinkles occur in the region of swelling.
5. If you do strenuous exercise or adopt a bad posture with insufficient
strength, swelling may become aggravated, so be careful.
(Immoderate exercise, stair climb, sitting with legs crossed, squats
should be avoided.)

PATIENT/CARER EDUCATION

since lymphedema can be prevented for it not to turn into a grave disease
depending on how well people exercise caution, roles of guardians as well as
those of patients are very important. therefore, all patients and guardians should
be educated about prevention and care.

 always keep the region of edema in the arms and legs clean and
apply lotion or ointment to the skin for it not to be dry.
 however, keeping the feet dry is a principle and it is necessary to give
information to wear anti-sweat cotton clothing.
 to prevent inflammation in the arms and legs, it is important to wear
gloves during working hours, and when doing outdoor activities,
wearing socks and shoes is required, and do not go around with bare
feet.
 nail cleaning should be done by not cutting near the skin and toenail
should be cut in line.
 by having people informed of their own methods of measurement
about the region of edema and having people taking their arms and
legs measurement regularly (every day or every week), have them
regularly (mostly in the morning) check if there is edema.

ADVISES FOR PHYSICAL THERAPISTS

▪ physical therapists should pay special attention to the potential symptoms
and signs of skin cancer and check dermal thickness and scar formation
resulting from skin cancer in advance.
▪ eczema, psoriasis, and seborrheic dermatitis occur in over the half of skin
pressure stocking method cancer patients, more frequently than in the ordinary people. however,
although a pale pink spot occurs in skin cancer, it is not important, and
explaining it to patients well is important
• using stocking, by giving proper pressure during daily life, it is
▪ physical therapists should minimize friction and contact caused by rough
possible that more edema cannot be increased. skin resulting from skin cancer, prevent the secondary hemorrhage, and pay
special attention to spots of the skin that is locally subject to sunlight.
PREVENTION AND MANAGEMENT ▪ changes such as color, size, shape, ulcer, hemorrhage, and uredo that
appear at lump or moles occurring on the skin should be referred to and
Lymph disease results in stasis of lymph system circulation and undercurrent of examined by doctors.
blood vessel within a body should be prevented. ▪ if people underwent lymphangiectomy, physical therapists should plan
measures about remaining lymphedema or draw up measures to minimize
▪ physical therapists lift the arms and legs higher than heart to it.
prevent lymphedema in cancers such as prostatic cancer, skin ▪ it is important for physical therapists to prevent skin cancer patients’ pain
cancer, lung cancer, stomach cancer, and especially skin cancer and reduce level of pain, and scar care of the skin should be accompanied
occurring after the surgery. by thorough checking and care.
▪ because reduction in circulation of blood and the secondary problems of
necrosis can occur when giving very strong pressure in care of lymphedema,
care is required during the treatment.
C.A.M.| IX
PROBLEM SOLVING QUESTIONS

1. Mr. A, who is 36 years old and was diagnosed with skin cancer 2 years ago,
has been regularly managed for his skin cancer. He, whose body has been
recovered recently, works. However, he requires the help of physical therapists,
visiting their place. That is because his working environment requires much
sedentary work, and he feels heavy and suffers from pain with a little restrained
movement. So, he wants to work continuously for the job, and what method is
needed to lessen his problems?

ANSWER: Pressure Stocking

2. Ms. A, who is 45 years old and was reported to suffer from squamous cell
carcinoma, suffered from depression, anxiety about recurrence, and decreased
body function 1 month before. What guidance do physical therapists need to take
ahead of the physical therapy interference after the contact to doctor in charge?

ANSWER: The program to increase maximum amount of oxygen uptake

3. Mr. A, who is 50 years old and was reported to suffer from squamous cell
carcinoma, contacted physical therapy room by the prescription of his doctor after
feeling pain. What physical factor interference is needed to facilitate lymph fl uid
and vein circulation?

ANSWER: Pressure Therapy

4. Ms. A, who is 50 years old and suffers from lymphedema after skin cancer
diagnosis, requires physical therapy. What physical therapy interference method
is needed for her?

ANSWER: Progress stroking lymph from the hands and feet to the body

5. Ms. A who is 50 years old and was operated 3 months before since her
diagnosis of breast cancer is reported to suffer from poor blood circulation and
decreased entire mobility. To intervene it, she requested physical therapy by
surgery. What physical therapy interference method is needed for her?

ANSWER: Circulatory Promotion Exercise

C.A.M.| X