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Abstract

Lymphedema associated with Breast cancer is a common occurrence in women. In this study, an obese patient with a complaint of lower back pain reported of breast cancer-related lymphedema in her left arm. She was experiencing the symptoms of heaviness and discomfort in her left arm since two years after her radical mastectomy with axillary lymph node dissection in the left breast. Following the assessment, it was determined that the lymphedema was in stage 2 and required immediate attention. Medical science believes manual lymph drainage or Arm massage designed to aid lymphatic circulation is the best treatment in such cases. Since, Siddha therapy includes the Uzhichil or the general pressure application with massage to cure chronic cases without harming the body, this study was conducted to nd out the impact of Siddha Varmam techniques on reducing edema in the patient's arm and also on the symptoms of pain and discomfort, ROM (range of movement), and pre and post treatment circumferential difference of Left arm. A 15-day treatment which included varmam pressure therapy and massage therapy and with various other therapeutic manipulation of varmam points was carried out. The left arm discomfort was taken on Perceived discomfort Proforma scale which reduced from severe to moderate during lifting and holding things with the hand. The Lt arm circumference was decreased from severe to moderate after the treatment. As patient was obese and had lower back pain, a special diet monitoring and weight reduction was also taken into consideration. At end of treatment, the patient's weight which was 140 kgs had reduced to 110 kgs by diet management. Though, the study showed a positive role of Siddha in reducing the edema but very less data are available and future research is needed to support the efficacy of siddha therapy as a conservative strategy and alternative option in cases of Lymphoedema.

Introduction

Accumulation of lymph fluid due to damage to the arm's lymphatic drainage system or mechanical blockage can cause lymphedema. Most common causes for lymphedema or swelling in one arm may attribute to tumors, lymph node surgeries, and certain infections. Breast cancerrelated lymphedema is the most common complication arising after breast cancer surgery and treatment. Removal of lymph nodes in the armpit as part of breast cancer treatment is a common cause for upper extremity lymphedema. This is a condition that is characterized by the presence of abnormal swelling in cases post-surgery or even years after treatment. WHO statistics shows, one out of five women having breast cancer have upper limb lymphedema. The risk of arm edema increases when axillary dissection and axillary radiation therapy are used..

Depending on the swelling progression, the Lymphedema is identifed in various stages with Stage 1 with abnormal flow but no sign or symptoms to Stage 4 with a serious condition like Elephantiasis. Lymphedema involves the accumulation of protein-rich build that impacts physical, functional, and psychosocial health and well-being .Other than changes in physical appearance and limitations created by lymphedema, the patient might report a variety of physical symptoms like pain, discomfort, heaviness, tenderness, numbness, and stiffness, arm swelling and limited range of motion of the affected arm .The pain can start immediately in post-operative period or onset can be delayed up to 6 months to 2 or more years post mastectomy. The pain is typically experienced as a shooting or burning pain, with point tenderness

To avoid worsening of condition, early intervention provides a best chance of control. Symptoms like swelling and measurable volume changes in arms may be the earliest indicator of lymphedema. The limb swells as the fluid increases with an observable increase in limb size.In lymphedema, the effect of pharmacologic interventions remains uncertain but non pharmacologic treatments, such as massage and physiotherapy exercises, have been shown to be effective therapies.

Modern Science believes that other than surgery; manual Lymph Drainage or Arm massage, the lymph can be moved from swollen area into an area with working lymph vessels. Arm massage is a specialized type of gentle massage that is designed to aid lymphatic circulation and should be done with someone specially trained in treating lymphedema. In this type of massage, the soft tissues of the body are lightly rubbed, tapped, and stroked. It is a very light touch, almost like a brushing and patients have seen positive results with it.

Since, Siddha therapy includes the Varma therapy or theUzhichil general pressure application with massage to cure chronic cases with no intervention of medicines and no harm to the body, this study results may help to understand the benets of Siddha therapy in cases of lymphedema. If proved positive, it will help to reduce the perceived discomfort and accumulation of lymph and also helps the participants to be prevented from complications and get good prognosis. The Varma therapy especially deals with certain points in the body and the treatment with the contemplation of such points. In Siddha the massage therapy is generally called as Thokkanam, which include massage with or without oil and with different pressures.

Case Presentation

A 45-year-old obese, home-maker U.S female patient came to Chakrasiddh in July, 2022 with complaints of severe lower back pain and swollen Left arm (lymphedema). She has a teenager son whom she breastfed for 2 years, no habit of smoking or drinking. The patient is diabetic and has hypothyroidism from last 10 years. In 2019, her Gall bladder was removed and Hysterectomy was performed.

She was 32 years old when she started experiencing a dull continuous pain in her left armpit and in her left breast. There was tenderness in the nipple area and noticed enlarged left breast as compared to her right breast. She consulted a gynecologist, had a mammogram and was diagnosed with stage 2 breast cancer. She had a radical mastectomy and axillary lymph node dissection in 2008. In subsequent months, she had 20 cycles of chemotherapy and three weeks of radiotherapy. During her therapy, she noticed heaviness and swelling in her left arm and some discomfort. When she started having problems in working and lifting her hand, she consulted her oncologist and was thoroughly evaluated. The oncologist confirmed her having pitting edema- a Stage 2 lymphedema on palpitation. She observed her weight also increased immensely from 90 kgs to 140 kgs. There is numbness and felt heaviness in left arm, she was advised by her Oncologist to wear arm stockinettes to keep her arm firm and control the edema in hands and to go for a Bariatric surgery.

In last 3 years, the patient was regularly monitored in US and was having her therapy but the edema was not reducing and her discomfort level had become severe. As the patient is staying in U.S and she has to do all household chores herself but due to her condition she was unable to perform them properly; she was under immense psychological stress and depression causing deterioration in her quality of life. She was advised by her parents in Hyderabad to visit Chakrasiddh for help in this respect.

The aim of presenting this case is to see how Siddha medicine by utilizing varmam pressure therapy worked on reducing the lymphedema without use of medicines. Also, whether siddha treatment along with diet modifications and physiotherapy is able to reduce the chances of Bariatric surgery and weight management.

Treatment Procedure

In initial phase, the treatment was started on 13th July, 2022 for lower back for 30 days and the rest 15 days after a gap of 2 months for Lt arm Lymphedema. The special therapies Pressure Manipulaiton Therapy (Varmam) was utilized to instigate the ow of energy. The 3 specic techniques which can stimulate the varmam points were used: Massage (Thadaval), Tapping (thattal) and pressure (Amartthal). The patient was kept on a strict liquid diet to reduce weight and daily physio exercises for 1/2 hr. In initial phase, she lost almost 10 kgs weight and in her break had lost another 7 kgs. According to the plan, she was given a break for a month but was advised to continue diet restrictions and physio strictly.

After break, her treatment for lymphedema was started on 15th Dec, 2022. At start of treatment, the Perceived Proforma scale and pain level in lt arm was severe on many aspects like holding, lifting, movement, bending etc. The measurement of Lt arm as compared to unaffected Rt arm was noted as severe. Every 3 days, the left arm circumference at shoulder point, elbow point and at wrist was noted to see the difference from the start of treatment. The ROM of lt arm was measured in all 3 planes by Physiotherapist at every session to see difference in movement. The therapy included Uzhichil or the general pressure application at varmam points like Kakkatai Kaalam, Savvu Varmam, Manibandha varmam and Soodothari Varmam to reduce the edema in lt hand. The patient's feedback was taken daily for pain level and she was told to do things with her leftt hand like holding things for > 10 mins, lifting her hand and folding it to visualize the changes pre and post treatment. After 8 days of treatment, patient could feel reduced heaviness in lt arm and she was advised to remove her socks. The treatment was given to her for 25 days with breaks in between and was completed on 12th Jan, 2023.


Results

Pre and post-treatment pain severity measurement were assessed using the NRS (Numeric Rating Scale) at each treatment session where 0 refers to no pain and 10 refers to worst possible, excruciating, unbearable pain. The pain was evaluated on different symptoms like during bending, walking, sleeping, working, lifting, exertion, movements of head, neck, shoulder, arms etc As spasms occurred in the same areas of pain, no separate measure was taken. The patient was asked to keep a daily record of overnight pain and spasm frequency over the next 6 months period. (Table-1)

Discussions

Lymphedema is a very common complication in patients who have undergone Breast cancer treatment. Due to sedentary lifestyle adaptation after surgery and side effects of treatment, the occurrence of lymphedema is quite high. The lymph accumulation in the affected limb not only affects the quality of life including physical concerns such as inability to complete movement like lifting & holding, feeling of discomfort, inactivity, and heaviness; but also results in psychological issues like embarrassment and a disturbed social life. This case study demonstrates that Siddha therapy worked like manual lymph drainage by utilizing the general pressure application with massage to cure the complication related to Breast cancer associated Lymphedema without any medications and harming the body. This study showed the positive effects of Siddha Varmam therapy on reducing edema in the patient's arm and also on the symptoms of pain and discomfort, ROM (range of movement), circumferential difference of Left arm pre and post treatment.

Conclusions

Siddha Vaidya, an ancient science that treats by aligning body energies (mind, body and spirit), to empower and activate the body's internal healing mechanisms results not only in cure but also an improved quality of life in cases of Breast cancer related Lymphedema. Siddha therapy along with diet and physiotherapy played a vital role in this case in reducing pain & discomfort, reducing the circumference of affected limb and improving the activities of the patient.

The left arm discomfort was reduced from severe to mild during lifting and holding things with the hand. The Lt arm circumference was decreased from severe grading to moderate after the treatment. The patient's weight which was 140 kgs had reduced to 110 kgs by diet management. From the above ndings, it is evident that Siddha therapy was effective in reducing perceived discomfort and lymphedema among patients with mastectomy and also helps the patients to be prevented from complications and get good prognosis.