Ask Cheryl Brunelle, PT, MS, CCS, CLT

Areas of expertise:

  • Breast cancer-related lymphedema
  • Prospective surveillance/screening
  • Risk factors for lymphedema
  • Symptoms of lymphedema
  • Measurement of lymphedema
  • Treatment of lymphedema: manual lymphatic drainage, compression, exercise, self-care
  • Early intervention for lymphedema
  • Breast edema after breast conserving surgery/radiation
  • Cording/Axillary web syndrome
  • Exercise after breast cancer
  • Rehabilitation after breast cancer
  • Side effects of COVID vaccination after breast cancer treatment

Cheryl Brunelle is the associate director of the Breast Cancer-Related Lymphedema Research Program and a clinical specialist in physical therapy at Massachusetts General Hospital.

Cheryl earned her physical therapy degrees at the University of Toronto, Canada. She completed her lymphedema certification with Drs. Albert and Olivier Leduc in London, England, and with Klose Training, in Boston, USA.

Cheryl’s clinical focus is on oncology program and staff development within the MGH department of physical and occupational therapy, and the evaluation and treatment of patients during and after breast cancer treatment, for issues such as surveillance and early intervention for lymphedema, shoulder morbidity, and deconditioning resulting from breast cancer and its treatment.

Cheryl is a strong proponent of lymphedema screening as standard of care for patients treated for breast cancer. Since 2005, over 6,500 women have been screened for lymphedema after breast cancer treatment within the MGH lymphedema prospective screening program.

Cheryl joined the Lymphedema Research Program in 2014, since which time she has published over 25 papers. She has collaborated on multidisciplinary teams to update hospital policies including recommendations for receiving the COVID vaccine after lymph node removal for breast cancer, as well as collaborated on a recent white paper establishing measurement guidelines for lower extremity lymphedema in research studies. She presents the team’s research works regularly at national and international conferences. Cheryl’s breast cancer-related lymphedema research interests include early intervention, measurement, effects of the COVID vaccine after lymph node removal, prospective surveillance, precautionary measures and breast edema.

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  1. Which pneumatic compression pump to buy?
    Question (Lisa, ):
    • I have lymphedema in my left leg and groin for 20 years (radical hysterectomy for cancer). My right leg is less swollen. I’ve worn 30-40 (R) and 20-30 (L) compression thigh high stockings. What pump is best to reduce fibrosis (foot ankle) swelling in legs feet & groin?

    • Sep 2023

      Thank you for your question. I am wondering if you have a certified lymphedema therapist you have worked with in the past? It sounds like you would benefit from further reduction therapy (complete decongestive therapy) and then perhaps new custom garments to keep the swelling down. A pump is really an adjunct to full therapy, not a treatment in and of itself. Each patient has individual needs with a pump, so I would suggest recommendations come from a CLT you are seeing, and only after reduction therapy and new garment fitting. Garment replacement every 6-9 months is also imperative to keep the lower legs and feet under control, and custom flat knit is far superior to off-the-shelf circular knit.

  2. LVA surgery and Velcro compression garment
    Question (Cindy, ):
    • I am having LVA surgery on Monday, my surgeon says he’s OK and thinks it would be a good idea with me wearing a Velcro compression garment a few days after the surgery. But he does not know what to recommend. My physical therapist has never worked with someone after

    • Sep 2023

      I am sorry for the delay in replying to you, as you have already had your surgery. Feel free to reach out again with further questions as you need.

  3. Full Body Compression Needed
    Question (Abigail, ):
    • I wear morning-and-night-garments both-legs-hands-arms-trunk-chest. It takes nine-pieces. I hit garment allowance/allotment quickly with insurance and can only get a piece at a time. I have to go without often and worsen quickly. How do you suggest I advocate for my insurance to help cover needed compression? Thank you!

    • Aug 2023

      Thank you for your question and I apologize for the delay in answering online. I am wondering what the etiology of your full body swelling is? Needing full body compression is not common. I agree it is very difficult with insurance coverage the way it is currently. In the next year, you will see great improvements as the Lymphedema Treatment Act is enacted. In the meantime, perhaps trying to decrease the number of pieces you are using, for example, sleeve and gloves, pantyhose and a long line trunk garment, which is 6 pieces. This is still very expensive, however. If you do not have a definitive diagnosis, I would suggest considering further work-up to see if there are perhaps any additional treatment options available to you, as I would guess this has a dramatic impact on your life. Garments, lymphatic imaging, lymphatic surgery and research has come a long way in the past few years, so I would suggest checking in with your team, including your CLT, at least yearly.

  4. MLD direction
    Question (Leslie , ):
    • I am a CLT now treating post VLNT in Colorado. We have no protocol in place for our post op VLNT. I have a protocol from Beth Israel LE center. Their protocol states MLD is now directed down the arm towards the new forearm flap. Is this correct?

    • Aug 2023

      Thank you for your question and I apologize for the delay in replying. I did not feel it was my place to advise re: the BI protocol, so I reached out to Kathy Shillue, PT, CLT in the Lymphatic Surgery Program at Beth Israel, who very kindly replied with the following:

      “We don’t use any compression or MLD immediately post op, and only resume once the patient is seen and cleared by the surgeon at the 3 week post op visit, and then resume pre op level of compression for all patients. 

      If the patient was using self MLD prior to LNT, we would generally resume that with a new drainage pattern towards the new lymph nodes, which we often place in the proximal forearm.  However,  we now are learning much about individual lymphatic anatomy and drainage patterns with imaging, so would also use information from pre operative ICG to assist in directing the patient in self-drainage,  and might use a more individualized pattern.   

      I would recommend speaking with the surgeon to find out where the lymph nodes were placed and what might be known from imaging about lymphatic drainage prior to surgery.    This should be a collaboration between surgeon and lymphedema therapist.”

      Thank you to Kathy for her quick reply and help with this question!

  5. Pneumatic Compression Pumps
    Question (Marian, ):
    • I have fairly well controlled lymphedema in my left leg. I do MLD, wear compression, and exercise regularly. Would you recommend adding a pump to my treatment regimen? Are there negatives associated with using a pneumatic pump?

    • May 2023

      It sounds like you have a very good program in place! Please ensure you are replacing your garments regularly. Pumps may be used as an adjunct to a program like yours, yes. I would suggest discussing this with your certified lymphedema therapist in case you have any contraindications to using a pump. In general, the only issue I have with pumps is if they are not being used in addition to all of these other things you are doing. They are not meant to be a stand-alone treatment. For patients who are very active, I generally would never recommend a pump if it means losing the time to exercise because of pump treatment. I would prefer a patient is exercising rather than sitting still with their limb in a pump.

  6. Pneumatic compression devices and pressure
    Question (Chris, ):
    • I have a unilateral lower limb primary lymphoedema. The foot and ankle are most problematic. What is the highest pressure setting of these pumps that would be safe to use? Which devices have been tested in clinical trials? I am in the uk. Thank you.

    • Aug 2023

      Thank you for your question and I apologize for the delay in replying. We know from the literature that lymphatic vessel closure pressure is higher than what we previously anticipated. In a 2016 study by Jean-Paul Belgrado, the observed mean occlusion pressure of the superficial lymphatic vessels was 86 ± 3.7 mm Hg. Saying that, I would suggest pressures of no higher than 80 mm Hg with a pneumatic compression pump. I would suggest trying different pressures and perhaps refitting appliances to ensure the foot and ankle are draining well. Working with company reps, programs can be altered on some pumps, for example, to increase time spent in one area that is more problematic. In any case, pumps have been shown to be an adjunct to a comprehensive lymphedema treatment program, including compression, self-care, exercise and proximal clearance before applying a pump to a limb.

  7. Lymphadenopathy in Breast
    Question (Gail, ):
    • I receive massage therapy but have found different bras cause varying raised welts in the inner bottom of my breast which over time appear to be getting longer and wider. The welts are just raised, not red, itchy or painful and disappear with no bra.

    • May 2023

      Thank you for reaching out. It sounds like the bra strap is digging into some swelling and causing pitting indentations into the skin. You would likely benefit from either a bra with a very wide band below the breast, or a long line compression garment (like a tank top but specifically for swelling/lymphedema). I would also recommend alternating or changing garments at least daily, to avoid developing welts in your skin. Finally, you could see a certified lymphedema therapist who can try different techniques for this swelling to try to improve it for you, so that your bra does not dig in.

  8. Lymphedema Training
    Question (Michelle, ):
    • I’m a MT in Grand Junction, CO. We don’t have any CLTs in a reasonable distance. My employer is encouraging us to treat lymphedema patients without significant training. Getting my CLT is not currently an option, but can you recommend training that would prevent patient harm and help them?

    • May 2023

      Thank you for reaching out, this is a very challenging situation. Lymphedema should be treated by certified lymphedema therapists, and I would strongly recommend that your employer consider supporting this for at least one if the staff in your facility. There are some programs to help with the cost of this training, and it sounds like your area would very much benefit from a certified therapist. Here is a link to LERN’s Please note that this is available to PT’s, PTA’s, OT’s, OTA’s, MD, DO, PA, DC and RN, so perhaps someone in your facility or community could apply for such an opportunity to help prioritize the needs of this patient population. As an MT, please note that manual lymphatic drainage in and of itself is not sufficient to treat lymphedema, as these patients also require compression between sessions to maintain the effects gained in each session. They also highly benefit from exercise. I applaud you for trying to meet the needs of a patient population lacking care, however, this should be met by CLT training.

  9. Lymphedema treatment vibrator frequency
    Question (Max, ):
    • Are there any studies on what vibrational frequencies are best for lymphedema treatments?

    • Apr 2023

      Thank you for your question. To my knowledge and upon a quick literature review, there is no evidence supporting use of vibration to specifically treat lymphedema. There were two studies completed 20-40 years ago, neither which evaluate the effectiveness of this treatment on its own. I am not aware of a particular frequency recommendation and would suggest more evidence-based methods of lymphedema management which should be provided by a certified lymphedema therapist.

  10. Question for Dr. Brunelle
    Question (Mary, ):
    • Could the pressure from a mammogram after 18 months bring on lymphedema for a patient who had 22 lymph nodes removed during a lumpectomy for breast cancer followed by 20 rounds of radiation? I was told to be careful with my arm, but they were sure rough on me! Thanks!

    • Apr 2023

      Thank you for your question. I am sorry to hear the mammogram was so uncomfortable for you. However, I have never seen a patient whose lymphedema was incited by a mammogram. You may have some acute breast swelling or discomfort, but this should be temporary and resolve quickly.

  11. pneumatic massage
    Question (Magda, ):
    • Good morning. I have a question. I have met with different approaches so I prefer to ask the best specialists. Is pneumatic sleeve massage in primary lymphedema recommended? If so, which program. From the foot to the groin or vice versa? Thank you in advance for the answer and greetings warmly

    • Apr 2023

      Good morning and thank you for your question. Intermittent pneumatic may be used as an adjunct to a full lymphedema treatment program, in addition to compression and potentially manual lymphatic drainage in clinic. It should not be used as a treatment by itself. Compression, fitted appropriately by a certified lypmhedema therapist, should be worn in between pump sessions. Because there are some precautions and contraindications to pump use, it would be best to work with a certified lymphedema therapist and your physician to consider whether a pump would be appropriate in your case. One would always work from the foot to the groin - the direction of movement should be up toward the hip.

  12. Preparation for knee surgery in leg with primary lymphedema
    Question (Serica, ):
    • I've had primary lymphoedema in left leg for 58 years and need replacement knee surgery. The swelling is well controlled but I'm fearful of what surgery might change. I have had a replacement in the other knee and both hips which were successful. What do i specifically need to do?

    • Mar 2023

      Thank you for your question. I would recommend that if you regularly wear compression, you ensure your garments are new and up-to-date. Garments that may be specifically helpful after knee replacement, when the knee is swollen postoperatively, would include velcro-closure wraps or ‘reduction’ velcro-closure wraps, that can be cut down as your leg decreases in size. I am glad to hear the surgery in your other knee and both hips was successful. As after any operation, prevention of infection is key, and infection can certainly worsen lymphedema. It would be best to ensure that anyone touching near your incision practices hand hygiene before touching your leg and follow the surgeon’s instructions regarding infection prevention. Regaining your mobility with the help of the therapy team will be key to ensure good circulation in the leg and ongoing use of your muscle pump which also helps fluid to clear. Best of luck with your surgery.

  13. Weight loss and stability of lymphedema
    Question (Shrinjoy , ):
    • Does weight loss help with lymphedema also does lymphedema stabilizes after few years ?? I don't wear compression any more and the leg has stopped growing is this something all lymphedema patients go through?? The swelling was really bad in the first couple of years

    • Mar 2023

      Thank you for your excellent question. Each person’s lymphedema course is different, so it is difficult to generalize. Lymphedema is a chronic disease, however, it can stabilize, and I see that likely more in cases of primary lymphedema than in lymphedema that is secondary to cancer surgery, for example. I am glad yours seems to have stabilized and is doing well even without compression. I will say, however, if your swelling is still not really well controlled (if the volume of the leg is still greater than the other side), I would suggest continuing with compression and reduction treatment as needed, to avoid lymphedema progressing to later stages. This is because in later stage lymphedema, the tissue changes to a more fat-dominant swelling, which really cannot be treated without surgery and can predispose the limb to infections.

      As for weight loss, our research team found that weight loss did not decrease lymphedema risk in patients at risk for lymphedema after breast cancer. Katie Schmitz’ research group found that weight loss did not improve lymphedema outcomes in her WISER trial. However, I would argue that weight loss, for those who are overweight or obese, has so many other health benefits, I would suggest aiming for attaining a healthy body weight. Many patients at risk for or with lymphedema struggle with weight loss on their own, despite healthy lifestyle behaviors. This is sometimes due to treatment side effects or hormonal changes. In those cases, working with a registered dietician and your physician can be helpful.

  14. Pain relief
    Question (Cynthia , ):
    • I had 30 Lymphnodes removed from one arm. I wear compression sleeve, self massage and exercise. Have used Lidocaine and continue Advil/Tylenol prn. Any thoughts on other pain relief options? Have tried Arthritis pain relief creams. Have you heard of hyperbaric treatments? Thank you

    • Feb 2023

      Thank you for your question. I am wondering if your pain could be coming from a source other than lymphedema. There could be something orthopedic or neurologic, for example, in addition to any discomfort from swelling. In earlier stages of lymphedema, often the discomfort is described as heaviness, or fullness, or a sense of swelling. Pain can certainly be present in later stages of lymphedema, but it is always best to seek out any other issues that may be responsible for pain. These issues could be treatable and help to decrease the pain you are experiencing. I would suggest seeing your PCP, if you haven’t already, for an evaluation and referral as appropriate, including to a certified lymphedema therapist if you have not already received management. You can use a Find a Lymphedema Therapist function on the LERN website found under ‘Living with Lymphatic Disease’.

  15. Cracked skin at base of toes
    Question (Lorraine, ):
    • Lymphedema is worse on my feet, The skin at the base of my toes in front and in back is very, very dry and cracked. The dermatologist said to moisturize, but that doesn't seem to help. Is there any treatment you can recommend? Thank you.

    • Dec 2022

      Thank you for your question. This can be a common problem. I would ask your dermatologist for their recommendation re: moisture lotion. Something heavier/more emollient is usually more helpful as this won’t soak into the skin and disappear. Ensuring you apply this at night and in the morning, is helpful. If you wrap your toes for your lymphedema, ensuring there isn’t a fold in the toe wraps as they approach the web spaces is helpful as wraps can dig into the skin, make sure you are monitoring for openings in the skin. If you feel there is an infection at any point, you should seek medical attention right away.

  16. Ready wraps, vs velcro wraps, vs multilayered compression bandaging, vs patient self-bandaging.
    Question (Anna, ):
    • What's the preferred self-wrap technique for chronic patients unable to fit in a compression garment and are unable to receive daily compression bandaging. Juzo velcro wrap vs ready wraps vs jobst farrow wrap vs self-bandaging. Which method is most comparable to multi layered compression bandaging from a therapist.

    • Dec 2022

      Thank you for your question. If the goal is reduction, then a product suitable for limb volume reduction would be best. This would be either a reduction garment or self-bandaging. If patients are able to achieve good self-bandaging, this is a good option. Often this takes more than one session, and patients need to be aware that bandaging pressure decreases over the first 24 hours, so ideally, wraps should be reapplied daily.

  17. Exercise
    Question (Cheryl , ):
    • When using a rebounder should you wear compression hose while jumping? I wonder if it is an effective?

    • Nov 2022

      Thank you for your question. I would suggest that if you have a diagnosis of lymphedema or lipedema in your lower extremities and are advised to wear your compression hose daily by your lymphedema therapist or doctor, I would suggest you do so when rebounding as well.

  18. Lymphedema on ball of foot
    Question (Debbie, ):
    • What can be done for lymphedema on ball of foot. I am using pump with pants 2x daily 60 to 90 min. I am using compression socks 15-20 & 20-30. I am also using compression capris.. Do I just us metatarsal pads?

    • Nov 2022

      Thank you for your question. Lymphedema on the ball of the foot can be quite uncomfortable. You may wish to increase compression to 30-40 mm Hg or you may wish to try a toe cap and an open toe stocking, which sometimes can help that area. You could also try metatarsal pads, as you mention. If you wear night compression, a garment that has good foot and toe compression would be important.