This chapter aim to provide a critical appraisal and review of empirical literature which supports and justify the need of present study. It provides an incidence, risk factors of lymphedema and overview on women quality of life. Further chapter describe quality of life domains; physical, functional, body image, and psychosocial. The literature search revealed that lymphedema is a breast cancer treatment complication that has been assessed in different aspects.
This chapter comprises of five sections; the first section discusses search strategy, second section on introduction of topic, third section discuss about incidence and risk factors and fourth section discuses impact of lymphedema on Quality of life, and last summarize the chapter
Search Strategy
For the present study a comprehensive, computerized search was performed. Literature was obtained through several electronic databases such as Pub Med, Blackwell synergy, Ovid, sage, and science direct. Further consult in different books based on topic, search engines such Google scholar. The literature review was conducted by using key words resembling the given concepts, post mastectomy complications, ‘lymphedema and quality of life’, ‘chronic edema and quality of life’, ‘psychosocial and lymphedema’ and ‘patient experience and lymphedema. However, there are limited studies has been done in west and a few studies in Asian countries on incidence, risk factors and to explore quality of life with lymphedema in different manner. The different studies have been assessed by using different generic instruments to assess QOL at varying time point in lymphedema patients. There is no lymphedema study has been conducted in Pakistani context.
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Introduction
According to statistics approximately 1.3 million people worldwide develop breast cancer in each year (Jemal et al, 2008).In Asian countries like Pakistan has the highest rate of breast cancer and according to statistics an incidence rate of breast cancer among women is 50/100, 000. Howeevr, in the neighboring country like in India with similar socio-cultural background the incidence rate is 19/100,0 00 (Bughari, 2004). According to Karachi registry age standardized annual rate of breast cancer is 69.1 per 100,000 and breast cancer effects on both young and middle-aged women and can effect women as young as 20 years (Kayani , Zaheer, Ashraf &Malik,2008 :Banning, Hafeez, Faisal, Hassan, &M,Zafar,2009). However, with extensive literature search it has been found in west that lymphedema is more prevalent in old age after 60 years (Mahmood, Rana & Ahmad, 2006). Although, the advances have allowed for earlier diagnosis and the administration of better and more effective treatments to prolong the life of breast cancer patients.(Foldi ,1998; Cheville , McGarvey , Petrek , Russo ,Taylor, Thiadens &,2003). But despite advances in treatment, many breast-cancer survivors still face permanent and prolong risk of development of lymphedema (Paim, Lima, Fu, Lima,& Cassali,2008; Paskett, Naughton, McCoy, Case, & Abbott, 2008). Lymphedema is a condition that can be treated and managed over a lifetime but cannot be cured and it has a great impact on quality of life such as: pain, discomfort, disability, alteration in body image, and difficulty fitting clothing (Ridner, 2002).
Incidence of lymphedema
In west there are several studies have examined the incidence of upper arm lymphedema among breast cancer survivors but there are very few studies have been conducted in Asian countries to investigate the incidence, and risk factors of lymphedema. There are numerous reasons were identified for inconsistencies on reporting the incidence of lymphedema across studies due to; no standard measure of lymphedema exists, depend upon on the population studied, and depending upon how the condition was defined or how long the sample was followed (Farncombe et al., 1994; Carter, 1997; Hoe, Iven, Royle, & Taylor, 1992; Cidón,Perea & López-Lara.F,2011).
Furthermore, the duration of development of lymphedema also documented varies in different population. In western countries the incidence of lymphedema was reported 6% to 63% (Armer, 2005; Ozaslan & Kuru 2004).Further, according to one study 8.1% women self-report lymphedema, and 37.2% women self-reported arm symptoms (Ahmed et al2008) and in Spain the incidence of lymphedema was documented 23-38% (Cidón et al,2011)
The second aspect the duration of development lymphedema documented varies in literature for instance ; 38 months,9-18 months,06 months,1 years and even after 2o or 30 years women reported for lymphedema. In one of Australia study after 9- 18 months of surgery more than 30 % women were appeared with arm lymphedema (Hayes, 2008). Further in another case control study 24% women reported lymphedema duration of 38 months. (Meeske, 2009).
A case control study was conducted in USA and 24% women reported lymphedema in duration of 38 months. (Se Sagen1, 2009). Another aspect that how women have reported lymphedema condition. Moreover, a study was conducted in Poland and 33.47% women developed lymphedema between 1.10 years (Chachaj, 2010) .However, Fu, Axelrod, Haber (2008) indicated that lymphedema can develop during treatment or even after two to three decades later.
Moreover in Asian countries a few studies were conducted to explore the incidence and risk factors of lymphedema. A study was carried out in Korea and 24.9% women developed lymphedema after 12-24 months of breast cancer treatment (Park ,Lee,Chung ,2008). More over in one of Indian study the overall incidence of lymphedema was reported 41.1% in breast cancer survivor after ALND (Pramod et al, 2010).Whereas in another study which was conducted in India has reported prevalence of lymphedema in 13.4 % women who have treated with surgery and 42.4% women who have treated with surgery and radiotherapy (Deoet al,2004).In addition one Chines study reported the magnitude of lymphedema as 39.6% moderate and 33.7% severe lymphedema( Mak et al ,2009)
Risk Factors for Lymphedema
In western based literature there are many risk factors associated with lymphedema were identified. In next section the overall risk factors are divided into two categories for example the one is treatment related factors include; type of surgery, axillary lymph node dissection, and radiation. The other is patient and clinical related factors include; age, hypertension, diabetes, obesity, dominant hand site surgery, and lymphedema information.
Treatment related factors
Empirical evidence suggests that specific cancer treatments are main causative factors in breast cancer-related lymphedema, including removal of lymph nodes; and fibrosis from radiation, infection (Steven et al, 1998; Loudon & Petreck, 2000; Kwan et al, 2002; Hull., 2000).The treatment related factors base on which stage the breast cancer was diagnosed, because the treatment depend on stages, intensity of the disease. The higher the stage of breast cancer (larger or higher number of tumors and increased lymph node involvement) the more aggressive the treatment will be done like; in extensive surgery more breast tissue and more nodes will be removed and thus it increases the risk of lymphedema in arm (Erikson et al, 2001; Hull, 2000; Meeske et al., 2009; Ridner & Dietrich, 2008; Yen et al., 2009). In addition one more study affirmed that prevalence of lymphedema increased with the type of surgery performed in particular; modified radical mastectomy, and axillary lymph node dissection, the other are axillary radiotherapy and body mass index with greater than 25 kg/m2 (Park et al,2008 ;Vassard D,2010).
The upper extremity lymphedema is associated who have been treated either surgery, radiation, or both (Logan, 1995; Ozalslan, 2004) , and one study showed that women who have under gone axillary node dissection only suffer 10 % and combined with radiation increased the risk as 40% or more development of lymphedema (Johansson et al, 2003) .Also it has been notified that not only removal of lymph node but number of removal of lymph nodes is also associated with increased risk of swelling in arm (Pasket &Stark,2000).Moreover, several studies found that in breast cancer surgery the mastectomy, and removal of 10-20 lymph nodes were highly significant in developing lymphedema (Hayes,2008 ; Meeske,2009; Paskett et al, 2007; Deo et al,2004 ; Pramod et al, 2010) .
In one of Asian study found that after ALND the patient have developed lymphedema between 1-2 years (Mak, et al 2009).Moreover, the radiation is also a risk factor and it is evident that patients who have received radiation therapy directly to the axilla also developed lymphedema. However, development of lymphedema is not related to those who experience radiation to the breast only (Erikson et al., 2001; Hull, 2000).There are few studies conducted in Asian countries .In one of Korean study the treatment related factors for the lymphedema were identified; modified radical mastectomy, radiation therapy especially in axilla and breast and axillary lymph node dissection (Park et al,2008 ; Nesvold et al,2011). Further,few studies documented patient related risks for the lymphedema were younger age (Erikson et al., 2001; Geller et al., 2003; Meeske et al,2009), being overweight (Meeske et al.2009), and weight gain after breast cancer treatment (Petrek et al., 2001).
There are several studies documented that breast cancer diagnosis in younger age increases the risk of lymphedema although the etiology is missing or not documented anywhere in literature (Erikson et al., 2001; Geller et al., 2003; Meeske et al., 2009). A significant study findings revealed that young age 18-39 years is a higher risk for arm lymphedema especially when compared with women aged 60-69 (Gärtner, 2010). On contrary in one study the older age, and sedentary life style, found the increase risk of lymphedema but low yearly income decrease the risk of lymphedema over 12 month follow up period ( Hayes,2008). Furthermore, it is widely shown that obesity, overweight, body mass index (BMI) greater than 30 (obese) significantly increases the chance of lymphedema (Meeske et al, 2009; Rinder, 2005; Paskett et al, 2007; Gärtner, 2010; Mak, 2009; Passik, McDonald, 1998; Mak, 2009; Vassard D, 2010). Whereas, in a Korean study the body mass index was greater than 25 kg/m2 was associated with lymphedema (Park et al, 2008). Moreover, many studies have identified hypertension as a possible contributing factor to lymphedema (Mak, 2009; Passik, McDonald, 1998; Maka et al,2009; Gärtner, 2010; Deo, et al., 2004; Engel, et al. 2003; Geller, et al., 2003; Mak,2009).However, in few studies it is documented that treatment for hypertension is a protective factor for lymphedema due to use of pharmacological treatment of hypertension (Meeske et al., 2009 ; Geller et al ,2003 ; Deo, et al., 2004). Further, Engle et al. (2003) found that hypertension and diabetes are significant contributors to lymphedema.
Dominant Arm Site Surgery
There is only one study showed association between the surgery on dominant hand site and development of lymphedema (Soran et al., 2006). However treated breast cancer on dominant arm side reduce task in: child caring, and upper body function, but statistically is not significant reported (Hayes, 2008; Chachaj,2010). In addition Passik and Mc Donald (1998) identified that pain and swelling in dominant hand increase psychological, and physical concerns as well as increase body image concerns.
Lack of information regarding lymphedema
There are several studies showed that patient education on lymphedema play an important role and in one study it is highlighted that patient receiving pretreatment education showed prevention of lymphedema and patient without lymphedema showed higher preventive self-care activities (Park et al, 2008).Further, a cross sectional study was conducted in New York among 136 breast cancer survivor. It was highlighted that that those women were well educated and received lymphedema information reported earlier lymphedema symptoms such as swelling and heaviness as compare those who have not received information and did not reported any symptoms. Further, it was noted that women who have received lymphedema showed a more risk reduction behavior (Fu, Axelrod, Haber, 2008)
In literature breast cancer survivor experienced that lack of information is a big risk factor for developing lymphedema. Likewise, in New Brunswick a focus group interview was conducted among breast cancer related lymphedema women to share their views about information of lymphedema. Women have shared that they do not have any information regarding symptoms, management and which condition aggravate lymphedema condition.So,when they have developed pain and swelling in arm and these condition got aggravated due to cold places and hot weather they become fearful due to lack of information (Thomas-MacLean et al, 2005; Hare ,2001).
Moreover Woods (2003) conducted a semi structured interviews with 37 women to see the effectiveness of lymphedema education. After completion of breast cancer treatment some of women were referred to lymphedema specialist for getting and managing lymphedema condition. The result has revealed that those women have not received any basic information on lymphedema they got shock and fear while swelling start on operated site on arm. These women frustrated about their appearance and damage self-confidence. Moreover, it has been reported that lack of information about lymphedema correlated with poor adjustment with illness and consequently increase depression among women (Tobin, 1993)
Diagnosis of lymphedema
In literature it has been identified that there are different methods were used to assess the presence of lymphedema. There are a wide range of subjective and objective methods included; patient questionnaire based on symptoms of lymphedema, sequential arm circumferential measurement and volume measurement. But there is limitation of the research reviewed that there is no standardized method of measurement was used (Erikson et al., 2001)In one study the arm circumference measurement was used and criteria of lymphedema set as less than 3 cm mild,3-5 cm moderate, and more than 5 cm counted as severe lymphedema (Mak et al,2009).But in another study the arm lymphedema criteria kept that more than less than 2cm on arm circumference was accounted as lymphedema (Chachaj et al,2010).According to different literature the arm circumferential measurements is the most practical because no special skill or equipment is needed (Brown, 2004). This method appears to have the same accuracy as other methods and works very well if done serially.
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Quality of life Tools
A number of studies have been utilized different health related QOL tool to assess the Quality of life among lymphedema and non-lymphedema patients(Moffatt et al,2003).There are several researcher investigated the impact of lymphedema on QoL including physical, functional , physical symptoms, pain and psychosocial life.They have used different tools to assess the quality of life of patients such as ; Fact B + 4,ULL, F-36,the Arm Symptom Distress scale (Mak, et al ,2009; Fu,2008) ,Functional Assessment of Cancer Therapy-Breast instrument, Disability of the Arm, Shoulder and Hand Scale (Hayes et al,2008) quality of life scale, QLQ-C30, women who are without lymphedema (Paskett et al,2007) ,psychological distress (GHQ score, Short Form-36 (SF-36), and Impact of Cancer scale (IOC) (Nesvold et al, 2011),and WHO-DAS II, EORTC QLQ-C30, EORTC QLQ-BR23(Chachaj et al,2010).In current study a LYMQOL tool used which was adapted from UK(Refrence)
Impact of lymphedema on patient’s quality of life
Lymphedema can cause severe physical and psychological morbidity in breast cancer survivors and reduce quality of life in relevance to physical, functional, emotional, and psychosocial wellbeing (Beaulac et al, 2002 & Johansson et al, 2003).
The literature review presented here has been categorized under the heading of Impact lymphedema on physical, functional, physical symptoms, pain and on psychosocial life with lymphedema.
Impact of lymphedema symptoms on patient’s quality of life
The degree of swelling can occur mild to severe and it can be develop soon after competion of treatment or several years later (Pasket &Stark, 2000 ; Logan, 1995; Ridner, 2005; Armer et al., 2004 ).In addition there is a series of lymphedema related symptoms were experienced among breast cancer surrvirrrvor includes ; swelling, heaviness, tenderness, and numbness (Hull, 2000; Armer et al, 2003; Ridner, 2005 ; Coster et al, 2001; Hull, 2000; Thomas-MacLean et al, 2005 ).Furthermore, such symptoms may create frustration, physical limitations and subsequent psychosocial problems among breast cancer surrvivor (Radina and Armer, 2001; 2004; Thomas-MacLean et al, 2005; Radina and Watson, 2007).
Swelling and Heaviness
In various literatures arm swelling and heaviness has been reported is the principle symptoms with different duration of time among lymph edema patients. The development arm or heaviness lead.
There are varied time duration of symptoms were documented across the literature. Moreover, in one of study the 50% women have reported swelling or heaviness every day, whereas, 25% women reported 3 days a week, and 24% women reported symptoms rarely (Gärtner, 2010). s many problems in patients. According to Rinder, 2005 that women with swollen arm perceived symptoms as greater than 10% difference in affected limb as compared to non-affected limb. A focus group interviewed of breast cancer survivors who have arm lymphedema was conducted in Province of New Brunswick. During interviewed the Participants described their distress feeling in a way such as ; numbness, heaviness, tingling sensation , hardening in arm, tightness in arm limited the mobility of arm and they are not able to do anything.(Thomas-MacLean, Miedema, Tatemichi ,2005) In addition after seven years the similar findings has been reported in Nesvold et al,2011 study. Moreover, according to Gärtner, 2010, study findings about 13 to 65% women identified swelling/heaviness in one year period of time. In other three studies it depicted that most common symptoms experienced by patients with swelling, sensation, heaviness, numbness, and tiredness in affected arm caused reduction in functional activities (Armer et al, 2003; Ridner, 2005; Cidón, Perea, López-Lara, 2011). Furthermore a study support the view of impairment in functional activities such as swelling in their arms would worsen the arm activity, if severity of swelling increase then fear of movement also increased. At this point researcher has emphasized the early initiation of therapy programs for upper body lymphedema in order to alleviate the problems. (Ahmed, 2008; Karadibak et al, 2008).A cross sectional study conducted in New York among 136 breast cancer survivor. According to study that 18% patient with lymphedema along numbness, swelling impaired shoulder mobility (Fu et al, 2008).A substantial number of studies have been conducted and identified that number of symptoms and its severity is association with psychiatric morbidity. Because if after post breast cancer treatment the symptoms like ; stiffness, tightness/firmness swelling, heaviness and numbness become prolonged it creates create frustration due to physical limitations, which consequently lead to psychosocial problems in lymphedema patients (Radina & Armer, 2001; Thomas-MacLean et al, 2005; Radina &Watson, 2007 ; Radina.2007)). Nineteen years back Tobin, 1993 documented that women having arm lymphedema have been experienced psychiatric problems due to functional impairment in daily life. Moreover, another study determined the severity of symptoms also day by day decline women life and continue the psychological distress like fear, apprehension, anxiety, and feeling of uncertainty in their life (Mei , 2008) . However, in one of study there is a significant finding was emerged that up to 50% of survivors reported symptoms with or without diagnose of lymphedema (Petrek et al, 2001).Further in a qualitative study the descriptive analysis showed that 43% of participants reported arm symptoms without diagnosed lymphedema as well these symptoms include arm swelling, pain or discomfort, and functional impairment. In study women have shared that with arm lymphedema they felt physically handicapped and lost of independence due to tremendous limitations in performing daily tasks. Some of women have left their work because they can not full fill the heavy task like repeated lifting things and repeated typing according to job requirement (Fu, 2009).
In various studies the literature indicated that some time symptoms and swelling start simultaneously, but some time swelling in arm start first and then symptom or it start it vise versa .Additionally, in one study the researcher identified that the participants informed poor range of movement in arm, shoulders and hand reported after 18 months of surgery. However, the symptoms for lymphedema started between 6-18 months such as; transitory symptoms for 3 months, and rest showed with long period of time (Hayes, 2008).
Moreover, in one study about among lymphedema group the 8.1% women reported lymphedema, and 37% women reported arm symptoms without lymphedema.But later on 40% women reported arm symptoms included along 30.3% women indicated arm swelling, 21.3% women pain or discomfort, 17.6% women reported functional limitations i over three months period of time .The SF-36 tool was used to measure QOL and it showed poor QOL on all scale except mental summary scale, mental health subscale, and role limitations on emotional subscale (Ahmed, 2008).
Pain
Furthermore pain is an important aspect that among patients with lymphedema. The various studies indicated the pain symptom impair physical activity and lower the Quality of life (Dawes et al, 2008; Ridner, 2005, Bani et al, 2007; Armer et al, 2004).The pain reported duration was found varies in different literature .In addition, in Norway study there there were 204 breast cancer women with stage I and II underwent for mastectomy or breast conserving surgeries. It was identified that 13% women identified with arm lymph edema, 21% women developed sensation of heaviness but 36% women reported pain in arm after five years (Sagen1et al,2009). However, in some studies arm pain was reported between five to twelve years after surgery and it is significantly associated with poor Quality of life (Thomas-Maclean, Hack, Kwan , Towers , Miedema &Tilley,2008) .Moreover, a descriptive phenomenological study was conducted among 34 breast cancer survivor in USA. According to the study findings the lymphedema group reported severe arm pain most likely associated with continuous distress, fear, apprehension, anxiety , and uncertainty in their life (Fu & Rosedale ,2009).Furthermore, pain is a significant symptom to asses clinical arm lymphedema among breast cancer survivors (Thomas-Maclean et al, 2008). Moreover, the different researchers identified that degree of pain increase fatigue, frustration, and discomfort as a result decrease quality of life score in lymphedema patient (Woods, 1993; Passik, &Mc Donald, 1998; Velanovich, &Szymanski, 1999). Pain is one of the symptom which create difficulties in performing daily routine task either at home or at work and due to lack social support increase pain in arm avoid coping, and developed poor body image (Passik et al , 1995).There are numerous studies has been explored the impact of lymphedema on physical functniong.
Impact of lymphedema on Physical Functniong
In literature there has been many studies showed a significant impact of lymphedema on patient with physical impairment. Velanovich and Szymanski (199) conducted a study among 827 breast cancer patients in USA and SF-36 quality of life tool was used to measure the quality of life patients. Among of these, 8.3% have developed lymphedema during the follow up visit. It was found that bodily pain (p 0.005), mental health (0.01), and general health (0.04) domains with lymphedema were statistically significant. However, on scale role emotion domain percentage was high but it was not statistically significant.It has been shown in many studies the arm symptoms like ; pain, swelling, firmness, tightness, heaviness, fatigue, numbness, lead stiffness and disability of consequently limit the range of motion in hand,arm,and shoulder and effected the QOL of patient(Coster et al, 2001; Armer et al., 2004;Thomas-MacLean et al, 2005 ; Radina , Armer, Daunt, Dusold &Culbertson ,2007).Further, in 6 month follow up study the 56% women identified pain is the significant symptom which interfere women life those who are engage in daily activities or those women who are on rest (Sagen1et al, 2009;Mak, 2009).
A study was conducted in Denmark among breast cancer survivor women in age ranges between 18-70 years. According to study result 36% women left all house work due to intensity in arm symptoms. Similarly, the rest of 36% women also left sport activities due to pain, swelling and numbness in arm. The women shared that due to swelling the shoulder can not rotate in all range of motion thus due to shoulder problem 47 % women faced difficulties in doing light work such as dusting or holding small things and 59% women faced difficulties in doing heavy work like sweeping, washing cloths or floors. The study showed statistically significant association among functional impairment, pain and swelling of arm (Gärtner, 2010). Velanovich and Szymanski,(1999) conducted a study among 827 breast cancer patients in USA and SF-36 quality of life tool was used to measure the quality of life patients. Among of these, 8.3% women developed lymphedema during their follow up visit. It was found that arm swelling was highly associated with bodily pain (p= 0.005), mental health (p=0.01), and general health (p=0.04) domains and role emotion domain was not statistically significant.
Similarly a cross-sectional and longitudinal study was carried out among breast cancer survivor in 2004 and 2007.The study examines the associations in between arm/shoulder, and different aspects of quality of life (QoL).The study result indicated significantly poorer QoL on all SF-36 domains, physical (p=<0.001) role function (p=<0.001) general health (p=<0.001) except (MCS) Mental component Summary Scale (Nesvold et al, 2011).Like wise in one of match case control study the result showed lower or QoL scores on all five domains except on emotional wellbeing scale, which was not significant (Maka et al, 2009).
Moffat et al (2003) study reported that 80% woman with lymphedema financially support their families but due to in ability of work they have lost their jobs and heir employment status affected. Additionally, one study highlighted that some of women gave up their hobbies due to arm swelling (Fu 2005).It has been determined in some studies that women with swelling arm having difficulties in performing their responsibilities taking self-care like; searching fitting and wearing cloths, need support in performing core house hold activities, and need assistance while driving on long distances (Thomas-MacLean et al, 2005; Fu, 2005 ; Nesvold et al,2011). Moreover, women faced day by day constrains in functional activities like having difficulties in walking, bending west or arm, carrying objects or using effected arm, wearing of shoes cloths, writing, wearing jewelry gardening activities, and not able to enjoy life with their partner, family, friends due to pain and stiffness in arm (Lam ,Wallace ,Burbidge ,Franks & Moffat ,2006; Cidón1et al,2011; Tobin et al,1993; Carter 1997 ; Moffat,2006 )
Impact of lymphedema on psychosocial health among lymphedema patients
There are various studies shows that intensity of arm symptoms alter in limb sensation, which decrease physical activity, increase fatigue, loss of body confidence and increases psychological distress (Rinder, 2005).In addition in many studies showed that women with swollen arm developed discouragement, and depression due to impairment in performing daily activities (Nesvold et al, 2011; Moffatt et al ,2003; Karadibak et al., 2008; Ridner, 2005).Furthermore, when pain duration and intensity increase correlated with changes in role function, lack of social support, and decrease Qol (Velanovich &Szymanski,1999; Passik et al,1998) .Further, Thomas-MacLean et al,2005 stated that “despite indications of bodily acceptance, changes to one’s body are a constant reminder of illness, limitation and disability” (p. 247). Because women felt now they are disable and dependent on others to perform the task due to illness. In several studies it has been found that psychological distress increases with swollen arm. Likewise Passik et al (1993) case study demonstrated that women verbalized that she avoid to go outside in warm weather because she can not hide her swollen arm under cloths and similarly another women shared that when I go outside I become anxious because people stare my swollen arm and pass comments on it. In addition, breast cancer with lymphedema women shared that some time they feel anxious, depress, stigmatize, and as a result some of them disrupt of interpersonal relationship with husband children, family and friends (Fu, 2008; Pyszel et al,2006 ; Johansson et al ,2003).Also women shared their feelings that most of the time swollen arm making them frustrated, depressed, and anxious because every day they face challenges in their life for small tasks like zipping in shirt, opening and closing shirt buttons and cannot continue their jobs and left all social activities (Carter, 1997). Moreover, in another phenomenological study affirmed that women with lymphedema verbalize feeling of loneliness, sense of isolation, limitation in taking care of self like wearing clothes, jewelry, and sleep disturbance (Greenslade &, House ,2006). Tobin et al, 1993 conduct a match case control study in England. The 50 women in each group with and without lymphedema were recruited. The researcher used a psychological adjustment scale, and Karnofsky scale to assess functional impairment in both the groups. The study findings revealed anxiety, depression, and physical problems among lymphedema group. Moreover Passik et al, 1995 identified that women developed distress, negative body image if social support is not available. Because family members are immediate people who know the problem and they can help them in modifying daily tasks .It was significant that those women who have family support showed well adjustment as oppose those who have not any support from their families. There is a study carried out in Canada among twenty eight arm lymphedema women to find out the coping strategies with swollen arm. It has been identified that work is an important activity which keep person busy and divert her mind from illness (Maunsell et al,1993; Radina et al, 2001)
Body image
There are few studies highlight body image as a psychological implication of lymphedema (Carter,1997 ; Mirolo et al., 1995; Tobin etal,1993) .Similarly carter has identified that women with swollen arm wear lose sleeves to hide the swollen arm from other people and they avoid wearing short sleeves for showing good appearance. But poor body image and disfigurement of arm increase distress always remind them coming back of breast cancer again (Carter, 1997).
Further, a study supported that due to constantly pain in arm increases psychological problems and left women with poor body image (Passik et al ,1995). Farncombe et al, 1994 identified that swollen arm refer a disfigurement of arm which is related to poor body image. However, loss of function of arm is associate with negative image of arm and due to these reasons it is difficult to women stand in society to find fit, appropriate and attractive dresses. Moreover, it was found that
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