LYMPHEDEMA AND THE ROLE OF PHYSICAL THERAPY

Lymphedema affects approximately two million people in the United States. Its incidence is on the rise because each year approximately 500,000 Americans will be treated for some type of cancer that will be treated for some removal or the destruction of their lymph nodes. One out of every five of those people will then develop lymphedema.

 

Lymphedema occurs when the normal drainage of fluid in our body is disrupted. As the fluid accumulates, the area will become red, hot, swollen and painful. Often the arm or leg will double in size. In a normal lymph system, the body utilizes a network of nodes and ducts. Those nodes and ducts maintain the balance of the body’s fluid, they filter our waste products and fight bacteria.

 

However, when lymph nodes have been removed or destroyed by radiation this lymphatic system loses its ability to maintain this delicate fluid balance. As a result, there is an accumulation of protein-rich fluid that becomes a breeding ground for bacteria. If this swelling in the tissue is left untreated, it can lead to permanent tissue damage, scarring and long-term disability.

 

Presently, it is seen most often in women who have had breast cancer surgery where lymph nodes have been removed and radiation therapy has been done. This swelling in their arms can occur weeks, months or even years later after surgery.

 

That is exactly what happened for Sarah Micheals. She had decided to take an airplane trip to New York City to visit her daughter. Five years earlier she had breast cancer surgery and had been doing just fine since then. However, the next morning after she woke up at her daughter’s home, something just didn’t seem right. She felt like she was getting the flu. Her body ached and her right arm had a strange red streak on it. Throughout the day the pain in her arm became worse and her arm started to swell. She got so swollen she could barely hold her coffee cup and she had to remove her rings. Finally her daughter took her to the ER, where it was discovered she was suffering from an infection in that arm resulting from lymphedema. She was given antibiotics, which cured the infection, however, the swelling in her arm remained. She then was referred to physical therapy for treatment of the swelling.

 

Physical therapy care for lymphedema consists of Manual Lymph Drainage Massage (MLDM), Medical Compressions Bandaging (MCB), special exercises that milk the lymph system and supplement the massage, skin care and treatment of any infections.

 

The physical therapy care will help decongest the swollen body part, eliminate fiber tissue and improve the immune system function. Once the body part has reduced in size a protective garment needs to be worn on that extremity to avoid re-accumulation of that lymph fluid. This protective garment helps to maintain the natural fluid balance of the affected body part.

 

If you are a cancer patient who has had any lymph nodes removed or radiated here are some guidelines you should follow in order to prevent this chronic, progressive disease.

 

• Wear a protective garment for flying of when doing any new actives you are not accustomed to.

 

• Wear gloves during household chores or gardening to avoid minor cuts, animal scratches, bug bites and puncture wounds. Use antibacterial ointment right away if you do get a wound and consult your physician immediately.

 

• Avoid injections and blood pressure monitoring on the body part.

 

• Exercise at a moderate pace and keep “muscle pump” active. (Swimming in 75 to 85 degree F water is one of the best forms of exercise due to the natural pressure gradient in the water).

 

• Avoid hot baths such as Jacuzzi tubs, whirlpools, heat from hair dryer and sun exposure.

 

• Avoid any deep tissue massage.

 

• Wear clothing that is not restrictive to allow appropriate lymph flow. Wear your rings and watch on other extremity.

 

• Eat a diet low in sodium and saturated fats. Discontinue use of alcohol and nicotine.

 

• Keep skin clean and well moisturized. Use electric razors only.

 

If you have further questions regarding Lymphedema or you are wondering whether you have this disease, you can go online to the National Lymphedema Network at www.lymphnet.org or call them at (800) 541-3259.

 

Sheree DiBiase, PT, is a licensed physical therapist and the owner of Lake City Physical Therapy in Coeur d’Alene and the Spokane Valley. She has been practicing outpatient physical therapy for more than 20 years and was an Adjunct Professor at Loma Linda University, School of Physical Therapy for seven years, she instructed in Applied Kinesiology, Biomechanics and Gait Analysis. Both of her offices provide care for cancer related fatigue, weakness and lymphedema. She can be reached at (208) 667-1988.

BREAST CANCER MONTH

October is Breast Cancer Month. Breast cancer continues to affect too many of our friends and family members and the women we are doing life with everyday. The whole reason we take this month is to prevent and eradicate breast cancer. It is so we can tell all the women we know and love that we need to be proactive in preventive measures and to be there for each other if we do get breast cancer.

 

I just had a lovely woman who would tell you that you being too busy for a breast exam should not be an excuse. She learned to not put off her mammogram because it can give the vital information we need quickly and accurately. In her case, they caught a very small tumor that was very aggressive during a routine mammogram and as a result she will have great outcomes.

 

As Physical Therapists we play a role in caring for breast cancer patients. We usually see our patients about 12-14 days after surgery or once their drains are removed. We focus on getting their arms moving again and on restoring their overall strength with everyday activities. We educate our patients on skin care and scar mobility so edema doesn’t build-up in that area. Then we screen all patients for possible lymphedema issues from a long-term perspective so that they can be active in understanding symptoms such as pressure and “feelings of fullness” around the breast, chest or arm.

 

The two main reasons that you would get Lymphedema following breast cancer is:

 

If you had Lymph nodes removed, whether sentinel node, three nodes or all nodes removed, and radiation.

 

Often our patients have never heard of lymphedema or the possibility of lymphedema. Prevention now is the key. The more you know about the likelihood of it the more you can prevent it. If they do have lymphedema issues then there are easy steps that can be followed to ensure the proper care of this problem.

 

Lymphedema can be taken care of with Four Simple Steps:

 

1) Massage every day – Learn how to re-direct the lymph fluid to a new area around the area where the nodes were removed. Keep the scar lines mobile so that no fluid gets backed up behind the scar region.

 

2) Exercise on a daily basis – Learn special exercises that pump the lymph system and keep it moving where it should go.

 

3) Good Skin care – Keeping the skin in the area of where the lymphedema is located soft and pliable.

 

4) Use of compression sleeves – Use of garments especially during high risk activities such as flying, going over the pass and repetitive workloads.

 

Sheree DiBiase, PT, is a breast cancer specialist and she is the owner of Lake City Physical Therapy

. She and her staff treat breast cancer patients everyday. Please call or come in if you have questions or you are just not sure what to do, we can help. On Oct. 17 we will have a free educational class for anyone with Breast Cancer at 6 p.m. in our Coeur d’Alene office. Please call (208) 667-1988 to attend.

TELL ME A STORY

Who doesn’t love a good story! Especially one with adventure, a hero and heroine and all that stuff. Well growing up in my big Italian family we would often sit around the dinner table after church and talk the afternoon away. We heard all the adventures of our family’s life. My aunts, uncles and family friends would share funny and often amazing tales of their life. As kids, we would hang on their every word, even if the story seemed to get embellished as the years went on.

 

Now that I am a physical therapist I hear peoples stories everyday. And just for the record, they always amaze me. This window into a person’s life shows me so many things. I see their character, and drive to live life fully. The most amazing stories I am told often happen when my patients are under great adversity. Like when one of my patients was on vacation here from Guatemala and she had some pain in her chest and went to Urgent Care. It wasn’t what she thought they would find, but it was a tumor 5 cms in size. She had gone to the doctor in her hometown numerous times about this pain, but they told her it was nothing to worry about. She is so thankful she came to the states for a visit.

 

Or another one of my patients who was at the courthouse taking care of some business when a woman she didn’t even know, who had recently had breast cancer said to her “How long it had been since you have had a mammogram? You should have one right away, don’t wait.” And sure enough this woman went and had a mammo and she had early stage breast cancer. I mean who would think that a woman you don’t even know could save your life.

 

So here I am asking you the same thing. This is Breast Cancer Awareness Month and it is the time to tell all these stories so that we can help save people’s lives. Do not become too busy for your health. A few weeks ago I met a woman who has family who has a history of breast cancer and she got so busy in her life she hadn’t had a mammo in three years. When she finally got around to it, they found a tumor the size of a walnut deep in her chest wall. She had never even noticed it.

 

The National Cancer Society recommends the following when it comes to Breast Cancer Awareness:

 

1) Know your risks – is there a family history?

 

2) Get screenings – mammograms and breast exams, talk with your doctor about any abnormalities.

 

3) Know your body – you will notice tissue changes or lumps in your breast.

 

4) Make healthy lifestyle choices – what you eat, drink and how much sleep and exercise you get everyday makes a difference.

 

A story in past generations was how we learned valuable lessons. A story today could help save other women’s lives. Please keep telling your stories. We would like to be able to eradicate breast cancer and you are part of that story.

 

Sheree DiBiase, PT, can be reached at Lake City Physical Therapy

, (208) 667-1988. She and her staff are breast cancer specialists and having been caring for cancer patients in Coeur d’Alene and the Spokane Valley for more than 15 years.

PHYSICAL THERAPY AND WOMEN’S HEALTH

Women are unique! Because of that uniqueness women need a different type of health care. Women need health care that is specifically designed for them.

 

Lake City Physical Therapy sees you as not just another patient, but as someone special and amazing. Our staff knows what it is like for women to get what they need throughout all the stages of their life. Because we are women and we have struggles with all the same health issues you have. We’ve had athletic injuries, back pain while pregnant, weight gain after our babies that never went away, leaky bladders when we cough and laugh.

 

We know what it’s like to have a body that aches everyday, migraine headaches, perimenopuase and menopause issues that last for years, tummy muscles that never seem the same after a c-section, and a neck ache from carrying a five year old all over town. We often look in the mirror and wonder whose body is that anyway.

 

Our Lake City staff helps women through all the stages of their life, so you can achieve the level of health you desire. Our goal is to not only help you improve physically but for you to develop the confidence to know that your body can do what you need it to everyday. Because we know that you have people who need you and our depending on you. We want women who are beautiful in all aspects of their life.

 

Physical Therapy and Women’s Health Issues:

 

Headaches

 

Muscular Fatigue

 

Pre-natal and Postpartum issues

 

Pelvic Pain

 

Urinary Incontinence

 

Osteoporosis

 

Lymphedema

 

Breast cancer reconstruction

 

Back and neck pain from postural positions

 

Sheree DiBiase, PT, is the owner of Lake City Physical Therapy and she and her staff can be reached for a therapeutic massage at (208) 667-1988. We accept cash and insurance as indicated. Also, please join us at 6 p.m. Nov. 14 for a hour massage therapy class. You will learn massage techniques so you can take care of yourself and your family.

BITTER OR BETTER?

Thanksgiving is here and it is one of my favorite holidays. I love this time of year because I get to focus on what’s really important to me, my family and friends and this year is special because my oldest son will come home from college (and I miss him like crazy). It doesn’t matter if the turkey is perfect or the mashed potatoes are fluffy or if the gravy is too thick. It just matters that we are all together hanging around our big old table with everyone laughing, talking and teasing each other. It’s a time to let things of the past year roll under the table and be forgotten. I ask myself this same question every year right around Thanksgiving, will you become a bitter lady or a better lady this year?

 

Traditions and times change and sometimes that is hard for our family. This year we will celebrate Thanksgiving without my beloved mother-in-law and we will do it a little differently than we usually do. We are having a big breakfast that my sister-in-law is hosting with everyone and then we will all go our separate ways. It is a break from tradition, but one thing my mother-in-law shared with me before she passed away was that she hoped for peace for all of her children and their families. Peace to live and be without so much baggage from our past hanging around. She felt we wasted so much time and energy with all these past mind sets and it destroyed our opportunity for today and the future. She wanted us to live and be free to be what we were called to be. She was a good woman and I miss her so much. Anyway, this Thanksgiving, we will make new traditions, and we will be thankful for all the times we had together with her, and I will be forever grateful to her for the gift of her son to me.

 

As a physical therapist I see people everyday with physical challenges and disabilities, with terminal illnesses and loss of loved ones as a result. They truly have experienced a break from tradition and often their lives are never the same. It can be daunting to family to have loved ones sick and in pain everyday and it affects the whole family system. Family’s can often become torn apart from illness and devastating injuries. Divorce rates escalate and relationships are destroyed. The physical trauma from injuries can quickly turn the mind body connection upside down. What do we do?

 

Physical health issues happen everyday. Someone you love just gets diagnosed with juvenile diabetes, fibromyalgia, a mini stroke, breast cancer or heart disease and suddenly your life, as you know it is over. Do we give in to the despair or do we vow to take this challenge and let it makes us better? Such choices. Such a fight. What a battle. You must stand up and take charge and not let the physical challenges destroy who you are.

 

Come to physical therapy where we can help you integrate this physical challenge into your life. Education and your whole family understanding this physical change is the first step in wellness. Don’t ever give up on your physical health. As physical therapists we get it, we have been there. We know what to do. Will you be bitter or better? Only you can decide.

 

Sheree DiBiase, PT, and her staff can be reached at Lake City Physical Therapy (208) 667-1988, where we hope to grow better and not bitter from life’s challenges. Please join us from 5:30-8 p.m. Dec. 12 for our Christmas Health and Wellness Bazaar.

PICK UP YOUR PRESCRIPTION

The list is long and you just need to pick it up. It’s written, signed and already filled and ready for you to stop and get on your way home. When you pick it up it reads: Exercise daily. 30 minutes of cardio and 3 to 4 days of week of lifting weights. What? I don’t get to just take a pill and that will take care of all of this. What if you got a prescription like this and it was the only medicine you ever needed?

 

According to Exercise is Medicine.org, the majority of our country spends 8 hours a day in sedentary activities and over 70 percent of Americans don’t get enough exercise on a daily basis. In a 2009 study, utilizing direct evidence, the World Health Organization stated that physical inactivity is the number one leading cause of death in the United States. That is quite a statement isn’t it. All of our inactivity is causing a lot of health issues ranging from diabetes, to hypertension, to decreased immunity, which then often leads to a greater incidence of autoimmune diseases and related cancers.

 

So exercise is all we need, instead of all these different medications? Well, exercise is on the prescription, and the amazing thing is that the need for medications decreases as our exercise increases. We see the need for cholesterol medications decreasing. We see the need for high blood pressure medication decrease also. Even people with diabetes have a decrease in the need for their medications with a consistent exercise regime. Other studies indicate that the risk of strokes decreased by 26 percent with exercise and there was a 16 percent reduction in breast cancer with those who exercised. There is also an increase in white blood cell longevity, which then kills viruses, bacteria and reduces the risk of illness and colds. So people who exercised had less chance of getting any type of chronic illness.

 

So please let’s get started with your exercise prescription. First start with your cardio exercise. If you are not sure how hard you should be pushing yourself then you should follow the sing talk guidelines. If you can sing while on the treadmill, then you are not working hard enough, if you can’t talk, then you are probably working too hard. These are good ways to grade whether you are working at the level you should be for 30 minutes a day. Now consider what can you do for your muscles 3 to 4 days a week. This is a little bit trickier for some of us, so you may want some help from your physical therapist. But you can start with basic things like biceps curls, pec presses, tricep dips and lat pulls. Partial sit-ups, back extensions, push-ups, squats, lunges, and heel raises. If you happen to have health issues, like back pain or a tendonitis it doesn’t mean you can’t exercise, you might just need a physical therapist help you navigate your program. In fact, people in our country need to exercise daily regardless of their health status. There is something you can do, just come in and we can help you figure it out. So pick-up your prescription because exercise is medicine and the only one who can make you well is you.

 

Sheree DiBiase, PT is the owner of Lake City Physical Therapy and she and her staff understand the need for daily exercise. Please call us at (208) 667-1988 and they will be happy to help you establish a good exercise routine.

4 BREAST CANCER

Recently a charming young woman named Cindy came in to my office after having a bilateral mastectomy. She was sporting a cute hat and said she had just finished chemo and was on her way to radiation oncology. She said she had surgery more than 8 months ago and she wondered if she should be coming to physical therapy. She said she was stiff in the morning in her shoulders and that one of her scar lines was thicker than the other and there was a little fluid along the scar too. Otherwise she was doing well she thought.

 

More than 17 years ago I started treating clients after breast cancer surgery and our goal is still the same. Early rehabilitation in physical therapy after surgery yields the best results for our ladies in every way for them physically. Just as early detection is key so is early treatment in therapy for the best quality of life after surgery. In fact, our best results are with ladies who come in after their drains are removed which is usually at about two weeks after surgery or so. We can then start gentle active and assisted range of motion and begin the re-direction of lymphatic flow patterns due to lymph nodes being removed. It doesn’t matter if only the sentinel node is removed or a dozen nodes are removed the re-direction of the lymph system is needed and the body needs help in knowing where to go with that fluid because it is no longer being picked up by the nodes that are gone.

 

The scar also needs to be mobilized and this starts in the next two weeks. The scar line should be able to move in every direction with no areas of “pulling or tagging.” Something called “axillary cording” can also begin in the armpit after surgery. It usually starts very slow and almost has the feel of guitar strings and then becomes thicker like a strand of rope. It especially needs to be released otherwise it will slowly begin to limit your mobility and you will not even notice it. To check yourself for it, lie on your back and put your arm on the pillow over your head. Then rub your fingers across your armpit. If you feel any rough or thick areas when you compare it to the other side where no nodes were removed, then you know that axillary cording is beginning to occur. This cording should not be there and can be reduced with the right stretching, massage and exercise.

 

The key before you have radiation is to make sure you have full shoulder flexibility, make sure your scar lines are mobile and there is no axillary cording and to have no chest wall or under the arm pit swelling. Radiation is often the hardest on the system. It is because a lot of fibrosis can occur when you are having radiation. Fibrosis is when the tissue layers become thick and tough. There natural elasticity decreases and then swelling and fluid backs up in certain areas. The tissues that were flexible before will become stiff and hard to move again. If there was any axillary cording starting it will often become worse after radiation also.

 

Physical therapy rehabilitation after breast cancer surgery is a four-step process. If you are doing the four steps you will have done everything you can to take the best care of you. Come to physical therapy and learn the 4 steps, Cindy did and so can you.

 

Sheree DiBiase, PT, and her staff can be reached at (208) 667-1988 for the full 4-step rehabilitation plan for breast cancer. Lake City Physical Therapy.

‘DOC!’

In the spring of this year, I was back east in Maryland where I grew up, going to a continuing education conference and visiting my parents. One evening, I went out with my parents to a reception and the first thing I heard as we walked through the door was, “Hey, Doc!”

It was a familiar sound and I had heard it for a lot, especially during my high school years. My dad was a high school varsity basketball and softball coach. His players affectionately called him “Doc.” He is a dentist, and his players nicknamed him that the first year he coached and it just stuck.

This particular night, the words were from a 6-foot-6-inch 40-year-old medical doctor. He made his way over to my dad, hugged him and proceeded to tell my dad what an impact he had made on him and so many other kids in high school through his coaching career. This basketball player had gone on to college with a scholarship and played all the way through until he went to medical school. My dad thought the world of him, and it was a fun night catching up with him and his wonderful family.

That evening with my dad, who is now 80 years old, got me thinking about the awesome responsibility a coach has to his players. A coach can bring out the best and the worst in his team. His influence can be instrumental in their lives.

I have seen my dad have a positive influence on his players repeatedly throughout the years, and I am always so amazed at the things they tell him – things you never even knew were going on in their lives. Yet my dad was their rock, their consistent advocate through all kinds of adversity, and he didn’t even know that half of what was going on for them.

Every sport has their great coaches. Football had Vince Lombardi, men’s college basketball had John Wooden and still has Duke’s “Coach K,” and women’s college basketball had Pat Summit. I could go on and on about the greatest coaches of all time, but it is important for you to choose a coach for your physical health, even if you are not playing competitive sports anymore. We all need a person to be accountable to as we attempt to excel at our health objectives, whether we are 16 or 62.

Your physical therapists are just that type of coach for you. They understand how the body works and how it should move every day. That is their expertise. As you negotiate after your breast cancer surgery, your Achilles tendon rupture, or your rotator cuff tear, remember to have a physical therapist as your coach to ensure the best possible outcomes. Physical therapists know what it is to be a coach since they do it every day, so come see your coach and get on track for your health.

Sheree DiBiase, PT, owner of Lake City Physical Therapy, was recently certified by Stanford University for breast cancer lymphedema. She and her staff would love to be your Breast Cancer Coach.

Please join us at our booth this Sunday at 10 a.m. at North Idaho College at the Race for the Cure. We will have free prizes and education on breast cancer and lymphedema care programs.

If you can’t come, please attend our Wednesday night free educational seminar at 6 p.m. Sept. 25, at our office. Please call (208) 667-1988 to reserve a space, because it is limited.

SURVIVOR

I am not really a label kind of person, but this weekend at the Race for the Cure I met and saw a sea of beautiful people that were all survivors. Breast cancer survivors are brave, strong and resilient in a world that often thinks beauty is only skin deep. I am repeatedly amazed and surprised by the definitive choices they make to insure their health. They throw aside the world’s view and learn that their choices are theirs alone and then they stand tall on their decisions.

The definition of a survivor is to be able to carry on despite hardship or trauma, and to stay alive and thrive in the middle of it all. Surviving is not easy, and families and friends become the rock for so many survivors, along with their health care providers direction. That is why it is important for you to choose health care providers that you connect with because healing happens when you are surrounded by a positive support system at home and during your care programs.

For these reasons, Lake City Physical Therapy has devoted the last 17 years of its practice to caring for oncology patients, and especially for breast cancer patients. It is our specialty, and we are proud to provide our patients with the most advanced treatment options for the best possible outcomes. We are well aware of the challenges you face and we know that the best way to prevent future issues is to start early.

An evaluation with a physical therapist is the best way to start. We will quantify your arms’ flexibility, then measure the girth size of both of your arms to determine if there is any swelling. Next, we then test to see how strong you are, and we also look at your skin health and scar mobility. The scar should be pliable and there should be no “tugging and pulling” present on the scar to the chest wall or when you move your arm. This becomes your baseline for your program – whether you are in Chemo or radiation, you need to have an established program to make sure that you do not develop any disabilities.

Physical therapy programs consists of:

a) Exercise – Specific exercises to assist in mobility and healing

b) Massage – Gentle manual lymph massage, scar mobility, myofascial release

c) Compression Therapy – Garments such as camisoles, bras, sleeves, compression shorts, lower leg garments, etc. that prevent edema and Lymphedema

d) Skin care – promotes skin health, wound healing, 2x day Cetaphil or Eucerin

Sheree DiBase, PT, is the owner of Lake City Physical Therapy, PA, and she and her highly trained staff want to thank you for your support at the Race for the Cure. It was a great event. If you would like to learn more about breast cancer physical therapy or oncology care please come this Wednesday night, Sept. 25, at 6 p.m. to a free class at our Coeur d’Alene office at 2170 Ironwood Center Drive. Call for reservations at (208) 667-1988, seats are limited.

TWO WEEKS

A couple of months ago, a beautiful woman came into my office, wondering why she had been referred to physical therapy after she started radiation therapy. She had a partial mastectomy with axillary lymph nodes removed three months before, and had already had chemotherapy. She felt pressure in her arm with a little bit of stiffness when she did her hair each morning, but that was it. She thought she had no pain, and wondered why physical therapy was necessary and what the purpose of it was.

According to Dr. Susan Love in her book ” Dr. Susan Love’s Breast Book,” she reports “that all mastectomy and axillary lymph node dissection patients get an automatic referral to physical therapy where at a minimum, they are taught basic exercises and also receive additional lymphedema education.” Side effects of surgery and radiation can occur three to six months after treatment; it is best to start early with physical therapy so prevention techniques can be started with the patients. Research has indicated that physical therapy should begin after drains are removed or on the 12th to 14th day after surgery.

Side effects following mastectomies and lumpectomies are numerous. This is the reason skilled intervention by a breast cancer physical therapist is needed. Some of the problems come from the surgical intervention due to removal of the axillary lymph nodes. This resection in the armpit is the reason for most of the shoulder stiffness and axillary web syndromes.

Loss of mobility in the tissue under your armpit is painful; shortening of the muscles and tendons occurs as a result, and you become weak. Often, you don’t even realize that your arm is stiff and weak until you are tested. Other changes will occur in the tissue due to radiation. Radiation produces inflammation in the muscle tissue and the surrounding tissue; it is cumulative in nature, so may not show up for months after treatment. The tissue becomes thick and hard in nature, and mobility is lost in the scar lines. Physical therapy intervention is crucial for anyone who has had axillary nodes removed or tissue radiated.

Physical therapy for breast cancer includes a first visit evaluation for an hour with a breast cancer specialist. Then, an assessment will be made and goals established for your individualized program. This process should begin two weeks after surgery. This insures that a baseline is created, and then prevention techniques can be started.

In our program, Step Forward 4 Oncology Care, we utilize a four-step approach. The four steps include skin care; specific shoulder and neck exercises; specialized massage to re-direct lymph fluid, assist in reabsorption, and soften tissue scar lines; and compression therapy, which includes compression garments for your arm and chest wall and bandaging with compression, if needed.

Please do not wait to begin physical therapy with your breast cancer specialist; your long-term outcomes depend on how early you start your plan of care.

Sheree DiBiase, PT, is a breast cancer specialist certified with the International Lymphology Association. She and her staff have trained with Stanford University as breast cancer and lymphedema specialists. They can be reached in their Coeur d’Alene office at (208) 667-1988, and in their Spokane Valley office at (509) 891-2623. Lake City Physical Therapy.