Lymphoedema

Lymphoedema

 

Lymphoedema is an abnormal accumulation of protein-rich fluid (oedema ) in the interstitium most often in the arm(s) and/or leg(s), and occasionally in other parts of the body. This causes chronic inflammation and reactive fibrosis of the affected tissues. Lymphoedema can develop when lymphatic vessels are missing or impaired (primary), or when lymph vessels are damaged or lymph nodes removed with cancer surgery (secondary).

Conditions treated here at The O’ Reilly Centre:

Secondary arm, breast and trunk lymphoedema
Secondary leg lymphoedema
Primary leg lymphoedema
Genital and lower abdominal lymphoedema
Lipo-lymphoedema and lympho-lipoedema
Venous-lymphatic insufficiencies
Head and neck lymphoedema

Services and Treatment provided:

Assessment of swelling and discussion of treatment options
Manual Lymph Drainage (MLD)
Complete Decongestive Therapy (CDT)
Custom made compression garments (Measurement and fitting)
Training in Self Manual Lymph Drainage
Training in Self Multilayer Bandaging
Exercise prescription and preparation for return to sports/recreation
Follow up support
Referral to multidisciplinary team as needed

The benefits of treatment.

The % change in limb volume can be measured before and after treatment (CDT). Table 1 shows % reductions by some of the world’s leading clinical lymphoedema experts. However, as each and every patient is unique, these results serve as estimates of results, some patients may do better while others will reduce less dramatically. It is simply not possible to guarantee results. The Physiotherapist will carefully assess each patient’s stage of lymphoedema and/or post surgical healing and taking into consideration the persons general health and ambitions, will recommend what treatment the treatment options are, give an estimate of expected results and benefits, and together we proceed from there.

Author(s) % Reduction in limb volume with complete decongestive therapy (CDT) treatment Year of study
Foldi >50% 1989
Casley-Smith >60% 1991
Boris et al 65.6% 1997
Leduc 50% 1998
Ko et al 63.4% 1998
Lerner 68% 1998

The stages of lymphoedema.

Stage 0: subclinical state swelling not evident despite impaired system
Stage 1: early onset swelling, that reduces with elevation, pitting, no fibrosis (feels soft, spongy)
Stage 2: swelling, limb elevation may not change it, pitting more difficult.
Late Stage 2: swelling is fibrosing (feels harder)
Stage 3: swelling is fibrosing and sclerosing (severe induration) no pitting, Skin changes (papillomas, hyperkeratosis, etc.)
Late stage 3: Elephantiasis

The characteristics of lymphoedema.

  • Slow onset, progressive
  • Pitting (early stages)
  • In the leg it starts distally and in the arm more proximally
  • The leg
  • Squaring of toes, Stemmer’s sign positive
  • Dorsum of foot “buffalo hump”
  • Loss of ankle contour
  • Asymmetric (affects legs asymmetrically)
  • In the arm
  • Fullness under the armpit, lateral chest, below the elbow
  • Clothes feel tighter in upper arm
  • Watches and jewelry not fitting
  • Squaring of fingers, Stemmer’s sign positive
  • Cellulitis is common
  • It is rarely painful
  • Discomfort is common
  • Heaviness, achiness
  • Skin changes
  • Hyperkeratosis, Papillomas, Peau d’orange
  • Ulcerations unusual
  • In contrast with venous disease the skin maintains hydration and elasticity for longer in the disease process

Diagnostic Tests

Physical Exam and History is the most important.
Lymphoscintography – a lymphatic function test
Doppler/Duplex Ultrasound to rule out a deep venous thrombosis (DVT)
CT scan, MRI to rule out cancer.

Medications.

Penicillin (Antibiotics) to treat infections e.g. Erysipelas, Cellulitis, Lymphangitis.
Diuretics are useful for certain oedemas, but unfortunately are not useful for lymphoedema, as they drain the fluid but not the proteins and this is a protein rich oedema.

Treatment for Lymphoedema.

Complete Decongestive Therapy.

If you and your Physiotherapist agree that CDT is the indicated treatment for your condition, she will explain what is involved and carefully guide you through the process. This is a time consuming treatment but proven and safe. In some cases treatment can fail to yield the desired results but this is usually due to inaccurate diagnoses or poor compliance. So it is important to be well assessed and well prepared.

CDT treatment consists of two phases. The first phase is completed at the centre and the second at home with follow up support as needed. The objective of the first phase is to reduce the volume of the limb andthe second phase is to maintain that reduction so you may participate in regular activities of daily living including sports and recreation.

As with the successful treatment of all chronic conditions education and early intervention yields the most benefits. But it is never too late for treatment and 100% pf people with lymphoedema will enjoy some benefit from an accurate assessment of their condition and education on how they can help themselves.
The 4 Components of the two phases of CDT include: MLD, MLLB, Skin Care and Exercise

Manual lymph drainage (MLD).

An MLD massage, focuses on the lymphatic system. Benefits include: increases in lymph vessel activity, increases in re-absorption of protein-rich fluid (lymph), it promotes healing and relaxation, has an analgesic (soothing) effect and boosts the immune system.
MLD to divert accumulated lymph fluid. When patients have an accumulation of fluid they benefit from a particular sequence of MLD to divert the fluid to a healthy part of the lymphatic system. After treatment patients are trained to do self MLD (SMLD) at home for long term benefit.

Multi-layer bandaging (MLLB).

During phase 1 short stretch bandages are applied daily until circumferential measurements of the limb reduces significantly. This takes between 2 to 4 weeks. Once the limb is reduced, the reduction is maintained by a custom made ELVAREX compression garment. Each patient benefits from a particular approach to MLLB and is trained to do self MLLB at home for long term benefit.

Meticulous skin care.

Oedema dries out the skin and cuticles which may be easily broken and so increases a patients risk for cellulitis or other infections. Treatment includes meticulous skin care using low pH soaps to gently clean skin and moisturizers with 10% urea to strengthen the skin and the lymphatic system which is under the skin. Supple clean skin and nail cuticles decrease risk of infection (cellulitis). After treatment, patients are trained in meticulous skin and nail care and cellulitis risk reduction practices. This includes avoiding breaking the skin and inflammation from injury, nicks, bites, burns, sunburns, gardening and overuse or sports related injuries. Patients are advised how to clean and treat all injuries immediately and to call their GP at first sign of infection to avoid cellulitis. Finally patients are recommended to use low pH products (e.g. low pH soaps and moisturizers with urea) as part of their regular personal hygiene program for clean supple skin and long term benefit.

Exercise.

Exercise with lymphoedema follows a sequence that starts with the central muscle pumps to clear the way for lymph from the swollen limbs that can be mobilized by arm or leg muscles pumps. Each patient will benefit from a specific sequence of exercises and after treatment is trained to do a daily exercise sequence for long term benefits.

Fitness.

Exercise for general fitness is the ultimate objective of treatment so patients can enjoy general health benefits including: Normal blood pressure, aerobic fitness, bone density, balance, body weight and the ability to participate in activities of daily living, sports and recreational activities with family and friends.

If you have a question or a comment please contact me directly now via email.