Lymphoedema
Lymphoedema occurs when there is a dysfunction of the lymphatic system. This leads to swelling in certain parts of the body due to a build-up of protein rich fluid in the tissues. Lymphoedema can be primary (genetic, from birth presenting at various stages of life) or secondary (due to damage from surgery, cancer treatments, lymph node removal or immobility). Secondary lymphoedema is the most common type of lymphoedema. Damage to the lymphatic system is caused due to cancer surgeries, lymph node removal, radiation therapy, reduced mobility and infection. Lymphoedema symptoms can occur at any time once at risk. This may be days, months or even years after the initial treatment. This is often a slow build up with a triggering event causing the swelling to become noticeable. This may be due to increased use of the limb or a simple cute, scrape, or mosquito bite. Sometimes the cause is unknown. The key to management is early prevention, meaning seeking help from a qualified decongestive lymphatic therapist as soon as you are 'at risk', or at first signs of swelling. A qualified therapist can give a diagnosis and help tailor a treatment individualised to your personal needs and lifestyle.
Lymphoedema diagnosis, stages & symptoms
Diagnosis of lymphoedema must be carried out by a qualified therapist. This will include taking a full health history, examination of the affected limb, limb measurements, bioimpedance spectroscopy (L-dex), doppler ultrasound (to rule out a blood clot being the cause of the swelling), imaging such as MRI or CT or imaging procedures called lymphoscintigraphy where a dye is injected to show the lymph flow.
Lymphoedema has 4 stages:
- Stage 0 (latent stage) - This stage can have no visible swelling. People can experience their affected limb feeling heavy, tight or achy. They may notice things like rings and clothing not fitting as they did before. This is the earliest stage and the time to intervene to prevent progression.
- Stage 1 (mild) - Swelling is visible now but can be relieved with elevation or rest. This swelling can fluctuate.
- Stage 2 (moderate) - The swelling at this stage is more persistent and is not alleviated with elevation or rest. There can be tissue changes with the skin thickening (fibrosis). The skin, when pressed, can leave an indent that takes time to recover (pitting oedema)
- Stage 3 (Severe) - The swelling is severe and irreversible. The skin is thickened, has colour changes, an increase in skin folds, leaking of lymphatic fluid (lymphorrhea) and high risk of recurrent, dangerous skin infections (cellulitis)
Treatment options
Decongestive lymphatic therapy (DLT)
DLT is a combination of treatments aimed at reducing swelling to a manageable level.
Manual lymphatic drainage (MLD) massage
MLD massage is a specialised massage technique that stimulates the lymphatic system and moves lymphatic fluid out of the swollen tissue and back to the lymph nodes to be filtered and removed. This is a very light massage and should initially be done by a trained professional, due to the associated risks with certain health conditions.
Compression therapy
Compression therapy is one of the most important aspects of DLT. Compression can be done in the form of bandaging. This is specific bandaging technique that aims to reduce the volume of fluid in the limb. This is done daily for 2 to 3 weeks. Once the swelling volume has reduced significantly, the limb can be measured for garments.
This is the gold standard treatment for lymphoedema in the decongestive phase. This is the initial phase aiming to reduce volume and improve skin condition. This form of treatment is intense and requires multiple visits per week to a trained lymphatic therapist. This phase then leads onto the maintenance phase that can be managed by the individual through wearing garments, with monthly to quarterly visits to a therapist.
There are multiple types of compression garments available. These can be in the form of stockings, leggings, tights, Velcro adjustable sleeves, arm pieces, bras, body pieces and head and face pieces. They can be made of different materials and textures and can range from class 1 (mild compression) to class 4 (extra strong compression).
Compression pumps are a great tool to reduce compression and can be done in the comfort of your own home if rented through a company or bought. The pump is programmed to an individualised time and pressure. The pump box attaches to a chambered sleeve (can be in the form of single leg piece, arm piece, torso piece or full pant suit) and the pump inflates, from the outer aspect of the sleeve, each chamber in order to push the fluid towards the body centre. This can be used for 1 to 2 hours daily and is a great self-management tool.
Exercise
Gentle and specific exercises are aimed at stimulating the lymphatic system and creating pumping movements to keep the lymph fluid moving. Exercise must be something that can easily fit into your routine, be something you enjoy and something that makes you feel good. Reaching out to an exercise physiologist or physiotherapist who has a knowledge of lymphatics is always advised.
Skincare
Good skincare is imperative for preventing serious, and sometimes life threatening, skin infections. Due to sluggish lymphatic fluid not being able to remove infection, a simple mosquito bite or scratch from gardening can become serious. If left untreated, hospitalisation may be required with the use of intra-venous antibiotics. Keeping the skin clean and moisturised, while dealing with small skin tears or breaks is important. Monitoring any cuts, preventing scratches from the garden by wearing appropriate protective clothing and wearing mosquito repellant are all important aspects of good skincare with lymphoedema.
Self-management
Self-management includes anything you can personally do to keep swelling at a manageable level. There are simple self-massage techniques that your lymphatic therapist can teach you so you can perform MLD massage daily. Self-management includes combining all of the above and fitting it in with your personal lifestyle in order to maintain swelling and prevent progression.