Lymphedema

Foggy Valley outside Quilcene, Washington

Lymphedema is pronounced: "lim-fe-de-ma", or in Europe “lim-feed-emma”. Lymphedema is the swelling and soft tissue changes that occur in the area of the body where injury has occurred to the lymphatic system. LYMPH is a clear fluid that carries proteins and other materials back to the heart through the lymphatic system. EDEMA is swelling.

Certification

I was first trained in how to treat lymphedema, by my good friend, Doctor Marisa Perdomo, a physical therapist who now teaches at the University of California. She was certified at the Földi Klinic in Hinterzarten, Germany, and encouraged me to do the same training. I spent the month of May in 1999 studying at the Földi Klinic and am now a Certified Lymphedema Therapist (CLT) or CLT-Földi. I have taught at the University of Puget Sound in Tacoma, Washington, and throughout the United States teaching other medical professionals edema management strategies or how to treat edema or swelling problems. I consider myself a swelling specialist. What I have really worked at is to teach patients how to manage their own swelling problem to the best of their ability and the best of their desire.

The Circulatory and Lymphatic Systems

The heart pumps blood out into the body through the arteries–similar to a series of hoses that become progressively smaller until they are more narrow like the smallest part of a feather. The smallest diameter artery is called an arteriole. Once the blood reaches the arterioles it gets pumped out into the tissue space surrounding the other tubes and muscles and structure. These tissue spaces are called the “interstitial space or interstitium” (think of this as a holding pond). The arterioles connect to venules, which are the smallest part of the veins that get progressively bigger. The veins get larger closer to the heart. The veins or venous system carry most of the blood back to the heart.

In the tissue space surrounding the arterioles and venules, 90% of the blood is pulled back into the veins and returned to the heart. However, the holding pond has 10% of the fluid remaining which has protein molecules from the blood that are too big to fit back into the veins. The primary job of the lymphatic system is to carry these proteins back to the heart where they can rejoin the circulatory system. The protein molecules cause a proliferation of scar tissue, which can harden and develop fibrosis, a significant hardness.

The lymphatic vessels are similar to the arteries in that they have muscles and contract or pump like arteries. Like veins, lymphatic vessels have valves that shut and help propel the lymph fluid back up to the heart. The lymphatic collecting vessels connect to lymph nodes. Lymph fluid stops on the way back to the heart at the lymph nodes to clean the fluid and dispose of the nasty bits such as cancer cells and bacteria cells, working like a garbage disposal. This is part of the immune system keeping your body healthy. The last part of the lymphatic system is at the large veins below the collar bones where the lymph fluid joins back into the veins and returns to the heart to rejoin the circulatory system and recirculate.

Causes of Lymphedema--injury to the lymphatic system

Most lymph vessels are just under the skin, therefore any trauma that damages the skin can cause trauma to the lymphatic system. For example, radiation to the skin, any surgery, significant trauma, infections, pregnancy, obesity, or surgical removal of lymph nodes can injure the lymphatic system. Congenital malformations of the lymph nodes or lymphatic vessels can also cause lymphedema. If lymph nodes are removed, swelling can occur in the area that typically drains lymph fluid to those lymph nodes. The arm or chest can swell if the lymph nodes in the armpit are removed typically with breast cancer. Even if no lymph nodes were removed but a patient with cancer receives radiation, this can be enough of an injury to the lymphatic system to develop lymphedema.

A person who has surgery to a knee or ankle can develop lymphedema especially if they have a congenital problem with their lymph nodes, such as too few or inefficient lymph vessels or nodes. They can also develop lymphedema if they already have chronic venous insufficiency. If a person has a healthy lymphatic system but has a significant trauma such as serious burns or a motorcycle accident and the skin is badly damaged can also lead to lymphedema.

Time frame for developing Lymphedema

Lymphedema can develop any time after the injury to the lymphatic system. It can occur immediately following a surgery (especially for cancer if lymph nodes were removed) or many years later. Individuals with congenital problems with the lymphatic system can show signs of lymphedema at birth or around puberty. The greatest amount of lymph fluid your lymphatic system can transport is called your transport capacity. The amount of lymph fluid flowing in your body at any given time is known as your lymphatic load. As long as the lymphatic load remains below the transport capacity, no swelling will develop. With a decrease in your transport capacity (injury to your lymphatic system) any increases in the lymphatic load can overload the lymphatic system and lymphedema will result.

The lymphatic load can increase with any increase in the cardiac output (anything that makes your heart work harder). Activities such as repetitive motions, increased aerobic exercise, stress, airplane travel or elevation gain, or heat can increase the pumping of the heart, which increases the lymphatic load throughout the body. While increased exercise can cause lymphedema, exercise is actually one of the key treatments for lymphedema. Additional injuries to the lymphatic system such as a simple bee sting, infection, or a fall causing acute swelling in a person with a decreased transport capacity can then lead to lymphedema. Transport capacity also decreases with age, so a person who had lymph nodes removed earlier may eventually develop lymphedema due to aging. A person who has had an injury to their lymphatic system should always consider themselves "at risk" of getting lymphedema. By preventing further injury to the area with damaged lymphatics, such as protecting the left arm if the left axillary (armpit) lymph nodes were removed, you can reduce your risk of developing lymphedema. Avoid blood pressure cuffs, IVs, vaccinations, burns, pet scratches, insect bites, and gardening scratches, for example.

Infections

The lymphatic system is also an important part of the immune system. The lymph nodes help to fight infections by destroying bacteria, cancer cells, and other nasty bits before they flow back to the circulatory system. Tubes or vessels in the lymphatic system carry the fluid and blood products to the lymph nodes. With damage to the lymphatic system, a decrease in the immune system in this region occurs leaving a person susceptible to infections. Cellulitis is an acute bacterial infection, which is typically identified by REDNESS, WARMTH, SWELLING, and PAIN especially when associated with rapid onset of FEVER, HEADACHE, and CHILLS. Cellulitis can be quite painful, can worsen lymphedema, and can require hospitalization.

According to Dr. Michael Földi, adequate treatment of lymphedema with proper treatment can prevent cellulitis. A study performed by Etelka Földi, M.D., showed that 30% of people with lymphedema have recurrent cellulitis. 90% of these people never had another attack of cellulitis as long as they had adequate treatment and were compliant with compression.

Treatment of Lymphedema

Once lymphedema develops it can worsen without treatment. Individuals have lived with it for years and compensated by purchasing larger clothes to fit the swollen limb or simply adapted because adequate treatment was not available. Effective treatment for swelling problems uses Complex Decongestive Physiotherapy (CDP), now called Complete Lymphedema Therapy (CLT). This technique uses 4 components: Manual Lymphatic Drainage (MLD) a massage technique that re-routes the lymph fluid to adequately draining lymph nodes; compression with specialized short-stretch bandages and later specialized compression garments or wraps; exercise; skincare; and significant patient education. CLT varies on an individual basis but typically lasts 2-4 weeks (greater times are necessary for swelling that has hardened–fibrosis).

After working for several years with patients who have chronic venous insufficiency that leads to lymphedema, I have altered the protocol and am now seeing treatment only taking a few days to adequately reduce the girth with specialized compression bandaging and foam in addition to the skincare, exercises, and Manual Lymphatic Drainage. Then it takes several days to a few weeks to find the best type of long-term compression to keep the swelling down.

MLD can be done by a clinician who uses fancy massage maneuvers to stimulate the muscles surrounding the lymphatic vessels to contract which squeezes the fluid out of those tubes. The fluid gets trapped by the valves which then lift it up to the heart. I have radically simplified the MLD technique so patients can do it for themselves. I found that when I did MLD on patients in the clinic I was training them that they required someone else to do this for them. However, after changing my protocol for CLT by using a specialized foam and three layers of the specialized short-stretch compression bandages, I encouraged patients to do their self MLD every time they went to the bathroom. I had one patient who came back to the clinic who had done it 15 times one day. I asked why and she told me she had to go to the bathroom so much more that she kept having to do it more. I was shocked but even more pleased when removing her bandaging we found her legs reduced 10 cm or almost 4 inches in 24 hours. I also found that when I did the MLD on patients they would not do their home program.

It has been years since I did any MLD on patients. I did do this for my husband when he was diagnosed with prostate cancer and had a radical prostatectomy when they removed his prostate and some pelvic lymph nodes. I knew it would help him relax, have less pain, and reduce the risk of developing worsening lymphedema in his legs. He went into the surgery with chronic venous insufficiency, so he wears compression socks to prevent the swelling from worsening.

My CLT protocol typically only lasts 2-3 days in the decongestive phase and takes usually one to two weeks to find appropriate compression to maintain the reduction in girth (size of a body part). I wrap most people with 3 layers of short-stretch compression wraps over the specialized channel foam over a terry cloth stockinette and I have them doing the first 3 steps of the MLD massage technique every hour while they are awake. I instruct them to do the full MLD protocol 4 times a day.

Once the swelling is down I recommend they do the MLD 4 times a day or find the frequency they need to do it to maintain the reduction and we work to find the right amount of pressure to keep the swelling down. On the Swelling Spectrum page, I talk about the easiest, cheapest treatment is to start earlier than you think you need it.

Lymphedema is a chronic problem and is not curable. It is, however, manageable. A physical therapist trained in these methods can teach you how to manage this swelling problem. Call your local physical therapy office and ask for a therapist who is trained in treating lymphedema. I have also provided information on self-care strategies: