What is Lymphedema?
INTRODUCTION
What is
Lymphedema
Lymphedema is a swelling of a body part, most often an extremity, caused by the abnormal accumulation of lymph fluid. It can also occur in the face, neck, abdomen and lungs. Although it is a chronic and progressive condition, it can usually be brought under control by good care and attention to certain basic rules. Lymphedema is compatible with a normal and active lifestyle.
The condition most often causes a feeling of heaviness, cosmetic deformity, slight discomfort, repeated episodes of infection (cellulites and lymphangitis) and, in rare cases, malignant degeneration. Severe cases are associated with thickening of the skin, hardening of the limb, leakage of lymph and massive swelling (elephantiasis). Although many physicians think of lymphedema as a rare condition, it is in fact, fairly common, affecting roughly one percent of the population.
Primary
Lymphedema
Lymphedema is either primary or secondary. Primary cases are those that occur without any obvious cause. They may be present at birth (lymphedema congenital), occur later in life (lymphedema praecox), or develop after age 35 (lymphedema tarda). Some causes are familiar as well as congenital. Primary lymphedema is more common in females and occurs more often in the lower extremities.
Secondary
Lymphedema
Secondary lymphedema is caused by injury, scarring or excision of the lymph nodes. This usually occurs as a result of previous radiation and/or surgery of the lymph nodes in the neck, axilla, pelvis or groin. Such treatments are commonly given for cancers of the breast, uterus, bladder, ovary, prostate or testicle and for malignant melanomas and lymphomas. Occasionally, secondary lymphedemas are caused by trauma to or chronic infections of the lymph system.
It is estimated that
there are over two million cases of secondary lymphedema in the
Lymph
In addition to the blood circulating in arteries and veins, the body also possesses a second circulating fluid, lymph. The arteries carry blood from the heart to the different body tissues; the veins and lymphatics carry blood and lymph back toward the heart.
Lymph is a clear, colorless, transparent fluid that originates in tissue spaces throughout the body. From here, lymph vessels carry this fluid to the large veins in the neck
In the lymph vessels that drain the intestines, lymph is milky white because of it’s high fat content.
Lymph differs from blood in that it contains less protein and no red blood cells. It’s role is to remove excess fluid, bacteria, viruses and waste products from body tissues and interstitial spaces. Most of the tissue fluids return to the heart via the veins, The rest, about two liters a day, is transported back to the blood stream via lymphatic vessels.
Lymph
Flow
Lymph, in passing from one region of the body to the next, passes through the regions lymph nodes. Here, the lymph is filtered, freeing it of bacteria, toxins and dead cells. Along with the thymus gland, tonsils and the spleen, the lymph nodes produce lymphocytes, cells that are important in fighting infection and enhancing the body’s immune capabilities.
Lymph is propelled through the various lymph vessels by muscular activity, by contraction of the vessels themselves, by movement of the diaphragm (breathing) and by the negative pressures within the chest during the breathing cycle. Since lymph vessels have valves built into their walls, lymph can only be propelled in one direction – toward the great veins at the root of the neck, where it joins with the blood on it’s way to the heart.
Factors that contribute
to Lymphedema
· Surgery and/or radiation therapy
· Surgery and post-operative infection
· Obesity
· Infections (insect bites, athlete’s foot, paronychia)
· Sedentary lifestyle
· Constricting clothing or jewelry
· Dependent limb position
· Recurrent tumor
· Heavy breast prosthesis
· Trauma to remaining lymphatics
Impact on
Patient
· Swollen limb or body part
· Condition worsens over time
· Heaviness and limitation of motion
· Repeated episodes of infection
· Skin thickening, lymph leakage through skin
· Cosmetic problem, difficulty finding clothes or shoes
· Multiple hospitalizations
· Altered lifestyle, no sun or heat, limited activities
· Constant medical care and expenses
Treatment
Problems
Patients who develop lymphedema clearly face a major problem. The reasons for this are numerous. No existing medical specialty includes lymphedema among the conditions that it treats, and no residency training program offers specific instruction on it’s prevention or effective treatment. Since there are only few experts who specialize in lymphology or have devoted themselves to patients with this disorder, the patient is unsure about where to turn for advice or treatment. Many patients are referred from one doctor to another, and few physicians achieve great expertise or experience with lymphedema. Physiotherapists, too have little or no training in lymphedema therapy.
Next, there is no single medication that is effective in treating lymphedema. Diuretics are often prescribed, even though these have no lasting or beneficial effects.
Benzopyrones have been tried experimentally for many years and have shown themselves to offer little practical benefit to the lymphedema patient. The customary treatments (elevation, pneumatic pumps, elastic sleeves or stockings) are usually ineffective and the benefits shortlived. Surgery has also never solved the problem of lymphedema, even though dozens of different operations have been recommended and thousands of patients have been operated upon.
Finally, the number of cases of lymphedema appears to be increasing each year, in spite of the trend to less radical surgery fro breast cancer.
All of these factors focus on the need to instruct patients on how to avoid lymphedema where possible, and to provide safe and effective treatment where prevention is not possible.
AVOID LYMPHEDEMA – OR
KEEPING IT IN CHECK
Avoid Temperature
Extremes:
·
Hot baths, hot
tubs, hot showers
· Turkish baths, saunas
· Burns (cooking, sun)
· Travel in hot or cold climates
Avoid
Infections:
·
insect
bites
· Manicures, pedicures
· Vaccinations, venipunctures or acupuncture in affected limb
· Pet scratches
· Skin punctures and cuts
· Venography
· Lymphography
Avoid Blunt
Trauma:
·
Lifting heavy
objects
· Tennis or golf
· Blood pressure cuffs
· Tight clothing, especially bra straps
·
Heavy breast
prostheses
·
Rings, watches,
bracelets
General
Precautions:
·
Excellent nutrition
low salt, few fried foods, lots of fresh fruits and
vegetables
·
Avoid alcohol and
nicotine as much as possible
·
Avoid
obesity
·
Meticulous
cleanliness
·
Meticulous skin and
nail care
·
Sleep with limb
elevated or wrapped
·
Exercise – walking,
swimming and specially-prescribed exercises
·
Seek threatment for
even the slightest lymphedema
·
Treat infections
vigorously
·
Avoid high-heeled
shoes
·
Travel with limb
elevated
COMPLETE DECONGESTIVE
THERAPY
The four steps of
complete Decongestive Therapy
Meticulous hygienic care with or without antibiotics is essential. The aim of this treatment is to eliminate bacterial and fungal growth, either of which can lead to repeated attacks of cellulites and/or lymphangitis. Meticulous skin and nail care are taught and practiced.
Low pH, lanolin-based skin lotions are used twice a day to reduce the change of infection.
(A special lymphatic decompressive massage) is given for one hour twice a day. This involves specific manual movements along lymphatic pathways that empty and decompress obstructed lymph vessels. Such therapy facilitates the unhindered flow of lymph fluid into the venous circulation, where it is supposed to go, and allows the limb to return to normal or near normal size. It does this by utilizing subcutaneous lymph vessels, existing lymphovenous anastomoses and other segments of the lymphatic network which cross the midline, go around the back, over the top of the shoulder, etc..
3.
Bandaging and compression
Bandaging of the affected limb follows each MLD session. The bandages used for this purpose are minimally elastic and compensate for the diminished tissue pressure in lymphedema. This is an important component of the therapy in that it augments the diminished tissue pressure and prevents the affected limb from refilling with evacuated lymph. The bandages are worn overnight until the next MLD session is about to begin. At the end of the course of treatment when the limb is normal or close to normal, and elastic support garment is ordered for each patient.
4.
Remedial Exercises and Elevation
Remedial exercises with the bandages in place are prescribed for every patient. This step activates each muscle group and joint of the swollen limb and results in an increased in lymph flow and, over time, in dilatation of the lymph vessels.
Whenever possible, it is recommended that the patient sleep with the short-stretch elastic bandages on or with the swollen limb elevated to or just above the heart level. The bandaging option is more effective and is one that is most recommended. Bandaging is one for the skills taught to each patient during the treatment. Elevation is best done by means of padded, foam-rubber bolsters which can be readily purchased.
I.
Bandaging reduces the
Ultrafiltration Rate
Lymph originates as a clear, protein-rich fluid in tissue spaces throughout the body. This fluid (1-2 liters/day) is usually carried by lymph vessels, passes through regional lymph nodes and joins the venous blood shortly before this blood enters the heart.
The circulation of lymph is important in maintaining normal tissue homeostasis (balance) throughout the body.
The balance between the fluid leaving the arterial side of the capillaries (ultrafiltration) on the one hand and the reabsorbtion that occurs in the venous capillaries plus the drainage via the lymphatics on the other, is known as “Starling’s equilibrium”. Because of the disturbed lymph drainage in lymphedema, this equilibrium callapses, protein-rich fluid accumulates in the tissue spaces, the colloid-osmotic pressure rises and all of these events favor ultrafiltration.
By raising the tissue (interstitial) pressure by means of an external force (the compression bandage), one reduces the effective ultrafiltration pressure, less fluid accumulates and less fluid has to be removed from the tissue spaces. The lymphedema improves.
II.
Bandaging improves the
Efficiency of the Muscle and Joint Pumps
Lymph is propelled through the various lymph vessels by muscular activity, by contraction of the lymph vessels themselves, by the movements of the diaphragm (breathing) and by negative pressure within the chest during the breathing cycle. In the extremities the activity of the skeletal muscles is an important factor in lymph transport. During contraction of an arm or a leg muscle, the venous and lymphatic systems propel the fluids they contain towards the heart. This results in a more rapid flow and decompression of both systems. In order to preserve this process, normal tissue (skin) and joints are essential.
In lymphedema these conditions are damaged. The skin is more or less overstretched and, specially after any decongestion of the lymphedema has been achieved, skin and tissue pressures are even further diminished.
The use of external compression bandages compensates for this diminished tissue and skin pressure and thus improves the efficiency of the muscle and joint pumps.
III.
Bandaging prevents the
Reaccumulation of Evacuated Lymph Fluid
Manual Lymph Drainage (MLD) involves specific manual motions that follow lymphatic pathways, emptying and decompressing obstructed lymph vessels in the swollen body part. Each MLD treatment decongests the limb and helps return it to a more normal size.
The reduction of edema volume and the elastic insufficiency of the skin make refilling of the limb with edema fluid quite easy. Since the compression bandage makes up to the diminished tissue and skin pressure, it prevents the reaccumulation of evacuated, stagnating, lymph fluid.
It thus maintains the results of the MDL treatment.
IV.
MLD and Bandaging
break up Deposits of accumulated Scar and Connective
Tissue
First stage lymphedema is caused by an accumulation of protein-rich edema fluid. Lymphedema in a later stage is associated with thickening of the skin and hardening of the limb. This hardening is due to the proliferation of connective and scar tissue. In order to soften this connective tissue build-up one must make use of special techniques during the MLD treatment. Additional softening and breaking up of this fibrotic tissue is obtained by including foam rubber padding materials (e.G. Komprex) within a moderately tight bandage. This achieves a localized pressure increase in this area. Muscular activity further acts upon these fibrotic areas, loosening and breaking up accumulated deposits of scar and connective tissue.
In addition to the listed beneficial effects of compression bandages in lymphedema, they are also valuable in veneous disorders. Since there are a large nuber of techniques and different materials to choose from in the treatment of phlebology patients, it is impractical to include this subject.
Goal of complete
Decongestive Therapy
Currently, there is no cure for lymphedema: the main goal of the treatment, therefore, is to return the lymphedema to a stage of latency, utilizing remaining lymph vessels and other lymphatic pathways. The normal or near normal size of the limb should be maintained, and reaccumulation of lymph fluid should be prevented. Additional goals are prevention and elimination of infections and the reduction and removal of fibrotic tissues.
MANUAL LYMPH DRAINAGE – A
MORE DETAILED EXPLANATION USED AT CLOUD 9:
THE VODDER METHOD:
Manual Lymph drainage (MLD) is a gentle manual treatment technique
that is based on the four basic Vodder strokes: THE “
In the working phase of the stroke, stretch stimuli are applied to the subcutaneous tissues, resulting in the manipulation of anchoring filaments of lymph capillaries and the smooth musculature in the wall of lymph angions. The light directional pressure in the working phase also serves to move lymph fluid in the appropriate direction. The pressure in this phase should be sufficient enough to stretch the subcutaneous tissue against the underlying fascia to it’s elastic capacity. It is not necessary to apply high pressure to achieve this goal. In fact, too much pressure could damage anchoring filaments or other lymphatic structures, or cause lymphangiospasm in lymph collectors. The pressure should also be light enough to avoid vasodilation (active hyperemia). The amount of pressure is sometimes described as the pressure applied while stroking a newborn’s head. However, more pressure is needed if fibrotic tissue is present.
The pressure is released during the resting phase, in which the elasticity of the skin moves the therapist’s hand passively back to the starting position. In this pressure-free phase, initial lymph vessels absorb tissue fluid from the interstitial spaces.
To achieve maximum results, each working phase should last about 1 second and should be repeated five to seven times in the same area in either a stationary or a dynamic pattern.
Massage should not be
confused with the techniques of manual lymph drainage. The word massage, meaning “to knead”
(from the Greek massain), is used to describe the techniques employed in
“Swedish” or “classic” therapies.
To achieve the desired effects on musculature, tendons, and other
structures, massage is generally applied with considerably more pressure than
MLD. There is NO “kneading” in
manual lymph drainage.
EFFECTS OF MANUAL LYMPH DRAINAGE:
The most common effects of manual lymph drainage are the following:
· Increase in lymph production: stretch on the anchoring filaments of lymph capillaries stimulates the intake of lymphatic loads into the lymphatic system.
· Increase in lymphangiomotoricity: (1) mild perpendicular stimuli of the smooth musculature located in the wall of lymph collectors results in an increased contraction frequency of lymph angions: (2) increase of the volume of transported lymph fluid. The subsequently elevated intralymphatic pressure results in increased contraction frequency of lymph angions.
· Reverse of lymph flow: in the treatment of lymphedemal, MLD moves lymph fluid in superficial lymph vessels opposite to it’s natural flow pattern, lymph fluid is rerouted via collateral lymph collectors, anastomoses, or tissue channels.
· Increase in venous return: the directional pressure in the working phase of MLD strokes increases the venous return in the superficial venous system. Deeper and more specialized techniques of MLD, especially in the abdominal area, affect the venous return in the deep venous system.
· Soothing: the light pressures used in MLD decrease the sympathetic mode and promote the parasympathetic response.
· Analgesic: because of accelerated drainage of nociceptive substances from the tissues, light pressure used in MLD provides a stimulus for the “gate-control theory” of Melzack and Wall (1996), promoting pain control.
THE GOAL OF MANUAL LYMPH
DRAINAGE IN THE TREATMENT OF LYMPHEDEMA AND RELATED CONDITIONS IS TO REROUTE THE
LYMPH FLOW AROUND BLOCKED AREAS INTO MORE CENTRALLY LOCATED HEALTHY VESSELS,
WHICH DRAIN INTO THE VENOUS SYSTEM.
The techniques of MLD include the manipulation of healthy lymph nodes and lymph vessels, which generally are located adjacent to the area with insufficient lymphatic drainage. The resulting increase in lymphangiomotoricity in the healthy areas creates a “suction effect,” which enables accumulated lymph fluid to move from an area with insufficient lymph flow into an area with normal lymphatic drainage. To stimulate the return of lymph fluid into the venous system, the lymph nodes on the neck are manipulated. Depending on the location of the damage to the lymphatic system, the thorax, abdominal area, and ipsilateral (same side) and contralateral axillary or inguinal lymph node groups may be included in the treatment. The extremity itself is treated in segments (e.g., the proximal aspect of the affected extremity is decongested prior to expanding the treatment to the more distal aspects).
The therapist will explain the basics of the therapy prior to each treatment and expectations.
NATURAL HISTORY OF
LYMPHEDEMA
STAGE
I
Reversible Lymphedema: Accumulation of protein-rich fluid
STAGE
II
Spontaneously Irreversible Lymphedema: protein-rich edema fluid connective and scar tissue
STAGE
III
Lymphostatic Elephantiasis: Protein-rich edema fluid connective and scar tissue hardening of the dermal tissues papillomas of the skin.
Cloud 9
Therapeutic Massage
Massage Establishment Lic. MM14487
Ambassador Plaza
6447 Miami Lakes Dr. Suite 210E,
Miami Lakes, Fl. 33014,
(305) 989-7369