For those
that use colloidal silver...
http://www.redicecreations.com:80/article.php?id=14352
This is a nice article about the
importance of compression in controlling Lymphedema
http://elymphnotes.org/detail.asp?ci=142
http://aim.bmj.com/content/early/2011/06/17/aim.2011.004069.full.pdf
lymphedema and
accupressure
Podcasts by two women who have lymphedema post
breast cancer.
http://www.thecityfm.com/program.php?folder=mavens
Check out this story of a woman
determined to fight to get her life back.......
http://lymphedematreatmentact.org/karens-story/
This article looks really good.
Focuses on real people and their symptoms
http://www.jpsmjournal.com/article/S0885-3924(09)00743-X/fulltext
Story of lymphatic system expands to
include chapter on valve formation
St. Jude Children's Research Hospital
scientists show that a gene essential for normal development of the
lymphatic system also plays a critical role in forming the valves that
help maintain the body's normal fluid
balance
http://www.eurekalert.org/pub_releases/2011-11/sjcr-sol111411.php
http://www.silvercross.com/index-test.html?gclid=CP_51sy2ka0CFQ7atgodnxb5lQ
For chair lifts or elevator to get
in and out of their home or office, there is a company that 'recycles'
these
items.
SILVER CROSS Finds Recycled Stair Lifts -
Free Stair Lift, Home
Elevator & Mobility Product Information
Our mandate since 1993 has been
to empower your selection of stair lifts, home elevators and other
accessibility lifts and mobility devices. We are not a manufacturer but
rather, an objective information
resource that has served over
190,000 clients by providing the ideal solution at the best price. We take the
guess work out of the process for you, simplify the process and save
you time.
1. Manufacturers are Researched and Compared You do not have to
wade through the manufacturers and
vendors. An overview of approved
stair lifts, home elevators, ceiling lifts, dumbwaiters, wheelchair lifts, bath
lifts, electric scooters and power wheelchairs are detailed in the
comparison charts. Compare models in one
place. We help you match
your unique requirements with the manufacturer's specifications. Compare: stair
lifts to assist you in getting up and down stairs, ceiling lifts
that move a person from the bed or wheelchair via
a track mounted
on the ceiling, home elevators to move people from floor to floor, dumbwaiters
and
wheelchair lifts.
2. Local Funding Information is
Provided to You
Purchasing accessibility or mobility equipment can be costly
and sometimes an extreme burden to the family
finances. It is our
goal to assist you in learning about any local funding sources, if available in
your area. This
is a free resource, and your request for more
information will be used only to help us serve you.
3. Find Your Best
Value and Best Price in Your Area
Improve your quality of life by using our
service to help you determine the best purchase value in terms of
price and quality for both recycled and new stair lifts, home
elevators, wheelchair lifts or ceiling lifts to meet
your needs and
your
budget
http://www.lowerextremityreview.com/article/lymphedema-presents-therapeutic-challenges
Lymphedema
presents therapeutic challenges - February 2011
Although lymphedema in the
past has often been overlooked or misdiagnosed, a growing number of certified
practitioners are using the conservative treatment techniques of
manual lymph drainage and complete
decongestive therapy to
effectively treat lymphedema patients. By Harold Merriman, PT, PhD, CLTThe
clinical importance of lymphatic system disorders is becoming better
known among members of the medical
community, including physicians
and therapists. Most prominent of these disorders is lymphedema, which
involves a buildup of protein-rich lymph fluid in the
interstitium.
Some of the most common known causes of lower extremity
lymphedema include pelvic or lower extremity
cancer and cancer
treatment (e.g, lymph node resection or radiation) that can damage the
lymphatic system.
Other causes of lymphedema may be much more
subtle, such as an insect bite or sunburn that could
irreversibly
damage an already compromised and susceptible lymphatic system. Though
lymphedema can be
found in all types of individuals, active and fit
individuals are less likely than obese individuals to develop
lymphedema.
Once the diagnosis of lymphedema has been made,
appropriate conservative treatment should be
administered.
Currently, a certified lymphedema therapist (CLT) is the provider of choice to
administer the
recommended conservative treatment. Before the 1980s,
most of the research and treatment of lymphedema
and related
disorders occurred in Europe. Now there are also many opportunities for
practitioners to obtain
advanced training in lymphedema in North
America. For example, in North America a number of
lymphedema
schools teach certification courses that allow practicing clinicians to become
certified
lymphedema therapists. The Lymphology Association of
North America (LANA) administers a nationally
recognized lymphedema
certification exam to qualified and experienced lymphedema
clinicians.1
Though the topic of lymphedema and related disorders is
becoming better understood, patients with these
disorders may still
be ignored, misdiagnosed, or simply unable to find proper treatment.
Unfortunately, in
many areas of the United States there is a
currently a shortage or absence of qualified clinicians who can
successfully treat these conditions. This article will briefly review
the anatomy and physiology of the
lymphatic system and discuss the
conservative treatment options for the lymphedema patient.2-5
Lymphatic
anatomy and physiologyLymph originates from blood plasma that leaves the blood
capillaries and
enters into the interstitum. A percentage of that
interstitial fluid then enters the lymphatic system, where it is
then called lymph. Lymph matter consists of proteins, water, fatty
acids, and cellular components. The
typical lymphatic system vessel
has a three-layer wall structure and presence of valves, similar to the vessels
of the venous system. The inner layer (intima) consists of
endothelial cells, the middle layer (media) is made
up of smooth
muscle, and the outer layer (adventitia) is formed by collagen fibers that are
loosely anchored
to the extravascular connective tissue.4
The
functional unit of the lymph vessel is the lymphangion, which consists of a
lymph vessel bordered by two
valves. As the lymphangion contracts
due to the presence of smooth muscle in the middle layer, the valves
provide
directionality so that the lymph flows in only one direction. It should be
stressed that the lymphatic
vessel, unlike the vein, regularly
contracts (under the control of the autonomic nervous system) and that this
contraction rate can change depending on a number of factors. For
example, the lymphangion contraction
rate can be stimulated to
increase during the hands-on portion of conservative treatment.
While the
lymphangions have a distinct three-layer wall construction with valves, not all
lymphatic vessels are
that well organized. The first type of vessel
that collects what will later become lymph fluid is called the initial
lymph vessel or lymph capillary. These vessels are blind or dead-end
sacs (tubes) consisting of a single layer
of endothelium with
junctions that can open and close to let in interstitial fluid. The initial
lymph vessels lack
valves and are located near the blood
capillaries. As this fluid flows unidirectionally toward the heart, the
lymphatic vessels become larger in diameter and more organized. The
lymph collectors and the even larger
lymph trunks have the distinct
three-layer wall construction with valves. The diameter of the lymph collectors
can be as large as 0.6 mm, and the lymph collectors’ valves are
spaced 0.6 cm to 2.0 cm apart.3,5 Lymph
then flows into the larger
lymphatic trunks. The most important lymphatic trunks are the right lymphatic
duct
and the thoracic duct, which drain the lymph into the venous
system near the heart at the right and left
venous angles,
respectively. The right lymphatic duct drains the right arm, right side of the
head, and right
upper trunk; meanwhile, the body’s largest
lymphatic trunk, the thoracic duct, drains the left arm, left side of
the
head, both legs, and the rest of the trunk. 2-5
As the lymph moves
unidirectionally in the lymphatic vessels, lymph nodes filter and concentrate
the lymph
and also provide immune surveillance using T & B
lymphocytes. The 600 to 700 lymph nodes found in the
human body are
concentrated in the neck, axilla, chest, abdomen and—most importantly for the
lower
extremity practitioner—in the groin. In addition to immune
defense, the lymphatic system plays a critical role
in fluid
homeostasis as well as transport and drainage of excess fluids, proteins, and
cellular debris from the
interstitial spaces that are not reabsorbed
by the venous system. One can think of the lymphatic system as
the
body’s “sanitation system,” whose purpose is to dispose the body’s “waste
material.”2-5
Lymphedema results from mechanical failure of the lymphatic
system, which leads to an accumulation of
protein-rich edema in the
interstitium. Mechanical failure means that the “lymphatic load” (amount of
lymph
transported in a given time period) exceeds what an impaired
lymphatic system can handle (transport
capacity). In most cases,
lymphedema will present itself in a single extremity, or in bilateral cases one
extremity will often be more involved than the other (asymmetry).
Though one might picture lymphedema
occurring mostly in the upper
extremity, often lymphedema (especially primary lymphedema) occurs in the
lower extremity as well. 2-5
Diagnosis of lymphedemaLymphedema is
the most common disease of the lymphatic system. It is estimated
that lymphedema affects 140 million to 250 million people worldwide and
at least 3 million Americans.5
Lymphedema exists in two different
forms, primary and secondary. Primary lymphedema is believed to
result from an abnormally developed lymphatic system that can present
either at birth or later in life. In many
cases there is no known
cause of primary lymphedema. However, in some cases heat, puberty, pregnancy
or minor trauma such as insect bites, infections, sprains or
strains may be identified. 2-5
In contrast, secondary lymphedema results
from a known insult to the lymphatic system that causes a
reduced
transport capacity. Specific insults to the lymphatic system include surgery,
radiation, trauma, tumor
growth, infection, and chronic venous
insufficiency. 2-5 The two worldwide most common causes of
secondary
lymphedema are breast cancer surgery and lymphatic filariasis. It should be
stressed that even
with the advent of less invasive modern surgical
techniques such as sentinel lymph node biopsy and
lumpectomy,
lymphedema may still occur after breast cancer surgery and treatment.
2-5
Since lymphedema usually begins distally, it will first be noticed in
the lower extremity in the toes, feet, and
ankles before
progressing proximally up into the thighs. Lower extremity lymphedema would
typically be
caused by a lymphatic insult in the lower extremity
and/or pelvic region, but not by an upper-body lymphatic
insult
such as breast cancer surgery. The classic sign of lymphedema is a positive
Stemmer skin fold sign,
which can be defined as a thickened skin
fold at the base of the second toe such that the tissue cannot be
lifted away from the bone.6 A summary of lymphedema clinical features
are listed in Table 1. Since there is
no pain associated with
lymphedema, the classic symptom that brings a patient to a lower extremity
practitioner is edema or infection (cellulitis), which becomes more
prevalent as lymphedema severity
increases.2,4
It should also be
mentioned that combination forms such as lipo-lymphedema are not uncommon.
Lipo-
lymphedema is a condition in which individuals with lipedema
(symmetrical accumulation of fat rather than
edema in the
subcutaneous tissue) later develop lymphedema in addition to the underlying and
ongoing
lipedema. Unfortunately, many lipedema patients develop
lymphedema since the accumulation of fatty tissue
from lipedema
causes compression of the superficial lymph vessels.2
Table 1. Lymphedema
characteristicsClinical Feature Lymphedema
Gender Women >
men
Distribution Unilateral, or bilateral with one leg usually affected more
severely (asymmetric)
Pain on pressure Absent
Easy bruising of affected
area (hematoma) Absent
Distal edema in the foot Present
Stemmer sign
Present (positive)
TreatmentIt is well documented that lymphedema is
best treated using conservative methods administered by
the
certified lymphedema therapist.7-12 Unfortunately at times, lymphedema is still
treated with diuretics,
which is contrary to treatment guidelines
set forth by the International Society of Lymphology and by other
lymphedema physician specialists.2,4,12 Perhaps the best known
conservative method is manual lymph
drainage (MLD) which is a
component of complete decongestive therapy (CDT). MLD is a gentle manual
treatment technique originally developed in the 1930s by the Danish
couple Emil and Estrid Vodder.2,5
CDT consists of two phases; phase I is the
treatment phase, and phase II is the self-management phase.
CDT and
MLD should only be performed after the CLT has determined that no
contraindications (e.g.,
acute infections or cardiac edema) are
present. Phase I treatment consists of MLD, compression bandages,
exercise (in bandages), and meticulous skin care (to cure/prevent
bacterial and fungal infections). Once the
reduction in lymphedema
begins to plateau, the CLT will transition the patient to the self-management
phase
II. Phase II consists of compression (typically achieved by a
customized garment during the day and
bandages at night), exercise
(with the limb in either a compression garment or bandages), meticulous skin
care, and MLD as needed. Patient compliance with all treatment
components (especially during phase II) is
the key to a successful
long-term outcome, and it is crucial that the patient, therapist, and other
caregivers
work together as a team.5
One of the most important
skills the CLT performs is to provide MLD in the proper sequence. Since MLD
increases lymph flow, the therapist does not want this increased lymph
flow to overload and further damage
an already impaired lymphatic
system. For this reason, the CLT may need to initially limit the area to be
treated by MLD. For example, if a patient has lymphedema in both legs,
then the CLT may elect to initially
focus on only one leg.
Typically, the lymphedema therapist should first perform MLD on central and
uninvolved areas, followed by performing MLD on the involved areas
(e.g., the leg). This MLD strategy
prepares the uninvolved areas to
receive the additional lymph flow from the affected extremity. Again, it is
very important that the lymphedema therapist administers MLD in a
proper manner and sequence in order to
obtain optimal
outcomes.5
Proper compression during both phases of CDT is the key to the
successful management of the lymphedema
patient. If the affected
areas do not receive constant and appropriate compression, the improvements
achieved by MLD will be temporary (may last only a few hours).5
Therefore, the lymphedema therapist
should have a frank discussion
with the patient during the initial evaluation outlining the extreme importance
of continuous compression of the affected extremity. This discussion
should include the reasons why
compression is so important,
determining the method by which the patient (or other caregiver/family
member) can don/doff the compression bandages or garment at home, and
alerting the patient to the
financial implications of proper
compression since two compression garments per affected extremity will
need to be purchased about every six months.
In order to achieve
appropriate compression during phase I, the lymphedema therapist should use
textile-
elastic short-stretch bandages that provide a high working
pressure when the muscles contract (in contrast
with long-stretch
Ace bandages, which have a low working pressure). These compression bandages
should
be applied in such a way that there is more compression
distally than proximally. This compression gradient
can be achieved
by applying more layers of bandage distally and fewer layers proximally.
The
lymphedema patient is ready to be fitted for a garment (used for phase II) when
the improvements in
limb circumference measurements begin to
“plateau”. Although ready-made lymphedema garments are
available,
custom garments are usually made for patients with advanced stages of
lymphedema.
Compression for lower extremities is often in the range
of 40 mmHg to 50 mmHg, and values less than 20
mmHg are not suitable
for successful lymphedema management.5
Any exercise or activity that
contracts the muscles in the affected area will likely benefit the patient, as
activity can promote lymphatic system function. However, the
patient should be reminded that during both
phase I and phase II,
exercises of any type or any strenuous activity should only be performed when
the
affected extremity is compressed by either a bandage or
garment. One helpful strategy when developing an
exercise program
for a lymphedema patient is to start gradually, and to first start with core
muscle and
breathing exercises, then proceed to more distal
exercises, and finally return to the core muscles and
breathing
exercises. Examples of distal exercises include toe clenches, ankle curls, heel
slides and bike riding.
5 It is also very important to carefully
monitor the affected extremity of the lymphedema patient during and
after the exercise and/or activity to determine if the lymphedema has
increased, stayed the same or
decreased. Of course, if the
lymphedema increases, the intensity and frequency of the exercise should be
reduced. 5,12
Lymphedema treatment implicationsOnly a properly
trained lymphedema therapist should treat and educate
patients with
lymphedema. Unfortunately in North America, extensive instruction during
physical therapy
schooling is not yet standard. The American
Physical Therapy Association (APTA), among other groups, is
looking
for ways to increase the level of expertise among its members. However, with
the proliferation of
lymphedema certification courses available in
North America, many physical therapists and other healthcare
professionals are becoming CLTs. These certification courses are 135
hours or more in length and include
both didactic and laboratory
portions. A number of accelerated certification programs include an extensive
pre-course component, allowing the practitioner to take less time
off from work. Other important
lymphedema resources include the
National Lymphedema Network (NLN) and the International Society of
Lymphology (ISL).12,13
While lymphedema in the past has often been
overlooked or misdiagnosed, a growing number of CLTs are
using the
conservative treatment techniques of manual lymph drainage and complete
decongestive therapy to
effectively treat lymphedema patients. An
understanding of the pathophysiology of lymphedema on the part
of
lower extremity practitioners and an ability to recognize the symptoms will
enable more patients to get the
treatment they need.
Harold
Merriman, PT, PhD, CLT, is an assistant professor and General Medicine
Coordinator for the DPT
Program in the department of health &
sport science at the University of Dayton in Dayton, OH.References:
1. Lymphology Association of North America. www.clt-lana.org (accessed
9/16/2010)
2. Földi E, Földi M, Strößenreuther RHK, Kubik S, eds. Földi’s
Textbook of Lymphology for Physicians
and Lymphedema Therapists. 2nd
ed. Munich: Elsevier, Urban & Fisher; 2006.
3. Kelly DG. A Primer on
Lymphedema. Upper Saddle River, NJ: Prentice Hall; 2002.
4. Weissleder H,
Schuchhardt C, eds. Lymphedema Diagnosis and Therapy. 4th ed. Essen, Germany:
Viavital; 2008.
5. Zuther JE. Lymphedema Management–The
Comprehensive Guide for Practitioners. 2nd ed. New York:
Thieme;
2009.
6. Stemmer RA. A clinical symptom for the early and differential
diagnosis of lymphedema. Vasa 1976;5(3):
261-262.
7. Boris M,
Weindorf S, Lasinski B. Persistence of lymphedema reduction after noninvasive
complex
lymphedema therapy. Oncology 1997;11(1):99-109.
8.
Casley-Smith JR, Boris M, Weindorf S, Lasinski B. Treatment for lymphedema of
the arm–the Casley-
Smith method: a noninvasive method produces
continued reduction. Cancer 1998;83(12 Suppl Am):2843-
2860.
9.
Földi E, Földi M, Clodius L. The lymphedema chaos: a lancet. Ann Plast Surg
1989;22(6):505-515.
10. Földi E. Treatment of lymphedema and patient
rehabilitation. Anticancer Res 1998;18(3C):2211-2212.
11. Ko DS, Lerner R,
Klose G, Cosimi AB. Effective treatment of lymphedema of the extremities. Arch
Surg 1998;133(4):452-458.
12. International Society of
Lymphology. The diagnosis and treatment of peripheral lymphedema. 2009
Consensus Document of the International Society of Lymphology.
Lymphology 2009;42(2):51-60.
13. National Lymphedema Network.
www.lymphnet.org (accessed 9/16/2010)
http://www.amylhwilliams.com/lymphedema.html
Amy’s Story Living With
Lymphedema
that use colloidal silver...
http://www.redicecreations.com:80/article.php?id=14352
This is a nice article about the
importance of compression in controlling Lymphedema
http://elymphnotes.org/detail.asp?ci=142
http://aim.bmj.com/content/early/2011/06/17/aim.2011.004069.full.pdf
lymphedema and
accupressure
Podcasts by two women who have lymphedema post
breast cancer.
http://www.thecityfm.com/program.php?folder=mavens
Check out this story of a woman
determined to fight to get her life back.......
http://lymphedematreatmentact.org/karens-story/
This article looks really good.
Focuses on real people and their symptoms
http://www.jpsmjournal.com/article/S0885-3924(09)00743-X/fulltext
Story of lymphatic system expands to
include chapter on valve formation
St. Jude Children's Research Hospital
scientists show that a gene essential for normal development of the
lymphatic system also plays a critical role in forming the valves that
help maintain the body's normal fluid
balance
http://www.eurekalert.org/pub_releases/2011-11/sjcr-sol111411.php
http://www.silvercross.com/index-test.html?gclid=CP_51sy2ka0CFQ7atgodnxb5lQ
For chair lifts or elevator to get
in and out of their home or office, there is a company that 'recycles'
these
items.
SILVER CROSS Finds Recycled Stair Lifts -
Free Stair Lift, Home
Elevator & Mobility Product Information
Our mandate since 1993 has been
to empower your selection of stair lifts, home elevators and other
accessibility lifts and mobility devices. We are not a manufacturer but
rather, an objective information
resource that has served over
190,000 clients by providing the ideal solution at the best price. We take the
guess work out of the process for you, simplify the process and save
you time.
1. Manufacturers are Researched and Compared You do not have to
wade through the manufacturers and
vendors. An overview of approved
stair lifts, home elevators, ceiling lifts, dumbwaiters, wheelchair lifts, bath
lifts, electric scooters and power wheelchairs are detailed in the
comparison charts. Compare models in one
place. We help you match
your unique requirements with the manufacturer's specifications. Compare: stair
lifts to assist you in getting up and down stairs, ceiling lifts
that move a person from the bed or wheelchair via
a track mounted
on the ceiling, home elevators to move people from floor to floor, dumbwaiters
and
wheelchair lifts.
2. Local Funding Information is
Provided to You
Purchasing accessibility or mobility equipment can be costly
and sometimes an extreme burden to the family
finances. It is our
goal to assist you in learning about any local funding sources, if available in
your area. This
is a free resource, and your request for more
information will be used only to help us serve you.
3. Find Your Best
Value and Best Price in Your Area
Improve your quality of life by using our
service to help you determine the best purchase value in terms of
price and quality for both recycled and new stair lifts, home
elevators, wheelchair lifts or ceiling lifts to meet
your needs and
your
budget
http://www.lowerextremityreview.com/article/lymphedema-presents-therapeutic-challenges
Lymphedema
presents therapeutic challenges - February 2011
Although lymphedema in the
past has often been overlooked or misdiagnosed, a growing number of certified
practitioners are using the conservative treatment techniques of
manual lymph drainage and complete
decongestive therapy to
effectively treat lymphedema patients. By Harold Merriman, PT, PhD, CLTThe
clinical importance of lymphatic system disorders is becoming better
known among members of the medical
community, including physicians
and therapists. Most prominent of these disorders is lymphedema, which
involves a buildup of protein-rich lymph fluid in the
interstitium.
Some of the most common known causes of lower extremity
lymphedema include pelvic or lower extremity
cancer and cancer
treatment (e.g, lymph node resection or radiation) that can damage the
lymphatic system.
Other causes of lymphedema may be much more
subtle, such as an insect bite or sunburn that could
irreversibly
damage an already compromised and susceptible lymphatic system. Though
lymphedema can be
found in all types of individuals, active and fit
individuals are less likely than obese individuals to develop
lymphedema.
Once the diagnosis of lymphedema has been made,
appropriate conservative treatment should be
administered.
Currently, a certified lymphedema therapist (CLT) is the provider of choice to
administer the
recommended conservative treatment. Before the 1980s,
most of the research and treatment of lymphedema
and related
disorders occurred in Europe. Now there are also many opportunities for
practitioners to obtain
advanced training in lymphedema in North
America. For example, in North America a number of
lymphedema
schools teach certification courses that allow practicing clinicians to become
certified
lymphedema therapists. The Lymphology Association of
North America (LANA) administers a nationally
recognized lymphedema
certification exam to qualified and experienced lymphedema
clinicians.1
Though the topic of lymphedema and related disorders is
becoming better understood, patients with these
disorders may still
be ignored, misdiagnosed, or simply unable to find proper treatment.
Unfortunately, in
many areas of the United States there is a
currently a shortage or absence of qualified clinicians who can
successfully treat these conditions. This article will briefly review
the anatomy and physiology of the
lymphatic system and discuss the
conservative treatment options for the lymphedema patient.2-5
Lymphatic
anatomy and physiologyLymph originates from blood plasma that leaves the blood
capillaries and
enters into the interstitum. A percentage of that
interstitial fluid then enters the lymphatic system, where it is
then called lymph. Lymph matter consists of proteins, water, fatty
acids, and cellular components. The
typical lymphatic system vessel
has a three-layer wall structure and presence of valves, similar to the vessels
of the venous system. The inner layer (intima) consists of
endothelial cells, the middle layer (media) is made
up of smooth
muscle, and the outer layer (adventitia) is formed by collagen fibers that are
loosely anchored
to the extravascular connective tissue.4
The
functional unit of the lymph vessel is the lymphangion, which consists of a
lymph vessel bordered by two
valves. As the lymphangion contracts
due to the presence of smooth muscle in the middle layer, the valves
provide
directionality so that the lymph flows in only one direction. It should be
stressed that the lymphatic
vessel, unlike the vein, regularly
contracts (under the control of the autonomic nervous system) and that this
contraction rate can change depending on a number of factors. For
example, the lymphangion contraction
rate can be stimulated to
increase during the hands-on portion of conservative treatment.
While the
lymphangions have a distinct three-layer wall construction with valves, not all
lymphatic vessels are
that well organized. The first type of vessel
that collects what will later become lymph fluid is called the initial
lymph vessel or lymph capillary. These vessels are blind or dead-end
sacs (tubes) consisting of a single layer
of endothelium with
junctions that can open and close to let in interstitial fluid. The initial
lymph vessels lack
valves and are located near the blood
capillaries. As this fluid flows unidirectionally toward the heart, the
lymphatic vessels become larger in diameter and more organized. The
lymph collectors and the even larger
lymph trunks have the distinct
three-layer wall construction with valves. The diameter of the lymph collectors
can be as large as 0.6 mm, and the lymph collectors’ valves are
spaced 0.6 cm to 2.0 cm apart.3,5 Lymph
then flows into the larger
lymphatic trunks. The most important lymphatic trunks are the right lymphatic
duct
and the thoracic duct, which drain the lymph into the venous
system near the heart at the right and left
venous angles,
respectively. The right lymphatic duct drains the right arm, right side of the
head, and right
upper trunk; meanwhile, the body’s largest
lymphatic trunk, the thoracic duct, drains the left arm, left side of
the
head, both legs, and the rest of the trunk. 2-5
As the lymph moves
unidirectionally in the lymphatic vessels, lymph nodes filter and concentrate
the lymph
and also provide immune surveillance using T & B
lymphocytes. The 600 to 700 lymph nodes found in the
human body are
concentrated in the neck, axilla, chest, abdomen and—most importantly for the
lower
extremity practitioner—in the groin. In addition to immune
defense, the lymphatic system plays a critical role
in fluid
homeostasis as well as transport and drainage of excess fluids, proteins, and
cellular debris from the
interstitial spaces that are not reabsorbed
by the venous system. One can think of the lymphatic system as
the
body’s “sanitation system,” whose purpose is to dispose the body’s “waste
material.”2-5
Lymphedema results from mechanical failure of the lymphatic
system, which leads to an accumulation of
protein-rich edema in the
interstitium. Mechanical failure means that the “lymphatic load” (amount of
lymph
transported in a given time period) exceeds what an impaired
lymphatic system can handle (transport
capacity). In most cases,
lymphedema will present itself in a single extremity, or in bilateral cases one
extremity will often be more involved than the other (asymmetry).
Though one might picture lymphedema
occurring mostly in the upper
extremity, often lymphedema (especially primary lymphedema) occurs in the
lower extremity as well. 2-5
Diagnosis of lymphedemaLymphedema is
the most common disease of the lymphatic system. It is estimated
that lymphedema affects 140 million to 250 million people worldwide and
at least 3 million Americans.5
Lymphedema exists in two different
forms, primary and secondary. Primary lymphedema is believed to
result from an abnormally developed lymphatic system that can present
either at birth or later in life. In many
cases there is no known
cause of primary lymphedema. However, in some cases heat, puberty, pregnancy
or minor trauma such as insect bites, infections, sprains or
strains may be identified. 2-5
In contrast, secondary lymphedema results
from a known insult to the lymphatic system that causes a
reduced
transport capacity. Specific insults to the lymphatic system include surgery,
radiation, trauma, tumor
growth, infection, and chronic venous
insufficiency. 2-5 The two worldwide most common causes of
secondary
lymphedema are breast cancer surgery and lymphatic filariasis. It should be
stressed that even
with the advent of less invasive modern surgical
techniques such as sentinel lymph node biopsy and
lumpectomy,
lymphedema may still occur after breast cancer surgery and treatment.
2-5
Since lymphedema usually begins distally, it will first be noticed in
the lower extremity in the toes, feet, and
ankles before
progressing proximally up into the thighs. Lower extremity lymphedema would
typically be
caused by a lymphatic insult in the lower extremity
and/or pelvic region, but not by an upper-body lymphatic
insult
such as breast cancer surgery. The classic sign of lymphedema is a positive
Stemmer skin fold sign,
which can be defined as a thickened skin
fold at the base of the second toe such that the tissue cannot be
lifted away from the bone.6 A summary of lymphedema clinical features
are listed in Table 1. Since there is
no pain associated with
lymphedema, the classic symptom that brings a patient to a lower extremity
practitioner is edema or infection (cellulitis), which becomes more
prevalent as lymphedema severity
increases.2,4
It should also be
mentioned that combination forms such as lipo-lymphedema are not uncommon.
Lipo-
lymphedema is a condition in which individuals with lipedema
(symmetrical accumulation of fat rather than
edema in the
subcutaneous tissue) later develop lymphedema in addition to the underlying and
ongoing
lipedema. Unfortunately, many lipedema patients develop
lymphedema since the accumulation of fatty tissue
from lipedema
causes compression of the superficial lymph vessels.2
Table 1. Lymphedema
characteristicsClinical Feature Lymphedema
Gender Women >
men
Distribution Unilateral, or bilateral with one leg usually affected more
severely (asymmetric)
Pain on pressure Absent
Easy bruising of affected
area (hematoma) Absent
Distal edema in the foot Present
Stemmer sign
Present (positive)
TreatmentIt is well documented that lymphedema is
best treated using conservative methods administered by
the
certified lymphedema therapist.7-12 Unfortunately at times, lymphedema is still
treated with diuretics,
which is contrary to treatment guidelines
set forth by the International Society of Lymphology and by other
lymphedema physician specialists.2,4,12 Perhaps the best known
conservative method is manual lymph
drainage (MLD) which is a
component of complete decongestive therapy (CDT). MLD is a gentle manual
treatment technique originally developed in the 1930s by the Danish
couple Emil and Estrid Vodder.2,5
CDT consists of two phases; phase I is the
treatment phase, and phase II is the self-management phase.
CDT and
MLD should only be performed after the CLT has determined that no
contraindications (e.g.,
acute infections or cardiac edema) are
present. Phase I treatment consists of MLD, compression bandages,
exercise (in bandages), and meticulous skin care (to cure/prevent
bacterial and fungal infections). Once the
reduction in lymphedema
begins to plateau, the CLT will transition the patient to the self-management
phase
II. Phase II consists of compression (typically achieved by a
customized garment during the day and
bandages at night), exercise
(with the limb in either a compression garment or bandages), meticulous skin
care, and MLD as needed. Patient compliance with all treatment
components (especially during phase II) is
the key to a successful
long-term outcome, and it is crucial that the patient, therapist, and other
caregivers
work together as a team.5
One of the most important
skills the CLT performs is to provide MLD in the proper sequence. Since MLD
increases lymph flow, the therapist does not want this increased lymph
flow to overload and further damage
an already impaired lymphatic
system. For this reason, the CLT may need to initially limit the area to be
treated by MLD. For example, if a patient has lymphedema in both legs,
then the CLT may elect to initially
focus on only one leg.
Typically, the lymphedema therapist should first perform MLD on central and
uninvolved areas, followed by performing MLD on the involved areas
(e.g., the leg). This MLD strategy
prepares the uninvolved areas to
receive the additional lymph flow from the affected extremity. Again, it is
very important that the lymphedema therapist administers MLD in a
proper manner and sequence in order to
obtain optimal
outcomes.5
Proper compression during both phases of CDT is the key to the
successful management of the lymphedema
patient. If the affected
areas do not receive constant and appropriate compression, the improvements
achieved by MLD will be temporary (may last only a few hours).5
Therefore, the lymphedema therapist
should have a frank discussion
with the patient during the initial evaluation outlining the extreme importance
of continuous compression of the affected extremity. This discussion
should include the reasons why
compression is so important,
determining the method by which the patient (or other caregiver/family
member) can don/doff the compression bandages or garment at home, and
alerting the patient to the
financial implications of proper
compression since two compression garments per affected extremity will
need to be purchased about every six months.
In order to achieve
appropriate compression during phase I, the lymphedema therapist should use
textile-
elastic short-stretch bandages that provide a high working
pressure when the muscles contract (in contrast
with long-stretch
Ace bandages, which have a low working pressure). These compression bandages
should
be applied in such a way that there is more compression
distally than proximally. This compression gradient
can be achieved
by applying more layers of bandage distally and fewer layers proximally.
The
lymphedema patient is ready to be fitted for a garment (used for phase II) when
the improvements in
limb circumference measurements begin to
“plateau”. Although ready-made lymphedema garments are
available,
custom garments are usually made for patients with advanced stages of
lymphedema.
Compression for lower extremities is often in the range
of 40 mmHg to 50 mmHg, and values less than 20
mmHg are not suitable
for successful lymphedema management.5
Any exercise or activity that
contracts the muscles in the affected area will likely benefit the patient, as
activity can promote lymphatic system function. However, the
patient should be reminded that during both
phase I and phase II,
exercises of any type or any strenuous activity should only be performed when
the
affected extremity is compressed by either a bandage or
garment. One helpful strategy when developing an
exercise program
for a lymphedema patient is to start gradually, and to first start with core
muscle and
breathing exercises, then proceed to more distal
exercises, and finally return to the core muscles and
breathing
exercises. Examples of distal exercises include toe clenches, ankle curls, heel
slides and bike riding.
5 It is also very important to carefully
monitor the affected extremity of the lymphedema patient during and
after the exercise and/or activity to determine if the lymphedema has
increased, stayed the same or
decreased. Of course, if the
lymphedema increases, the intensity and frequency of the exercise should be
reduced. 5,12
Lymphedema treatment implicationsOnly a properly
trained lymphedema therapist should treat and educate
patients with
lymphedema. Unfortunately in North America, extensive instruction during
physical therapy
schooling is not yet standard. The American
Physical Therapy Association (APTA), among other groups, is
looking
for ways to increase the level of expertise among its members. However, with
the proliferation of
lymphedema certification courses available in
North America, many physical therapists and other healthcare
professionals are becoming CLTs. These certification courses are 135
hours or more in length and include
both didactic and laboratory
portions. A number of accelerated certification programs include an extensive
pre-course component, allowing the practitioner to take less time
off from work. Other important
lymphedema resources include the
National Lymphedema Network (NLN) and the International Society of
Lymphology (ISL).12,13
While lymphedema in the past has often been
overlooked or misdiagnosed, a growing number of CLTs are
using the
conservative treatment techniques of manual lymph drainage and complete
decongestive therapy to
effectively treat lymphedema patients. An
understanding of the pathophysiology of lymphedema on the part
of
lower extremity practitioners and an ability to recognize the symptoms will
enable more patients to get the
treatment they need.
Harold
Merriman, PT, PhD, CLT, is an assistant professor and General Medicine
Coordinator for the DPT
Program in the department of health &
sport science at the University of Dayton in Dayton, OH.References:
1. Lymphology Association of North America. www.clt-lana.org (accessed
9/16/2010)
2. Földi E, Földi M, Strößenreuther RHK, Kubik S, eds. Földi’s
Textbook of Lymphology for Physicians
and Lymphedema Therapists. 2nd
ed. Munich: Elsevier, Urban & Fisher; 2006.
3. Kelly DG. A Primer on
Lymphedema. Upper Saddle River, NJ: Prentice Hall; 2002.
4. Weissleder H,
Schuchhardt C, eds. Lymphedema Diagnosis and Therapy. 4th ed. Essen, Germany:
Viavital; 2008.
5. Zuther JE. Lymphedema Management–The
Comprehensive Guide for Practitioners. 2nd ed. New York:
Thieme;
2009.
6. Stemmer RA. A clinical symptom for the early and differential
diagnosis of lymphedema. Vasa 1976;5(3):
261-262.
7. Boris M,
Weindorf S, Lasinski B. Persistence of lymphedema reduction after noninvasive
complex
lymphedema therapy. Oncology 1997;11(1):99-109.
8.
Casley-Smith JR, Boris M, Weindorf S, Lasinski B. Treatment for lymphedema of
the arm–the Casley-
Smith method: a noninvasive method produces
continued reduction. Cancer 1998;83(12 Suppl Am):2843-
2860.
9.
Földi E, Földi M, Clodius L. The lymphedema chaos: a lancet. Ann Plast Surg
1989;22(6):505-515.
10. Földi E. Treatment of lymphedema and patient
rehabilitation. Anticancer Res 1998;18(3C):2211-2212.
11. Ko DS, Lerner R,
Klose G, Cosimi AB. Effective treatment of lymphedema of the extremities. Arch
Surg 1998;133(4):452-458.
12. International Society of
Lymphology. The diagnosis and treatment of peripheral lymphedema. 2009
Consensus Document of the International Society of Lymphology.
Lymphology 2009;42(2):51-60.
13. National Lymphedema Network.
www.lymphnet.org (accessed 9/16/2010)
http://www.amylhwilliams.com/lymphedema.html
Amy’s Story Living With
Lymphedema