http://www.lymphedema-therapy.com/FAQ.htm
Frequently Asked Questions
"FAQ"
--------------------------------------------------------------------------------
The
following are frequently asked questions about managing lymphedema and
lymphatic system disorders.
They are by no means complete answers
to what are always very complex questions but are meant as a
guide.
Each individual's situation is unique and each person should consult with their
treatment team for their
specific recommendations for their
particular case.
Question #1:
"Why do I have to
exercise?"
Answer:
Appropriate exercise stimulates the flow of lymph.
Muscle contraction and changes in pressure in the chest
from deep
breathing cause changes in pressure on the lymphatic vessels. When the muscles
contract against
the compression of the compression bandages or
compression garments worn on the affected limb this
creates changes
in tissue pressures that help the lymph to flow.
Question #2:
"Why do I
have to wear my compression garment/bandages when I
exercise?"
Answer:
When an individual has lymphedema, the pressure of the
edema stretches out the skin so that it no longer
provides a firm
surface for the muscles to contract against. Exercise causes increased blood
flow which
caused an increase in lymph load in an already
compromised limb. The compression of the garment/bandage
provides a
"new firm skin" for the muscles to contract against so that the pressure will
be exerted on the
lymph vessels and the fluid will move. Without
the garment/bandage, the skin will just stretch and the force
of the
muscle contraction will not be translated to the lymph vessels. The involved
limb could swell more if
you exercise without
compression.
Question #3:
"Why do I need to change my compression garment
twice a day?"
Answer:
Compression garments are made of elastic materials
that stretch out after wearing for about 12 hours. The
areas where
a limb bends (knee, elbow) stretch out more than the rest of the garment and
then those areas
do not receive the correct amount of compression
which can allow pooling of edema fluid that can cause
constriction
at those areas. Some individuals can wear compression garments day and night
and do not need
to bandage their involved limb at night. These
individuals should change their garments in the morning and
again
in the evening. Others may need to apply compression bandages for nighttime
wear or use an
alternative device such as a Reid sleeve, Tribute, or
Jovi. Consult with your treatment team to discuss which
option is
right for you.
Question #4:
"Why do I have to wash my compression garment
every time I change it?"
Answer:
Compression garments are made of elastic
materials that stretch out after wearing. Washing them daily helps
them to retain their elasticity as well as removes perspiration,
bacteria and dead skin that accumulate inside
the garment from
normal wear.
Question #5"
"Why do I have to use moisturizer on my
affected limb?"
Answer:
Moisturizing the skin helps to retain the
elasticity of the skin which helps to avoid cracks/breaks in the skin.
This is important because any break in the skin allows bacteria to
enter the limb which is at risk for infection
because of the
lymphedema.
Question#6:
"Why do I have to wear compression on my affected
limb 24 hours a day?"
Answer:
Our tissues are supplied with oxygen and
nutrients by the blood. This blood is pumped around the body by
the
heart. With every beat of the heart, blood is filtering into our tissues. 90%
of the blood volume in the
tissues is picked up by the veins and
brought back to the central circulation. 10% of the fluid volume in the
tissues can only be brought back to the central circulation by the
lymphatics. So, even when you are
sleeping, even if your arm is
elevated, blood is getting to your tissues (thank goodness!). Remember that in
an impaired lymphatic system, the muscles need something to
contract against to assist the flow of lymph
fluid. Otherwise, the fluid will just pool under the skin and the limb will swell overnight. Then you may not be
able to fit properly into your compression garment the
next morning. That 10% of fluid volume, the lymph
fluid, amounts to
2 liters a day in the whole body. Remember that a compression garment is not
engineered
to "reduce" a limb. It is engineered to "hold" a limb
that has already been reduced. However, you should
always discuss
your individual case with your treatment team, as there are no absolutes and
each person is
different. 24 hour compression may not be right for
you.
Question #7:
"How long can I keep my garment
off?"
Answer:
Generally, in the first few months of CLT treatment it is
not recommended that you remove your garments
for more than 30-60
minutes at a time. Again, the skin of a lymphedematous limb is often stretched
and will
allow edema fluid to rapidly re-accumulate if there is no
compression on the skin. The goal after treatment is
for the skin
and subcutaneous tissues to remodel to the new "smaller" size. This will not
happen if the skin is
allowed to stretch significantly. Once the
limb has remodeled (6-12 months after CLT treatment) you may
be
able to remove the garment for longer periods without the limb
swelling.
Question #8:
"How long after treatment will I have to wear the
garment?"
Answer:
Generally, for as long as the lymphatic impairment
lasts. The short answer is until someone finds a way to
reverse
that impairment. Right now that means forever as there is no cure for
lymphedema. In the case of
impairment secondary to the surgical
removal of lymph nodes/vessels, this is usually not reversible. In the
case of lymphatic impairment due to primary lymphedema, this is not
reversible. Microsurgical techniques to
re-connect lymphatics with
other lymphatics or veins have not been very successful. Scientists are working
on techniques to encourage re-growth of lymphatic vessels but these
are in the experimental stages and on
animal models. But, this is
encouraging. Finally, there are scientists interested in the lymphatics! This
is
progress!
Question #9:
"Can I go swimming and if so, do I
have to wear the garment in the water?"
Answer:
Swimming is one of the
best exercises for lymphedema. If the affected limb is submerged in the water,
then
you do not have to wear your garment because the hydrostatic
pressure of the water is providing the
compression on your limb.
Some people like to wear an old garment in the water because they like the
extra
compression that it provides, and they don't worry about
getting in and out of the water and putting on and
taking off the
garment repeatedly. Always rinse the garment well after swimming, whether in
chlorinated,
fresh or salt water. Take care walking at poolside or
on the shore to avoid cutting your feet. Wear water
shoes or
sneakers on the beach. Wear rubber soled shoes/sandals at poolside and in
shower/locker room
areas to avoid catching fungal infections. And
always wear sunscreen outdoors to avoid sun damage to the
skin.
Question #10:
"Why can't I put my garment in the
dryer?"
Answer:
You can but the heat will ruin the elasticity of the
garment and perhaps shrink it. Some manufacturers say
that you can
put them in the dryer, but that will wear them out faster and they are costly
to replace.
Garments are best air dried - out of direct
sunlight.
Question #11:
"Can I remove my garment to have relations with
my partner?"
Yes, of course, and if you fall asleep without it, that's OK
too. There are always exceptions to the rule.
While you want to do
the best for your condition, you need to work your lymphedema home program into
your lifestyle, keeping in mind the basic principles of the
lymphatic system and lymphedema management.
Consistent compression
is important but there are times when you need to be without compression. Just
make sure that you are monitoring your limb and that any increase
in swelling is addressed quickly to avoid
problems.
Question
#12:
"When I receive lymphatic drainage treatment, where is all that fluid
going?"
Answer:
The fluid is directed back into the central circulation
and whatever volume of fluid is in excess of the "normal"
volume of
your limb is excreted from your kidneys in your normal urine.
Question
#13:
"What are the signs of infection in my affected limb and how do I know
whether I have an infection?"
Answer:
Infection in a lymphedematous
limb/area can look different in each individual and with each infection.
Common signs of infection are unusual redness, warmth, blotchy
appearance to the skin of the affected
limb/area. This is sometimes
accompanied by a sensation of itching, burning, or pain in the area. Some
people develop a fever or feel like they "have the flu" in the affected
limb/area. Regional lymph nodes can be
painful and swollen. Some
people are nauseous. The problem with these symptoms is that they also occur
with other conditions. You can have a red rash from an allergic
reaction or insect bite. You can have nausea
and fever from the flu
or a viral or bacterial infection that does not involve your affected limb.
Sometimes,
the inflammatory reaction to a rash or insect bite can
precipitate an infection. That is why you should always
carefully
inspect your involved/at risk areas carefully every day for any signs of breaks
in the skin, redness,
increased swelling, etc. As soon as you
notice something different, call your physician/therapist to discuss it
with them. Many physicians provide their patients with oral antibiotics
and instructions that they start to take
them if they feel that
they have an infection and then to call the office IMMEDIATELY to come for an
emergency visit to have the area evaluated. You should never
attempt to "treat" an infection yourself. The
reason to have
antibiotics on hand is to be able to start them at the first sign of infection,
just until you can get
medical attention. Abuse of antibiotics is
dangerous, but under-treating an infection in a lymphedematous
limb
or limb at risk for lymphedema is also dangerous.
Question #14:
"Why
should I avoid prolonged sun exposure?"
Fist of all, the sun is hot and
direct exposure causes the skin temperature to rise. The application of heat to
the involved extremity causes the blood vessels to open up (dilate)
and more blood to flow into the area.
This causes an increase in
fluid load in the affected extremity and can cause an increase in swelling. The
sun's
rays damage the skin. A "tan" is really the skin's way of
responding to damage from the sun by depositing
melanin, a skin
pigment, in the upper layers of the skin. Even if you don't normally "burn",
you should wear
sunscreen on your affected limb as well as the
quadrant of your body that connects to that limb. For
example, if
you have lymphedema in your right arm, you should also have sunscreen on your
neck, shoulder
and chest and back on the right side. Actually, you
should always use sunscreen on your entire body to
avoid skin
cancer, but at least have good coverage on your affected areas.
Question
#15:
"Why are people with lymphedema of the arm/hand told to avoid
manicures?"
The skin is a very porous organ. It absorbs chemicals. Acetone
and other nail polish removers are
chemicals. The solvents that are
used to remove artificial nails are strong chemicals. Cutting cuticles too
close can allow bacteria that are always on the skin to enter and
possibly trigger an infection. Nail salons are
public places and
instruments are not sterile. People who wear artificial nails are more prone to
develop
fungal
infections
--------------------------------------------------------------------------------
Lymphedema
Therapy
77 Froehlich Farm Blvd., Woodbury, New York 11797
1-800-MD-LYMPH
or (516) 364-2200
Marvin Boris, MD
Stanley Weindorf, MD
Bonnie B.
Lasinski, MA, PT, CI, CLT-LANA
-----------------------------------
some info on
lymphedema types problems and more
http://www.fpnotebook.com/Surgery/CV/Lymphdm.htm
http://www.lymphedema-therapy.com/FAQ.htm
Frequently Asked Questions
"FAQ"
--------------------------------------------------------------------------------
The
following are frequently asked questions about managing lymphedema and
lymphatic system
disorders. They are by no means complete answers
to what are always very complex questions but
are meant as a guide.
Each individual's situation is unique and each person should consult with their
treatment team for their specific recommendations for their
particular case.
Question #1:
"Why do I have to
exercise?"
Answer:
Appropriate exercise stimulates the flow of lymph.
Muscle contraction and changes in pressure in
the chest from deep
breathing cause changes in pressure on the lymphatic vessels. When the
muscles contract against the compression of the compression bandages or
compression garments
worn on the affected limb this creates changes
in tissue pressures that help the lymph to flow.
Question #2:
"Why do I
have to wear my compression garment/bandages when I
exercise?"
Answer:
When an individual has lymphedema, the pressure of the
edema stretches out the skin so that it no
longer provides a firm
surface for the muscles to contract against. Exercise causes increased blood
flow which caused an increase in lymph load in an already
compromised limb. The compression of
the garment/bandage provides a
"new firm skin" for the muscles to contract against so that the
pressure will be exerted on the lymph vessels and the fluid will move.
Without the
garment/bandage, the skin will just stretch and the
force of the muscle contraction will not be
translated to the lymph
vessels. The involved limb could swell more if you exercise without
compression.
Question #3:
"Why do I need to change my compression
garment twice a day?"
Answer:
Compression garments are made of elastic
materials that stretch out after wearing for about 12
hours. The
areas where a limb bends (knee, elbow) stretch out more than the rest of the
garment
and then those areas do not receive the correct amount of
compression which can allow pooling of
edema fluid that can cause
constriction at those areas. Some individuals can wear compression
garments day and night and do not need to bandage their involved limb
at night. These individuals
should change their garments in the
morning and again in the evening. Others may need to apply
compression bandages for nighttime wear or use an alternative device
such as a Reid sleeve,
Tribute, or Jovi. Consult with your
treatment team to discuss which option is right for you.
Question
#4:
"Why do I have to wash my compression garment every time I change
it?"
Answer:
Compression garments are made of elastic materials that
stretch out after wearing. Washing them
daily helps them to retain
their elasticity as well as removes perspiration, bacteria and dead skin
that accumulate inside the garment from normal wear.
Question
#5"
"Why do I have to use moisturizer on my affected
limb?"
Answer:
Moisturizing the skin helps to retain the elasticity of
the skin which helps to avoid cracks/breaks in
the skin. This is
important because any break in the skin allows bacteria to enter the limb which
is
at risk for infection because of the
lymphedema.
Question#6:
"Why do I have to wear compression on my affected
limb 24 hours a day?"
Answer:
Our tissues are supplied with oxygen and
nutrients by the blood. This blood is pumped around the
body by the heart. With every beat of the heart, blood is filtering into our tissues. 90% of the blood
volume in the tissues is picked up by the veins and
brought back to the central circulation. 10% of
the fluid volume in
the tissues can only be brought back to the central circulation by the
lymphatics.
So, even when you are sleeping, even if your arm is
elevated, blood is getting to your tissues (thank
goodness!).
Remember that in an impaired lymphatic system, the muscles need something to
contract against to assist the flow of lymph fluid. Otherwise, the
fluid will just pool under the skin
and the limb will swell
overnight. Then you may not be able to fit properly into your compression
garment the next morning. That 10% of fluid volume, the lymph fluid,
amounts to 2 liters a day in
the whole body. Remember that a
compression garment is not engineered to "reduce" a limb. It is
engineered to "hold" a limb that has already been reduced. However, you
should always discuss
your individual case with your treatment
team, as there are no absolutes and each person is
different. 24
hour compression may not be right for you.
Question #7:
"How long can I
keep my garment off?"
Answer:
Generally, in the first few months of CLT
treatment it is not recommended that you remove your
garments for
more than 30-60 minutes at a time. Again, the skin of a lymphedematous limb is
often
stretched and will allow edema fluid to rapidly re-accumulate
if there is no compression on the skin.
The goal after treatment is
for the skin and subcutaneous tissues to remodel to the new "smaller"
size.
This will not happen if the skin is allowed to stretch significantly. Once the
limb has remodeled
(6-12 months after CLT treatment) you may be
able to remove the garment for longer periods
without the limb
swelling.
Question #8:
"How long after treatment will I have to wear the
garment?"
Answer:
Generally, for as long as the lymphatic impairment
lasts. The short answer is until someone finds a
way to reverse
that impairment. Right now that means forever as there is no cure for
lymphedema.
In the case of impairment secondary to the surgical
removal of lymph nodes/vessels, this is usually
not reversible. In
the case of lymphatic impairment due to primary lymphedema, this is not
reversible. Microsurgical techniques to re-connect lymphatics with
other lymphatics or veins have
not been very successful. Scientists
are working on techniques to encourage re-growth of lymphatic
vessels but these are in the experimental stages and on animal models.
But, this is encouraging.
Finally, there are scientists interested
in the lymphatics! This is progress!
Question #9:
"Can I go swimming and
if so, do I have to wear the garment in the water?"
Answer:
Swimming is
one of the best exercises for lymphedema. If the affected limb is submerged in
the
water, then you do not have to wear your garment because the
hydrostatic pressure of the water is
providing the compression on
your limb. Some people like to wear an old garment in the water
because they like the extra compression that it provides, and they
don't worry about getting in and
out of the water and putting on
and taking off the garment repeatedly. Always rinse the garment
well
after swimming, whether in chlorinated, fresh or salt water. Take care walking
at poolside or
on the shore to avoid cutting your feet. Wear water
shoes or sneakers on the beach. Wear rubber
soled shoes/sandals at
poolside and in shower/locker room areas to avoid catching fungal
infections. And always wear sunscreen outdoors to avoid sun damage to
the skin.
Question #10:
"Why can't I put my garment in the
dryer?"
Answer:
You can but the heat will ruin the elasticity of the
garment and perhaps shrink it. Some
manufacturers say that you can
put them in the dryer, but that will wear them out faster and they are
costly to replace. Garments are best air dried - out of direct
sunlight.
Question #11:
"Can I remove my garment to have relations with
my partner?"
Yes, of course, and if you fall asleep without it, that's OK
too. There are always exceptions to the
rule. While you want to do
the best for your condition, you need to work your lymphedema home
program into your lifestyle, keeping in mind the basic principles of
the lymphatic system and
lymphedema management. Consistent
compression is important but there are times when you need
to be
without compression. Just make sure that you are monitoring your limb and that
any increase
in swelling is addressed quickly to avoid
problems.
Question #12:
"When I receive lymphatic drainage treatment,
where is all that fluid going?"
Answer:
The fluid is directed back into
the central circulation and whatever volume of fluid is in excess of the
"normal" volume of your limb is excreted from your kidneys in your
normal urine.
Question #13:
"What are the signs of infection in my
affected limb and how do I know whether I have an
infection?"
Answer:
Infection in a lymphedematous limb/area can
look different in each individual and with each
infection. Common
signs of infection are unusual redness, warmth, blotchy appearance to the skin
of the affected limb/area. This is sometimes accompanied by a
sensation of itching, burning, or pain
in the area. Some people
develop a fever or feel like they "have the flu" in the affected limb/area.
Regional lymph nodes can be painful and swollen. Some people are
nauseous. The problem with
these symptoms is that they also occur
with other conditions. You can have a red rash from an
allergic
reaction or insect bite. You can have nausea and fever from the flu or a viral
or bacterial
infection that does not involve your affected limb.
Sometimes, the inflammatory reaction to a rash
or insect bite can
precipitate an infection. That is why you should always carefully inspect your
involved/at risk areas carefully every day for any signs of breaks
in the skin, redness, increased
swelling, etc. As soon as you notice
something different, call your physician/therapist to discuss it
with them. Many physicians provide their patients with oral antibiotics
and instructions that they
start to take them if they feel that
they have an infection and then to call the office IMMEDIATELY
to
come for an emergency visit to have the area evaluated. You should never
attempt to "treat" an
infection yourself. The reason to have
antibiotics on hand is to be able to start them at the first sign
of infection, just until you can get medical attention. Abuse of
antibiotics is dangerous, but under-
treating an infection in a
lymphedematous limb or limb at risk for lymphedema is also
dangerous.
Question #14:
"Why should I avoid prolonged sun
exposure?"
Fist of all, the sun is hot and direct exposure causes the skin
temperature to rise. The application of
heat to the involved
extremity causes the blood vessels to open up (dilate) and more blood to flow
into the area. This causes an increase in fluid load in the affected
extremity and can cause an
increase in swelling. The sun's rays
damage the skin. A "tan" is really the skin's way of responding
to
damage from the sun by depositing melanin, a skin pigment, in the upper layers
of the skin. Even
if you don't normally "burn", you should wear
sunscreen on your affected limb as well as the
quadrant of your
body that connects to that limb. For example, if you have lymphedema in your
right arm, you should also have sunscreen on your neck, shoulder
and chest and back on the right
side. Actually, you should always
use sunscreen on your entire body to avoid skin cancer, but at
least have good coverage on your affected areas.
Question
#15:
"Why are people with lymphedema of the arm/hand told to avoid
manicures?"
The skin is a very porous organ. It absorbs chemicals. Acetone
and other nail polish removers are
chemicals. The solvents that are
used to remove artificial nails are strong chemicals. Cutting cuticles
too close can allow bacteria that are always on the skin to enter and
possibly trigger an infection.
Nail salons are public places and
instruments are not sterile. People who wear artificial nails are
more prone to develop fungal
infections
--------------------------------------------------------------------------------
Lymphedema
Therapy
77 Froehlich Farm Blvd., Woodbury, New York 11797
1-800-MD-LYMPH
or (516) 364-2200
Marvin Boris, MD
Stanley Weindorf, MD
Bonnie B.
Lasinski, MA, PT, CI,
CLT-LANA
http://www.lymphedema-therapy.com/03paper.htm
Secondary
Lymphedema:
Non-Cancer
Related
--------------------------------------------------------------------------------
SECONDARY
LYMPHEDEMA: NON-CANCER RELATED
BONNIE B. LASINSKI, MA, PT, CI,
CLT-LANA
--------------------------------------------------------------------------------
"Doctor,
why is my leg still swollen? What do I have and can it be treated?" These are
questions
often go unanswered, despite numerous diagnostic tests
and evaluations, and in spite of endless
hours of limb elevation.
Why is chronic limb edema (non-cancer related - NCR) such a mystery?
Perhaps
it is because the lymphatic system remains the most neglected organ system in
the body
and is rarely thought about as a logical cause of limb
edema unrelated to cancer treatment.
The key to early diagnosis and
intervention for secondary lymphedema, non-cancer related, is
increasing awareness and education about lymphatic system
pathophysiology and anatomy so that
every physician, regardless of
specialty, recognizes the possibility of lymph system dysfunction as
the
cause of chronic limb edema.
This presentation will review actual clinical
cases that illustrate some of the "uncommon" causes of
secondary
lymphedema, non-cancer related. The following categories will be
represented:
Orthopedic injuries/surgeries - i.e. fractures,
meniscal/ligamentous injuries/repairs, joint
replacements, and
tendon releases.
Neurological conditions - muscle paresis - CVA, post polio,
spastic paralysis.
Vascular injuries/surgeries - vessel injury from trauma
or unintended trauma from catheterization,
removal of a vein/veins
for CABG or leg bypass.
Integumentary injury - trauma to skin, degloving
injuries, burns, damage to skin from long term
steroid use, i.e. for
COPD or RA.
Infection
Scar tissue formation - multiple abdominal
surgeries, i.e. Gall bladder, TAH, umbilical/abdominal
hernias.
Lipedema
Most often it is the combination of
factors that causes the lymphedema to develop. A precise
chronological history of symptoms, surgeries, traumas, medications
used, therapies received, and
co-morbidities can clarify the
"unexplainable" and diagnose the problem, leading to a plan to
manage the lymphedema, thus improving the patient's quality of
life.
The lymphatic system is a regional system. Individual lymph drainage
territories of the skin are
independent of one another. Collateral
connections between these areas exist but are small and are
not
needed when lymph transport capacity exceeds lymph load in the unimpaired
lymphatic system.
When there is disruption to lymph vessels/nodes
from trauma, surgery, infection, scar tissue, etc. or
when the
elasticity of the skin and subcutaneous tissues is poor or when muscle tone is
poor, then
lymph load may exceed lymph transport capacity and
lymphedema results. Usually, edema begins
distal to the site of the
damage/obstruction.
A basic understanding of the normal anatomy of the
lymphatic system is critical for anyone
evaluating an individual
with edema of unknown origin, where testing has already ruled out most of
the common causes of edema, namely cardiac, renal, hepatic, thyroid,
venous, or drug induced.
The major lymph node basins for the
extremities are the axillary (armpit) for the upper extremities
and
the inguinal (groin) for the lower extremities. Lymph from both lower
extremities and the
genitalia drains into the pelvic and abdominal
lymph node basins. From here, the lymph eventually
moving into the
thoracic duct which is the major lymph vessel that transports lymph fluid form
the
lower half of the body into the left venous angle between the
left jugular and left subclavian veins,
and into the right side of
the heart. Lymph from the right upper extremity drains into the right axilla
and then into the right lymphatic duct which empties into the right
venous angle between the right
jugular and right subclavian veins,
into the right side of the heart. Anatomically, one can see that
disruption from infection, scarring, inflammatory processes, accidental
injury during a surgical
procedure in the pelvic/abdominal areas can
result in lower extremity lymphedema as well as
abdominal and
genital edemas. In the same way, any injury along the path from the upper
extremity
to the axilla and then into the chest can result in
lymphedema in the arm/hand. Trauma, infection, or
the formation of
a blood clot in the area around the venous angles can cause lymphedema.
An
individual who undergoes multiple abdominal surgeries with scarring near/around
the abdominal
lymph nodes and the afferent vessels carrying lymph
from the lower extremities, may develop
lymphedema in the legs. An
individual who sustains a severe fracture/dislocation of the ankle
disrupting pathways from the foot/ankle may develop lymphedema of the
foot and ankle which may
progress to the calf due to an overloading
of the functioning vessels in the lower leg. A woman
having
cosmetic surgery to remove excess fat pads in the anterior axillary line may
incur damage to
the axillary nodes if the surgery extends too far
into the axilla. Does this sound far-fetched? I
consulted with a
nurse who had this surgery (after a pregnancy left her with large bulging fat
pads at
the anterior axillary line) and developed lymphedema in her
left hand post operatively. When she
obtained the pathology report,
the specimen from the right side contained fatty tissue only, but the
specimen
from the left side contained fatty tissue and three axillary lymph nodes.
In
most cases of secondary lymphedema non-cancer related, the patient endures
multiple physician
visits and diagnostic tests that rule out the
heart, thyroid, kidney, liver, and cardiovascular system as
causes
of the edema. CAT scans, MRI's and bone scans rule out occult cancer as the
cause of the
swelling. While the patient is heartened that he/she
does not have cancer or a life-threatening
condition, they are
frustrated by the lack of diagnosis of their problem. They know what they don't
have, but they still don't know why their limbs are swollen. An
obvious diagnosis may be venous
dysfunction. Oddly enough, chronic
venous insufficiency may be part of the problem or the root
cause
of the secondary lymphedema, which is still often not diagnosed and properly
treated.
Pure venous edema reduces on elevation. Lymphedema may reduce with
elevation in early Stage
1, but when fibrosis begins to develop the
limb no longer completely reduces with elevation and
skin and
subcutaneous tissue changes occur, leading to decrease oxygenation, an
increased risk for
infection and a decrease in limb
mobility.
The key to early diagnosis and intervention for secondary
lymphedema non-cancer related is an
Increased awareness/education
regarding lymphatic anatomy/physiology and pathophysiology for
every physician and health-care professional, regardless of specialty.
The cases I will review have
seen internists, dermatologists,
podiatrists, cardiologists, neurologists, orthopedists, and
physiatrists, physical and occupational therapists. Many missed the
diagnosis all together.
Unfortunately, progressive skin changes and
bacterial and fungal infections have been misdiagnosed
as
dermatitis, eczema, gout, etc. resulting in improper drug prescription or other
treatments that not
only didn't improve the situation but allowed
the lymphedema to progress unchecked, to the
detriment of the
patient.
What is the solution to this problem? First, a good basic overview
of the lymphatic system
(presented by a lymphologist who can
explain common clinical presentations to the students) needs
to be
included in medical/allied health curricula. The NLN recently offered a 4-hour
instructional
course during their conference held in August 2002 in
Chicago: "Lymphedema management for the
practicing physician". This
session was attended by --- physicians and ---. It provided a wonderful
overview of the lymphatic system anatomy, physiology, and
pathophysiology, and was presented
by some of the leading
lymphologists in this country.
The NLN is trying to set up a Speakers Bureau
of experts who would agree to be available to
present at
conferences, Grand Rounds, Awareness Events, etc. After discussing some basic
lymphatic anatomy and pathophysiology with the physician/husband of
a patient with breast cancer
related lymphedema, he excitedly
admitted that he and his colleagues have seen many patients with
unexplained extremity edema. He was amazed to realize the implication
of the cumulative effects of
surgeries, obesity, trauma, chronic
inflammation requiring long-term steroid treatment, vein harvest
for bypass surgeries, (the list goes on and on) on the lymphatic
system. Of course he is sensitized,
having watched his wife deal
with progressive upper extremity lymphedema, which progressed
despite months of ineffective "treatment". Once she received
appropriate treatment and her
lymphedema began to reduce, he
realized the importance of specialized training/knowledge to treat
lymphatic system disorders. He certainly will never stop his clinical
investigation short of the
lymphatics when diagnosing edema of
unknown origin.
A Review of 24 randomly selected cases revealed the
following causes of lymphedema (several
cases had more than one
cause):
CVA or neuromuscular spasticity - 2 Knee injury/sprain -
1,
Lipedema - 2, Total hip replacement - 1
Fracture - 5 Total knee
replacement - 4
Leg bypass - 1 Coronary bypass - 2
Infection - 9
Abdominal surgery - 5
Chronic steroid medication - 3 Skin ulceration -
3
Arthroscopic surgery of the knee - 2 Vein ligation - 1.
The following
are representative examples of secondary lymphedema non-cancer related.
Case
1 - PP - 49-year-old male, sustained a compound proximal and distal tib/fib
fracture,
trimalleoar fracture/ dislocation of the ankle. He had
ORIF and 4 months of rehab. He did not
progress in rehab due to
severe pain, swelling, heat and redness in the affected lower leg. He had
several episodes of redness, heat and fluid leakage from the sites
where the external fixation device
had been removed. He had seen 3
orthopedists, a physiatrist who prescribed an ankle foot orthosis
to support the distal ankle, and a dermatologist who diagnosed
dermatitis instead of cellulitis and
prescribed a topical steroid
cream. He could not progress in his rehab due to the chronic redness,
pain,
swelling, and limited mobility in his ankle and foot. He could only walk short
distances, had
great difficulty negotiating stairs, and performing
any ADL's involving weight bearing. He was on
disability from his
job as a police officer. He was self- referred to a lymphologist after a friend
and
informed breast cancer survivor recognized that he might have
lymphedema. His lymphedema was
secondary to the trauma of the
fracture/dislocation, surgery, and chronic, untreated cellulitis in his
leg. The swelling was labeled as "post-operative" and the cellulitis was
misdiagnosed as a skin
irritation. He lost 4 months of his life and
his return to work and his life in general was delayed that
much
longer.
Case 2 - MA - 75 year old female who sustained a fracture of the
left second and third metatarsals
when a brick retaining wall in
her garden fell on her as she was weeding. The fractures were casted
in
a short leg cast and in 4 weeks she developed an infection, severe pain in her
leg and foot, and
an ulceration on her heel because her leg swelled
in the cast.
Dopplers and x-rays were negative for any new pathology.
Fortunately, her orthopedist had a
patient who had received CDT
treatment and had done well. She was referred to that lymphologist
after 8 weeks of physical therapy failed to heal the ulcer or reduce
the pain, swelling and limited
mobility in her left
foot/ankle/lower leg. Her lymphedema was secondary to the trauma of the
incident and the infection. After one month of CDT treatment, her ulcer
was completely healed,
range of motion of the foot and ankle were
improved, she could walk without her cane, fit into her
shoes, and
pain was 2/10 reduced from 10/10. Most importantly, she was able to get back to
her
gardening.
Case 3 - PM - 56 year old female with a history
of severe rheumatoid arthritis for 20 years, with a
nine-month
history of progressive swelling in both legs following 18 months of oral
steroid
medication for her arthritis. Because she had been on many
toxic medications to treat the arthritis,
she was referred to a
hematologist for a bone marrow and bone biopsy which were negative. She
was seen by a vascular surgeon who did Dopplers that were negative for
DVT. Her internist
ordered a CAT scan of the abdomen and pelvis
that was negative. She developed progressive
weakness and decreased
mobility in her lower extremities. The skin of both lower extremities was
thin, taut and shiny, and the patient reported that they were
chronically red and warm. She had
been hospitalized for an
infection in her legs in June of 01. There were several small ulcerations on
the right lower leg which were had been leaking lymph for
approximately two months prior to her
referral to the lymphologist.
There was a 4-cm diameter 1-cm deep ulceration on the plantar
surface of the MP joint of the left great toe. Her podiatrist had
"shaved" a callus from this area, and
she reported that she had
been treated for a "staph" infection by the podiatrist, but that he said that
it was resolved.
At the time of her referral, she was dependent
in all ADL's, could not negotiate stairs (she turned
her living room
into a hospital room), spent most of the time in a wheelchair, and could only
ambulate 10 feet with a rolling walker. She developed flexion
contractures in her hips and knees
from the prolonged sitting and
immobility. Her husband had to dress her lower body. Her pain was
10/10 and she was severely depressed. Wound cultures revealed MSRA in
the left great toe
ulceration, and in the small ulcerations on her
right lower leg. No one could figure out what was
wrong with this
woman. She had lymphedema in her legs secondary to prolonged steroid treatment
that worsened after the chronic antibiotic-resistant infection
remained untreated for several months.
The elasticity of her skin
was severely weakened and the skin itself was paper thin and opened
easily. After nine months, her rheumatologist referred her to a
lymphologist after researching on the
Internet.
Once the
lymphedema was addressed (the patient underwent a course of CDT) and the
infection
appropriately treated with a drug that MRSA was sensitive
to, the wounds healed, the edema and
pain resolved, and the patient
began to increase strength and mobility. After 4 weeks of CDT, the
patient was able to ambulate 50-100 feet with her rolling walker. At
the one-month follow-up
appointment, the patient ambulated with a
straight cane, was independent in most of her ADL's,
and was able to
drive herself to the appointment. She was referred to PT for strengthening and
mobility exercises. Her rheumatologist was astounded and vowed to
discuss this case with all her
colleagues and spread the word about
remembering to include the lymphatic system when
evaluating edema of
unknown origin.
Case 4 - RL - a 60 year old male, retired airforce test
pilot, with a six-year history of progressive
lower extremity edema,
onset 6 months following coronary artery bypass using donor veins from
both lower extremities. As the edema worsened, it extended into the
abdomen. Unfortunately for
this patient, he was obese, had a large
abdomen, and did have a history of heart disease. He was
told that
the edema in his legs was just water retention because he was fat and had some
heart
disease. The patient had been sleeping in a recliner chair
for 6 years. He had been diagnosed with
sleep apnea. The patient
referred himself after searching on the Internet for months. His physician
refused to give him a referral because he didn't believe he had
lymphedema because he never had
lymph nodes removed! He traveled
from New Hampshire to New York to consult with a
lymphologist and
receive CDT treatment. His only treatment prior to that had been diuretics. He
was dependent in lower body dressing, only ambulated 10 feet before
stopping to rest and lean on
furniture due to pain and SOB. His
pain was 10/10. He was severely depressed. He scored his
functional
impairment a 10/10. The lymphologist referred him to his cardiologist to rule
out
abdominal ascites or CHF as the cause of his SOB. His
cardiologist did an abdominal US that
found no fluid in the
abdominal cavity. However, he did have abdominal lymphedema!
This
patient received one month of CDT treatment achieving a 53.3-cm reduction in
his left lower
extremity and a 44.5-cm reduction in his right lower
extremity. His weight reduced from 298 to
273 pounds. At one-month
follow-up, he reduced another 21.8 cm on the left leg and 13.3 cm on
the
right. He slept supine in a bed with his wife for the first time in 6 years and
he was able to play
with his grandchildren. He scored his
post-treatment functional impairment a 3/10 because he
needed
assist to don his compression stockings. He did acknowledge that although he
hated the
stockings, they were a small price to pay for getting his
life back. His lymphedema was secondary
to the disruption of the
venous system and scarring/probably damage to lymphatics from the vein
harvest, the subsequent infections, and his obesity. Once again, an
individual who was receiving
regular medical care from an internist
and cardiologist suffered needlessly because the lymphatic
system
was not considered when lower extremity edema developed.
Case 5 - MR a
78-year-old recent widower with a one-month history of severe swelling in his
left
forearm/hand since IV infusions for dehydration caused by
depression. He had seen vascular
specialists who ruled out DVT as
the cause of the edema. His ADL's were impaired 5/10 and he
reported chronic pain and a feeling of bursting in his left hand 5/10.
His grip strength was poor in
the left hand and he was having
difficulty dressing and doing his daily chores. His significant past
medical
history included intestinal resections in 1960 and 1963 for severe Crohn's
disease for
which he required chronic steroid treatment to be able
to function. The skin of all extremities was
thin and there were
multiple scars/bruises from old skin tears/traumas.
MR had lymphedema of his
left upper extremity secondary to damage to the skin lymphatics from
chronic
steroid treatment. He responded well to lymphedema treatment, regaining his
strength and
mobility in his left hand/arm. He was able to
discontinue his compression sleeve/glove after 6
months.
Unfortunately, the lymphedema recurred in 9 months when he again required
hospitalization for dehydration and IV therapy. Except that this time,
MR did his own self MLD
and compression bandaging and then wore his
compression garments for about 3 months and was
able to discontinue
their use.
Case 6 - LK is an independent 85 year old widow with a long
history of osteoarthritis and a 3-year
history of chronic swelling
in her left lower extremity. The swelling limited her safe ambulation and
caused impairment in her strength and range of motion of her left
leg/foot. She required the
assistance of a home health aide for her
ADL's. She could only walk short distances with a quad
cane. She had
had a left total knee replacement in 1995, followed by the removal of a Baker's
cyst
from the left popliteal area in 1997. Two months after that
operation, she developed a fungal
infection around the left knee
prosthesis, necessitating its removal in 12/97. She underwent a
second total knee replacement on the left in 2/98. She was told that
she had "post-op edema"
which had unfortunately lasted for 3 years!
She had consulted several vascular surgeons and
another
orthopedist, none of whom could diagnose the cause of her chronic edema, other
than to
say that she should expect it at her age, after the repeat
surgeries she had had. Once the
lymphedema (which was secondary to
the traumas of the repeat surgeries and the infection) was
treated,
LK was able to "fire" her home health aide and she continues to live
independently in her
own home, needing only a straight cane for
balance when walking.
Case 7 - AS is a 73 year old female with an 18-year
history of primary lateral sclerosis/familial
spastic paresis. She
was dependent in all areas of ADL and required a reclining wheelchair for
optimal positioning. In 4/00 she had a Baclofen pump inserted to
control her severe spasticity. She
developed cellulitis in both
legs shortly after that procedure. Relevant past medical history included
a total abdominal hysterectomy in 1990 and the repair of an umbilical
hernia after that developed
after that procedure. As was advised
that she was not a candidate for "traditional CDT" but she
was
relieved to have a diagnosis for her problem. Her lymphedema was most likely
secondary to
the severe spasticity in her lower extremities
complicated by three abdominal surgeries and cellulitis
in her
legs.
Case 8 - MS is a 66 year old female with a 26 year history of chronic
edema in both lower
extremities. MS was always "overweight" since
her teen years. The swelling in her legs and feet
progressed over
the years and no longer reduced on elevation. In the last few years, she has
been
hospitalized 5 times for IV treatment of cellulitis and
ulcerations in her legs. MS was treated with
diuretics and told to
lose weight. She tried both but the swelling and skin changes kept worsening.
MS has lymphedema in her legs secondary to longstanding
lipedema.
To the trained lymphologist, these cases are self-explanatory. For
each case there is a cause and
effect. The challenge for every
health-care professional is to become educated in the anatomy,
physiology and pathophysiology of the lymphatic system so that no
individual has to live with
lymphedema undiagnosed and
untreated.
--------------------------------------------------------------------------------
Lymphedema
Therapy
77 Froehlich Farm Blvd., Woodbury, New York 11797
1-800-MD-LYMPH
or (516) 364-2200
Marvin Boris, MD
Stanley Weindorf, MD
Bonnie B.
Lasinski, MA, PT, CI,
CLT-LANA
http://www.lymphedema-therapy.com/Lipedema.htm
Lipedema
--------------------------------------------------------------------------------
Overview
and Etiology.
The term lipedema was first used by Allen and Hines (1940) to
describe a symmetrical "swelling"
of both legs, extending from the
hips to the ankles, caused by deposits of subcutaneous adipose
(fatty) tissue. The underlying etiology of these fat deposits remains
unknown. While lipedema is not
a disorder of the lymphatic system
per se, it is frequently confused with bilateral lower extremity
lymphedema. It occurs almost exclusively in women and may have an
associated family history (20
per cent of cases) and is usually
accompanied by hormonal disorders as well (Strossenreuther,
1999).
If present in a man, it is accompanied by massive hormonal disorder.
Fat in
the lower extremities extends to the malleoli (ankle bones), often with flaps
of tissue hanging
over the foot. The feet are not affected;
occasionally, lipedema is found in the arms. Typically, there
are
also fatty bulges in the medial proximal thigh and the medial distal thigh,
just above the knee.
Clinically, the affected individuals complain
of pitting edema as the day progresses, which is
relieved by
prolonged elevation of the leg(s) overnight (Rank and Wong, 1966; Rudkin and
Miller,
1994; Casley-Smith, 1997).
Stages of Lipedema.
In
Stage I, the skin is still soft and regular, but nodular changes can be felt
upon palpation (see
photo #1). There are no color changes in the
skin and the subcutaneous tissues have a spongy feel,
like a soft
rubber doll. In Stage II, the subcutaneous tissue becomes more nodular and
tough.
Large fatty lobules begin to form on the medial distal and
proximal thigh and medial and lateral
ankles just above the
malleoli (see photo # 2). Pitting edema is common, increasing as the day
progresses. The individual may report hypersensitivity over the anterior
tibial (shin) area. Skin color
changes occur in the lower leg,
indicative of secondary lymphedema, which often occurs in later
stage lipedema.
Pathophysiology of Lipedema (Strossenreuther,
1999).
There are many histological and physiological changes that occur in
lipedema. There is a decrease
in the elasticity of the skin and
underlying connective tissue. The basement membrane of blood
vessels is thickened and there are disturbances in vasomotion. There is
decreased vascular
resistance, increased skin perfusion, and
increased capillary filtration. There is increased
venous/blood
capillary pressure causing increased ultrafiltration. These vascular changes
combined
with the decreased efficiency of the calf muscle pump,
result in both the dependent pitting edema
seen in Stage I, as well
as the the secondary lymphedema that often complicates lipedema in its
later stages. Histological changes seen in lipedema include a thinning
of the epidermal layer,
thickening of the subcutaneous tissue
layer, fibrosis of arterioles, tearing of elastic fibers, dilated
venules and capillaries, and hypertrophy and hyperplasia of fat cells.
Clinical studies show that
there is enlargement of the
pre-lymphatic channels (Stoberl et al., 1986) as well as defects in
capillary perfusion (Weinert and Leeman, 1991). Some authors have
reported no alteration in
lymphatic transport (Brautigam et al.,
1998) while others (Bilancini et al., 1995) have reported
decreased
lymph outflow in those individuals with lipedema. Foldi and Foldi (1993)
reported an
increase in fat cell growth during
lymphostasis.
Medical Management
Diagnosis. The diagnosis of lipedema is
difficult if the clinician is unfamiliar with this condition.
Often, these people are told that they are "fat" and should just lose
weight to resolve the problem.
For reasons still unknown, the fatty
tissue accompanying this condition cannot be significantly
decreased
by diet. It is not uncommon for a diagnosis of primary lymphedema to be made.
This
results in frustration for the person who then seeks out
lymphedema therapy with poor results.
There are several significant
clinical differences between lipedema and bilateral primary
lymphedema. The feet are not involved in lipedema; while they are
edematous with a positive
Stemmer's sign in lymphedema, Stemmer's
sign is negative in lipedema (see fig. 12-17). The
"swelling" in
lipedema is symmetrical, while in primary lymphedema usually one limb is more
involved than the other. The subcutaneous tissues feel rubbery in
lipedema. In advanced Stage II
lymphedema, there is significant
subcutaneous fibrosis, which feels firmer than lipedema.
While there have
been reported incidences of cellulitis in Stage II lipedema (usually with a
component of lymphedema as well), the frequency of cellulitis in Stage
II lymphedema is much
higher. The time of onset of the "swelling"
in lipedema is usually around puberty and 90 per cent of
these
cases have accompanying diagnoses of hormonal disturbance (thyroid, pituitary,
or ovarian).
This is usually not the case with primary
lymphedema.
A lymphoscintigram may be helpful to differentiate between
lymphedema and lipedema, however,
there can be conflicting results
as lymphedema often occurs to some degree in the later stages of
lipedema, probably due to impairment of lymph flow caused by the
pressure of fatty tissue. In fact,
there are clinical cases of
bilateral lower extremity lymphedema in the morbidly obese individual;
the onset of the lymphedema occurs after body weight exceeds 350-400
pounds. It is plausible to
suspect that the pressure of a large
apron of abdominal fat can effectively block lymph flow through
the
inguinal area causing the lymphedema but there is a difference between these
cases and
lipedema because obesity does not cause lipedema.
Lipedema is caused by a hormonal imbalance
resulting in excessive
deposition of adipose tissue, most often in the lower extremities (see Figs.
12-
21; 12-22) although it can occur in the upper extremities as
well.
Treatment and Prognosis.
There is no effective medical
treatment for lipedema and the prognosis is guarded; however,
significant functional improvements are possible with good program
compliance and therapy
intervention. Medical management involves
treating the hormonal disturbance as effectively as
possible and
providing nutritional guidance to avoid additional weight gain. Many of these
individuals have endured years of ridicule because of their
physical appearance and become
recluses in their homes, further
limiting their activity level. As lipedema progresses and the
hypersensitivity increases, they feel less inclined to walk or exercise
because of the pain. They
inevitably gain more weight due to the
inactivity and depression, often finding food their only
comfort.
The primary goal of therapy intervention in the person with
lipedema is symptomatic relief and
realistic improvement of trunk
and lower extremity function. Application of the combined
lymphedema treatments has shown some success in relieving the pain and
hypersensitivity in the
lower legs and improving general mobility.
Usually, a lower level of compression is needed to
support a
lipedematous limb, compared to a lymphedematous limb of the same size and
girth. This
guideline applies to the compression garments as well.
These individuals often require more
padding under the compression
bandages, particularly in the anterior tibial area. They do not
tolerate the heavier, denser compression fabrics and usually require a
lower grade compression
garment than someone with uncomplicated
lymphedema. The therapist must remember, however,
that later stage
lipedema is often accompanied by lymphedema as well, and the treatment and
management must take that factor into consideration when recommending
exercise and garments.
The main goals of intervention are to decrease pain
and hypersensitivity, to decrease the
lymphedematous component of
the disease, and to assist the individual in maintaining and/or
reducing adipose tissue through exercise and nutritional guidance. The
compression garments can
help to decrease the adipose tissue with
exercise and weight loss. The most difficult task is fitting
the
compression garments. They must be custom made due to the large size of the
individual and
are often uncomfortable at the waist, particularly
when sitting. Making the radical change in daily
activity level is
most challenging for these individuals. Providing continued support and
encouragement is important.
Networking is helpful and is facilitated
by offering a support group, even when held on an irregular,
informal basis. An hour-long educational meeting, even if only offered
three or four times per year
can provide a neutral meeting place
for people to begin networking. Nothing can compare to the
encouragement and hope that an individual with lipedema/lymphedema can
derive from seeing and
talking with someone else living with the
same problem and hearing how others cope on a day-to-
day basis.
Therapists can learn some of the best guidance on exercise and coping with
garments in
a group like
this.
--------------------------------------------------------------------------------
Lymphedema
Therapy
77 Froehlich Farm Blvd., Woodbury, New York 11797
1-800-MD-LYMPH
or (516) 364-2200
Marvin Boris, MD
Stanley Weindorf, MD
Bonnie B.
Lasinski, MA, PT, CI,
CLT-LANA
http://www.lymphedema-therapy.com/lymphedema-exercise.html
Lymphedema
and
Exercises
--------------------------------------------------------------------------------
Exercise
for Lymphedema Benefits Supported by Studies
Bonnie B. Lasinski, MA, PT,
CLT-LANA
--------------------------------------------------------------------------------
Exercise
and lymphedema - it is a controversial subject
How is lymphedema and
exercise viewed today? How many clinicians are at a loss for words
when they are asked about what kind of exercise is "good" for
individuals with lymphedema? How
many individuals living with
lymphedema or a limb at risk for lymphedema have asked their
healthcare professional for advice concerning exercise only to receive
conflicting information? It is
difficult to "recruit" presenters to
provide workshops/discussions on lymphedema and exercises for
both
patients and professionals alike. Exercise and lymphedema - it is a
controversial subject.
Our Nearly 30 Years of Research on Exercise for
Lymphedema
Twenty-nine years ago in 1980, I was asked to do a presentation
on exercise after mastectomy for
a one day seminar sponsored by the
American Cancer Society's Long Island Division, entitled
"Living
With Cancer". When I contacted the coordinator of the workshop, Diana Rulon,
she
informed me that she was not "interested in exercise after
mastectomy - she was interested in
exercise for
lymphedema!"
You can imagine my shock and fear at that moment. I had no
special training in lymphedema
management, never mind lymphedema
and exercise; in fact, no one did. We were just beginning to
hear
strange tales of a treatment from Europe that seemed ridiculously mild for the
severe swellings
I had seen in my limited experience. But, I
figured “no problem”. I'll just go to the medical library,
research
the articles, and develop my talk from there. Well, that was 1980 and there
were no
articles on exercise for lymphedema, except for a few
abstracts of German and French studies.
Now, I was really in
trouble. Well, long story short, I was inspired by the dedication of Diana
Rulon who tried to find help for other women like herself, who had long
been ignored by their
doctors and told to live with their problem.
Thus began my journey in lymphedema management.
Trial by fire, you
might say!
We presented a very basic, common sense talk on lymphedema,
trying to define it in simple terms
(no small feat when the
literature was so poor - the definition at that time was a 2 centimeter
difference between forearms - as if that was the only place one could
have lymphedema!). Next,
Diana presented some practical suggestions
for nutrition that she had found helpful to her and
several other
women she knew. Finally, I wrapped up the session with some very basic
information
on lymphedema and exercise progression and then opened
the floor for questions.
In 2009, although the medical management of
lymphedema has come a long way, thanks in great
part by the
advocacy of Saskia Thiadens and the NLN and many others, there is still much
work to
do. Basic and advanced research on the effects of exercise
as a lymphedema risk reduction
modality must be explored.
The
basic criticism of the precautions about exercise for lymphedema contained in
the Risk
Reduction Guidelines is that they are "anecdotal" at the
present time, due to the lack of controlled
double-blind studies to
prove their efficacy.
Some medical professionals have taken the position
that the individual with a limb at risk (or with
lymphedema) should
go ahead and pursue whatever exercise/activity they wish and "see what
happens". Unfortunately, lymphedema is a chronic condition, which,
presently, has no cure.
While it is true that not all individuals who have
had lymph node disruption (surgical or radiological)
will develop
lymphedema, until physicians can better predict who is at greater risk for
lymphedema,
a prudent approach to exercise for lymphedema is
advisable. In the case of individuals with primary
lymphedema or
established secondary lymphedema, working up to a level of exercise that
promotes fitness while avoiding exacerbating the lymphedema is a good
goal.
Exercise for Lymphedema makes Medical Sense
I'm sure that some of
you may have been told in the past that you should not exercise if you have
lymphedema, or that certain types of exercise are contraindicated if
you have lymphedema. This is
not the case. I would like to review
some basic principles of anatomy and physiology and
pathophysiology
of lymphedema and how these relate to exercise and lymphedema.
Basic
principles behind occurrence of lymphedema
•Lymphedema occurs when there is
an imbalance between lymph transport capacity and lymph
load.
•After any surgical disruption or radiation treatment to a
lymph node region, a state of latent
lymphedema occurs. That is to
say that the lymph transport capacity is reduced but it is still greater
or equal to the lymph load.
•Acute/chronic lymphedema develops when
that balance is shifted and lymph load exceeds the
impaired lymph
transport capacity.
•In the case of Primary Lymphedema, where there is a
malformation/malfunctioning of the
lymphatic transport system that
results in a reduced lymphatic transport capacity, lymph load often
exceeds that transport capacity, and progressive lymphedema develops
over time.
Lymphedema is a problem of excess water and protein
Our
lymphatic system, in addition to filtering out waste products, helps our bodies
maintain fluid
balance so that we are neither dehydrated nor
edematous.
Up to 90% of the water component of our blood that perfuses the
capillary network and nourishes
our cells returns to the heart via
the venous system.
The 10% (or more) that is left behind in the tissues
along with the extracellular protein that filters
out of the
capillaries, can only return to the heart via the lymphatics. That 10% (or
more) can
amount to up to 2 liters a day. While 2 liters may not
seem like much, it adds up day after day, if
there is impairment in
lymph drainage.
In addition, the extracellular proteins can only return to
the central circulation via the lymphatic
vessels. The diameter of
these molecules is too large to fit into the openings in the vein walls - the
openings in the lymphatic vessel walls are large enough for these
protein molecules to enter easily.
So lymphedema is not only a problem of
excess water remaining in the tissues, but of excess
protein that
remains in the tissues as well. Unfortunately, the body always moves for a
state of
balance so it actually tends to pour more water into the
tissues to "dilute" this protein concentration
- thus a vicious
cycle develops. This problem is compounded by the fact that the white blood
cells
called macrophages, which are part of our immune response, do
not work properly in the
lymphedematous fluid. This is why anyone
with lymphedema is at increased risk for infection in his
or her
affected limb.
Relation between lymphedema and exercise
What does all
this have to do with exercise? A review of the acute and chronic effects of
exercise
is helpful to understand how the limb at risk or a
lymphedematous limb might respond to various
types of exercise. The
acute responses to exercise include increases in heart rate, stroke volume,
cardiac output, blood flow to active muscles, systolic blood pressure,
arteriovenous oxygen
difference, ventilation, oxygen uptake, and a
decrease in blood pH and plasma volume.
Chronic adaptations to exercise
include biochemical changes in skeletal muscles, decreased resting
heart rate, decrease in total body fat, blood lipids, and the density
and strength of bone and
connective tissue.
During exercise,
blood is redirected to the muscles. At rest, only 21% of the cardiac output
goes to
the muscles, compared with as much as 88% during exhaustive
exercise. As the body heats up, an
increasing amount of blood is
directed to the skin, to conduct heat away from the body core.1
Remember that lymph transport has to be equal to or greater than lymph
load. When you exercise,
your muscles need extra blood to supply
the oxygen needed for your muscles to do the work of the
exercise.
Extra blood flow means that extra water will remain in the extracellular spaces
needing
transport via the lymphatic system.
So exercise for
lymphedema may be beneficial, however the question is how much is too much?
That is very individual. It is important that any exercise program be
gradually progressed to avoid
sprain/strain. More importantly, a
slow progression allows the individual to monitor their affected
limb or limb at risk for any sensation of aching or fullness that could
indicate an overwhelming of the
lymphatic system.
Lymphedema and
Exercises are specific to each individual
Benefits of exercise for
lymphedema
•Exercise can increase the uptake of fluid by the initial
lymphatics and enhance the pumping of the
collecting
lymphatics.
•In addition, exercise mobilizes the joints and strengthens the
muscles of the involved
limb/limbs/trunk quadrant, thus decreasing
the risk of strain/sprain.2
Exercise for lymphedema is best done with
compression
Exercise for lymphedema is best done with compression on the
affected limb either from
compression bandages or compression
garments. The bandages provide a new "tight" skin for the
muscles
to contract against, assisting in pumping the lymph out of the extremity into
the central
circulation. When lymphedema exists, the remaining lymph
vessels that are functioning are working
double time to try to
carry the load. These vessels become over dilated (stretched) and eventually,
their walls can overstretch and fail, causing a worsening of the
swelling.
Wearing compression bandages/garments provides support to the skin
and to the lymphatic vessels
directly under the skin, called the
superficial lymphatic network. It is these vessels that help to carry
the
load when the larger vessels have been cut away from the lymph nodes or have
been damaged
due to trauma or chronic venous disease, or in the case
of primary lymphedema, when there are
too few large lymph
collectors in a region due to improper vessel/node development during fetal
growth
Certain types of exercise are considered higher risk
Of
course, certain types of exercise are considered higher risk than others for
individuals with
lymphedema. For example, high speed activities like
tennis, bowling and racquetball, place more
stress on the upper
limb while jogging, stair-climbing machines, downhill skiing, water skiing,
football, soccer place more stress on the lower extremities or have
higher injury risk than other
activities such as swimming, brisk
walking, and cycling. That is not to say that someone with
lymphedema of the leg should not jog for exercise, or that the person
with lymphedema of the arm
and hand should not play tennis or
golf.
It is also important to know whether an individual was skilled at a
sport/activity prior to their
developing lymphedema. A
sport-specific exercise program can be developed for the individual to
build strength, flexibility and endurance in the muscle groups most
used in that sport/activity.
Ultimately, the decision to "play"
should be an individual one, but an informed one.
Things to consider
regarding lymphedema and exercise
•Many men and women with lymphedema or a
limb at risk want to work out with weights. A slow
progression of
light weights can be done safely and can allow an individual to develop good
strength and power in any muscle group.
•The important thing to
consider is whether you feel good after the exercise and how your affected
limb reacts after you exercise.
•You must also consider your level
of daily activity and modify accordingly - if you have had a
particularly difficult day and your affected limb is more swollen, you
may choose to do a different
activity i.e. swim instead of walk, or
you may realize that the best activity for that day is to rest with
your limb elevated.
•The importance of deep abdominal breathing
exercise should not be overlooked. Deep breathing
enhances the
pumping in the thoracic duct (the major lymphatic vessel draining the lower
body and
the left upper trunk/arm/hand).
Exercise for lymphedema
is one component of the treatment for lymphedema. You’ll find more
information here on other components of Comprehensive Lymphedema
Treatment with our
certified lymphedema therapists.
Lymphedema
and Exercise Case Studies
Case Study of Upper Body Exercise for
Lymphedema
A series of case reports published in the Journal of Surgical
Oncology3 challenges the theory that
vigorous upper body exercise
is contraindicated for individuals who have had axillary dissection
during surgery for breast cancer. The study followed a group of 24 women
for 9 months. These
women were recruited to participate in a
training program to prepare for competition in the World
Championship Dragon Boat Festival in Vancouver, British Columbia.
Dragon Boat racing involves
strenuous repetitive upper body
exercise. 18-20 women paddle 40-60 foot boats for a distance of
500-650 meters. Circumferential measurements were collected on 20 of
the 24 participants (limbs
were measured at 4 places) pre training,
at the start of the racing, and 7 months after the races.
According to the
authors, only two women, who had pre-existing mild lymphedema, had increases
in their upper arms (5/8 inch) and none of the other participants
developed lymphedema. One of
the authors of the study, herself a
breast cancer survivor participated in the program. Regarding
lymphedema and exercise, the authors conclude that strenuous upper body
exercise may not cause
lymphedema or worsen a pre-existing
lymphedema.
It is important to note in this lymphedema and exercise study
that the participants in this study
completed a two-month training
program of stretching, strengthening, and aerobic exercises prior
to engaging in the actual strenuous activity of Dragon Boat
racing.
Many individuals who undergo breast surgery/axillary
dissection/radiation are not enrolled in
supervised progressive
exercise programs like the participants of this study. Providing structured,
individualized exercise programs should be a goal of all centers
that perform cancer surgeries. The
at risk/limbs with lymphedema
should be measured periodically to insure that there are not subtle
volume changes that may not be visible to the individual.
While I
do not discourage individuals from participating in sports and exercise, I do
caution them
that they should consider themselves "athletes" in the
"game" of life. As such, each individual should
engage in a
stretching/strengthening program to prepare them for full participation in
whatever
activity they choose.
Case Study of Weight Training
Effects on Lymphedema
Ahamed et al in 2006 examined the effects of
supervised upper and lower body weight training on
the incidence
and symptoms of lymphedema in 45 breast cancer survivors who participated in a
supervised, graduated program of exercise twice weekly for 6 months.
None of the participants
experienced a worsening of their
lymphedema or a triggering of lymphedema in their at risk limbs.
Schmitz et
al in 2009 assessed the safety of a graduated exercise program on 295 survivors
with
breast cancer related lymphedema (BCRLE) and 154 at risk for
lymphedema. Their results were
similar, demonstrating that
individuals who are at risk for lymphedema or who have lymphedema
can participate in exercise, provided it is progressed slowly and their
limbs are assessed for any
signs of increased or developing swelling
throughout the program and the program is modified
accordingly for
each person.
The key is proper evaluation and assessment for signs of
swelling, tightness, or skin and tissue
changes, before, during and
after exercise.
A related study that we conducted can be found here
involving Upper Extremity Lymphedema
Secondary to Breast Cancer. The
study involved patients with unilateral upper extremity
lymphedema
secondary to axillary node dissection (accompanying lumpectomy or mastectomy
for
carcinoma of the breast). It was done to evaluate the
persistence of reduction in lymphedema
following a single course of
Complex Lymphedema Therapy.
Please write us any questions or concerns
you may have about treatment options at Lymphedema
Therapy.
Our
Certified Lymphedema Specialists will be happy to answer your questions on how
we may
help you or someone you know who has lymphedema. We invite
you to fill out and submit your
questions to us here on our Contact
Form.
The physicians and certified lymphedema therapists at Lymphedema
Therapy are experienced in
these assessments. For more
information, contact our center at
516-364-2200
References:
1.Nieman, David C. Exercise Testing and
Prescription: A Health Related Approach, 4th ed.
Mountain View,
California, Mayfield Publishing Co., 1999: P, 190-205.
2.Casley-Smith,
Judith R, Casley Smith, John R. Modern Treatment for Lymphoedema, 5th ed.
Adelaide, Australia, The Lymphology Association of Australia, 1997: p.
188-189.
3.Harris, Susan R, Niesen-Vertommen, Sherri. Challenging the Myth
of Exercise-Induced
Lymphedema Following Breast Cancer: A Series of
Case Reports. Journal of Surgical Oncology
2000;
74:94-99.
--------------------------------------------------------------------------------
Lymphedema
Therapy
77 Froehlich Farm Blvd., Woodbury, New York 11797
1-800-MD-LYMPH
or (516) 364-2200
Marvin Boris, MD
Stanley Weindorf, MD
Bonnie B.
Lasinski, MA, PT, CI, CLT-LANA
Frequently Asked Questions
"FAQ"
--------------------------------------------------------------------------------
The
following are frequently asked questions about managing lymphedema and
lymphatic system disorders.
They are by no means complete answers
to what are always very complex questions but are meant as a
guide.
Each individual's situation is unique and each person should consult with their
treatment team for their
specific recommendations for their
particular case.
Question #1:
"Why do I have to
exercise?"
Answer:
Appropriate exercise stimulates the flow of lymph.
Muscle contraction and changes in pressure in the chest
from deep
breathing cause changes in pressure on the lymphatic vessels. When the muscles
contract against
the compression of the compression bandages or
compression garments worn on the affected limb this
creates changes
in tissue pressures that help the lymph to flow.
Question #2:
"Why do I
have to wear my compression garment/bandages when I
exercise?"
Answer:
When an individual has lymphedema, the pressure of the
edema stretches out the skin so that it no longer
provides a firm
surface for the muscles to contract against. Exercise causes increased blood
flow which
caused an increase in lymph load in an already
compromised limb. The compression of the garment/bandage
provides a
"new firm skin" for the muscles to contract against so that the pressure will
be exerted on the
lymph vessels and the fluid will move. Without
the garment/bandage, the skin will just stretch and the force
of the
muscle contraction will not be translated to the lymph vessels. The involved
limb could swell more if
you exercise without
compression.
Question #3:
"Why do I need to change my compression garment
twice a day?"
Answer:
Compression garments are made of elastic materials
that stretch out after wearing for about 12 hours. The
areas where
a limb bends (knee, elbow) stretch out more than the rest of the garment and
then those areas
do not receive the correct amount of compression
which can allow pooling of edema fluid that can cause
constriction
at those areas. Some individuals can wear compression garments day and night
and do not need
to bandage their involved limb at night. These
individuals should change their garments in the morning and
again
in the evening. Others may need to apply compression bandages for nighttime
wear or use an
alternative device such as a Reid sleeve, Tribute, or
Jovi. Consult with your treatment team to discuss which
option is
right for you.
Question #4:
"Why do I have to wash my compression garment
every time I change it?"
Answer:
Compression garments are made of elastic
materials that stretch out after wearing. Washing them daily helps
them to retain their elasticity as well as removes perspiration,
bacteria and dead skin that accumulate inside
the garment from
normal wear.
Question #5"
"Why do I have to use moisturizer on my
affected limb?"
Answer:
Moisturizing the skin helps to retain the
elasticity of the skin which helps to avoid cracks/breaks in the skin.
This is important because any break in the skin allows bacteria to
enter the limb which is at risk for infection
because of the
lymphedema.
Question#6:
"Why do I have to wear compression on my affected
limb 24 hours a day?"
Answer:
Our tissues are supplied with oxygen and
nutrients by the blood. This blood is pumped around the body by
the
heart. With every beat of the heart, blood is filtering into our tissues. 90%
of the blood volume in the
tissues is picked up by the veins and
brought back to the central circulation. 10% of the fluid volume in the
tissues can only be brought back to the central circulation by the
lymphatics. So, even when you are
sleeping, even if your arm is
elevated, blood is getting to your tissues (thank goodness!). Remember that in
an impaired lymphatic system, the muscles need something to
contract against to assist the flow of lymph
fluid. Otherwise, the fluid will just pool under the skin and the limb will swell overnight. Then you may not be
able to fit properly into your compression garment the
next morning. That 10% of fluid volume, the lymph
fluid, amounts to
2 liters a day in the whole body. Remember that a compression garment is not
engineered
to "reduce" a limb. It is engineered to "hold" a limb
that has already been reduced. However, you should
always discuss
your individual case with your treatment team, as there are no absolutes and
each person is
different. 24 hour compression may not be right for
you.
Question #7:
"How long can I keep my garment
off?"
Answer:
Generally, in the first few months of CLT treatment it is
not recommended that you remove your garments
for more than 30-60
minutes at a time. Again, the skin of a lymphedematous limb is often stretched
and will
allow edema fluid to rapidly re-accumulate if there is no
compression on the skin. The goal after treatment is
for the skin
and subcutaneous tissues to remodel to the new "smaller" size. This will not
happen if the skin is
allowed to stretch significantly. Once the
limb has remodeled (6-12 months after CLT treatment) you may
be
able to remove the garment for longer periods without the limb
swelling.
Question #8:
"How long after treatment will I have to wear the
garment?"
Answer:
Generally, for as long as the lymphatic impairment
lasts. The short answer is until someone finds a way to
reverse
that impairment. Right now that means forever as there is no cure for
lymphedema. In the case of
impairment secondary to the surgical
removal of lymph nodes/vessels, this is usually not reversible. In the
case of lymphatic impairment due to primary lymphedema, this is not
reversible. Microsurgical techniques to
re-connect lymphatics with
other lymphatics or veins have not been very successful. Scientists are working
on techniques to encourage re-growth of lymphatic vessels but these
are in the experimental stages and on
animal models. But, this is
encouraging. Finally, there are scientists interested in the lymphatics! This
is
progress!
Question #9:
"Can I go swimming and if so, do I
have to wear the garment in the water?"
Answer:
Swimming is one of the
best exercises for lymphedema. If the affected limb is submerged in the water,
then
you do not have to wear your garment because the hydrostatic
pressure of the water is providing the
compression on your limb.
Some people like to wear an old garment in the water because they like the
extra
compression that it provides, and they don't worry about
getting in and out of the water and putting on and
taking off the
garment repeatedly. Always rinse the garment well after swimming, whether in
chlorinated,
fresh or salt water. Take care walking at poolside or
on the shore to avoid cutting your feet. Wear water
shoes or
sneakers on the beach. Wear rubber soled shoes/sandals at poolside and in
shower/locker room
areas to avoid catching fungal infections. And
always wear sunscreen outdoors to avoid sun damage to the
skin.
Question #10:
"Why can't I put my garment in the
dryer?"
Answer:
You can but the heat will ruin the elasticity of the
garment and perhaps shrink it. Some manufacturers say
that you can
put them in the dryer, but that will wear them out faster and they are costly
to replace.
Garments are best air dried - out of direct
sunlight.
Question #11:
"Can I remove my garment to have relations with
my partner?"
Yes, of course, and if you fall asleep without it, that's OK
too. There are always exceptions to the rule.
While you want to do
the best for your condition, you need to work your lymphedema home program into
your lifestyle, keeping in mind the basic principles of the
lymphatic system and lymphedema management.
Consistent compression
is important but there are times when you need to be without compression. Just
make sure that you are monitoring your limb and that any increase
in swelling is addressed quickly to avoid
problems.
Question
#12:
"When I receive lymphatic drainage treatment, where is all that fluid
going?"
Answer:
The fluid is directed back into the central circulation
and whatever volume of fluid is in excess of the "normal"
volume of
your limb is excreted from your kidneys in your normal urine.
Question
#13:
"What are the signs of infection in my affected limb and how do I know
whether I have an infection?"
Answer:
Infection in a lymphedematous
limb/area can look different in each individual and with each infection.
Common signs of infection are unusual redness, warmth, blotchy
appearance to the skin of the affected
limb/area. This is sometimes
accompanied by a sensation of itching, burning, or pain in the area. Some
people develop a fever or feel like they "have the flu" in the affected
limb/area. Regional lymph nodes can be
painful and swollen. Some
people are nauseous. The problem with these symptoms is that they also occur
with other conditions. You can have a red rash from an allergic
reaction or insect bite. You can have nausea
and fever from the flu
or a viral or bacterial infection that does not involve your affected limb.
Sometimes,
the inflammatory reaction to a rash or insect bite can
precipitate an infection. That is why you should always
carefully
inspect your involved/at risk areas carefully every day for any signs of breaks
in the skin, redness,
increased swelling, etc. As soon as you
notice something different, call your physician/therapist to discuss it
with them. Many physicians provide their patients with oral antibiotics
and instructions that they start to take
them if they feel that
they have an infection and then to call the office IMMEDIATELY to come for an
emergency visit to have the area evaluated. You should never
attempt to "treat" an infection yourself. The
reason to have
antibiotics on hand is to be able to start them at the first sign of infection,
just until you can get
medical attention. Abuse of antibiotics is
dangerous, but under-treating an infection in a lymphedematous
limb
or limb at risk for lymphedema is also dangerous.
Question #14:
"Why
should I avoid prolonged sun exposure?"
Fist of all, the sun is hot and
direct exposure causes the skin temperature to rise. The application of heat to
the involved extremity causes the blood vessels to open up (dilate)
and more blood to flow into the area.
This causes an increase in
fluid load in the affected extremity and can cause an increase in swelling. The
sun's
rays damage the skin. A "tan" is really the skin's way of
responding to damage from the sun by depositing
melanin, a skin
pigment, in the upper layers of the skin. Even if you don't normally "burn",
you should wear
sunscreen on your affected limb as well as the
quadrant of your body that connects to that limb. For
example, if
you have lymphedema in your right arm, you should also have sunscreen on your
neck, shoulder
and chest and back on the right side. Actually, you
should always use sunscreen on your entire body to
avoid skin
cancer, but at least have good coverage on your affected areas.
Question
#15:
"Why are people with lymphedema of the arm/hand told to avoid
manicures?"
The skin is a very porous organ. It absorbs chemicals. Acetone
and other nail polish removers are
chemicals. The solvents that are
used to remove artificial nails are strong chemicals. Cutting cuticles too
close can allow bacteria that are always on the skin to enter and
possibly trigger an infection. Nail salons are
public places and
instruments are not sterile. People who wear artificial nails are more prone to
develop
fungal
infections
--------------------------------------------------------------------------------
Lymphedema
Therapy
77 Froehlich Farm Blvd., Woodbury, New York 11797
1-800-MD-LYMPH
or (516) 364-2200
Marvin Boris, MD
Stanley Weindorf, MD
Bonnie B.
Lasinski, MA, PT, CI, CLT-LANA
-----------------------------------
some info on
lymphedema types problems and more
http://www.fpnotebook.com/Surgery/CV/Lymphdm.htm
http://www.lymphedema-therapy.com/FAQ.htm
Frequently Asked Questions
"FAQ"
--------------------------------------------------------------------------------
The
following are frequently asked questions about managing lymphedema and
lymphatic system
disorders. They are by no means complete answers
to what are always very complex questions but
are meant as a guide.
Each individual's situation is unique and each person should consult with their
treatment team for their specific recommendations for their
particular case.
Question #1:
"Why do I have to
exercise?"
Answer:
Appropriate exercise stimulates the flow of lymph.
Muscle contraction and changes in pressure in
the chest from deep
breathing cause changes in pressure on the lymphatic vessels. When the
muscles contract against the compression of the compression bandages or
compression garments
worn on the affected limb this creates changes
in tissue pressures that help the lymph to flow.
Question #2:
"Why do I
have to wear my compression garment/bandages when I
exercise?"
Answer:
When an individual has lymphedema, the pressure of the
edema stretches out the skin so that it no
longer provides a firm
surface for the muscles to contract against. Exercise causes increased blood
flow which caused an increase in lymph load in an already
compromised limb. The compression of
the garment/bandage provides a
"new firm skin" for the muscles to contract against so that the
pressure will be exerted on the lymph vessels and the fluid will move.
Without the
garment/bandage, the skin will just stretch and the
force of the muscle contraction will not be
translated to the lymph
vessels. The involved limb could swell more if you exercise without
compression.
Question #3:
"Why do I need to change my compression
garment twice a day?"
Answer:
Compression garments are made of elastic
materials that stretch out after wearing for about 12
hours. The
areas where a limb bends (knee, elbow) stretch out more than the rest of the
garment
and then those areas do not receive the correct amount of
compression which can allow pooling of
edema fluid that can cause
constriction at those areas. Some individuals can wear compression
garments day and night and do not need to bandage their involved limb
at night. These individuals
should change their garments in the
morning and again in the evening. Others may need to apply
compression bandages for nighttime wear or use an alternative device
such as a Reid sleeve,
Tribute, or Jovi. Consult with your
treatment team to discuss which option is right for you.
Question
#4:
"Why do I have to wash my compression garment every time I change
it?"
Answer:
Compression garments are made of elastic materials that
stretch out after wearing. Washing them
daily helps them to retain
their elasticity as well as removes perspiration, bacteria and dead skin
that accumulate inside the garment from normal wear.
Question
#5"
"Why do I have to use moisturizer on my affected
limb?"
Answer:
Moisturizing the skin helps to retain the elasticity of
the skin which helps to avoid cracks/breaks in
the skin. This is
important because any break in the skin allows bacteria to enter the limb which
is
at risk for infection because of the
lymphedema.
Question#6:
"Why do I have to wear compression on my affected
limb 24 hours a day?"
Answer:
Our tissues are supplied with oxygen and
nutrients by the blood. This blood is pumped around the
body by the heart. With every beat of the heart, blood is filtering into our tissues. 90% of the blood
volume in the tissues is picked up by the veins and
brought back to the central circulation. 10% of
the fluid volume in
the tissues can only be brought back to the central circulation by the
lymphatics.
So, even when you are sleeping, even if your arm is
elevated, blood is getting to your tissues (thank
goodness!).
Remember that in an impaired lymphatic system, the muscles need something to
contract against to assist the flow of lymph fluid. Otherwise, the
fluid will just pool under the skin
and the limb will swell
overnight. Then you may not be able to fit properly into your compression
garment the next morning. That 10% of fluid volume, the lymph fluid,
amounts to 2 liters a day in
the whole body. Remember that a
compression garment is not engineered to "reduce" a limb. It is
engineered to "hold" a limb that has already been reduced. However, you
should always discuss
your individual case with your treatment
team, as there are no absolutes and each person is
different. 24
hour compression may not be right for you.
Question #7:
"How long can I
keep my garment off?"
Answer:
Generally, in the first few months of CLT
treatment it is not recommended that you remove your
garments for
more than 30-60 minutes at a time. Again, the skin of a lymphedematous limb is
often
stretched and will allow edema fluid to rapidly re-accumulate
if there is no compression on the skin.
The goal after treatment is
for the skin and subcutaneous tissues to remodel to the new "smaller"
size.
This will not happen if the skin is allowed to stretch significantly. Once the
limb has remodeled
(6-12 months after CLT treatment) you may be
able to remove the garment for longer periods
without the limb
swelling.
Question #8:
"How long after treatment will I have to wear the
garment?"
Answer:
Generally, for as long as the lymphatic impairment
lasts. The short answer is until someone finds a
way to reverse
that impairment. Right now that means forever as there is no cure for
lymphedema.
In the case of impairment secondary to the surgical
removal of lymph nodes/vessels, this is usually
not reversible. In
the case of lymphatic impairment due to primary lymphedema, this is not
reversible. Microsurgical techniques to re-connect lymphatics with
other lymphatics or veins have
not been very successful. Scientists
are working on techniques to encourage re-growth of lymphatic
vessels but these are in the experimental stages and on animal models.
But, this is encouraging.
Finally, there are scientists interested
in the lymphatics! This is progress!
Question #9:
"Can I go swimming and
if so, do I have to wear the garment in the water?"
Answer:
Swimming is
one of the best exercises for lymphedema. If the affected limb is submerged in
the
water, then you do not have to wear your garment because the
hydrostatic pressure of the water is
providing the compression on
your limb. Some people like to wear an old garment in the water
because they like the extra compression that it provides, and they
don't worry about getting in and
out of the water and putting on
and taking off the garment repeatedly. Always rinse the garment
well
after swimming, whether in chlorinated, fresh or salt water. Take care walking
at poolside or
on the shore to avoid cutting your feet. Wear water
shoes or sneakers on the beach. Wear rubber
soled shoes/sandals at
poolside and in shower/locker room areas to avoid catching fungal
infections. And always wear sunscreen outdoors to avoid sun damage to
the skin.
Question #10:
"Why can't I put my garment in the
dryer?"
Answer:
You can but the heat will ruin the elasticity of the
garment and perhaps shrink it. Some
manufacturers say that you can
put them in the dryer, but that will wear them out faster and they are
costly to replace. Garments are best air dried - out of direct
sunlight.
Question #11:
"Can I remove my garment to have relations with
my partner?"
Yes, of course, and if you fall asleep without it, that's OK
too. There are always exceptions to the
rule. While you want to do
the best for your condition, you need to work your lymphedema home
program into your lifestyle, keeping in mind the basic principles of
the lymphatic system and
lymphedema management. Consistent
compression is important but there are times when you need
to be
without compression. Just make sure that you are monitoring your limb and that
any increase
in swelling is addressed quickly to avoid
problems.
Question #12:
"When I receive lymphatic drainage treatment,
where is all that fluid going?"
Answer:
The fluid is directed back into
the central circulation and whatever volume of fluid is in excess of the
"normal" volume of your limb is excreted from your kidneys in your
normal urine.
Question #13:
"What are the signs of infection in my
affected limb and how do I know whether I have an
infection?"
Answer:
Infection in a lymphedematous limb/area can
look different in each individual and with each
infection. Common
signs of infection are unusual redness, warmth, blotchy appearance to the skin
of the affected limb/area. This is sometimes accompanied by a
sensation of itching, burning, or pain
in the area. Some people
develop a fever or feel like they "have the flu" in the affected limb/area.
Regional lymph nodes can be painful and swollen. Some people are
nauseous. The problem with
these symptoms is that they also occur
with other conditions. You can have a red rash from an
allergic
reaction or insect bite. You can have nausea and fever from the flu or a viral
or bacterial
infection that does not involve your affected limb.
Sometimes, the inflammatory reaction to a rash
or insect bite can
precipitate an infection. That is why you should always carefully inspect your
involved/at risk areas carefully every day for any signs of breaks
in the skin, redness, increased
swelling, etc. As soon as you notice
something different, call your physician/therapist to discuss it
with them. Many physicians provide their patients with oral antibiotics
and instructions that they
start to take them if they feel that
they have an infection and then to call the office IMMEDIATELY
to
come for an emergency visit to have the area evaluated. You should never
attempt to "treat" an
infection yourself. The reason to have
antibiotics on hand is to be able to start them at the first sign
of infection, just until you can get medical attention. Abuse of
antibiotics is dangerous, but under-
treating an infection in a
lymphedematous limb or limb at risk for lymphedema is also
dangerous.
Question #14:
"Why should I avoid prolonged sun
exposure?"
Fist of all, the sun is hot and direct exposure causes the skin
temperature to rise. The application of
heat to the involved
extremity causes the blood vessels to open up (dilate) and more blood to flow
into the area. This causes an increase in fluid load in the affected
extremity and can cause an
increase in swelling. The sun's rays
damage the skin. A "tan" is really the skin's way of responding
to
damage from the sun by depositing melanin, a skin pigment, in the upper layers
of the skin. Even
if you don't normally "burn", you should wear
sunscreen on your affected limb as well as the
quadrant of your
body that connects to that limb. For example, if you have lymphedema in your
right arm, you should also have sunscreen on your neck, shoulder
and chest and back on the right
side. Actually, you should always
use sunscreen on your entire body to avoid skin cancer, but at
least have good coverage on your affected areas.
Question
#15:
"Why are people with lymphedema of the arm/hand told to avoid
manicures?"
The skin is a very porous organ. It absorbs chemicals. Acetone
and other nail polish removers are
chemicals. The solvents that are
used to remove artificial nails are strong chemicals. Cutting cuticles
too close can allow bacteria that are always on the skin to enter and
possibly trigger an infection.
Nail salons are public places and
instruments are not sterile. People who wear artificial nails are
more prone to develop fungal
infections
--------------------------------------------------------------------------------
Lymphedema
Therapy
77 Froehlich Farm Blvd., Woodbury, New York 11797
1-800-MD-LYMPH
or (516) 364-2200
Marvin Boris, MD
Stanley Weindorf, MD
Bonnie B.
Lasinski, MA, PT, CI,
CLT-LANA
http://www.lymphedema-therapy.com/03paper.htm
Secondary
Lymphedema:
Non-Cancer
Related
--------------------------------------------------------------------------------
SECONDARY
LYMPHEDEMA: NON-CANCER RELATED
BONNIE B. LASINSKI, MA, PT, CI,
CLT-LANA
--------------------------------------------------------------------------------
"Doctor,
why is my leg still swollen? What do I have and can it be treated?" These are
questions
often go unanswered, despite numerous diagnostic tests
and evaluations, and in spite of endless
hours of limb elevation.
Why is chronic limb edema (non-cancer related - NCR) such a mystery?
Perhaps
it is because the lymphatic system remains the most neglected organ system in
the body
and is rarely thought about as a logical cause of limb
edema unrelated to cancer treatment.
The key to early diagnosis and
intervention for secondary lymphedema, non-cancer related, is
increasing awareness and education about lymphatic system
pathophysiology and anatomy so that
every physician, regardless of
specialty, recognizes the possibility of lymph system dysfunction as
the
cause of chronic limb edema.
This presentation will review actual clinical
cases that illustrate some of the "uncommon" causes of
secondary
lymphedema, non-cancer related. The following categories will be
represented:
Orthopedic injuries/surgeries - i.e. fractures,
meniscal/ligamentous injuries/repairs, joint
replacements, and
tendon releases.
Neurological conditions - muscle paresis - CVA, post polio,
spastic paralysis.
Vascular injuries/surgeries - vessel injury from trauma
or unintended trauma from catheterization,
removal of a vein/veins
for CABG or leg bypass.
Integumentary injury - trauma to skin, degloving
injuries, burns, damage to skin from long term
steroid use, i.e. for
COPD or RA.
Infection
Scar tissue formation - multiple abdominal
surgeries, i.e. Gall bladder, TAH, umbilical/abdominal
hernias.
Lipedema
Most often it is the combination of
factors that causes the lymphedema to develop. A precise
chronological history of symptoms, surgeries, traumas, medications
used, therapies received, and
co-morbidities can clarify the
"unexplainable" and diagnose the problem, leading to a plan to
manage the lymphedema, thus improving the patient's quality of
life.
The lymphatic system is a regional system. Individual lymph drainage
territories of the skin are
independent of one another. Collateral
connections between these areas exist but are small and are
not
needed when lymph transport capacity exceeds lymph load in the unimpaired
lymphatic system.
When there is disruption to lymph vessels/nodes
from trauma, surgery, infection, scar tissue, etc. or
when the
elasticity of the skin and subcutaneous tissues is poor or when muscle tone is
poor, then
lymph load may exceed lymph transport capacity and
lymphedema results. Usually, edema begins
distal to the site of the
damage/obstruction.
A basic understanding of the normal anatomy of the
lymphatic system is critical for anyone
evaluating an individual
with edema of unknown origin, where testing has already ruled out most of
the common causes of edema, namely cardiac, renal, hepatic, thyroid,
venous, or drug induced.
The major lymph node basins for the
extremities are the axillary (armpit) for the upper extremities
and
the inguinal (groin) for the lower extremities. Lymph from both lower
extremities and the
genitalia drains into the pelvic and abdominal
lymph node basins. From here, the lymph eventually
moving into the
thoracic duct which is the major lymph vessel that transports lymph fluid form
the
lower half of the body into the left venous angle between the
left jugular and left subclavian veins,
and into the right side of
the heart. Lymph from the right upper extremity drains into the right axilla
and then into the right lymphatic duct which empties into the right
venous angle between the right
jugular and right subclavian veins,
into the right side of the heart. Anatomically, one can see that
disruption from infection, scarring, inflammatory processes, accidental
injury during a surgical
procedure in the pelvic/abdominal areas can
result in lower extremity lymphedema as well as
abdominal and
genital edemas. In the same way, any injury along the path from the upper
extremity
to the axilla and then into the chest can result in
lymphedema in the arm/hand. Trauma, infection, or
the formation of
a blood clot in the area around the venous angles can cause lymphedema.
An
individual who undergoes multiple abdominal surgeries with scarring near/around
the abdominal
lymph nodes and the afferent vessels carrying lymph
from the lower extremities, may develop
lymphedema in the legs. An
individual who sustains a severe fracture/dislocation of the ankle
disrupting pathways from the foot/ankle may develop lymphedema of the
foot and ankle which may
progress to the calf due to an overloading
of the functioning vessels in the lower leg. A woman
having
cosmetic surgery to remove excess fat pads in the anterior axillary line may
incur damage to
the axillary nodes if the surgery extends too far
into the axilla. Does this sound far-fetched? I
consulted with a
nurse who had this surgery (after a pregnancy left her with large bulging fat
pads at
the anterior axillary line) and developed lymphedema in her
left hand post operatively. When she
obtained the pathology report,
the specimen from the right side contained fatty tissue only, but the
specimen
from the left side contained fatty tissue and three axillary lymph nodes.
In
most cases of secondary lymphedema non-cancer related, the patient endures
multiple physician
visits and diagnostic tests that rule out the
heart, thyroid, kidney, liver, and cardiovascular system as
causes
of the edema. CAT scans, MRI's and bone scans rule out occult cancer as the
cause of the
swelling. While the patient is heartened that he/she
does not have cancer or a life-threatening
condition, they are
frustrated by the lack of diagnosis of their problem. They know what they don't
have, but they still don't know why their limbs are swollen. An
obvious diagnosis may be venous
dysfunction. Oddly enough, chronic
venous insufficiency may be part of the problem or the root
cause
of the secondary lymphedema, which is still often not diagnosed and properly
treated.
Pure venous edema reduces on elevation. Lymphedema may reduce with
elevation in early Stage
1, but when fibrosis begins to develop the
limb no longer completely reduces with elevation and
skin and
subcutaneous tissue changes occur, leading to decrease oxygenation, an
increased risk for
infection and a decrease in limb
mobility.
The key to early diagnosis and intervention for secondary
lymphedema non-cancer related is an
Increased awareness/education
regarding lymphatic anatomy/physiology and pathophysiology for
every physician and health-care professional, regardless of specialty.
The cases I will review have
seen internists, dermatologists,
podiatrists, cardiologists, neurologists, orthopedists, and
physiatrists, physical and occupational therapists. Many missed the
diagnosis all together.
Unfortunately, progressive skin changes and
bacterial and fungal infections have been misdiagnosed
as
dermatitis, eczema, gout, etc. resulting in improper drug prescription or other
treatments that not
only didn't improve the situation but allowed
the lymphedema to progress unchecked, to the
detriment of the
patient.
What is the solution to this problem? First, a good basic overview
of the lymphatic system
(presented by a lymphologist who can
explain common clinical presentations to the students) needs
to be
included in medical/allied health curricula. The NLN recently offered a 4-hour
instructional
course during their conference held in August 2002 in
Chicago: "Lymphedema management for the
practicing physician". This
session was attended by --- physicians and ---. It provided a wonderful
overview of the lymphatic system anatomy, physiology, and
pathophysiology, and was presented
by some of the leading
lymphologists in this country.
The NLN is trying to set up a Speakers Bureau
of experts who would agree to be available to
present at
conferences, Grand Rounds, Awareness Events, etc. After discussing some basic
lymphatic anatomy and pathophysiology with the physician/husband of
a patient with breast cancer
related lymphedema, he excitedly
admitted that he and his colleagues have seen many patients with
unexplained extremity edema. He was amazed to realize the implication
of the cumulative effects of
surgeries, obesity, trauma, chronic
inflammation requiring long-term steroid treatment, vein harvest
for bypass surgeries, (the list goes on and on) on the lymphatic
system. Of course he is sensitized,
having watched his wife deal
with progressive upper extremity lymphedema, which progressed
despite months of ineffective "treatment". Once she received
appropriate treatment and her
lymphedema began to reduce, he
realized the importance of specialized training/knowledge to treat
lymphatic system disorders. He certainly will never stop his clinical
investigation short of the
lymphatics when diagnosing edema of
unknown origin.
A Review of 24 randomly selected cases revealed the
following causes of lymphedema (several
cases had more than one
cause):
CVA or neuromuscular spasticity - 2 Knee injury/sprain -
1,
Lipedema - 2, Total hip replacement - 1
Fracture - 5 Total knee
replacement - 4
Leg bypass - 1 Coronary bypass - 2
Infection - 9
Abdominal surgery - 5
Chronic steroid medication - 3 Skin ulceration -
3
Arthroscopic surgery of the knee - 2 Vein ligation - 1.
The following
are representative examples of secondary lymphedema non-cancer related.
Case
1 - PP - 49-year-old male, sustained a compound proximal and distal tib/fib
fracture,
trimalleoar fracture/ dislocation of the ankle. He had
ORIF and 4 months of rehab. He did not
progress in rehab due to
severe pain, swelling, heat and redness in the affected lower leg. He had
several episodes of redness, heat and fluid leakage from the sites
where the external fixation device
had been removed. He had seen 3
orthopedists, a physiatrist who prescribed an ankle foot orthosis
to support the distal ankle, and a dermatologist who diagnosed
dermatitis instead of cellulitis and
prescribed a topical steroid
cream. He could not progress in his rehab due to the chronic redness,
pain,
swelling, and limited mobility in his ankle and foot. He could only walk short
distances, had
great difficulty negotiating stairs, and performing
any ADL's involving weight bearing. He was on
disability from his
job as a police officer. He was self- referred to a lymphologist after a friend
and
informed breast cancer survivor recognized that he might have
lymphedema. His lymphedema was
secondary to the trauma of the
fracture/dislocation, surgery, and chronic, untreated cellulitis in his
leg. The swelling was labeled as "post-operative" and the cellulitis was
misdiagnosed as a skin
irritation. He lost 4 months of his life and
his return to work and his life in general was delayed that
much
longer.
Case 2 - MA - 75 year old female who sustained a fracture of the
left second and third metatarsals
when a brick retaining wall in
her garden fell on her as she was weeding. The fractures were casted
in
a short leg cast and in 4 weeks she developed an infection, severe pain in her
leg and foot, and
an ulceration on her heel because her leg swelled
in the cast.
Dopplers and x-rays were negative for any new pathology.
Fortunately, her orthopedist had a
patient who had received CDT
treatment and had done well. She was referred to that lymphologist
after 8 weeks of physical therapy failed to heal the ulcer or reduce
the pain, swelling and limited
mobility in her left
foot/ankle/lower leg. Her lymphedema was secondary to the trauma of the
incident and the infection. After one month of CDT treatment, her ulcer
was completely healed,
range of motion of the foot and ankle were
improved, she could walk without her cane, fit into her
shoes, and
pain was 2/10 reduced from 10/10. Most importantly, she was able to get back to
her
gardening.
Case 3 - PM - 56 year old female with a history
of severe rheumatoid arthritis for 20 years, with a
nine-month
history of progressive swelling in both legs following 18 months of oral
steroid
medication for her arthritis. Because she had been on many
toxic medications to treat the arthritis,
she was referred to a
hematologist for a bone marrow and bone biopsy which were negative. She
was seen by a vascular surgeon who did Dopplers that were negative for
DVT. Her internist
ordered a CAT scan of the abdomen and pelvis
that was negative. She developed progressive
weakness and decreased
mobility in her lower extremities. The skin of both lower extremities was
thin, taut and shiny, and the patient reported that they were
chronically red and warm. She had
been hospitalized for an
infection in her legs in June of 01. There were several small ulcerations on
the right lower leg which were had been leaking lymph for
approximately two months prior to her
referral to the lymphologist.
There was a 4-cm diameter 1-cm deep ulceration on the plantar
surface of the MP joint of the left great toe. Her podiatrist had
"shaved" a callus from this area, and
she reported that she had
been treated for a "staph" infection by the podiatrist, but that he said that
it was resolved.
At the time of her referral, she was dependent
in all ADL's, could not negotiate stairs (she turned
her living room
into a hospital room), spent most of the time in a wheelchair, and could only
ambulate 10 feet with a rolling walker. She developed flexion
contractures in her hips and knees
from the prolonged sitting and
immobility. Her husband had to dress her lower body. Her pain was
10/10 and she was severely depressed. Wound cultures revealed MSRA in
the left great toe
ulceration, and in the small ulcerations on her
right lower leg. No one could figure out what was
wrong with this
woman. She had lymphedema in her legs secondary to prolonged steroid treatment
that worsened after the chronic antibiotic-resistant infection
remained untreated for several months.
The elasticity of her skin
was severely weakened and the skin itself was paper thin and opened
easily. After nine months, her rheumatologist referred her to a
lymphologist after researching on the
Internet.
Once the
lymphedema was addressed (the patient underwent a course of CDT) and the
infection
appropriately treated with a drug that MRSA was sensitive
to, the wounds healed, the edema and
pain resolved, and the patient
began to increase strength and mobility. After 4 weeks of CDT, the
patient was able to ambulate 50-100 feet with her rolling walker. At
the one-month follow-up
appointment, the patient ambulated with a
straight cane, was independent in most of her ADL's,
and was able to
drive herself to the appointment. She was referred to PT for strengthening and
mobility exercises. Her rheumatologist was astounded and vowed to
discuss this case with all her
colleagues and spread the word about
remembering to include the lymphatic system when
evaluating edema of
unknown origin.
Case 4 - RL - a 60 year old male, retired airforce test
pilot, with a six-year history of progressive
lower extremity edema,
onset 6 months following coronary artery bypass using donor veins from
both lower extremities. As the edema worsened, it extended into the
abdomen. Unfortunately for
this patient, he was obese, had a large
abdomen, and did have a history of heart disease. He was
told that
the edema in his legs was just water retention because he was fat and had some
heart
disease. The patient had been sleeping in a recliner chair
for 6 years. He had been diagnosed with
sleep apnea. The patient
referred himself after searching on the Internet for months. His physician
refused to give him a referral because he didn't believe he had
lymphedema because he never had
lymph nodes removed! He traveled
from New Hampshire to New York to consult with a
lymphologist and
receive CDT treatment. His only treatment prior to that had been diuretics. He
was dependent in lower body dressing, only ambulated 10 feet before
stopping to rest and lean on
furniture due to pain and SOB. His
pain was 10/10. He was severely depressed. He scored his
functional
impairment a 10/10. The lymphologist referred him to his cardiologist to rule
out
abdominal ascites or CHF as the cause of his SOB. His
cardiologist did an abdominal US that
found no fluid in the
abdominal cavity. However, he did have abdominal lymphedema!
This
patient received one month of CDT treatment achieving a 53.3-cm reduction in
his left lower
extremity and a 44.5-cm reduction in his right lower
extremity. His weight reduced from 298 to
273 pounds. At one-month
follow-up, he reduced another 21.8 cm on the left leg and 13.3 cm on
the
right. He slept supine in a bed with his wife for the first time in 6 years and
he was able to play
with his grandchildren. He scored his
post-treatment functional impairment a 3/10 because he
needed
assist to don his compression stockings. He did acknowledge that although he
hated the
stockings, they were a small price to pay for getting his
life back. His lymphedema was secondary
to the disruption of the
venous system and scarring/probably damage to lymphatics from the vein
harvest, the subsequent infections, and his obesity. Once again, an
individual who was receiving
regular medical care from an internist
and cardiologist suffered needlessly because the lymphatic
system
was not considered when lower extremity edema developed.
Case 5 - MR a
78-year-old recent widower with a one-month history of severe swelling in his
left
forearm/hand since IV infusions for dehydration caused by
depression. He had seen vascular
specialists who ruled out DVT as
the cause of the edema. His ADL's were impaired 5/10 and he
reported chronic pain and a feeling of bursting in his left hand 5/10.
His grip strength was poor in
the left hand and he was having
difficulty dressing and doing his daily chores. His significant past
medical
history included intestinal resections in 1960 and 1963 for severe Crohn's
disease for
which he required chronic steroid treatment to be able
to function. The skin of all extremities was
thin and there were
multiple scars/bruises from old skin tears/traumas.
MR had lymphedema of his
left upper extremity secondary to damage to the skin lymphatics from
chronic
steroid treatment. He responded well to lymphedema treatment, regaining his
strength and
mobility in his left hand/arm. He was able to
discontinue his compression sleeve/glove after 6
months.
Unfortunately, the lymphedema recurred in 9 months when he again required
hospitalization for dehydration and IV therapy. Except that this time,
MR did his own self MLD
and compression bandaging and then wore his
compression garments for about 3 months and was
able to discontinue
their use.
Case 6 - LK is an independent 85 year old widow with a long
history of osteoarthritis and a 3-year
history of chronic swelling
in her left lower extremity. The swelling limited her safe ambulation and
caused impairment in her strength and range of motion of her left
leg/foot. She required the
assistance of a home health aide for her
ADL's. She could only walk short distances with a quad
cane. She had
had a left total knee replacement in 1995, followed by the removal of a Baker's
cyst
from the left popliteal area in 1997. Two months after that
operation, she developed a fungal
infection around the left knee
prosthesis, necessitating its removal in 12/97. She underwent a
second total knee replacement on the left in 2/98. She was told that
she had "post-op edema"
which had unfortunately lasted for 3 years!
She had consulted several vascular surgeons and
another
orthopedist, none of whom could diagnose the cause of her chronic edema, other
than to
say that she should expect it at her age, after the repeat
surgeries she had had. Once the
lymphedema (which was secondary to
the traumas of the repeat surgeries and the infection) was
treated,
LK was able to "fire" her home health aide and she continues to live
independently in her
own home, needing only a straight cane for
balance when walking.
Case 7 - AS is a 73 year old female with an 18-year
history of primary lateral sclerosis/familial
spastic paresis. She
was dependent in all areas of ADL and required a reclining wheelchair for
optimal positioning. In 4/00 she had a Baclofen pump inserted to
control her severe spasticity. She
developed cellulitis in both
legs shortly after that procedure. Relevant past medical history included
a total abdominal hysterectomy in 1990 and the repair of an umbilical
hernia after that developed
after that procedure. As was advised
that she was not a candidate for "traditional CDT" but she
was
relieved to have a diagnosis for her problem. Her lymphedema was most likely
secondary to
the severe spasticity in her lower extremities
complicated by three abdominal surgeries and cellulitis
in her
legs.
Case 8 - MS is a 66 year old female with a 26 year history of chronic
edema in both lower
extremities. MS was always "overweight" since
her teen years. The swelling in her legs and feet
progressed over
the years and no longer reduced on elevation. In the last few years, she has
been
hospitalized 5 times for IV treatment of cellulitis and
ulcerations in her legs. MS was treated with
diuretics and told to
lose weight. She tried both but the swelling and skin changes kept worsening.
MS has lymphedema in her legs secondary to longstanding
lipedema.
To the trained lymphologist, these cases are self-explanatory. For
each case there is a cause and
effect. The challenge for every
health-care professional is to become educated in the anatomy,
physiology and pathophysiology of the lymphatic system so that no
individual has to live with
lymphedema undiagnosed and
untreated.
--------------------------------------------------------------------------------
Lymphedema
Therapy
77 Froehlich Farm Blvd., Woodbury, New York 11797
1-800-MD-LYMPH
or (516) 364-2200
Marvin Boris, MD
Stanley Weindorf, MD
Bonnie B.
Lasinski, MA, PT, CI,
CLT-LANA
http://www.lymphedema-therapy.com/Lipedema.htm
Lipedema
--------------------------------------------------------------------------------
Overview
and Etiology.
The term lipedema was first used by Allen and Hines (1940) to
describe a symmetrical "swelling"
of both legs, extending from the
hips to the ankles, caused by deposits of subcutaneous adipose
(fatty) tissue. The underlying etiology of these fat deposits remains
unknown. While lipedema is not
a disorder of the lymphatic system
per se, it is frequently confused with bilateral lower extremity
lymphedema. It occurs almost exclusively in women and may have an
associated family history (20
per cent of cases) and is usually
accompanied by hormonal disorders as well (Strossenreuther,
1999).
If present in a man, it is accompanied by massive hormonal disorder.
Fat in
the lower extremities extends to the malleoli (ankle bones), often with flaps
of tissue hanging
over the foot. The feet are not affected;
occasionally, lipedema is found in the arms. Typically, there
are
also fatty bulges in the medial proximal thigh and the medial distal thigh,
just above the knee.
Clinically, the affected individuals complain
of pitting edema as the day progresses, which is
relieved by
prolonged elevation of the leg(s) overnight (Rank and Wong, 1966; Rudkin and
Miller,
1994; Casley-Smith, 1997).
Stages of Lipedema.
In
Stage I, the skin is still soft and regular, but nodular changes can be felt
upon palpation (see
photo #1). There are no color changes in the
skin and the subcutaneous tissues have a spongy feel,
like a soft
rubber doll. In Stage II, the subcutaneous tissue becomes more nodular and
tough.
Large fatty lobules begin to form on the medial distal and
proximal thigh and medial and lateral
ankles just above the
malleoli (see photo # 2). Pitting edema is common, increasing as the day
progresses. The individual may report hypersensitivity over the anterior
tibial (shin) area. Skin color
changes occur in the lower leg,
indicative of secondary lymphedema, which often occurs in later
stage lipedema.
Pathophysiology of Lipedema (Strossenreuther,
1999).
There are many histological and physiological changes that occur in
lipedema. There is a decrease
in the elasticity of the skin and
underlying connective tissue. The basement membrane of blood
vessels is thickened and there are disturbances in vasomotion. There is
decreased vascular
resistance, increased skin perfusion, and
increased capillary filtration. There is increased
venous/blood
capillary pressure causing increased ultrafiltration. These vascular changes
combined
with the decreased efficiency of the calf muscle pump,
result in both the dependent pitting edema
seen in Stage I, as well
as the the secondary lymphedema that often complicates lipedema in its
later stages. Histological changes seen in lipedema include a thinning
of the epidermal layer,
thickening of the subcutaneous tissue
layer, fibrosis of arterioles, tearing of elastic fibers, dilated
venules and capillaries, and hypertrophy and hyperplasia of fat cells.
Clinical studies show that
there is enlargement of the
pre-lymphatic channels (Stoberl et al., 1986) as well as defects in
capillary perfusion (Weinert and Leeman, 1991). Some authors have
reported no alteration in
lymphatic transport (Brautigam et al.,
1998) while others (Bilancini et al., 1995) have reported
decreased
lymph outflow in those individuals with lipedema. Foldi and Foldi (1993)
reported an
increase in fat cell growth during
lymphostasis.
Medical Management
Diagnosis. The diagnosis of lipedema is
difficult if the clinician is unfamiliar with this condition.
Often, these people are told that they are "fat" and should just lose
weight to resolve the problem.
For reasons still unknown, the fatty
tissue accompanying this condition cannot be significantly
decreased
by diet. It is not uncommon for a diagnosis of primary lymphedema to be made.
This
results in frustration for the person who then seeks out
lymphedema therapy with poor results.
There are several significant
clinical differences between lipedema and bilateral primary
lymphedema. The feet are not involved in lipedema; while they are
edematous with a positive
Stemmer's sign in lymphedema, Stemmer's
sign is negative in lipedema (see fig. 12-17). The
"swelling" in
lipedema is symmetrical, while in primary lymphedema usually one limb is more
involved than the other. The subcutaneous tissues feel rubbery in
lipedema. In advanced Stage II
lymphedema, there is significant
subcutaneous fibrosis, which feels firmer than lipedema.
While there have
been reported incidences of cellulitis in Stage II lipedema (usually with a
component of lymphedema as well), the frequency of cellulitis in Stage
II lymphedema is much
higher. The time of onset of the "swelling"
in lipedema is usually around puberty and 90 per cent of
these
cases have accompanying diagnoses of hormonal disturbance (thyroid, pituitary,
or ovarian).
This is usually not the case with primary
lymphedema.
A lymphoscintigram may be helpful to differentiate between
lymphedema and lipedema, however,
there can be conflicting results
as lymphedema often occurs to some degree in the later stages of
lipedema, probably due to impairment of lymph flow caused by the
pressure of fatty tissue. In fact,
there are clinical cases of
bilateral lower extremity lymphedema in the morbidly obese individual;
the onset of the lymphedema occurs after body weight exceeds 350-400
pounds. It is plausible to
suspect that the pressure of a large
apron of abdominal fat can effectively block lymph flow through
the
inguinal area causing the lymphedema but there is a difference between these
cases and
lipedema because obesity does not cause lipedema.
Lipedema is caused by a hormonal imbalance
resulting in excessive
deposition of adipose tissue, most often in the lower extremities (see Figs.
12-
21; 12-22) although it can occur in the upper extremities as
well.
Treatment and Prognosis.
There is no effective medical
treatment for lipedema and the prognosis is guarded; however,
significant functional improvements are possible with good program
compliance and therapy
intervention. Medical management involves
treating the hormonal disturbance as effectively as
possible and
providing nutritional guidance to avoid additional weight gain. Many of these
individuals have endured years of ridicule because of their
physical appearance and become
recluses in their homes, further
limiting their activity level. As lipedema progresses and the
hypersensitivity increases, they feel less inclined to walk or exercise
because of the pain. They
inevitably gain more weight due to the
inactivity and depression, often finding food their only
comfort.
The primary goal of therapy intervention in the person with
lipedema is symptomatic relief and
realistic improvement of trunk
and lower extremity function. Application of the combined
lymphedema treatments has shown some success in relieving the pain and
hypersensitivity in the
lower legs and improving general mobility.
Usually, a lower level of compression is needed to
support a
lipedematous limb, compared to a lymphedematous limb of the same size and
girth. This
guideline applies to the compression garments as well.
These individuals often require more
padding under the compression
bandages, particularly in the anterior tibial area. They do not
tolerate the heavier, denser compression fabrics and usually require a
lower grade compression
garment than someone with uncomplicated
lymphedema. The therapist must remember, however,
that later stage
lipedema is often accompanied by lymphedema as well, and the treatment and
management must take that factor into consideration when recommending
exercise and garments.
The main goals of intervention are to decrease pain
and hypersensitivity, to decrease the
lymphedematous component of
the disease, and to assist the individual in maintaining and/or
reducing adipose tissue through exercise and nutritional guidance. The
compression garments can
help to decrease the adipose tissue with
exercise and weight loss. The most difficult task is fitting
the
compression garments. They must be custom made due to the large size of the
individual and
are often uncomfortable at the waist, particularly
when sitting. Making the radical change in daily
activity level is
most challenging for these individuals. Providing continued support and
encouragement is important.
Networking is helpful and is facilitated
by offering a support group, even when held on an irregular,
informal basis. An hour-long educational meeting, even if only offered
three or four times per year
can provide a neutral meeting place
for people to begin networking. Nothing can compare to the
encouragement and hope that an individual with lipedema/lymphedema can
derive from seeing and
talking with someone else living with the
same problem and hearing how others cope on a day-to-
day basis.
Therapists can learn some of the best guidance on exercise and coping with
garments in
a group like
this.
--------------------------------------------------------------------------------
Lymphedema
Therapy
77 Froehlich Farm Blvd., Woodbury, New York 11797
1-800-MD-LYMPH
or (516) 364-2200
Marvin Boris, MD
Stanley Weindorf, MD
Bonnie B.
Lasinski, MA, PT, CI,
CLT-LANA
http://www.lymphedema-therapy.com/lymphedema-exercise.html
Lymphedema
and
Exercises
--------------------------------------------------------------------------------
Exercise
for Lymphedema Benefits Supported by Studies
Bonnie B. Lasinski, MA, PT,
CLT-LANA
--------------------------------------------------------------------------------
Exercise
and lymphedema - it is a controversial subject
How is lymphedema and
exercise viewed today? How many clinicians are at a loss for words
when they are asked about what kind of exercise is "good" for
individuals with lymphedema? How
many individuals living with
lymphedema or a limb at risk for lymphedema have asked their
healthcare professional for advice concerning exercise only to receive
conflicting information? It is
difficult to "recruit" presenters to
provide workshops/discussions on lymphedema and exercises for
both
patients and professionals alike. Exercise and lymphedema - it is a
controversial subject.
Our Nearly 30 Years of Research on Exercise for
Lymphedema
Twenty-nine years ago in 1980, I was asked to do a presentation
on exercise after mastectomy for
a one day seminar sponsored by the
American Cancer Society's Long Island Division, entitled
"Living
With Cancer". When I contacted the coordinator of the workshop, Diana Rulon,
she
informed me that she was not "interested in exercise after
mastectomy - she was interested in
exercise for
lymphedema!"
You can imagine my shock and fear at that moment. I had no
special training in lymphedema
management, never mind lymphedema
and exercise; in fact, no one did. We were just beginning to
hear
strange tales of a treatment from Europe that seemed ridiculously mild for the
severe swellings
I had seen in my limited experience. But, I
figured “no problem”. I'll just go to the medical library,
research
the articles, and develop my talk from there. Well, that was 1980 and there
were no
articles on exercise for lymphedema, except for a few
abstracts of German and French studies.
Now, I was really in
trouble. Well, long story short, I was inspired by the dedication of Diana
Rulon who tried to find help for other women like herself, who had long
been ignored by their
doctors and told to live with their problem.
Thus began my journey in lymphedema management.
Trial by fire, you
might say!
We presented a very basic, common sense talk on lymphedema,
trying to define it in simple terms
(no small feat when the
literature was so poor - the definition at that time was a 2 centimeter
difference between forearms - as if that was the only place one could
have lymphedema!). Next,
Diana presented some practical suggestions
for nutrition that she had found helpful to her and
several other
women she knew. Finally, I wrapped up the session with some very basic
information
on lymphedema and exercise progression and then opened
the floor for questions.
In 2009, although the medical management of
lymphedema has come a long way, thanks in great
part by the
advocacy of Saskia Thiadens and the NLN and many others, there is still much
work to
do. Basic and advanced research on the effects of exercise
as a lymphedema risk reduction
modality must be explored.
The
basic criticism of the precautions about exercise for lymphedema contained in
the Risk
Reduction Guidelines is that they are "anecdotal" at the
present time, due to the lack of controlled
double-blind studies to
prove their efficacy.
Some medical professionals have taken the position
that the individual with a limb at risk (or with
lymphedema) should
go ahead and pursue whatever exercise/activity they wish and "see what
happens". Unfortunately, lymphedema is a chronic condition, which,
presently, has no cure.
While it is true that not all individuals who have
had lymph node disruption (surgical or radiological)
will develop
lymphedema, until physicians can better predict who is at greater risk for
lymphedema,
a prudent approach to exercise for lymphedema is
advisable. In the case of individuals with primary
lymphedema or
established secondary lymphedema, working up to a level of exercise that
promotes fitness while avoiding exacerbating the lymphedema is a good
goal.
Exercise for Lymphedema makes Medical Sense
I'm sure that some of
you may have been told in the past that you should not exercise if you have
lymphedema, or that certain types of exercise are contraindicated if
you have lymphedema. This is
not the case. I would like to review
some basic principles of anatomy and physiology and
pathophysiology
of lymphedema and how these relate to exercise and lymphedema.
Basic
principles behind occurrence of lymphedema
•Lymphedema occurs when there is
an imbalance between lymph transport capacity and lymph
load.
•After any surgical disruption or radiation treatment to a
lymph node region, a state of latent
lymphedema occurs. That is to
say that the lymph transport capacity is reduced but it is still greater
or equal to the lymph load.
•Acute/chronic lymphedema develops when
that balance is shifted and lymph load exceeds the
impaired lymph
transport capacity.
•In the case of Primary Lymphedema, where there is a
malformation/malfunctioning of the
lymphatic transport system that
results in a reduced lymphatic transport capacity, lymph load often
exceeds that transport capacity, and progressive lymphedema develops
over time.
Lymphedema is a problem of excess water and protein
Our
lymphatic system, in addition to filtering out waste products, helps our bodies
maintain fluid
balance so that we are neither dehydrated nor
edematous.
Up to 90% of the water component of our blood that perfuses the
capillary network and nourishes
our cells returns to the heart via
the venous system.
The 10% (or more) that is left behind in the tissues
along with the extracellular protein that filters
out of the
capillaries, can only return to the heart via the lymphatics. That 10% (or
more) can
amount to up to 2 liters a day. While 2 liters may not
seem like much, it adds up day after day, if
there is impairment in
lymph drainage.
In addition, the extracellular proteins can only return to
the central circulation via the lymphatic
vessels. The diameter of
these molecules is too large to fit into the openings in the vein walls - the
openings in the lymphatic vessel walls are large enough for these
protein molecules to enter easily.
So lymphedema is not only a problem of
excess water remaining in the tissues, but of excess
protein that
remains in the tissues as well. Unfortunately, the body always moves for a
state of
balance so it actually tends to pour more water into the
tissues to "dilute" this protein concentration
- thus a vicious
cycle develops. This problem is compounded by the fact that the white blood
cells
called macrophages, which are part of our immune response, do
not work properly in the
lymphedematous fluid. This is why anyone
with lymphedema is at increased risk for infection in his
or her
affected limb.
Relation between lymphedema and exercise
What does all
this have to do with exercise? A review of the acute and chronic effects of
exercise
is helpful to understand how the limb at risk or a
lymphedematous limb might respond to various
types of exercise. The
acute responses to exercise include increases in heart rate, stroke volume,
cardiac output, blood flow to active muscles, systolic blood pressure,
arteriovenous oxygen
difference, ventilation, oxygen uptake, and a
decrease in blood pH and plasma volume.
Chronic adaptations to exercise
include biochemical changes in skeletal muscles, decreased resting
heart rate, decrease in total body fat, blood lipids, and the density
and strength of bone and
connective tissue.
During exercise,
blood is redirected to the muscles. At rest, only 21% of the cardiac output
goes to
the muscles, compared with as much as 88% during exhaustive
exercise. As the body heats up, an
increasing amount of blood is
directed to the skin, to conduct heat away from the body core.1
Remember that lymph transport has to be equal to or greater than lymph
load. When you exercise,
your muscles need extra blood to supply
the oxygen needed for your muscles to do the work of the
exercise.
Extra blood flow means that extra water will remain in the extracellular spaces
needing
transport via the lymphatic system.
So exercise for
lymphedema may be beneficial, however the question is how much is too much?
That is very individual. It is important that any exercise program be
gradually progressed to avoid
sprain/strain. More importantly, a
slow progression allows the individual to monitor their affected
limb or limb at risk for any sensation of aching or fullness that could
indicate an overwhelming of the
lymphatic system.
Lymphedema and
Exercises are specific to each individual
Benefits of exercise for
lymphedema
•Exercise can increase the uptake of fluid by the initial
lymphatics and enhance the pumping of the
collecting
lymphatics.
•In addition, exercise mobilizes the joints and strengthens the
muscles of the involved
limb/limbs/trunk quadrant, thus decreasing
the risk of strain/sprain.2
Exercise for lymphedema is best done with
compression
Exercise for lymphedema is best done with compression on the
affected limb either from
compression bandages or compression
garments. The bandages provide a new "tight" skin for the
muscles
to contract against, assisting in pumping the lymph out of the extremity into
the central
circulation. When lymphedema exists, the remaining lymph
vessels that are functioning are working
double time to try to
carry the load. These vessels become over dilated (stretched) and eventually,
their walls can overstretch and fail, causing a worsening of the
swelling.
Wearing compression bandages/garments provides support to the skin
and to the lymphatic vessels
directly under the skin, called the
superficial lymphatic network. It is these vessels that help to carry
the
load when the larger vessels have been cut away from the lymph nodes or have
been damaged
due to trauma or chronic venous disease, or in the case
of primary lymphedema, when there are
too few large lymph
collectors in a region due to improper vessel/node development during fetal
growth
Certain types of exercise are considered higher risk
Of
course, certain types of exercise are considered higher risk than others for
individuals with
lymphedema. For example, high speed activities like
tennis, bowling and racquetball, place more
stress on the upper
limb while jogging, stair-climbing machines, downhill skiing, water skiing,
football, soccer place more stress on the lower extremities or have
higher injury risk than other
activities such as swimming, brisk
walking, and cycling. That is not to say that someone with
lymphedema of the leg should not jog for exercise, or that the person
with lymphedema of the arm
and hand should not play tennis or
golf.
It is also important to know whether an individual was skilled at a
sport/activity prior to their
developing lymphedema. A
sport-specific exercise program can be developed for the individual to
build strength, flexibility and endurance in the muscle groups most
used in that sport/activity.
Ultimately, the decision to "play"
should be an individual one, but an informed one.
Things to consider
regarding lymphedema and exercise
•Many men and women with lymphedema or a
limb at risk want to work out with weights. A slow
progression of
light weights can be done safely and can allow an individual to develop good
strength and power in any muscle group.
•The important thing to
consider is whether you feel good after the exercise and how your affected
limb reacts after you exercise.
•You must also consider your level
of daily activity and modify accordingly - if you have had a
particularly difficult day and your affected limb is more swollen, you
may choose to do a different
activity i.e. swim instead of walk, or
you may realize that the best activity for that day is to rest with
your limb elevated.
•The importance of deep abdominal breathing
exercise should not be overlooked. Deep breathing
enhances the
pumping in the thoracic duct (the major lymphatic vessel draining the lower
body and
the left upper trunk/arm/hand).
Exercise for lymphedema
is one component of the treatment for lymphedema. You’ll find more
information here on other components of Comprehensive Lymphedema
Treatment with our
certified lymphedema therapists.
Lymphedema
and Exercise Case Studies
Case Study of Upper Body Exercise for
Lymphedema
A series of case reports published in the Journal of Surgical
Oncology3 challenges the theory that
vigorous upper body exercise
is contraindicated for individuals who have had axillary dissection
during surgery for breast cancer. The study followed a group of 24 women
for 9 months. These
women were recruited to participate in a
training program to prepare for competition in the World
Championship Dragon Boat Festival in Vancouver, British Columbia.
Dragon Boat racing involves
strenuous repetitive upper body
exercise. 18-20 women paddle 40-60 foot boats for a distance of
500-650 meters. Circumferential measurements were collected on 20 of
the 24 participants (limbs
were measured at 4 places) pre training,
at the start of the racing, and 7 months after the races.
According to the
authors, only two women, who had pre-existing mild lymphedema, had increases
in their upper arms (5/8 inch) and none of the other participants
developed lymphedema. One of
the authors of the study, herself a
breast cancer survivor participated in the program. Regarding
lymphedema and exercise, the authors conclude that strenuous upper body
exercise may not cause
lymphedema or worsen a pre-existing
lymphedema.
It is important to note in this lymphedema and exercise study
that the participants in this study
completed a two-month training
program of stretching, strengthening, and aerobic exercises prior
to engaging in the actual strenuous activity of Dragon Boat
racing.
Many individuals who undergo breast surgery/axillary
dissection/radiation are not enrolled in
supervised progressive
exercise programs like the participants of this study. Providing structured,
individualized exercise programs should be a goal of all centers
that perform cancer surgeries. The
at risk/limbs with lymphedema
should be measured periodically to insure that there are not subtle
volume changes that may not be visible to the individual.
While I
do not discourage individuals from participating in sports and exercise, I do
caution them
that they should consider themselves "athletes" in the
"game" of life. As such, each individual should
engage in a
stretching/strengthening program to prepare them for full participation in
whatever
activity they choose.
Case Study of Weight Training
Effects on Lymphedema
Ahamed et al in 2006 examined the effects of
supervised upper and lower body weight training on
the incidence
and symptoms of lymphedema in 45 breast cancer survivors who participated in a
supervised, graduated program of exercise twice weekly for 6 months.
None of the participants
experienced a worsening of their
lymphedema or a triggering of lymphedema in their at risk limbs.
Schmitz et
al in 2009 assessed the safety of a graduated exercise program on 295 survivors
with
breast cancer related lymphedema (BCRLE) and 154 at risk for
lymphedema. Their results were
similar, demonstrating that
individuals who are at risk for lymphedema or who have lymphedema
can participate in exercise, provided it is progressed slowly and their
limbs are assessed for any
signs of increased or developing swelling
throughout the program and the program is modified
accordingly for
each person.
The key is proper evaluation and assessment for signs of
swelling, tightness, or skin and tissue
changes, before, during and
after exercise.
A related study that we conducted can be found here
involving Upper Extremity Lymphedema
Secondary to Breast Cancer. The
study involved patients with unilateral upper extremity
lymphedema
secondary to axillary node dissection (accompanying lumpectomy or mastectomy
for
carcinoma of the breast). It was done to evaluate the
persistence of reduction in lymphedema
following a single course of
Complex Lymphedema Therapy.
Please write us any questions or concerns
you may have about treatment options at Lymphedema
Therapy.
Our
Certified Lymphedema Specialists will be happy to answer your questions on how
we may
help you or someone you know who has lymphedema. We invite
you to fill out and submit your
questions to us here on our Contact
Form.
The physicians and certified lymphedema therapists at Lymphedema
Therapy are experienced in
these assessments. For more
information, contact our center at
516-364-2200
References:
1.Nieman, David C. Exercise Testing and
Prescription: A Health Related Approach, 4th ed.
Mountain View,
California, Mayfield Publishing Co., 1999: P, 190-205.
2.Casley-Smith,
Judith R, Casley Smith, John R. Modern Treatment for Lymphoedema, 5th ed.
Adelaide, Australia, The Lymphology Association of Australia, 1997: p.
188-189.
3.Harris, Susan R, Niesen-Vertommen, Sherri. Challenging the Myth
of Exercise-Induced
Lymphedema Following Breast Cancer: A Series of
Case Reports. Journal of Surgical Oncology
2000;
74:94-99.
--------------------------------------------------------------------------------
Lymphedema
Therapy
77 Froehlich Farm Blvd., Woodbury, New York 11797
1-800-MD-LYMPH
or (516) 364-2200
Marvin Boris, MD
Stanley Weindorf, MD
Bonnie B.
Lasinski, MA, PT, CI, CLT-LANA