Five facts about lymphoedema
Helen Eason, Tara McKenzie, Elizabeth Ringrose and Teresa Lee contribute five discussion points about lymphoedema.
Lymphoedema is not limited to cancer survivors
While removal of lymph nodes and radiation treatment for cancer leaves survivors with a lifelong risk of developing lymphoedema, the most common cause of lymphoedema worldwide is ﬁlariasis, which is contracted in tropical areas.
Filariasis is a parasitic worm transmitted by mosquitoes that lives in and blocks/ destroys the lymphatic system, causing severe limb and genital lymphoedema. Filariasis has infected 120 million people, with 40 million disﬁgured and incapacitated (World Health Organization (WHO)).
The WHO is undertaking preventive chemotherapy programs in 49 countries to stop its spread. History of travel to the tropics should, therefore, always be included in subjective examination when other causes of lymphoedema have been excluded.
Primary lymphoedema, where genetic lymphatic mutations occur or defects inherited, can affect any body part in people of all ages. A one in 6000 prevalence is suspected. Adolescence is when symptoms commonly arise (75 per cent) with girls affected four times more than boys (lymphoedema praecox). Five to 10 per cent occurs from birth (congenital lymphoedema) and 10 per cent after 35 years (lymphoedema tarda). The genetic mutation/abnormality leads to aplasia or hypoplasia of lymph vessels and/or nodes, or hyperplasia of vessels/ nodes with impaired function.
Lymphoedema secondary to skin or deeper lymphatic vessels/node trauma can be suspected by therapists when post-trauma—or postoperative oedema after hip and knee replacements—fails to resolve as expected. If you suspect your client has lymphoedema, use the national lymphoedema practitioner register (tinyurl. com/s7zgo89) to ﬁnd an accredited practitioner for assessment and treatment.
Lymphoedema can be effectively managed with compliance to a treatment regimen
Once developed, lymphoedema is a chronic lifelong condition that needs to be managed. Management is shown to be most successful when it includes early education about the condition, a prospective monitoring program that is cost-effective and guidance for self-management strategies to be continued at home.
Optimal care for those who develop lymphoedema are determined by the stage of disease; however, all stages undergo components of complex lymphoedema therapy (CLT). This involves education about lymphoedema, skin care, manual lymphatic drainage (MLD) and compression garmenting with or without prior compression bandaging.
Research shows that patients who are educated prior to surgery improve their ability to detect the early signs of disease development. Successful monitoring tools are also helpful. Having baseline measurements such as bioimpedance spectroscopy and limb circumference measures allows the detection of small changes, thereby allowing treatment to commence and potentially reversing the condition.
MLD is used to move congested fluid areas by bypassing ineffective lymph vessels and encourage new paths. MLD is not sufﬁcient on its own but maintains positive results when used in conjunction with garment prescription. MLD can be taught to the patient and continued at home. Garment prescription gives best results in preventing or slowing the swelling of the limb and build-up of ﬁbrotic tissue.
Exercise is safe for people at risk or who have lymphoedema
There has long been controversy surrounding exercise with those who have or are at risk of lymphoedema. So is it safe? Yes. Studies have looked at the use of resistance or aerobic exercise, or a combination of both, in this population and have found no increase in limb volumes or occurrences. So at minimum, exercise does not exacerbate lymphoedema. It has been shown that an exercise program of varying modalities that is progressed slowly is a safe option for patients with lymphoedema. Lymphoscintigraphy post-exercise has shown to increased lymph flow due to the associated muscle activation, increased heart rate and deep breathing. This has shown to be true in both primary and secondary lymphoedema.
Exercise, combined with compression therapy, has shown to be more effective in improving limb volumes than compression alone. Those garmented for lymphoedema will beneﬁt more with the inclusion of exercise in their self-management program and perhaps light compression for those at risk could have potential beneﬁts as well. Due to the compressive forces at play in water, aquatic-based exercise programs are a great option for lymphoedema patients.
Looking at the research, you need to be mindful that most studies have been done on secondary—not primary—lymphoedema, predominantly upper limb and undertaken six months after cancer treatment has ceased. Few studies have addressed the effects during the treatment phase but it is reasonable to assume the beneﬁts can be applied to patients during this time as well.
There is plasticity in the lymphatic system
Damage to the lymphatic system may be imperative to local cancer control but the good news is that lymphatic vessels have the ability to reconnect to other functioning lymph vessels and venules. This includes the regeneration of collateral lymphatic pathways, superﬁcial to deep lymphatic pathways and lymphovenous shunts (Suami et al 2007). This amazing ability varies between, and within, individuals.
The ‘plasticity’ of an individual’s lymphatics is probably dependent on their body’s ability to produce proteins that stimulate growth of endothelial cells and new lymphatics, as well as the resilience of their pre-existing lymphatic system. This may explain why only a proportion of patients develop lymphoedema following lymphadenectomy, and why some patients progressively worsen and some recover from early lymphoedema.
The knowledge of plasticity in lymphatics opens up many questions about lymphoedema treatment. For example, would compression and manual lymphatic drainage help drive regeneration of collateral lymphatic pathways? With current indocyanine green infrared imaging techniques allowing real time visualisation of superﬁcial lymphatic pathways, the future for research into this area of lymphoedema is bright.
Lymphoedema increases the risk of cellulitis
Cellulitis is an infection of the skin and superﬁcial tissue that can occur in the presence of lymphoedema, or a compromised lymphatic system. Bacteria favours the high-protein environment of lymphoedematous tissue. Poor skin quality and/or skin injury can lead to cellulitis.
The more severe the lymphoedema is, the greater the risk of cellulitis, with each episode of cellulitis often worsening existing lymphoedema.
Early symptoms of cellulitis are usually conﬁned to the local infected area. The skin may look red, accompanied by swelling, heat and tenderness. If left untreated, the infection can spread to the blood stream and other parts of the body causing fevers, chills, malaise and nausea.
Immediate treatment is recommended if there is suspicion of cellulitis. If detected early, oral antibiotics can be given, but for more severe infection, intravenous antibiotic treatment may be required with or without a hospital admission. Rest and elevation are recommended for cellulitis and compression garments may need to be removed until the acute pain settles and the patient can tolerate pressure on the body part again. Prophylactic antibiotics are recommended for patients who develop repeated episode of cellulitis.
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Helen Eason, APAM, is a Melbourne- based private practitioner. Helen is an advanced practice physiotherapist in oncology and lymphoedema. She has worked in this field for 21 years.
Tara McKenzie, APAM, is the owner and director of Central Coast Physiolates on the Central Coast of New South Wales. Tara has a special interested in women’s health, cancer rehabilitation and lymphoedema.
Elizabeth Ringrose, APAM, has worked in the area on cancer, lymphoedema and palliative care for more than a decade, with particular interest in lymphoedema prevention and cancer rehabilitation. Elizabeth is the principal physiotherapist at Onccare, she is an Australasian Lymphology Association committee member, a lymphoedema therapist and a Pinc and STEEL physiotherapist.
Teresa Lee is an APA Cancer and an APA Lymphoedema physiotherapist at the Melanoma Institute Australia and Royal North Shore Hospital, and is a research associate at The University of Sydney. She was the APA NSW Cancer, Palliative Care and Lymphoedema group chair from 2013 to 2019, the convenor of the 12th Australasian Lymphology Association conference and she won the 2017 APA NSW Branch Award for ‘Outstanding Contribution to the Profession’.
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