Lymphedema Treatment

Lymphedema Management

At Body In Balance 

Laura Germanio OTR, RYT, LMT, CLT


Lymphedema is a specific type of edema (swelling) that most commonly occurs following cancer treatment, radiation or surgery that damages the lymphatic system. This is a particularly difficult type of edema to treat as it does not respond to elevation or the use of diuretics.  The most effective form of treatment and management of lymphedema is known as Complete Decongestive Therapy (CDT) carried out by a Certified Lymphedema Therapist (CLT).  When the acute and maintenance phase are performed correctly there is a significant decrease in limb size that can be maintained long term with proper compression garments.

The Lymphatic System: A Basic Overview of Fluid Movement:The lymphatic system works closely with our circulatory system to transport fluid, nutrients and protein from the tissue in the body. Unlike the circulatory system, the lymphatic system does not contain a central pump. Instead, the fluid is moved by tiny pulses created within the vessel as well as the pressure created by muscle contractions. The lymphaticcapillaries collect fluid, protein and cellular waste from the cellular space. This is then transported to larger Precollectors and collectors that move the lymphatic fluid to the regional lymph nodes. After the lymph nodes filter the fluid it is sent to Larger Trunks and then lymphatic Ducts that return the lymphatic fluid to the Right and Left venous angle, at the base of the neck. The fluid that is returned to the circulatory system will then be filtered by the liver and kidneys. Excess fluid will be removed from the body as urine.  The lymphatic system plays a vital role in the body’s immune function because it transports lymphocytes that work to fight infection. 

Lymphatic Flow Blood Flow

No central pump to move lymph

One way movement

1-2 litres/day

No continuous column of fluid

Lymphatic pressure unaffected by position

Obstruction causes collection of high protein fluid

Accounts for 10% of the fluid movement in the body

Heart pumps blood through the body

Circular system

Liters/minute

Continuous column of fluid

Venous pressure changes with position

Obstruction causes collection of low protein fluid

Accounts for 90% of the fluid movement in the body

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Factors that Influence Lymph transport

Intrinsic contraction of the lymphatic vessels

Deep breathing

Muscle contraction

Arterial and venous blood pressure

External pressure (air, water, compression garments)

New lymph production (from stretch & pull stimulation to the lymphatic capillaries in the skin)

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What is Lymphedema?  Lymphedema is an accumulation of fluid and protein in an area of the body where the lymphatic system’s transport capacity is insufficient.  The characteristics include a slow but progressive onset that may take years to reach a noticeable level of swelling. The progression will almost always start distally and progress proximally. There will be a loss of contours, bony landmarks and wrinkles in the skin as the fluid accumulates and the limb takes on a columnar shape.  Lymphedema is rarely painful, but often associated with feeling dull, aching, heavy and tight. When more than one limb is involved the presentation will often be asymmetrical as the different quadrants will not accumulate fluid at the same rate.  A history of cellulitis in the area is common because of the decreased immune function associated with lymphatic insufficiency. The presence of necrotic ulcerations is not associated with pure lymphedema because blood supply remains intact, however ulcers can be present in a patient with comorbid lymphedema and venous insufficiency.  When left untreated the protein buildup caused by lymphedema will cause skin inflammation and the development of fibrosis, hyperkeratosis, papillomas, Peau D’orange and fluid reflux.

How is Lymphedema Diagnosed?-          
-History of trauma, radiation, cancer treatment, surgery or lymph node removal         
-Palpation, measurement and visual exam       
-Stemmer Sign: pinch and lift the skin on the tops of the fingers and toes. If the skin is fibrotic, squared off or resistant to lifting the stemmer sign is positive.      
-Presence of the “buffalo hump” swelling on the dorsal foot or hand      
-History of cellulitis or fungal skin infections

What is a Certified Lymphedema TherapistCLT has prior training as a Physical Therapist, Occupational Therapist, Nurse or Massage Therapist. They then go through an intensive training in the anatomy, physiology, pathology and treatment of lymphatic disorders and edema. Each CLT is able to create a customized multistep program to bring the patient through the acute (decongestive phase) to the maintenance phase of lymphedema management. The CLT is able to measure the patient for an off the shelf or custom compression garment based on their needs. This treatment protocol can also be appropriate for other forms of edema when medically indicated. 

Lymphedema Resources

Understanding the condition of Lymphedema is the first step to proper management. These videos contain great information on what causes the condition and how to best manage it. Watch these videos regularly to refresh your understanding of the condition.

This is a link to Laura's playlist of Lymphedema Education Videos: https://www.youtube.com/playlist?list=PLIgEfyd4hn5oI2X5dYewTz9hOixdJ3oCV 

This is a link to Laura's playlist of Lymphedema Exercise Videos: 
https://www.youtube.com/playlist?list=PLIgEfyd4hn5pMmqJk_wqIiQvUO91pqFov

This is a link to Laura's playlist of Manual Lymphatic Drainage Videos: 
https://www.youtube.com/playlist?list=PLIgEfyd4hn5poRypdA3rqQyV92OKe9mOh

This is a link to Laura's playlist of Compression Wrapping Videos: 
https://www.youtube.com/playlist?list=PLIgEfyd4hn5qlIoyxeqV9MDwzgeN-NQEy
This is a link to Laura's playlist of Compression Garment Videos: 
https://www.youtube.com/playlist?list=PLIgEfyd4hn5oThmM9stDh6nVjLEMXFCTW

www.youtube.com/lymphnet
www.lymphnet.org

Complete Decongestive Therapy:(CDT)
Acute Phase:

-Thorough skin care

-Manual Lymphatic Drainage (MLD)

-Short stretch compression wrapping

-Muscle pump exercises

Maintenance Phase:

-Daily skin care routine

-Self Manual Lymphatic Drainage

-Daytime wear of a compression garment

-Night wear of a multi-layer wrap or wrap alternative

-Daily muscle pump exercises and activity program

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Types of Lymphedema:
-Primary Lymphedema- A collection of protein rich fluid due to a congenital lack of proper lymphatic system structures in the body.  The onset of symptoms can be from birth to early adulthood.
-Secondary Lymphedema- A collection of protein rich fluid due to damage or removal of part of the lymphatic system. The most common cause is surgery or radiation for cancer treatment. Lymphedema can also be caused by trauma to the body that overloads the lymphatic system’s transport capacity.
-Filariasis- A type of secondary lymphedema caused by infection with the philarial worm parasite. This is a mosquito born parasite found in tropical areas and is the most common cause of lymphedema worldwide.  It is very uncommon in developed countries but can be seen in individuals that traveled to tropical areas and were infected. Symptoms may take years to develop following infection.
-Lipedema- this condition is diagnosed mainly in women as it is an estrogen related collection of fat cells. The patient will present with a large collection of adipose tissue from the pelvic crests to the ankles in a symmetrical distribution. There is a noted band around the ankles and the feet are spared the collection of adipose tissue. The upper body may be noticeably thinner than the lower body and the patient often expresses frustration that exercise has had no effect on decreasing the size of the lower body. The tissue has a very soft texture but exhibits little or no pitting. There is no history of cellulitis but the skin may be sensitive to palpation and bruise easily.
Lipolymphedema- This is a combination of Lymphedema and Lipedema. When left untreated lipedema strains the lymphatic system. Over time this strain can cause damage and lymphedema will be present with the lipedema.
Malignant Lymphedema- the presence of a tumor can put pressure on the lymphatic system to a point where fluid movement is restricted and lymphedema results. The tumor must be medically managed before treatment of the lymphedema can be considered.
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Other Conditions related to Edema:
o   Venous Edema: the most common cause of edema in the lower extremities that arises from vascular damage. This is a low-protein, water rich edema. The collection of fluid and the associated gaiter distribution of darkened skin (hemosiderin staining) is present from the ankle to the upper calf with little to no pitting.  The skin becomes dry, tight, shiny and inelastic.  Necrotic ulcerations are common as the condition progresses. When left untreated the excess fluid in the cellular space will put stress on the lymphatic system and cause a co-morbid lymphedema (phlebo -lymphostatic edema).   CDT is indicated as an appropriate treatment for mild to moderate venous disease if no other contraindication are present.
o   Cardiac Edema:  A collection of fluid in the legs from Congestive Heart Failure that creates hypertension in the venous limb. Right sided heart failure causes a distal collection of low-protein, water rich edema that is increased by gravity. There is a bilateral symmetrical presentation of fluid collection that pits easily with pressure.  The edema may resolve partially or completely with elevation of the limb, but will return when in a dependent position.   When left untreated the excess fluid will tax the lymphatic system and cause a co-morbid lymphedema.  Modified CDT can only be performed on patients that are medically stable and will be closely monitored during treatment.
o   Myxedema: (pretibial myxedema)- a collection of fluid that begins on the anterior calf caused by hypothyroidism. The lymphatic vessels are compressed by changes caused by hypothyroidism and the resulting damage will cause lymphedema. CDT is indicated as a treatment to remove the collection of fluid.
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Stages of Lymphedema: All patients that have undergone lymph node removal or radiation treatment are considered to be in the latency phase of lymphedema because their transport capacity is decreased.  Not all patients in the latency stage will progress to having an active form of lymphedema, however Any patient that progresses to stage I of lymphedema will eventually progress to stage 3 if left untreated.

Latency Stage:

o No visible or palpable symptoms, patient may report feeling heavy or achy

o Lymphatic system that has decreased the transport capacity of the lymphatics 

Stage I: (variable)

o Protein rich fluid accumulated

o Pitting edema

o Limb volume may show a temporary decrease in circumference following elevation, however volume returns

Stage 2: (chronic)

o Greater accumulation of protein rich fluid that does not respond to elevation

o Area feels firm and does not pit easily

o Increased skin fibrosis and inflammation

Stage 3: (Elephantiasis)

o Large accumulation of protein rich fluid

o No pitting

o Skin is fibrotic and contains folds

o Skin has noted changes including possible reflux, papillomas, hyperkeratosis

o Proliferation of connective tissue causes increased limb volume


Lymphedema Treatment: 

Complete Decongestive Therapy:

Acute Lymphedema Treatment(2-4 weeks)

1. The patient is trained in meticulous skincare to prevent cellulitis or other infection

2. Manual Lymphatic Drainage is performed by the therapist to establish collateral fluid movement away from the damaged area of the lymphatic system

3. The limb is wrapped daily with short stretch bandages that create a compression gradient to move fluid from the congested area.  The use of multi-layer short stretch bandages creates an environment of low resting pressure and high working pressure.  This creates the necessary environment for the muscle pump exercise sequence to move fluid from the area while still allowing for adequate circulation to reach the area.

4. Muscle Pump Exercises: A specific sequence of movements and exercises are performed to contract and relax the muscles to create a pumping effect. The low exertion, slow, rhythmic movements are emphasized by the high working pressure created by the multi-layer short stretch compression wrap. 

Maintenance Phase(continuously following the conclusion of the acute phase)

1. Daily skin care to prevent infections

2. A daily exercise program is performed to improve circulation, activate the muscle pump and encourage fluid movement.

3. The fitted compression garment is worn during the entire day except during hygiene

4. The pt. has a nightly routine of performing a Self-Manual Lymphatic Drainage Sequence

5. Nightly compression: the patient can perform nightly short stretch bandage wrapping or wear a bandage alternative overnight

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Manual Lymphatic Drainage: (MLD)Also known as the Vodder Technique, MLD is a process of establishing collateral circulation and drainage for the lymphatic system.  The lymphatic system drains the body by designated quadrants so damage to the regional lymph nodes will cause a buildup of fluid in that quadrant.  Light stretch and pull stimulation is performed on the skin to stimulate the lymphatic capillaries to take up fluid. The direction of the stretch and pull movements will direct the fluid away from the congested area to the closest intact lymph nodes.  When used in combination with compression garments and muscle pump exercises this is an effective way to direct fluid removal from the area of lymphedema. 

Complete Decongestive Therapy can be used as an effective treatment program for lymphedema and other forms of edema when no contraindications are present.

Indications to treatment:These conditions benefit the most from CDT: Precautions to Treatment:These conditions must be well managed before starting CDT or a modified treatment may be indicated: Contraindications to Treatment:CDT cannot be performed with these conditions:

-Lymphedema

-Phlebo

-lymphostatic edema

-Chronic venous insufficiency

-Post traumatic edema

-Post surgical edema

-Lipedema

-Lipo-lymphedema

-Numbness or decreased sensation

-Paralysis of the limb

-Nail or skin infections (should be treated or stable prior to starting treatment)

-Venous ulcers (must be stable and healing)

-Mild venous insufficiency

-Cardiac history (must be stable and able to handle the fluid being moved in the body during wrapping)

-Kidney insufficiency (must be stable and able to handle the fluid being moved in the body during wrapping.

-Skin weeping or fluid reflux (bandages will need to be changed more frequently for skin care)

-Diabetes (must be well managed)

-Hypertension (must be medically managed to prevent fluid movement from raising BP)

-obesity

-Active bacterial or fungal infections of the skin

-Advanced venous insufficiency

-Renal failure

-Acute Deep Vein Thrombosis

-Acute cellulitis

-Congestive Heart Failure

-Patient is not willing to continue the maintenance phase of treatment

-Patient is not able or willing to purchase the wrapping materials or the compression garments needed for treatment and management

-Current cancer treatment (only for palliative care)

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If CDT is indicated for the patient they will need a prescription to begin therapy:

Medical Perscriptions for CDT:

The pt. will require a prescription for therapy that includes:

o Diagnosis (lymphedema or other related condition)

o Frequency and duration of treatment (5x/week for 4 weeks in the acute phase)

o At Body in Balance Lymphedema treatment is performed by the Occupational Therapist

The pt. will also require a prescription for a compression garment later in their treatment:

o The body part and area being covered by the garmento   The compression class:

TED stockings or Subclinical level: 14-21 mmHg

· Low level compression for those at risk for lymphedema but do not have a clinical presentation yet

· Prevention of blood clots and support to circulation

Class 1: 20-30 mmHg

· Arm Sleeve for mild lymphedema, not strong enough for the leg

Class 2: 30-40 mmHg

· The minimum compression for a leg, Moderate arm lymphedema

Class 3: 40-50 mmHg

· For stage 2 lymphedema of the leg, rarely used for the arm

Custom Compression: 50-70 mmHg

· For severe leg lymphedema that requires strong support and compression such as elephantiasis

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Updates to the Medical Treatment of Lymphedema:

Mechanical or pneumatic Pumps are not seen as a practical treatment for swelling caused by lymphedema.  This is due to the fact that lymphedema is a collection of both fluid and protein in the interstitial space. The pump will remove the water content from the tissue while the protein remains. Over time the increased concentration of protein will cause greater inflammation and fibrosis of the tissue.  The high concentration of proteins in the area will also continue to draw fluid to the area.  The external pressure of the pump and the pull of fluid to the area will further tax the lymphatic system and can cause additional damage over time.  There is also an increased incidence of developing genital or truncal lymphedema following long term use of a pneumatic compression pump.  CDT is a more effective treatment and does not cause additional damage to the lymphatic system.

Diuretics are not effective in treating pure lymphedema for the same reasons. Diuretic medications will decrease some of the fluid content while leaving the protein at a higher concentration. This will cause increased skin inflammation and fibrosis over time.  Diuretic medication may be indicated for patients that have lymphedema as well as another condition that would benefit from such medication. 
Debulking surgery- the surgical removal of excess fibrotic and adipose tissue is very rarely needed if the patient undergoes proper Complete Decongestive Therapy. The performance of a debulking procedure leaves the patient with excessive scar tissue that further impedes or completely blocks the movement of lymphatic fluid. The pt. will still need to wear compression garments for life following this procedure.  Extensive CDT should always be performed as the primary treatment for lymphedema and debulking surgery is reserved as a last resort for severely involved patients.
- The only way to encourage movement of protein out of the tissue affected by lymphedema is to perform Manual Lymphatic Drainage.  The stretch stimulation created on the skin during MLD stimulates the lymphatic capillaries to draw in both fluid and protein to be directed away from the area.