March is Lymphoedema awareness month and we want to take this opportunity to explain exactly what it is, when it can occur, how to prevent it and what are the treatment options.

First we need to introduce the lymphatic system, which is very important but unfortunately neglected by most of us. The lymphatic system runs parallel to the bloodstream and its role is to drain lymph from every part of the body before joining the venous system; it transfers the fats from the small intestine to the main circulation and tracks/destroys pathogens by producing the immune system’s cells.

Lymphatic System
[1] Lymphatic capillaries draining interstitium

• The lymphatic system avails of many structures; the smallest are the lymphatic capillaries, which resemble the fingers of a glove. These capillaries drain the interstitial fluid (the space in between the cells) and converge into the bigger lymphatic vessels (collecting lymphatics). The lymphatic vessels have the important task to absorb macromolecular substances, mainly proteins but also the absorption of cells, bacteria, metabolic waste products and solid particles from tissues.

The characteristics of the vessels are:
• The ability to contract, thanks to the lymphangion.
• To move the lymph only in the direction of the heart.
• They are collected in the lymphatic ducts that merge with the venous system at the base of the neck.

All along this pathway there are the lymph nodes, whose role is to filter the lymph coming from the vessels. These produce the cells of the immune system and also detect the antigens. In case an infection is detected, the closest lymph nodes will swell to produce a higher amount of lymphocytes. The lymph nodes work as chained main stations for the collection of lymph from many vessels coming from the same “district”, which is the reason why if they are removed or injured we might develop lymphoedema on a whole limb (Saladin, 2011).

[2] Lymphatic Vessel

In early-diagnosed cancer patients the first step is to use the sentinel lymph node biopsy technique to check if the cancer cells have yet entered the lymphatic system. If the test is positive a full axillary lymph nodes dissection will be performed which can be seen as the main cause of lymphoedema (Manca et al., 2016).
So lymphoedema is a lymphatic disorder that occurs when there is a congenital malfunction (primary lymphoedema), or a damage/removal of the lymph nodes, secondary lymphoedema, that interrupts or impairs the lymphatic system drainage chain, letting the lymph to pour in the surrounded tissue.

The characteristics of lymphoedema are:
• Increased volume of the limb
• Difficulties in bending and moving the limb
• Feeling of heaviness
• Skin cold, pale and fragile
• Pitting positive

[3]Example of pitting on the foot
[3]Example of pitting on the foot

Lymphoedema can be developed straight after the surgery or can be triggered years after the surgery by trauma, infections and even insect bites.

Over the years the diagnosis and management of lymphoedema has widely improved to help patients carrying a normal life from a practical and psychological point of view (Fu et al., 2015).

The classification of Lymphoedema is divided in different stages and grades:

Stage 0 –  Lymphoedema is not present yet. The functionality of the lymphatic vessel is enough to drain the lymph
Stage 1  – Pitting is positive. Lymphoedema reverses with elevation, can be absent in the morning.
Stage 2 – It is irreversible. The tissue loses elasticity and starts becoming fibrotic.
Stage 3 – It is irreversible. The affected area is very hard and bulky; the tissue is fibrotic and hard.

Grade 1 – Difference in volume with unaffected limb < 4cm. No modification of tissue
Grade 2 – Entire limb affected. Difference in volume with unaffected limb > 4cm and < 6cm. Modifications in the tissue.
Grade 3a  – Entire limb is affected + trunk quadrant. Difference in volume with unaffected limb > 6cm
Grade 3b – Same as Grade 3a but two or more extremities are affected
Grade 4 – Complete blockage of the lymphatic system in the affected area. This grade is also known as elephantiasis because of the massive volume.

The protocols that have been developed consists of a multidisciplinary approach (Leduc and Leduc, 2002) (Cho et al., 2015):

Manual lymphatic drainage (Ezzo et al., 2015). It is used to mobilize and facilitate the lymphatic vessels to carry the lymph. We can see a reduction of the volume and the patients often claim to feel the limb lighter, especially in stage 1. The most common and recognised methods are Vodder and Leduc (Fiaschi et al., 1996). At PhysioFit Woman we are trained and specialized in the Leduc Method®, which is constantly evolving and updating through scientific research. It is important to underline that Leduc’s training is available only to healthcare professionals.

Pressotherapy –  It consists of an electrical air compression pump attached to an inflatable plastic garment that is placed over the affected limb; the garment is inflated and deflated cyclically for a set period, between 30-120 minutes (Moffatt, Doherty and Morgan, 2006). It allows the patients to have treatment at home especially for the elderly or patients with mobility complications. It allows the patients to have treatment at home especially for the elderly or patients with reduced mobility. Physiofit Woman uses a state-of-the-art pressotherapy called Lympha-Press®.

Lympha Press
[4]Lympha-Press®

Multilayer Bandaging – It is an essential part of the rehabilitation. Straight after the drainage it is important to preserve the reduced volume of the limb with a system of elastic bands. There are different types of bands, which will be used according to the progression of the treatment.

Exercise –  Supervised by a Physiotherapist, the patient needs to perform simple exercises wearing the compression bandaging to make the best of the pumping effect of the muscles against the hard barrier of the bands.

Compression Garment –  After the protocol is applied and the patient has reached the maximum volume reduction, the patient must undergo a maintenance program using the specific compression garment. Because the garments come in different grade of compression and sizes a measurements should be taken by a qualified healthcare professional.

Muscle contraction using Compression Garment
[5]Muscle contraction using Compression Garment

Another very important aspect is to differentiate lymphoedema from other type of pathologies that might present similar symptoms.

Congestive heart failure
The hearth is not able to provide enough blood to every district of the body and the venous pressure is not sufficient to win the gravity, this will cause another type of oedema. In this case the protocol for lymphoedema is contraindicated.

Kidney failure
The kidneys are not able to eliminate the excess water or there is a heavy loss of proteins in the urine that causes the fluid to move back in the interstitium. As well as for the congestive heart failure, the lymphoedema protocol is contraindicated.

Lipoedema
This disorder concerns the fat cells on hips and legs, sometimes arms, and affects mainly women. The alteration in these cells causes them to multiply, preventing the fat from being used and burnt (Okhovat and Alavi, 2014) (Szél et al., 2014). In fact, it is not affected by exercises and/or dieting.
The characteristics are:
• Fat localized on the lower half of the body, sometimes arms.
• Hands and feet are not affected.
• Pitting is negative.
• Pain on the affected areas is very common.
• Skin can be red and warm.
• Both limbs affected symmetrically.
• Easily bruised.
• Arises with hormonal changes, stress or psychological traumas.

In the severe stages of lipoedema quite often we observe the development of lymphoedema as a complication, which is one of the reasons lipoedema is often confused and misdiagnosed (Seo, 2014).

In conclusion there is a number of treatments that can be performed to address lymphoedema. Definitely the first step is to create awareness, a duty that should be carried by all healthcare professionals with responsibility, honesty and adequate training so that the patient is offered the best care possible.

Physiofit Woman offers a full Lymphoedema & Mastectomy Physiotherapy service.

Article written by Physiofit Woman Chartered Physiotherapist, Isabella Fraia, MISCP.

Bibliography

Cho, Y., Do, J., Jung, S., Kwon, O. and Jeon, J. (2015). Effects of a physical therapy program combined with manual lymphatic drainage on shoulder function, quality of life, lymphoedema incidence, and pain in breast cancer patients with axillary web syndrome following axillary dissection. Support Care Cancer.

Ezzo, J., Manheimer, E., McNeely, M., Howell, D., Weiss, R., Johansson, K., Bao, T., Bily, L., Tuppo, C., Williams, A. and Karadibak, D. (2015). Manual lymphatic drainage for lymphoedema following breast cancer treatment. Cochrane Database of Systematic Reviews.

Fiaschi, E., Francesconi, G., Fiumicelli, S., Nicolini, A. and Camici, M. (1996). Manual lymphatic drainage for chronic post-mastectomy lymphoedema treatment. Biomedicine & Pharmacotherapy, 50(8), p.414.

Fu, M., Axelrod, D., Cleland, C., Qiu, Z., Guth, A., Kleinman, R., Scagliola, J. and Haber, J. (2015). Symptom report in detecting breast cancer-related lymphoedema. Breast Cancer: Targets and Therapy, p.345.

Leduc, A. and Leduc, O. (2002). Rehabilitation protocol in upper limb lymphoedema. Annali Italiani di Chirurgia, 73(5), pp.479-484.

Manca, G., Tardelli, E., Rubello, D., Gennaro, M., Marzola, M., Cook, G. and Volterrani, D. (2016). Sentinel lymph node biopsy in breast cancer. Nuclear Medicine Communications, p.1.

Okhovat, J. and Alavi, A. (2014). Lipedema: A Review of the Literature. The International Journal of Lower Extremity Wounds, 14(3), pp.262-267.

Saladin, K. (2011). Anatomia & fisiologia. Padova: Piccin.

Seo, C. (2014). You Mean It’s Not My Fault: Learning about Lipedema, a Fat Disorder. Narrative Inquiry in Bioethics, 4(2), pp.E6-E9.

Szél, E., Kemény, L., Groma, G. and Szolnoky, G. (2014). Pathophysiological dilemmas of lipedema. Medical Hypotheses, 83(5), pp.599-606.

Images sources

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[2] Pascal, A. (2016). Patologie del sistema flebo-linfatico e taping kinesiologico kinesiobellia method Italy | Corsi di formazione Taping Kinesiologico. [online] Kinesiobellia.com. Available at: http://kinesiobellia.com/patologie-del-sistema-flebo-linfatico-e-taping-kinesiologico-kinesiobellia-method-italy/ [Accessed 21 Feb. 2016].

[3] Rexdton’s Blog, (2010). r7_edema. [online] Available at: https://rexdton.wordpress.com/2010/10/13/insuficiencia-cardiaca-congestiva/r7_edema/ [Accessed 21 Feb. 2016].

[4] Lympra-Press® UK

[5] Lymphoedemasupport.com, (2016). Exercises Lymphoedema | Lymphoedema Support Group of NSW Australia. [online] Available at: http://www.lymphoedemasupport.com/articles/exercises-for-lymphoedema [Accessed 21 Feb. 2016].