Lymphoedema is a swelling that develops as a result of an impaired lymphatic system. This may be as a result of the lymphatic system not developing properly or through damage or trauma (see section on types of lymphoedema). It can affect any part of the body but is most commonly seen in an arm or a leg. Although thought to be relatively uncommon, recent research suggests that 6 in every 1,000 people in the UK may be affected by this condition. In order to understand how lymphoedema occurs, it is important to have an understanding of the lymphatic system in general – what it is and how it works.
The Lymphatic System
The lymphatics form part of your immune system, helping to deal with infection at a local level but just as importantly, they are responsible for cleansing your tissues and maintaining a balance of fluids in your body.
It can be likened to a waste disposal system, taking tissue fluid, bacteria, proteins and waste products away from the tissues around skin, fat, muscle and bone.
Once inside the lymphatic vessels (not visible just under the surface of the skin) the tissue fluid becomes known as ‘lymph’ and it is then transported in one direction, by increasingly larger and deeper lymphatic vessels. Movement of lymph depends on muscle movement (exercise) and the contraction of the deeper vessels themselves. Gentle massage known as Manual Lymphatic Drainage (MLD) and deep breathing can also help to move the lymph more effectively.
At some point in its journey, lymph will pass through a lymph node, or gland. Clusters of these nodes are found in the neck, armpits and groins. It is here that the lymph is filtered and cleansed, so that the waste matter, bacteria and harmful cells can be identified and removed by the body’s defence system.
Having passed through these nodes, lymph finally drains back into the large veins of the body at a point just behind the collarbone, on each side of the neck. From here it travels in the blood back to the heart and is eventually removed from the body as urine through the kidneys.
How Does Lymphoedema Occur?
If, for whatever reason, the lymphatic system is not working correctly, or the vessels are not draining adequately, the fluid and other materials in lymph build up in the tissues (as when a river is dammed and flooding occurs). Swelling occurs when the amount of fluid in an area is greater than the capacity of the lymphatic system to transport it away. Lymphoedema can be defined as ‘oedema (swelling) due to the accumulation of lymph in the tissues’.
Types of Lymphoedema
Lymphoedema can be described as primary or secondary.
Primary Lymphoedema is usually determined from birth and arises due to some failure of the lymphatic system itself – usually with the underdevelopment of the lymphatic system. It may occur without any obvious cause at different stages in life, but particularly at puberty.
Secondary Lymphoedema is the result of some influence from outside of the lymphatic system that prevents it working properly. Examples of secondary lymphoedema are:
- Surgery – particularly when lymph nodes are removed during treatment for cancer: breast, prostate, gynaecological, head or neck, sarcoma or melanoma.
- Radiotherapy – this kills cancer/tumour cells, but it can also cause scar tissue that interrupts the normal flow of lymph in the lymphatic system.
- Accidental trauma/injury or infection – that may damage the lymph vessels and therefore, reduces drainage of lymph.
- Reduced mobility/paralysis – muscle contractions (during activity/exercise) are important to help the lymph to move
- Problems with veins not working efficiently (varicose veins/after deep vein thrombosis) – often known as venous insufficiency. This results in the lymph system becoming overloaded and unable to function effectively.
- Obesity – this can also cause lymphoedema or exacerbate the problem.
- Cancer itself – may also result in a blockage of the lymphatic system.
Unfortunately, most of the underlying causes of lymphoedema are irreversible and as such, there is currently no known cure – however, appropriate treatment can be implemented to reduce the swelling and keep it to a minimum. (See section on ‘What can be done to help?’). This medical (conservative) treatment can, in most cases, improve quality of life dramatically.
How Does Lymphoedema Progress?
Initially, lymphoedema may not be troublesome at all. It may be just a slight swelling that comes and goes (intermittent) – and it is quite common to notice worse swelling as the day goes on. For example, the swelling may be minimal on waking – but become larger as the day progresses – especially in warm weather. It is often possible to use simple measures to resolve the swelling at this stage so treatment should always be started as soon as possible.
If left untreated, the swelling over time becomes more permanent; it doesn’t subside overnight and the area will begin to feel increasingly hard and solid.
What Can Be Done To Help?
Firstly, it is essential that lymphoedema is correctly diagnosed and appropriately assessed. Unfortunately, there is still a major lack of medical knowledge and expertise and some people are still told ‘there is nothing that can be done to help’, which is not true. There are treatments which work well to reduce and control the swelling.
The LSN has a comprehensive directory of services, which will highlight the nearest specialist centre to you. The British Lymphology Society has also produced a document that sets out minimum standards of care. If you are experiencing difficulties obtaining help, ensure your GP is given a copy. E-learning modules are also available to improve GP knowledge – ask the LSN for the information to pass to him/her.
Assessment (usually carried out by specially trained nurses and physiotherapists) will ascertain the actual cause of the swelling, as well as determining the overall size and extent of the swelling, which may alter the type of treatment you are offered.
Generally, there are four components of care that will be recommended for people with mild to moderate swelling of their limbs:
- Skin Care– to keep the skin and tissues in good condition and to prevent/reduce the risk of infection (Cellulitis). For more information see the LSN fact sheet ‘Skin Care For People With Lymphoedema’.
- External Support/Compression– in the form of elastic compression garments to help prevent the swelling from building up in the limb. For more information see the LSN fact sheet ‘The Use of Compression Garments in Lymphoedema Management’.
- A programme of exerciseand movement– to try and maximise lymph drainage without overexertion (this would cause the swelling to worsen).
- Simple Lymphatic Drainage (SLD)– a gentle massage technique that is based on the principles of Manual Lymphatic Drainage (MLD) (see below). It involves the use of simple hand movements to try and move the swelling out of the affected area. It is designed to be carried out by patients themselves – or their relatives or carers. The LSN has produced two self-management DVDs, one for upper limb and one for lower limb which demonstrate this technique.
Reassessment and monitoring of progress is essential to ensure good results. It is also vital that patients help themselves. Lymphoedema is a long term, chronic condition and one that requires a high level of motivation and compliance by the patients themselves.
For people with a more severe swelling, additional treatments may be recommended within a more intensive treatment programme called Decongestive Lymphatic Therapy (DLT) or Combined Decongestive Therapy (CDT). This intensive treatment may last for a period of 2 – 4 weeks and combines a package of treatments on a daily basis. These may include some of the above, plus one or more of the following:
- Manual Lymphatic Drainage (MLD)– a specialised form of massage carried out by a trained therapist to move the skin in specific directions based on the underlying anatomy and physiology of the lymphatic system.
For more information see the LSN’s ‘Manual Lymphatic Drainage Therapy’ fact sheet.
- Multi-Layer Lymphoedema Bandaging (MLLB)– a multi-layer system of bandages provides a rigid casing for the muscles to work against which helps to improve the shape and size of severe swelling and reduce the hardness of the tissues. For more information, see the LSN fact sheet, ‘Multi-Layer Lymphoedema Bandaging’.
- Adjustable Velcro Compression Devices
- Intermittent Sequential Pneumatic Compression Therapy– despite this type of therapy being available for many years, robust research is lacking. However, they can help certain patients and when used appropriately are helpful within a course of treatment. Caution should be taken when using these machines. They should only be used under the supervision of a lymphoedema practitioner who will demonstrate the principles of their use.
- Other devices– such as the Hivamat (deep oscillation therapy), Low Level Laser Therapy, PhysioTouch and Bodyflow machines are also becoming more popular in some clinics for certain types of swelling.
- Kinesio Taping– Is commonly used in lymphoedema clinics to assist with fluid drainage (in both the intensive and self-care phase of treatment). This taping therapy was originally designed to help with sporting injuries, but can also help reduce swelling. For more information, see the LSN fact sheet ‘The Use of Kinesio Tape in Lymphoedema Management’.
- Drug Therapy– although research is still ongoing, drug therapy for pure lymphoedema is very limited. However, there are certain situations when some drugs will be of benefit – your therapist will be able to advise you.
- Surgery– traditional de-bulking operations rarely prove beneficial for lymphoedema, though there are certain situations where it may prove essential e.g. for eyelid or genital swelling. Liposuction is now more commonly used for debulking the fat component of the swelling. Surgery should only be performed by surgeons who have experience with lymphoedema and the lymphatic system. Advances are coming through however, and microsurgical techniques and Liposuction are being increasingly explored (though they are not as yet, widely available on the NHS).
With appropriate information and the help and support of a lymphoedema practitioner, there is much that patients can do to help themselves in the management and control of their condition. Indeed, patient education, advice and support is now at the forefront of care, ensuring all patients diagnosed with lymphoedema, become an expert in managing their own condition.
Denise Hardy, LSN Nurse Advisor
Professor Peter S. Mortimer, Consultant Dermatologist at the Royal Marsden and St. George’s Hospitals, London.
Last reviewed June 2019
Bron: LSN (UK, Lymphoedema Support Network) www.lymphoedema.org