WHAT IS LYMPHEDEMA?
Lymphedema is an accumulation of lymphatic fluid that causes swelling in the arms and legs. Edema occurs when venous or lymphatic vessels or both are impaired. When the impairment is so great that the lymph fluid exceeds the lymphatic transport capacity, an abnormal amount of protein fluid collects in the tissues of the extremity. Untreated, this stagnant, protein-rich fluid, not only causes tissue channels to increase in size and number, but also reduces oxygen through the transport system, interferes with wound healing, and provides a culture medium for bacteria that can result in various infections. A chronic inflammatory condition stemming from this accumulation of fluid eventually results in fibrosis (hardening) of the extremity tissues.
THE NORMAL LYMPHATIC SYSTEM: A DESCRIPTION
To understand the condition called lymphedema, we first must understand the normal lymphatic system. Consisting of lymph vessels, nodes and tissues, the lymphatic system is part of the circulatory system of veins and arteries. The important role of the lymphatic system is to remove impurities from the circulatory system and to produce cells of the immune system (lymphocytes) that are vital in fighting bacteria and viruses. Produced in the lymphatic system and mostly in the spleen, these important lymphocytes are a crucial part of the immune system. Lymph vessels are channels that contain colorless fluid called lymph. The lymph comprises white blood cells and waste products from lymph tissue. Lymph fluid passes through nodes, or valves, located in the lymph vessels at one to two centimeter intervals. As the fluid passes through the nodes, it is purified of harmful bacteria and viruses. Networks of the lymphatic system comprising these vessels, tissue and nodes are situated in several areas of the body:
- the neck (supraclavicular)
- the armpits (axillary)
- along the windpipe (trachea)
- adjacent to the lung (thoracic)
- near the intestines (abdominal)
- behind the abdominal cavity (retroperitoneal)
- the pelvic area
- the groin (inguinal)
Lymph tissue is found in other areas of the body as well, including the tonsils, spleen, intestinal wall and bone marrow.
HOW DOES LYMPHEDEMA CAUSE INFECTION?
Lymph fluid is rich in albumin, or protein. When lymphatic flow is obstructed, the fluid accumulates and lays stagnant in the tissues of the limb closest to the obstruction. This creates an environment favorable for growth of and, ultimately, infection. Low prophylactic doses of antibiotics are prescribed for people who experience recurrent infections. Note: Always carry your antibiotics or a prescription with you.
HOW CAN LYMPHEDEMA BE PREVENTED?
If you had lymph nodes removed surgically, or if you have been treated with radiation therapy, it is important that you protect the limb closest to the treatment from injury. The following chart offers suggestions to avoid developing lymphedema.
WHAT YOU SHOULD DO
- Wear gloves while doing housework, gardening or other types of work that can result in even minor injuries.
- Never allow an injection or blood drawing in the affected extremity.
- Have blood pressure checked in the unaffected extremity.
- Avoid heavy lifting with the affected arm. Do not carry heavy handbags with over the shoulder straps.
- Avoid vigorous, repetitive movements against resistance with the affected arm or leg (rubbing, scrubbing, pushing or pulling).
- Elevate the affected arm(s) or leg(s) whenever possible.
- Consult your therapist about sports activities in which you participate. Some sports activities may aggravate the condition. Swimming, bike riding, walking and specially designed ballet or yoga movements are advised.
- Avoid extreme temperature changes in bathing, washing dishes, or sunbathing. Keep the limbs protected from the sun.
- Maintain good hygiene by keeping skin clean and dry with hypoallergenic soap and deodorant.
- Use an electric razor rather than a safety razor.
- Do not wear tight jewelry or elastic bands around affected finger, arms or legs.
- Avoid cutting cuticles when manicuring hands or pedicuring feet.
- Maintain your ideal weight through a well-balanced, low-salt diet. Avoid smoking and alcoholic beverages.
A lesion in the skin will allow infectious bacteria to enter the tissue. Injections or blood drawing will pierce the skin, providing an entry for infection.
The inflated blood pressure cuff further limits the circulation in an arm that already has poor circulation.
Lifting puts strain on the arm with poor circulation.
Physical exertion causes the blood to flow more rapidly through the muscle and tissue, further damaging an already compromised system. Elevating your arm or leg will help improve circulation in the affected extremity. Physical exertion forces the damaged lymphatic system to try to do work that it cannot do.
Heat increases blood flow through the tissues. Sudden temperature change causes unnecessary stress on the weakened system.
Hygiene will prevent the skin from irritation and possible infection. An electric razor will prevent puncturing the skin and subsequent infection. Constricting items of clothing or jewelry will worsen an already compromised circulatory system. Any skin puncture risks introducing infection.
Maintaining your weight and salt reduction will avoid adding excess weight fluid in the limbs.
WHAT IS THE TREATMENT FOR LYMPHEDEMA?
Planning the treatment depends on the cause of the lymphedema.
For example: If the lymphedema is caused by an infection (redness, rash, blisters, and pain may indicate an infection), your doctor will prescribe appropriate antibiotics.
If the lymphedema is not caused by infection, compression must be applied to the limb to reduce the swelling. Compression may be applied by surgical compression stockings or sleeves. Massage (Manual Lymph Drainage) may also be performed by specially trained therapists. The therapy focuses on gently massaging, with a pumping motion, connective tissue rather than muscle tissue. This stimulates the weakened lymphatic system by pushing the stagnant fluid through the vessels, allowing the venous system to reabsorb the fluid and helping to develop collateral channels through which the lymph can begin to flow.
If, after the conservative treatment, lymphedema persists, a special sequential gradient pump may be used. Pressure is sequentially distributed through overlapping air compartments constructed in a special appliance that envelope the affected limb. The compartments, inflate sequentially, causing the lymphatic fluid to circulate out of the affected limb, thereby reducing the swelling. This treatment can be done in an outpatient setting and even at home after the patient has been trained to operate the pump. Before beginning treatment, your physician should take a history and perform a physical examination.
CONTRADICTIONS: Patients who have had congestive heart failure, any venous or arterial obstruction, or acute infection should not be treated with compression pumps. Patients who are receiving anticoagulant therapy should have a venous screening to rule out deep venous thrombosis before being treated.
If the lymphedema does not respond to the treatments described above, surgery may be a consideration. However, this surgery is seldom done in the United States at the present time.
In several medical centers, a variety of diagnostic studies are being done. Lymphangioscintigraphy, a method of following by x-ray a radioactive trace protein injected in the skin of the hand or foot, allows the doctor to see a major portion of the lymphatic system and where the system is blocked. Magnetic resonance imaging (MRI), which does not require an injection or x-rays, also allow the doctor to see the soft tissues and lymphatics and to determine the area of blockage.
SOME SPECIAL WARNINGS
AFTER A MASTECTOMY:
Heavy breast prosthesis used after mastectomy may put too much pressure on lymph nodes above the collarbone. This pressure risks slowing and interrupting the lymphatic pathways, preventing the fluid from flowing through and out of the lymphatic system. If your prosthesis is large, request that it be lightweight. If you have questions about prosthesis, you should consult your physician. Information also is available from representatives of the American Cancer Society Reach to Recovery, John Wayne Cancer Center's Positive Appearance Center or your local breast prosthesis distributor.
AFTER AN INSECT BITE OR PET SCRATCH:
If you receive an insect bit or are scratched by a pet on the affected extremity, seek medical attention immediately. Medical treatment with antibiotics is very important to prevent a serious infection.
REIMBURSEMENT FOR LYMPHEDEMA TREATMENT
When these procedures, therapies and diagnostic studies are medically necessary, most insurance companies will provide reimbursement. You should discuss your insurance coverage after the treatment is determined. Compression garments prescribed by a physician are usually covered by most insurance companies. Medicare covers compression sleeves, but does not cover compression stockings.
Compression therapy by sequential gradient pump prescribed by a physician is usually covered by most insurance companies. Manual Lymph Drainage (MLD) prescribed by your physician usually is not covered by most insurance companies at this time.