Lymphedema Management
The lymph system is an unsung hero in our body's ability to function properly. Yet many people are unaware of the lymph system except that it helps fight off infection, lymph nodes can become swollen and sore, and cancer may affect the lymph system. However, it contributes a lot more to daily life than you might guess, and when the system is overloaded or damaged, it may result in lymphedema, which is excess fluid in the tissues that causes swelling. Lymphedema management consists of four main components: patient education, exercise, manual lymph drainage and compression. There are also two phases of treatment: decongestion and maintenance. Continue reading for an overview of the lymph system, types of lymphedema, each component and phase of Complete Decongestive Therapy (CDT).
The Lymphatic System
The lymphatic system is comprised of several lymph organs, lymph nodes, collectors and ducts. The body has two layers of lymph collectors: superficial and deep. Superficial collectors are in the layer of fatty tissue between the skin and fascia of the limbs and trunk. Deep lymph collectors are in the trunk and collect fluid from the superficial lymph collectors, joints and organs of the body. Lymph fluid is collected and returned to the cardiovascular system for recycling of components or flushed out as waste. Consider the lymph system as the "garbage" collectors for our body. Lymph fluid is loaded with cellular debris, long chain fatty acids, protein and water that accumulates in the tissues. This debris is too large for the cardiovascular system to manage. The lymph collectors pick up this debris in the tissues, then pump it toward the lymph nodes for that area of the body. When something damages an area of the pathway, it's like a garbage strike. Everything gets backed up into one area. Until that strike is dealt with by re-routing the pathway, fluid and debris will build up, causing edema in the area below the damage. (Lymph vessels are similar to veins in that they only flow in one direction, back to the heart.) Once the pathway is cleared or another pathway is formed, the lymphatic system will start to remove the excess fluid from the body. However, this can be a prolonged process, since our system can get overloaded by too much fluid and debris. Lymphangiomotoricity is the rate at which lymphangions (the functional units of lymph vessels) contract, which determines the speed of lymph fluid movement through the lymphatic system. It is the "pumping speed" of the lymphatic vessels. Three components of CDT (exercise, manual lymph drainage and compression) address the back up of fluid, creating new pathways and improving the rate at which lymph is removed. The fourth component of CDT--education--is to help patients understand the risks and problems associated with lymphedema and how to become independent with management.
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Exercise
The least popular part of CDT, it is still a vital component to managing lymphedema. Despite the dread some people express in trying to lift a limb that is already too heavy from increased fluid, there are ways to modifiy exercise in order to gain the results we need.
The first phase of exercise is simple active range of motion, just moving the limb (arm, leg, head/neck) and trunk in order to stimulate the manual muscle pump.
When muscles contract, they help to "pump" blood and fluid through the veins back to the heart.
Deep breathing, or diaphragmatic breathing, also act as a pump, pulling fluid up to the heart and lungs for recycling.
Exercise stimulates both increased breathing rate and muscle activation, pumping fluid from the farthest point in your body (toes and fingers) back to the trunk.
Exercises to assist with lymph flow start at the most distal (farthest away) to the proximal (closest to) the heart.
For the arm, that means working the fingers, wrist, elbow and then shoulder. For the leg, you start with the toes, foot, ankle, knee and hip.
If a person has difficulty with movement, therapists will modify exercises as needed until you progress to something more vigorous.
Walking is an excellent way to stimulate the muscles and breathing at the same time. Aquatic therapy is also a great way to assist with removing fluid from the limbs and trunk, since it is pleasurable to do, decreases stress on the joints and adds increased tissue pressure to stimulate lymph removal.
Manual Lymph Drainage
MLD is NOT massage. It is a soft tissue stretch that stimulates lymph collection from the superficial fatty tissue.
MLD is a soothing stroke which improves lymph production, the rate at which lymph is removed, improves venous return and aids in pain relief.
The goal of MLD is to reroute lymph flow around blocked areas to more centrally located healthy lymph vessels which drain into the venous system.
Compression: Phase I
Compression is the most difficult aspect for patients to tolerate. That being said, it is an absolute must for reducing lymphedema and maintaining progress.
Phase one is reduction of limb girth. This phase includes wrapping the limb (arm or leg) with compression bandages with a gradiation of pressure from bottom to top.
This requires dedication and compliance from the patient, since it includes visits at least 3x/week for wrapping and keeping the wraps on until the next visit.
When the legs are wrapped, it can become difficult to walk effectively, unless another form of compression is used. The type of compression applied is determined by the therapist based on a patients history, stability, cognition and other factors discussed during evaluation.
For the arm, compression is much easier to tolerate, but if it is the patients' dominant arm, it may impair eating, bathing, dressing, doing dishes, etc. Therapists will help modify any activites the patient is having difficulty with, or will provide suggestions for keeping the compression in place until the next visit.
Compression: Phase II
Phase Two of compression is much more tolerable, but still requires committment from the patient, since it will become the daily routine for life.
Lymphedema doesn't resolve or go away with treatment. It is a lifelong process of management. Phase II is the maintenance phase and requires some type of compression garment to help maintain the girth reduction achieved in the first phase.
There are multiple different types of compression garments available, based on a patient's needs and functional level. Again, a therapist will help determine the best type of garment and help assure proper fit, ability to don/doff the garment, comfort, affordability and successful maintenance of limb size.
Garments range from the generic sleeves and compression socks, to custom made compression with various types of weave, velcro compression, night time garments and swell spots, to name a few. If you ever want to see how vast the products are, simply look it up online. It is staggering. But this allows patients to find something that works for them, which is a tremendous benefit when they will have to wear it daily.
The reason why compression is necessary to maintain your progress is due to tissue pressure changes that occur with lymphedema. The elastic fibers of the cutaneous tissues are damaged and skin elasticity may never be regained completely. Compression garments are used to offset that loss in compression from the skin.
Lymphedema Education
Although a Certified Lymphedema Therapist will provide a comprehensive plan and specific education for each individual treated, there are universal precautions and recommendations that everyone with lymphedema should know.
Skin Care
Keep skin clean: Wash with a pH-neutral soap, moisturize dry skin, and avoid scented products.
Protect skin from injury: Wear gloves during gardening, housework, and when handling pets. Use sunscreen and insect repellent.
Prevent infections: Address any cuts or scratches immediately with soap and water, apply antibiotic ointment, and bandage.
Avoid trauma: Be cautious with needles, injections, and blood draws in the affected limb.
Avoid cutting cuticles: This can create an entry point for infection.
Use electric razors: For shaving underarms, an electric razor is recommended.
Lifestyle
Maintain a healthy weight: Obesity can worsen lymphedema.
Exercise regularly: Gradually build up tolerance and engage in low-impact activities like walking, swimming, or water aerobics.
Avoid prolonged pressure: Don't wear tight clothing, jewelry, or carry heavy bags on the affected side.
Protect against temperature extremes: Avoid hot tubs, saunas, heating pads, and prolonged exposure to extreme cold.
Avoid vigorous, repetitive movements: Limit activities like scrubbing, pulling, or pushing with the affected limb.
Elevate the affected limb: Whenever possible, elevate the arm or leg above the heart.
Other Precautions
Wear compression garments: If recommended by a doctor or therapist, wear compression sleeves or stockings, especially during exercise or air travel.
Seek early treatment: If you notice any signs of lymphedema (swelling, heaviness, tightness), consult a healthcare professional.
Be mindful of air travel: Compression garments may be recommended for air travel due to pressure changes.
Consider sodium intake: A low-sodium diet may help minimize swelling.
Avoid deep tissue massage: Deep tissue massage in the affected area can worsen lymphedema.