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What is lymphoedema? Read on to find out what happens when there is a defect in our lymphatic system and how it can be managed.

The lymphatic system is part of our body’s circulatory system, together with the blood system. It is important in cleansing our tissues and keeping the balance of fluids in our body.

Its two key functions are:

1. To fight infection as lymph nodes contain lymphocytes (bacteria-fighting cells).
2. To drain fluids and waste from our cardiovascular system to ensure that we remain healthy.

Lymphoedema occurs when there is a defect in our lymphatic system. It is “the accumulation of lymph in the interstitial spaces, principally in the subcutaneous fatty tissues” and marked by “an abnormal collection of tissue proteins” (Foldi et al 1985).

There are two types of lymphoedema:

• Primary lymphoedema with a genetic component resulting in the abnormal development of the lymphatic system in utero.
• Secondary lymphoedema, most usually associated with cancer surgery or treatment such as radiotherapy, which this article will address.

Secondary lymphoedema can develop at any point following surgery and treatment, the risk area being the cancer site and surrounding tissues. For example, if you had left breast cancer surgery and lymph nodes there were removed, the area most at risk would be your left limb and left breast/chest.

Not everyone will develop lymphoedema even if they have had surgical and/or radiotherapy treatment or damage to the lymph nodes or vessels.

Sometimes the lymphatic system adapts to the disruption and finds other routes for the lymph to flow. In such instances, the system remains functional and there is no sign of oedema.

Signs and symptoms

In the event that fluid build-up occurs, one may see signs and symptoms in the affected area. This is especially so when compared to the unoperated parts/surrounding area of the body.

• Feeling of tightness and/or heaviness, e.g. your watch or clothing feels more snug or leaves a mark when previously there was none
• Visible swelling
• Swelling remains despite resting overnight or keeping limb in an elevated position
• Skin feels tight/bursting/burning
• Skin changes, e.g. thickening or inflammation

Cellulitis, a bacterial infection of the skin, can develop in severe cases of unmanaged or undermanaged lymphoedema. The priority is to seek the doctor’s advice and get treatment as soon as possible.

Lymphoedema staging

According to the International Society of Lymphology (ISL), the stages are:

• Stage 0: Swelling is not evident despite impaired lymph transport.
• Stage 1: This represents the early onset of the condition where there is accumulation of tissue fluid that subsides with limb elevation. The swelling may be pitting at this stage.
• Stage 2: Limb elevation alone rarely reduces swelling and pitting is manifest.
• Late Stage 2: There may or may not be pitting as tissue fibrosis is more evident.
• Stage 3: The tissue is hard (fibrotic) and pitting is absent. There are skin changes such as thickening, hyperpigmentation, increased skin folds, fat deposits and warty overgrowths.

Being alert to these potential problems is the first step in the management or prophylactic treatment against lymphoedema.

Early detection and management yields the best outcomes as it is easier to treat lymphoedema at the early Stage 1 of ISL lymphoedema staging.

Managing lymphoedema

The current best practice in lymphoedema management is decongestive lymphatic therapy (DLT)/complete decongestive therapy (CDT). DLT is highly individualised to the patient’s needs.

Following a comprehensive assessment by a trained therapist, DLT will usually range from a few sessions to months or even years, and comprise all or a combination of the following:

1. Manual lymph drainage (MLD)

A specialised massage technique employed by a trained lymphoedema therapist to decongest, stimulate and direct lymph towards patent pathways. MLD can soften and reduce oedema. Patients will also be taught how to do a simple self drainage as part of self management.

2. Compression therapy

Multilayer lymphoedema bandaging (MLLB): This is employed to recontour and normalise limb shape and size. It is usually done in the initial intensive phase of management for oversized limbs and limbs with hard or fibrotic tissue.

Compression wear: These include compression garments for day/night/flight and can be custom-made or are commercially available. The therapist will usually recommend compression wear once contours and circumferences are stable;  garments should be matched with lifestyle and compliance. Patients will be measured and these garments then fitted and regularly reassessed for efficacy. Ideally there should be at least two sets of the garment so one set can be washed while the other is being worn.

Intermittent pneumatic compression (IPC): This can be used as an adjunct therapy to MLD with a therapist’s supervision.

3. Exercise

Exercise including deep breathing and range of motion (ROM) stretches together with general conditioning exercises for improved lymphatic efficiency and cardiovascular, musculoskeletal function.

4. Skin care

Skin care ensures that the skin is well hydrated and conditioned to act as a protective barrier. Care and precautions need to be taught to prevent risks of lymphoedema, for example:

• Daily inspection of the skin to check for any cuts/bites/abrasions
• No blood pressure measurements on the at-risk arm if breast cancer surgery is done
• Avoid hot baths
• Ensure proper fitting garments and undergarments

5. Establish a daily routine

• Deep breathing exercises
• Stretching exercises
• Gentle self-drainage
• Keeping skin moisturised and free from injury
• Eating a balanced diet

6. Patient/family/caregiver education

An occupational therapist (OT) trained in DLT can guide a patient through not only the physical but also the psychosocial and emotional aspects experienced.

A holistic approach should be adopted with the ultimate goal of empowering patients to resume independent and meaningful lives as far as possible.

Apart from the physical rehabilitation of patients, the OT would also be able to provide activities of daily living and ergonomic advice, leisure exploration, return-to-work advice and assist with the resolution of concerns which patients and their families and caregivers may have beyond the medical aspects of the diagnosis.

* For more information on lymphatic system and lymphoedema, please visit http://www.breastcancer.org/treatment/lymphedema/how/lymph_system

Source: Mount Elizabeth Rehabilitation Centre (Occupational Therapy)