Lymphoedema – The ‘Silent’ Chronic Disease – Part 2

Lymphoedema Treatment Target: Normalise the extremity. This is achieved by an increase in lymph transport in the oedematous area and accelerated breakdown of proteins.

Primary Lymphoedema arises from developmental abnormalities within the lymphatic tissue. Damage is congenital and is either genetic or has no known cause. Oedema usually only appears during periods of growth and during puberty. Secondary lymphoedema has a known cause and the most common is filariasis (parasite infection).

Secondary lymphoedema is often as a result of a cancer operation in which the corresponding group of lymph nodes is also removed. If and when lymphoedema occurs depends on the surgical technique, the number of lymph nodes removed, and the intensity of radiation. Lymph collectors can also be interrupted or damaged by other operations, e.g. by-pass operations, vein removal or varicotomies. Secondary lymphoedema also includes post-traumatic lymphoedema. Post-traumatic lymphoedema occurs if one or more large lymph collectors are damaged due to tissue contusion, burns or open fractures.

The characteristics of benign lymphoedema are a slow progressive onset with pitting in the early stages. It always starts distally and is asymmetrical. A typical clinical picture would be the squaring of toes, a “buffalo hump” on the dorsum of the foot and the loss of the ankle contour. Cellulitis and discomfort are common and is rarely painful.

Lymphoedema has four stages of development (Primary and Secondary). The Latency Stage – lymphatic vessels are damaged but the oedema is not yet visible. The patient is usually unaware of the underlying threat of lymphoedema.

Stage 1 – reversible stage: The swelling, which will pit in response to pressure, is soft. The oedema disappears during the night or after a few days of bed-rest.

Stage 2 – spontaneously irreversible stage: This stage is the most common in practice. Even after a period of bed-rest the oedema no longer disappears. The swelling is hard. In the area of protein-rich congestion, connective tissue replication occurs, forming fibrosis which becomes harder and harder. At this stage there is an increased risk of infection (erysipelas, mycosis).

Stage 3 – lymphostatic elephantiasis. The extremity shows extreme swelling as a result of inflammatory episodes.  This stage is also characterised by hardening of the skin and verruciform excrescences. If this stage persists for years and is left untreated, there might be a risk of malignancy: lymphangiosarcoma, which is usually fatal.

Lymphoedema will progress and considerably reduces the quality of life. Patients complain about a feeling of tension and heaviness in affected limbs, limited mobility, numbness in certain areas as well as loss of strength.

There is a ‘quick’ checklist you can run through to determine whether you might suffer from lymphoedema or not. Should you answer “yes” to any one of these questions, please consult with a vascular surgeon and get a proper diagnosis.

  •  Is the skin smooth and swollen?
  •  Does the swelling affect one leg or one arm only
  •  Did you have an operation or radiotherapy before the swelling started?
  •  Did you injure that part of the body?
  •  Are the back of your hands or feet swollen?
  •  Are your natural skin folds deeper?

The treatment target for lymphoedema patients would be to normalise the extremity. This is achieved by an increase in lymph transport in the oedematous area and accelerated breakdown of proteins.

Complex Physical Decongestion (CPD) is the most effective method for treating lymphoedema. CPD treatment is divided into two phases. 

Phase 1: Decongestion (lasts on average 25 days depending on how advanced the oedema already is). During this phase, the therapist will concentrate on the removal of the protein-rich fluid accumulation.

Phase 2: Preservation and optimisation (life-long). Reduction of superfluous tissue and keeping the extremity stabilised.

The 4 cornerstones of CPD are:

1. Manual Lymphatic Drainage 

2. Bandaging, followed by compression stockings 

3. Decongestion exercises 

4. Skin care

Written by Carla Potgieter Medical Orthotist Prosthetist (SA) / CDT Therapist (Norton).

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