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Background
Lymphedema is a swelling of a body part usually occurring
in the extremities. It can also occur in the face,
neck, abdomen, or genitals. Lymphedema is the result
of the abnormal accumulation of protein-rich edema
fluid in the affected area. Remarkably, even though
it afflicts approximately 1% of the U.S. population
(nearly 3 million Americans), there is a shortage of lymphedema information,
and the problems it creates are poorly understood
in the medical community. Lymphedema is classified
as either primary or secondary. Primary lymphedema
is the result of lymphatic dysplasia. It may be
present at birth but more often develops later
in life without obvious cause. Secondary lymphedema
is much more common and is the result of surgery
or is a side effect of radiation therapy for cancer.
Secondary forms may also occur after injury, scarring,
trauma, or infection of the lymphatic system. Lymphedema
has important pathological and clinical consequences.
In stage I lymphedema, the swelling consists of
protein-rich fluid and may be temporarily reduced
by simple elevation of the limb. If it remains
untreated, however, the lymphedema causes a progressive
hardening of the affected tissues which is the
result of a proliferation of connective tissue,
adipose tissue, and scarring (stage II lymphedema). Stage III lymphedema is characterized by a tremendous increase in volume, hardening of the dermal tissues,
hyperkeratosis, and papillomas of the skin. Infections
such a cellulitis, erysipelas, and lymphangitis
frequently develop in individuals suffering from
lymphedema. Infections are most common in stage
II and III lymphedema with each infection contributing
to a worsening of the condition making frequent
hospitalizations necessary. Lymphedema treatment options
offered in the United States include surgery, medication,
pneumatic compression pump therapy, Manual Lymph
Drainage (MLD), and Complete Decongestive Therapy
(CDT).
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STAGES
OF LYMPHEDEMA
LATENCY
STAGE
• lymphatic transport capacity is reduced •
• no visible/palpable edema •
• subjective complaints are possible •
STAGE I
(Reversible Lymphedema)
• accumulation of protein-rich edema fluid •
• pitting edema •
• reducible with elevation (no fibrosis) •
STAGE II
(Spontaneously Irreversible Lymphedema)
• accumulation of protein-rich edema fluid •
• pitting becomes progressively more difficult •
• connective tissue proliferation (fibrosis) •
STAGE III
(Lymphostatic Elephantiasis)
• accumulation of protein-rich edema fluid •
• non-pitting •
• fibrosis and sclerosis (severe induration) •
• skin changes (papillomas, hyperkeratosis,
etc.) • |
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Manual Lymph
Drainage (MLD)
MLD, a gentle manual lymphatic therapy technique, is a potent way to
activate the lymphatic system, especially when the
transport capacity of the lymph vessel is reduced because
of prior surgery and/or radiation therapy. However,
if carried out as an isolated treatment for lymphedema,
the results are very temporary and lasting evacuation
of lymph fluid from a congested limb is not possible.
Many MLD practitioners have been trained only in basic
MLD and are not qualified to treat lymphedema at all.
However, MLD alone may be used with much success in
many conditions unrelated to lymphedema.
Complete Decongestive
Therapy (CDT)
CDT is a combination of MLD, bandaging of the affected
areas, remedial exercises, and skin and nail care.
CDT is divided into a two-phase program that initially
involves an intensive treatment phase and is then followed
by a maintenance program continued by the patient at
home. Carried out with great care and consistency by
a certified lymphedema therapist, CDT is the treatment
of choice for chronic extremity lymphedema. Even in
advanced lymphedema, CDT achieves excellent results
with no side effects. Because CDT is labor intensive,
time-consuming, and requires patient compliance, many
patients have difficulty committing to the program
at first. However, because the results of CDT are always
superior to those achieved with all other treatments,
increasing numbers of patients are undergoing CDT treatment
and are consequently able to maintain the reduction
of their limbs through diligent participation in a
home maintenance program. Because CDT is fairly new
in the United States, staff training and treatment
standards vary from clinic to clinic. For a lymphedema
therapist to be fully competent in treating lymphedema
using CDT, it is vital that the CDT training consist
of the four components of CDT: (1) basic and advanced
MLD, (2) lymphedema bandaging, (3) remedial exercises,
(4) skin and nail care. The therapist must also have
a complete understanding of the anatomy, physiology,
and pathophysiology of the lymphatic system, the treatment
of primary and secondary lymphedema, the indications
and contraindications of CDT, and the proper measuring
techniques for lymphedema support garments. Furthermore,
lymphedema therapy should not begin unless the patient
has been examined and diagnosed by a board-certified
physician who understands lymphedema and its complications.
Once the diagnosis of lymphedema has been confirmed
and treatment has begun, the progress must be monitored
by the physician. Whereas the clinical diagnosis of
lymphedema can most often be established without invasive
testing, and electrocardiogram before the treatment
begins and during the course of treatment is sometimes
necessary to ensure safe treatment for each patient.
Lymphangioscintigraphy (LAS), CT scans, and MRIs are
also recommended for lymphedema patients before starting
CDT. The physician will be able to decide and inform
the patient about the necessity of such procedures
at the time of consultation. Because of the complications
associated with lymphedema, the involvement and supervision
of a qualified physician is essential for safe and
effective lymphedema therapy. |
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Surgery
Surgical procedures are sometimes suggested to a lymphedema
patient. Numerous operational procedures have been
devised and thousands of operations have been carried
out over the past century. None of the surgical
techniques has been shown to give consistent or
dependable results. In addition, any surgery performed
on a lymphedematous (swollen) extremity may further
reduce the transport capacity of an already-incapacitated
lymphatic system.
Medications
Diuretics, while often prescribed, usually make the
lymphedema worse. Diuretics are able to draw off
the water content of the edema while the protein
molecules remain in the tissue spaces. These proteins
continue to draw water to the edematous areas as
soon as the diuretic loses its effectiveness. These
accumulated proteins also lead to a higher concentration
of proteins in the edema fluid and cause the tissues
to become even more fibrotic and indurated. Benzopyrones
for lymphedema have been tried for many years, primarily
in other countries. Their therapeutic effect as it
relates to lymphedema continues to be debated. Furthermore,
the product lacks FDA approval. Some patients who
have used the drug here in the United States have
discontinued its use after having experienced adverse
side effects.
Pump Therapy
The pneumatic compression pump is a mechanical device
that "milks" the lymph fluid out of the
swollen extremity. The problems with pneumatic pumps
are numerous and any results achieved are usually
very temporary. Pump therapy, for instance, disregards
the fact that the ipsilateral trunk quadrant is also
more or less congested or lymphedematous. Hence,
lymph fluid that is pumped into the trunk quadrant
adjacent to the lymphedematous extremity will create
congestion, connective and scar tissue, and induration
(hardening) at the root of the extremity, namely
the hip and buttock areas in lower extremity lymphedema
and the shoulder, chest, and back areas in upper
extremity lymphedema. This lymphedema will continue
to worsen in spite of vigorous pumping. In lower
extremity lymphedema, extensive pumping may cause
genital lymphedema, which will not only create more
physical difficulties but also immense psychological
problems for the patient. In addition, pumps do nothing
to eliminate scar and connective tissue (lymphatic
fibrosis) which always exist in stage II and III
lymphedema. In most cases, lymphedema recurs the
moment the patient stops using the compression pump.
Pump therapy is still
offered in many treatment centers. Some clinics use
pumps because of the financial advantages achieved
through facilitated insurance reimbursement. In addition,
it is quite easy to place a patient on a pump without
the attention of qualified or experienced personnel.
Some clinics may also use pumps because they simply
do no have trained lymphedema therapists on staff. |
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