Please note the following is a guide to Lymphoedema. The Movement Clinic will no longer see new patients for Lymphoedema.
Lymphoedema due to mechanical insufficiency is a protein rich swelling that accumulates within spaces or gaps called interstitial tissues in the body. This can be caused by the removal of lymph nodes due to cancer, injury, or infection.
Another type of lymphoedema is swelling associated with heart problems, kidney failure, renal failure or starvation. This is a low protein dynamic swelling where the lymph vessels are functioning normally but are unable to remove the excess fluid resulting in leakage into the interstitial tissues.
The lymphatic system is like a sewer system, it cleans and protects your body from bacteria and other pathogens and aids in the reduction of fluid build up. The lymphatic system is one of the most important systems in our body. If you develop a blockage or a disruption in the flow of the lymphatic fluid this can cause the system to work overtime which may lead to increased pressure and a bank up of fluid which can have a run on effect to other parts of the body.
One of the most prevalent forms of lymphoedema is post cancer. Not all post cancer patients will develop Lymphoedema.
Factors depend on the number of lymphatic nodes removed, type of surgery, and post surgery care of the affected area. Lymphoedema symptoms can develop up to 20 years later.
Some people may develop swelling whilst having radiation or chemotherapy. This may not be diagnosed as lymphoedema but should still to be treated with Manual Lymphatic Drainage, compression garments,, exercise and skin care. The reduction of swelling post surgery helps reduce the stress placed on the lymphatic system at such a crucial time. This post operative swelling can be present for many months following surgery.
Primary or Secondary Lymphoedema
Primary lymphoedema is a deficiency in the formation of lymph pathways and or nodes in the body.
Patients can be born with too many lymph nodes, not enough lymph nodes or none at all primary lymphoedema may be hereditary and can develop at any stage of life.
Primary Lymphoedema can develop slowly over years with no real understanding from the patient as to why this is happening.
In some instances an injury, disease or a long haul flight may cause a substantial amount of swelling. Over time this swelling may reduce but will never fully return to the state it was at before the incident.
People that develop primary lymphoedema often find that the swelling develops within the feet or hands and will work its way up the body.
Secondary lymphoedema is caused by a damaged or impaired lymphatic system. It could be due to cancer, removal of lymph nodes, radiation, trauma or disease.
When swelling forms it moves towards the extremities. This can happen rapidly or over a prolonged period.
Swelling associated with heart problems, kidney failure, renal failure or starvation, is a low protein dynamic oedema. With this kind of swelling, the lymph vessels are functioning normally, but are unable to remove the excess fluid resulting in leakage into the interstitial tissues.
Most common cause of secondary lymphoedema is cancer, injury, or if you live in tropical nations, filariasis.
Stages of Lymphoedema
Lymphoedema is usually classed in progressive stages as follows.
At this stage there is no swelling present and lymphatic vessels are still able to carry fluid away.
Symptoms may include:
- No known swelling present;
- You may experience or have feeling of changes under the skin;
- Legs and arms may feel heavier and
- Tingling in the extremities (fingers or toes).
At this stage the swelling can be reversed or may dissipate after time.
Symptoms may include:
- Swelling disappears on bed rest;
- Swelling with pitting of the skin;
- Arm or leg feels soft to touch;
- Swelling may not be as prominent in the morning, and gets progressively worse as the day continues;
- Reduces when the limb is rested, and
- Tingling in the extremities (fingers or toes)
At this stage swelling is irreversible. If not treated by a professional therapist may get worse over time.
Symptoms may include:
- Swelling does not disappear on bed rest;
- To make an indent in the skin it needs a firm touch;
- Limb feels heavy and tiredness may occur;
- May develop hard spots in arm or leg due to Scar Tissue (fibrosis);
- Fibrosis forming around ankle, knees, elbows and wrist;
- Swelling prominent in hands or feet and can have a dramatic effect on movement;
- Clothing may become constrictive around arm or leg and can cause a tourniquet effect producing more swelling and
- May suffer from small bouts of cellulitis.
At this stage people are usually diagnosed with elephantiasis. They appear massive in size due to the fluid, and have numerous problems due to size of limb or weight.
Symptoms may include:
- Complete changes in the skin;
- Wounds may appear;
- Nerves, veins and arteries become hard;
- Frequent cellulitis issues;
- Stretching of the skin may cause the skin to split;
- To large to fit into any compression garments and needs to have compression bandages;
- Excess fluid can leak from skin, and
- Massive weight gain.
Many stage 3 or elephantiasis cases are caused by filariasis. Mosquito’s are a major cause of lymphoedema in tropical nations.
Often patients will get to this stage due to inadequate facilities to deal with lymphoedema, poor squalid conditions or lack of awerness on how to treat this condition.
Watch this video to get a nice basic understanding of Lymphoedema.
Cancer and swelling, fluid retention
Cancer patients always ask why do I have this swelling and how do I get rid of it?
It’s not the easiest question to answer, sometimes fluid retention can be from a number of related issues and at times it can be complications that all seem to happen at once, which can add not only one source of a swelling problem, but can increase the swelling by the onset of comorditities
Not every cancer has a fluid retention side effect, any number of complications can cause fluid to build up, organ dysfunction can cause fluid around the organ and in the extremities, chemotherapy and radiation, hormone replacement and scar tissue, the amount of surgery all have fluid associated side effects, infection can also cause added fluid issues.
Swelling builds up in the tissues between the skin and muscle, and is usually more present in the arms, legs, feet, ankles, abdominals and neck. It can be a very gradual build up over time, or in the case of a infection or a reaction to medication can be suddenly.
Lymphatic vessels and lymph nodes transport lymphatic fluid, waste and nutrients throughout the body, the lymph nodes are part of our immune system. The lymphatic system can transport cancer throughout our body or the cancer can start in the lymph nodes.
Glands or lymph nodes can be felt in the neck, Arm pit, (Axilla), groin, thoracic and abdominal if a cancer is blocking the return of fluid to the lymphatic nodes or vessels this will cause a swelling in and around the area of the lymphatic nodes. (Example lymph nodes in the groin,filter fluid return from the leg, if a lymph node is blocked from the cancer the leg or lower abdominal could swell.
Ascities is a swelling in the cavities lining of the abdominals, this pressure from the fluid can also cause thoracic build up around the lungs, effects organs, kidney, renal and heart. As abdominal pressure builds it also cause a swelling in the legs, this is due to impared lymphatic pathway from the legs into the groin, the leg fluid return has no where to go so will continue to build, movement and functioning of the joints become increasingly difficult. Ascities needs to be drained by catheter that can relieve the pressure internally, this should be performed at a hospital with a referral from your specialist.
With so much fluid building up in the extremities skin starts to break down, cracks, open wounds and scratches will not heal, this can lead to an attack of cellulitis which is a bacterial infection in the skin that can cause rapid, swelling,heat, pain redness and a rash that can travel with speed.
Chemotherapy, DVT and blood clotting agents can also increase fluid retention and place extra pressure on organs that are already under stress, muscle contraction issues, fatigue, and psychological stress all increase the amount of fluid in the soft tissues.
One way of reducing the fluid build up is a therapy called manual lymphatic drainage, light hands on technique that moves fluid through the interstitial spaces to a less congested area that has functioning lymphatic nodes.
Slowly working on a limb that has fluid build up can enhance movement through the joints, by moving the fluid on it can reduce the onset of an infection, reducing the internal pressure can help veins, skin and circulation to improve. The feeling patients have after a lymphatic drainage is they feel so light and able to move and walk freely.
Lymphatic drainage can be a therapy that is an added benefit to your cancer rehab, with manual lymphatic drainage the therapist main aim is to control and constantly try and reduce the swelling, by keeping you mobile and active this can have an overall positive effect on wellbeing physically and psychological. Session’s are tailored to what stage of cancer therapy you are having, how your body is responding to treatments and complications associated with medications.
Manual lymphatic drainage for cancer related swelling should only be performed by a trained lymphoedema lymphatic therapist. Lymphoedema therapists have higher level training in lymphatic dysfunction and disease, working with you and your specialist team and allied health.
Lymph nodes are small in size and look similar to a bean. There are about 700-1000 lymph nodes throughout the body. A large number of them are located in the upper half of the body, this is due to orifice locations.
Lymph nodes make up part of the immune system, inside the lymph node are a number of cells called lymphocytes ( Type of white blood cell) and macrophage ( another form of white blood cell which ingest pathogens). They act as a filter to fight bacteria, breaking down and cleaning up small pathogens that invade our body. Lymph nodes are connected throughout the body via lymph vessels.
Fluid enters the node via ducts in one end and exit the other end. Lymph carries the pathogens through the node encountering lymphocytes and macrophage.
There are several types of lymphocytes and macrophages that break down and kill the bacteria, once this is done the lymph fluid leaves via the out going duct, travels through the lymph vessels and distribute to the venous blood vessels.
This process of fighting infection happens when our lymph nodes swell, for instance the common cold or flu, lymph nodes under the chin and in the neck become swollen and painful to touch. Other sources of swelling of lymph node or nodes can be associated with cancer, disease, or parasitic infection.
Further reading on Lymph Nodes, filariasis, Lymphocyte, Macrophage.
Lymph node (Wikipedia)
The Global Alliance to Eliminate Lymphatic Filariasis
Filariasis (World Health Organisation)
Further reading on Dr Vodder Manual Lymphatic Drainage and Lymphoedema.
Textbook of Dr. Vodder’s manual lymph drainage, Volume 1By Günther Wittlinger, Hildegard Wittlinger Edition: 7