Lymphoedema and Chronic Oedema
Melanie Atteridge is a qualified Level 1 lymphoedema practictioner
What is lymphoedema?
Lymphoedema is a build up of lymph fluid, which is usually drained and pumped away by the lymph system. Our body produces litres of lymph fluid every day, as a normal process. Arteries carry blood rich in oxygen and nutrients to the capillaries, where a lot of fluid is released. Some of the fluid is returned in the veins, however most relies on the lymph system to move it along. This fluid is rich in proteins, as well as cells. In a healthy system this is drained into small vessels similar to veins and pumped very slowly towards lymph nodes. Lymph nodes act as a filter and are important parts of our immune systems. Once filtered the lymph progresses along the vessels and is eventually returned to the blood supply into a large vein near the heart.
Lymphoedema (which means lymph swelling) results when the lymph system is unable to drain and remove the protein rich fluid. It then builds up in the affected area, causing heaviness, tightness, and swelling. If this swelling is stagnant and not removed, it causes inflammation in the tissues surrounding it. This inflammation in turn increases the fluid load on the area. It is considered a progressive disease because the inflammation and swelling results in fibrosis, fibres forming within the fluid, thickening and changing the structure of the skin and surrounding tissue. Chronic fibrosis can progress into fat build up.
What is chronic oedema?
Chronic oedema is swelling that persists for more than 6 weeks. It is common in many medical conditions and occurs when the veins are overloaded in the legs, and allow more fluid than usual to backlog in the tissues. This overloads the lymph system, which doesn’t keep up with returning this fluid to the trunk. It is usually in both legs, quite symmetrically. Congestive heart failure, kidney disease and venous insufficiency are all common conditions that result in chronic oedema. When untreated, it progresses in the same way lymphoedema does, with inflammation, fibrosis, and thickening tissues of the lower legs. This predisposes people to other problems such as cellulitis and impaired wound healing. It is very common in the older population. Historically it has not been addressed in many people, however it is now recognised that this swelling needs to be treated in the same way as lymphoedema is, for optimum health.
What causes lymphoedema?
The most common cause of lymphoedema in Australia is damage to the lymph system due to cancer treatment. When lymph nodes are removed, the capacity of the system decreases. It can no longer collect and move as much fluid. If lymph vessels are damaged due to radiotherapy, the capacity decreases further. There is usually a buffer between load and capacity so that some reduced capacity does not cause a problem in many people. In fact, after a clearance of axillary nodes, only 20-25% of people go on to develop lymphoedema. That is only 1 in every 4 or 5 people. Conditions that cause an increased load on the system can also cause lymphoedema. Examples of this are obesity, some medications including taxanes used in some chemotherapy, and congestive heart failure. When the fluid load is above the capacity of the system to move it along, the fluid backlogs and stays in the tissues. Lymphoedema can have other causes, such as an infection called filariasis, which has been common in the developing world, however is not really seen in Australia. Lymphoedema can develop with no known cause, which is believed to result from a congenital weakness in the lymph system present from birth. This can present at any age.
What are the risk factors?
Anything that compromised the lymphatic system or increases the fluid load increases the risk of developing lymphoedema. The more the lymphatic system is damaged by surgery, trauma or radiotherapy, the higher the risk of developing swelling. Some medications and obesity, as mentioned, increase the load on the system. Infections such as cellulitis both add to the fluid load and damage the lymph vessels, so are a risk for increasing or triggering lymphoedema. People with a family history of lymphoedema are also at higher risk. Often these elements are outside of our immediate control. The biggest risk factor that we can control is body mass. People with a healthy body mass have a much lower risk of developing problems, than those with a high body mass.
How does lymphoedema progress?
The progression is the same regardless of the cause. The more fluid in the tissues, and the longer it is stagnant, the more inflammation is triggered. This then increases the fluid load further. If untreated, the vessels get overstretched and damaged, further reducing their capacity to clear this fluid. Over time the body lays down fibres in the fluid, causing the skin and subdermal tissue to be thickened and hard. If untreated, over a long period of time, this fibrosis is converted into fat tissue. Lymphoedema is classed as a progressive disease, because if untreated, it will continue to worsen.
How is lymphoedema treated?
It is best treated EARLY!! There is good evidence in the medical literature to show that early intervention results in much less progression, much less dysfunction, and much less treatment needed. Gold standard treatment includes a baseline measurement and some education pre-surgery for removal of lymph nodes, then monitoring over a few years to recognise and address it early, should it develop. Pre-surgery is often a stressful and hectic time, so this isn’t always possible, however the screening and education around the signs is imperative.
Treatment is individualised, and includes compression therapy, manual lymphatic drainage either by a therapist or by the client or family member, meticulous skin care and regular exercise. More intensive treatments can be added as needed including intermittent pneumatic pumping and serial bandaging.
If you have any concerns regarding lymphoedema, you are welcome to book an appointment to discuss these and have a personal plan made. All lymphoedema bookings must be made by phone,
please don't hesitate to call us.
The initial appointment made is one hour. You will be sent a questionnaire prior to the appointment time. Please take the time to fill this out, it will take around 10-15 minutes, and will streamline the appointment so there is more time for targeting your personal goals. Once at the appointment, firstly a thorough history is taken. All aspects of the symptoms will be discussed, and importantly, the impact symptoms are having on your life and activities. A physical assessment follows next, so the therapist can examine the affected areas for swelling, behaviour of the swelling, mobility of relevant tissues, skin health and any other concerns raised in the history. Measurements are taken using a tape measure, and photos are usually taken, for future comparison. If you have had a SOZO scan and have the report, please bring it along (If not, no problems). Then a discussion around exactly what is happening in the affected areas, and a plan is made for treatment. This includes education around how best to manage the swelling independently. Sometimes a garment can be decided on in this first appointment, and then ordered.
Follow up appointments are made for fitting of garments, monitoring if needed, and to implement any other aspect of treatment. These are likely to be half an hour in duration.