Useful articles

The information contained in the articles below is not intended to replace individual advice you may receive from your healthcare practitioner and falls outside the scope of the Information Standard.

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arrowpng Alternative therapies for the management of lymphoedema
arrowpng The use of pumps in the management of lymphoedema
arrowpng Imaging and screening for lymphoedema
arrowpng Exercise and movement
arrowpng Obesity and lymphoedema
arrowpng Lymphorrhoea
arrowpng Have you got Cellulitis... or Red Legs?
arrowpng The surgical management of limb lymphoedema
arrowpng Lymphatico-venous bypass surgery for lymphoedema
arrowpng Lymphoedema and Pregnancy
arrowpng Lymphoedema and orthopaedic surgery
arrowpng Blood Pressure tablets – Watch point
arrowpng To needle or not to needle… that is the question!
arrowpng What is the Lymphatic System?

 

This article is taken from the Spring 2016 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Alternative therapies for the management of lymphoedema

By Rebecca Elwell, Msc Lymphoedema, Macmillan Lymphoedema CNS
and Denise Hardy, CNS Lymphoedema, Cumbria

Introduction

41The standard approach to the management of lymphoedema as stated by the International Consensus, Best Practice for the Management of Lymphoedema (2006) – often referred to as the ‘gold standard care model’ – includes an intensive treatment phase of Multi-layered Lymphoedema Bandaging, Manual Lymphatic Drainage, Skin Care and Exercise followed by a maintenance phase of compression hosiery or wraps and Simple Lymphatic Drainage. The gold standard care model outlined above, has been adapted over the years by lymphoedema therapists from all over the world, to include a wide range of alternative or novel techniques, often with a focus on symptom management rather than volume reduction. However, a number of different therapies exist for the management of lymphoedema but the evidence to support their use is often poor and sometimes their use relies solely on the experience of the therapists who use it (anecdotal evidence) or of the patients who receive the therapy. Not all clinics have access to such therapies, which are often extremely expensive and not funded by all providers. This article simply aims to inform you of an interesting new tool to measure how much fluid is being retained under the skin, and some alternative therapies including:

• Moisture Meter
 
• Low Level Laser
 
• Hivamat (Deep Osscilation)
 
• PhysioTouch (Negative Suction)
 
• BodyFlow (Mild electrical stimulation)

A recent article in LymphLine highlighted the extensive use of Sequential Pneumatic Compression Pumps in the management of lymphoedema and they will therefore not be discussed further in this article.

A brief overview of the moisture meter and 4 therapies will be given, describing how it is thought that they work, what you might experience if you were to undergo the therapy and if there is any robust evidence to support its use.

Moisture Meter

The overall aim of lymphoedema treatment is to facilitate a reduction in the volume of fluid, often within a limb. However, there are an increasing number of people living with breast oedema in the UK as a result of more conservative breast cancer treatment. Measuring the amount of swelling in this area is more difficult than measuring swelling in an arm or leg. Subjective measures are therefore put in place to demonstrate improvements, such as how the tissues have softened, how the breast feels, or how much the bra digs into the skin. With the introduction of innovative products, some clinics are combining these measures with more objective measures such as by using moisture meter readings (a ‘pen like’ device which when held onto the skin can work out exactly how much fluid is being retained under the skin). The same device can also be used after treatment, to demonstrate oedema reduction more accurately.

 

alternative therapies

Low Level Laser Therapy (LLLT)

LLLT is light therapy, also known as LED therapy, rather than a true laser therapy, it is therefore safe and does not burn the skin or harm the eyes in any way

LLLT aims to soften the skin and underlying tissues to increase lymphatic drainage by increasing the amount of oxygen in the cells. It is thought that it may have the ability to encourage the growth of new lymphatic vessels, though this is as yet not proven. As it has an effect on the regeneration of cells, LLLT should not be used in those with untreated cancer; if you are concerned in any way you should discuss LLLT with your oncologist or cancer specialist nurse. You should also not undergo LLLT if you are pregnant or under 18.

LLLT has anecdotally been reported as being beneficial to treat pain and increase range of movement e.g. in softening the skin and scar tissue in head and neck lymphoedema (following surgery and/or radiotherapy) to increase head turn and improve posture/discomfort.

LLLT should be given regularly to start with, e.g. 2-5 times in the first 2-3 weeks and then may be reduced over time. The LLLT probe (different sizes exist from a small pen type probe to one that looks like a shower head) is held on the skin in each affected area for 1 minute, with a total treatment time of 10-30 minutes. Most people do not feel anything, though some may experience a “creeping sensation”.

Limited robust evidence exists to support the use of LLLT in lymphoedema management and larger, wide-scale studies are required before it will become part of standard lymphoedema practice in the UK.

Hivamat/Deep Oscillation Therapy

Deep Oscillation Massage Therapy originated in Germany in 2007 and uses the Hivamat to create low frequencies of gentle electrostatic impulses that ‘vibrate’ your skin’s tissue by attracting and releasing it between 5-250 times a second. It is thought to remove excess inflammation caused by products, protein solids and lymph fluid build-up.

Your therapist is connected to the Hivamat machine using an electrode and you will hold a light neutral titanium bar loosely between your fingers. Wearing vinyl gloves and sometimes using talc, your therapist massages your swollen area allowing the pulsed oscillations to penetrate your skin to a depth of 8-12cm. The therapy can also be self-administered using an applicator which is moved over the skin, similar to an ultrasound probe.

The Hivamat Deep Oscillation Massage Therapy is extremely relaxing and enables your therapist to provide an effective deep tissue massage, without causing you pain or discomfort or further damage to your lymphatic system.

Extremely limited robust evidence exists to support the use of Hivamat in lymphoedema management, limited evidence exists to support its use as a treatment for breast pain post operatively and larger, wide-scale studies are once again required before it will become part of standard lymphoedema practice in
the UK.

Contraindications to Hivamat therapy include:

• Acute infections
 
• Infectious diseases of the skin
 
• Non-treated blood clots and vascular diseases
 
• Untreated cancer
 
• Cardiac pacemakers
 
• Pregnancy
 
• Hypersensitivity to electric fields 
• Under 18 


METAL PROSTHESIS ARE NOT A CONTRAINDICATION


Physiotouch (formerly known as Lymphatouch)

PhysiotouchOriginating from Finland, this device has a number of different sized suction cups a therapist can use in different areas of the body, using negative pressure to stretch the skin and underlying tissues. It is thought to enhance the opening of the cells of the initial lymphatic channels to allow them to absorb more fluid, thus reducing swelling. Therapists often use it as they report, anecdotally, that it leads to a softening of thickened tissues and scar tissue (allowing lymph to flow through the areas more easily) and some say it also alleviates pain and increases range of movement.

When the device is applied to the skin it gently sucks in the skin and there is a sensation of ‘pulling’ (which can be adjusted and should not be unpleasant) followed by a ‘release’.

Contraindications are quite vague but include: 

• Acute infection
 
• Recent blood clot
 
• Swelling caused by heart failure
 
• Patients on active cancer treatment 
• Caution should be observed when treating the neck area in patients over 60 years of age 
• Under 18

Anecdotal evidence exists to support the use of Physiotouch or Lymphatouch but there is currently no robust evidence to support its use in the management of lymphoedema.


BodyFlow/Mild electrical stimulation

This therapy uses an electrical current to stimulate the lymphatics, and to a lesser extent, the smooth muscles. Such muscle stimulation has been shown to change tissue pressure which helps in lymph absorption and increases lymph flow.

The treatment involves attaching a number of electrodes to the appropriate part of your body, which apply a mild transdermal (through skin) electrical stimulus.

You may experience a light tingling sensation, felt through your skin under the electrode and a minor muscle twitch may occur, indicating the stimulation effect.

BodyFlow treatment is not suitable if you: 

• Have an internal cardiac device such as a permanent pacemaker or internal defibrillator 
• Are pregnant
 
• Have a DVT
 
• Have active cancer
 
• Have an acute infection 
• Under 18

Some limited evidence exists to support the use of BodyFlow, but as is becoming
 a familiar story, larger wide-scale studies are required before it will become part of standard lymphoedema practice in the UK.

Conclusion

Novel approaches to lymphoedema cannot be ignored, many clinics are now offering these techniques, obtaining good results and increasingly patients are reporting a benefit in symptoms. There are testimonials to this on many of the company websites and health fora, e.g. The HealthUnlocked forum frequently features threads related to alternative therapies for lymphoedema. Some of the therapies can be used at home with portable machines which can be bought directly. If you would like further information please ask your lymphoedema therapist.

It is important to remember, however, that none of these therapies should be offered alone, they should only be offered as part of lymphoedema management in association with compression, skin care, exercise and massage and caution should be exerted if claims are made related to their efficacy and success in treating lymphoedema, as for the main part, little or no robust evidence exists to support their use.

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This article is taken from the Winter 2015 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

The use of pumps in the management of lymphoedema

By Jane Wigg, Director Lymphoedema Training Academy, Board member LymphCare UK

Introduction

42‘Pumps’ is a general term used for the application of external compression applied to a limb by a machine. This is usually applied by inserting your arm or leg into a sleeve which inflates with air. There are many terms used to describe pumps and you may have heard of Intermittent Pneumatic Compression (IPC), Pneumatic Compression Therapy (PCT), Active Compression Therapy (ACT) or just ‘Pumps’. Pumps have been used successfully in the treatment of lymphoedema since the 1950s and as there was very little other treatment available for lymphoedema at this time, they became more mainstream use. They are also first line treatment for the management of lymphoedema in the USA where patients are provided with a simple pump, which is increased to a more sophisticated one, should their condition deteriorate.

How do they work?

In lymphoedema, tissue water is maintained within the subcutaneous tissue and skin. Often a change in pressure
 will allow for the fluid to be removed, either through the lymphatic system or the veins. By applying external compression to the limb, the pressure within the tissues, and in the veins and blood capillaries, can be altered. This will facilitate the ability for the veins to absorb more fluid from the tissues. This is what happens when receiving compression therapy from bandages or garments. Most of the research surrounding IPC shows that the fluid will return to the blood circulatory system and little into the lymphatic system, meaning that pumps work better where there is a pitting or soft swelling. More modern machines intend that fluid is also returned via the lymphatic system and there is good evidence of this.

There are several additions to the pump which can influence the effectiveness by which it works. The sleeve can have several chambers which can inflate in different sequences. Chambers range from 1, 3, 6, 8 and 12. Some machines have smaller and narrower chambers than others. It is considered that the more chambers, the better the effect. Some 
of the chambers overlap having a more peristaltic effect. If purchasing your own machine it is recommended to not use a 1 chamber sleeve.

Sequences on the machines work differently. Many of the traditional machines will start with an inflation at the foot with the highest pressure, and this will be held but gradually reduce in pressure with each inflation of each chamber. Other sequences have a peristaltic effect commencing at the bottom of the limb and continuing to the top. Over the past 7 years, many of the new style pump sequences have been developed and altered to commence closest to the body and work down to the bottom, with the aim of decongesting the limb and clearing an area for the fluid to drain into.

Cycles on pumps are becoming more complex and follow the theory of Manual Lymphatic Drainage (MLD) closer. Some of the pumps have shown through lymphatic imaging that these sequences can remove fluid better and improve lymphatic drainage. If you have ever had any genital swelling it is important that you use one of the modern day pumps with sequences commencing proximal and working distal (closest to the body).

Are there any side effects?

Many of the pumps have adjustable pressure dials on them and on some machines these can be increased to as high as 160mmHg. This is extremely high pressure and it is suggested that you should only use pressures as high as 40mmHg. There are some reports that the initial lymphatics could be damaged by using high pressure. It is also important to remember that the pump does not know if you have a bandage or stocking on your arm/leg, so if you apply the pump
 in this method you may cause complications and have very high pressure to your limb. Always remove your garment before using a pump. Pumps used at high pressure could cause problems if you have any circulatory or arterial problems. In this instance they can be used but should always be used with medical supervision.

Some of the traditional pumps have been blamed for the increase of a genital oedema or for pushing fluid up to the top of the limb. This can be the case if used at high pressure and is why it is essential that you carry out Simple Lymphatic Drainage (SLD) prior to using a pump. The study identifying genital oedema looked at information historically, and concluded that genital oedema was present in 43% of pump users, regardless of the pump used, the amount of pressure, time or type of oedema.

I have carried out a study auditing the same parameters using a modern day ‘MLD pump’ and did not identify any genital oedema from the machine used. This has been presented at several international conferences. When IPC has been used within the lymphoedema services I have worked with, we had set controls and low pressure and there was no evidence of genital oedema caused on the cycle used.

Some people will want to purchase their own machine. This is fine, if 
you can afford it, but it is important
 to remember to use it under your therapist’s guidelines. This is usually for an hour a day with pressure no more than 40mmHg. This will prevent any complications. I have known some patients who have been able to manage their lymphoedema without garments by using a machine daily or twice daily, ‘sensibly’ but they are in a minority.

the use of pumps

A course of treatment from your lymphoedema clinic will usually be daily or 3 times per week for 3 weeks. Many clinics now provide a ‘treat
 and go’ service where you can attend, receive supervised self-management 
of pump therapy and then leave. Some lymphoedema services also provide
 loan machines. In this instance, you will be provided with a machine to use at home. You will receive information from the therapist regarding the settings you should use. Remember that this is prescribed treatment and you must not alter the settings and use as instructed. A loan service is usually provided to patients who have stubborn lymphoedema or who have completed complex treatment and still require ‘MLD’, but maybe have to return to work and cannot take any more time off.

There are hundreds of clinics now using ‘modern’ pumps with retrograde sequences. They assist the therapists by changing the tissue softness and allowing for a faster reduction of oedema when using your hands with MLD. They will never replace Manual Lymphatic Drainage but the therapist can allow 
the machine to do the ‘heavy’ work and then use their hands on specific problem areas. In addition, pumps cannot easily apply compression to the body, although there are some garments for this.

Conclusion

In summary, pumps are not a new treatment but were dismissed due to 
the complications they caused many years ago when lymphoedema services were not yet established. Now, technology has allowed for them to work better than previously and this continues to be developed. They are getting closer to mimicking MLD but still are not able to fill the lymphatics, just disperse the fluid to somewhere it can drain better and particularly in the veins.

Ensure that you don’t get addicted to your pump if you purchase your own, there is little evidence to show that it 
is more effective than wearing your garment and walking! Personally, I 
love the pumps I have been involved with. They offer the therapist (and patients alike) a tool for altering firm and thickened tissue and reducing limb volume, but please ensure that you are supported by a good lymphoedema therapist. I can’t wait for the next new generation as technology is assisting us.

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This article is taken from the Winter 2014 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Imaging and screening for lymphoedema

By Mr Alex Ramsden, Consultant Plastic and Reconstructive Surgeon at the Oxford University Hospitals

Introduction

Alex RamsdenLymphoedema is tissue swelling due to a failure of lymphatic drainage. The diagnosis is often made by doctors of various types based on the history and examination of the patient with tissue swelling (oedema). However, there are many causes of oedema, particularly of the lower limb, so making the diagnosis can sometimes be difficult from history and examination alone. There are two main types of lymphoedema, primary and secondary. Investigations in primary lymphoedema aim to confirm a diagnosis and exclude other reasons for oedema. Other tests that may be used are genetic screening and blood tests but these are not discussed here. The diagnosis of secondary lymphoedema is easier to make from the patient’s history and here investigations are directed towards confirming the diagnosis but also to grade the extent of lymphoedema. Investigations can provide the patient with an indication of future disease progression and can also form the basis for individualised treatment programs. Recent developments in the surgical treatment of lymphoedema have led to the need to help identify groups of patients that would benefit most. New investigations can decide if surgery would be beneficial and guide a highly targeted surgical approach.

Lymphoedema is a relatively neglected condition by the medical research establishment. Probably because it is nonfatal and commonly considered difficult to treat, there has been little progress with the development of investigations until recently. As surgical treatments become available there is a new and growing demand amongst surgeons for better and more accurate investigations.

An ideal investigation for lymphoedema would be cheap, safe and reliable. It would provide accurate diagnosis, guide treatment options and be suitable for all patients. It would demonstrate both the lymphatic anatomy and give an indication of functional capacity. This ideal investigation currently doesn’t exist but this review will consider common investigations and when they might be used.

The main problem all investigative techniques face is the small size of the ultra fine network of lymphatics they are attempting to visualise. Many commonly used forms of simple imaging such as computed tomography (CT), magnetic resonance imaging (MRI) or ultrasound (US) can’t see the fine lymphatic system
as most vessels are measured in millimeters. This size is beyond the current resolution of these systems without enhancement techniques.

There are two main types of investigation. One type injects a special marker substance into the lymphatic system. The specific properties of this marker allow it to be seen by the imaging technique, highlighting the lymphatic system specifically, allowing it to build up a functional and anatomical picture of the lymphatic system. The second type images an area of the body using non-specific means but can visualise anatomical structures, which may be the cause of or be affected by lymphoedema.

Lymphoscintigraphy

This technique has been in use for over 60 years and involves injection of a radioactive tracer into the foot or hand. The tracer is the correct size to be taken up into the lymphatic system and moves slowly along the lymphatic channels. The radioactive material produces gamma radiation, which can then be detected using a gamma camera in a radiology department. A picture is built up of where the radiotracer has moved in the body of the patient. By taking pictures at different time intervals, following injection, a quantitative assessment of function can be made. Images are often taken 30 minutes, 1 and 2 hours after the injection and give an indication of how slowly the radiotracer moves through the body. The camera is very sensitive and the dose of radiation is low. The black and white images produced are interpreted by a radiologist, but don’t provide accurate anatomical information as they have low resolution. Radiation passes completely through the body and so even deep lymphatic channels can be visualised. They can be difficult to interpret and unreliable. This technique can diagnose lymphoedema and give an indication of the function of the lymphatic system. It is considered the gold standard for investigation of primary lymphoedema.

Figure 1. Lymphoscintigraphy 

Indocyanine Green (ICG) Lymphography

Figure 2. ICG lymphographyIntroduced in 2007, ICG lymphography involves a fluorescent marker rather than one that is radioactive. The injected dye will fluoresce in infra-red light and a special video camera is used to make images from the light given out by the dye. Indocyanine Green dye has been used in many fields of medicine such as neurosurgery for around 50 years. A tiny dose is injected into the skin of the hand or foot. It is absorbed into the lymphatics
and moves up the limb with the lymphatic fluid. The dye can then easily be visualised by the infra-red camera and the lymphatics mapped. It doesn’t require a radiologist to interpret the images or expensive gamma cameras and so is cheaper than lymphoscintigraphy. Indeed, the images can be displayed in clinic on a laptop computer so that both the doctor and patient can see the images giving the patient a real idea of the nature and extent of any lymphoedema.

Live imaging allows the patient to see the effect
of lymphatic massage as the dye can be seen being pushed along intact lymphatics and accessory channels.

The rate of movement of the dye up the limb can also be measured giving an indication of lymphatic transport speed. A practical advantage of this technique is that it can be used in an outpatient clinic or theatre with simple portable equipment. Surgeons can mark the lymphatic channels on the skin and plan surgical intervention accurately in discussion with the patient.

Unfortunately, the infra-red light only penetrates a couple of centimeters into the body and so deeper lymphatics such as those in the abdomen cannot be visualised. ICG lymphography is an important step forward in the investigation of lymphoedema.

Magnetic Resonance Lymphography

Magnetic Resonance Imaging (MRI) is a routine investigation from orthopaedics to neurology. Recent demands for improved anatomical accuracy from lymphatic surgeons has prompted research into the role of MRI for lymphoedema. Plain MRI doesn’t currently have the resolution to see lymphatic vessels
 but can differentiate between lymphoedema and lipoedema
due to the different appearance of subcutaneous fat. It is very good at imaging lymph nodes and their anatomy. To image the lymphatic vessels, MRI needs to be enhanced with contrast agents that are taken up by the lymphatics and show up clearly on MRI scanning. This process allows 3D images to be produced that demonstrate the lymphatic anatomy throughout the limb and trunk. Resolution is significantly better than lymphoscintigraphy and there is no radiation dose. However, this investigation is only performed in very specialist centres, requires an experienced radiologist to interpret the images and is expensive. These limitations may be overcome if it can be proven to add significant and useful information. Computed Tomography (CT) scanning with contrast media is a similar process. These scans have an advantage of giving accurate information on other structures that may cause lymphatic obstruction such as tumours. Currently MRI and CT imaging techniques are at the early phase of development but show promising advantages that may be realised in the next decade.

Ultrasound (US)

Commonly used as a complementary investigation for lymphoedema, ultrasound can exclude venous disorders that can cause limb swelling such as deep venous thrombosis. It doesn’t have the resolution to image lymphatic vessels but can show oedema, lymph nodes and fibrosis in the subcutaneous tissue.

Screening for lymphoedema

Evidence suggests that early treatment of lymphoedema slows disease progression and gives better outcomes. It is known that between 20 and 40% of patients undergoing axillary procedures for breast cancer are at risk of developing lymphoedema, and the figure may be higher for other cancers. Early diagnosis in these high-risk groups is important. Recent reports from Japan show that ICG lymphography can diagnose lymphoedema at a very early stage before patients develop significant clinical signs. Early identification of the earliest signs of lymphoedema would allow surgical intervention before significant limb swelling and before garments are required. By closely monitoring high-risk groups and treating at the earliest possible opportunity the chronic changes of lymphoedema may be avoided. Surgical intervention at this stage promises to be easier and with greater chance of preventing the disease. Reliance on compression garment use may be reduced or avoided altogether.

 

imaging and screening

Summary

Imaging in lymphoedema aims to confirm the diagnosis and plan treatment. Lymphoscintigraphy remains a gold standard investigation in the diagnosis of lymphoedema. ICG lymphography is low risk, accurate in making a diagnosis and excellent for surgical planning. MRI and CT scanning are specialist and developing areas that may add important information in future. Simple screening tests allow early diagnosis and intervention aimed at preventing disease progression. 

 

Table 1. Comparison of common imaging techniques
 


This article is taken from the Autumn 2014 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Exercise and movement

By Melanie Thomas, National Clinical Lead Lymphoedema, Welsh Government

It does not seem that long ago that Wales, like many other countries, was struggling to support people with lymphoedema. Through continued political pressure and increasing awareness and communication, inequity of lymphoedema service provision ceased in 2011. The development of the Welsh Lymphoedema Network enabled all people with lymphoedema to be assessed and treated, regardless of where they resided in Wales. We currently have seven Health Boards in Wales and seven Lymphoedema services. Each is managed by a Clinical Lead lymphoedema therapist and the whole network is overseen by me, the National Clinical Lead. As part of our lymphoedema development programme, Lymphoedema Network Wales has created exercise leaflets that we are willing to share with the LSN for patient benefit.

Exercise is vital in lymphoedema management. Exercise is not just about putting on a pair of trainers and going to a gym, it’s much more. In Wales we are focussing more on movement, activity and exercise. Moving your body will help the muscles pump lymph fluid through the body. Exercise helps you improve and maintain flexibility and keep your bones strong. Being more active helps you achieve and maintain a healthy weight, and it may improve your emotional wellbeing. Moving your body and exercising decreases stress and frustrations, as well as people who exercise, are generally happier! Exercise also improves your metabolism, increases your concentration and decreases your chances of other diseases such as heart problems.

exercise and movement

Tips for Patients with Lymphoedema

  • Wear your compression garment or bandages when exercising to get the best out of the muscle pump action
  • Do a little every day and build up to about 30 minutes of activity, 5 days a week
  • Set yourself personal and achievable goals. Sometimes keeping a record of how much activity you do can be beneficial
  • Pace yourself, use your common sense; listen to your body when it says ‘I am tired’

  • Drink plenty of water
  • Wear sensible clothing and shoes
  • Do not exercise if you feel unwell
  • Make moving your body a part of your life

Ideas for Moving

  • Walking on the spot, walking with or without a pet, walk to a friend’s home, walking groups
  • Parking further away from the shop entrance; getting off at an earlier bus stop
  • Cleaning the house
  • Hide the remote control for the television
  • Gardening and even shopping
  • Activities like jogging, cycling, bowling or dancing
  • Water activities such as walking in the water, aqua aerobics, swimming
  • Vibration plates such as the Power Plate and VibroGym have proved to be beneficial in patients with lymphoedema
  • ‘Fun’ exercise can be using a console (Wii, Xbox or similar) with games that allow you to play sports whilst sitting down

Breathing Exercises

Breathing exercises help to move lymph fluid around the body. This is an easy activity to do and helps with relaxation and reducing stress. 


  • Sit or lie down with your shoulders relaxed and hands resting below your ribs
  • Breathe in and feel your stomach rising (imagine a balloon inflating under your hands)
  • Slowly breathe out and press gently inwards with your hands
  • Repeat five times

Specific Exercises for Lower Limb Lymphoedema

  • Repeat 10 times both sides
  • You can increase the number of repetitions as you get stronger:

Exercises for lower limb lymphoedema

Specific Exercises for Upper Limb Lymphoedema

  • Repeat 5 times both sides
  • You can increase the number of repetitions as you get stronger
Exercises for upper limb lymphoedema

 

If your mobility is limited, you can still exercise. Try the following:

1. Move your arms when in bed or on the chair:


  • Repeat 5 times for both sides. You can increase the number of repetitions as you get stronger
Exercises with limited mobility

2. Move your legs when in bed or on the chair


  • Repeat 10 times for both sides. You can increase the number of repetitions as you get stronger
Exercises with limited mobility

 

Remember, exercise does not have to be vigorous it’s about making exercise a daily part of your life. Walk more, use the stairs instead of the lift – basically move your body. Even people who cannot easily walk can gain excellent benefits if they do chair exercises or just stepping on the spot holding on to the sink. Small amounts of change add up and become a big change in your own self-management of lymphoedema. Start small, I know patients who started a walking group and now regularly run 5K every week. Raise funds for the LSN by doing a charity fun walk. This could be the start of a new, fitter, you, which will help your lymphoedema both physically and you mentally.

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This article is taken from the Autumn 2014 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Obesity and lymphoedema

By Sue Lawrance, Clinical Nurse Specialist, Florence Nightingale Hospice, Aylesbury

45Obesity is rapidly becoming a national epidemic, with estimates of 50% of the UK’s adult population being obese by 2030 (Lancet 2011). Large increases in body weight can potentially lead to a variety of illnesses such as diabetes, venous disease, joint problems, heart disease, as well as chronic oedema and the development and deterioration of lymphoedema. There is, perhaps more worryingly, an increase in childhood and adolescent obesity, which is storing problems for our future generations.

What we eat in our ‘normal’ diet and how it may affect the development of lymphoedema is unclear. However, we do know that some primary lymphoedema patients experience symptoms similar to Irritable Bowel Syndrome due to abnormal gut lymphatics. Changing the type of fat in the diet of these patients can significantly reduce these symptoms and in some cases, improve the severity of their lymphoedema. It is also becoming clear that fat cells have an effect on our lymphatic system and its ability to function normally. It is
well recognised that obesity is associated with the development of secondary lower limb lymphoedema, especially in patients who already have chronic venous insufficiency (CVI), which is also often initiated by a high Body Mass Index (BMI). BMI is a recognised measurement tool that uses body weight and height to determine if we are overweight and to what degree. In 2012 (Green et al, N Engl J Med 2012;366:2136-2137) a study of 15 patients with a BMI of 30+, swollen lower legs, but no other cause for the swelling, were examined using lymphoscintigraphy. The results showed 5 of them had abnormal lymphatic function; all of these patients had BMI of 59+. These results suggest, as BMI increases, there may be a threshold at which our lymphatic flow reduces. This may be due to compression or inflammation of vessels, causing them to function less effectively. Theoretically, this may then also exacerbate primary lymphoedema. It may also indicate that once the BMI starts to reduce, the lymphatics may, to some extent, improve again.

Common sense should tell us that carrying excess body weight will put strain on the heart, lymphatic and venous systems which we rely on to pump, transport, and drain tissue fluid, thus preventing us developing oedema. In addition, venous disease, direct pressure on lymphatic vessels from fatty tissue, positional obstruction of drainage
vessels in the groin by a large abdomen and inability to elevate heavy legs, all exacerbate the situation. Other systems then become affected – knees and hips in particular suffer from the strain of carrying excess weight, which in turn leads to reduced mobility and calf pump action – one of the keys to reducing oedema. It is not just lower limbs that are affected; studies in 2008 from the University of Missouri, Columbia (Journal of Lymphoedema Vol3 No2) suggest there is an increased risk of 40-60% of developing lymphoedema after breast cancer surgery in women with a high BMI.

The problem doesn’t stop with a high BMI influencing how lymphoedema develops, it also restricts how it can be managed and treated.

It is much more difficult for therapists to treat high BMI patients. Apart from the obvious risks associated with the manual handling of heavy limbs, there may be limitations for some areas around the country as specialist equipment may not be available, or clinics may not have the space to safely treat patients. Specialist equipment, such as wider and higher weight bearing couches, is required to safely treat obese patients, along with access to appropriate toilet facilities and physical access to treatment rooms. The room I currently use does not have a doorway large enough for an extra wide bariatric wheel chair. All this may require extra resources, not readily available
in the current financial climate, especially for small clinics or independent therapists. Treatment may then have to be delayed until the patient has shown a decrease in weight.

In order to protect therapists from injury due to lifting/manually handling heavy limbs, one clinic in Scotland has recently introduced a traffic light scheme of allocating work to therapists. This ensures they have an even daily allocation of patients and limit the number of high BMI patients seen each day. If your therapist injures their back from repetitive lifting of a heavy limb, they could be off work for several weeks, which in turn will delay your treatment and that of others.

 

obesity

Treatment generally is less effective and the overall course of treatment takes longer when dealing with fatty tissue. However experienced the therapist is, bandages tend to slip/crease easily. This has a knock-on effect with the length
of treatment time required, which may then build up a waiting list for the clinic, delaying treatment availability. Hosiery is also much more expensive and difficult to fit correctly, which may prove to be a financial problem for some services who are on limited budgets, and restrict what is available. Although many garments
are supplied on prescription, there are,
at times, issues with obtaining expensive garments.

As therapists, we know from experience that when patients reduce weight significantly, there is a direct improvement in oedema – in both upper and lower limb. We do, however, appreciate how difficult weight management can be, but we also know that any treatment options are really hampered unless weight and BMI are within reasonable limits. Your therapist will guide and support you to a certain degree to reduce weight and various schemes to help you are available through GP referral now e.g. prescribed access to ‘Weight Watchers’, ‘Slimming World,’ dietetic advice, and possible referral to a specialist Bariatric Team and potential gastric band surgery in extreme cases. However, ultimately the only person who can loose weight, is the person themself, and unless that happens, your therapist will be very limited in how far they can improve your condition.

There are success stories, and several of my patients now have much more manageable limbs due to weight loss.

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This article is taken from the Summer 2014 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Lymphorrhoea

By Melanie McCann, Macmillan Lymphoedema Nurse at Herts Community Trust

 

What is Lymphorrhoea? Pronounced lim-fo-re-a

46Lymphorrhoea is defined as ‘leaking of lymph fluid from the surface of skin’. This simple description does little justice to this condition as lymphorrhoea can be very distressing to experience. The affected area can feel tender, fragile, cold and constantly wet. It is important to know that there is something that can be done. The purpose of this article is
to explain what lymphorrhoea is, why it might happen, explain what you can do if it happens to you and what help health care professionals might be able to offer.

Lymphorrhoea is most commonly
 associated with cancer-related
 lymphoedema, however, it can happen 
to people who have lymphoedema from
 any cause. Lymphorrhoea represents a 
change in the nature of swelling that
 means that the pressure inside the
 tissues is so high that the skin can no 
longer contain this. The result is that 
beads of fluid leak from the skin. Lymphorrhoea often represents a sudden change and therefore, to be able to manage this effectively, it is important to establish why it has occurred in the first place.

Lymphorrhoea looks straw coloured. There does not necessarily need to be a knock or scratch to the skin to make this leaking happen, however, often the skin at this stage is so tense with fluid, a very minor knock can result in a wound, which can lead to significant leaking. If a knock has occurred some blood might be mixed too.

The most common place for lymphorrhoea to occur is the legs, but it can affect any area of the body.

Common causes of lymphorrhoea are:

  • Leg dependency (i.e. sleeping in an armchair or spending all day in a wheelchair)
  • Immobility (i.e. suddenly changing to being very sedentary where you were normally very active)
  • Not using compression garments or bandages if you need them
  • Changes in medical health such as breathing difficulties or cellulitis
  • Low protein levels (known as albumin)
  • Cancer (sometimes because of cancer progression, sometimes when the body is weakened by successful treatment)
  • Secondary to cellulitis
Lymphorrhoea is more likely to occur when several
 factors happen together; for example, if someone who has lymphoedema of the legs then develops a severe chest infection, several of the above risk factors occur in quick succession. The fictional case study below demonstrates how this could occur:

Mr Jones has long standing asthma. He also has primary lymphoedema of his left leg. One Autumn, he developed a chest infection. This resulted in him feeling very short of breath, weak and tired. As his coughing was worse when he tried to lie down, he spent a few nights sleeping in the chair downstairs, partly as his sleep was unsettled and partly so his wife could sleep. As he felt weak, he was not moving around much during the day. He also found the effort of pulling on his compression stocking made him cough, so for a few days he left them off. After around four days, lymphorrhoea developed.

What can you do to prevent lymphorrhoea?

  • Get appropriate, ongoing advice and treatment for your lymphoedema (treatment and knowledge changes over time; keep going back to your lymphoedema practitioner, if you have one).
  • Skin care: ensure the skin is washed, dried and moisturised each day.
  • Exercise at your level: For some, this might be running a marathon, for others, it might be having someone else help the swollen limb bend and stretch (this is known as passive exercise).
  • Maintaining a healthy weight can help improve lymph and venous return.
  • Elevation of the affected area: ideally to the same level as the heart when you are resting.
  • Wear your compression (garments or bandages) as advised by your therapist.
  • Self or assisted lymphoedema specific massage (Simple Lymphatic Drainage or Manual Lymphatic Drainage).
  • Ensure your medical health is as good as possible and any conditions such as high blood pressure are well managed*.
  • Eat a healthy, well-balanced diet.
A lymphoedema therapist can advise on more specific treatment pathways designed specifically for you.

 

Key Note:

*It is worth knowing that Calcium channel blockers (a group
 of drugs often used to help control high blood pressure) and other drugs such as steroids can make swelling worse. If you are on this group of drugs it might be worth discussing this with your GP. However, do not stop taking them without discussion as poorly controlled blood pressure can be more dangerous for your general health.

Should lymphorrhoea occur, it is essential that you get help promptly. The next working day is OK. You should not need to call a doctor or go to Accident and Emergency overnight unless the skin leaking develops in conjunction with redness, heat or pain in that affected area. If this occurs, there is a high likelihood that you have cellulitis. This requires prompt medical attention either through your GP or, on the weekend, Accident and Emergency.

What to do if lymphorrhoea occurs:

In an ideal world, we would hope everyone should have access to a lymphoedema specialist who can provide appropriate and timely support; however, we recognise that isn’t always the case. In the absence of a lymphoedema practitioner, the following suggestions might be useful.

  • With your doctor, try and establish if the leaking is lymphorrhoea and look at what is going on with your general health to see if anything can be improved. There may be medical investigations worth undertaking where there is a sudden change, such as blood tests or a review of your medication.
  • Skin care remains essential. When lymphorrhoea gets on 
the skin, it further damages the skin’s condition. Also, the leaking areas create a portal for infection to get in. This could lead to cellulitis.
  • Washing the skin with products such as DERMOL 500 can be good as they are anti-microbal whilst avoiding drying the skin out too much.
  • Unless there are open wounds, you can wash or shower normally and you can pat the skin dry with a towel as long as it is clean.
  • Dressings: What dressings to use on the leaking areas will vary. The nurse assisting you (this could be a lymphoedema practitioner, practice nurse, district nurse or palliative care nurse) will assess the amount of leaking and look at your skin generally. There are thousands of products available and no single one has been found to be the best.

Lymphorrhoea

Ideally any dressing should:
  • Absorb the moisture and hold it away from the skin to prevent further skin damage.
  • Be non-adherent to avoid damaging the tissues at times of dressing change.
  • Compression bandaging is the most important element of care. At this stage, the skin is too fragile to simply go into compression hosiery.
  • If there is lots of leaking, the bandages and dressings may need changing several times a day initially. Although this can seem laborious, good care early on can result in the areas healing within a few days. More complex lymphorrhoea can sometimes persist for longer though.
  • Once the skin is better, compression garments should be resumed to prevent the lymphorrhoea re-occurring.
  • Elevation and exercise remain important.
  • Elevation really does mean elevating the affected areas to the level of the heart. Where this isn’t achievable, elevation as far as is practical and comfortable is still worthwhile. This can be achieved by resting on the sofa or a recliner chair.
  • Exercise is harder when bandages are on, but keeping as active as possible is still important. Simply bending and pointing the foot is great for helping lymph flow. Bandages and compression stockings all help the most when the muscles are moving against them.

Sometimes, it is possible that you could learn how to change the dressings and apply bandaging either by yourself or assisted by someone close to you. If you choose to do this, try not to lose contact with a qualified health care professional who can oversee what is going on and who will be able to advise you when it is time to change tact. They can also answer any questions you have or problems that need to be addressed. Please let your nurse know if you want to be more involved in your treatment or if you are very nervous of being asked to be involved so that the care plan can be what suits you best.

Other causes of lymphorrhoea:

Lymphangiomas are commonly known as ‘lymph blisters’.
 They look very much like little blisters and could occur in isolation or in groups. These can happen in primary or secondary lymphoedema. Commonly they appear on the leg, genitals, armpit, fingers or toes, but again, can occur anywhere. In many cases, these can be reduced or reversed by good skin care and compression. For genital swelling, a good starting point is to use lycra based, cotton rich underwear. For women, body control underwear is a good starting point. For men Speedo style (i.e. tight and more Y-front shaped) underwear can be good. Double layering underwear or using padding inside can help provide more compression, but this must be a clean, breathable, non- irritant padding.

If the lymphangiomas become more established, they can become more solid and ‘warty’. When they are new or in moist areas, such as the genitals, these can easily break and lymphorrhoea can occur. In difficult cases further intervention, such as laser or surgery might be worth looking into. At this stage it is essential that experienced medical advice should be sought from a doctor used to managing lymphatic disorders.

Where lymphorrhoea is secondary to cellulitis, it is imperative that the cellulitis is addressed by appropriate antibiotic therapy first and foremost. In the initial stages, if the skin has broken, skin care, dressings, rest and elevation are the most significant interventions. Once the acute cellulitis is settling down, you can start introducing compression (if this is suitable for you). You and your therapist will need to discuss when and how this is implemented and varies from person to person.

Summary

Lymphorrhoea can occur suddenly and in all types of lymphoedema in all areas of the body. There are risk factors and early warning signs. Effective management requires commitment from yourself and the doctors, nurses and lymphoedema practitioners looking after you.

Lymphorrhoea can be managed and in most cases can be stopped, but the earlier it is treated, the better.

Editor’s note: This article was originally published in the Winter 2009 issue of LymphLine. Due to many requests for information on this topic, it is has been reviewed by the author and republished.

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This article is taken from the Spring 2014 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Have you got Cellulitis... or Red Legs?

By Rebecca Elwell, Macmillan Lymphoedema Nurse Specialist,
University Hospital of North Staffordshire


Cellulitis is an acute, painful and potentially serious infection of the skin and subcutaneous tissue, most commonly caused by the bacteria, Staphylococcus aureus and Streptococcus (Wingfield, 2012). Cellulitis can affect any part of the body but evidence suggests the most common parts of the body affected by cellulitis are the lower limbs (Cox et al, 1998; Halpern et al, 2008).
It is well documented that cellulitis is common in those individuals with lymphoedema (Dupuy et al, 1999). The risk of cellulitis is increased in chronic oedema/lymphoedema due to the protein-rich lymphatic fluid serving as an excellent medium for growth of bacteria, and the pooling of the lymphatic fluid in the limbs with associated reduced lymphatic filtration (Baddour and Bisno, 1985; Mortimer and Levick, 2004). The relationship between cellulitis and lymphoedema is like a vicious circle, with each episode causing further damage to the lymphatic system, leading to increased swelling and thus an increased risk for further cellulitis (Firas and Cox, 2009). Mortimer et al (2006) agree, adding that once bacteria have gained entry to an area of swelling, it is very difficult to eradicate them.

The symptoms of cellulitis may include developing a temperature, fever, ‘flu-like’ symptoms, pain and redness which spreads. If you believe you may be suffering from cellulitis you should contact your GP or out of hours service for advice and treatment as soon as possible.

In those who are diagnosed with cellulitis there is often an untreated, underlying skin condition which highlights the importance of the role of self-management in early identification of conditions and prompt treatment to prevent cellulitis or the recurrence of cellulitis. For example, athlete’s foot, in between the toes or on the balls of the feet is extremely common and easily treated. This very itchy fungal infection causes the skin to peel and crack, which significantly increases the risk of infection (cellulitis). Athlete’s foot can be easily treated with over the counter remedies; ask your pharmacists for help and remember, if the symptoms do not go away, you must seek medical advice.

Chronic oedema/lymphoedema management has shown to reduce the incidence of cellulitis from 58% to 9% (CSP, 2012) so, good news, carrying out your daily skincare, exercises, massage and wearing your hosiery not only controls your swelling but is also serving to reduce your risk of infection.
The LSN and BLS have produced guidelines to manage cellulitis and recurrent cellulitis in patients with lymphoedema and these guidelines are available free to members from the LSN.

However, many people with lymphoedema and chronic oedema (swelling present for more than 3 months due to various causes e.g. after a stroke, related to immobility, or due to vein insufficiency) develop red legs and this is not due to cellulitis.
“Red Legs” can be defined as redness throughout both legs, usually below the knee only. There can be associated warmth and tenderness but generally individuals do not feel unwell.

The CREST guidelines 2005 for the MANAGEMENT OF CELLULITIS IN ADULTS is very clear in stating that bilateral (both legs) leg cellulitis is extremely rare! However, many patients are given antibiotics just because the legs are red, on the assumption that there is an underlying infection. This results in a number of patients whose condition does not respond to the antibiotics, possibly raising the question of antibiotic resistance and on occasion the non response to treatment can lead to unnecessary hospital admission.


Fig. 1 Red Legs

47

The main differences between cellulitis and Red Legs can be seen below:

comparison table 

In many cases, the symptoms of ‘Red Legs’ can be attributed to gravitational eczema, infected dermatitis, tinea pedis (athlete’s foot) or other chronic conditions, which will not respond to antibiotics and are more skin related.

 

redlegs2figFig 2. shows mild gravitational eczema (also known as varicose eczema or stasis eczema). There is an inverted champagne bottle shape (sclerosis), reddy brown colour, some itchy, scaly, weepy skin which is rough and no associated pain.

At the University Hospital of North Staffordshire (UHNS) a Red Legs service has been developed due to the high number of patients suffering from this debilitating condition. The aim was to raise awareness among healthcare professionals of appropriate treatment for patients with red legs, leading to improved patient experience and quality of life.

The initial step in setting up the new service was to iden
tify the key stakeholders, this included those clinicians who would traditionally be responsible for treating patients with red legs, namely dermatology, tissue viability, podiatry, infectious diseases/microbiology and vascular departments. These clinicians were brought together with A & E medics and nurses (i.e. those encountering patients at the beginning of the journey), the Matron for the area, the directorate manager and patient representatives (selected from willing and interested members of the local lymphoedema support group). One patient was then invited to share their story, this proved to be extremely powerful in breaking down barriers and allowing the group to really focus on the task in hand.

Diagnostic and treatment pathways were developed with the relevant clinicians, along with patient representatives. These were to be used to assist in the differential diagnosis of each patient attending the new service with red legs and to develop the appropriate treatment plan.

The new service opened in July 2013 and referrals have mainly been received from emergency portals e.g. A & E, GPs and District Nurses.

Self-management of Red Legs

It is important to know what you can do to treat your red legs in the absence of a Red Leg clinic. There are some easy self-care measures that can be employed to treat this disabling and embarrassing condition.

The treatment for red legs includes: skincare, exercise and compression, very much the same as in the management of swelling.

Skincare

The legs and feet should be washed daily in a soap substitute e.g. aqueous cream or Dermol 500 e.g. Epaderm/Hydromol cream, and then dried thoroughly, paying particular attention between the toes. Observe for any cracking of the skin, peeling or white, wet skin in between the toes and/or on the sole of the foot as this may be tinea pedis (athlete’s foot) and will require prompt treatment with an anti-fungal preparation.

Once the legs are dry, the legs and feet can be moisturised again with an ointment e.g. Epaderm/Hydromol. An ointment is preferential over a cream as they contain less additives and therefore, cause less irritation, but they should be smoothed on, in the direction of hair growth and not rubbed in, to avoid folliculitis (infected hair follicles).

You should then wait 10-15 minutes for the moisturiser to soak in before applying a steroid ointment (only available on prescription). This should be applied sparingly to the affected areas and should be rubbed in until it has disappeared (you must then wash your hands). Initially, a potent steroid may be required e.g. Betnovate ointment 0.1% but in time this can be reduced to Betnovate RD or stopped if the symptoms are resolved.

Exercise

It is imperative to keep as active as possible. If you are able, increase your walking each day but if your mobility is severely limited, do these exercises sitting down at least once a day:

  1. Roll your ankle/foot in a circular movement, 10 times each foot
  2. Rock backwards/forwards (toe-heel then heel-toe) 10 times each foot
  3. Straighten your leg out in front, hold for 3 seconds, then release, 5 times each leg
  4. With your knee bent, lift your thigh off the chair, hold for 3 seconds, then release, 5 times each leg
  5. March on the spot, lift knees as quickly as possible and stamp your feet, repeat 10 times

 

cellulitis

Compression

Following arterial assessment e.g. Doppler (which can be arranged via your GP or district nurse), compression should be applied in the form of stockings or bandages, depending on the amount of oedema (swelling) that may or may not be present.

Elevation

When you are not exercising you should sit with your legs elevated preferably at or above heart level. This really means reclining on a sofa, bed or reclining chair. Whatever you do never fall asleep in a chair with your legs down!

Ongoing management

Once the redness has resolved, skincare (without the steroid ointment and with a cream rather than an ointment to moisturise if preferred), exercise and compression should be continued. There is a risk of the redness recurring and if this happens, the steroid ointment can be reintroduced.
If the redness does not improve it may be necessary to arrange a dermatology review, for patch testing, to check for any allergies/sensitivities to ingredients that are coming into contact with the skin.

Conclusion

Red Legs must be separated from cellulitis at all times. Too often patients are given a course of antibiotics for redness on the legs, when they otherwise, feel well and do not have a temperature/ fever, just in case! This over use of antibiotic therapy can be responsible for the development of antibiotic resistance. If you believe you are suffering from Red Legs, discuss this with your GP and try the simple steps for self-management to see if this will help.

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This article is taken from the Autumn 2013 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

The surgical management of limb lymphoedema

By Stephen Black
Consultant Vascular Surgeon and Honorary Senior Lecturer, St George’s and St Helier’s Hospitals

 

48The majority of patients with chronic lymphoedema (90%) are managed without the need for surgery. Non-surgical (so called conservative) interventions include elevation, lymphatic massaging, compression devices, compression garments, exercise, and skin care. These are often successful initially, but recurrence is commonplace once therapy is discontinued. Conservative interventions also become less feasible in advanced lymphoedema, e.g. compression bandaging is more difficult with severe deformity and loss of limb contour. 
Indications for operative intervention include recurrent infection, severe lymphoedema (e.g. elephantiasis), and failure of conservative management. Surgical interventions include debulking and physiological operations. 

Debulking procedures attempt to remove lymphoedematous tissue, thereby reducing the size of the affected limb or area and include both excisional operations (e.g. Charles’ and Homans’ procedures) and liposuction. Physiological operations aim to restore or optimise existing lymphatic drainage. They include omental transposition, lymphangioplasty and the microsurgical techniques, i.e. lympho-venous, lymph node-vein
and lympho-lymphatic anastamoses, lymphatic grafting, and lymph node transfer.

Excisional operations

Excisional operations with skin grafting are used for severe lymphoedema and aim to remove both the tissue affected by lymphoedema and surplus skin.

Charles’ procedure

Charles’ procedure was one of the earliest operations for lymphoedema and
it remains the favoured bulk reducing procedure. It was initially described as a treatment option for scrotal lymphoedema, but evolved to be used for limb lymphoedema. It involves extensive removal of skin, subcutaneous tissue (the fatty layer between the skin, muscle and bones), and deep fascia (a layer of thick fibrous tissue that envelops the muscle layer). In the lower limb an attempt is usually made to leave these layers intact over the foot and region overlying the calcaneal (achilles) tendon. The exposed region is then covered immediately with a thin skin graft which can be taken from the tissue that has been removed or alternatively a suitable site on the thigh. In some cases amputation of digits that have been affected by severe lymphoedema may be required at the same time. 
Most authors that have reported their results from this procedure achieve significant volume and circumference reduction of the treated limbs. The average reduction in limb circumference reported is 30%. Other benefits included reduced infection recurrence with 90% patients unafflicted by an average of three years follow-up. Increased patient mobility and quality of life were also commented upon but not quantified. Recurrence of lymphoedema after Charles’ procedure has not been widely reported. 
Many authors have counselled against using Charles’ procedure because of its associated side effects and post-operative morbidity (complications) which can be significant. Complications include post-operative leakage of blood and other fluid from the wound, chronic infection, and failure of the skin grafts along with other scar problems. Importantly, approximately 60% of patients required further operative intervention after discharge, e.g. excision of skin crypts (these are areas where the skin grafts are trapped deep to the surface and can form small abscesses), further debulking, and digit amputations. Mobilisation after the procedure may also be slow with non-assisted ambulation taking approximately four weeks and that wound healing is achieved by eight weeks.

Staged subcutaneous excisions (Auchinloss/Homans’ operation)


This procedure was first reported by Sistrunk, and then modified by Homans and Auchinloss. It involves staged (i.e. multiple procedures performed on separate occasions) removal of skin and the fatty layer beneath it, usually 3-6 months apart. A large incision is typically made between the upper, inner thigh, to just above the inside of the ankle. The skin above and below this incision is then lifted up (the lifted skin is called a ‘flap’) and the fatty layer beneath down to the muscle is removed. The flaps are then replaced and the skin is stitched back together.
This procedure can achieve similar size reductions to the Charles’ procedure. However, there is significant risk of lymphoedema recurrence post-operatively which increases significantly over time. This deterioration in most patients is related to compliance with the on-going need for compression therapy and other conservative measures.

The rate of infection is thought to
be reduced when compared with more radical procedures, e.g. Charles’ operation. Infection rates are unfortunately reported inconsistently in the literature. Time to ambulation is typically quicker and hospital stay shorter, but this is offset against the necessity for repeated operations and the long-term higher recurrence rate.

Conservative excisional approaches

Some surgeons have tried using special pneumatic pumps to squeeze fluid out of the leg before performing either of the operations described above. There is little evidence in the literature that gives sufficient answers to the long-term results of this approach with complications being similar to both Charles’ and Homans’ procedures. It is therefore hard to know whether this provides an advantage.

Liposuction

Lymphatic liposuction provides a potentially better treatment alternative to
 the operations described above. This is mainly due to the ability to keep the skin layer without the need for skin grafts or large incisions to get to the lymphoedema layer. The evidence for liposuction is derived predominantly from patients with upper limb lymphoedema, usually secondary to breast cancer treatment. Liposuction has been used alone and together with excisional debulking. Liposuction has previously been offered in few centres but uptake is increasing. This procedure is technically demanding and there are currently only two centres in the United Kingdom that have received formal training in the correct technique (St Georges Hospital, London, and Ninewells Hospital, Dundee). 
All authors found reductions in limb size after liposuction. The most striking results have been reported by Brorson & Svenson who found that 15 of 28 patients (53.6%) had no upper limb lymphoedema 12 months after liposuction and a mean reduction of 105% was achieved, i.e. the treated arm was somewhat smaller than the normal arm.

Most studies report only minimal complications. Complications following liposuction have included persistent hyperpigmentation (darkening of the skin), cellulitis, wound necrosis, and transient limb paraesthesia (loss of sensation). All resolved with conservative management. Liposuction has been conducted under general and local anaesthetic. Local anaesthesia may therefore be used in patients deemed unsuitable for general anaesthesia. 
Recurrence of lymphoedema is problematic after liposuction and the continued wearing of compression garments is mandatory to maintain the reduction in limb size.

Physiological operations

Physiological operations aim to restore function to the lymphatic system thereby improving lymphatic drainage. The options of lymphatic bypass and lymph node transposition can be found in Kelvin Ramsey’s article published in the Summer issue of LymphLine. Additional procedures include omental transposition.

surgical management

Omental transposition

Omental transposition with micro vascular anastomosis (very small joins between the lymph and blood vessels) aims to recreate a physiological (i.e. normal) lymph drainage system. This operation aims to create a bed to receive the lymph flow (e.g. in the groin) before a large cut called a laparotomy is made in the wall of the tummy (abdomen). This allows the surgeon to remove a large layer of fat called the greater omentum that covers the bowel. In addition
to the fat layer, lymph nodes from inside the abdomen are removed. These are then joined with more micro vascular anastomoses to the main blood vessels in the groin. This hopefully allows drainage of lymph from the leg, via these new channels or connections through the abdomen. A number of minor complications were reported including partial transplant necrosis (gangrene of the fat layer moved from the abdomen in two cases), lymphorrhoea (leakage of lymph from the wounds in two cases), dyspepsia (heartburn in two cases),
and groin wound infection (one case). Four patients required skin grafting and hospital length of stay ranged from two to three weeks.

Discussion

Existing research on surgical management of lymphoedema is of insufficient quality to make authoritative clinical recommendations. There were few prospective studies (i.e. studies in which patients data are collected on purpose from the time of the operation) and randomised controlled trials. The available literature suffers from a number of methodological problems, largely related to inconsistent reporting of patient selection, demographics, operation details, and outcome measurements. It remains, therefore, that surgical intervention for lymphoedema should only be considered after appropriate attempts at medical management have failed. Furthermore, it is the opinion of the author that this should only take place in centres with appropriate and robust multi-disciplinary support. 
Surgery is rarely a cure and still requires ongoing compliance with conservative measures, particularly compression therapy, which is important for those contemplating surgical treatment to understand. In addition, the recurrence of lymphoedema after any of the surgical measures remains high. 
Surgery in the context of scrotal or genital lymphoedema provides better results than in the limb. There is still a need to establish the combined role of debulking operations, particularly lymphatic liposuction, when successful physiological operations have been performed.

Summary

  • Surgery should only be considered if conservative measures have failed
  • The results of surgery are unpredictable and further research is needed
  • Treatment should be offered in the context of robust multi-disciplinary team support.

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This article is taken from the Summer 2013 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Lymphatico-venous bypass surgery for lymphoedema

By Kelvin Ramsey, Consultant Plastic & Reconstructive Surgeon The Royal Marsden NHS Foundation Trust, London

Management of lymphoedema has historically centred around techniques focusing on compression bandaging, decongestive therapy and symptom control. These techniques involve a combination of elevation, compression and exercise, while avoiding injury and attempting
to control infection. They are designed to manage the condition and minimise complications, rather than cure.

Historically, the only surgical options for these patients were extremely mutilating operations. However, there have been a number of advances in the surgical management of lymphoedema over recent years. The most accepted of these are liposuction, lymph node transfer and lymphatico-venous bypass surgery.

Liposuction, while being effective in skilled hands, reduces the volume of the affected limb but does not address the cause of the disease. The vast majority of patients will still require the use of a compression garment.

Lymph node transfer is a technique whereby a lymph node is removed from an unaffected area of the body and inserted into the affected lymph node basin (usually armpit or groin). The concept depends upon the new lymph node being incorporated into that area and stimulating improved drainage of the affected limb. Although this is clearly an exciting idea in principle, there remain some unresolved issues with the possibility of causing secondary lymphoedema at the donor site of the transplanted lymph node. Until these issues are resolved,
 this is a technique that we at the Royal Marsden Hospital are not performing.

Lymphatico-venous bypass surgery is 
a technique which involves re-routing the lymphatic fluid, by joining lymphatic vessels onto small veins positioned just under the surface of the skin. Thus in the case of secondary lymphoedema (after cancer surgery for example), the condition is treated by diverting the fluid that cannot leave the limb by the normal channels. These are tiny vessels (usually 0.5mm diameter or less) that are joined together under a surgical microscope. It is a day-case operation, leaving only a few short scars in the skin of the affected arm or leg. This Lymphatico-Venous Anastomosis (LVA) surgery diverts lymphatic fluid into the venous blood system and has been proven to be advantageous to sufferers from post-surgical lymphoedema. It has been suggested that it has the possibility of curing the patient, with no further need for bandaging, elevation or any of the other techniques that would otherwise be employed lifelong.

 

Lymphaticovenousbypass

Performing this LVA procedure on patients with lymphoedema has been reported to result in symptom improvement in 95% of patients and a quantitative (volume reduction) improvement of up to 66%. However, there is significant variation between patients with regards the amount of reduction in size of the limb that occurs. One suggested reason for this variation is because it has previously been difficult to assess which of the lymphatic channels are still functioning, and therefore suitable for re-routing.

The arrival of new imaging techniques may allow us to isolate which lymphatic channels are suitable for bypass. Near-infrared spectroscopy is one of these new imaging systems and it allows real-time visualisation of lymphatic vessels with minimal invasiveness. It accurately shows the flow of lymphatic fluid without the use of expensive radioactive isotopes, which was the previously available technique. It employs the principle of fluorescence lymphography, which detects near-infrared light emitted by indocyanine green dye that has been injected into the affected limb. This not only demonstrates the exact position and path of superficial lymphatic vessels within a limb, but also shows which of those channels are functional. This information can show us which, if any, lymphatic channels can be diverted, with the aim of improving the outcomes of the procedure for the patient.

Fluorescence lymphography using indocyanine green dye in this manner has been used for many years in numerous medical situations such as liver function evaluation, assessment of intraocular neovascular formation, sentinel lymph node detection, cardiac output measurements and assessment of myocardial blood flow. The only factor for exclusion of patients from this technique is a history of allergic reactions to iodine and thyroid gland dysfunction.

Extensive studies of this imaging system combined with LVA in countries such as the USA, Japan and Spain have shown that its use during surgery enables real-time visualisation of dynamic
lymph flow and consequently makes the time required for detecting functional lymphatics shorter and the operation less invasive. Publications in the international literature and research presented at recent scientific meetings have shown that this is an exciting development in lymphoedema management, which can revolutionise our care for these patients.

As a world-leading cancer centre,
 the Royal Marsden Hospital is one of the very first centres in the United Kingdom to offer this surgery to sufferers of cancer-related lymphoedema. In addition to carrying on the work that has been pioneered in Tokyo and Barcelona, we hope to more accurately image the patients pre-operatively, so that those patients who would benefit from this procedure the most can be identified. Previously it has been shown that timing of surgery from the onset of lymphoedema is crucial and this area also requires clarification.

Using near-infrared imaging for lymphatico-venous anastomosis surgery provides patients with lymphoedema at the Royal Marsden Hospital leading edge surgical technology aimed at enhancing their care well above current NHS standards.

Some key advantages of this technique are:

  1. The system allows more accurate real-time visualisation of 
dynamic lymph flow so that functional lymphatics can be identified prior to skin incision. These vessels can then be used for lymphatico-venous bypass, resulting in a faster, more physiological operation.
  2. It is a simple technique, requiring only injection of a nontoxic tracer dye subcutaneously or intradermally and using a non- invasive image sensor. Images can be easily interpreted and examinations can be repeated in the same patient.
  3. The imaging system is portable, enabling imaging in clinic or in the operating theatre. Furthermore, because indocyanine green and fluorescence are easy to handle, a special facility is not needed for use of the system.

Thus the combination of new dynamic imaging techniques as well as advancements in supermicrosurgery has led to significant developments. Imaging delineates which lymphatic channels are still functioning, and these are used for lymphatico-venous bypass procedures.

Results for this technique have shown optimistic results and we are presenting the first British experience combining these techniques at the British Plastic Surgery Meeting in June 2013.

Lymphoedema of all causes has been treated with this technique, but the majority of cases to date are those of secondary lymphoedema – usually after treatment for cancer. Patients suffering from breast cancer-related lymphoedema in particular form a substantial proportion of those treated with this technique at the Royal Marsden Hospital, not least as a result of the prevalence of the disease.

After an initial consultation which involves extensive questioning and examination to assess suitability for treatment, the patient may be selected to proceed to near-infrared spectroscopy imaging. This imaging involves an injection of a very small volume of indocyanine green dye in between the fingers or toes of the affected limb. Although allergic reactions to iodine or thyroid gland dysfunction may preclude the patient from having this imaging, it is otherwise extremely well tolerated.

The results of the imaging are discussed with the patient and the proposed surgery may then be discussed at length. The highly trained Royal Marsden lymphoedema therapy team separately assesses all patients and limb volumes are accurately measured, in order to quantify improvements.

The operation involves a day case, general anaesthetic procedure resulting in a small number of short scars on the affected limb. A small incision is used to open the skin and find the tiny lymphatic channels, as well as suitable small veins for the bypass procedure (Figure 1). The anastomosis is then performed (Figure 2) and repeated at different positions on the limb.

Figure 1Figure 2

As with all surgery, there is the risk of infection and wound healing problems. Our series to date has had no such complications and extensive precautions are taken to minimise such risks. There is some blue and green discolouration around the scars which can take some time to fade.

Near-infrared spectroscopy imaging is used to analyse the functioning lymphatics in the affected limb pre and post-operatively.

The post-operative regimen involves initial bandaging of the limb with a dressing change at one week. The stitches will be removed after two weeks at which time the patient can mobilise as normal. At this stage the patient is fitted into the compression garment they were previously using and their progress is carefully monitored. Post-operative volumetric improvements of the affected limbs are measured at regular intervals with a perometer.

We recommend against flying or strenuous exercise for the first month. We also reinforce the importance of elevation of the limb whenever not mobilising to improve swelling and give the wounds the best chance of healing.

Clearly the aim is to see a gradual reduction in the volume of the limb, resulting in the need for progressively smaller garments and ideally resolution of the condition.

Although this is a well documented and minimally invasive procedure it is not possible to guarantee that it will cure the lymphoedema. However, the evidence that we have from the international literature as well as from our work show that many patients gain symptom improvement and more than 50% of patients get at least some volumetric improvement – i.e. the volume of the affected limb decreases. However, the degree of this improvement is difficult to quantify, and it is identification of those patients most likely to benefit that is the drive of our work.

Lymphatico-venous anastomoses compare favourably to other more traditional options and can be a useful adjunct in the management of this most debilitating condition. Patient selection, using imaging techniques, is crucial and there is a clear need for further investigation and research.

Editor’s note: Due to funding restrictions, this procedure is currently only available under the NHS to Royal Marsden Hospital patients. Hopefully, this will change in the future.

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This article is taken from the Spring 2012 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Lymphoedema and Pregnancy

By Sarah Jones, Lymphoedema Assistant, Kendal Lymphology Centre

Introduction

50Expecting a baby is usually a wonderfully exciting and apprehensive time. However, when the mum-to-be has an underlying medical condition like lymphoedema, the apprehension can often take over. 

Very little research has been carried out regarding the effects of pregnancy on lymphoedema so expectant mums usually only have their lymphoedema therapists to turn to for help 
and advice. According to a study published in 2009, the main concerns of a mum-to-be are whether their lymphoedema will get worse during pregnancy and whether their child will inherit the condition. 

It is important to remember that if you suffer from Secondary Lymphoedema (e.g. after cancer treatment or from an injury or infection, etc.) that it is unlikely your child will suffer from the condition. However, if you have Primary Lymphoedema then there is a risk that your baby will also suffer. (See the section on Lymphoedema and Genetics at the end of this article). 

The following information may prove helpful to any mum-to-be who also suffers from lymphoedema:

Healthy Eating & Exercising

We know that physical changes, in particular weight gain, place a considerable strain on a woman’s body. The old adage “eating for two” is no longer encouraged; you only actually need an extra 200 to 300 calories a day! An average woman will gain between 9-14kg with the most rapid gain between weeks 24 
and 32. This, coupled with fatigue and an expanding girth, can reduce the amount of exercise a woman may feel capable of and as the level of movement and exercise slows down, so does the drainage of lymph.

The movement of lymph is dependent on
 the muscle activity in the body so any exercise, however gentle, will always be beneficial to you and your baby. Eat as healthily as possible; a balanced diet with plenty of fruit and vegetables and taking regular gentle exercise such as Aqua Natal, Pilates or Yoga for Pregnancy classes will also help support you and your growing baby. Your lymphoedema therapist will also show you some gentle exercises that you might find beneficial.

Lymphoedema and Skin Care

Weight gain can mean stretch marks. Ideally, you should already be keeping your skin well moisturised to keep it in good condition and free from infection. Use a non-perfumed moisture cream and inspect your affected limb(s) carefully every day. Fungal infections can develop quickly between swollen toes; treat it promptly with diluted tea tree oil or a preparation recommended by your pharmacist. Some expectant mothers like to use a massage oil that is infused with essential oils. There is very little evidence for the safety of essential oils in pregnancy, in fact NICE guidelines published in 2003 on antenatal care advise that they should be used “as little as possible”. To be safe, find a midwife who has undergone 
the appropriate maternity aromatherapy training who can advise and guide you. If you suspect that you have an infection (Cellulitis) in your affected limb (signs to look out for are redness, increased swelling and pain in the affected area +/- ’flu’-like symptoms) then consult your GP straight away for antibiotics.

Although you may be worried about taking medication during pregnancy, advice from the Department
of Health for expectant Mums is not to be concerned about taking antibiotics during their pregnancy. Your GP will know what is safest for you to take (though the LSN does have a fact sheet on the best way to manage Cellulitis). One final note about skin care, the trend these days among mums to be is to have a full leg and bikini wax done prior to the EDD (estimated delivery date), this of course is not advisable if you have leg or genital swelling, an electric razor is less likely to damage your skin and cause further problems with Cellulitis. 

If you were already having Manual Lymphatic Drainage (MLD) sessions prior to becoming pregnant then do remember to inform your therapist as the usual MLD techniques may have to be adapted during the pregnancy. Ask for a lesson in Simple Lymphatic Drainage (SLD), which is a simplified version that you or your partner can perform at home. If you would like to find an MLD therapist near you, then do consult the LSN who has a list of qualified therapists.

Lymphoedema and Compression Hosiery

It’s not just your waistline that grows during pregnancy; the cardiovascular system also expands. When you are pregnant your body carries 50% more blood than usual and all blood vessels enlarge, often leading to varicose veins in the legs and/or the vulva. This in turn can make any existing oedema worse as fluid from the blood is pushed into the surrounding tissues. 

It is vital that you continue to wear your prescribed compression garments! Most of the lymphoedema garment companies make maternity tights that provide compression for your legs with a comfortable panel over your growing tummy (though 
not all are available on prescription). Your therapist, however, will guide you as to what is best for you at this time and will re-measure you regularly for hosiery as you gain weight and your body shape changes.

You may like to ask for some extra appointments so that your lymphoedema therapist can monitor you more closely. Towards the end of your pregnancy you may find thigh high garments preferable and these should be worn in the delivery room and as much as possible after delivery. Putting hosiery on and taking it off can get trickier as your pregnancy progresses. Your lymphoedema clinic will have aids that can help you such as the Ezy-As Applicator and Medi Butler Doffing Aid. Try to wear your hosiery all the time while you are in hospital, and remember to keep up with your gentle lymphoedema exercises. Also try to elevate your legs when sitting and feeding your baby. 

Make sure that your midwife is aware of your lymphoedema by writing a paragraph highlighting your lymphoedema in your Birth Plan. That way everyone involved in your care is aware of your needs, especially should you need an emergency caesarean section or have a very long labour. Either of these scenarios could make any leg or pelvic swelling worse. If you are planning to have an injection to help your body expel the placenta more quickly then ask to have it in your unaffected leg or your bottom. 

pregnancy

The LSN sells plastic hospital style Medical Alert wristbands that you can wear as a visual reminder. If your midwife has
 any questions or concerns regarding your lymphoedema she/he should contact your therapist or the LSN directly for support and further information.

Lymphoedema and Genetics

If you suffer from primary lymphoedema, your therapist may have explained that this is due to a developmental (congenital) abnormality in the lymphatic system. Sometimes (but not always), this condition is also hereditary or inherited (and 
you may also know of other family members who suffer from lymphoedema). This type of lymphoedema is described as “autosomal dominant inheritance”. A baby has a 50% chance of inheriting that altered gene and although an ultrasound scan may detect an abnormality, it is more often only detected at birth. 

Several types of primary lymphoedema have now had their genetic mutation identified, such as Milroy’s Disease, which is usually evident at birth and typically affects the lower limbs. The affected gene, known as VEGFR3 or Vascular Endothelial Growth Factor Receptor 3 is responsible for the development of the lymphatic vessels in the baby and genetic testing is now available to determine whether your child may be at risk of developing the same condition. 

Another identified form of genetic mutation is a condi
tion known as Lymphoedema-Distichiasis. This type of lymphoedema is not present at birth but often develops as the child reaches puberty and is sometimes accompanied by an extra set of eyelashes, found on the inside of the eyelids. People with distichiasis have fully formed lymphatic systems but unfortunately the lymphatics do not work efficiently. There are now at least 7 mutations known to cause lymphoedema. 

Should you suffer from primary lymphoedema and worry that your baby will inherit the condition, remember that your baby will be much more likely to get early and more appropriate treatment than you did as we have far more knowledge and information now about how best to treat it effectively. 

Research continues into primary lymphoedema with genetic testing in parents and children at St George’s Hospital in London led by Professor Peter Mortimer and his team.

A Final Note

Every mum-to-be worries about whether she is doing the best for her growing baby, you wouldn’t be normal if you didn’t! Rest assured that you will have help from professionals who are there to advise you. Nine months is such a short space of time in the scheme of things, so try to enjoy your pregnancy, spend time looking after yourself and look forward to the most exciting and fulfilling time of your life.

References:
Foldi M, Foldi E, S Kubik (Eds). Textbook of Lymphology. Urban & Fischer 2003 pgs 240-242 430-431 
LSN Fact Sheet. Skin Care in Lymphoedema 

Hardy D. Going into Hospital. Kendal Lymphology Centre 2008 
Mortimer P. Changes in a Normal Pregnancy. LSN 2004 Sumer Issue 
Nursing Times. Net Antibiotics Safe During Pregnancy. 30 September 2008
 
Price L. Aromatherapy for Professionals. Churchill Livingstone 2007 pg 68, 270-272
 
Stoppard M. New Pregnancy & Birth. DK 2007 Pgs 107-110, 117 
Vignes S, Arrault M & Porcher R. Subjective Assessment of Pregnancy Impact on Primary Lower Limb Lymphoedema. Angiology 2010 61:222 originally published 2009 

Woods M. Lymphoedema Care. Blackwell Publishing 2007 pgs 5-7 
Zuth J E. Lymphoedema Management. Thieme Medical Publishers Inc 2005 pgs 41, 166

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This article is taken from the Autumn 2011 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Lymphoedema and orthopaedic surgery Is it safe to have surgery on my swollen limb?


By Gloria Armstrong, Specialist Physiotherapist in Lymphoedema,
St George’s Hospital, London
 

‘I have been referred to a surgeon who has said I need carpal tunnel surgery on my affected arm. Do you think this is a good idea?’

Questions like this one regarding carpal tunnel surgery, or knee/hip replacements are common questions put to lymphoedema therapists, and unfortunately there is no simple answer. Most people with lymphoedema know that they must avoid any form of trauma to the affected limb, so surely any kind of surgery is out of the question. However, one of the cornerstones of lymphoedema management is the ability to move and exercise to within your limits. If pain from your joints is significantly limiting your ability to move, it may become impossible to keep up this important part of your swelling management strategy.

The purpose of this article is to explore the risks and benefits associated with undergoing orthopaedic surgery on your lymphoedematous limb, and to discuss the ways to improve your chances of having the best outcome should you and your surgeon decide that surgery is the best option for you.

What are the risks?

Any surgical procedure has inherent risks even for people without lymphoedema. Before undertaking any surgical procedure your surgeon should discuss these risks with you. Some of the most common associated risks include: infection, swelling and pain. There may be others related to the particular surgery you are considering. Infection risk, swelling, and pain are complications commonly associated with lymphoedema, and are also a consideration for those at risk of developing lymphoedema (for example, if you have had lymph nodes removed as part of your cancer treatment but do not currently have any swelling). Let’s examine these risks individually:

Infection – Lymphoedema increases your risk of infection because the lymphatic system is an important component of your body’s immune system. Maintaining skin integrity is such an important part of lymphoedema management because the skin is your body’s first line of defense against infection. Scrapes, insect bites, and surgical procedures create openings in the skin that allow bacteria, that otherwise live quite safely on the outside of our skin, into the body. In your unaffected limbs this is not usually an issue because these bacteria would be picked up by your lymphatic system and transported to your lymph nodes (or glands) where the lymph is filtered and cleaned. Your immune system can therefore identify and launch a successful counterattack against any bacteria. In your swollen limb, if these same bacteria enter through a cut in the skin, the lymph fluid will not be properly filtered and cleaned in the lymph nodes, so the infection can continue to build in the tissues and cellulitis will develop which can make you feel very unwell. 

There is also another type of infection that must be considered which is a risk during any hospital admission and that is a hospital-acquired infection. Common infections of this type include pneumonia, urinary tract infections, and bloodstream infections, many of which are antibiotic resistant strains. The risk of hospital-acquired infection is the main reason why hospital stays following surgery are now very short.

Swelling – Swelling is a common after effect of any orthopaedic surgery. It is part of the body’s normal response to injury, and a necessary part of the healing process. Most of the body’s healing and defense mechanisms are found within the blood stream. When there has been tissue injury (for example during surgery) the surrounding blood vessels become more ‘leaky’ to allow these healing cells into the area. It is through these healing cells that the bleeding stops (clots), antibodies arrive to fight infection, and other proteins arrive to allow new blood vessels to grow and a scar to form. Therefore, in the short term following surgery, swelling and inflammation are an important part of the healing process.

A concern for people with lymphoedema who are considering surgery is whether their swelling will worsen following surgery. The lymphatic system must cope with this excess fluid that arrives to start the healing process, and a compromised lymphatic system makes the removal of post-operative swelling all the more difficult. Prolonged or chronic swelling around the incision site may begin to cause problems such as delayed wound healing resulting in a poor cosmetic outcome of your surgical scar. Such swelling also increases the possibility of acute infection. Furthermore, the more oedema that exists around a joint, the stiffer the joint is, with a consequent reduction in range of movement and function.

Pain – Pain is one of the main reasons people seek orthopaedic surgery. However, it is likely you will experience a different type of pain in the initial days and possibly weeks following surgery as your tissues heal and recover. This pain may impact your ability to perform activities you were managing before surgery, for example putting on and taking off your compression garment(s).

What are the benefits?

Despite the risks of surgery, for some people the benefits of having surgery far outweigh the associated risks. Orthopaedic surgery is usually considered when increased pain and decreased range of movement are having a detrimental effect on someone’s ability to move and overall quality of life. Pain and reduced range of movement will lead to decreased strength, which in turn can worsen pain and further decrease range of movement. Surgical intervention is often the only way to break this vicious cycle.

Movement and exercise are crucial components of lymphoedema management. Movement stimulates the lymphatic system to work better. If your ability to move is being severely affected by pain, and you become increasingly sedentary as a result, then your swelling is likely to worsen. A decreased level of activity is associated with weight gain, which will cause your swelling to become worse.

Your current quality of life is an important consideration. If you only have knee pain after playing tennis, but you prefer swimming anyway, then it is probably not worth undergoing surgery at this point. However, if you develop pain and pins and needles in your hand and fingers after only 20 minutes on the computer, the pain in your wrists wakes you up at night despite the use of a night splint, and your work requires a full day of computer work, then surgical intervention is probably something you should consider. In other words, if your current pain levels are not having an impact on activities you must do or enjoy doing on a regular basis, then you should postpone surgical intervention until you feel your quality of life is being more severely affected. You could think of that scenario as the cons outweighing the risks. However, if you feel that your pain is having a negative impact on your day-today activities then it is worth pursuing a surgical consultation.

Exhaust all conservative measures first

In most situations where orthopaedic surgery is being considered, it is usually recommended that a more conservative approach such as physiotherapy be tried first. Some patients find this delay frustrating, but often having a specialist assess your strength, range of movement, and current activities can help you to postpone or avoid surgery.

 

Lymphoedema and orthopaedic surgery

‘I’ve been referred to a physiotherapist for my hip pain, what should I expect?’

51Unfortunately there is often a delay between when your doctor sends a referral for physiotherapy and your initial consultation. It is worth asking your local service what the current wait time is, as this can vary depending on where you live and what level of severity your problem is. 

At your first visit to the physiotherapist you will be asked questions about your general medical history (not just about your current problem), and you should be prepared with a list of any medications you are taking. If the physiotherapist is not familiar with lymphoedema they may want to know if there are any activities you should avoid. If you are unsure, make sure you talk to your lymphoedema therapist before your first visit with the physiotherapist so you can be prepared with answers. It is often a good idea to suggest that the physiotherapist speaks to your lymphoedema therapist directly. It is a good idea to think about what sort of activities make your pain better or worse throughout the day as this is information that will help your physiotherapist get a better idea of the exact nature of your problem and how it affects your daily life.

Your physiotherapist will measure your range of movement and strength, and will usually teach you a few exercises (usually 2-3) for you to start doing at home. You may even be given some suggestions on how to modify activities that regularly cause you pain. It is important that you ask any questions regarding your ‘homework’ before you leave your appointment. You will need to know how many times to do a particular exercise each day and what to do if any of the prescribed exercises seem to make your pain worse. Before you leave, your physiotherapist will tell you when they next want to see you to review your progress. 

It is important to keep in mind that the one thing that will have the biggest impact on physiotherapy helping at all is whether or not you do your exercises! Remember that the stronger you are before surgery, the faster your recovery will be after surgery.

‘I’ve been diagnosed with carpal tunnel syndrome and my doctor has suggested I have an injection into my wrist, but I know I’m not supposed to have needles in my swollen arm!’

The option of an injection (usually a corticosteroid injection) is considered to be a less invasive measure than undergoing surgery and can often provide a significant amount of pain relief. This is usually suggested if something like splinting, in the case of carpal tunnel syndrome, or physiotherapy, in the case of knee/ankle arthritis, fails to provide sufficient improvement. If you are considering having an injection into your affected limb to help with pain management, then this is another scenario where the risks (such as a possible increase in swelling) must be weighed against the benefits (such as pain relief).

You’ve got a date set for your surgery

You should advise your lymphoedema therapist that you have a date set for your surgery. He or she may want to adjust the date of your next lymphoedema appointment accordingly to review your progress. It will be important that you ensure you have made every effort to minimise the swelling in your limb before your surgery. This can be achieved through being very diligent with wearing your compression garments, or in some cases your lymphoedema therapist may suggest a short period of bandaging prior to surgery.

You will also want to have a plan in place for resuming compression as soon as possible following surgery (this can often be done as soon as the surgical drains are removed). This will help to reduce the risk of prolonged post operative inflammation, which will, in turn, reduce the risk of cellulitis and wound breakdown. You should also discuss with your lymphoedema therapist if you will need any special devices to help you get your compression garments on or off. In some cases you may need to arrange for friends or family to be available to help you for the first few weeks after surgery. If this won’t be possible, you may need to discuss the possibility of arranging either nursing or social assistance with this for a short period when you first return home.

Special mention must be made of those people with lymphoedema who already have a history of recurrent cellulitis, and those who may already be on a daily prophylactic dose of antibiotics. It is important to bring this aspect of your medical history to your surgeon’s attention. If you have a history of cellulitis it will be worth discussing the possibility of beginning a treatment dose of antibiotics prior to your surgery. For those already taking prophylactic antibiotics, this level of antibiotic cover should be discussed with the doctor who originally prescribed this for you in case alternative antibiotics are recommended for the period before and after your surgery.

The ‘Take Home’ message

If your quality of life is being significantly affected by pain and you are planning to have surgery on your lymphoedematous limb to address this, then it is important that you discuss the risks of the surgery with your doctor, keeping in mind the additional risks that lymphoedema poses. It is also important to involve your lymphoedema therapist throughout this process by keeping them advised of any decisions you make. He or she may be able to offer support in terms of suggesting questions to ask your surgeon or physiotherapist, and may even suggest changes to how you will manage your swelling both before and after surgery.

With the appropriate advice and support, there is much you can do to minimise your risks and have the best possible outcome following your surgery.

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This article is taken from the Autumn 2009 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

Blood Pressure tablets – Watch point

52At the patient conference held at Ascot in April 2009, Professor Peter Mortimer commented on a type of blood pressure tablet that was discouraged for patients living with lymphoedema. For the benefit of members unable to attend the conference, the class of drug is a calcium channel blocking agent and includes such drugs as Nifedipine, Amlodopine and Felodopine - in other words any heart or blood pressure drug ending in ‘...ine’. 
50% of patients on these drugs develop swollen ankles and the mechanism is likely to be paralysis of lymphatic vessel pumping. Their use is therefore discouraged by anyone diagnosed with lymphoedema.

Anyone concerned about their use of these drugs should contact their GP before taking any action.

Bloodpressuretablets

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This article is taken from the Summer 2005 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

To needle or not to needle… that is the question!

By Tracey Cole RN BSc Hons, Specialist Lymphoedema Practitioner

Introduction

55When Anita first asked me to write an article for the LSN about my particular interest in venous access and lymphoedema, I was thrilled, but after I'd put the phone receiver down, the realisation set in that I had a difficult task ahead. 

Needles and Lymphoedema is often an emotive issue. I know the LSN have many queries about injections and I have attempted to answer many of the frequently asked questions. As you read on, my hope is that you will see how complex an issue this is and that the answers are not always straight forward.

So why have I been asked to talk about this issue?

I am a nurse whose main speciality has been cancer treatment and giving chemotherapy treatments for the cure or palliation of cancer patients. I love nursing and remain passionate about excellence in nursing practice and provision of the highest quality patient care. Over the years, I have gained a lot of experience in venous access in patients receiving cancer treatments. I have been putting needles into patients' veins for many years and believe me, I have heard every nickname you can imagine! 

I first became interested in lymphoedema back in 1998 when I worked for the vascular access team at the Royal Marsden. The standard advice given to patients at the time of their breast surgery is to avoid having blood pressure measurements and injections on their "at risk of lymphoedema" arm. I was informed that the reason for this is that it may reduce the likelihood of swelling developing. For my BSc dissertation, I decided to conduct a systematic review of the evidence relating to the risk factors for lymphoedema development with a particular focus on the subject of needles and lymphoedema.

There is anecdotal evidence where patients have reported swelling developing after blood pressure recordings and injections, however, I found that there was little good research based evidence relating to this subject. I have been working within the field of lymphoedema for nearly 18 months now and am currently attempting to write guidelines for professionals on the subject of injections in patients at risk of lymphoedema, however, the process is taking longer than I expected, but I'm nearly there!

"At risk" versus those with existing lymphoedema

Those who have lymphoedema are people who have swelling present in their arm (or other body part, but for this instance we will be discussing arm lymphoedema). Those who are at risk of lymphoedema are people who have had one or more of their axillary nodes removed. If someone has never had their nodes removed but has disease present in their axillary nodes, they are also at risk. People who have undergone axillary radiotherapy are also at risk, due to the scarring of the nodes which can occur years after radiotherapy.

Some useful definitions and explanation of terms you may hear: 

Venepuncture

  • The procedure for taking a blood test is known as venepuncture. The needle only remains in the vein for as long as is needed to withdraw blood. It is then promptly removed.
Cannula (sometimes known as a venflon, peripheral line or drip device)
  • A cannula is a flexible tube which is placed into a vein for purposes of administering medication or fluids. It is introduced using a needle and the cannula can remain in the vein for a few days.
Injection
  • A subcutaneous injection is an injection which goes into the tissues of the limb, for example, a local anaesthetic to numb an area.
  • An intramuscular injection goes into the muscle of the arm, for example, a flu vaccination.
BM test (Blood sugar testing)
  • This is a very fine needle which pierces the finger tip in order to produce a droplet of blood to find out the level of sugar in one's blood.
Central venous access device
  • This is a device which is inserted into one of the larger veins near the heart and they can remain in place for extended periods of time. There are three main types of central venous catheters; a peripherally inserted central catheter (inserted via a large vein in the arm), a skin tunnelled catheter and an implanted port (inserted via the chest).

So why should injections be avoided? 

At the time of breast surgery, patients should be advised to avoid having injections and blood pressure recordings taken in the affected side. This means blood tests, cannulae, BM tests and injections listed above. Theoretically, the affected limb is more at risk of developing infections within the arm because axillary nodes (the lymphatic nodes in the armpit) have an immunity function and if they are removed this immunity role is compromised. If a foreign object (that is a needle, for example) is placed in the arm, an immune response occurs and this puts the lymphatic system under more stress. 

People who have lymphoedema are at an increased risk of cellulitis (an acute inflammatory episode). This is an infection of the tissues in the limb and may cause pain, the lymphoedema to worsen and may make you feel quite unwell. Injections should be avoided in someone who has swelling but sometimes injections into a swollen arm are necessary. Entry into veins in a swollen arm is more problematic because the swelling makes the veins harder to visualise and palpate. The risk of developing cellulitis is theoretically higher in someone with existing swelling. 

Those at risk of developing lymphoedema but who have no swelling to the arm are still at an increased risk of developing an infection compared to someone who has not had the nodes removed. There have been reports that lymphoedema has been triggered by an injection in the arm where no associated cellulitis has been diagnosed. It often occurs immediately or within a period of a week or so.We are not sure why this occurs but it has been reported by patients we look after. Conversely, there have been reports of injections being given with no adverse effects and swelling never developing. "What is the percentage risk of getting lymphoedema if you put a needle into my affected arm?" is one of the most common questions I used to hear. I've made it one of my professional aims to find out the answer to this question but this is not as easy as it may seem.

All of this is anecdotal and until an audit or further research can be carried out, we will not be able to give patients statistical likelihoods. To be able to give patients a percentage risk can help direct future choices regarding venous access and help patients and staff make decisions on whether to use the arm that has had axillary node treatment. However, there are many factors which need considering, for example; is the likelihood increased in the older person, or is the incidence higher in someone who has had more nodes removed? Is hand dominance a factor relating to increased swelling? How do we ethically carry out this research?

So what should you do?

In the first instance, always offer your unaffected arm for injections of any type. Educating practitioners is not forbidden! Let staff conducting procedures involving needles know that it should be avoided so they can look into this in more detail. I have been attempting to spread the word by talking to district nurses and speaking at conferences. It is not uncommon for medical, nursing and phlebotomy staff to have never heard of lymphoedema, let alone know what it is and its implications on someone's life. The purchase of a medic alert bracelet may be a useful tool to help people who are conducting these procedures know that use of the patient's affected arm should be avoided.

Practitioner competency?

Everyone has to learn somehow. Contrary to popular opinion, nurses generally don't enjoy hurting people. Conducting such a procedure needs confidence and expertise. How do you become an expert if you don't start somewhere? It is important that if practitioners are having problems accessing your veins for either a blood test or a cannula, you ask for an experienced member of staff to conduct the procedure. Our rule is to try twice and refer on, as after two attempts, both the patient and the practitioner are getting anxious and this will not help. Ensure that warming the limb has been tried before gaining venous access as this helps enormously. It is worth spending a few extra minutes warming the arm in order to achieve a successful result!

Problematic veins?

Patients who need repeated chemotherapy treatments may develop problems with their veins. The veins may become hard to find and the walls of the veins can become hardened and phlebitis may occur. This is when the wall of the vein can become inflamed causing discomfort and the vein may need to be avoided for further cannulation attempts. Some people are born with "bad veins", often members of the same family have difficult veins. It isn't that the veins aren't there (otherwise the arm would not be a very good colour!) but it is that the veins may be deeper within the tissues and harder to access.

 

needles

What happens when there are no suitable veins left in the unaffected side?

This is a common question. The most important thing to do in this situation is to discuss any problems with your medical team or your general practitioner. Until we have percentage risk figures then we have to look at the whole picture and each patient's medical history.

Some questions to consider may be:

  • What is the regularity of having to have needles in the affected arm?
  • What type of treatments are you receiving?
  • Is an occasional blood test needed or regular intravenous treatment?
  • Can foot veins be used instead for blood tests?
  • Should a central venous access device be placed?
  • What are the risks of these devices and do they outweigh the risk of potentially developing or worsening lymphoedema?
It is obviously vital, particularly in the case of cancer patients, that they receive suitable treatment for their disease. There may be a possibility of having a central venous access device placed, but these devices carry with them significant risks. The pro's and con's of having such a device placed will need to be weighed up.


What happens if both arms have had their associated axillary nodes affected?

If you only require the occasional blood test, then the feet may be able to be assessed for suitable veins. Venepuncture can sometimes be more painful in the top of the foot. By heating the foot and using anaesthetic creams, the procedure can be carried out more comfortably. Some phlebotomists (practitioners who are specifically trained to take blood) are instructed not to use the feet, especially in the general hospital setting. If this occurs, ask your breast care specialist nurse or your GP for advice on who to contact for a blood test should the need arise. Often, blood tests in the feet can be carried out by staff in the chemotherapy day unit. If no suitable veins are present in the foot then a choice needs to be made on which arm should be offered for such procedures. If longer term treatment and/or frequent blood tests are required, then further venous assessment may be necessary.

Consensus on the issue of venous access in patients who have had bilateral axillary node treatment can be problematic. Some medical centres advocate early placement of a central venous access device, while others advocate using the arm which had its associated axillary nodes operated on first (providing that side had not undergone axillary radiotherapy). Again, the regularity of the need to gain intravenous access needs to be considered, as well as the potential risks of central venous access devices.

Conclusions

There are still a lot of questions as to why some people develop swelling and others do not. Unfortunately, we still have a lot to learn and medicine does not always have the answers we want. By medical and nursing staff working together with patients, we give the best advice we have at the time and give you the high quality care you deserve. By raising awareness in avoiding the use of the affected side, we can reduce the likelihood of swelling occurring. Prompt and early detection of potential problems means that decisions regarding someone's venous access can be made earlier so that the most appropriate device is selected for the job!

Editor's note: If you have had personal experience of having an injection in the arm and subsequently developed persistent arm swelling we would like to hear from you. Conversely, if you have had an injection of any type in the affected limb and not developed or exacerbated existing swelling, we would also like to hear from you. Your letters will increase our knowledge base in this area and help professionals and patients make informed decisions.

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This article is taken from the Spring 2005 issue of LymphLine, the LSN's quarterly newsletter available to all LSN members. For details of how to become a member, click here.

What is the Lymphatic System?

By Sandy Ellis, Clinical Nurse Specialist, Lymphoedema

What are the differences between arteries, veins and lymphatics and how do they all connect?

The circulation of blood and other fluids around the body is performed by the circulatory system and this is broadly divided into three parts: the arterial system, the venous system and the lymphatic system.

The arterial system consists of arteries which transport blood, rich in oxygen (carried by red blood cells) and nutrients, to the tissues (muscles and organs) of the body. As this blood passes through the tissues, the nutrients and oxygen are taken up and used by the tissues. Afterwards, the blood is channelled into the venous system which is made up of veins. The blood is then transported through the veins with the help of valves placed along the inside of the veins. These valves push the blood along the veins and away from the tissues, directing it back to the heart and onwards through the arterial system and so the cycle begins again.

It is the arterial system which carries the blood to cleansing organs such as the liver and kidneys, where the unwanted substances can be filtered out. The blood is also replenished with new oxygen as it passes through the lungs and with nutrients as it passes through the gut. It is the heart which pushes the blood through the arteries by its strong pumping action. This pumping action is so strong and achieves such a high pressure in the arteries that, unlike the veins, they do not require valves to help the blood along.

If you think about how we measure somebody's heart rate, we don't usually listen to their heart and count what we hear. We feel their pulse at certain parts of the body where an artery can be felt (usually the wrist) and we simply count what we feel and what we are feeling is the blood passing along the artery with each beat of the heart.

Similarly, when we measure somebody's blood pressure it is the pressure within the arteries that we are actually measuring. If you have ever had your blood pressure taken you may have seen that two numbers are recorded. The top number is the pressure within your arteries during a beat (pump) of your heart and the bottom number is the pressure within your arteries when the heart is resting between beats (pumps).

what lymphatic system

In addition to the arteries and veins, the circulatory system also involves what is referred to as the microcirculation and it is here where the cells of the tissues or organs gain access to the nutrients brought there in the blood. It is also where the debris, unwanted substances and waste materials are collected and the drainage process begins. Tissue uptake of oxygen results in carbon dioxide which is transported back to the veins. Waste materials and excess fluid drains into the lymphatic system.

The term micro means tiny or very small and this gives us a clue as to what happens in the microcirculation. Because tissue cells are so tiny, they need their blood supply to be brought to them in tiny blood vessels. Arteries, which are very big, divide into a network of tiny vessels at the points where they need to supply the tissues. Once this blood is 'used' by the tissues it has to be taken away and this is done via another network of tiny blood vessels. This network is attached to the veins (venous system) so the blood can be transported away by the veins as described earlier.

So that the tissue cells have access to the nutrients and substances in the blood which has been brought to them, the blood passes from the tiny arterial vessels into highly specialised blood vessels called capillaries. Capillaries are attached at one end to the tiny arterial vessels and at the other end to the tiny vessels leading to the veins, so forming the link between the arterial and venous systems.

As blood passes through a capillary it allows fluid, nutrients and other substances to leak out through its walls and fill the spaces between the cells. (The spaces between the cells contain special proteins which bind themselves to water, and also contains fibres and collagen type substances.) So the spaces between the cells become a kind of reservoir and the cells can absorb what they need from the fluid surrounding them. The cells will also push out any waste matter and excess fluid back into the spaces between the cells and it is here that we first encounter the lymphatics.

How do the lymphatics work?

As nutrient rich fluid flows out through the walls of the capillaries into the spaces between the cells, so an equal amount of fluid, laden with waste substances, drains back into the circulation via tiny vessels. These vessels are the initial lymphatics, so called because they form the beginning of the lymphatic system. Fluid is directed into the initial lymphatics through channels which occur in the spaces between cells. These channels are known as the prelymphatic channels, so called because they occur just before the beginning of the lymphatic system.

The capillaries, initial lymphatics and the combined components of the spaces between tissue cells all work in partnership and this is what we are referring to when we talk about the microcirculation.

Lymph flow

Once fluid enters the initial lymphatics it is referred to as lymph or lymph fluid.

The initial lymphatics are a network of literally millions of hollow tubes, which cover the whole body. As lymph fills the initial lymphatics it flows down away from the skin surface into slightly deeper lymph vessels called the precollectors. These precollectors can also take up some extra fluid from the tissues, in addition to the lymph draining into them from the initial collectors.

So far, the lymph has been gathered by two types of lymph vessels, forming a network of a kind of three dimensional mesh, designed to fill as much space between the cells as is necessary to collect the waste fluid etc.

The precollectors deliver the lymph to vessels (tubes) even deeper and these are known as the collecting lymphatics or collectors (sometimes referred to as the true collectors).

The collecting lymphatics are rather like a chain where each link of the chain is a chamber, separated from the next chamber by a valve. This valve only allows lymph to travel in one direction and the lymph is squeezed from one chamber to the next by the muscular contraction of each chamber in turn.When a chamber has emptied into the next one, it relaxes and because it is empty, the pressure within it drops. This means that when the chamber behind it contracts it has a higher pressure than the empty chamber. This pressurised lymph forces open the next valve and the lymph passes from the full chamber to the empty chamber. As this process is repeated all the way along the chain, so lymph is forced in one direction, towards the lymph nodes (lymph glands).

The body of these lymphatic vessels sends out chemical messages which act on the microcirculation and regulate how much lymph is produced. They also send chemical messages to other chambers (other links in their own chain) which make the chambers contract and relax (pump) faster or slower, depending on the amount of lymph passing through them.

The collecting lymphatics use their valves to direct lymph to clusters of lymph nodes situated in certain regions of the body. There are hundreds of lymph nodes of different sizes (between 0.5 - 3cm in diameter) all around the body. If we look at Figure 1 we can see the direction of the flow of lymph represented by the arrows. It is being directed to clusters of lymph nodes, shown as black dots on the diagram.

Normal lymph flow in skin, towards the lymph nodes 
Figure 1. Normal lymph flow in skin, towards the lymph nodes

You will notice from the diagram that the direction of the flow of lymph within the skin is different in different areas or zones of the body. For example: look at how the arrows on the left side of the chest show lymph being directed to the nodes in the left armpit; whereas lower down on the left side of the body we can see arrows indicating lymph flow being directed towards the nodes in the left groin area. These zones are called lymphatic basins or lymph territories and are separated from each other by borders which are known as watersheds. This means that the amount of lymph being transported around a particular zone at any one time is controlled to a certain extent.

Once the lymph arrives at the lymph nodes it enters the nodes and is cleansed by a filtering process as it passes through the node. The cleansed lymph then passes out of the other side of the node into new collecting lymphatics. These collecting lymphatics join up with others along the way and form larger vessels called lymph trunks.

So far we have seen that the journey taken by lymph starts in the free spaces between tissue cells and then into tiny little vessels and continues along through bigger and bigger vessels, being filtered by the nodes en route, until this point; where all the lymph produced by the body ends up in the lymph trunks. True to form, these lymph trunks then pass the lymph into even bigger lymph vessels known as thelymphatic ducts, which are the largest lymph vessels in the system and represent the end of the line for the transport of lymph.

The body has two lymphatic ducts situated between the collar bone and the upper part of the chest: one on the left side of the body and one on the right. The right lymphatic duct is only about 1.3cm long because it only takes the lymph drained from the right side of the head and neck, the right arm and hand and the right side of the chest, including the right lung and the right side of the heart. It also takes lymph drained from that small part of the liver that sits in the right side of the chest.

The lymph that enters the right lymphatic duct is finally emptied into the venous bloodstream via a large vein just below the right collar bone.

The left lymphatic duct is also known as the thoracic duct and it takes all the lymph produced from all the other areas of the body, including the right side of the body from the waist down. This means that the majority of the body's lymph trunks drain into it, so it is much longer than the right lymphatic duct, at about 42cm.

The lymph that enters the left lymphatic duct is finally emptied into the venous bloodstream via a large vein just below the left collar bone.

What happens when it goes wrong?

Some people are born with some of their lymphatic system missing or not working properly. Swelling may be obvious at birth or become apparent when a child or adolescent develops. Sometimes it is necessary to surgically remove lymph nodes and surrounding lymph vessels. Damage to the lymphatics may occur through injury, or treatments such as radiotherapy. Other problems in the body may also cause Lymphoedema such as untreated venous disease in the legs, which may increase the amount of fluid in the tissues; eventually overwhelming the superficial lymphatics, which fail from exhaustion.

We know that our bodies can cope without some lymphatics to a certain extent. Our superficial lymphatics seem to be able to reroute some lymph where an original route is blocked, or there are nodes missing. Normal lymphatics can cope with a greater than usual volume of lymph for a while but they do reach a kind of saturation point. At this point there will be more fluid in the spaces between the cells than the lymphatics can cope with and that is when we see swelling appear. The swelling is the visible sign of excess fluid in the tissues. This is Lymphoedema.

Increased lymph in the tissues means an increase of proteins, fluid, fibres and other substances found there. Over time, these substances cause changes in the skin, making it feel tougher and less pliable.

Factors influencing management

Management of Lymphoedema involves the removal of as much excess fluid, proteins, fibres etc. and the prevention of them building up again. This can be achieved by compression garments, massage, bandaging, exercising and addressing any other factors which are contributing to the problem. The approach used will depend on the degree and nature of the swelling and other factors such as what is acceptable to the person with Lymphoedema. Management may be with compression garments only, or with a combination of the other approaches.

Can we retrain our bodies to redirect lymph?

We cannot really retrain our bodies, but we can exploit what we know about lymph drainage and the structure of the lymphatic system. Simple lymphatic drainage, or SLD, guides some excess fluid away from the area of swelling via the superficial lymphatics in the skin.

Manual Lymphatic Drainage, or MLD, opens up new drainage routes in the superficial lymphatics in the skin. It breaches the watersheds, those barriers between the different zones (lymphatic basins or territories) of the body and the fluid is guided to lymph nodes which will be able to drain and filter the excess lymph. MLD also helps to break down the build up of excess fibres within the skin (fibrosis).

Exercise plays an important role in the management of lymphoedema

Exercise is a most important part of managing lymphoedema. Walking is excellent because it helps to pump fluid back up the venous system. Also, as the leg muscles contract and relax they change the pressures in and around the lymphatics, causing a kind of siphoning effect in the superficial lymphatics and helping the initial and collecting lymphatics to pump more effectively. Specific exercises for the arms and hands also employ this technique. Wearing a compression garment during exercise enhances the effect considerably.

Any exercising in water is excellent for reducing swelling, because water pressure exerts a force on the body which is greater then the pressure in the superficial and initial lymphatics. This results in excess lymph flowing into the lymphatic system. If Lymphoedema is present in the lower body or legs, simply walking through chest high water will have excellent results. This is because water pressure increases, the deeper the water; so the feet and lower legs are in a more pressurised (compressive) environment than higher up the body; thus transporting lymph upwards and inwards. The pressure of the water massages the tissues and can act like a sleeve or stocking. Swimming is very good as it uses muscle pumps without putting any load bearing strain on the joints.

Author's note: The lymphatic system also plays a vital role in the body's defences against infection, which is an entire subject in its own right. This article has only looked at the circulatory functions of the lymphatics.

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