Physical Medicine and Rehabilitation
Lymphoedem And Its Treatment
Lymphedema is a lifelong disease. With the patient's awareness and compliance with treatment, its progression can be prevented.
The circulatory system in the body contains 3 different systems: the arterial system, the venous system and the lymphatic system.
The blood required for the nutrition and oxygenation of the tissues is carried to the body by the arterial system. About 90 percent of the waste materials in the tissues are transported back to the heart by the venous system. The 10% part is large molecules and cannot pass into the vein system. These large molecules form the lymphatic fluid and are transported through the lymphatic system. Lymphatic fluid is protein-rich fluid and is the capacity to carry the body's lymphatic load under normal conditions. The lymphatic system also plays a major role in the body's immune system. It prevents the spread of the microorganism in the body.
When insufficiency develops in the lymphatic system, the lymphatic fluid accumulates in the intercellular fluid and lymphedema develops. Three types of failures can be seen in the lymphatic system.
failure There is more fluid in the body than the lymphatic system can handle. Heart failure, early stage chronic venous insufficiency, renal failure, hypothyroidism can be given as examples. Oedema in the presence of dynamic insufficiency is not lymphedema.
The lymphatic load is normal, but the lymphatic system cannot function due to pressure and obstruction. For example, due to small congenital lymphatic vessel structure, subsequent trauma, surgery or radiotherapy, vascular deterioration or removal of lymph nodes can be given as examples. In the presence of mechanical failure, waste materials and protein accumulate in the intercellular fluid. White blood cells, our protective cells, have difficulty reaching the incoming microorganisms. In short, the situation of lymphedema begins to appear.
If dynamic failure lasts for a long time, mechanical failure may develop on it. This is the type of situation seen especially in patients with advanced varicose veins. Lymphedema can be primary or secondary depending on the underlying cause.
Lymphedema that occurs as a result of developmental anomalies in the lymphatic system is called primary lymphedema. It is related to innate or heredity. Lymph vessels may be wider or narrower than normal. The lymphatic vessel may not have formed at all. Depending on the cause of the disorder, the age of onset of lymphedema may vary.
Lymphedema, which occurs as a result of the deterioration of the developmentally normal lymphatic system due to a cause, is called secondary lymphedema. Lymphedema, which we see more frequently in the community, is secondary lymphedema. In our country, it is most commonly seen due to cancers and their treatment. Traumatic conditions, major orthopaedic surgeries, venous surgeries, chronic venous insufficiency, lipoedema, some infections and rheumatic diseases can also cause lymphedema. Breast cancer-associated lymphedema is a condition that should be mentioned separately.
It was first defined in 1921 as "Postmastectomy Lymphedema". The risk factors for the development of lymphedema after breast cancer are very clear. Factors related to the disease itself (stage of the disease, number of lymph nodes removed, location of the tumour in the breast), treatment (surgery, radiotherapy, chemotherapy) and the patient (age, weight, infection in the arm, genetic characteristics) may accelerate the development of lymphedema.
The patient diagnosed with lymphedema is lucky. This may seem a little strange, but many patients do not know what this disease is and which doctor they should go to, so they lose time and the stage of the disease progresses.
A clinician with lymphedema training is required for the diagnosis of lymphedema. Although patient history and physical examination are often sufficient, ultrasonography and magnetic resonance imaging can also be used. Lymphoscintigraphy is required for diagnosis in primary lymphedema. For breast cancer-associated lymphedema, which is a common condition, it should be emphasized that before the development of lymphedema, the patient need to be directed to a Physiotherapy and Rehabilitation physician who has received lymphedema training so that the training provided reduces the risk of developing lymphedema.
In the treatment of lymphedema, the aims of a Physiotherapy and Rehabilitation physician are as follows:
1. Provide education on topics such as “What is lymphedema to the patient, how to stop its progression, how to protect it from infections, what is done to treat it?”
2. Stopping the progression of lymphedema,
3. Reducing the resulting swelling as much as possible,
4. Increasing lymphatic system flow,
5. Protecting skin integrity; preventing infection, treating the infection if there is any,
6. Solving the joint limitations, preventing their formation,
7. Supporting the patient in terms of psychological stress that lymphedema may cause.
he globally accepted gold standard treatment for lymphedema is complex decongestive therapy. Complex decongestive therapy consists of 2 phases. Phase 1 covers the treatment in the hospital. Phase 2 covers the things that should be done at home.
Phase 1 and Phase 2 treatments are summarized in Table 1.
Skin and nail care
Manual lymphatic drainage
Regular doctor visits
Skin and nail care
Manual lymphatic drainage
Compression garments (all day) and night bandaging when needed
Skin and nail care:
It is the most important step in the prevention and treatment of lymphedema. Attention should be paid to hygiene. 15-minute showers with not too hot water are recommended. Of course, pumping exercises should be done afterwards. Because of the risk of burns, it is necessary to be protected from hot water and sun. It is recommended to apply a high factor sunscreen cream before going out in the sun. Thermal waters and hot springs are prohibited due to both the risk of burns and the fact that the heat can increase oedema by causing vascular contraction.
Moisturizing is just as important as cleaning. Before going to bed at night and wearing a morning compression garment, a pH 5.5, oil-free, odourless, perfume-free moisturizer should be used. It is important to be protected from cuts, but if there is a cut, it should be washed with soap and water immediately, and an antiseptic cream should be applied. In such a case, swelling, redness and fever should be followed, and in the presence of these findings, the relevant doctor should be consulted immediately.
Manual lymphatic Drainage:
It is a rhythmic and slow massage performed by hand, covering the abdomen, neck and back regions and in accordance with the lymphatic anatomy. Its purpose is to add the lymph fluid to the lymph circulation by changing the direction of the flow (directed to the lymph vessels that are not occluded in accordance with the anatomy), thus reducing the amount of oedema. In addition to reducing oedema, it provides relaxation and has analgesic effects. It is applied by a physiotherapist with lymphedema training and the application takes 30-45 minutes on average.
It is an application made with the help of the device. The oedematous limb is placed inside the air cushions, which are inflated with the help of a pump in a pressure-adjusted manner. Thus, it is aimed to remove the accumulated lymph fluid from the tissues by applying external pressure and add it to the circulation. This application can be added to the patient deemed appropriate by the doctor.
Oedema, which is reduced by manual lymphatic drainage, prevents it from increasing by external pressure. It reduces the rate of lymphatic fluid exiting the vessel, and prevents refilling of the emptied areas. It is a safe and effective treatment method when applied correctly.
Compression garments: It prevents the increase of oedema by applying external pressure. It is used during the day. At the end of phase 1 treatment, it is prescribed by the doctor according to its dimensions. Compression garments may need to be renewed every 6-12 months.
Exercise should be done because of its positive effects on muscle strength, functional capacity, psychological state and bone health. With exercise, the contraction of the muscles occurs and the return of lymph fluid is increased by affecting the lymphatic vessels. The most important point to be considered while exercising is that the compression garment or bandage is on the patient. The planned exercise program should include aerobic exercises, resistance exercises and breathing exercises.
Although many surgical techniques have been tried in the treatment of lymphedema, none of them have been effective enough. However, surgical approaches can be tried by surgeons experienced in lymphedema surgery in cases where conventional treatment fails. In the early stages, microsurgical operations connecting the lymphatic vessels to the veins and lymph node transplantation can be performed. In advanced stages, liposuction is one of the current surgical approaches that can be used to remove skin and subcutaneous tissues.
Diagnosis, treatment and follow-up of lymphedema should be done by a knowledgeable and competent Physiotherapy and Rehabilitation physician. Lymphedema is a lifelong disease, but its progression can be prevented with the patient's awareness and compliance with treatment.