 | General advice
for patients and those at risk of developing lymphoedema| Advice when flying
| |
The lymphatic system is a one-way drainage system which transports a colourless fluid called lymph, which consists of fluid, plasma proteins, fats, cells and debris in the form of dead blood cells and bacteria, from the tissues to the blood vascular system. It is also part of the body's immune system, filtering the lymph as it passes through the lymph nodes, killing bacteria by the action of blood cells called phagocytes and producing another form of blood cell called lymphocytes. Nodes are usually situated in groups, such as are found in the axilla (armpit) or inguinal area (groin), and are often surgically removed in the treatment of cancer, for example, at the same time as a mastectomy.
The lymphatic system is unlike the blood vascular system which is a true circulatory system. Blood is pumped by the heart to all parts of the body through the arteries to provide tissues with a constant supply of oxygen and nutrients which are necessary for the body to work efficiently. The transfer of oxygen, nutrients, fluid and protein from the blood to the tissues takes place through the walls of the smallest blood vessels called capillaries and is called capillary filtration. Approximately 90% of the waste products and carbon dioxide pass from the tissues into the blood stream in the same manner, that is, back through the capillary walls. This complex exchange through the capillary walls takes place because of the difference in the pressure of the blood and the pressure of the tissues at the arterial and venous sections of the capillary circulation. The de-oxygenated blood is then returned through the veins to the heart and onto the lungs where it is re-oxygenated and pumped again around the body.
It is imperative that the fluid and proteins are returned to the blood circulation to maintain the normal body fluid balance and to enable the waste products to be excreted from the body, but the remaining 10 % of the fluid, large protein molecules and other particles in the tissues are unable to pass back through the capillary walls and into veins due to the pressure gradient. So, this mixture of fluid and large molecules is able to pass from the blood into the tissues due to a relatively high blood pressure in the capillaries but is unable to pass from the tissues back to the blood due to a relatively low pressure in the tissues and the large size of the protein molecules. This excess fluid and waste products are returned to the blood system in the lymphatic system. The transportation of lymph through the system takes place through a network of vessels. The large particles and proteins pass, with tissue fluid, into the smallest lymphatic vessels called capillaries which join to form larger vessels called lymphatic collectors. On entering the lymphatic capillaries, the tissue fluid is called lymph. The collectors possess one-way valves situated every few millimetres along their course. These valves direct the flow of lymph and prevent any back flow, the section of a collector between two valves being called a lymphangion. Collectors join and become larger, eventually forming the two largest lymphatic trunks in the body called the thoracic duct and the right lymphatic duct. These empty their contents into the blood system at the junction of two large veins on either side of the lower neck immediately behind the collar bones. The excess fluid and waste products are transported in the blood to the kidneys where they are excreted in the urine.
Lymph drainage takes place through a superficial and a deep system and there are connections between the two systems. The superficial lymphatic vessels drain the skin and subcutaneous tissues and are situated immediately below the skin. They may run independently or accompany superficial veins. The deep lymphatic vessels drain the musculature, internal organs and deep tissues. They always accompany deep veins with which they are in close proximity. Lymph nodes do not have the ability to regenerate, so those that are removed surgically in the treatment of cancer are never replaced.
The body surface is divided into specific superficial lymphatic drainage areas called territories, which drain lymph to specific lymph nodes. For example, the trunk is divided into four territories, two upper and two lower, the vertical dividing line being the mid-line of the body and the horizontal dividing line being approximately at waist level. The dividing line between any two territories is called a watershed. The upper territories drain to their respective armpit nodes, right and left, and the two lower territories drain to their respective groin nodes, right and left.
In addition, the two upper limbs and the two lower limbs are also divided into territories, each limb being drained by the respective armpit or groin nodes.
Diagrams of Lymphatic Territories and Watersheds
Lymph is pumped through the system in three ways:
1. Breathing raises and lowers the pressure within the abdomen and chest with each inspiration and expiration. This causes a sucking effect in the chest and a pumping effect in the abdomen which assist the lymphatic flow in the deep lymphatic system including the two largest vessels in the body, the thoracic duct and the right lymphatic duct. This is known as the respiratory pump effect.
2. Contraction and relaxation of muscles during exercise create a pumping effect on all tissues in the area by raising and lowering pressure, including lymphatic and blood vessels. This is known as the muscle pump effect.
3. Lymph is continually pumped from all parts of the body by the rhythmical contraction of small sections of the lymph vessels, called lymphangions, at a rate of 6-10 beats per minute when the body is at rest. These contractions, and consequently the rate of the lymph flow through the vessels, are increased by up to ten times, i.e. to 60 beats per minute, in time of need, for example during exercise
There are a number of reasons why tissues of the body swell, such as trauma to the musculo-skeletal system or malfunction of the thyroid gland, the cardiovascular system or the lymphatic system.
Oedema is the medical term for a swelling so lymphoedema is the name given to a swelling that is due to a malfunction or abnormality of the lymphatic system in a particular part of the body. The oedema consists of excess tissue fluid and protein molecules, which stagnate in the tissues. The affected area can become grossly swollen, painful, heavy, unsightly and incapacitating.
The International Society of Lymphology (ISL) definition of lymphoedema is as follows:
"Lymphoedema occurs when a reduced lymphatic transport capacity is overwhelmed by a normal lymphatic load resulting in the stagnation of protein rich fluid in the interstitial tissues".
The lymphatic transport capacity refers to the ability of the lymphatic vessels in a particular area of the body to transport lymph to the draining lymph nodes. This transport capacity can be reduced when, for example in secondary lymphoedema, lymph nodes are surgically removed in the treatment of cancer, or when a person is born with a reduced number of lymphatic vessels, as in primary lymphoedema.
The lymphatic load refers to the amount of lymph that can be transported through the lymphatic vessels in any given period of time. The load is variable, being high, for example, during physical activity and low during inactivity. However, when the lymphatic transport capacity is normal, oedema does not develop as the lymphatic system is able to cope with any load which is placed upon it.
The treatment of lymphoedema is designed to improve the transport capacity and reduce the load.
The lymphatic system may be likened to a city street which, like the lymphatic system, has a capacity and a load. The street transport capacity refers to the ability of the street to transport vehicles along it. This transport capacity can be reduced when, for example, there are road works taking place or when there is an accident blocking part of the road. The street vehicle load refers to the volume of traffic that can travel along the road during any given period of time. This load is also variable, being high during peak hour traffic and low at relatively quieter periods.
Lymphoedema is divided into two basic types, primary and secondary.
The cause of primary lymphoedema is still unknown but it is thought to be due to a birth defect involving impaired lymph vessel and/or lymph node development. Secondary lymphoedemas are caused by some form of trauma to the lymphatic system.
a) Primary Lymphoedema
Primary lymphoedema may be subdivided according to two criteria.
The first classification is based on the age of the patient at the onset of the symptoms. There are three different types - congenital, praecox and tarda.
I. Milroy’s Disease
This describes a congenital familial lymphoedema. The oedema is present at birth or soon after. It accounts for approximately 5-10% of all primary lymphoedemas and usually affects the legs but can affect the arms, face and genitalia. It is twice as common in females as in males and may be associated with other congenital abnormalities.
Milroy's Disease
II. Lymphoedema Praecox
The oedema develops in the second or third decades of life. Lymphoedema Praecox accounts for approximately 80% of all primary lymphoedemas, predominantly in females.
Lymphoedema Praecox
III. Lymphoedema Tarda
Lymphoedema Tarda develops after the age of 35 years, also predominantly in females, making up approximately 10% of all primary cases.
The onset of the oedema in Praecox and Tarda is triggered by an initiating factor, which overloads the reduced lymphatic drainage capacity in the limb, such as trauma or infection. The oedema begins in the foot and ankle, progressing to involve the whole calf but rarely the thigh, there being no further progression after the initial years of development.
70% of primary lymphoedema patients show oedema in one leg. The other leg may become involved as well, often years later, in the remaining 30%.
Lymphoedema Tarda
The second classification of primary lymphoedema is dependent on the degree of malformation of the lymphatics, there being three different patterns. Aplasia is most frequently seen in congenital lymphoedema and is characterised by an absence of lymphatic vessels. Hypoplasia represents the most common pattern and is characterised by either a decreased number of lymphatics or lymphatics which are unusually small in calibre. The hyperplasia type shows vessels which are increased in size and number and have valves which malfunction.
b) Secondary Lymphoedema
Secondary lymphoedema can develop following a variety of traumas to the lymphatic system such as wounds, surgery, malignancies or radiotherapy.
In developed countries, the most common cause is surgical removal of lymph nodes, with or without radiotherapy, in the treatment of cancer of the breast or pelvic organs. However, with the increasing use of the Sentinel Lymph Node (SLN) biopsy in the surgical treatment of cancer, the incidence of post-surgical lymphoedema is likely to decrease in the future. A sentinel lymph node is defined as the first node(s) in the lymphatic chain to receive lymphatic drainage from a primary tumour. Identification of the SLN allows the detection and surgical removal of the affected nodes which clinically may have appeared normal.
Secondary Lymphoedema of the Right Leg
In developing countries, the most common type is usually filaritic lymphoedema caused by direct parasitic invasion of lymph nodes and vessels following a bite by a mosquito which is carrying the filariasis worm, Wulcheria Bancrofti. The filarial larva is deposited by the mosquito into lymphatic vessels where it develops into an adult worm. Months to years later, after the death of the worm, scar tissue develops blocking the lymphatic vessels. Only mosquitos in filaritic areas such as India, Malaysia and Thailand carry this worm. The World Health Organisation has estimated that over 120 million people are affected by filariasis worldwide.
Traumatic secondary lymphoedema of left lower leg with acute cellulitis
Onset of Lymphoedema
There is no set period of time for the oedema to be visible, whether the condition is primary or secondary. It can occur months or years later in life, triggered by an incident which overloads the lymphatic system in the limb, such as an insect bite which becomes infected, an injury or a plane flight, even one of short duration. For weeks, months or years, the limb, although having defective lymphatic drainage and therefore at risk of developing lymphoedema, is able to cope adequately with any trauma, so oedema does not develop. However, there comes a time for many patients who are at risk when the lymphatic system in the limb is overwhelmed and is unable to deal with the resultant acute inflammation. Stagnation of tissue fluid, protein and debris results. This is the start of visible lymphoedema. If the oedema is only mild, it may disappear within a few days. It may return a short time later and stay or it may never return again.
In secondary lymphoedema, the period between the causative incident and the onset of the oedema is termed the latent phase. In primary lymphoedema, the latent phase is the period between birth and the onset of the oedema.
Grades of Lymphoedema
Lymphoedema may be classified into two grades.
Grade I oedema is soft and feels like putty. It pits on pressure, that is, an indentation is left after finger pressure of a few seconds. The oedema is largely reduced overnight or by elevation.
Grade II oedema is firm and feels rubbery. It does not pit on pressure, is not reduced overnight or by elevation and shows varying degrees of fibrosis. Fibrosis occurs as a result of chronic inflammation after the oedema has been present for months or years, giving the limb a hard, rubbery feel. Grade I lymphoedema is therefore usually easier to treat than Grade II as the oedema is softer and more responsive to massage. For this reason, it is better for the limb to be treated as soon as possible after the onset of the oedema in order to bring it quickly under control and stop it developing further rather than to wait and allow it to become established before treatment is started. It is possible to have Grades I and II in the same limb at the same time.
The clinical presentation of a lymphoedematous limb depends on the type of lymphoedema and the grade of the condition. Subjective symptoms can include any combination of pain, ache, heaviness, tightness, discomfort, pins and needles, numbness, itching and burning. Objective signs can include any combination of oedema, skin changes such as dryness, scaliness, infection such as cellulitis, reduced joint range of movement and restricted or reduced activities of daily living. The amount of oedema is not always a true indication of the severity of these symptoms. For example, a grossly swollen limb may not ache appreciably, where as a limb which is only mildly swollen can be painful. In addition, some patients suffer from psychological effects.
Elephantiasis is considered to be an extension of Grade II lymphoedema and usually develops in untreated cases of primary lymphoedema and filarial lymphoedema. It is the result of years of progressive deterioration of the condition through chronic inflammation of the tissues, irreversible fibrosis and recurring attacks of infection. It shows gross oedema, loss of limb shape, thickened skin, ulcers, increase in body weight, poor posture and reduced activity.
Early diagnosis of primary lymphoedema is not always possible. When the oedema is evident at birth, the diagnosis should be a formality. But the oedema can develop in later life and often for no apparent reason. Mild, localised oedema in a limb, usually a leg, is sometimes overlooked at first by the patient and may be initially noticed by a friend or relative. Even when it is detected, medical opinion may not be sought due to the patient believing that it is something minor such as a sprain, a bruise or an insect bite. If the oedema persists and becomes worse, then the patient may consult a medical practitioner who will include lymphoedema as one of the possible causes of the oedema and investigate further.
Early diagnosis of secondary lymphoedema should be straight forward, particularly if the oedema follows surgery in the treatment of cancer, for example, in an arm following a mastectomy or a leg following removal of the uterus or cervix or a prostatectomy.
If the diagnosis is unclear
and there is no obvious cause, or the extent of the condition needs to be
determined, a non-invasive nuclear medical procedure called a lymphoscintigram
is required to accurately assess the capacity of the lymphatic system in the
affected limbs.
Image of a lymphoscintigram showing Image of a lymphoscintigram showing
normal lymphatic drainage of both legs abnormal lymphatic drainage of the left leg
Various treatments have been performed over the years. These may be classified as invasive and non-invasive.
1. Invasive Treatment
Surgery
Numerous procedures have been performed in the treatment of lymphoedema over the last century. Some of the procedures have been unsuccessful while others have been provided some relief.
The operations performed fall into three groups –
I. Procedures to remove lymphoedematous tissue
II. Procedures to improve lymphatic drainage
III. Procedures to reconstruct damaged lymph vessels.
Debulking operations have been used to good effect to excise oedematous tissue, improve function and cosmetic appearance. These procedures are indicated when there is gross chronic lymphoedema with fibrosis. Liposuction is now being used to effect reliable improvements in limb shape.
These procedures have been used in the past to attempt to connect lymphatic vessels to veins in the early stage of lymphoedema.
This micro-surgical procedure attempts to connect blocked lymphatics to functional ones to by-pass an obstruction, but this appears not to have been used in recent times.
2. Non-Invasive Treatment
The first recorded treatment regime
may be traced back to 1892 when Winiwarter, a German surgeon, proposed that a
combination of meticulous cleanliness, bed rest, elevation, massage, compression
bandaging and remedial exercises should be used before surgery. This was published in his book “Die
Elephantiasis”.
Almost 100 years later, Dr Michael
Foldi published his article “Conservative treatment of lymphoedema of the limbs” in 1985
describing a treatment which he called “Complex Decongestive Physiotherapy”
consisting of manual lymph drainage (massage), skin hygiene, compression
bandaging and remedial exercises, followed by application of suitable
compression garments. This
treatment has been modified in
recent times with the addition of deep breathing exercises.
This combination of modalities has
proven to be the most effective conservative non-invasive treatment
worldwide. The title of the
treatment has been changed over the years by some authorities but the components
have stood the test of time. The
current title usually used is “Complex Physical Therapy” (CPT) or Complete
Decongestive Therapy (CDT).
Complex Physical Therapy (CPT)
Foldi designated the treatment of
CPT as “Phase I of decongestion” and the ongoing maintenance in the ensuring
years as “Phase II of optimisation and conservation.”
Phase I of CPT
Phase I is a period of intensive
daily treatment given for a variable period of time, depending on the severity
of the condition and the progress made.
Treatment reduces the oedema, improves lymphatic drainage, softens
fibrotic oedema and increases limb mobility, thereby increasing activities of
daily living and quality of life.
The components of CPT are:
1) Manual
lymphatic massage with breathing exercises
2) Multi-layer
bandaging
3) Skin
hygiene
4) Active
exercises
1)
Manual lymphatic massage
Lymphatic massage is performed to assist the superficial lymphatic drainage, reduce the oedema and soften fibrotic areas. It is given in a methodical sequence, starting with massage of the trunk to stimulate the central body drainage before treating the affected limb. The strokes are slow, gentle and repetitive and are directed to the appropriate functional lymph nodes. They may be likened to stroking a cat.
Deep breathing exercises to stimulate the deep central lymph flow through the two largest lymphatic vessels in the body, the thoracic duct and the right lymphatic duct, are performed in conjunction with the lymphatic massage. Deep breathing alternately raises and lowers the pressure in the abdomen and chest, exerting a pumping effect on all lymphatic and blood vessels in the trunk. It has been shown that these pressure changes propel lymph through the thoracic duct in volume increments proportional to the rate and depth of respiration. This is known as the respiratory pump.
Massage of the oedematous limb is commenced after stimulation of the deep and superficial trunk lymphatic drainage. The proximal end of the arm or leg is massaged first, stimulating the functional lymph nodes in the armpit or groin, followed by the forearm and hand or lower leg and foot, depending on whichever limb is affected.
This routine of trunk massage and deep breathing, followed by limb massage is repeated any number of times during one treatment session, depending on the therapist’s treatment plan and the progress made.
There are two absolute contraindications to lymphatic massage:
i. Untreated cardiac failure
ii. Renal failure
Relative contraindications are:
i. Malignant lymphoedema
ii. Acute cellulitis
2) Multi-layer bandaging
Bandaging consists of four layers: stockinette, cotton wool bandages, foam
padding and low stretch bandages, applied in that order. Stockinette protects the skin and absorbs
perspiration. Cotton wool bandages also
protect the skin and help to produce a regular cylindrical shape to the limb by
reducing shape distortions and deep skin folds. Low density foam pads protect potential pressure
areas, reduce shape distortions and soften areas of fibrosis. High density foam
is used to soften and reshape fibrotic areas. Low stretch bandages are
used to apply necessary compression to the limb. They have a high working
pressure and a low resting pressure providing a firm but flexible support to the
limb, causing tissue pressure variations as the muscles contract and relax
against the resistance of the bandages, thereby stimulating the muscle pump.
These bandages are applied according to the Law of Laplace in order to provide
greater pressure at the distal end of the limb than at the proximal
end. Pressure in the tissues is thereby increased,
assisting the passage of oedema fluid from the tissues into the lymphatic
vessels via the lymphatic capillaries, and lymph flow through the lymphatic
vessels to assist drainage. In
addition, bandaging helps to soften fibrosis, restore elasticity to the
over-stretched skin and re-shape the limb.
There are three absolute contraindications to multi-layer bandaging:
i. Advanced peripheral arterial insufficiency
ii. Septic phlebitis
iii. Congestive heart failure
Relative contraindications are:
i. Some advanced skin conditions
ii. Advanced peripheral neuropathy
iii. Sensory disturbances of the skin
The skin is the largest organ in the body and has several functions. It supports and shapes the body, regulates body temperature, protects the body from infection, excretes waste products, prevents tissue dehydration and is an organ of communication.
Skin changes can be a feature of
lymphoedema, particularly in the chronic stage. These are due to poor skin hygiene, the
stagnant oedema fluid, chronic inflammation and the impaired lymphatic
drainage. The skin can become dry,
hard, scaly and thickened, easily succumbing to infection due to its poor
quality.
Recurrent episodes of cellulitis are
not uncommon in leg lymphoedema, resulting in further overloading of the
lymphatic system and an increase of oedema.
Lymphoedematous limbs have an immune
deficiency and are, therefore, more susceptible to infection. Skin hygiene is therefore
critical. Daily skin care should
include scrupulous inspection of the skin, application of a moisturising lotion
and treatment of any infection, abrasion or pressure area.
4)
Active Exercises
Contraction and relaxation of
muscles in an oedematous limb which is bandaged or enclosed in a compression
garment cause variations in tissue pressure and activation of the muscle
pump. This promotes lymphatic
drainage, reduction of the oedema and further softening of fibrotic oedema.
Secondary Lymphoedema of the Left Arm - Before and After Treatment
Secondary Lymphoedema of the Right Leg - Before and After Treatment
Compression Garments
At the completion of Phase 1 of CPT
treatment, a suitable compression garment is fitted to the limb, taking the
place of the bandaging. The
garment applies external support
which keeps the oedema under control, assists lymphatic drainage, helps to soften any remaining fibrosis
and maintains the newly acquired shape of the limb.
Compression garments are available in a variety of different brands, styles and compression ratings and can be fitted from stock sizes or be custom made for irregular shaped limbs or those which do not fit into a stock size. Correct choice is critical for the efficient functioning of the garment and comfort of the patient. Not only must it be the correct size, it must also be an appropriate compression rating.
Compression ratings are:
Low compression 15-25mm Hg
Medium compression 25-35mm Hg
High compression 35-45mm Hg
Very high compression > 45mm Hg
It is normal practice for two
garments to be supplied for each oedematous limb to allow time for them to be
washed regularly.
Made to measure calf stocking with toe glove Made to measure toe glove
Thigh with waist attachment stocking Ready made pantyhose
Arm sleeve with glove Glove with short fingers
Hydrotherapy
Hydrotherapy provides an ideal medium for lymphoedema patients to perform their exercises utilising the hydrostatic and physiological properties of thermal immersion. Water at a temperature of 35 degrees is pleasantly warm and is termed thermo-neutral as it has no effect on core temperature.
The gravitational pressure in a body of water increases by 1mm Hg for each 13.6 millimetres of water depth. This pressure results from the weight of the water. For each 30cm of water depth, therefore, 22mm Hg pressure (300mm x 13.6 = 22.05) is exerted on a standing immobile body such that, at a depth of 1.2 metres, 88mm Hg pressure is exerted on the ankles. This pressure is approximately double the pressure which is exerted on the ankle by a compression stocking. Blood is thereby forced back to the heart from the lower legs and oedema fluid passes from the tissue spaces into the vascular and lymphatic systems. This compressive effect is increased when the muscle pump effect is activated by the performance of active exercises.
Compression
therapy using various forms of pneumatic pumps has been a popular form of
treatment for lymphoedema for many years, particularly for mild cases when the
oedema is still soft.
Pumps which have multi-compartmental sleeves are more successful as the compartments are activated in sequence so have a better pumping affect. Uni-compartment sleeves are less effective. The use of a compression pump is not recommended unless it is preceded by measures to stimulate the central trunk lymphatic drainage as is done when performing manual lymphatic massage.
The word LASER is an acronym for “light amplification
by stimulated emission of radiation”
Low level laser therapy (LLLT) is
used in the treatment of lymphoedema producing low intensity irradiation,
causing biological effects in the tissues, not heating. It is claimed that LLLT stimulates the
regeneration of lymphatics, increases the contractibility of lymphatics and
stimulates changes in the fibre content of oedematous tissues, thereby softening
hard fibrotic oedema. Laser also
usually provides dramatic relief in the treatment of cording in the axilla and
inner aspect of the arm particularly when combined with graduated stretching
exercises. These cord-like
bands, which sometimes develop post-surgically in the treatment of breast cancer
can cause pain and discomfort when they are stretched inadvertently on certain
shoulder movements.
The most common lasers used in the
treatment of lymphoedema are:
The use of two groups of drugs has
been advocated in the treatment of lymphoedema.
I. Diuretics
Diuretics are recognised as being of
use in the treatment of generalised low-protein oedemas which have an elevated
sodium content in the body, such as congestive heart failure, renal disease and
hypertension. Their administration
in high protein oedemas such as lymphoedema is sometimes beneficial for a short
time in those with mild, soft oedema but is contra-indicated in the long term
due to the potential to induce fluid and electrolyte imbalance in the body,
increased protein concentration and resultant increase in fibrosis.
It has been shown that any improvement gained when used in the treatment of lymphoedema is achieved by reduction of the water content of the oedema which is excreted in the urine rather than removal of the protein molecules.
II. II. Benzo-pyrones
It has been
shown that the benzo-pyrone group of drugs break down the large protein
molecules present in the oedema so assist in its reduction. However, registration of the
benzo-pyrone drug Coumarin (Lodema) was cancelled in Australia in 1996 by the
Department of Health and Family Services due to the increasing number of
reported cases of hepatoxicity received by the Australian Drug Evaluation
Committee.
Phase II of CPT
This starts at the completion of
Phase I when the oedema has been reduced and the affected limb has been fitted
with a compression garment. It is
normal practice for two garments to be supplied for each oedematous limb,
allowing time for them to be washed regularly.
Phase II is the continuous period of
self-management by the patient in the ensuing years along with supervision,
assistance and possible intermittent treatment from the therapist.
Patients are usually reviewed by
their therapist every three months to check on the progress of the condition,
the circumferential measurements of the oedematous limb and supply of new
garments as and when required. The
effective life of compression garments is usually 4-6 months, after which time
they have lost their elasticity and are consequently no longer providing
adequate support to the limb, sometimes allowing some oedema to return.
During Phase II, lymphoedema patients are usually required to wear some form of compression on the affected limb daily, and sometimes at night, in order to keep the oedema under control. In theory, the oedematous limb does not need the same compression at night as it does during the day, due to the reduced effect of gravity while lying down. Patients can, therefore, usually wear a garment of a lesser compression at night to keep the oedema under control or no garment if the oedema is only mild.
Clinical experience has
shown that obesity inhibits the effective management of lymphoedema.
An increase in the amount of
adipose tissue (fat) in the body causes greater pressure on lymphatic and
blood vessels, particularly in the legs, adversely affecting lymphatic drainage
and venous return to the heart.
Generally speaking, obese
people suffer from greater immobility so experience a reduced muscle pump effect
from exercise. Sometimes they have difficulty elevating their legs and are
therefore less able to benefit from the effect of gravity in assisting lymph
drainage. They may also have a poor body posture causing an increase in
abdominal pressure and consequent reduced lymphatic drainage. Respiratory
function can be impaired causing difficulty performing deep breathing exercises,
so the respiratory pump effect is adversely affected.
In addition, obese oedematous limbs are more difficult to massage and bandage adequately due to their size and shape, thus making treatment by physical means less effective.
The BMI is an accurate, universally accepted method of determining whether a person's weight is proportionate to their height. This was recommended in the USA by the National Institute of Health Consensus Development Conference in 1985 as an accurate index for the prediction of medically significant obesity. The body weight in kilograms is divided by the height in metres squared, the resultant number being the BMI number which is equally applicable to men and women.
For example, in a person of height 1.75m and weight 75kg
75 75
_________ = _________ = 24.5 BMI
(1.75 x 1.75) 3.06
This is within the normal range of 20 - 25.
Besides obesity being claimed to be a causative factor in the development of post-mastectomy lymphoedema, Bertelli et al (1992) claim that arm lymphoedema patients who increase their body weight post-operatively achieve less of a reduction of oedema from treatment than patients who receive the same treatment but who do not put on weight post-operatively. In a study of 120 patients with arm lymphoedema who received the same treatment, those who did not gain weight after their mastectomy achieved a 25% reduction of oedema.
In summary, the foregoing evidence would appear to confirm the influence of a high Body Mass Index on lymphoedema in two ways. Firstly, people who are overweight who undergo surgery for breast cancer are twice as likely to develop post-operative secondary arm lymphoedema as those who are not overweight. Secondly, people with lymphoedema who put on weight after having undergone surgery for breast cancer achieve approximately half the reduction of oedema from treatment as those who do not put on weight post-operatively.
Chronic venous insufficiency is a common chronic condition, particularly in those of advancing years. It is characterised by lower leg oedema, heaviness, tightness, aching and discomfort, all of which are relieved, to some extent, by elevation. This oedema is called venous oedema.
One way valves situated every few millimetres in the veins assist the heart to pump blood back to the heart. With increasing age and other factors such as being overweight, chronic heart failure, hypertension, pregnancy, deep vein thrombosis or an excessive amount of standing, an additional strain is placed on the leg veins by the resultant high gravitational forces causing them to dilate. This, in turn, makes the valves less effective in the process of returning blood to the heart by allowing backflow of blood to occur and collection or "pooling" of blood in the calves. The valves become non-functional and the veins misshapen. These are termed varicose veins. They cause stagnation of blood in the calves and an increased amount of fluid to pass from the blood capillaries into the tissues and the onset of oedema. As the condition progresses, the lymphatic drainage from the legs becomes overloaded and the condition of the skin deteriorates. It becomes pigmented, dry, fragile, easily breaking down and becoming infected, leading to ulceration.
Vascular surgery does not always provide long term relief for CVI. However, compression therapy has been shown to be effective in improving venous and lymphatic drainage from lower limbs, as well as keeping oedema under control.
Mild to moderate oedema is treated by fitting low to medium compression calf stockings.
Moderate to severe oedema require multi-layer bandaging for a few days to reduce the oedema before fitting stockings.
