The lymph system is part of the circulatory system responsible for transporting fluid from the body’s soft tissues and also transporting substances too large to travel in the blood vessels. It can be thought of as a “house cleaning” system for the body. The lymphatic system also works to monitor this fluid for the presence of bacteria and viruses, as well as housing the white blood cells which produce antibodies to fight disease. The lymphatic system is also important in helping to digest and absorb fats in the gut.

Lymphedema is a condition in which excess protein-rich fluid (lymph) collects in tissues and causes swelling (edema) and/ or thickening and hardening of body tissues. This collection occurs because the lymphatic system is inadequate or has been damaged and can no longer adequately drain excess lymph fluid from the arm, leg, neck, or other areas of the body. Lymphedema may or may not be painful. Having lymphedema puts you at risk for developing a serious skin infection called cellulitis or erysipelas. Lymphedema is a chronic condition for which there is no cure, but it is controllable when cared for properly. When not cared for properly, lymphedema tends to gradually get worse.

In some cases, people inherit or are born with a poorly working lymph system. They may start to develop problems early in life, or well into adulthood. This is called primary lymphedema. Lymphedema can also occur as a result of damage to the lymph nodes or lymph vessels: this can be from trauma, infection, a tropical parasite (Lymphatic Filariasis: not a significant concern in Hong Kong), or, the most common cause in the developed world, surgery and/or radiation for cancer treatment. This is called secondary lymphedema. Regardless of the cause, the treatment will be the same.

Leg veins damaged by age, injury, or blood clots can cause a back up of blood and fluid in the small vessels of the body and progress to the lymphatic system. The early stages of this condition, when the swelling stays soft to the touch and may go away when you put your feet up, is called venous insufficiency. When this problem persists for so long that the skin and tissues become hardened it is called phlebolymphedema. Ankle swelling during pregnancy is often related to a mild case of venous insufficiency because of the pressure the baby puts on the veins in the hips. Venous insufficiency is usually easier to treat than lymphedema and responds more quickly to complete decongestive therapy treatment or a modification of the technique.

Swelling can also be caused by serious medical conditions such as liver or kidney disease, heart failure, malnutrition, or cancer. Therefore any new or sudden swelling should be discussed with your doctor and any health conditions you have must be discussed with the therapist evaluating your swelling.

Depending on its cause, lymphedema can affect any part of the body. It is found in arms, legs, face and neck, breast and torso, and the genitals. Although some areas of the body are more challenging to treat than others, lymphedema is treatable wherever it is found.

In the case of known damage to lymph nodes, such as cancer treatment, the area of the body at risk of developing lymphedema is known, because each set of lymph nodes serves a specific region of the body. Damage to the armpit lymph nodes puts the arm, chest, and back on that side at risk. Damage to the groin and abdomen nodes puts the leg, lower body, and genitals at risk. Damage to the neck nodes puts the head and neck at risk.

Complete decongestive therapy is, by an overwhelming consensus of international lymphedema specialists, the standard of care for the treatment of lymphedema.

CDT was developed by a husband and wife team of medical doctors Professor Michael Foeldi and Professor Etelka Foeldi in the 1970’s and 80’s. The technique has been refined over the years and remains the international standard of care for lymphedema. It is a synthesis of several treatment methods, including Dr Emil Vodder’s manual lymphatic drainage (MLD) technique.

CDT has 4 components:
Manual Lymphatic Drainage (MLD): A light massage-like skin stretching technique that stimulates the lymphatic system.
Compression: Well-padded layered bandaging or specially fitted medical garments that support the swollen area to control swelling.
Exercises: While wearing your compression, special exercises use your own muscles to help pump lymph out of the swollen area.
Skin Care: Keeping the skin clean and moisturized will help to prevent skin damage and infections that can happen with lymphedema.

There are two phases of CDT treatment.
Phase one is the active phase. This is when you come into the clinic for treatment. Phase one generally lasts for 3 to 5 weeks depending on the amount of swelling and tissue firmness. Therapy sessions last for about one hour, 3 to 5 days per week. Exercise, MLD, and self-care education are performed with each session ending with the affected arm or leg being bandaged. Well-padded compression bandages are worn 23 hours per day in order to rapidly reduce the swelling and break up the hardness in the tissues. Phase one ends when you have obtained your compression garment and have learned to perform your self-care activities.

Phase two is the maintenance phase. This is what you continue to do on your own, having been taught how to manage your lymphedema in phase one. In order to prevent the swelling from returning to the area, regular self-care is needed. Compression garments that fit like a second skin are worn during the day and well-padded compression bandages are generally worn at night. Exercises are done while wearing compression. Self-MLD can be done for 10-20 minutes 1 or more days per week.

CDT for lymphedema of the head, neck, or body is performed somewhat differently due to the inability to apply the same sort of bandaging. Learning to perform self-MLD, or having a loved one learn how to help you with MLD, is extremely important in managing lymphedema in the head and neck.

Treatment plans are individualized. In mild cases the full CDT protocol may not be required. If you are unable to commit to the full recommended treatment, your therapist will work with you to find the most effective alternative that you are able to work into your lifestyle, however, be aware that the further your treatment deviates from CDT, the less effective it may be. Just as a diabetic needs to take insulin every day, so do people with lymphedema need to make some changes to their daily routine to control their condition.

International organizations of lymphedema advocates and specialists recommend that lymphedema be evaluated and treated only by those therapists and nurses who have completed a minimum amount of training to obtain the designation of a certified lymphedema therapist (CLT), although this credential is not recognized by the Hong Kong Physiotherapist’s Board.

Anyone with long-term swelling that is not happening due to a known medical condition such as heart, kidney, or liver disease may benefit from an evaluation by a lymphedema therapist.

Because lymphedema can be best managed when it is detected early, anyone who is at risk for lymphedema due to radiation or surgery can benefit from having a thorough evaluation by a health care practitioner who is skilled and experienced in treating lymphedema. Your therapist will examine you and keep records of the size and tissue firmness of your arm or leg. By having these records available to compare against, your therapist will be better able to detect the subtle changes of early lymphedema should something change in the future.

All radiation and surgical treatment which affects lymph nodes leave the body at risk for developing lymphedema. This is even true of the minimally invasive “sentinel node biopsy”, although this surgical technique will greatly reduce the risk. Unfortunately, there is no way to know who will develop lymphedema and who will not. We do know that your risk for developing lymphedema increases with the greater the number of lymph nodes removed, receiving radiation therapy, being overweight, having active cancer, or having an infection or injury to the at-risk body part. Although there is no 100% effective way to avoid lymphedema, there are things you can do to lower your risk. A few of these include maintaining a health body weight and avoiding injury to your at-risk limb by: wearing insect repellent and sunscreen; not letting anyone take your blood pressure or give you an injection on that side; lifting heavy bags with your other arm. Anyone who has had lymph node surgery or radiation treatment needs to be educated on lymphedema risk reduction by an appropriately trained health care professional. Below are links to more complete information on risk reduction from the Hong Kong Cancer Fund and the (USA) National Lymphedema Network.

http://www.cancer-fund.org/upload/booklets/file/Understanding%20Series/un_12lymphoedema.pdf
http://lymphnet.org/pdfDocs/nlnriskreduction.pdf

In addition to lymphedema risk, cancer survivors potentially face unique physical problems from surgical scarring and radiation aftereffects. These can lead to pain or mobility problems, especially in the shoulders and rib cage. Physiotherapy can often help with these problems. Physiotherapy can also help with lasting fatigue that can persist for many months after cancer treatment.

There is a consensus of expert opinion amongst lymphedema specialist doctors, nurses, and therapists worldwide that every person diagnosed with lymphedema should wear a compression garment when active during the day, and many will benefit from another form of compression at night. This is not “alternative medicine”. This is not “one option among many equally effective options”. This is the expert medical recommendation based upon the best available scientific evidence. I wish that this was not true. I wish that there was a pill or an operation or an exercise or a machine that would treat lymphedema by itself. But, there are no easy answers to the problems caused by lymphedema.

If you had a broken arm you would need to wear a cast. If you had appendicitis you would need to have surgery. If you had severe diabetes you would need to inject insulin. You may not want to do these things, but you would need to do these things for the sake of your health.  If you have mild lymphedema you need to wear a compression garment. If you have uncontrolled lymphedema you need to wear a bandage for a few weeks and a compression garment afterwards.

In brief: lymphedema is a 24-hour a day problem, it needs a 24-hour a day solution. The body is constantly producing lymph fluid as the blood circulates. Only by offering the counteracting force of a compression garment can we prevent the fluid from building up. Treating lymphedema without a compression garment is like bailing out a sinking boat without plugging the hole in the bottom.

Specific questions about medication and surgery should be addressed to your doctor. A physiotherapist is not trained nor qualified to make recommendations regarding medication and surgery.

Diuretics, or “water pills”, may have a temporary effect but they have not been shown to reduce lymphedema in the long run.

Exercise and Manual Lymphatic Drainage (MLD) are important parts of lymphedema management, and are part of the Complete Decongestive Therapy (CDT) practiced at CLTVR, but they have only been shown to be effective when used along with compression garments or bandaging. MLD without compression offers nothing more than a temporary reduction of lymph fluid. It does nothing by itself to stop the further accumulation of fluid and so does not address the long term problems of lymphedema. Exercise without compression may actually worsen lymphedema by causing increased blood flow and inflammation of muscle tissue.

There is controversy over the effectiveness of Intermittent Compression Pumps. At CLTVR we do not advocate the use of pumps. Some studies show that they are helpful, other studies show that they can actually be harmful. The few studies that have shown pumps helping to decrease edema in the long run have been studies comparing people using a pump and a compression garment against people only using a compression garment. Either way, the garment remains the most important element in the treatment program.

There are a small number of surgeons around the world who are performing operations that seem to help people with lymphedema. These are being done by highly specialized surgeons with specific training in operating on people with lymphedema. This is still a relatively new field and at this point in time it is still being determined for whom and under what circumstances these surgeries should be recommended. CDT remains the standard of care for lymphedema. Those patients who have these surgeries are typically required to undergo CDT, including wearing compression garments, before and for at least some months after the surgeries, including those who continue to need their garments every day even after surgery. People interested in surgical options are advised to discuss this with their doctor.