Lymphedema

What is Lymphedema?

Lymphedema is a common but often misunderstood condition that affects the quality of life of many cancer survivors. It is caused when protein-rich lymphatic fluid accumulates in tissues, engorging and enlarging vessels and often causing visible swelling, tenderness, and often pain. Left untreated, the affected tissues may continue to swell, and can become hardened or fibrotic and susceptible to infection.

While primary lymphedema is congenital and may occur at birth, the teenage years (praecox) or in mid life (tarda), secondary lymphedema may arise after an insult to the skin such as surgery or radiation or if the lympnodes have been compromised or removed. The risk is present especially after breast cancer treatment when the nodes in the armpit may have been removed or the lymphatics of the breast tissue have been disrupted by surgery or radiation. These patients are at risk for not just arm lymphedema but also lymphedema of the chest wall and or remaining breast tissue. 

DocHealer, CC BY-SA 4.0 , via Wikimedia Commons

Awareness of lymphedema is low considering the number of women who suffer from it. Currently,  over 3.8 million women with a history of breast cancer in the United States alone.  According to estimates of lymphedema incidence in breast cancer patients, this would mean that about half a million women in the US suffer from various stages of the condition. In addition, many others may be at risk and not know it, because lymphedema can arise at any time after breast cancer diagnostic procedures or treatments — even decades later.

Lymphedema Causes and Concerns

The lymphatic system is a complex network of lymph nodes and vessels that carry and remove lymph fluids throughout the body. Lymph nodes filter bacteria and foreign matter from the bloodstream, which is why they are sometimes called the "garbage collectors" of the body. When lymph nodes are damaged, however, as they frequently are during breast cancer treatment, they lose their ability to perform their usual function.

After the lymphatic system is compromised, the excess of stagnant, protein-rich lymph fluid in affected body tissues engorges lymph nodes and vessels in the skin creating pressure and decreased micro-circulation.This condition may impede wound healing and provides an excellent breeding ground for infection-causing bacteria.

The lymphatic system has the ability to manage up to ten times the amount of lymph fluid that it normally processes. This means that by the time swelling occurs, the system is already extremely challenged.

Lymphedema Signs and Stages

Symptoms of lymphedema include swelling, heaviness, pain, pitting of the skin, and tightness or hardness of the tissues. The skin of the affected part of the body may also feel hotter or drier and there may be reduced mobility.

Depending on the severity of symptoms, lymphedema is classified into three stages. In stage one (mild lymphedema), tissue is in a "pitting" stage, meaning that when pressed by a finger the area will indent and hold the indentation briefly. In stage two, moderate lymphedema, the tissue becomes "non-pitting," meaning that it has become spongy and bounces back without leaving an indentation. With severe lymphedema, stage three, the tissue becomes hard and is unresponsive to touch. The swelling at this point can be great and it does not reverse itself.

Lymphedema Treatment Options

Unfortunately, there are no "quick" cures and limited types of treatments for lymphedema. Patients can find relief, however, from properly trained therapists who move accumulated fluid out of the affected area. This process is called Complete Decongestive Therapy (CDT). For years, CDT has been known throughout Europe and Australia as the most effective long-term treatment for primary and secondary lymphedema, and it is now becoming more prevalent in the United States as well.

The individual elements of CDT are Manual Lymph Drainage (MLD), compression bandaging, remedial exercise, and skin care. MLD is a form of massage that stimulates the lymphanogions to increase their activity, resulting in decompression and emptying of lymphatic channels. Limb volume reduction usually occurs in 4-14 treatments over 2-4 weeks, depending on the severity of edema and fibrosis. Treatment time is spent opening collateral lymphatic channels, softening fibrotic tissue, mobilizing lymphatic fluid, and applying compression bandaging. During treatment sessions, the patient is also taught self-massage and trunk clearance, proper skin care, appropriate exercise routines, and self-bandaging and compression garment use.

To help sustain the reduction in swelling and discomfort obtained through concentrated treatment, medical grade compression garments are usually required. In most cases, if the garments are not worn as directed, the lymphedema returns, and patients are at increased risk of infection and cellulitis. In other words, medical-grade compression, along with massage and exercise, is often essential to maintain post-therapeutic results and general patient health.

Well-made Compression Sleeves and stockings are widely available for controlling swelling in the arms and legs, the most common sites for lymphedema. Lymphedema also frequently occurs in the chest wall and in soft breast tissue. These patients also need compression to control their lymphedema.  Conventional bras do not address lymphedema, and are often very uncomfortable (and may even exacerbate pain) for those suffering from the condition. Women complain about the under-wires and about the thin elastic straps and bands "digging in" at the shoulders, the rib cage, and especially under the breast and armpit, often a sensitive post surgical area. Athletic bras, while offering some degree of compression, are also cut incorrectly for the lymphedema patient. The construction tends to be bulky, the garment lacks appropriate adjustability, and it is difficult to get on and off. Thus, like conventional bras, athletic bras can actually increase discomfort in areas where lymphatic fluid collects. For some women, the pain can be so unbearable that it severely restricts their daily activities.  A better option is Compression and Lymphedema Garments and Compression Bras specifically designed to address these issues.

Additional Treatment Aids

There are several treatment aids on the market that can complement Compression Bras, Lymphedema Sleeves, Guantlets, socks and stockings to enhance their therapeutic effect. One of these is Kinesiotape. Kinesiotape is applied directly to the skin by a therapist. It “tents” the skin, thus dilating the superficial lymphatic vessels so that lymphatic fluid can move more freely. The result is that fluid is directed out of congested areas.

Another useful supplement to compression garments are “chip pads”, which are textured pads that are worn inside the bra. The pad provides additional compression, and the texture stimulates the skin and encourages lymphatic fluid to move.

Crescent-shaped chip pads (dubbed “blue bananas” by therapists) can also be tucked into the armpits to provide additional compression and lymphatic stimulation.