Lymphedema treatment requires quick recognition
Watch for these symptoms
Lymphedema can develop in any part of the body but is most common in the arms and legs. The symptoms of lymphedema include a full sensation in the affected limb or limbs, skin that feels tight, decreased flexibility in the affected joints, difficulty fitting into clothing in one specific area, and persistent swelling. Acquired lymphedema can appear shortly after surgery but has been known to emerge years after surgery.1The condition is caused by an accumulation of lymphatic fluid that can cause limb swelling. According to experts, it often goes untreated in the United States. Lymphedema is strongly correlated with surgical procedures in which lymph nodes and vessels are removed. The condition is related to wound care because it provides a ripe environment for the development of skin breakdown, infection, and inflammation. For a patient with one or more chronic wounds, lymphedema significantly decreases the level of oxygen perfusion to tissue and may severely delay or even prevent the healing process.
The removal of any portion of the lymph system results in an obstruction of lymphatic fluid from the affected area, explains John Macdonald, MD, director of the Wound Healing and Lymphedema Center in Fort Lauderdale, FL. With no drainage route, the fluid, which is highly viscous, backs up and collects in the interstitial tissue, resulting in the characteristic swelling. But the typical response of a surgeon is that they can’t do anything about it, according to Macdonald. "They tell patients they should just be thankful that they got the cancer out," he says.
If lymphedema strikes
Any patient who notices persistent swelling should be urged to seek immediate medical attention, according to the National Lymphedema Network in San Francisco (NLN). Early diagnosis and treatment improve both the prognosis and the condition. The longer lymphedema goes untreated, the greater the likelihood of infection. And, notes Macdonald, the psychosocial effects of lymphedema can be devastating.
"A woman with arm lymphedema may not be able to button her blouse because of the pain," he says. "A man who gets lymphedema after prostatic surgery may have a tense, tight, swollen leg that he can hardly walk on. Patients undergoing rehabilitation after a knee replacement are set back months because their leg is too swollen to continue therapy."
Left untreated, the lymphedema site can also become infected, leading to recurrent lymphangitis. Factors such as insect bites, burns, and cuts can all contribute to the risk of acquiring lymphangitis, according to Thiadens. The early signs and symptoms of the disease include itching, rash, increased swelling, discoloration, pain and, in many cases, a sudden onset of high fever and chills, she adds.
In the presence of lymphangitis, Thiadens strongly advises the discontinuation of all lymphedema treatment modalities so that appropriate antibiotics can be administered. She also stresses that lymphedema sufferers should always carry antibiotics when they travel.
Treatment options
Several treatments for lymphedema have proved successful, including manual lymphatic drainage, bandaging, proper skin care and diet, compression garments, remedial exercises, and appropriate self-care. The application of these techniques in some combination is referred to as complex decongestive therapy.
"There’s no cure for lymphedema," Macdonald says. "If you don’t treat it, it will persist. Surgical and pharmaceutical treatment of lymphedema is ineffective for all practical purposes. The only treatment is to squeeze the limb down and keep it down with compression. That’s the essence of treatment."
For example, manual lymphatic drainage is a gentle method of massage developed in Europe that focuses on stimulating connective tissue, Thiadens explains. The goal is to create alternate pathways for the lymphatic fluid to drain and ultimately pass into the bloodstream.
Pumps no longer recommended
Until recently, special lymphedema pumps were also commonly used to treat lymphedema. These devices apply pressure to the swollen limb via a sleeve composed of overlapping air compartments that inflate and deflate sequentially. However, pumps have fallen out of favor because clinicians found that, though the devices often produced a rapid reduction in fluid within the swollen area, the fluid often just migrated to another interstitial area and did not drain. "It’s important to first open up the area proximal to the swelling before you begin to literally move the fluid back into the blood stream," says Thiadens. Medicare no longer reimburses for any lymphedema pumps.
Private payer reimbursement for lymphedema care varies greatly by location. In select areas, patients can expect complete coverage for prolonged treatment, while in other locations private carriers may not pay for anything related to lymphedema care.
Medicare has been very selective in what aspects of lymphedema it will pay for. For instance, according to the National Association of Breast Cancer Organi-zations, compression sleeves prescribed by a physician usually are covered by insurance companies but not by Medicare, while physician-prescribed manual lymphatic drainage and bandaging are usually not covered by most carriers, though reimbursement is becoming more available as awareness of the technique’s effectiveness grows.
Two categories
Lymphedema can be categorized as either primary or secondary. Primary lymphedema results from congenital defects in the lymphatic system. People with primary lymphedema characteristically have some degree of lymphatic abnormality. The condition is further subdivided by the age at which symptoms first appear.
While the causes of the various types of primary lymphedema are still unknown, the root causes of secondary, or acquired, lymphedema are associated with a variety of surgical procedures, as explained previously. According to the NLN, more than a quarter of women who undergo surgery for breast cancer experience some degree of arm swelling. The rate is higher for patients who also receive radiation therapy. Saskia Thiadens, RN, president of the NLN and clinical director of the Aurora Lymphedema Clinic, estimates that 60% of all lymphedema cases are acquired.
Other oncologic surgical procedures in which lymph node excision is
commonly practiced include those for uterine, colon, kidney, prostate,
vaginal and vulval cancers, and melanoma of the skin. Lymphedema is also
associated with venous conditions such as phlebitis, Whipple’s disease,
Crohn’s disease and untreated venous insufficiency, a condition often associated
with immobilized patients. Filiarisis, a parasitic disease, transmitted
by mosquitoes accounts for a high incidence of lymphedema in third-world
countries. Occasionally, lymphedema follows a severe trauma.
Reference
1. Brennan MJ, DePompolo RW, Garden FH. Focused review: Postmastectomy
lymphedema. Arch Phys Med Rehabil 1996; 77:S74-S80.
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