Lymphoedema

The lymphatic system is part of both the circulatory and immune systems. It consists of:

• Lymph vessels – a large network of thin tubes found throughout the body that carry lymph fluid from our tissues, organs and structures to the lymph nodes.
• Lymph fluid – this normally clear fluid travels to and from the tissues in the body, carrying nutrients and taking away bacteria, viruses, abnormal cells and cell debris.
• Lymph nodes (glands) – small, bean-shaped structures found along the lymph vessels. Lymph nodes are located throughout the body, including in the neck, underarms, chest, abdomen and groin. The lymph nodes filter lymph fluid as it passes through the body, before emptying most of the fluid into the bloodstream.
• Other lymph tissue – found in other parts of the body including the spleen, bone marrow, thymus, tonsils and digestive tract.

The lymph fluid, lymph nodes and lymph tissue contain white blood cells called lymphocytes, which help protect the body against disease and infection.

If left untreated, lymphoedema can progress and cause a range of problems including:

• trouble moving around and doing your usual activities
• discomfort and sometimes pain
• difficulty fitting into clothes or shoes
• an increased risk of infections and of small infections becoming more serious
• further hardening of the skin and other structures (fibrotic changes)
• lymph fluid leaking from the skin (known as lymphorrhea)
• very rarely, the development of lymphangiosarcoma, a soft tissue cancer.

• Don’t try to protect the affected limb by limiting its movement – moving the limb normally will keep the lymph fluid flowing.
• Avoid repeated heavy lifting, such as moving heavy boxes or furniture, as it may worsen your symptoms.
• Avoid pressure in the wrong place, such as a tight bra strap or underwear with tight elastic.
• Research shows that it is not necessary to wear a compression sleeve during airplane travel if you don’t have lymphoedema. 

• Keep your skin clean. Wash with a pH-neutral soap and avoid scented products.
• Moisturise your skin every day. Dry and irritated skin is more likely to tear and break.
• Protect your skin – wear gloves for gardening, housework, handling pets. Use insect repellent to prevent insect bites. Avoid cutting or burning your skin when cooking. Wear protective clothing, a broad-brimmed hat, sunglasses and sunscreen when in the sun.
• Seek medical help urgently if you think you may have a skin infection.

• Keep physically active to help the lymph fluid flow.
• Do regular exercise such as swimming, yoga, bike riding, aquarobics, walking or running. Gardening and housework also count as exercise.
• It’s okay to do resistance training – increase the weight and intensity gradually. Be guided by how your limb responds, and cool down slowly.
• Start any exercise slowly and build-up gradually.
• Visit an accredited exercise physiologist or physiotherapist to develop an exercise program.

• Aim to stay in a healthy weight range. Being overweight can be a risk factor for developing lymphoedema.
• Eat a variety of nutritious food each day – aim for at least 5 serves of vegetables and 2 serves of fruit, and choose a variety of wholegrain, wholemeal and high-fibre foods, such as bread, pasta, oats, rice, legumes (beans, peas and lentils) and nuts.

For most people, CLT helps control the symptoms of lymphoedema. It includes a treatment phase and a maintenance phase. During the treatment phase, a lymphoedema practitioner provides a combination of regular skin care, exercises, manual lymphatic drainage (MLD), and compression bandaging.

It may take a few days or up to several weeks to reduce the swelling and then you will be fitted with a compression garment. You will also be taught how to take over the management of your lymphoedema. During the maintenance phase, you continue to look after your skin and exercise regularly.

Wearing the compression garments prescribed by your practitioner will help maintain the improvements made in the treatment phase. It is recommended that you see your lymphoedema practitioner every 6–12 months for regular reviews, but this may vary depending on your circumstances.

CLT consists of the following strategies:

• Skin care – it is important to keep your skin in good condition to prevent infection.
• Exercise – regular physical activity such as walking and/or resistance training can reduce the severity and symptoms of lymphoedema by encouraging the lymph fluid to move around the body. It can also help you stay a healthy weight. Flexibility exercises can help maintain your mobility. Resistance exercise can improve your strength plus reduce lymphoedema symptoms.
• Manual lymphatic drainage (MLD) – a specialised type of massage that is performed by a trained lymphoedema practitioner. Mild pressure is applied to the skin around the affected area to move fluid towards lymph nodes that are draining normally.
• Simple lymphatic drainage (SLD) – a simplified form of MLD, which your lymphoedema practitioner may teach you or a carer to do daily.

Compression therapy involves applying graduated pressure to the affected area to reduce and contain swelling, and soften any thickened tissue. Compression for the treatment of lymphoedema needs to be used on an ongoing basis. If stopped, the swelling will usually return. 

There are different ways to apply compression. Bandages and wraps are used to stimulate the lymph fluid, remove the fluid and reduce swelling:

• applied by a trained lymphoedema practitioner
• uses inelastic (short-stretch) bandages or wraps
• changed regularly as the swelling reduces
• worn day and night.

Compression garments are used to maintain improvements:

• self-applied (you put them on yourself)
• worn during the day as soon as possible after getting up – you may wear a lighter garment at night
• can be off-the-shelf or custom-made
• may be a stocking (leg), sleeve (arm), glove/gauntlet (hand), bra/singlet/vest (breast or chest), leotard (trunk), bike shorts with padding, or scrotal supports (genitals)
• available in different skin tones, sizes and grades of pressure
• garments must be professionally fitted to ensure the pressure and fit are correct
• handwash garment daily according to the manufacturer’s instructions – this will help it last longer and maintain its compression
• you will need at least two sets – one to wear and one to wash
• replace garment regularly (every 6 months or as required) – you need to remeasure for a new garment if your body weight changes or the size of the affected area changes
• you may need to wear a cotton liner between the compression garment and your skin
• you may need to use it with additional padding material to increase or spread the local pressure
• ask your lymphoedema practitioner whether you should wear a garment during airplane travel.

Compression can also be applied by intermittent pneumatic compression (also called a pump):

• a machine inflates and deflates a plastic garment placed around the affected area to stimulate lymphatic fluid
• recommended you have MLD or SLD before using the pump
• can be used at home but it’s important a trained practitioner shows you how to use the pump and adjust the pressure to your needs
• depending on the type of pump, you either sit or lie down while wearing it
• may be used for people who are unable to wear a compression garment.

Compression therapy is not suitable for everyone with lymphoedema. It can be dangerous for people with a range of conditions, for example, uncontrolled congestive heart failure or uncontrolled high blood pressure. These conditions need to be under control before you start compression therapy. 

This treatment uses low-level laser to target cells in the lymphatic system. This may reduce the volume of lymph fluid in the affected area, any thickening of the skin and pain.

Your lymphoedema practitioner will use a handheld device or a larger scanner to apply infra-red-light beams to the affected area. You will not feel any heat. There is some evidence that laser treatment works well when used with lymphatic drainage and compression therapy. Research is still continuing to find the treatment that works best.

Some early research suggests that a special tape called kinesio tape can help lymph fluid drain from the affected area to working nodes. The tape is different from strapping tape, and your lymphoedema practitioner will tell you whether this could be part of your management plan.

Most people are able to manage lymphoedema with CLT, but surgery may be an option when lymphoedema doesn’t respond to other treatments or you are not satisfied with standard treatment.

To work out whether surgery is right for you, your specialist will consider the extent of the swelling, how often you get infections and your general health. It is becoming common to have surgery before the lymphatic system becomes badly affected and the tissues have changed a lot.

As with all surgery, there are significant risks involved. These include scarring, nerve damage, blood clots, infection, loss of mobility, further damage to the lymphatic system, and continuing lymphoedema. Most people still need to wear a compression garment after surgery.

Examples of surgery for lymphoedema include:

• Liposuction – In some people, the lymphoedema fluid changes into fatty tissue, but CLT doesn’t reduce the fat. Liposuction removes fat from under the skin of the affected area but the limb will look smaller. It should only be an option when CLT cannot reduce the swelling. Liposuction can reduce swelling in the long term and the size of the affected area can be maintained when combined with compression therapy. This treatment is not a cure for lymphoedema – it’s essential to continue wearing a compression garment.
• Lymphatic reconstruction (anastomosis) – This uses microsurgery to repair or create a new pathway for the lymph fluid to drain out of the area. This technique appears to work better for people with early-stage lymphoedema. Further research on the long-term impact on people who have undergone this surgery is needed.
• Tissue transfer – This involves transferring healthy lymph nodes from an unaffected area of the body to the affected limb. Further research is required into whether this technique is effective in the long term.

There is no proven drug treatment for lymphoedema. Although diuretics (water pills) help remove fluid from the body when it’s caused by heart or blood pressure problems, they don’t work well for lymphoedema as lymph fluids are generally protein rich. Once the diuretic is stopped the fluid usually returns to the area affected by lymphoedema.

There is little evidence to support taking naturopathic medicines or supplements such as selenium to help reduce the symptoms of lymphoedema. High doses of selenium can be harmful. Talk to your doctor before taking any supplements or medicines.