Lymphoedema is the accumulation of excessive amounts of protein-rich fluid resulting in swelling of one or more regions of the body. This is due to a mechanical failure of the lymphatic system and occurs when the demand for lymphatic drainage exceeds the capacity of the lymphatic circulation. The condition usually affects the limb(s) although it may also involve the trunk, breast, head and neck or genital area. The lymphatic system is a network of vessels and nodes throughout the body that transports fluid (lymph) from the body tissues back to the bloodstream. The functions of the lymphatic system are to maintain the volume and protein concentration of the extracellular fluid in the body and to assist the immune system in destroying pathogens and removing waste products from the tissues.
Lymphoedema most often develops in one arm or leg but may be present in both arms and both legs. It may also occur in the hands of feet, and even in the chest, back, neck, face, abdomen and genitals. Primary Lymphoedema is caused by malformations of the lymphatic system. These malformations are most common in women. They may be present at birth or may develop later, often during puberty or pregnancy. Primary lymphoedema is most common in the legs. Other causes may include a traumatic injury, infection or severe chronic venous insufficiency. Secondary lymphoedema is a result of damage to the lymphatic system. Surgical procedures such as mastectomies, lumpectomies with radiation and/or removal of lymph nodes are the most common causes. Secondary lymphoedema occurs most commonly in the arms, but may also develop in the legs. Other causes may include a traumatic injury, infection, or severe chronic venous insufficiency.
Lymphoedema may develop within the first few months after a procedure, years later, or not at all. The first obvious sign of lymphoedema is swelling characterized by “pitting”. This is recognizable when the skin is depressed for a few seconds and the indentation does not immediately disappear. Other symptoms include a tightness or heaviness in the affected area or changes in the texture of the skin. You may even notice that jewellery and clothing feel tighter. Clients report that the swelling associated with lymphoedema is often aggravated by heat, at the end of the day, with overuse, with sustained positions and prolonged inactivity. They report that gentle exercise, elevation, massage and compression can ease their symptoms.
An accurate diagnosis is essential for appropriate therapy. This is determined from the clinical history and physical examination. Co-morbid and confounding conditions of morbid obesity, lipoedema, cardiac disease, renal disease, metabolic disorders, infection, and venous insufficiency will require thorough medical evaluation. Lymphoedema usually has a gradual onset. However, when lymphoedema has an acute onset appropriate tests to exclude, deep venous thrombosis (DVT), recurrence of cancer and infection may be necessary. Sometimes lymphoscintigraphy will be offered to confirm a clinical diagnosis of Primary Lymphoedema. Whether primary or secondary, lymphoedema develops in stages, from mild to severe. Methods of staging are numerous and inconsistent. They ranged from three to as many as eight stages. In Australasia, the most commonly used stage scale is that adopted by The International Society of Lymphology (ISL) (3), which identifies the following stages:
A latent or subclinical state where swelling is not evident despite impaired lymph transport.
This represents the early onset of the condition where there is an accumulation of tissue fluid with higher protein content, which subsides with limb elevation. The oedema may be pitting at this stage.
Limb elevation alone rarely reduces swelling and pitting is manifest. In later Stage II the limb may or may not pit as fat and fibrosis supervene. Stage III The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening, hyperpigmentation, increased skin folds, fat deposits and warty overgrowth develop. Stage III encompasses lymphostatic elephantiasis. At this stage, the swelling is spontaneously irreversible and usually, the limb(s) is very large. Here at Bn2 Health we use a Bio Impedance Analyser, called the L-Dex XCA. It is designed to assist in the clinical assessment of unilateral lymphoedema of the arm. The L-Dex technology is specific for extracellular fluid and as fluid accumulates, the L-Dex value increases on the scale. The L-Dex number provides an instant tool for aiding in the clinical assessment of unilateral lymphoedema of the arm as well as an easy way for clinicians to track the extracellular fluid change in the patient’s arm over time.