Lymphedema manageable, not curable Many people may know someone who has an enlarged or swollen arm or leg, but few have heard of the chronic disorder of lymphedema. Lymphedema is swelling of a limb or other body part due to damage to the lymphatic system. It can occur in arms after breast cancer surgery or in legs after any treatment that alters the flow of lymphatic fluid from the legs. The lymphatic system runs throughout the body. It helps carry lymph from the body tissue back into circulation. Lymph is a clear, thick, syrup-like fluid that moves through the lymph system toward the blood system. In surgery to remove cancer, lymph nodes, which are attached to lymphatic vessels, often are removed. "The lymph node acts as a filter," said Stuart Tipping, M.D., an oncologist at Marshfield Clinic-Marshfield Center. "It helps fight infection and often filters out cancer cells that can then grow in the lymph node." People who are at highest risk for lymphedema are those who have had damage from surgery, radiation, infection or trauma to one of the major lymph node areas. A person also can be born with absent or dysfunctional lymph vessels. Lymphedema can occur in arms, legs, the pelvis, face and breast tissue. Lymphedema may occur immediately after the surgery or event, or as many as 15 years later. That's why patients must be careful when carrying items, wearing jewelry or doing certain activities. Patients should also not allow blood to be drawn, blood pressure checked or IVs started in the affected limb and they should protect themselves from bites, scratches or constriction. Extra precautions also may be needed for air travel. The diameter of the affected limb can vary by a few inches over time. Humid weather generally increases the size. Patients should call their surgeon or primary healthcare provider if they have any changes in their affected limb, such as swelling or infection. The first sign of a problem may be jewelry that feels tighter than normal. And the earlier lymphedema is recognized, the more likely treatment will be successful in controlling it, said Julie Will, an occupational therapist trained in caring for patients with lymphedema. Once the limb swells, it is possible to decrease the amount of fluid through various non-invasive techniques. However, if it is allowed to remain swollen over a longer period, the treatment may take longer, but it can still be beneficial. Untreated lymphedema can lead to skin problems and increased risk of infection. Some patients have been hospitalized for days to treat infections that were not treated early. Patients also can lose their mobility if the affected limb is a leg, and, in some cases, their ability to care for themselves or use their limb effectively. Options for treatment have grown over the past decade. Steps include elevating the affected limb at heart level or above when possible. This lets gravity help drain the lymph system. Exercise, including aerobic exercise and a program of specific movements, helps increase the flow of the fluid. Sometimes a compression garment or wrap can help reduce the size of the limb, and manual massage and lymph node clearing techniques help force the fluid out of the limb. Patients also must reduce their salt intake because salt causes the body to retain fluid. Patients with lymphedema are referred to the Occupational and Physical Therapy Center at Marshfield Clinic-Marshfield Center. Vivian Gamble, like Will, an occupational therapist with certification and additional training in comprehensive lymphedema management, teaches patients how to better manage lymphedema themselves. They give each patient a thorough evaluation prior to beginning therapy. Each therapy session includes clearing the lymph fluid from unaffected lymph vessels near the affected limb. The therapist performs a manual lymphatic therapy a specific massage technique to that drains and moves the lymphatic fluid. It is useful to reroute lymph fluid around damaged or blocked areas. "It's a very specific massage," Will said. "We don't use a lot of pressure because the part of the lymph system we work with is very close to the skin's surface and deep pressure would only block the flow of fluid." After manual lymphatic therapy, a multi-layered low or non-elastic compression wrap is applied to the limb. This is not the same as an ace wrap, which is highly elastic. "The purpose of this wrap is to provide firm external support to the tissue and gives the muscles something to push against, thus promoting lymph pumping even during the slightest muscle motion," Will explained. When no further girth decrease is obtained, a compression garment is ordered. Other components of a therapy program may include exercise (with compression wrap or bandage on), use of a pump to remove lymph fluid from the limb, frequent reassessment of girth measurements, and coordination with Marshfield Clinic's Orthotics and Prosthetics Department to get each patient the proper compression garment. Therapy requires a strong commitment from the patient. "They may come to therapy for an hour or more daily for a few weeks," Gamble said. The frequency of therapy decreases as improvements are made. Self-management techniques such as self-massage, compression wrapping and exercise also are taught. The othotist fits a compression garment once the therapy goals are reached. The garment does not reduce lymphedema, but it does help to maintain the size reduction already attained. For more information on lymphedema or to schedule an appointment, call the Department of Physical and Occupational Therapy at 1-800-782-8581, ext. 7-5529 or 715-387-5529. http://www2.marshfieldclinic.org/CATTAILS/02/JANFEB/LYMPHEDEMA.ASP
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