Lymphedema

lymphedema refers to the type of edema produced by an obstruction in the body's lymphatic channels.

This situation is produced by the accumulation of lymph (composed of a clear liquid rich in lipids and fibroblasts) in the interstitial spaces (the area between the different cells of a tissue), within the subcutaneous cell tissue.

It is generally due to a failure or insufficiency in the lymphatic system, which results in a partial or complete increase in the volume of the extremities and the disappearance of the reliefs that can be seen under the skin. It must be closely monitored in extirpation of the breast (for a breast tumor) and lymphadenectomy.

Causes

An accumulation of lymph at some point in the body causes lymphedema, which in turn can be primary or secondary.

Primary lymphedema

It occurs when the system of ducts and/or lymph nodes in an area have difficulties or are directly unable to transport large proteins and other molecules to be reabsorbed by the venous system.

Secondary lymphedema

It is a consequence of surgery or radiation therapy that required removal or radiation of the lymph nodes, causing a subsequent abnormality in the drainage process.

How Lymphedema Develops

Lymphedemas usually present in a wide variety of forms.

When it comes to primary lymphedemas, which generally are due to some anatomical or congenital alteration of the lymphatic ducts, the presentation can even be from birth or childhood, but more frequently they appear from the age of 35, as consequence of a small trauma or sprain in an extremity. It usually begins as an edema in the tarsus and ankle.

On the other hand, secondary lymphedemas are related to the existence of tumors that affect the lymph node chains (prostate, ovary, breast,...) or with the surgical extirpation or radiotherapy of these tumors and peripheral areas. Its appearance can be immediate, although there are also cases in which it does so many years after treatment and without an apparent triggering reason.

Diagnosis

Although there are different imaging tests that facilitate the diagnosis of lymphedema (such as CT, MRI, lymphography), there is consensus that the test that provides the most information is isotopic lymphography. These are images called lymphatic system scans.

This alternative is found in so-called nuclear medicine, which uses very small amounts of radioactive material to diagnose or treat different diseases, including many types of cancer, heart disease and certain other bodily abnormalities.

These are non-invasive procedures that are generally pain free. Nuclear medicine images have the great advantage of providing precise information for making diagnoses.

Radiopharmaceuticals, which are radioactive materials, are used for imaging. Depending on the type of examination in question, the radiopharmaceutical may be injected into a vein, ingested orally or inhaled as a gas, although generally on an outpatient basis. Finally, this material accumulates in the area of the body that is intended to be examined and from there it emits energy in the form of gamma rays.

The process is complete when this energy is detected by a device called a gamma camera, a scanner and/or PET (positron emission tomography) probe. All these receptors work in tune with a computer that manages to measure the amount of radiopharmaceutical absorbed by the body, and based on this, it generates special images that provide details of both the structure and function of organs and tissues.

A small needle is used to inject the radiopharmaceutical below the skin, or even deeper. Immediately afterwards, the gamma camera will begin to record images of the area of the body that is intended to be monitored. The camera can even make some rotating movements around the patient, or in return, the patient can be asked to change position in front of a fixed camera. The procedure can affect people who suffer from claustrophobia, for which it is necessary to inform it in advance.

With this new technology, it has been possible to replace somewhat more complex procedures that were previously used to evaluate the lymphatic system. But it also makes it possible to determine the spread of cancer to the lymph nodes (lymphangiography).

Utilities of lymphoscintigraphy

• Identify the sentinel lymph node or the first lymph node to receive lymphatic drainage from a tumor.
• Planning a biopsy or surgery that will help evaluate the stage of the cancer and create a treatment plan.
• Identify locking points in the lymph system, such as lymph flow in an arm or leg or lymphedema.

Treatment

Complex decongestant physical therapy is considered the most effective treatment for lymphedema. It is a set of techniques whose purpose is to eliminate edema and then try to normalize the function of the lymphatic system by generating "neolymphatic" ducts. Under this therapy various resources are included that are combined in a single treatment.

• Manual (DLM): It helps decrease the volume of the member, and favors the creation of alternative drainage paths.
• Skin care: They try to keep the skin free from infections that aggravate lymphedema, since the affected tissue has less defenses.
• Cinesiterapia: Physical exercises that improve the circulation of the lymph.
• Compressive bandages: They allow to maintain the effect of manual lymph drainage and favor the reabsorption of edema. Sometimes compressive bandages can be replaced by containment sleeves.
• Neuromuscular bandage or Kinesiotape: It is a novelty in the treatment of lymphedema.

Manual lymphatic drainage (MLD)

This is the manual activation of interstitial fluid transport through prelymphatic channels and lymph through lymphatic vessels. What is sought with the DLM is to manually reproduce those movements that for some reason the lymphatic system can no longer do by itself. This is intended to eliminate edema and develop potential new lymphatic ducts in a given area or limb.

The DLM consists of a superficial, very soft and slow massage. In general, it begins in an area far from the patient, but gradually advances towards her, trying to ensure that the tissues are favored to evacuate the distal edema towards them, especially the accumulated in the skin and under it (the subcutaneous cellular tissue, located between the skin and the muscle layer).

There are many advantages of MLD, both in its physiological and therapeutic effects. These are some:

• Drenant effect: is the one that is caused by the discharge of the fluid from the interstitial spaces, either by driving it through its natural vessels or by diverting it to other functional areas, creating new anastomosis (connections between different vessels) or opening existing pathways.
• Neurovegetative Effect: at the level of the vegetative or autonomous nervous system produces a sedative and relaxing effect, by action on the parasympathetic system.
• Effects on musculature: both on the smooth and striated muscle. It acts on the musculature of the intestinal wall, favoring peristalism so it is very useful in the treatment of constipation. On the other hand, it has tonifying effects on the walls of the arteries and enhances the movement of the lymph vessels. It also exercises a regulatory action of the muscle tone on the striated musculature.
• Immune Effects: this is achieved indirectly, as by draining tissues better ensures an efficient flow of these defensive cells to all tissues.

Skin care

The occurrence of local infections is extremely threatening for patients with lymphedema. This is so because they can affect and injure existing lymphatic ducts and thereby aggravate lymphedema. For this reason, skin care is so necessary, which makes it necessary to monitor daily if there are small skin lesions (hangnails, ingrown toenails, cuts, folliculitis, athlete's foot, etc.) in the affected area, and that could be the door of entry for infections. In such a situation, it is essential to immediately take antibiotics.

In addition, chronic edema causes dry skin, the appearance of eczematous lesions, pruritus (itching) and scratching lesions. For this reason, correct and abundant hydration of the limb on a daily basis is essential to prevent this type of complications.

Kinesitherapy

Part of the treatment against lymphedema involves performing certain physical exercises, specifically designed to act on three levels:

1. First level. They will seek to empty the ganglion chains next to the big collectors.
2. Second level. It includes exercises that seek to improve the work of lymphatic muscle pump and favor drainage through interstitial tissue.
3. Third level. They help mobilize joints and edematized areas. They also strengthen the affected limb.

In general, any physical exercise that promotes weight control will be favorable for those who suffer from lymphedema. The most recommended are swimming or aquagym and Tai Chi. However, exercises such as aerobics or trampoline, which can cause damage, should be avoided. For its part, cold water jets can also be beneficial to improve lymphedema.

Compression bandages

They are a fundamental part of the treatment and control of lymphedema, and are performed either with compression bandages or with elastic stockings, with the general recommendation that the thinnest tissues that the necessary compression allows be used. This is so because areas of strangulation in the skin must be definitely avoided, and also guarantee that the compression is comfortable and decreasing (greater in the leg or forearm and less in the thigh or arm).

The bandages are used while manual lymphatic drainage is performed and must be placed by the physiotherapist after the end of each session and maintained during the night's rest.

Custom-made elastic stockings should have extra-high compression (>60 mmHg). Like bandages, they are used at the conclusion of the DLM session. In general, its placement can be difficult, especially for older patients. They must be placed in the morning, before getting out of bed and removed at the end of the day to replace them with the compression bandage. In general, for the placement of the latter correctly, the assistance of a person is necessary.

Kinesiotape

This is a technique born around the 1970s in Korea and Japan. It is an elastic adhesive tape made with a thickness, weight and elasticity similar to that of human skin. In addition to being hypoallergenic, it is waterproof and elastic lengthwise. It was developed to facilitate movements and simulate them during rest, helping muscle function without limiting body movements.

Based on the concept that muscular activity is essential to regain health, kinesiotape manages to improve blood and lymphatic circulation, but it also has analgesic effects, improves joint mobility and normalizes muscle tone.

The mechanism of action on lymphedema is generated by producing elevation of the skin, creating more space in the subcutaneous zone, where the initial lymphatic vessels (lymphangions), capillaries, and various afferent and efferent receptors are located. Such an elevation immediately lowers the pressure, restoring blood circulation and lymphatic evacuation. But in addition, the movement of the patient causes the kinesiotape to perform a pump that stimulates lymphatic circulation throughout the day.

The placement of the kinesiotape will depend on the area to be treated. However, the common thing is that long, thin strips are used with a slight tension. The direction of placement of the strips is very important to favor lymphatic return in the correct direction, trying to achieve an artificial anastomosis.

As an additional effect, the kinesiotape promotes healing, helps eliminate or reduce adhesions and facilitates lymphatic circulation on both sides of the scar. It is also used successfully to aid in the resorption of bruises. This technique should only be practiced by qualified personnel.

Some contraindications:

• It should not be applied in newly irradiated, newly intervened areas or to present recent injuries.

• It is contraindicated when there is thrombosis, since increased blood circulation can cause a thrombo to be released.

• Beware of dermatitis, allergies or eczema in the skin.

Others

There are other treatments that can be used for lymphedema, including some that are pharmacological.

Although there are many alternatives, so far the only ones that have shown some effectiveness are Benzopyrones, although in certain groups of patients they are hepatotoxic, which is why they have been withdrawn from the market in many countries.

Diuretics should be avoided, since used long-term they produce side effects that can worsen the condition.

Presotherapy is only useful if used as a complement to lymphatic drainage.

Diets are a complement, but only when they try to avoid being overweight, avoiding the consumption of fat and excess protein.

Lymphedema care

1. Keep your arm or leg elevated above the heart level whenever possible. Avoid quick circular movements of arms and legs so that blood is not accumulated on the outside of the limbs.
2. Clean daily and apply moisturizing creams on the skin of the affected sector.
3. It is key to avoid injuries or infections in the affected area.