What is lymphoedema?

Lymphoedema is defined as the excessive accumulation of tissue fluid (or 'lymph') that results from impaired lymphatic drainage and the term 'lymphoedema' should be confined to describing oedema in patients in whom a lymphatic abnormality has been confirmed.
Lymphoedema can affect anyone at any age and can affect any part of the body. Although it is not life-threatening it can be very distressing and can become a major physical and social problem. There is no cure at present, but with appropriate treatment and the patients co-operation it can be kept under control.

What are lymphatic vessels?

These are tiny vessels, which, under normal circumstances, remove the tissue fluid that is constantly leaking out of the other small blood vessels, and return it back into the circulation. Lymph is collected from the arms, legs, trunk and body cavities by a complex network of lymphatics and is returned back into the circulation via a larger lymphatic (the thoracic duct) in the base of the neck.

What areas of the body can be affected by lymphoedema?

Lymphoedema principally involves the legs (80%), although the arms, genitalia and face can also be affected.

How common is lymphoedema?

It is difficult to be sure of the precise incidence of this condition but it is thought to affect about 500 million people worldwide and about 2% of the population in the United Kingdom.

Causes of Lymphoedema

What causes lymphoedema?

In most cases the cause of lymphoedema is damage to the lymphatic vessels which can follow surgical procedures, radiotherapy or other conditions such as certain infections. This type of lymphoedema is termed 'secondary' lymphoedema.
In some cases there is no obvious cause and the lymphoedema has developed because of a developmental abnormality of the lymphatic vessels. Sometimes the swelling is present at birth but in many cases the swelling does not develop until later life. This form of lymphoedema is known as 'primary' lymphoedema. A number of genetic causes for primary lymphoedema have now been identified.

What kind of lymphatic abnormalities can cause lymphoedema?

A number of different types of abnormality of the lymphatic vessels can cause lymphoedema.
First of all, the lymphatic channels may be absent (aplasia). Sometimes the lymphatics are few in number (hypoplasia). There may be an excessive number of abnormally functioning lymphatics (numerical hyperplasia) or there may be dilated vessels (megalymphatics) which are often associated with lymphatic fluid collections or leaks such as chylothorax (lymph in the chest), chylous ascites (lymph collection in the abdomen). Rarely, the lymph can actually leak out of vesicles or 'blisters' on the skin, mucous membranes or bowel. Finally, the lymphatics may be obstructed secondary to an inflammatory-type process in the lymph nodes draining an area of the body. This causes the lymph flow to be slowed or halted.

Complications of Lymphoedema

What are the other causes of swelling?

Before the diagnosis of lymphoedema is made, the other many causes of swelling (oedema) must be excluded. These include cardiac oedema, low blood protein, kidney oedema, allergic oedema and hereditary angioedema (a particular inherited intermittent swelling). Another important cause of swelling is an abnormality of the veins. In lipodystrophy, there is an abnormality of subcutaneous fat deposition and this is frequently misdiagnosed as lymphoedema. In some cases it is important to make sure that the swelling is not a result of a tumour or mass obstructing the lymphatics. In other cases the swelling occurs when a limb is not being used normally. Occasionally, there is a congenital abnormality of blood vessels, veins or arteries, in the affected limb.

Can lymphoedema come on suddenly?

In most cases the onset of lymphoedema is insidious but the onset can be sudden. Many patients say that they had very mild or no swelling initially but that some trauma, such as a twisted ankle, minor infection or insect bite, precipitated a rapid progression of the lymphoedema.

What are the complications of lymphoedema?

Because the tissue fluid is not being cleared normally, any bacteria which get into the skin or subcutaneous tissues from a minor trauma or scratch are more likely to cause an infection. The infection which results is called cellulitis. It is unfortunate that with each episode of cellulitis lymphatic vessels are damaged further. Avoidance of infections is therefore important.
Very rarely after many years of lymphoedema, a malignant tumour of the lymph vessels can occur.

Treatment and MLD (Manual Lymphatic Drainage)

What can be done about lymphoedema?

There are two forms of treatment, the medical (non-surgical) and surgical forms. Surgery is only indicated with severe cases and even after surgery it is important to continue with the many aspects of medical treatment.

What medical therapies are there?

Manual lymphatic drainage (MLD) is a specialised form of therapy which is gentle and rhythmic. It is a technique which was developed in Europe in the 1930s by Emil Vodder. The method has now been adapted by medical professionals around the world to treat lymphoedema and there are a number of schools of MLD (including Asdonk and Földi in Germany, Casley-Smith in Australia, LeDuc in Belgium and Vodder in Austria). The aim is to encourage protein reabsorption and stimulate lymphatic flow to improve drainage away from congested areas.

How does MLD work?

Manual lymphatic drainage (MLD) is a specialised form of therapy which is designed to improve the functions of the lymphatic system. The specific movements used in MLD treatments allow the superficial lymph vessels to reabsorb excess fluid, metabolic waste, large protein molecules and foreign substances from the tissues.
The lymphatic fluid is then encouraged to empty into the deep lymphatic vessels and filtered through series of lymph nodes along its route before it is returned to the blood circulatory system in the neck area.

Who benefits from MLD?

All patients with lymphoedema or at risk of developing it (for example after breast cancer surgery or after+ radiotherapy to the pelvis) can benefit from MLD.

What kind of treatment protocols are used?

1.Intensive Therapy comprises
a)a course of 10 to 15 MLD treatments over a period of 2 to 3 weeks. b)exercises
c)compression hosiery
This is followed by maintenance therapy.

2.Complex decongestive therapy involves 2 to 4 weeks of
a)Multilayer bandaging
b)pneumatic compression therapy
c)manual lymphatic drainage
This is followed by maintenance therapy.

3.Maintenance therapy comprises
b)manual lymphatic drainage
c)self lymphatic drainage
d)compression hosiery
e)skin and nail care and careful chiropody
f)occasionally prophylactic antibiotics can reduce the number of episodes of cellulitis

What are the benefits of treating lymphoedema?

Apart from the relief or reduction in swelling and therefore improved comfort and quality of life, there is evidence that treatment also reduces the number of infective episodes and cellulitis. In addition, the skin and subcutaneous tissues often feel much softer after MLD.