The word lympha derives from Latin and it means clear water. It is a liquid that is slightly yellow and its speed is five or six times slower than blood, which is why the movement is slow and rhythmic when a manual lymphatic drainage is performed …
LYMPHEDEMA TREATMENT BY MEANS OF COMPLEX DISCONGESTANT PHYSICAL THERAPY (DCPT)
WHAT IS LYMPHATIC SYSTEM?
The circulatory system consists of three subsystems or trees: arterial, venous and lymphatic. The arterial has the function to distribute the oxygenated blood which reaches the lungs to the left chambers of the heart throughout the whole body to deliver nutrients to our cells and oxygen. The venous system collects the blood, the CO2 that the cells eliminate after exchanging it for oxygen and other cellular waste materials to then return it to the heart and lungs and finally the lymph system which is also responsible for carrying out the functions of collecting substances that have to be returned to the bloodstream but cannot be transported through the veins, usually high molecular weight proteins, help transport fats from the digestive tract, perform a filtering function of some body fluids and produce antibodies.
The liquids flowing through the lymphatic system are called lymph and chyle, the first one possesses a crystalline colour and the second is milky and it is only found in the intestinal lymphatic ducts. These liquids are very similar to blood but without red blood cells and rich in high density proteins (macro-proteins) that cannot circulate through the veins and in lymphocytes (cells actively involved in defense and immune processes of our body).
The lymphatic system forms an extensive network throughout the body except in the placenta, where it does not exist. It carries the lymph through its own ducts draining it in the subclavian vein where it mixes with venous blood to finally reach the heart and repeat the general circulation cycle again.
WHAT IS COMPOSED BY LYMPHATIC SYSTEM?
The lymphatics is originated in the conjunctive tissue forming lymphatic capillaries ending at bottom pouch, at this level they form a dense network and its size is somewhat larger than that of arterial and venous capillaries. From this network collector stems or lymphatic vessels arise: when they do not have valves they are cylindrical (sub-dermal are more frequent) and if they have valves they are as filaments (most often sub-aponeurotic). In any case they are usually attached to the wall of the adjacent veins. The direction of lymph within the lymphatic vessels is regulated by the valves and when normal they go in a centripetal direction.
On its route the lymphatic vessels can lead to nodes that gather the different lymphatic groups into new major collectors that disembogue into two main channels: the grand lymphatic vein and the thoracic duct, which both drain into the large subclavian veins.
It is important to point that the lymphatic vessels have a contractile muscle layer that is capable of propelling the lymph and some valves that prevent the lymph to retreat under physiological conditions.
In this network of structures that constitutes our lymphatic system each one has its own role for its proper functioning:
- First we have the lymphatic capillaries that are in charge of absorbing and taking the lympha from the different tissues of the body.
- From these the lymph passes on to vessels called pre-collectors and lymphatic collectors, being these responsible for transporting the lymph to the lymphatic nodes.
- The lymphatic nodes are a very important part of the lymphatic system, basically because of two outstanding functions:
In the first place for its function of filtering the lymph, depurating waste and germs, avoiding that these reach the blood. And also for its function in defense of the body by creating white blood cells preventing attacks to our body
- We also have the lymphatic stems, which are larger vessels that receive the lymph from extensive regions of the body and they cluster to take it to the thoracic ducts.
- The thoracic ducts, which receive the lymph from these lymphatic stems, lead them to an area called terminus.
- Terminus is the drainage of the lymphatic system into the blood stream, for it is here where the content of this system is returned to the blood. This area is situated the base of the neck together with the subclavian vein and the internal jugular.
The lymphatic system is composed of a series of lymphatic organs such as:
- Thymus: it is responsible for the maturation at immune level and the creation of T lymphocytes.
- The bone marrow: it is responsible for the formation of blood cells.
- The spleen: it acts as a blood reservoir and helps get rid of red blood cells or other worn cells, apart from the formation of white blood cells.- Tonsils: defensive function, found at the entrance of the respiratory and digestive tracts.
WHAT IS THE LYMPH?
The word lympha derives from Latin and it means clear water. It is a liquid that is slightly yellow and its speed is five or six times slower than blood, which is why the movement is slow and rhythmic when a manual lymphatic drainage is performed.
Its composition is basically water in a 90% apart from:
- Proteins: which result from the non-usage by the cells of the body, and are returned by the lymphatic system into the bloodstream to make use of them.
- Fat: product of its absorption in the intestine basically.
- Cellular debris, bacteria and other particles in the interstitial space.
WHAT IS LYMPHADEMA?
Lymphedema is the accumulation of lymph (high density protein-rich fluid) in the interstitial spaces, especially in the subcutaneous tissue as a result of a failure in the lymphatic system and produces a volume increase of limbs or part of them, gradually erasing the reliefs that can be seen under the skin.
A primary lymphedema can occur when the duct system and / or lymph nodes of a zone is unable to transport large proteins and other molecules to be absorbed again by the venous system, or secondary to surgery and / radiation therapy that has required the excision / radiation of lymph nodes and, therefore, the lymphatic system cannot drain or function normally.
Primary lymphedema can be divided into four groups depending on the distribution, location and appearance of the lymphatics of the limb:
TYPE I. Initial nodes are not seen but there are big collectors although in pathological forms (common in congenital lymphedema).
TYPE II. Initial lymphatic hyperplasia and hypoplasia networks of collectors (they typically treated as mild lymphedemas).
TYPE III. Initial and collecting lymph nodes enlarged and very numerous (they are usually clinically very showy and they are often similar to those secondary to surgery and radiotherapy).
TYPE IV. There are no lymph nodes found.
HOW IS LYMPHADEMA DEVELOPED?
There is great variability in the presentation of lymphedema. In the primary lymphedemas, usually related to a congenital anatomic alteration of the ducts and lymph nodes, the presentation can be from birth or childhood or, in a second most frequent group, it can occur after age 35, after a simple sprain or minor trauma in the extremity and usually begins as an edema on tarsus and ankle. In the case of secondary lymphedema they are related to the presence of tumors involving lymph node chains (prostate, ovary, breast ...) or with surgical removal or radiotherapy of these tumors and peripheral areas. Its appearing can be immediate or occur many years after treatment and without apparent precipitating cause.
HOW TO DIAGNOSE LYMPHADEMA ?
There are different imaging tests to diagnose lymphedema (CT, MRI, Lymphography) but the test that provides more information is the ISOTOPIC LYMPHOGRAFY: The are images scans called scintigraphs of the lymphatic system.
Nuclear medicine is a subspecialty of the field of medical imaging that uses very small amounts of radioactive material to diagnose or treat a variety of diseases including many cancers, heart disease and certain other abnormalities within the body.
The procedures for nuclear medicine imaging or radionuclide are noninvasive and usually painless medical tests that help doctors diagnose health problems.
These imaging scans use radioactive materials called radiopharmaceuticals. Depending on the type of nuclear medicine exam you are undergoing, the radiopharmaceutical can be injected into a vein, taken orally or inhaled as a gas and eventually accumulates in the organ or body area being examined, where it emits energy in the form of gamma rays. This energy is detected by a device called a gamma camera, scanner and / or probe for PET (positron emission tomography) and / or probe. These devices work together with a computer to measure the amount of radiopharmaceutical absorbed by the body and to produce special pictures offering details on both the structure and function of organs and tissues.
Lymphoscintigraphy is useful to:
• identify the sentinel lymph node or the first lymph node to receive lymphatic drainage from a tumor.
• plan a biopsy or surgery that will help assess the stage of cancer and create a treatment plan.
• identify points of blockage in the lymphatic system, such as lymph flow in an arm or leg, or lymphedema.
The diagnostic nuclear medicine imaging is usually performed as an outpatient.
The radiopharmaceutical is injected just under the skin, or sometimes deeper, using a tiny needle. Immediately after injection, the gamma camera will take a series of images of the body area being studied. When it comes time to start imaging, the gamma camera will take a series of images. The camera may rotate around you or stay in one position and will ask you to change positions between images. While the camera captures images, you must remain still for brief periods of time. In some cases the camera can move very close to the body. This is necessary to obtain better images. If you suffer from claustrophobia, you must inform the technician before starting the test.
The type of examination carried out will determine the location of the injection and the number of scans performed.
This nuclear medicine test has essentially replaced the more complex procedures previously used to assess the lymphatic system, as well as to determine the spread of cancer to lymph nodes (lymphangiography).
What treatments exist to combat lymphedema?
The most effective treatment of lymphedema is what is known as Complex Decongestive Physical Therapy, which is a set of techniques in order to eliminate the edema and attempt to normalize the function of the lymphatic system generating conduits "neo-lymphatics”. This therapy comprises mainly to the:
- Manual lymphatic drainage (MLD): To decrease the volume of the member, and encourage the creation of alternative drainage pathways).
- Skin Care: To prevent infections that may exacerbate lymphedema because the edematous tissue has fewer defenses.
- Kinesiotherapy: Exercises that improve lymphatic circulation.
- Compression bandages: To maintain the effect of manual lymphatic drainage and assist in the reabsorption of the edema. The pressure bandages are sometimes substituted for containment sleeves.
- Neuromuscular taping or Kinesiotape: is the latest contribution in treating lymphedema and will be discussed it below.
The manual lymphatic drainage (MLD) is the manual activation of interstitial fluid transport through the pre-lymphatics channels of the lymph through lymphatic vessels. In short, we are manually performing the movements that the lymphatic system cannot do for itself in case of illness to eliminate edema and develop new potential lymphatic channels in a given area or limb.
Basically it is a superficial massage, very gentle and slow that "generally" begins far from the diseased area and gradually approaches it allowing the tissue to be "ready" to evacuate the distal edema to them, especially accumulated in the skin and under it (subcutaneous cellular tissue located between the skin and muscle layer).
It has a variety of physiological and therapeutic effects. The most prominent are:
Draining effect: it causes the output of the interstitial fluid spaces (space between the various cells of a tissue) led by their natural vessels or divert to other functional areas, creating new anastomoses (connections between different vessels) or by opening existing routes.
Neurovegetative effect: it produces at the vegetative or autonomic nervous system sedative and relaxing effect by action on the parasympathetic system.
Effects on musculature: on both smooth and striated muscle. It acts on the musculature of the intestinal wall, inducing peristalsis and therefore is useful in the treatment of constipation. It also tones the walls of the arteries and enhances the movement of lymphatic vessels. About striated muscle: regulatory action exerted of the muscle tone.
Immune Effects: Powers the immune system by indirect action, since it drains the tissue better; it ensures a better flow of these defensive cells to all tissues.
The lymphedema is the main indication of the DLM, either alone or generally associated with other treatments. When the lymph cannot move on, either primary or secondary causes, they try to advance alongside trips, with the MLD we act physically drifting them towards neighboring quadrants which have previously been prepared so that the lymph drains normally through interconnecting lymphatic vessels.
There are also many other therapeutic uses of DLM in all types of edemas, pregnancy, joint or ligament injury, constipation, ... etc.
The DLM, despite being non-invasive therapy and noninvasive, is not free of contraindications:
Severe infections (due to the risk of spreading the infection). In erysipelas and lymphangitis, physical therapy is contraindicated.
Lymphocele and lymphorrhea. These lymphatic leakages are a contraindication of DLM in the affected limb, however, in some chronic cases it may be associated with an adaptation of the DLM technique to compression.
Thrombosis, phlebitis (fearing of worsening of the inflammation or cause an embole).
Cardiac descompensation (fearing of overloading the heart and produce a pulmonary edema).
Tortuous varices and with relief.
Asthma attacks, tuberculosis: the DLM can induce a vagotonic state that can trigger an asthma attack.
Treated Cancers. Skin precancer, nevus. Chronic inflammations. Hyperthyroidism. Bronchial asthma. Hypotension. Carotid sinus syndrome. Chronic renal failure (for severe loss of proteins). Mycoses, the risk of contamination from one patient to another (nosocomial risk).
The skin care is also essential in the treatment of lymphedema. On these patients they are especially dangerous the occurrence of local infections as they tend to affect and injure the lymphatic ducts and worsen the existing ones, therefore, the lymphedema. The affected limb/s should be monitored daily for small skin (agnails, ingrown toenails, cuts, folliculitis, athlete's foot, etc.) that can be gateway for infection. In these cases antibiotics should be taken immediately. A chronic edema produces dry skin, eczematous injuries, pruritus (itching) and scratching injuries. In the case of lymphedema it is important a proper and abundant daily hydration of the limb to prevent such complications.
Kinesiotherapy is the use of exercises that have proven useful for lymphedema. Exercises designed specifically for lymphedema demand three levels of proceedings: 1 .- the first exercises serves to empty ganglionic strings adjacent to major collectors, 2 .- the second step are exercises that improve muscle pump working and lymphatic promote drainage through interstitial tissue, 3 .- The last group of exercises helps mobilize joints and swollen areas and strengthens the limb.
Overall, maintenance exercises to control overweight are needed but are specifically Tai Chi type exercises, swimming or aqua-gym are used to improve lymphedema, however aerobic exercises like or trampoline can be harmful. The jets of cold water may also be beneficial to improve lymphedema.
The compressive elastic supports are an essential part of treatment and control of lymphedema. We must differentiate between compressive bandages and elastic stockings. In either case both tissues used should be the thinnest that the compression requiring allows. They must not produce ridges leading to bottlenecks in the areas of skin, they should be comfortable and produce a downward compression (higher in leg or forearm and minor on the thigh or arm). The bands are used as they perform manual lymph drainage and must be placed by the physiotherapist after completion of each session and then be worn at other times during the night's rest. Elastic stockings "should" have an extra-strong compression (> 60 mm Hg), and should be used as the standard after completion of manual lymphatic drainage sessions. Initially they are difficult to put on, especially for older patients and should be adjusted periodically to the diameter of the limb. They should be put on in the morning before getting out of bed and take off at the end of the day to replace them with a compressive bandage. The latter is unlikely that a person can put them on by himself correctly so they would need the assistance of another person.
The Kinesiotape is a technique that was first used in Asia in the seventies, especially in Korea and Japan, and it is based on the concept that the movement and muscle activity are essential to maintain or regain health. To facilitate and simulate movements during sleep they developed an elastic tape which aids in muscle function without restricting body movement. The elastic adhesive tape is characterized by a thickness, weight and elasticity similar to human skin; it is water resistant, hypoallergenic and longitudinally elastic. The main effects of the Kinesiotape is the improving of the blood stream and lymphatic circulation, analgesia, improved joint mobility and muscle tone normalization.
The mechanism of action of the Kinesiotape on the lymphedema is generated by producing an elevation of the skin, creating more space in the subcutaneous area, where the initial lymphatic vessels (lymphangions), capillaries and different afferent and efferent receptors. This elevation reduces immediately the pressure by restoring blood circulation and lymphatic evacuation. The patient’s motion causes the Kinesiotape to pump stimulating the lymphatic circulation throughout the day. The Kinesiotape placement depends on the area being treated, but long narrow strips with a slight tension is typically used. It is very important the direction of the placement of the strips to favour the lymphatic return in the right direction. Thus we get an artificial anastomosis.
Besides the effect of the Kinesiotape in the treatment of lymphedema, the enormous effectiveness is highlighted of this bandage over the scars. It helps to eliminate or reduce adhesions and facilitate lymphatic circulation on both sides of the scar. It is also used successfully to assist in the reabsorption of ecchymosis (bruises).
Between the contraindications of the Kinesiotape we can highlight:
- It must not be applied in areas recently irradiated, freshly made surgery or showing fresh wounds.
- It is contraindicated in the existence of thrombosis, since the increase in blood circulation may cause a thrombus to be released.
- Be careful with dermatitis, allergies or skin rashes.
Importantly, the technique of Kinesiotape for the treatment of lymphedema must be performed by a qualified professional, as it is essential to know the human anatomy and physiology and the different ways to apply the bandage depending on what is to be achieved.
There are other treatments that can be used for lymphedema. Amongst drug treatments, the only one that has somewhat shown to be effective is benzpyrene, but has been withdrawn from the market in many countries because it is hepatotoxic in certain subgroups of patients. Diuretics should be avoided because long term use carries side effects that can worsen lymphedema. The acupressure is very popular but only useful if used as a complement of lymphatic drainage. For a while there has been much emphasis on special diets for lymphedema but what has finally found really useful is to prevent overweight, maintaining a balanced food diet and avoid excess consumption of fats and proteins.
GENERAL GUIDELINES FOR CARE IN LYMPHEDEMA
1. Keep the arm or leg elevated above heart level whenever possible. Avoid rapid circular movements of arms and legs to keep blood from accumulating on the outside of the limbs.
2. Cleanse and apply moisturizer to the skin of the arm or leg.
3. Avoid injury and infection in the affected arm or leg:
• use an electric shaver.
• Wear gloves for gardening and cooking, use a thimble for sewing.
• Watch your fingernails, do not cut cuticles.
• cover your feet when you go outside.
• keep your feet dry and clean, wear cotton socks.
• Trim your toenails straight, see a podiatrist as needed to prevent ingrown nails and infections.
Arms or Legs
• get a nice tan gradually; use full protection against the sun.
• clean the wounds of the skin with soap and water, and then use an antibacterial ointment.
• use gauze bandages instead of tape; do not tighten so that it cuts the circulation.
• Consult your doctor in case of rashes and skin irritations.
• Avoid needle punctures of any kind in the affected limb (for example, draw blood samples for analysis).
• avoid the cold and extreme heat, or ice packs and heating pads.
• Avoid exhausting and prolonged work with the affected limb.
4. Avoid putting too much pressure on the arm or leg
• do not cross your legs when sitting.
• Do not wear jewelry or tight clothing or tight bands.
• wear the handbag on the arm that is not affected.
• do not use the measuring blood pressure sleeve on the affected arm.
• do not use elastic bandages or stockings with tight garters.
• do not sit in the same position for more than 30 minutes.
5. Watch for signs of infection: redness, pain, burning, swelling or fever. Call your doctor immediately to any of these signs.
6. Exercise regularly to improve the instructions of your doctor or therapist.
7. Go to the doctor for regular follow-up appointments.
8. Check all areas of your legs and arms daily for any signs of complications:
• Measure the circumference of the arm or leg at regular intervals as per the recommendations of the doctor or therapist.
• Use a measure tape to measure the arm or leg, always in the same two places.
• Tell your doctor if the limb suddenly increases in diameter.
9. The ability to sense touch, temperature or pain in the arm or leg could decrease. Use the unaffected limb to test the temperature of the water for cooking or bathing.
10. Make a pattern of the manual lymphatic drainage therapy at least every 6 months and after the treatment adjustment the elastic to the new diameter of the limb. If you can afford it, make a DLM maintenance session once every 2 weeks.
11. Use daily the extra-strong compression elastic stocking and change it every time you lose elasticity.
12. Use pressure bandages at night.
13. Check the overweight and make a balanced diet avoiding fats and meats.
14. If depilating, it is preferable to perform a permanent hair removal with laser rather than hair removal with wax or regular razor.15. Do not take diuretics without medical supervision.