Running head: LYMPHEDEMA CAUSES AND TREATMENT 1

Lymphedema: Common Causes and Current Treatment Options

Virginia Johnson, BSN, RN, LMT
Vodder Certified Manual Lymphatic Drainage Therapist
New York Chiropractic College
HAP5130
Spring 2014


Running head: LYMPHEDEMA CAUSES AND TREATMENT 2
Introduction
Lymphedema, if not managed properly, can become a debilitating disease affecting the
patients mobility, self-image, ability to work, and resistance to disease. With regards to post-op
breast cancer patients, by far the most affected population, the incidence of lymphedema is
estimated to be 24.9% (Park, Lee, & Chung, 2008). Women are more affected than men, even
with non-breast-cancer related lymphedemas. Treatment is aimed at management of the affected
limb, as there is no cure. The author of this paper was certified to treat lymphedema patients with
the application of manual lymphatic drainage in 1998, and has incorporated her experience with
lymphedema patients into this report.
Lymphedema
When dissecting the word lymphedema, it breaks down into lymph; the fluid that flows
throughout the lymphatic system, and edema; an abnormal accumulation of fluid. When
interpreted together, lymphedema defines an abnormal accumulation of fluid due to an anomaly
of the lymphatic system. This should not be confused with the wide array of edemas that can
occur for various pathological reasons, including inflammation.
Lymph, the fluid in the lymphatic vessels, is absorbed from the interstitial fluid of the
capillary bed. Hydrostatic pressure forces fluid out of the arterioles, into the interstitial space,
fluid that is not reabsorbed by the veins is absorbed by blind-ended lymphatic vessels, and
ultimately returned to the vascular system. Lymph is returned to the vascular system at the
junction of the subclavian veins and the right lymphatic duct or thoracic lymphatic duct. Under
normal conditions, the lymphatic system reacts to excess fluid to maintain homeostasis and
prevent the accumulation of excess protein-rich interstitial fluid. According to Gary (2007), The
amount of lymph generated ranges from 2 to 4 L every 24 hours.
Running head: LYMPHEDEMA CAUSES AND TREATMENT 3
Several conditions carry the risk for edema; genetics, venous insufficiency, and filariasis,
a worm infection. The most common cause of lymphedema, however, is a byproduct of cancer
treatment, particularly breast cancer (Gary, 2007). For the purpose of this paper, lymphedema
due to cancer will be based upon breast cancer, as that is by far the leading cause of lymphedema
today.
Lymphedema occurs primarily in the extremities. Most commonly an arm, on the same
side a mastectomy was performed. Bilateral lymphedema usually occurs in the lower extremities
(legs), due to genetics or compromised venous circulation. In underdeveloped nations, filariasis
can lead to an extreme form of lymphedema known as elephantiasis (Gary, 2007). Lymphedema
falls into one of two classifications: Primary Lymphedema, which is inherited, and may or may
not be present at birth, or, more commonly, Secondary Lymphedema, which is caused by trauma,
radiation therapy or surgery. Currently, there is no cure for lymphedema. There are a wide
variety of treatment options, to manage the excess fluid, and aim to prevent further fluid
accumulation. A combination of therapies has proven to provide the best results.
Common Causes of Lymphedema
Lymphedema can be caused by cancer treatment therapies, genetics, venous insufficiency
or an infection by a mosquito-transferred worm; filariasis (Gary, 2007).
Cancer
When a mastectomy is performed, part of the lymphatic system is removed to be tested for
metastasis. Additionally, radiation to the breast and axilla is a standard post-op procedure. This
ensures that any cancer that has infiltrated the lymphatic system will be destroyed. Both of these
procedures lead to a lymphatic system susceptible to the development of lymphedema. Both
radical mastectomy and mastectomy with radiation have a 58% or greater risk of developing
Running head: LYMPHEDEMA CAUSES AND TREATMENT 4
lymphedema (Shah, Arthur, Riutta, Whitworth, & Vicini, 2002). Newer surgical procedures, that
remove a sentinel node instead of a cluster of nodes, have reduced the risk to 3%-23% (Shah et
al., 2002).
Genetics
When lymphedema is due to an inherited gene, it is a Primary lymphedema. Primary
disorders can be present at birth or develop later in life. Gary (2009) defines the three types of
hereditary lymphedema: Milroy disease is present at birth, Meige disease or lymphedema
praecox occurs at time of puberty to the age of 35 or in association with pregnancy, and
lymphedema tarda develops after the age of 35.
Venous Insufficiency
A compromised vascular system can be a cause of secondary lymphedema. When veins
are unable to reabsorb their share of the vascular fluid that is pushed into the interstitial space
from the arteries through hydrostatic pressure, the lymphatic system becomes overloaded. When
the lymphatic system, can no longer keep up with the excess fluid, it remains in the interstitial
space resulting in a protein-rich edema. Kuralic and Kapidzic-Basic (2010) state that treatment of
this type of lymphedema requires the underlying, chronic venous insufficiency to be addressed.
Filariasis
According to the Centers for Disease Control and Prevention (2013) filariasis is a
lymphatic system infestation of microscopic, adult worms. Filariasis is transmitted from human-
to-human through mosquito bites. The best treatment option is with early medication
administration. When left untreated, the most severe type of lymphedema develops;
elephantiasis. Elephantiasis affects both legs, and males can develop hydrocele, scrotal edema,
which requires surgery.
Running head: LYMPHEDEMA CAUSES AND TREATMENT 5
Treatment Options
A wide array of treatment options for lymphedema exists. Treatments are aimed at
reducing the size of the affected limb and preventing the further accumulation of edema. There is
no cure for lymphedema, although cutting edge treatment provides hope for an alternative to the
daily self-management routine. The simplest measure to prevent the build-up of lymph is to
elevate the affected limb. Elevation assists the return of lymph to the vascular space. Joint
movements and swimming are effective forms of exercise that promote the optimal flow of
lymph. There are an increased number of lymph nodes and lymph vessels concentrated at the
joints, relative to the surrounding area. By moving the joints, flow is promoted through these
areas. Swimming, on the other hand, utilizes the counter-pressure of water to mimic skeletal
muscles pumping effect on lymph vessels. Compression in the form of wraps or garments is
another way to mimic skeletal muscle and maintain the reduced circumference of the limb
between massage treatments. Manual lymphatic drainage is a massage technique that utilizes a
light, rhythmic, pumping motion, following the direction of lymphatic flow. Since 60% of the
delicate lymphatic vessels are located in the skin, the technique is necessarily light, and coaxing
in nature (Wittlinger, & Wittlinger, 1995). The next treatment modality, which is an attempt to
mimic the manual massage, is a sequential pneumatic pump. The affected limb is inserted into a
tube, and ring-shaped compartments are inflated, from distal to proximal. All of the treatment
modalities listed thus far should be administered on a daily basis for the effective management of
lymphedema.
Beyond the physical, non-invasive treatments there is medication, surgery, and most
recently laser and stem-cell therapy. Pharmaceutical measures include enzymes that target the
lymphatic circulation, and benzopyrones that target the venous system. Diuretics, although
Running head: LYMPHEDEMA CAUSES AND TREATMENT 6
commonly prescribed for lymphedema, actually have the effect of dehydration because the fluid
is eliminated, but the proteins remain. (Vojackova, Fialova, & Hercogova, 2012).
Surgery is a last resort, as many complications exist. A procedure called debulking
removes the subcutaneous layer and grafts skin over the area (Vojackova, Fialova, & Hercogova,
2012). Another surgical option is a bypass from the lymphatic system to the venous system, and
can only be done if the venous system is healthy. (Gary, 2007).
Mourao e Lima, Mourao e Lima, Carvalho de Andrade, & Bergmann (2014), state in an
article that In all studies, LLLT [low level laser therapy] showed favorable results in limb
volume reduction as compared with the control group, especially in longer periods of follow-up.
Finally, autologous stem cell (ASC) therapy shows promise of a permanent treatment.
Lymphedema patients are injected with ASCs to trigger the generation of lymphatic vessels.
Patients receiving injections of ASC showed a decrease in the volume of edema in the first 2
weeks after the procedure and gradually improved their associated swelling during the 12-week
follow up. (Maldonado et al., 2011).
Class Activity
The following is a list of questions designed to promote critical thinking.
Questions
Is edema due to venous insufficiency a true lymphedema?
Lymphedema patients, regardless of cause, are more susceptible to infection. Why is this
so?
Compare the pathway of blood and lymph to flow of water through plumbing filling and
draining a tub. Which vessels are the spout, the drain, the overflow drain?
Running head: LYMPHEDEMA CAUSES AND TREATMENT 7
How would wearing a pair of stockings that are too tight at the border, just below the
knee, affect someone with lymphedema?
Why would someone who has had a mastectomy not want to have blood pressure taken in
the arm of the affected side?
Stem cell therapy sounds like the perfect answer for lymphedema patients. Why doesnt
everyone with lymphedema have this treatment?
Laser therapy appears to be an effective long-term treatment for lymphedema patients.
Why doesnt everyone with lymphedema have this treatment?
Diuretics can dehydrate someone with lymphedema. Explain why this is the case by
relating this to osmosis.
Each student will receive one of the questions printed on the top of a sheet of paper.
Individually, they will write out their response. Next, the students will be matched up with those
that had the same question to compare answers, deciding what answer is the best. Finally, each
group will present what they have determined to be the best answer for the entire class. During
the final phase of this activity, I will project the questions for everyone to see, and type in the
answers, creating a reference for the students future use. By integrating concepts from prior
lectures, such as the vascular system, and osmosis from the cellular level of organization,
problem solving skills, and the realization that the bodys systems are integrated will be fostered.


Running head: LYMPHEDEMA CAUSES AND TREATMENT 8
References
Centers for disease control and prevention. (2013). Parasites: Lymphatic filariasis.
Retrieved June 1, 2014 from http://www.cdc.gov/parasites/lymphaticfilariasis/
Gary, D. E. (2007). Lymphedema diagnosis and management. Journal of the American
Academy of Nurse Practitioners, 19, 72-78). doi:10.1111/j.1745-
7599.2006.00198.x
Kuralic, S. & Kapidzic-Basic N. (2010, January). Lymphedema in chronic venous
insufficiency and physical procedures. Acta Medica Sainianal. Third congress of
Bosnia and Herzegovina Physiatrists.
Maldonado, G. E. M., Perez, C. A. A., Covarrubias, E. E. A., Cabriales, S. A. M., Leyva,
L. A., Perez, J. C. J., & Almaguer, D. G. (2011). Autologous stem cells for the
treatment of post-mastectomy lymphedema: A pilot study. Cryotherapy, 13, 1249-
1255. doi: 10.3109/14653249.2011.594791
Mourao e Lima, M. T. B. R., Mourao e Lima, J. G., Carvalho de Andrade, M. F.,
Bergmann, A. (2014). Low-level laser therapy in secondary lymphedema after
breast cancer: systematic review. Lasers in Medical Science, 29, 1289-1295. doi:
10.1007/s10103-012-1240-y
Park, J. H., Lee, W. H. Chung, H. S., (2008). Incidence and risk factors of breast cancer
lymphedema. Journal of Clinical Nursing, 17(11), 1450-1459.
Shah, C., Arthur, D., Riutta, J., Whitworth, P., & Vicini, F. A., (2012). Breast-cancer
related lymphedema: A review of procedure-specific incidence rates, clinical
assessment aids, treatment paradigms, and risk reduction. The Breast Journal,
18(4), 357-361. doi: 10.11118/j.1524-4741.2012.01252.x
Running head: LYMPHEDEMA CAUSES AND TREATMENT 9
Vojackova, N., Fialova J., Hercogova, J. (2012). Management of lymphedema.
Dermatologic Therapy, 25, 352-357.
Wittlinger, H. & Wittlinger G. (1995). Textbook of Dr. Vodders manual lymph
drainage: Volume 1: Basic course. (5
th
ed.). Brussels, Belgium: Haug
International.