Lymphoedema
Localised moisture accumulation

Lymphoedema is a condition in which an abnormal amount of fluid and protein accumulates in a body part. There is an imbalance between the supply and removal of this fluid.

Lymphoedema can be caused by a congenital defect or, for example, by an illness, operation or medication. Both forms can lead to serious physical complaints.

Description of the condition

Lymphatic vessels and lymphatic pathways are scattered throughout the body. These end in the so-called lymph nodes. Groups of these lymph nodes can be found, for example, in the groin, armpit, neck and abdomen.

The task of the lymphatic system is to transport and purify the lymph fluid, which is then released back into the bloodstream. The lymphatic system helps remove fluid and waste products and fight infections. When this system does not work properly, an accumulation of fluid, the lymphoedema develops.

Cause and origin

Lymphoedema can be divided into two types: congenital and acquired lymphoedema. In case of congenital lymphoedema, there is a defect in the lymphatic system which takes care of the supply and drainage of lymph fluid.

There may not be enough lymphatic vessels present or they are too narrow or, on the contrary, too wide. Problems also arise when the lymph nodes do not function properly. When the abnormalities are serious, symptoms may already be present from birth. The complaints are then usually present in (both) feet and legs.

The lymphoedema can also spread to other parts of the body such as the arms and the face. In the milder cases, complaints usually arise between the age of 18 and 35 and are then more often present on one side. Women four times more likely to develop lymphoedema, partly due to hormonal changes, the monthly hormonal cycle and possible pregnancy(ies).

Non-congenital or acquired lymphoedema can for instance occur after surgery, radiotherapy, infection, use of medication or as a result of trauma in which the lymphatic vessels or nodes are damaged.

Lymphoedema is seen relatively often in people who are treated for cancer. In this context, it may be necessary to remove or irradiate part of the lymph nodes. This causes damage to the lymphatic system so that it no longer functions properly. Tumours, too, can compress the lymphatic vessels.

Most forms of lymphoedema are not hereditary, certainly not the acquired variety. However, there may be a familial predisposition.

Signs & symptoms

People who suffer from lymphoedema may experience varying degrees of complaints such as:

• Swelling of one or more body parts.
  
• Pain and/or tingling.
  
• Local fatigue and a heavy feeling in the affected area.
  
• Restrictions in movement due to swelling and/or pain.
  
• Skin abnormalities such as fluid-filled blisters, hardening of the skin, blue spots or nodules.
  
• Infections.

Diagnosis

To find out if it is lymphoedema, the doctor will ask a number of questions about the symptoms. It is important to find out whether there has been surgery or trauma, for example, or whether there is a disease that can explain the swelling.

In case of congenital lymphedema, the doctor will also ask if there are other people in the family with these symptoms. Furthermore, a physical examination will be performed during which the affected body part will be examined.

Swelling is the most pronounced symptom of lymphoedema. This swelling can be divided into impressionable and non-impressionable oedema and can be tested with the sign of Godet. When pressing on the swelling with a finger, a small impression may remain visible for a short period of time, this is called pitting oedema. When the swelling is hard and cannot be pressed well, this is referred to as non-pitting oedema. When the lymphoedema has been present for a long time, the tissue hardens so that it is no longer compressible. Thus, the sign of Godet can be used to explain the stage of the lymphoedema.

In addition, doctors use the sign of Stemmer manoeuvre. This is to check if changes are present in the skin between the second and third toe or finger. When the skin cannot be lifted at this spot, this is an indication for lymphoedema.

In rare cases, additional testing, called lymphoscintigraphy, is performed. This procedure establishes how the lymph fluid is drained off and where possible obstructions are located.

Treatment

A specially trained physiotherapist, the oedema therapist, plays an important role in the treatment of lymphoedema. Within the treatment of lymphoedema, two phases can be distinguished. These are the reductive phase and the maintenance phase.

The reductive phase is aimed at reducing the lymphoedema as quickly as possible. This is done, among other things, by means of lymph drainage in which the oedema therapist applies a specific massage technique. The oedema therapist can also make use of a special taping technique with elastic tape to stimulate the drainage of lymph fluid.

Exercise is also a good way of pumping the fluid away, as it were, by contracting and relaxing the muscles. In addition, it may be necessary to wear bandages or support stockings to prevent the swelling from returning (quickly). As long as improvement is obtained, these techniques will continue to be used intensively.

If there is no further improvement, the treatment will move on to the maintenance phase. In this phase, the aim is to keep the complaints under control. In principle, the treatment is the same as in the reductive phase, only the frequency of treatment decreases. Lymphoedema is a chronic disorder that therefore requires lifelong treatment.

Sometimes the above treatment is not sufficient and it is necessary to intervene with surgery. In this case, fluid, connective tissue and fatty tissue are removed. Even after this operation, treatment by an oedema therapist is necessary.

Exercises

You can check your symptoms using the online physiotherapy check or make an appointment with a physiotherapy practice in your area.

References
Damstra, R.J. (2014). Richtlijn lymfoedeem. Multidisciplinaire evidence-based richtlijn. Utrecht: Nederlandse Vereniging voor Dermatologie en Venereologie.