Diagnosis and Management of Lymphoedema

Jan 20, 2021

Lymphoedema is the accumulation of excessive amounts of protein-rich fluid leading to swelling of one or more regions of the body. It occurs when the lymphatic load exceeds the transport capacity of the lymphatic system, resulting in mechanical failure of the lymphatic system. The condition primarily affects the limb(s), however it may also involve swelling of the breast, trunk, head and neck or the genitals.

The lymphatic system is comprised of vessels and nodes that transports fluid (lymph) from the body tissues back to the bloodstream.

Functions of the lymphatic system include:

• Maintain the body’s extracellular fluid volume and protein concentration
• Help the immune system to destroy pathogens and remove waste products from the tissues.

While lymphoedema starts as a fluid focused condition, for some, it can progress to accumulation of adipose and/or fibrotic tissue in affected regions. This change in tissue composition is also known as staging, with lymphoedema currently divided into four stages depending on the progression of the tissue changes.

International Society of Lymphology (ISL) lymphoedema staging

Damage to the lymphatic vessels or nodes, or incorrect formation of the lymphatic system may result in lymphoedema.

Secondary lymphoedema is the most common type, developing following damage to the lymphatic system. Cancer treatments such as removal of lymph nodes and radiotherapy will often cause damage to the lymphatic system. The onset of lymphoedema is variable, and may occur within months of the damage or it may occur years later.

Secondary lymphoedema may also occur without a cancer diagnosis due to any of:

• Chronic venous insufficiency
• Immobility (dependent oedema)
• Trauma and tissue damage
• Factious – self harm
• Infection such as cellulitis
• Filariasis – damage from parasitic filarial worms transmitted through mosquito bites. The parasites embed themselves into the lymphatic system causing destruction of the healthy vessels and nodes, resulting in lymphoedema. This mainly occurs in the sub-tropical areas of the world.
• Obesity

Primary lymphoedema is the result of a congenital condition that affects how the lymph vessels were formed. This may be due to hypoplasia of lymphatic vessels (a reduced number of lymphatic vessels), hyperplasia of lymphatic vessels (too large to be functional), or aplasia (absence of part of the lymphatic system). Primary lymphoedema may be present at birth, may develop at puberty, or may not become apparent until adulthood. At birth, about one person in every 6000 will develop primary lymphoedema.

Research from the National Breast and Ovarian Cancer Centre (NBOCC) reveals that “conservative estimates suggest that 20% of breast, genitourinary, gynaecological, or melanoma survivors will experience secondary lymphoedema.”

The incidence of secondary lymphoedema associated with vulval cancer is estimated at 36-47%, breast cancer 20%, cervical cancer 24% and melanoma 9-29%. The incidence of lymphoedema following sentinel lymph node biopsy (SLNB) is reported to range from 4-8%.

Diagnosis of lymphoedema is determined from the clinical history and physical examination. Lymphoedema normally presents with a gradual onset; however when lymphoedema has an acute onset, further testing should be considered, such as checking for deep vein thrombosis, or further investigation of cancer recurrence or infection.

ACI Chronic Care Network - Lymphoedema: A guide for clinical services pg11

Care provided to people with lymphoedema can commence in the primary care setting. GPs are often responsible for an initial diagnosis, referring on to specialist services or clinics, coordinating care and supporting the patient’s journey. The role of GPs outside of cities or towns is particularly important, due to decreased awareness of the services that exist. GPs may require support and guidance to effectively manage a person with lymphoedema.

Clients will ask me “What should I look out for?” in regards to early warning signs of lymphoedema. I generally advise to monitor the involved limb for swelling, as well as limb heaviness, areas of tightness, restricted range of movement or temperature changes. Lymphoedema is not usually a painful condition, but some people report pain and tension in an affected limb or body part. People may notice that lifting an arm up to hang the washing out might feel more arduous than normal, or they may have more difficulty donning/doffing clothes due to reduced upper limb range of motion. They may encounter altered sensation or feelings of restriction from clothing or jewellery. Clients often report that their lymphoedema swelling is exacerbated by heat, with overuse, sustained positions, prolonged inactivity, and at the end of the day. Gentle exercise, elevation, massage and compression can ease their symptoms.

Early intervention is vital to minimise time and age related changes, as lymphoedema is a progressive disease.

Ramsay Health Plus Figtree, located at Figtree Private Hospital, provides lymphoedema services, including diagnosis and treatment of upper limb and lower limb lymphoedema. Our specialised lymphoedema therapist currently provides early intervention screening and education for breast cancer related lymphoedema, as well as various treatment techniques to lessen the impact of the condition. Further lymphoedema services will be offered in 2021.

At Ramsay Health Plus Figtree, sessions are 60 minutes for an initial assessment and therapy, and 45 minutes for subsequent visits. Assessment and treatment options available:

• L-Dex Readings (Bioimpedance Spectroscopy)
• Circumferential measurements
• Lymphoedema education
• Adhesive Capsulitis and Axillary Web Syndrome management
• Upper limb strength and range of motion exercises
• Lymphatic drainage massage
• Bandaging
• Compression garments
• Compression therapy pump (SIPC)
• Low Level Laser Therapy (LLLT)

Referrals

Patients referred by their GP CDM Plan are eligible for a Medicare rebate. Patients can arrange their first appointment by contacting Figtree Private Hospital on 02 4255 5000.

Alex Stanicic
B.Sc (ExSc) / M.Phty
Physiotherapist / Lymphoedema Therapist

Alex is a physiotherapist who has worked at Lawrence Hargrave Private Hospital, Figtree Private Hospital and Wollongong Private Hospital since October 2018. Alex’s areas of special interest include Lymphoedema, Pre & Post Breast Surgery, Breast Cancer and Musculoskeletal Conditions. He is a Category 1 Lymphoedema Therapist, allowing him to diagnose, assess and treat lymphoedema patients with or without a referral.