About the Lymphatic System

The Lymphatic System


Image courtesy of Bauerfeind

Lymphatic Vessels make up their own vascular network that connects the tissues with the venous system.

Pre lymphatic channels start blind in the tissue and direct lymph into initial lymph vessels which then flow into increasingly larger and more structured vessels. Lymph passes through lymph nodes on its one way journey through the lymph system back to the venous system. The lymph system not only cleans tissues through drainage, but is also a protection and a defence mechanism. It carries out vital functions, absorbing from the digestive system, maintaining fluid balance and protein circulation.

The Lymph vessels carry the Lymph Obligatory Load (LOL), this is the amount of lymph needed to be removed from the tissues daily. The transport capacity of our lymph system is the amount of lymph that a normally functioning system can handle in a period of time. There are conditions when the LOL is actually greater than what our Lymph system can cope with. The excess remains in our tissues.

Sometimes our lymphatic system transport capacity is decreased for some reason & can no longer cope with a normal LOL. It is also possible for the LOL to be too great & transport capacity to be decreased at the same time. All of these result in oedema or swelling, and can involve pain, infection or loss of range of motion.

 

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So what about Lymphoedema?

Lymphoedema can occur in many parts of the body, arms & legs, trunk, abdomen, head & neck, external genitalia, and inner organs. The onset may be slow or sudden. There are long term physical, psychological and social consequences for people with lymphoedema.

Primary lymphoedema: This is a congenital abnormal development of the lymph vessel system. It occurs predominantly in woman. It manifest in the 2nd or 3rd decade of life. The Oedema is usually unilateral or if bilateral it is typically worse on one side of the body. There is no apparent incident prior to the development of primary lymphoedema.

Secondary Lymphoedema: In our society the most common development is post-surgery or radiation for various cancers e.g. breast, prostate, bladder, lymphoma, bowel, uterine, cervical and melanoma. It also develops from vein-stripping surgery, trauma to
tissues and tumours. This is due to damage or removal of lymph nodes & vessels by these treatments. There is a known event pre development of the lymphoedema.

Phlebolymphoedema: This is associated with chronic venous insufficiency. This causes oedema and skin pigmentation
of the lower extremity and over time the constant strain on the lymphatic system from excess leakage from the venous system
results in Lymphoedema.

Lipoedema: A progressive chronic metabolic disorder of the adipose tissue. Symptoms are bilateral and symmetrical swelling usually
of the legs, especially the outer hip and inside knee. Feet are normal unless lymphoedema is also present. It is characterised by tenderness, easy bruising & a feeling of heavy tired legs especially at the end of the day.
Although there is no cure, management with MLD and compression prevents later stages of the disease developing and provides maximum comfort & quality of life.

Stages of Lymphoedema
Latent: This stage is not apparent to the eye. It is now recognised scientifically that best outcomes for lymphoedema are when
treatment begins at this stage. You may feel something is wrong, your limb just feels different but there is no visible change.

Neil Pillar

 Image courtesy of Professor Neil Pillar

Stage 1: The oedema is reversible with elevation, is soft pitting, visible to the eye, there is no pain and no skin changes

Stage 2: Irreversible with elevation and rest, but able to be reduced with CDT. The oedema is harder to touch and more
difficult to get pitting. Normally there is no pain and no changes to the skin​.

Stage 3: Skin changes occur and large folds of fatty and fibrotic tissue develop which are increasingly disfiguring.
This stage is irreversible, but is able to be managed with CDT. There may be pain. Commonly known as elephantiasis

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Low level laser

Also known as cold or soft laser, using photochemical reaction at a cellular level. It is an emerging therapeutic approach in which cells or tissues are exposed to low levels of red and near IR light from lasers or LEDs. As the laser light penetrates into tissue it is absorbed by cells and converted into energy that influences the course of metabolic processes. This makes it useful in treatment of:

  • Oedema and Lymphoedema.
  • Fibrous tissue from scarring or long standing oedemas.
  • Slow healing wounds.
  • Sprains and strains.
  • Muscle spasm
  • Muscular & skeletal pain.

The laser is safely used with pace makers, breast implants and orthopaedic plates or screws. It can be used in conjunction with Massage, MLD or CDT to optimise treatments.

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Medical Taping

This is the use of an elastic cotton hypoallergenic adhesive tape. It has applications in lymph flow, muscle facilitation and inhibition, ligament correction, correction of joint position and fascia and cross taping for scars. With correct application of medical tape for a lymphatic purpose the epidermis is slightly lifted by the tape creating some space in the dermis below. As the pressure under the tape is lower than in a skin region without the tape, free fluid moves to the lower pressure under the tape and then flows in the direction of the tape to its base where there are functioning lymph vessels to drain the fluid. With this technique we are able to direct movement of Lymph fluid to an area where we want it to go. In some instances it may be used in conjunction with bandaging or as an alternative in hot weather or other determining factors may make it the best option or an alternative option for a person. Lymph tape also greatly assists the fascia with movement and stretching. Freeing up stuck damaged tissue for flow. It is very useful in areas of the body that are difficult to apply other forms of compression to such as the breast and the face.

Medical tapping

Images courtesy of Josya Sijmonsma

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Manual Lymphatic Therapy (MLD)

This therapy involves gentle, rhythmic manipulation of the skin performed with precision. The specific and repetitive movements are
both soothing & relaxing with no side effects, to aid in stimulation of the lymphatic vessels to pump faster and stronger, improving the functioning of the Lymph System. It will not cause reddening of the skin or pain. MLD has a profoundly relaxing effect on the sympathetic nervous system (this is our fight-flight, & stress response).

As the superficial vessels are linked to the deeper system it also effects the functioning of our deeper Lymph vessels even though
it is a very gentle Therapy. It can be used for treating many conditions such as:

  • Venous stasis ulceration
  • wounds, bruising
  • scar tissue
  • burns
  • traumatic oedema (from sprains, strains, fractures, post-surgery, after cosmetic surgery)
  • rosacea and other skin conditions
  • arthritic conditions
  • whiplash
  • meniere’s syndrome
  • migraines
  • stress
  • stroke with hemiplegia
  • bronchitis & sinus
  • constipation and other digestive disturbances
  • frozen shoulder
  • elbow problems such as tennis elbow

It is an important part in the treatment of primary and secondary lymphoedema, and lipoedema. MLD is a treatment that takes advantage of the physiology of the Lymphatic system to move fluid from malfunctioning areas to functioning drainage pathways in the body.

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Bio Impedance Spectroscopy  (L-Dex)

Bio Impedance Spectroscopy (L-Dex) is a method which aids in the clinical assessment of extracellular fluid in arm and leg. The detection of fluid increases may be indicative of early stages lymphoedema, this latent stage lymphedoema is not visible to the eye and is usually not known to the individual. A low frequency electrical signal is transmitted to the patient from the U400 device via skin surface electrodes, the signal only moves through fluid due to this low frequency. It is completely harmless, non- invasive, pain free and takes a very short time for a reading to be completed.

Impedimed L-Dex high/low frequency

Measurement taken prior to any treatment for cancer is preferred so a base line reading is known before any intervention. If a pre operation reading is not taken an initial consultation reading is used as the baseline and changes are then monitored from this point.

Suggested times for subsequent readings is 3 monthly or 6 monthly, if you are high risk or have a reading that shows an increase
in fluid levels in a limb then 3 monthly or even closer readings are preferred for a time.

L-Dex reading enable you to:

  • Know your baseline L-Dex level
  • Know when things are changing, assessing early fluid changes in your limb
  • See how treatments or management regimes are progressing and whether changes need to be made to these
  • Have peace of mind
Impedimed LDex graph

Images courtesy of ImpediMed

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Combined Decongestive Therapy (CDT)

This involves the use of MLD, Compression, Exercise and Skin Care. A combination of all these are necessary for the management and treatment of primary and secondary lymphoedema and also help with lipoedema. Diet is also an important aspect of minimising development and progression of Lymphoedema. Whatever the cause, Lymphoedema is a progressive condition and needs to be managed
for optimal comfort and well-being. There are many management choices available for a person with Lymphoedema. We are able to assist in the discovery of what works for an individual, and we are available for ongoing support.

CDT has 3 phases:

  • Prevention
  • Reducing risk that may cause onset. Having MLD to keep the Lymph System functioning well
  • Changing behaviour to assist in prevention
Neil Pillar

Image courtesy of Professor Neil Pillar

Reduction
When a person has developed Lymphoedema it is always recommended to have MLD and reduction bandaging to reduce the fluid in the limb as much as possible before fitting for a garment to wear. Compression at this stage helps with softening of any fibrosis that may be present due to accumulated protein in the tissues. There are several different bandaging systems and many types of garments, some of these have Velcro adjustments enabling a client to help manage with their own reduction.

We can determine with a client the options that best suit them taking into account their private life, work life and also time of the year. This is an intensive period of treatment and a time to learn of what habits and skills are necessary for the maintenance.

Maintenance
To maintain the gains in reduction, this involves client and therapist input. Exercise, skin care, elevation, self-massage, MLD treatments and compression. Compression garments are worn to maintain the limb to the level achieved with the reduction bandaging and MLD treatments. Clients are measured and either fitted with a ready to wear or a made to measure garment. This depends on the individual measurements and requirements.

With any Lymphoedema it is optimal to wear compression garments everyday as the Lymphatic Systems Transport Capacity is damaged
or not formed optimally and requires assistance. All compression needs to be correctly applied and fitted otherwise it creates additional problems for the limb.

Compression, Compliance and Commitment are necessary for the best outcomes.

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Breast Cancer Rehabilitation and Wellness

This resource has been developed from the Breast Cancer Rehabilitation & Wellness Summit 2017.
 Health professionals and service providers from across the globe have come together to share their experience of breast cancer specific rehabilitation and wellness strategies. 
The presentations will guide and inspire you with solutions to the side effects people can experience after breast cancer.

Your experience with this information can be fleeting/binge or immersion. To find out more information, visit the Breast Cancer Rehabilitation & Wellness website.

BCRW2 web

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Links to further information

The first and only Australasian Lymphoedema Registry for all people living with lymphoedema was launched on International Lymphoedema Day 6th March 2015. This is an ALA project powered by the IBM Impact Grant to enable all those with lymphoedema in Australia and New Zealand to anonymously complete a short online registration survey at www.lymphoedemaregistry.org.au or www.lymphoedemaregistry.co.nz. A mobile phone version is also available. This initiative is supported by lymphoedema support groups and the members of the Lymphoedema Action Alliance.

The Lymphoedema Registry
New Zealand Lymphoedema
Australian Lymphology Association
www.L-Dex.com

Massage New Zealand
Impedimed
Dr Vodder

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