Lymphedema – General Recommendations
Lymphedema refers to the abnormal accumulation of lymphatic fluid, often in the limbs, resulting from blocked lymphatic drainage channels. The majority of my patients with Lymphedema have improved with time and proper treatment, so don’t despair, effective approaches do exist.
Lymph, a milky, proteinaceous fluid, forms in most tissues of the body. Blood, carrying oxygen and essential nutrients, travels from the aorta to larger arteries and then into a series of successively smaller, widely branching arteries and arterioles. As an image, think of the branching structure of a tree, that begins with a single large trunk, and ends in a cascade of tiny twiglets.
The arteries eventually end in the smallest of blood vessels, our capillaries, lined by a single layer of endothelial cells. Here, the flow pressures of arriving arterial blood can be quite strong, strong enough to force water, electrolytes such as sodium and potassium, as well as proteins and a myriad of nutrients, into the surrounding tissues, providing the materials needed to sustain cellular life. This nutrient rich interstitial fluid literally bathes all the cells of all the tissues of all the organs of our body. Red blood cells, too big and bulky to escape through the capillary walls, and the largest blood proteins continue along with most of the blood fluid into the small venules, that merge into the progressively larger veins, ultimately arriving in the large vena cava that carries blood back to the heart.
Much of the interstitial broth makes its way back into the capillaries and the systemic blood circulation, pushed along by the constant force of fluid under pressure arriving from the arterioles upstream. However, more interstitial fluid forms in the tissues than can be funneled back into the venous circulation. Fortunately, we have an ancillary circulatory system, our lymphatic channels, an alternative circulatory system which drains excess interstitial fluid efficiently. Without the lymphatic system, our cells and tissues would face the dilemma of a flood, with tissues overloaded to the brim.
In many respects, these lymph vessels resemble the venous system in their microscopic structure and in their anatomical distribution, converging into larger and larger vessels, that ultimately form a single large lymph channel that empties into the superior venous cava at the level of the chest. Through this connection, the lymphatic fluid ultimately rejoins the blood and the blood circulatory system.
Smooth muscle cells line the medium sized lymphatic vessels, which allow for some contraction and reflex pumping, to help keep lymph fluid moving on its journey back into the vena cava. The muscles of our legs also help force both venous blood and lymph fluid upwards against gravity, toward the abdomen and ultimately the heart. Normally, the flow of blood and lymph moves effortlessly and efficiently, requiring no thought or concern. At times, for any number of reasons, lymph flow can be blocked, so that, like a dammed stream, fluid and pressure build behind the obstruction so that lymph fluid backs out into the tissues. Over time, the fluid can build in quite substantial amounts. If the blockage occurs in the drainage system of the abdomen, ascites can form, to the point the patient may appear to be pregnant with fluid. If the blockage occurs in the pelvis, fluid tends to collect around the ankles and calves, eventually, in severe cases, involving the entire limb, which then may appear quite distended.
Scientists divide lymphedema into primary or secondary forms; primary lymphedema includes cases resulting from a congenital malformation – an inherited defect or from scarring in the lymphatic vessels. At times, the vessels fail to develop properly, so that lymph channels are more like a solid rope, than a tube. Primary lymphedema can be evident at birth but often edema doesn’t become obvious until puberty, as in this reader’s case, in a form known as lymphedema tarda (meaning late).
Secondary lymphedema occurs when previously normal lymph channels become damaged by infection, cancer, or, as often happens, by mastectomy performed for breast cancer, in which the surgeon removes many axillary (armpit) lymph nodes on the side of the tumor.
Usually, lymphedema progresses to a certain point, then stabilizes. And though cosmetically annoying and somewhat uncomfortable, fortunately it isn’t life-threatening, and often patients can adapt and learn to live with the problem. At times, however, lymphedema, either primary or secondary, can become a pervasive, extensive problem, leading to reduced mobility in limbs and chronic discomfort.
In my practice, I have treated many patients with lymphedema, particularly women who have undergone breast surgery. I have found that a massage therapist or physical therapist with specialized lymphedema training can be of great help in stabilizing and sometimes reversing the condition. A particularly helpful form of lymphedema physical therapy came over from Germany, where a group of physicians proposed that proper daily massage can stimulate the formation of new lymphatic vessels that can effectively bypass the blockage, wherever it might be. In consequence, the lymphedema improves or resolves completely. Many hospitals now employ therapists trained in the “German” technique.
Dr. Robert Lerner developed quite a reputation and established a number of clinics known as “Lerner Lymphedema Services”. Depending on the severity of the situation, usually the therapist will prescribe pressure sleeves for the affected arm, or pressure stockings if the edema involves the leg, that force the excess fluid up through the blocked channels. These do help, but they must be worn daily (or nightly) for maximum benefit. In my experience, sometimes a patient must try a number of therapists, before finding a good fit. I had one patient in a major metropolitan city who went through three physical therapists at a major academic medical center before finding a massage therapist who had been extensively trained and specialized in helping patients with lymphedema. The final results have been very gratifying. So, if you find yourself stalling with your current massage treatment plan, move on and don’t be shy, ask about their training and experience before you begin with someone new.
I have found that the lymphatic draining pumps, which patients apply daily, to be less effective than a properly trained massage or physical therapist. Despite the promotion, I just haven’t found them particularly useful, and patients who’ve tried them find them uncomfortable to use.
I believe appropriately prescribed diet and supplement protocols do help, but for lymphedema they are not magical, since the problem often involves lymphatics blocked by extensive fibrosis and scar tissue. Here, hands on intervention, to break up obstructions and help foster new vessel formation, makes the critical difference. You need to find the right people to help, and follow the treatment plan, be it massage, application of pressure sleeves, exercise, etc., diligently.
By Nicholas Gonzalez, M.D.
