Appointments: 0789 9964163 Lymphoedema Clinic What is Lymphoedema? • Primary Lymphoedema • Secondary Lymphoedema Treatment-4 Cornerstone Therapies • Manual Lymphatic Drainage • Multi-layer Compression Bandaging • Skin Care • Exercise What is Lymphoedema If the drainage routes through the lymphatic system become blocked or damaged, lymph accumulates in the tissues and swelling [oedema] occurs. The oedema is not simply made up of fluid but also contains waste products and fat cells. Unlike other oedemas, lymphoedema can lead to changes in the tissues such as fibrosis and an increased risk of infection. The swelling then becomes even more difficult to control. Lymphoedema can be further classified as Primary and Secondary Lymphoedema. Lymphoedema is an underestimated health problem with about 2% of the UK population being affected to varying degrees. The prevalence of lymphoedema in women treated for breast cancer is estimated at about 25-30% [Journal of Clinical Nursing]. Primary Lymphoedema Primary Lymphoedema is usually present at birth and may be due to the malformation or malfunctioning of the lymphatic system. It may however not present symptomatically until later in life when demands on the lymphatic system become such that it is unable to cope with the increased load and swelling occurs. • Common triggers may include: • Puberty • Pregnancy • Menopause • Trauma such as fracture or sprain   Secondary Lymphoedema Secondary Lymphoedema occurs when an otherwise healthy lymphatic system becomes damaged. This may occur either as a symptom of cancer [tumor growth] or treatment for cancer following surgery or radiotherapy. It may also occur as a result of trauma to the system such as injury, infection, burns or following cosmetic and surgical procedures. In most cases lymphoedema will develop soon after treatment but swelling can occur many years after. Lymphoedema Treatment Many medical practitioners and health care professionals are unaware of treatment available for the symptoms of lymphoedema and many doctors are skeptical and negative about treatments offered. However Combined Decongestive Therapy [CDT] has been the treatment of choice for lymphoedema and many other associated conditions for many years. The UK health system has only recently begun to realize the effects CDT can have on the successful management of this debilitating condition. It is important to realize that true lymphoedema is not curable or reversible but it is possible to manage the condition with correct treatment and compliance. Even severe and chronic lymphoedema will respond well to appropriate treatment over time. Skin and body tissue has a remarkable ability to regenerate and re-shape with expert and correctly applied therapy such as that offered at Lighterlimbs. Generally speaking lymphoedema treatment is made up of the four cornerstone therapies – Manual Lymphatic Drainage Massage [MLD], Compression Therapy, Skin Care and Exercise collectively known as Combined Decongestive Therapy [CDT] Manual Lymphatic Drainage Massage [MLD] The therapist uses a range of specialised and gentle rhythmic pumping techniques to move the skin in the direction of the lymph flow. This stimulates the lymphatic vessels, which carry substances vital to the defence of the body, and removes waste products. The massage helps lymph to move from areas of swelling into other parts of the body where it can drain away normally. Advanced techniques can stimulate new lymph pathways to‘re-route’ lymph away from affected areas. This type of massage is extremely gentle and unlike traditional body massage it works to ‘pull’ fluids towards drainage routes rather than ‘pushing’ fluid through the tissues. It works to maximise the potential and efficiency of a compromised lymphatic system. Treatment with MLD Massage normally starts at the neck before the therapist works distally clearing exit pathways for the lymph to flow.  MLD can be used in both a preventative and remedial context to enhance well being. Patients can practice self treatment [Simple Lymphatic Drainage – SLD] in between sessions of MLD. These techniques can be taught in clinic. Compression Therapy The process of treating lymphoedema with MLD Massage is further     enhanced by the use of suitable compression therapy. This may take the form of bandaging [especially in the initial intensive phase of treatment] or compression hosiery or a combination of both. Compression therapy assists the tissues by applying pressure from the outside which allows the fluids to flow back into the lymph and venous systems. Bandaging used in conjunction with padding can resize and reshape a limb even when the lymphoedema is chronic. Many patients struggle with the concept of having to wear compression garments to manage their condition. At Lighterlimbs we understand the problems and practicalities of compliance with the use of compression therapy. We therefore strive to develop individual patient treatment programmes that are achievable and acceptable to both patient and therapist. Many patients with orthopaedic and other health conditions may simply be unable to put on and remove hosiery easily. As such we look for the best possible solution to the problems but always with compromise in mind. Most patients find that once they are used to the wearing of compression they feel more comfortable and the tissues feel better supported. Use of compression apart from maintaining a reduced limb volume will lower the incidence of infection and aid in the healing of wounds and ulcers. Skin Care Lymphoedema predisposes to various skin problems. The main aim of skin care is to maintain skin hydration and reduce the risk of infection. Used in combination with Manual Lymphatic Drainage and compression therapy skin condition can be greatly improved. The pictures below show the results of treatment on legs severely affected by chronic lymphoedema and associated dermafibrosis development. First assessment.   Following 8 weeks of therapy with Lighterlimbs Where the lower extremity is affected, meticulous care of the feet and toes is needed to prevent infection. We use a variety of skin care products and essential oils during treatment which are specific to the patient and condition being treated. Exercise There is considerable diversity of opinion amongst medical professionals as to whether exercise is to be recommended to individuals with lymphoedema or at risk of lymphoedema. There are a handful of studies that indicate exercise in itself does not trigger lymphoedema nor will it worsen an existing lymphoedema. Lymphoedema and Exercise Case Studies Case Study of Upper Body Exercise for Lymphoedema A series of case reports published in the Journal of Surgical Oncology3 challenges the theory that vigorous upper body exercise is contraindicated for individuals who have had axillary dissection during surgery for breast cancer. The study followed a group of 24 women for 9 months. These women were recruited to participate in a training program to prepare for competition in the World Championship Dragon Boat Festival in Vancouver, British Columbia. Dragon Boat racing involves strenuous repetitive upper body exercise. 18-20 women paddle 40-60 foot boats for a distance of 500-650 meters. Circumferential measurements were collected on 20 of the 24 participants (limbs were measured at 4 places) pre training, at the start of the racing, and 7 months after the races. According to the authors, only two women, who had pre-existing mild lymphoedema, had increases in their upper arms (5/8 inch) and none of the other participants developed lymphoedema. One of the authors of the study, herself a breast cancer survivor participated in the program. Regarding lympheodema and exercise, the authors conclude that strenuous upper body exercise may not cause lymphoedema or worsen a pre-existing lymphedema. Case Study of Weight Training Effects on Lymphoedema Ahamed et al in 2006 examined the effects of supervised upper and lower body weight training on the incidence and symptoms of lymphoedema in 45 breast cancer survivors who participated in a supervised, graduated program of exercise twice weekly for 6 months.  None of the participants experienced a worsening of their lymphoedema or a triggering of lymphoedema in their at risk limbs. Schmitz et al in 2009 assessed the safety of a graduated exercise program on 295 survivors with breast cancer related lymphoedema (BCRLE) and 154 at risk for lymphoedema.  Their results were similar, demonstrating that individuals who are at risk for lymphoedema or who have lymphoedema can participate in exercise, provided it is progressed slowly and their limbs are assessed for any signs of increased or developing swelling throughout the program and the program is modified accordingly for each person. It is important to recognise that individuals taking part in exercise research programmes are properly supervised and undergo a period of strengthening and stretching in order to be fit and able to undertake any exercise regime. The risks involved with exercise are increased where there is no correct supervision when the risk of trauma or injury to joints and muscles and connective tissue is increased. Any exercise induced injury has the capability of triggering or worsening a lymphoedema. We consider exercise therapy to be an important component in the management of lymphoedema and it forms part of the treatment plan that can be carried out at home as an active programme of specific exercises or as part of a passive programme during the treatment session. The benefits of exercise to an individual with lymphoedema by far outweigh the disadvantages or risks. The exercises chosen will be standard exercises for lymphoedema as well as patient specific exercises that will take into consideration any individual orthopaedic and mobility problems. For patients presenting with cardiovascular and heart related problems or who may suffer from any of the risk factors associated with heart disease such as diabetes, high blood pressure or obesity, we are able to offer fully supervised exercise sessions endorsed by the British Association for Cardiac Rehabilitation(BACR). At Lighterlimbs we believe that Lymphoedema should not be or become a barrier to exercise. Exercise regimes may need modification and monitoring but everything is achievable. We have at the clinic patients who actively participate in swimming, horse riding, golf, surfing, abseiling to name but a few. We will actively encourage you and assist you to achieve your goals and ambitions. Injury and Pain Often people presenting for treatment of lymphoedema will also have joint injury and back pain issues. This is often due to abnormal musculoskeletal and biomechanical stresses put on the body as a result of swollen limbs. These issues are dealt with as part of a standard lymphoedema treatment programme.