Lymphedema occurs when fluid rich in protein accumulates in the soft tissues after disruption of the lymph-conducting pathways in the setting of normal capillary filtration. In advanced stages it cannot be cured, and requires active management—such as physical therapy—to prevent worsening morbidity.

Primary lymphedema is due to an inherited abnormality of the lymphatic system, so it usually occurs in families.
Secondary lymphedema, which is much more common, is due to a lymphatic system damaged either by infection (e.g., cellulitis, parasitic infections), inflammation (e.g., rheumatoid arthritis), cancer, cancer treatment (e.g., radiotherapy or lymph node dissection), obesity, or venous diseases (e.g., varicose veins, deep vein thrombosis).

It is diagnosed by clinical assessment.
• Signs: hardening or thickening of the skin and swelling of the affected extremity, often unilateral.
• Symptoms: tightness, tingling, pain, and a sense of heaviness of the affected limb. In severe cases, weeping of the affected skin can develop.

Lymphedema treatment includes reducing the swelling and improving function, quality of life, symptom management, and skin integrity. There is a great possibility of persistent symptoms if removal of an obstructing source is not possible (e.g., incurable cancer).
Specialized lymphedema treatment can be provided by physicians (physical medicine and rehabilitation), massage, physical, and/or occupational therapists, and trained nurses. Therapeutic response is less likely to occur and less clinically significant with diuretics and elevation.

Regular monitoring of the skin in the affected area is a must to monitor erythema, warmth, and tenderness.

Recognized management approaches for lymphedema
• Complete decongestive therapy (CDT) includes five lymphedema treatments provided by a lymphedema specialist: manual lymphatic drainage, multilayer short-stretch bandaging, lymph-reducing exercises, skin care, and compression therapy. CDT can achieve limb volume reductions of 50-70%. Phase 1 consists of manual lymph drainage (twice daily for 3-5 days per week), followed by extremity wraps, followed by compression bandages. Phase 2 CDT is designed to maintain these volume reductions at night via compression garments.
• Manual lymphatic drainage involves 30-45 minutes of gentle massage designed to mobilize congested lymph, followed by application of multilayer compression bandages.
• Compression therapy includes applying a compression sleeve, elastic therapeutic tape, or multiple layers of bandages with extremity elevation for several days.
• Closed-controlled subcutaneous drainage should be performed selectively for patients with severe (e.g., exuding edema) and refractory symptoms, since it has been associated with infection and poor wound healing. The technique consists of inserting needles at the subcutaneous level of the affected extremity.

See reference for more information.

Adapted from Brown SR and Skock DO. Lymphedema considerations in palliative care. Palliative Care Network of Wisconsin. Fast facts and concepts #447. Internet. Available at https://www.mypcnow.org/wp-content/uploads/2022/06/FF-447.pdf/ Accessed on January 15, 2022