Secondary lymphedema

Secondary lymphedema is often a sequential disorder to untreated chronic venous insufficiency, requiring different treatment strategies that focus on lymphatic mobilization in addition to venous return.

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Jun 23, 2019
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One of the functions of the lymphatic system is to transport proteins and fat molecules that are too large to enter venules from the interstitial tissue to the central cardiovascular system.  The system consists of lymphatic vessels that intertwine with the arterial and venous capillary bed, these vessels then transport the fluid and molecules to precollectors, then collectors to lymphatic trunks to regional lymph nodes.  When chronic venous insufficiency (CVI) prevents accommodation of the normal amount of venous flow, the lymphatic system compensates by increasing its transport volume up to 10 times normal amounts.  If the amount of fluid exceeds what the venous and lymphatic systems can transport, secondary lymphedema develops.  If not treated effectively at the onset, this chronic inflammatory condition will lead to deposition of collagen fibers and adipose cells in the interstitial tissue of the affected region, and a different treatment regimen is indicated. 

The risk factors for CVI and lymphedema are very similar, as are the initial complaints of heaviness, tightness, aching, and sometimes sensory changes.  There is initial loss of skin mobility that becomes tighter and less mobile as the condition progresses, thus limiting range of motion and impairing function.  One of the clinical symptoms that may differ is the extent of edema.  In CVI the edema is usually limited to below the knee, whereas in secondary lymphedema it may progress up the thigh.  The skin changes are similar to CVI; however, there may also be a positive Stemmer sign in which the clinician is unable to pinch or tent the skin the distal foot. 

The table below emphasizes some of the differences in treatment strategies for CVI and lymphedema. 

Strategies to Optimize Venous and Lymphatic Flow

Exercise

Compression Therapy

Precautions

For lymphedema:

Diaphragmatic breathing.

Range proximal joints first and move distally; begin with active and gradually add resistance.

Aerobic exercise.

End exercise session with diaphragmatic breathing.

Muylti-layer compression bandages with short-stretch bandages

Intermittent compression pumps

Garments to assist in maintaining reduction of lymphedema. Best used after physical therapy reduces the lymphedema.

 

Maintain healthy skin.

Wear non-restrictive clothing.

Avoid excessive weight gain.

For venous insufficiency without lymphedema:

Ankle mobilizations and stretches.

Ankle pumps.

Heel/toe raises, sitting and progress to standing.

Walking with exaggerated heel/toe sequence.

Multilayer compression systems.

Semi-rigid compression with short stretch bandages.

Compression stockings measured to fit the individual

Garments essential for prevention of venous dysfunction after DVT to prevent CVI.

Intermittent compression pump as adjunct to self-management program.

Avoid prolonged sitting with legs crossed.

Avoid prolonged standing.

Wear non-restrictive clothing.

Avoid smoking.

 

The primary differences are in the exercises and compression.  CVI exercises focus on activating the venous pump, i.e. gastroc-soleus muscles, whereas lymphedema exercises focus on return of the lymph fluid to the central system via deep breathing exercises, joint range of motion to compress lymph nodes, and aerobic exercises.  Compression for CVI (without arterial compromise) consists of a multi-layer system from the toes to just below the popliteal fossa because the purpose is to get the fluid to the popliteal vein.  Compression for lymphedema usually is from toe to thigh and consists of multiple layers of foam, gauze rolls, soft padding, and short stretch bandages of various widths.  Compression is combined with manual lymphatic drainage to mobilize the fluids prior to application of compression.

Successful long-term treatment of both disorders involves continued compression therapy with the appropriate length garments, exercise, and meticulous skin care.  A complete discussion of lymphedema, its physiology, pathophysiology, differential diagnosis, and treatment is available at the following link: 

Perdomo M, Hamm R.  Lymphedema. In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2nd edition.  New York: McGraw Hill Education.  2019, 145-169.  Available at https://accessphysiotherapy.mhmedical.com/book.aspx?bookid=1334

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Rose Hamm

Physical Therapy, University of Southern California

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