Lymphedema is a stagnation of lymph fluid which results in swelling in any area of the body, most often noted in the arm or the leg. Lymphedema is a progressive condition characterized by four main components:

• Excessive protein in the tissues

• Excessive fluid in the tissues

• Chronic inflammatory reactions

• Excessive deposition of fibrous tissue.

If untreated, lymphedema can result in an abnormal amount of protein fluid collecting in the tissues of the extremity. This stagnate, protein rich fluid not only causes tissue channels to increase in size and number, but also reduces oxygen through the port system, which interferes with wound healing and provides a culture of medium for bacteria that can result in various infections. A chronic inflammatory condition stemming from this accumulation of fluid eventually results in fibrotic or hardened tissues.

Primary Lymphedema is typically related to an abnormal formation of the lymphatic system in utero. The symptoms may be noted at any point in the life of the person, however many we see have some commonalties.

Often patients first note swelling of a limb during pregnancy. Typically edema associated with pregnancy occurs in the last trimester and usually will resolve within 2-3 weeks after birth. If one limb, in particular, does not reduce, check with your physician. This could be related to the venous system but may also be the onset of a congenital lymphedema. I once saw a client whom with her first pregnancy her right leg began to swell. With her second pregnancy her right arm and left leg began to swell. This is an extreme case. Most often, a client will note one swollen extremity or a combination of two with one most often worse than the other.

A typical age for adult onset lymphedema is around 35-40 years old. People often ask why now, why did I not swell much younger. The lymphatic's developed adequately enough to maintain the lymph workload for many years, but as we age the body's abilities slowly decline. At some point the decline reaches the lymphatic maximal capabilities and edema becomes evident.

B. Secondary Lymphedema

This is lymphedema that is caused by many other sources, but not related to a defect in lymphatic formation. Secondary lymphedema can be related to many causative factors such as; trauma, surgery related to cancer, radiation, venous insufficiency etc. Many of the clients we see have undergone mastectomy's with lymph node removal and often radiation. Lymph nodes are responsible for processing lymphatic fluid. If these nodes are removed leaving less 'workers' to carry on the extra workload, a backup can occur. As an example, if you have 10 factories processing so many orders a day and you close 5 of these factories, without charging the amount of orders production slows down causing a backup to occur.

Radiation and the surgical procedure itself can also lead to scarring. Radiation can scar some of the lymph nodes that are remaining leaving the system further compromised. Scarring associated with the surgical incisions can further block lymphatic fluid.

No! It is not your physician's fault that you are swollen. Your physician did all he/she was able to do to save your life, to rid you of your cancer. Lymphedema, unfortunately, is a side effect of the treatment, but the treatments had to be done.

Here are a few reasons why this might be:

• The number and size of lymph nodes removed.

• Amount of scar tissue formation.

• Some individuals have an extra bundle of lymphatic vessels present.

• Radiation can cause additional damage.

• Clothing fitting tighter on involved extremity

• Ring or other jewelry notably tighter or cutting into the skin

• Feeling of heaviness, Achiness, tight sensation in the involved extremity.

• Visible swelling of the limb

• Pitting of the skin

1. Skin becomes increasingly drier

2. Skin becomes discolored (Picture)

3. Chronic bouts of infection/cellulites

4. Chronic fungal infections (lower extremities)

5. May note clear drainage from the pores of your skin (lymphatic fluid seeping from pores)

6. Skin texture changes occur. May feel like that of an orange peel.

7. As edema progresses blisters may begin to appear leading to non- healing or very slow healing wounds.

Without treatment, lymphedema symptoms will fluctuate, going up and down. As time progresses, so will the lymphedema condition. I like to compare your skin to that of a new sock. When you first put on that new sock, it's nice and tight. It stretches out throughout the day, but when you wash and dry it, the tightness comes back. Over time, through repetition of stretching and tightening, the new sock becomes an old sock that no longer tightens up. Your skin is like this. In the beginning you see flucuations in your swelling often going up during the day and down at night. Over time you may see very little change from one day to the next. As the extremity continues to swell and reduction is no longer noted, you have now reached the 'old sock' phenomenon.

Well, that little swelling contributes to a reduction of nutrients to the skin. The swelling is a buildup of infectious waste, bacteria, and other things you would not want sitting around. The Lymphatic System is the sewer system of the body and if that plumbing gets backed up, many undesirable things can occur. (see question #5) A little swelling can lead to a lot of swelling, which results in reduced mobility, changes in clothing and shoe sizes, pain, infection, wounds, amputations, and in some cases rare forms of cancer.

1. Maintain a well balanced diet, with low sodium intake. Keep a healthy weight, avoid obesity. Good nutritional guidelines are provided by the American Health Association and the American Cancer Society.

2. Keep the affected arm or leg clean and well moisturized. Lotion should be at a relatively low pH balance. The goal is to prevent skin breakdown. Skin breakdown allows bacteria to enter the limb, causing infections to occur.

3. Use hypo-allergenic soap when washing. Anti-microbial soaps are very drying.

4. Avoid injections, vaccination, flu-shots, blood draws and IV lines in the affected extremity.

5. If at all possible, avoid having blood pressure taken in affected arm. Every hospital and doctors office should have blood pressure cuffs for the leg. Do not be afraid to inquire about this before your scheduled appointment. If you are going to have surgery, make a sign and place it above the bed 'no blood pressure in the involved arm.'

6. Many people enjoy having a manicure. There is always a risk with this but you can decrease your risk by keeping your cuticles moist with lotion and push them back instead of cutting them. You could also consider buying your own manicure set and have the salon use only your tools.

7. When cleaning the house, wear a good quality rubber glove when handling harsh chemicals such as ammonia, bleach, furniture polish, abrasive cleaners etc. It is important to wear protective gloves when working in the garden, the yard, and the garage.

8. Avoid using a razor or chemical creams for the armpit and leg hair. The safest would be an electric razor.

9. When cooking, wear long protective mitts (to the elbow) when taking food out of the oven and when boiling a pot of water, soup, etc.

10. It is important to avoid pet scratches, insect bites, spider bites etc. If you would like to hike avoid times when flies and mosquitoes are in season. Using an insect repellent may be necessary but remember some brands are very harsh. Look for a natural insect repellent if possible.

11. Avoid sunburn at all cost!! Especially if you have received radiation therapy or are currently ongoing chemotherapy.

12. Beware of items that can cause a burn such as curling iron, space heaters, etc.

13. Avoid saunas, hot tubs, showers. Avoid extreme temperatures, very cold, or very hot.

14. Avoid lifting or moving heavy objects.

15. Avoid tight fitting clothing and jewelry.

16. Exercise, and be knowledgeable of how exercise affects the lymphedema.

17. Check your skin daily, call your physician immediately if you notice any adverse changes in the effected limb. Fever/chills, warmth with redness in the limb are examples to seek immediate attention.

Additional Precautions for Leg Lymphedema

18. Proper shoe wear is essential in avoiding blisters and in grown toenails, avoid high heeled shoes.

19. Do not walk bare foot, especially outside.

20. Get all fungal infections treated immediately

• In 2001, a study of 950 modified mastectomy clients revealed 49% of the survivors had lymphedema.

• 2-3 million cases of secondary and 1-2 million cases of primary lymphedema are currently in existence in the United States.

• In 2004, 400,000 mastectomy clients and 440,000 clients with vascular insufficiencies suffered from the effects lymphedema.

• A recent study in New England Journal of Medicine found at least 60% of women with radical mastectomies and 30% with modified mastectomies experienced lymphedema.

Unfortunately, there are no regulations in place to govern who can treat a client with lymphedema. You may have a therapist who watched another therapist treat a patient, and now considers themselves more than qualified to treat you. You may have a therapist who has taken a weekend course and you're his first patient and you have stage III Lymphedema. You should always ask if they therapist has been nationally certified by the lymphology association of North American (LANA). LANA has very strict guidelines. To be certified you must have taken a 130 hour Lymphedema course. You also must have treated Lymphedema patients for 1 year and passed an extensive certification exam in lymphedema.