Lymphedema and Musculoskeletal Dysfunction
Lymphedema is defined as localized swelling of the body, most often an extremity, caused by an abnormal accumulation of lymphatic fluid, or lymph. It can also occur in the face, neck, abdomen or genitals. Lymph contains a variety of substances that are products of tissue metabolism and catabolism, including proteins, salts, fats, glucose, water and white blood cells. The lymphatic system has the ability to remove waste and other products that are released from the tissues, which gives rise to a fluid that is more dense than that of the circulatory system. While there are strategies you can implement to decrease your risk of lymphedema, it cannot always be prevented. It is often impossible to know where we stand individually in this regard. Some individuals are born with abundant lymphatic systems which can withstand tremendous strain and insult before failing. Others have a less resilient system which does not offer sufficient reserve capacity to compensate for the lymphatic load.
There are two types of lymphedema, primary and secondary. Primary lymphedema is due to imperfect development of the lymphatic system and is present at birth. Secondary lymphedema may be the result of surgery, radiation, cancer, trauma, infection, obesity, chronic venous disease or can be self induced. The most common cause of secondary lymphedema is cancer and its treatments. The two biggest risk factors of secondary lymphedema include lymph node dissection (this is correlated with the extent of the dissection) and radiation treatment. Other risk factors are obesity, advanced disease progress at diagnosis, post-surgical drainage/seroma, recurring infection and venous and arterial blood flow abnormalities.
Lymphatic System Functions + Anatomy
The lymphatic system functions in three ways:
1. To return proteins and water from the tissues back to the blood stream
2. To absorb proteins, fat and fat-soluble vitamins through the lymph vessels
3. To recognize and respond to foreign cells, microbes and defend the body against disease
The lymphatic system primarily consists of lymphatic vessels and lymph nodes, but also includes other lymph organs including the tonsils, spleen and thymus. Let’s take a look into each components overall function:
Lymphatic vessels: similar to the circulatory system's veins and capillaries, these are connected to the lymph nodes and, eventually, the circulatory system, they are the roadway to return lymphatic fluid into circulation
Lymph nodes: 600-700 in the body, produce and store cells that fight infection and disease, filtering system for foreign particles and cancer cells
Tonsils: first line of defense as part of the immune system, they sample bacteria and viruses that enter through the nose and mouth
Spleen: largest lymphatic organ, acts as a blood filter and helps fight infection by creating lymphocytes, along with the lymph nodes, which act as defender against invaders
Thymus: stores immature lymphocytes and prepares them to mature into T-cells, T-cells help destroy infected cells
Stages of Lymphedema
There are 4 stages of lymphedema. They are identified as stages 0-3, each stage represented by specific swelling and tissue characteristics which are explained below:
Stage 0: defined as latent or non-visible lymphedema. The swelling is not evident despite impaired lymph transport. Clients will often complain of tightness of the skin or heaviness of the involved area even though there is no swelling seen.
Stage 1: defined as mild or spontaneously reversible lymphedema. This staged is marked by mild swelling which typically starts in the furthest part of the limb and slowly moves upward as it worsens. The swelling may improve at night or disappear completely, only to come back as the day progresses.
Stage 2: defined as moderate of spontaneously irreversible lymphedema. The skin will take on a more spongy appearance in this stage and “pits” less when you press gently on the skin due to fibrosis and gradual thickening. At this stage swelling rarely reduces with just limb elevation and requires an increase in edema management strategies.
Stage 3: defined as severe of lymphostatic elephantiasis lymphedema. In stage 3 lymphedema the skin typically becomes hard and scaly and enlarges significantly. There may be leakage of the lymph fluid from breaks in the skin. Skin lobules are common and skin folds can become problem areas to keep clean and dry and free of infection.
Lymphatic Transit + Flow
One of the primary functions of the lymphatic system is lymph transit. This system, unlike the circulatory system, flows in one direction and is designed to carry fluid away from the tissues. A second characteristic differing the lymphatic system from the circulatory system is that the lymph transit does not rely on an organ system pump, rather it is dependent on body movement, muscle movement and breathing. The lymphatic vessels connect to two larger lymphatic ducts which then transit fluid into the two subclavian veins (under the collar bone) that are present on each side of the body. The right duct drains the right upper extremity, right side of the thorax and the right half of the neck and face. The left duct drains the remainder of the body.
Traditional Treatment Approach for Lymphedema Management
Traditionally, lymphedema management is approached with complete decongestive therapy, or CDT. This is considered the gold standard for lymphedema management. CDT is a therapy program that is divided into two phases: Phase I, the decongestion phase, and Phase II, the maintenance phase.
The goal of Phase I is to decrease the swelling in the affected area while maintaining healthy skin. There are four basic components to phase I:
1. Manual Lymph Drainage (MLD): a light, skin stretching massage that helps promote the movement of lymphatic fluid out of the affected area, a Certified Lymphedema Therapist (CLT) who has been specially trained in MLD should perform this therapy as there are certain contraindications to CDT, so it is very important that the clinician be properly trained.
2. Compression Therapy: multi-layered bandaging to help move the extra fluid out of the involved region, this specific bandage application is designed to work with body movements to enhance lymphatic return.
3. Exercise: the muscle pumping action, especially combined with the resistance of the compression garments or bandaging, helps move fluid out of the limb.
4. Skin Care: healthy skin and nails will help prevent infections, diligent skin care will be an important component throughout the lifetime of management.
The goal of Phase II is to preserve the results from Phase I treatment. The four components of Phase II treatment are the same as in Phase I.
For more information on skin and nail care management, please visit the handouts page of my website for a free informational download!
Neuromusculoskeletal Considerations for Treatment
Let’s now consider a more holistic management of lymphedema with a focus on clients who are experiencing secondary lymphedema.
If the lymphatic system works via body movement, muscle movement and breathing then, as clinicians, we need to address the musculoskeletal fallout that occurs following trauma, surgical procedures and radiation, otherwise the lymphatic system will remain compromised. Consider this, if a joint is not moving properly or if there is dysfunction within the muscular system that is preventing full or proper movement strategies, then the client will be unable to fully utilize body and muscular movement to promote lymphatic transit. Additionally, what if the client is unable to properly perform a diaphragmatic breath? The same principle applies here, there will be a decrease in lymphatic transit if there is difficulty obtaining proper recruitment of the diaphragm during breath cycles.
What we know about tissue dysfunction…
What happens to the microenvironment when a tissue is dysfunctional? Tissue dysfunction results in the presence of biochemicals in the surrounding environment, inclusive of introducing these chemicals into the lymphoid microenvironment. In recent studies, researchers examined the overall concentration of biochemicals that are found in and around dysfunctional tissue. The outcomes showed elevated concentrations of the biochemicals that increase tissue nociception (pain), increase inflammatory cascades in the region and systemically, lower the pH of the environment and increase the activity of our sympathetic nervous system (1-3).
Neurology and the lymphatic system
The sympathetic nervous system is part of the autonomic nervous system, which also includes the parasympathetic nervous system. An imbalance between the sympathetic and parasympathetic branches of the autonomic nervous system can keep the body in a fight or flight mode, contributing to a sluggish movement of lymph fluid.
Recent studies have also provided us with the following information as it relates to the direct neural influences of the lymphatic system:
1. the immune and nervous systems are anatomically and functionally interconnected (4)
2. there is dense innervation, mainly sympathetic fibers, of the primary and secondary lymphoid organs (5)
3. the sympathetic and parasympathetic nervous systems are present on the lymph vessels themselves (4,6)
How does this apply to treatments?
We know that neuromuscular dysfunction is a direct side effect associated with the treatments and procedures that often precede development of secondary lymphedema. The dysfunction leads to the presence of biochemicals, increased acidity within the environment and activation of the sympathetic nervous system (1-3) which can all contribute to neurogenic and chemogenic shutdown of the systems, including the lymphatic system.
We also know that by treating the underlying neuromuscular dysfunction of the tissues we can influence the presence of the biochemicals within the local and corresponding tissue environments (3), inclusive of the microenvironment of the lymphatic system. By addressing the dysfunction, we can see an improved homeostasis of the tissue, restoring normal pH and reducing the biochemicals responsible for increasing the pain response, increasing inflammatory cascades and stimulating the sympathetic nervous system (1-3). By restoring tissue homeostasis, this will theoretically assist in promoting healthier functioning systems, including the lymphatic system.
Furthermore, by applying sympathetic downregulation techniques, we can reduce the activity of the sympathetic nervous system and increase the activity of the parasympathetic nervous system. This can also lead to increased health of the lymphatic system and improvement in lymphatic transit.
When considering sequencing our treatment, it would make sense to focus on the clearing the neuromuscular dysfunction prior to performing the components of complete decongestive therapy.
When holistically treating the body we should see an overall improvement in lymphatic return. It will be important to treat the local tissues, but also equally important to clear the tissues proximal to the region affected by lymphedema, just as we do with manual lymphatic drainage. This will ensure more effective body movement and muscle movement globally which will enhance the movement of lymph throughout the entire lymphatic system.
To health + wellness for your lymphatics,
1. Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, Gerber LH. Biochemicals Associated with Pain and Inflammation are Elevated in Sites Near to and Remote From Active Myofascial Trigger Points. Arch Phys Med Rehabil. 2008; 89:16-23.
2. Shah JP and Gilliams EA. Uncovering the Biochemical Milieu of Myofascial Trigger Points Using In Vivo Microdialysis: An Application of Muscle Pain Concepts to Myofascial Pain Syndrome. Journal of Bodywork and Movement Therapies. 2008; 12:371-384.
3. Hsieh Y, Yang S, Yang C and Chou L. Dry Needling at Myofascial Trigger Spots of Rabbit Skeletal Muscles Modulates the Biochemicals Associated with Pain, Inflammation and Hypoxia. Evidence-Based Complementary and Alternative Medicine. 2012; 1-13.
4. Kenney MJ and Ganta CK. Autonomic Nervous System and Immune System Interactions. Compr Physiol. 2014 July; 4(3):1177-1200.
5. Anagnostou V, Doussis-Anagnostopoulou I, Tiniakos D and Kittas C. Innervation of the Human Thymus and Spleen - an Overview. Brain Immune Trends, September 14, 2010. http://www.brainimmune.com/innervation-of-the-human-thymus-and-spleen-an-overview/
6. Mignini F, Sabbatini M, Coppola L and Cavallotti C. Analysis of Nerve Supply Pattern in Human Lymphatic Vessels of Young and Old Men. Lymphatic Research and Biology. 2012; 10(4):189-97.