What is lymphoedema? 

Lymph is a clear fluid that plays an important role in the body’s immune system. It contains water, proteins, white blood cells, and other substances that leak out of our tiniest blood vessels, called capillaries, into the surrounding tissues. 

These capillaries are the smallest and thinnest blood vessels in the body, and they allow the exchange of nutrients and waste between the blood and tissues. The leaked fluid, now called lymph, gathers temporarily in the spaces between cells (also called interstitial spaces).

From there, the lymph travels through a network of vessels known as the lymphatic system, which includes small filtering structures called lymph nodes. These nodes help filter out harmful substances, like bacteria and viruses. Eventually, the lymph is returned to the bloodstream, helping to maintain fluid balance in the body. You can find your lymph nodes in the armpit, under your jaw, and in the groin and numerous other places. 

However, this normal circulation of lymph can be disrupted, especially after medical treatments such as surgery or radiation therapy used to treat cancer. These treatments can damage or remove parts of the lymphatic system, such as lymph nodes. 

When this happens, lymph fluid cannot flow properly through its usual channels. Instead of draining away, it builds up in the soft tissues, most commonly in the arms or legs, causing noticeable swelling. This persistent swelling is called lymphoedema.¹

Management and complications of severe lymphoedema

Severe lymphoedema means swelling caused by chronic (long-term) lymph buildup, which impairs movement in the affected limb, heightens the chances of skin infections and sepsis, and may result in skin alterations and deterioration. 

To manage the swelling, healthcare professionals may recommend compression wraps, massage, compression stockings, sequential pneumatic pumps, diligent skin care, and occasionally, surgery to eliminate swollen tissue or establish new drainage pathways.²

Stages of lymphoedema

Refers to progressive changes that occur:³

• Stage 1: No symptoms, in which the lymph system has unusual flow but no fluid build-up
• Stage 2: Swelling, due to a build-up of lymph fluid that may go down when raised
• Stage 3: Ongoing swelling that cannot be eased through raising, along with changes in the skin (hardening)
• Stage 4: Lymph build-up, elephant skin, or the misshaping of a limb due to strong swelling, skin thickening, and scarring

How Lymphoedema affects the body over time

Fluid accumulation and chronic swelling

The progressive buildup of fluid, high in protein, within the interstitium and fibro-adipose tissue surpasses the lymphatic system's ability to move the fluid. This persistent swelling linked to lymphoedema can occur in any part of the body, such as the arms, legs, genitals, face, neck, chest area, and mouth.⁴

Changes in tissue composition

The chronic presence of protein-rich fluid triggers an inflammatory response that triggers fibroblasts to produce collagen, leading to fibrosis (hardening of the affected tissues) in patients with lymphoedema. Enhanced adipogenesis (formation of fat cells) takes place in the impacted limb, leading to both limb swelling and tissue rigidity.⁵

Impact on surrounding structures (muscles, tendons, joints)

Lymphoedema impacts patients' health in certain ways. Long-term lymphoedema can impact the surrounding tissues, joints, and muscles, resulting in damage. The hardening of skin and joints causes stiffness and limits mobility in people with lymphoedema and affecting daily activities. Moreover, the changes in soft tissue and skin cause infection to occur, like cellulitis, which damages lymphatic vessels and worsens the condition.²

Joint issues caused by long-term lymphoedema: 

Reduced joint flexibility and range of motion

Chronic lymphoedema restricts joint movement because of ongoing protein accumulation in the adjacent tissues, leading to stiffness and hardening of the joints. This might restrict mobility and flexibility, impacting daily activities like bending, walking, typing, putting on shoes, etc.⁶

Joint stiffness and discomfort

The accumulation of lymphatic fluid and associated tissue changes results in hardness and stiffness of the joint, causing pain and discomfort.

Secondary joint degeneration 

Chronic lymphedema can change movement mechanics, increasing stress on the joints, which over time may speed up wear and tear, possibly resulting in secondary joint degeneration.

Risk of inflammation (arthritis-like symptoms)

The long-term inflammation linked to lymphoedema can elevate arthritis-like symptoms, including joint discomfort, swelling, and limited mobility.³

Mobility challenges related to lymphoedema

• Swelling and tissue alterations due to lymphoedema can significantly impair the ability to walk, bend, or lift, restricting everyday tasks 
• Muscle weakness due to inactivity or limited mobility 
• Alterations in walking or standing
• Changed limb function and ongoing swelling can lead to significant alterations in gait or posture over time
• Exhaustion resulting from the greater exertion needed for mobility - The added effort needed to shift a swollen limb often leads to tiredness and low stamina 

Management and prevention strategies

What are lymphoedema treatments?

There is no cure for lymphoedema; however, there is a range of treatments available that differ based on the cause and stage of your condition. 

Options for treatment could involve:

• Physical therapy 
• Alternative methods to promote lymphatic fluid circulation to alleviate swelling and discomfort
• Your healthcare provider might also recommend antibiotics for infections or pain relief medication

What are the physical treatments for lymphoedema?

Lymphoedema treatment involves a combination of physical therapy and compression garments to reduce swelling and lymphoedema complications. Compression garments, such as socks, sleeves, or wraps, help move fluid from affected areas back into circulation. 

Physical therapists use manual lymphatic drainage (MLD) to stimulate circulation. Multilayer compression bandaging is used to exert consistent pressure on swollen areas, while compression devices provide on-and-off pressure to keep fluid moving through lymph vessels and veins. 

Elevation is another crucial step to prevent lymphedema complications, whereby it is recommended to sleep with the affected limb elevated above your head, with a pillow under the leg, for example, to help the fluid drain overnight or when you are resting. 

Exercise is also essential to stimulate lymphatic drainage.⁷

Exercise and lymphoedema in breast cancer survivors

A study investigated the safety of physical activity for breast cancer survivors who have or were at risk for lymphoedema. Various exercise types were examined, such as resistance training, combined with aerobic-resistance workouts, and additional physical activities. 

The results indicate that gradually increasing exercise did not worsen or lead to the onset of lymphoedema in survivors of breast cancer. In particular, resistance training was recognised as safe and did not elevate the risk of lymphoedema in at-risk people, contrary to some previous worries. Moreover, the synthesis of aerobic and resistance training seemed to be safe for survivors.

The findings highlighted that carefully monitored and progressive exercise programs can boost physical fitness, lessen fatigue, and improve the general quality of life for survivors while not aggravating or causing lymphoedema symptoms. This highlights the significance of including physical activity in care strategies for cancer survivors and those with lymphoedema.⁸

Summary

• Chronic lymphoedema leads to ongoing swelling that limits joint mobility and decreases the range of motion 
• Persistent inflammation and alterations in tissue composition result in joint rigidity and pain, which can complicate regular movements
• Limb mechanics change due to swelling, leading to greater wear and tear on the joints, increasing the chance of secondary joint degeneration
• Muscle weakness arises from lack of use and limited movement, which in turn diminishes mobility and stability
• Greater exertion needed for movement leads to tiredness, fatigue, and an abnormal gait or stance, as the body adjusts to the impacted limb