Lymphoedema is a swelling that results from a dysfunction of the lymphatic system. The dysfunction can be a result of:

• some inadequacy in the growth or development of the lymphatic system
• injury such as severe burns, lacerations, crush injuries, severe infections
• medical intervention for cancer which may either result in the surgical removal of lymph nodes or radiation to lymph nodes
• a particular parasitic infection

Treatment for cancer is probably the most widely recognised cause of lymphoedema in western society.

For a person who has been treated for cancer where the lymph nodes have been sampled, removed or irradiated, there may be swelling in the closest limb and the quadrant of the trunk which adjoins the surgery. More specifically, if the groin or abdominal lymph nodes have been affected, the leg on that side, the lower abdomen, buttock and genitals may be swollen. If the armpit lymph nodes are affected, then the arm, chest and upper back on that side may be swollen.

The swelling normally starts at the top of the limb or on the trunk and may be very variable at first, increasing with activity or during the day and disappearing overnight. As time progresses, the swell tends to spread lower on the limb and remains longer. Also, the nature of the swelling will change from pitting oedema (depression left by finger when swelling is pressed) to a more fibrotic (more wooden) oedema.

For arm lymphoedema, often the first complaint is of being unable to put the arm close by the side. Many women feel as though there is a ball of swelling at the back of the armpit. Otherwise, it is often noticed if jewellery becomes tight, or the tendons on the back of the hand become obscured by swelling.

Leg lymphoedema is often picked up when underwear or trousers become tight on one leg, or there is a greater dent from socks or stockings.

Lymphoedema is NEVER the cause of sharp, severe pain unless the swelling results in compression of nerves. Many people complain of aching, heaviness, tightness or a bruised feeling in the swollen area.

Chronic swelling that is not a result of lymph node damage can also be lymphoedema. Lymphoedema is simply oedema (fluid retention) which results from an impairement of the lymphatic system. There are various genetic (inherited) conditions which result in poor development of the lymphatic suystem, These may become apparent at birth, at puberty, or later in life when we start slowing down or sustain an injury. The oedema can range from a swollen ankle following a plane flight which persists for a couple of hours once you become active again, to grossly swollen limbs which limit movement and hygeine, and make buying clothing and footwear extremely difficult.

Chronic swelling which is caused by heart disease, liver disease, or kidney disease is not lymphoedema, and should be managed by your medical specialist.

The lymphatic system is basically a garbage collection system for the connective tissue (i.e. muscle, fascia, skin etc). Within the connective tissue, capillaries leak fluid from the blood into the tissue, carrying essential nutrients to the cells. This fluid then collects the waste from the connective tissue and moves into lymphatic vessels. The lymphatic vessels transport the proteins and large particles to the lymph nodes where they are filtered. The resulting fluid (waste) is then emptied into the large veins behind the collar bones, and is excreted from the body via the kidneys.

If the lymphatic vessels are damaged, or the lymph nodes are removed,there is a backlog of protein trying to exit from the tissues, resulting in waste protein not being cleared. If this protein cannot find another pathway to an intact part of the lymphatic system, more fluid is drawn into the tissues in that area, and it appears waterlogged. That is lymphoedema.

When a part of the body is injured, there will be a certain amount of leakage of blood from broken capillaries, as well as an infiltration of repair materials to mend the rift. This is seen as bruising and swelling. When this occurs, the lymphatic system will then increase the rate of drainage to clear out the leaked blood and damaged tissue. Once this has gone the swelling will subside. If the lymphatic system is damaged in the injury, or there is excessive damaged tissue, some of the waste may congeal before the lymphatic system can remove it. In this case there may be persistent swelling.

Heart failure, kidney failure, varicose veins and arthritis are also associated with swelling. These occur for various reasons, but it is still the lymphatic system which is usually responsible for returning the fluid from the swelling back into the circulation.

"At risk" people are those people who have had some damage to the lymph nodes, but have no swelling (yet). Many of these people are eager to learn ways that they can minimise the risk of developing lymphoedema.

The following methods are not foolproof, but will help some people to avoid lymphoedema:

• skin care: the skin is an excellent barrier to the bugs and germs which are present around us. Healthy, supple skin will withstand a certain amount of trauma before being torn, so we advise people to moisturise the limb after showering, and more often if the skin is dry. Additionally, care should be taken to limit skin cuts and tears in the garden, the kitchen, the workshop, around pets, avoid insect bites and avoid sunburn. If a patient has had armpit lymph nodes removed, we will normally advise against having blood taken from that arm, having vaccinations in that arm, or having intravenous drips put in that arm as occasionally these have resulted in inflammation of the vein. Obviously if it is a life or death situation, the lymphoedema does not become a priority.
• stay cool: a hot environment will result in dilation of skin capillaries and leakage of blood fluid into the surrounding tissue resulting in some swelling in all of us. This is normally rectified at night when the temperature reduces, and the lymphatic system returns the fluid to the circulation. If the function of the lymphatic system is diminished, the swelling may not resolve in a short time. Therefore in the hot, and especially humid weather, it is better to stay in airconditioning, or somewhere cool. Also, remember to stay hydrated in hot weather.
• avoid tight clothing: there is a fine network of lymphatic vessels lying between the skin and the muscle underneath. Tight clothing, rings or watchbands (those which leave a red ring) may compress the lymph vessels and impair their drainage, especially if the assault is repeated.
• maintain a healthy body weight: increased body fat will not only squeeze the lymph vessels in the skin, but due to the extra blood vessels and burden on the heart, will result in more fluid leaving the blood system to be recycled by the lymphatic system. Unfortunately some of the hormone treatments for cancer increase the appetite, so a lot of breast cancer patients find it hard to maintain their ideal weight. Exercise is probably the best way to counter this, however, fitness needs to be increased gradually to allow the lymphatic system time to increase its clearing capacity. Low impact exercise is preferred since it is associated with lower injury levels, and rhythmical exercise rather than static holding exercise is more gentle on the lymphatic system.
• wear a light but well fitting compression garment on the limb when flying in a plane, or at a high altitude: No-one is absolutely sure of the mechanism which can trigger lymphoedema at lower air pressures, but a significant number of people can trace the onset of their lymphoedema to plane flights. Wearing a compression garment is cheap insurance.
• be active, flexible, and strong:the body's own mechanism for aiding lymphatic drainage is movement. Muscles working around lymphatic vessels both contracting and relaxing move the lymphatic fluid into, and then up through the lymph vessels. Tight muscles which chronically contract, and scar tissue, can create areas where lymph flow is impeded. Gentle active stretching of these tight areas can have a huge effect on overall limb swelling. Likewise, deep breathing helps to drain lymph fluid back into the blood because of the pressure change in the chest.

No! Occasionally patients are angry that healthy lymph nodes have been removed or destroyed when that person has ended up with lymphoedema. Unfortunately lymph node sampling is the least invasive, early way to determine if there is a likelihood of the tumor already having spread. If the lymph nodes are simply left when they do have tumor cells present, the resulting tumor growth will definitely result in a lymphoedema which is very hard to control. Surgical methods are improving for minimising the lymph node damage, such as a sentinel node biopsy prior to clearance of lymph nodes. If the sentinel lymph node is clear of tumor cells at the time of surgery, then there is a good chance that the rest of the lymph nodes will also be clear. In this case the surgeon may elect not to complete the lymph node clearance.

Because lymphoedema is associate with retained protein in the connective tissue, many people ask whether or not they can control it with diet. The waste protein has been digested, reassembled, integrated into body tissue and is now obsolete. So, eating a low protein diet will not assist with controlling lymphoedema. However, a sensible balanced diet, with lots of fresh fruit and vegetables, which helps to maintain a healthy weight is recommended. However, if you ar aware of food which causes bloating or discomfort, it may be better to avoid these foods.