Grades of Lymphedema

Grades of Leg Lymphedema

In establishing a more accurate 'staging" system for lymphedema, a Lymphedema Grades list has been proposed.

In the grading system, lymphedema can (like stages) be categorized by its severity (usually referenced to a healthy extremity)

• Grade 1 (mild edema): Lymphedema involves the distal parts such as a forearm and hand or a lower leg and foot. The difference in circumference is less than 4 centimeters, and other tissue changes are not yet present.

• Grade 2 (moderate edema): Lymphedema involves an entire limb or corresponding quadrant of the trunk. Difference in circumference is more than 4 but less than 6 centimeters. Tissue changes, such as pitting, are apparent. The patient may experience erysipelas.

• Grade 3a (severe edema): Lymphedema is present in one limb and its associated trunk quadrant. The difference in circumference is greater than 6 centimeters. Significant skin alterations, such as cornification or keratosis, cysts and/or fistulae, are present. Additionally, the patient may experience repeated attacks of erysipelas.

• Grade 3b (massive edema): The same symptoms as grade 3a, except two or moreextremities are affected.

• Grade 4 (gigantic edema): Also known as elephantiasis, in this stage of lymphedema, the affected extremities are huge due to almost complete blockage of the lymph channels. Elephantiasis may also affect the head and face.

Stages of Leg Lymphedema

Stages of Leg Lymphedema

There are three basic stages active of lymphedema. The earlier lymphedema is recognized and diagnosed, the easier it is to successful treat it and to avoid many of the complications.

It is important as well to be aware that when you have lymphedema, even in one limb there is always the possibility of another limb being affected at some later time. This “inactive” period referred to as the latency stage. It is associated with hereditary forms of lymphedema.

LATENCY STAGE or STAGE 0

Lymphatic transport capacity is reduced No visible/palpable edema Subjective complaints are possible

STAGE I

(Reversible Lymphedema) Accumulation of protein rich edema fluid Pitting edema Reduces with elevation (no fibrosis)

STAGE II

(Spontaneously Irreversible Lymphedema) Accumulation of protein rich edema fluid Pitting becomes progressively more difficult Connective tissue proliferation (fibrosis)

STAGE III

(Lymphostatic Elephantiasis) Accumulation of protein rich edema fluid Non pitting Fibrosis and sclerosis (severe induration) Skin changes (papillomas, hyperkeratosis, etc.)

STAGE IIII

The limb is so densely fibrotic that it is not possible to make any indentation when pressed. It becomes impossible for ultrasound testing to pick even the blood pulse. The skin becomes brittle and even the slight of bumps causes a serious, extensively weeping wound. Because of the hardness of the tissue, it has become a total septic foci for bacteria and constant cellulitis and systemic infections become the norm. The only treatment for cellulitis is an extended period of IV antibiotics.

There is no treatment option for Stage Four. The complete focus is on management, containment of infections, prevention if at all possible of amputation.

Stage four information is strictly my own thinking as many do not yet recognize as Stage Four, while others have even mentioned a stage Five.

A new staging system has been set forth by Lee, Morgan and Bergan and endorsed by the American Society of Lymphology. This provides a clear technique which can be employed by clinical and laboratory assessments to more accurately diagnose and prescribe therapy for lymphedema. In this improved version, four stages are identified (I-IV). Physicians and researchers can use additional laboratory assessments, such as bioimpedance, MRI, or CT, to build on the findings of a clinical assessment (physical evaluation). From this, results of therapy can be accurately be determined and reported in documentation, as well as research.

Treatment of Leg Lymphedema

The treatment for arm lymphedema is much the same as treatment for leg lymphedema. The preferred treatment is decongestive therapy.

Secondary Leg Lymphedema

Secondary Leg Lymphedema

Related terms: leg swelling, leg edema, leg lymphoedema

Introduction

If you ask most people that are familiar with lymphedema the question, “Are you aware of secondary lymphedema,” most would reply that “yes, it is where the arm swells after the lymph system has been damaged by breast cancerbiopsy and treatment.” This is called arm lymphedema.

Even if they are aware that such a condition as secondary leg lymphedema exists, their response might well be that it is a small group of afflicted men who have prostate cancer.

Thus shows how little awareness there is about this particular form of lymphedema. Even in the lymphedema world it is a poor step-child.

However, if the membership of Lymphedema People and the posts in the online lymphedema support groups are an indication, this condition is increasing dramatically.

The reasons for this increase are multiple. They include:

1. increased survival rates of cancer 2. improved treatment of trauma injuries that previously would have been terminal 3. increase in antibioticsfor infections and treatment for other conditions that previously might have resulted in death.

It is also important to note that secondary leg lymphedema does not necessarily start immediately after the injury or trauma. It may not start for years.

What is secondary leg lymphedema?

Secondary lymphedema is a condition where the lymphatic system has been damaged. The main job of this system is to move excess through and out of our bodies. When it becomes damaged or impaired, it is no longer able to accomplish this function and these fluids (lymph fluids) collect in the interstitial tissues of our legs. This causes leg swelling.

Another important function of the lymph system is to help our bodies fight infections. With lymphedema, this ability is also weakened and the patient becomes more susceptible to infections.

What causes secondary leg lymphedema?

Secondary leg lymphedema (also referred to as acquired lymphedema) is caused by or can develop as a results of:

1.) Surgeries involving the abdomen or legs where the lymph system has been damaged. This includes any intrusive surgery.

Examples are

vein stripping surgery for peripheral vascular disease hip replacement knee replaement insertion of bolts, screws and other devices in orthopaedic repair lipectomy

2.) Removal of lymph nodes for cancer biopsy. These cancers include, but are not limited to

prostate cancer testicular cancer ovarian cancer uteran cancer vulva cancer bladder lymphoma - both hodgkins and non hodgkinsmelanoma colon Kaposi Sarcoma

3.) Radiation treatment of these cancers that scars the lymph system and lymph nodes

4. Some types of chemo therapy. For example, tamoxifen has been linked to secondary lymphedema and blood clots.

5.) Severe infections/sepsis. Generally referred to as lymphangitis, this is a serious life-threatening infection of the lymph system/nodes.

6.) Trauma injuries such as those experienced in an automobile accident that severly injures the leg and the lymph system.

7.) Burns - this even includes severe sunburn. We have a member that acquired secondary leg lymphedema from this.

8.) Bone breaks and fractures.

9.) Morbid obesity - the lymphatics are eventually crushed by the excessive weight. When that occurs, the damage is permanent and chronic secondary leg lymphedema begins.

10.)Insect bites

11.)Parasitic infections

What are some of the symptoms of secondary leg lymphedema?

These symptoms may include:

1.) Unexplained swelling of either part of or the entire leg. In early stage lymphedema, this swelling will actually do down during the night and/or periods of rest, causing the patient to think it is just a passing thing and ignore it.

2.) A feeling of heaviness or tightness in the leg

3.) Increaseing restriction on the range of motion for the leg.

4.) Unsual or unexplained aching or discomfort in the leg.

5.) Any change involving hardening and/or thicking of the skin or areas of skin on the leg.

Prospective, randomized, controlled trial comparing a new two-component compression system with inelastic multicomponent compression bandages in the t

Prospective, randomized, controlled trial comparing a new two-component compression system with inelastic multicomponent compression bandages in the treatment of leg lymphedema.

2011 Jul

Lamprou DA, Damstra RJ, Partsch H.

Source

Department of Dermatology, Phlebology, and Lymphology, Nij Smellinghe Hospital, Drachten, The Netherlands.

Abstract

BACKGROUND:

New, less-bulky, short-stretch compression bandages could be a valuable alternative in the management oflymphedema of the leg.

OBJECTIVE:

To compare the effectiveness of a two-component compression (2CC) system in the treatment of leglymphedema with that of the traditional treatment with conventional inelastic multicomponent compression bandages (IMC).

METHODS:

Thirty hospitalized patients with moderate to severe unilateral lymphedema (stage II-III) of the leg were included. Patients were divided in two groups; one (n=15) received a 2CC, and the other (n=15) received IMC. Primary outcome was volume reduction of the affected leg; secondary outcome was loss of interface pressure.

RESULTS:

Median leg volumes before bandaging were 4,150 mL (2CC) and 4,360 mL (IMC). Median volume reduction after 2 hours was 120 mL (2.9%) with the 2CC system and 80 mL (1.8%) with IMC (p>.05). After 24 hours, volume reduction was 8.4% and 4.4% respectively (p>.05). Interface pressure dropped significantly within 2 hours of bandage application in both groups.

CONCLUSION:

Our results indicate that the 2CC system forms a suitable alternative to IMC in the conventional treatment of moderate to severe lymphedema.

Wiley Online Library

Intensive decongestive treatment restores ability to work

Intensive decongestive treatment restores ability to work in patients with advanced forms of primary and secondary lower extremity lymphoedema.

Dec 2011

Stanisic MG, Gabriel M, Pawlaczyk K.

Source

Department of General and Vascular Surgery, Poznan University of Medical Sciences, ul Długa 1/2, 61-848 Poznań, Poland.

Abstract

OBJECTIVE:

To show that adequate therapy for lymphoedema is able to restore ability to work.

MATERIALS AND METHODS:

The population of patients with primary lymphoedema registered in the university clinical centre diagnosed with primary or secondary lymphoedema and presumed by the national social institution as completely unable to work was selected for the retrospective analysis and divided into two groups. Group 1 consisted of 25 patients treated with a complex decongestive therapy programme daily for 3-6 weeks. The study population comprised 19 women and six men from 14 to 61 years of age (mean 31.5). In all 25 patients, complete inability to work was certified by the social institution before the treatment started. Group 2 consisted of 47 patients, 14 men and 33 women, aged from 26 to 71 years (mean 39 years) treated by so-called standard methods, who resigned from the proposed intensive treatment. In all 47 patients, complete inability to work was declared by the social institution before the treatment. Ability to work and oedema reduction were assessed by the treating physician.

RESULTS:

The intensive phase of treatment succeeded in 3870-15,330 mL oedema reduction in Group 1. After the end of therapy, 21 patients were able to work or study without any limitation and patients returned to their regular professional activity. Among four others, two were on welfare for at least 10 years, for another one welfare was their only income and one person was receiving a social pension. In none of the patients from group 2 was any significant oedema reduction observed. Every patient from group 2 maintained the social pension due to ineffective treatment.

CONCLUSIONS:

Complex decongestive therapy is a very efficient form of treatment in advanced primary and secondarylymphoedema. It allows returning to work after a short period of temporary disability without the necessity of a social pension.

PubMed

PREVENTATIVE STEPS FOR LEG LYMPHEDEMA

For the patient who is at risk of developing Lymphedema, and for the patient who has developed Lymphedema.

WHO IS AT RISK? At risk is anyone who has had gynecological, melanoma, prostate or kidney cancer in combination with inguinal node dissection and/or radiation therapy. Lymphedema can occur immediately postoperatively, within a few months, a couple of years, or 20 years or more after cancer therapy. With proper education and care, Lymphedema can be avoided or, if it develops, kept under control. (For information regarding other causes of lower extremity Lymphedema, see What is Lymphedema?) The following instructions should be reviewed carefully pre-operatively and discussed with your physician or therapist.

1. Absolutely do not ignore any slight increase of swelling in the toes, foot, ankle, leg, abdomen, genitals (consult with your doctor immediately).

2. Never allow an injection or a blood drawing in the affected leg(s). Wear a LYMPHEDEMA ALERT Necklace.

3. Keep the edemic or at-risk leg spotlessly clean. Use lotion (Eucerin, Lymphoderm, Curel, whatever works best for you) after bathing. When drying it, be gentle, but thorough. Make sure it is dry in any creases and between the toes.

4. Avoid vigorous, repetitive movements against resistance with the affected legs.

5. Do not wear socks, stockings or undergarments with tight elastic bands.

6. Avoid extreme temperature changes when bathing or sunbathing (no saunas or hottubs). Keep the leg(s) protected from the sun.

7. Try to avoid any type of trauma, such as bruising, cuts, sunburn or other burns, sports injuries, insect bites, cat scratches. (Watch for subsequent signs of infection.)

8. When manicuring your toenails, avoid cutting your cuticles (inform your pedicurist).

9. Exercise is important, but consult with your therapist. Do not overtire a leg at risk; if it starts to ache, lie down and elevate it. Recommended exercises: walking, swimming, light aerobics, bike riding, and yoga.

10. When travelling by air, patients with Lymphedema and those at-risk should wear a well-fitted compression stocking. For those with Lymphedema, additional bandages may be required to maintain compression on a long flight. Increase fluid intake while in the air.

11. Use an electric razor to remove hair from legs. Maintain electric razor, properly replacing heads as needed.

12. Patients who have Lymphedema should wear a well-fitted compression stocking during all waking hours. At least every 4-6 months, see your therapist for follow-up. If the stocking is too loose, most likely the leg circumference has reduced or the stocking is worn.

13. Warning: If you notice a rash, itching, redness, pain, increase of temperature or fever, see your physician immediately. An inflammation or infection in the affected leg could be the beginning or a worsening of Lymphedema.

14. Maintain your ideal weight through a well-balanced, low sodium, high-fiber diet. Avoid smoking and alcohol. Lymphedema is a high protein edema, but eating too little protein will not reduce the protein element in the lymph fluid; rather, this may weaken the connective tissue and worsen the condition. The diet should contain easily-digested protein such as chicken, fish or tofu.

15. Always wear closed shoes (high tops or well-fitted boots are highly recommended). No sandals, slippers or going barefoot. Dry feet carefully after swimming.

16. See a podiatrist once a year as prophylaxis (to check for and treat fungi, ingrown toenails, calluses, pressure areas, athelete's foot).

17. Wear clean socks & hosiery at all times.

18. Use talcum powder on feet, especially if you perspire a great deal; talcum will make it easier to pull on compression stockings. Be sure to wear rubber gloves, as well, when pulling on stockings. Powder behind the knee often helps, preventing rubbing and irritation.

Unfortunately, prevention is not a cure. But, as a cancer and/or Lymphedema patient, you are in control of your ongoing cancer checkups and the continued maintenance of your Lymphedema.

Revised © January 2001 National Lymphedema Network. Permission to print out and duplicate this page in its entirety for educational purposes only, not for sale. All other rights reserved. For more information, contact the NLN: 1-800-541-3259.

Foot care for Lower Extremity Lymphedema

Foot care for Lower Extremity Lymphedema

Keith Smiley

The National lymphedema network NLN has been flooded with questions regarding foot and ankle care for patients with lower extremity lymphedema. Dr. Joseph Hewitson, a San Francisco Podiatrist, who has worked with many lymphedema patients, provided NLN a list of guidelines and suggestions for proper foot care for people suffering from lower extremity lymphedema. These guidlelines are excerpted from The July NLN newsletter.

Nail Care

Be sure to trim your toenails, but not necessarily straight across. If the corners have grown into the skin, trim the offending border.

If you get an infection, you should remove that side of the nail to resolve the infection. Antibiotics often will not work because an abscess (walled off infection) has occurred. Soaking may only provide temporary relief.

A lymphedema patient should never undergo a chemical matrisectomy (destroying root growth matrix with a chemical to permanently remove nail).

Fungal nails are common in lymphedema patients and should be soaked in 1:1 vinegar/water solution for 20 minutes, with antifungal solution applied afterwards.

Routine foot care every three months with a podiatrist if possible or your physician.

Meticulous nail care decreases the chance for inflammation and infection.

Taking Care of Your Toes

The inner spaces between your toes need to be kept clean and dry.

Soaking in a 1:1 vinegar/water solution for 20 minutes at least once a week and running a piece of gauze between your toes to remove any debris will help keep your web spaces clean.

Using a drying agent/antifungal solution like Castelani's Paint decrease chances of irritation and infection.

Applying lambs wool (see your pharmacist) between the toes allows the web greater breathability.

Open toed compression garments will also allow greater breathability, as will breathable footwear that is fitted correctly.

Dr. Hewitson says that proper footwear is very important. He says always buy your shoes at the time of day when your foot is most swollen (usually the end of the day). If you wear a compression garment, make sure you fit your shoes to accommodate this. Good athletic shoes are excellent to wear because they are more supportive, and more breathable. For very large feet, a Velcro strap shoe is usually more accommodating.

If you have painful corns and calluses, they should be routinely trimmed by a podiatrist or practitioner. Never use any callous removal pads, because they can cause burns and infections.

Dr. Hewitson also says to always work with reputable practitioners who are willing to further educate themselves on lymphedema. He adds, you may be their best and only teacher.

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