HEALTH: A BIG SWELL
Swollen lower legs and underlying cardiovascular disease are common cousins. Swollen ankles are more common with advancing age even in the absence of any significant heart disease. A typical situation is to awake with normal sized ankles that swell with dependent edema as the day progresses.
Persistent swelling of an extremity is about as welcomed as a spoiled fish. Swelling that does not improve after a good night’s sleep can be a troublesome condition called lymphedema.
Any surgery or radiation that disrupts normal lymph flow can cause lymphedema. The most common cause is breast cancer surgery. Severed lymphatic drainage channels during surgery to remove regional lymph nodes in a woman with breast cancer can cause a persistent swelling of the affected arm that can be very uncomfortable and painful.
Due to less extensive surgeries for breast cancer, lymphedema after breast cancer is not as frequent as it once was, but it still occurs.
The swelling and discomfort of lymphedema can also affect one or both legs. For men, radiation treatment for prostate cancer can cause lower extremity lymphedema. However, a cause for lower extremity lymphedema is not always so obvious.
Lois Young Blanchard is an advocate for people with lymphedema. She developed lymphedema of both legs in 2004.
“At the time I was working as a customer service representative at the Circle K Store in Schriever. My legs kept swelling until I had to quit work in December 2004. I couldn’t work and keep my legs up all the time. There was nothing else wrong with me except being a little over weight. I don’t have high blood pressure, diabetes or anything like that,” says Blanchard.
“Lymphedema runs in my family. My mother told me that my grandma on my daddy’s side had it before I was born. The only treatment she ever got was to sit with her legs propped up all the time, But I didn’t want to live like that.
“My regular doctor sent me to a dermatologist. Dr. Grafton in Houma, took one look and diagnosed it. ‘You have lymphedema,’ he said. My left leg was worse then my right, but it was in both of them,” says Blanchard.
Lymphedema is more than just too much fluid in an extremity. The excess, undrained fluid causes tissue inflammatory changes.
The lymphatic system is a low-pressure continuous “body wash” which circulates protein rich cleansing fluid through an intricate series of thin walled channels and regional lymph nodes throughout the body. The lymphatics mop up excess fluid, stray bacteria and noxious byproducts of normal metabolism.
As a freshman medical student, I remember an elderly lady with lower legs the size of elongated watermelons who would climb aboard the Dauphine Street bus at the St. Ann Street stop every morning. Being a newly minted medical student in this exotic semitropical city, I was sure I was seeing a person with elephantiasis due to filariasis – a tropical disease caused by a mosquito transmitted parasite that clogs up the lymphatics.
Lymphedema caused by these filarial parasites is indeed the major cause of lymphedema worldwide. However, it was not until the following year in my medical parasitology class that I learned that filariasis is not a disease present on our continent.
Like heartworm in dogs, symptomatic filariasis takes repeated bites by infected mosquitoes over years to accumulate the adult worm burden necessary to block lymph channels. Almost all lymphatic filariasis cases diagnosed in the U.S. are in immigrants from endemic countries such as sub-Saharan Africa, Egypt and parts of Brazil. It is not a tropical disease that plagues vacationing travelers or workmen abroad.
The abnormal swelling of an arm or leg from any cause can range from barely noticeable to a huge difference. Untreated lymphedema can progress to frank elephantiasis – a condition when the skin becomes very thickened and hardened just like an elephant’s hide.
Rare genetic forms of lymphedema occur when the lymph vessels develop abnormally. These abnormalities occur more frequently in woman and usually involve the legs. Milroy’s disease, a congenital malformation of lymph nodes, begins in infancy. Lymphedema praecox or Meige disease is another rare, inherited disorder that is first noticeable around puberty. A third form of inherited lymphedema begins after age 35.
Impaired lymphatic drainage of an extremity is not life threatening, but it can be uncomfortable, disfiguring and painful. Arms or legs with lymphedema are more likely to become infected. Many patients with lymphedema need to be on long-term antibiotics to prevent recurrent bouts of cellulitis.
Most treatments for lymphedema revolve around applying tight bandages or compression garments made to fit and compress the swelling in the affected limb. Careful massage of the affected limb can also provide temporary relief.
Blanchard first went to a therapist who fit her with compression pumps for her legs. These are pressure pulsating sleeves connected to a pump that inflate and then deflate in an attempt to push the lymph fluid out of her lower legs and thighs.
“It didn’t work that well, so I got on the Internet and found a lymphedema specialist who uses massage. I am much happier now,” says Blanchard, who was treated at the The Women’s Center at Thibodaux Regional Medical Center.
“Now I’m being fitted for some specially made stockings to keep the fluid from returning,” adds Blanchard.
The Outpatient Rehabilitation Center at Thibodaux Regional Medical Center actually has a lymphedema program partially funded by the national Susan G. Komen Breast Cancer Foundation. The therapist who Blanchard considers her savior, however, was not allowed to discuss her program without a hospital PR representative listening in on the phone, an arrangement that time restraints made impossible.
People with lymphedema problems need therapists with special training in lymphedema treatment and management. There are several in Louisiana. For example, at East Jefferson General Hospital the “go to” person is Amy Hirsch, an occupational therapist. Hirsh has advanced training and certification in the Vodder method [see box.]
Finding Help for Lymphedema
• The Vodder method of lymph drainage: A manual therapeutic method of stimulating the movement of fluids in the tissues especially for lymphedema patients. Their technique of combined decongestive therapy is used to relieve the edema, scarring, pain and discomfort of lymphedema and venous insufficiency edema. Information,
• The National Lymphedema Network: a nonprofit organization providing education and guidance to lymphedema patients, health care professionals and the general public. It provides listings of treatment centers and therapists. Information,
www.lymphnet.org or (800) 541-3259.
• The Lymphology Association of North America: a nonprofit organization that promotes standards for management of individuals with lymphedema and related disorders. Information,
• Juzo Patient Care: a complete line of lymphedema products for both treatment and preventative care. Information,
Causes of Lymphedema • Milroy’s disease: a rare inherited disorder that begins in infancy.
• Meige disease: another inherited disorder of lymph channel valves that causes lymphedema in childhood or around puberty.
• Lymphedema tarda: late-onset inherited lymphedema that usually begins after age 35.
• Surgery: any type of surgery that damages or removes lymph nodes.
• Radiation treatments: evolving studies show the risk of lymphedema may outweigh the benefit from “boosted” radiation for early-stage breast cancer.
• Tumors growing near and blocking lymph nodes.
• Infection that infiltrates and damages the lymph vessels and lymph nodes.
• Any injury that damages lymph nodes or lymph vessels.
*JOSEPH DANIEL FIEDLER ILLUSTRATION*