Understanding Lower Extremity Secondary Lymphedema
Venous insufficiency is one of the most common issues with chronic swelling in your lower extremities. Veins are designed to carry blood and fluid away from the tissues (skin). When the veins are not as effective as they should be, they allow fluid to build up in the tissues (mostly in your legs). This happens because the valves that are supposed to prevent a back flow of blood in the veins don’t work. This can be from genetics, injury or clots. A doctor can do an ultrasound to check how good your veins are working and if they are causing your swelling. The lymphatic system is responsible for removing fluid the veins don’t. If the lymphatic system is overworked due to poor veins, it can cause premature fatigue of the lymph system and cause chronic swelling or “lymphedema.”
Chronic Venous Insufficiency
Chronic Venous Insufficiency (CVI) means your veins are not working properly. CVI is not the same as poor circulation because you can have strong blood flow into the legs (arterial), but poor flow out of your legs (venous). This causes swelling in your legs.
If you’ve been diagnosed with CVI, ask your physician for two referrals: a vein specialist and a lymphedema therapist. A vein specialist is a vascular doctor who will assess the size and function or dysfunction of your veins. They use ultrasound to visualize the level of disease in your veins and determine the need for intervention. They may decide to treat your veins before therapy starts or in many cases, after. A lymphedema therapist is a highly trained medical professional (usually from physical therapy, occupational therapy, massage therapy or nursing) who can help reduce your swelling and manage your lymphedema. It is important to remember to tell each of the professionals to talk to each other, so they can formulate the best plan for your success and reduction.
Before seeing the lymphedema therapist, you should set goals of what do you want to achieve from therapy. This sounds simple, but if you say, “I want to be better,” the next question is, “Better than what?” Setting goals will help develop a successful treatment plan. If you say “I want to go shopping without my legs aching and ankles swelling,” that helps you recognize when you are “better.” Goal setting is very important so your therapist understands what better means to you, but also for you to know what you want.
You’ll likely visit your lymphedema therapist in a lymphedema clinic. They will measure your legs and may take pictures. Ask them to also take pictures of your legs on your phone, so you can check your progress throughout treatment. Your therapist will check your strength and range of motion to determine if you have any weakness or range that may interfere with you getting better. They will also do specialty tests depending on your symptoms – none of these tests will be hard or painful. If you have any issues, let them know right away. They may test your balance to make sure you don’t have instability. If you do, they will create a customized exercise program.
They will ask if your toes and feet swell, and if you have swelling above the knee. This information will determine how they’ll suggest you wrap your legs. Next, they will submit a durable medical equipment (DME) request to an in-network provider for your compression garments (day and if needed, night), as well as bandages. Most major insurances do cover your compression needs and will provide an authorization number to show coverage. Be sure to ask if the DME provider is in network to ensure you get the best possible coverage. If you have Medicare or similar program, yourcompression products will be self-pay.
The next part of your evaluation includes education on what to expect from the four basic components of lymphedema therapy, which includes Manual Lymph Drainage (MLD), compression, exercises and skin care to reduce your swelling. Using all four parts for your therapy will give you the best results and training to manage your swelling for the long term.
Step 1: MLD is the mild stimulation of the skin (similar to massaging the skin) and specific to you. Your therapist should have specialized training to do it properly with effective results. They will manually (and gently) move the fluid from your swollen area to healthy nodes that will filter it before it’s reabsorbed into the blood stream.
Step 2: Compression starts with bandaging, using a short-stretch compression wrap or bandage, that will help reduce the size of your limb. This compression helps prevent back filling of edema/swelling into your affected area. People often ask why they have to wear compression garments for so long. This is because fluid is moving around your body 24/7, and some fluid is left behind when you are not compressed. Lymphedema wrapping is not like other wrapping, it is specific to your swelling and it is graduated (meaning firmer at the lower end and decreasing firmness as you get closer to the heart). Eventually, you’ll wear medical compression garments instead of wrapping, which are easier to put on and take off. These garments also offer more consistency in maintaining your reduced limb size.
Occasionally, people think the compression garments are supposed to reduce their swelling, but this is not true. Garments are made to maintain your limb size, not make it smaller. Learn more about the benefits of medical compression therapy. It’s important to understand that your treatment is based on your unique swelling. If you have minimal swelling in your limb, you will likely wear mild compression. Your therapist and certified fitter will determine the appropriate size, compression range, style and material with the necessary degree of containment for your medical compression garment. Today’s compression garments are available in a variety of fashion colors and print choices. Spend some time finding the right garment for you.
Step 3: Each person has different needs when it comes to exercise. It is important to stay active in your compression to move the fluid and blood out of your limb. Your therapist may suggest repetitive exercises to increase the joint muscle pump and range of motion. They also may suggest different shoes to help increase fluid and blood flow out of your legs as you walk. Your therapist also will work with you to become independent with your lymphedema self-care. That means you will need range of motion to wrap your extremity and put on or take off your compression garments. Each exercise will meet your needs but also help you reach the goals you set during your initial evaluation.
Step 4: Skin Care is essential since lymphedema is limited only to the skin in almost all cases. That makes taking care of you skin extremely important, as your skin can fill up like a sponge, get stretched out and become fragile and thin on the outer layers. The larger your skin gets, the more likely you are to contract fungal or bacterial infections due to the excess fluid and the body’s limited ability to fight infections in the affected skin area – this can lead to wounds. Cleaning your skin and knowing signs and symptoms of infections are very important, as is keeping your skin soft with lotions. Note that Juzo garments are not affected by any lotions you use.
Wound Care may be included as part of your treatment plan, if you have extensive vein problems. This is easy to manage in the lymphedema clinic. If you find after two weeks you are not seeing results, sit down with your therapist and discuss your progress or lack thereof. It may be possible there are other issues that are making you swell or slowing your progress. Either way, make sure you are talking with your physician and therapist to determine what is the best course of action and make sure they are talking to each other about your diagnosis, symptoms and treatment.
Other Causes of Secondary Lymphedema can also result from trauma to the lymphatics cause by poor veins, being sedentary for long periods of time, genetics or blood clots. A clot can cause continued slowed blood flow and create a back pressure, making the veins below the clot start to become diseased. Normally, the body can resolve this with collateral circulation as well as increased lymphatic flow. If swelling remains, you likely need a higher level of compression to contain the swelling.