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Enhance Your Understanding of Lower Quadrant Lymphedema
Ting-Ting Kuo, PT, MS Clinical Specialist, Lymphedema New York University/Rusk Institute of Rehabilitation Medicine ting-ting.kuo@nyumc.org
Patients undergoing any type of lymph node dissection or radiation therapy are at risk for developing what is becoming an increasingly recognized and acknowledged potential side effect: lymphedema. Lymphedema is localized retention of protein-rich fluid that can result in chronic swelling and lead to episodes of cellulitis and :infections associatedwith lymphedema|infections]].
In the past, the focus of lymphedema and its associated management has been on the breast cancer population. The following discussion highlights key points in other cancer populations, specifically patients with gynecologic cancers and melanoma, who are at risk for developing this highly intrusive but manageable condition.
The majority of literature and research focuses on management of lymphedema of the upper extremities, most often because of sentinel and axillary lymph node dissections and radiation therapy. Scant attention is given to lymphedema of the abdomen, pelvis, and lower extremities. Inguinal groin dissections, pelvic and abdominal nodal dissections, and radiation therapy can create a sequela of events that leads to the disruption of the lymphatic system, resulting in lymphedema of the lower quadrant(s).
The human lymphatic system is comprised of a superficial and deep system. Right below skin level, a vast network of vessels makes up the superficial lymphatic system, which eventually connects to the deep lymphatic system, creating an incredibly complex and sophisticated thoroughfare of structures that fight disease and maintain fluid balance. In the lower quadrants, the right and left inguinal lymph nodes filter lymph from each respective lower extremity. From there, lymph is transported into the right and left lumbar trunks, eventually emptying into the thoracic duct at lumbar level L2 via the cisterna chyli and the intestinal trunk, which drains the small intestines. The thoracic duct then continues to extend in a cephalad direction until it reaches the left venous angle, where it concludes. Oftentimes melanoma of the lower extremities will require an ipsilateral inguinal groin dissection, whereas gynecologic cancers may require pelvic and abdominal node dissections. Because of the location of nodes in close vicinity and in relation to the functioning of the superficial and deep lymphatic systems, it is easy to comprehend how and why lymphedema can occur. Healthcare providers should be able to assist in planning treatment strategies should lymphedema develop.
Similar to lymphedema of the upper extremeties common symptoms reported with lower quadrant lymphedema may include
- Pressure
- Tightness
- Heaviness
- Sensory changes
- Increased size of the affected area
- Limitations in range of motion
- Weakness
- Impaired balance
- Scarring and fascial restrictions
- Tissue firmness and fibrosis
- Poor posture
- Discomfort and pain
- Limited endurance
- Cellulitis
These impairments often translate into functional limitations and disabilities, including
- Difficulty with basic grooming, bathing, and hygiene
- Difficulty in finding clothing and shoes that fit
- Difficulty in performing household chores and responsibilities
- Limited tolerance to prolonged standing and walking
- Difficulty in returning to exercise and physical activities
- Limitations participating in social and leisure activities
- Limitations in returning to work.
What can be done to decrease the risk of developing lymphedema and minimize effects once it develops? It all starts and ends with education. Education of what lymphedema is, how it can develop, what measures healthcare professionals and patients can take as precautions, what signs and symptoms to anticipate and recognize, and knowing where and what treatment can be obtained should lymphedema develop are all key elements.
Doctors, nurses, nursing aides, physical and occupational therapists, and all others involved in direct and indirect patient care should be able to demonstrate knowledge of the lymphedema precautions that follow. In addition, patients should be educated on how to decrease their risk of developing lymphedema prior to or immediately following lymph node removal by understanding these precautions.
Lymphedema precautions
- Recognize the signs of infection (e.g., redness, pain, increased temperature, swelling).
- Avoid punctures, cuts, and bruising.
- Understand the importance of skin care and hygiene, particularly of the feet.
- Push, don't cut, cuticles during a pedicure.
- Wear closed-toe, supportive shoes.
- Minimize insect bites by using insect repellant or wearing long pants.
- Participate in a slow, progressive return to exercise and activities, and take frequent rest breaks.
- Minimize tight clothing, including belts, shoes, and socks.
- Maintain a healthy weight.
- Obtain a properly fitted prophylactic compression garment prior to air travel.
If symptoms of lymphedema develop, patients should be instructed to rest and elevate the extremity to decrease any strain placed on the affected area because of overexertion and gravitational force. Early stages of lymphedema have demonstrated potential reversibility with early intervention. Patients should be referred immediately to an experienced physical therapist who has been trained in providing manual lymphatic drainage (MLD), multilayer bandaging (MLB), exercise, obtaining a properly fitted compression garment, and lymphedema management education to develop an individualized plan of care geared specifically to the patient. Scar management, myofascial techniques, neuromuscular re-education, gait training, and a progressive home exercise program also may be incorporated to return patients to their optimal functional status.
Lower quadrant lymphedema often presents a greater challenge in treatment compared to its upper extremity counterparts. An individual's premorbid status, current comorbidities, age, and physical status, including flexibility and weight, play an important role in the treatment of lower quadrant lymphedema. As one ages, a concomitant venous component often develops because of refluxing valves, causing further potential compromise of overall functioning of the circulatory system. In addition, nurses must understand that the presentation and location of swelling often are variable. A common misperception is that lymphedema-associated swelling must involve the entire leg, but this is often not the case. Many individuals present with swelling solely in the foot and ankle, upper thigh, hip and buttock, genitalia, or abdomen. In addition, with abdominal, pelvic, and female genital edema, treatment may require more creative strategies, such as the use of corsets, girdles, or pads, because of the inability to apply traditional MLB. Physical therapists must have a strong foundation and a firm understanding of the anatomical lymphatic pathways and watersheds. Care should be taken to avoid exacerbating symptoms to involve other currently non-affected areas, such as the opposite lower extremity in cases of pelvic and abdominal nodal dissection because it may be predisposed to developing lymphedema as well. Patient compliance, support, and willingness to fully participate in treatment are integral to the success of lower quadrant lymphedema treatment.
Lower quadrant lymphedema, including abdominal, pelvic and genital, and lower extremities, can be treated safely and managed with proper care and attention. Early education, detection, and intervention of signs and symptoms need to be communicated and are key to minimizing the often intrusive side effects associated with this chronic condition. Focus should be on an individual's quality of life, which can be achieved with a team approach.
ARTICLES FROM OUR FORUM ON LEG LYMPHEDEMA
Quality of Life in Patients with Lymphedema of Lower Limb
Lymphscintigraphic evaluation MLD for lower limb lymphedema
Management of lower limb lymphedema in the United Kingdom
Arthritis of the knees and lymphedema
Multilayer Compression Bandaging of the Lymphedema Leg
Leg Lymphedema in women after treatment gynecological cancer
Why Compression Pumps Cause Damage
Additional Lymphedema People links
Lymphedema from Sirolimus Treatment
Compression Pumps for Lymphedema Treatment
Diuretics are not for Lymphedema
How to Find a Lymphedema Therapist
How to Assess the Size and Composition of a lymphedema limb
Podoconiosis Lymphedema from exposure to clay soil
Preventing Hospital Infections
Short Stretch Bandages for Lymphedema
Compression Bandages for Lymphedema
Compression Garments Stockings for Lymphedema
LYMPHEDEMA LEG GARMENTS, SLEEVES AND GARMENTS
These are garments that are designed to help control the swelling and should be utilized after you have undergone treatment to reduce to the size of your arm. They are also used inconjunction with compression bandage wrapping.
Suppliers of arm wraps, compression garments and sleeves
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Lymphedema People Resources
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