Lymphedema (elephant disease) is the accumulation of lymphatic fluid in the intercellular tissue, often causing swelling in the arms or legs, sometimes in the trunk. The fluids between the cells are filtered and mixed into the blood. The system that performs this task is called the lymphatic system and the fluid carried in this system is called lymphatic fluid. A normal person has about a quarter of his body weight of lymph fluid. The movement of the lymph fluid is provided by the pressure of the skeletal muscles and respiratory movements. Lymph movement is considerably slower than blood. Because there is no pump like the heart that pressures the lymph system. If the lymph ducts and lymph nodes carrying the lymph fluid are damaged or innate, the lymph fluid accumulates in the body. Lymphedema occurs when the amount of fluid accumulated in a region is greater than the carrying capacity of the lymphatic system.

Causes

The cause of some of the lymphedema is unknown. Acquired lymphedema may develop after surgery, radiation, infection or trauma. The removal of lymph nodes for the treatment of certain cancers, such as breast cancer, always carries a risk of lymphedema. The more lymph nodes removed surgically, the greater the risk of developing lymphedema. If radiotherapy is performed after removal of the lymph node, the risk of lymphedema increases. Lymphedema developed after mastectomy (breast removal) is characterized by weight, pain, loss of sensation, loss of movement and dysfunction in the involved arm. This situation affects the quality of life negatively. Anxiety, depression and adjustment problems and social and sexual problems occur. Lymphedema can easily catch infection of the arm or leg. Therefore, it is very important to start treatment early.

Symptoms

Lymphedema may not develop immediately, sometimes occurs within 15 years or more following injury to the lymphatic system. Symptoms are first seen on the back of the hand and foot. There is an increase in arm or leg weight. The skin is taut and firm. Sensory disorders and joint stiffness can be seen in hands and feet. Reduced resistance to infection may occur. There may be symptoms of fullness in the arm or leg, tension in the skin, decreased mobility of the wrist or ankle and fingers, narrowing of clothes, bracelets, watches, rings, shoes, socks while they also leave traces.

Phases

Lymphedema is a progressive disease if left untreated. Lymphedema is divided into three stages and untreated patients progress from stage 1 to stage 3:

Stage 1: Reversible lymphedema. Temporary swelling occurs with unspecified symptoms. The edema gradually increases during the day and disappears at night after rest.

Stage 2: Chronic irreversible lymphedema. It is characterized by continuous swelling, decreased sensation, pain, burning and limitation of movement.

Stage 3: Lymphostatic Elaphantiasis (Elephant Disease). As time goes on, increased limb deformation, significant movement and function restriction, and severe pain occurs.

Treatment

Lymphedema has two types of treatment: physical therapy and surgery. Physical therapy involves complex evacuation physiotherapy, manual lymph drainage, compression bandages and exercise. In the complex evacuating physiotherapy method, patients are given a special hand-made lymph drainage massage. After the massage, compression treatment with special lymphedema-specific bandages are conducted with the self-massage. Edema is significantly reduced in the first 10 sessions of treatment. Depending on the patient's condition, 20-30 sessions of treatment are applied. At the end of the treatment, the patient is given compression garments at appropriate pressure. This treatment reduces the volume of the involved arm or leg and provides lymph circulation. The free flow of blocked lymph fluid in the lymph system is provided by manual lymphatic drainage technique. Manual lymph drainage is a special massage technique applied by hand to take the lymph fluid from the edematous region and to flow to other parts of the body. Manual lymph drainage is performed by applying light pressure to the superficial lymph vessels just below the skin. The type and sequence of the manual technique for each patient is determined by the physiotherapist on a different principle, which depends on the stage and area of ​​the edema. Manual lymph drainage should not be confused with other massage techniques that have no effect on lymph circulation. Other massage techniques are not beneficial for lymphedema or can be harmful. Compression therapy is applied in two ways to provide pressure to the external lymphedema area: compression bandages and compression garments. The properties of bandages used in the treatment of lymphedema is their prevention of re-accumulation of lymph fluid in the affected limb by application of high-pressure during muscle activity and low pressure during muscle rest. Other forms of bandage may be harmful to lymphedema and should not be used. Compression stockings are the materials that should be worn during the follow-up process at the end of the treatment and should be custom made. The flow rate of the lymphatic fluid depends on the intermittent external pressure exerted by the skeletal muscles. Therefore, muscle activity is also required to aid in fluid drainage. Exercises should be performed with the use of bandages or socks. Resistance and weight training should be avoided. The exercise program should be prepared by the physiotherapist carrying out the treatment specifically for the patient. Exercises are warming and pumping and breathing and stretching exercises.

Recommendations for Patients with Lymphedema

(Protection of the arm or leg having lymphedema)

Care and protection of the limb which is at the risk of lymphedema is very important. In order to continue the success of the treatment after therapy, the patient should pay attention to the following issues:

1. The skin should be kept clean and dry thoroughly and should not be left moist.

2. Skin care and flexibility should be taken into consideration. Moisturizers such as fat-free creams, body milk, body lotion should be used for moisturizing.

3. Antifungal powders should be used to prevent perspiration on hot days and to prevent fungal formation on the skin.

4. Incision, cat-dog scratching and impacts that may cause infection and damage to the lymphatic tract should be avoided.

5. Lymphedema patients should take care to avoid hot water, hot spring water, sunbathing while they keep the edematous arm or leg cold instead.

6. Repetitive and strenuous movements can worsen edema.

7. Excess weight, unbalanced nutrition, inadequate or excessive exercise, exposure to excessive heat in the limb, travel, tightening of the affected arm or leg (e.g., measuring blood pressure, tight watches, tight clothing) triggers and increases lymphedema.

8. Manicure and injection should not be done on the affected arm.

9. Calluses should not be cut on the affected feet but should be protected with softening creams.

10. When cutting the nails, care should be taken not to cut the skin.

11. Blades should not be used; unwanted hair should be removed with the help of an electric safety-razor.

12. When working in the kitchen or garden, gloves should be worn to prevent cuts.

13. Sunburns should be avoided. Sun protection products with high protection factor should be used during sun tanning. The affected limb should never be exposed to the sun for a long time.

14. Compression stockings often do not protect from the sun and can cause the limb to burn.

15. The most ideal sports are swimming and diving. In addition, exercises recommended to the patient after treatment should be done regularly to ensure lymph circulation.

16. Bra, underwear, other clothes and jewelry should not be tight. The redness left by these garments on the skin means that the lymph circulation is blocked.

17. Arm stockings and compression bandages should be used  during flights due to the drops in pressure.

18. When sleeping at night, care should be taken not to lie on the affected arm.

19. Regular nutrition should be maintained. Excessive salt should not be used, but you should never cut salt and drink plenty of water.

20. Excess weight should be avoided and, if there is excess weight, a diet and exercise program prepared by the doctor or dietitian should be implemented.

21. Pressure socks that are used after treatment should be used regularly, especially during the first 6 months, day and night.

22. If the arm or leg shrinks themselves at night, the compression garment may be removed at night. Pressure clothing can also be removed for a few hours on special occasions. When they are loose or tight, you should consult a doctor.

23. Compression garments should not squeeze a certain area in the form of tape, nor should it cause redness.

24. If the limb swollen due to inadequate lymphatic circulation becomes normal or close to normal with treatment, it should be remembered that care should continue to prevent the condition from recurring.

Last word: Follow-up and care should be continued after the swelling arm or leg becomes normal or close to normal after the treatment. Lymphedema can be prevented, reduced and controlled in almost all patients.