Defining each condition is an essential first step for every healthcare professional:
- Swelling is a more general term, encompassing both edema and lymphedema. According to WebMD, “swelling is an increase in the size or a change in the shape of an area of the body. Swelling can be caused by collection of body fluid, tissue growth, or abnormal movement or position of tissue.”
- Edema is a slightly more specific term, limiting the cause of swelling to fluid accumulation. According to Barron’s Dictionary of Medical Terms, edema is “an abnormal collection of fluid in spaces between cells, especially just under the skin or in a given cavity or organ.”
- Lymphedema is even more specific, describing the fluid that has accumulated as lymphatic fluid. According to the Society for Vascular Surgery, “Lymphedema occurs when lymphatic fluid builds up in the soft tissues of your body, usually in an arm or leg.”
Why Edema Can Occur
When a blood vessel’s outward force is greater than the inward force, osmosis causes fluid to move out of the capillaries. Any condition resulting in increased outward force results in edema. Examples of this outward force are:
- After standing a long time, edema may accumulate in the lower extremities because gravity causes blood to pool in the leg’s veins. This pooling increases the capillary hydrostatic pressure, which increases the blood vessel’s outward force.
- Protein deficient malnutrition causes a decrease in capillary osmotic pressure. This pressure drop reduces the inward force, changing the relationship of forces and resulting in a greater net outward force. Once again, the greater outward force draws fluid out of the blood vessel, resulting in edema.
Clinically, lymphedema is classified as either primary or secondary. Primary lymphedema is due to congenital malformations in the lymphatic system such as defective valves or vessels. Secondary or acquired lymphedema is more common and is due to problems with the lymphatic system occurring after birth. Some of the common causes of secondary lymphedema are:
- Lymph node or vessel removal surgery (e.g., cancer surgery)
- Radiation therapy
- Cancer metastasis to lymph vessels and nodes
- Scarring of lymph vessels and nodes following infections
- In developing countries, a parasitic infestation known as filariasis causes lymphedema
Today’s cancer treatments have resulted in improvements in radiation and surgical techniques (such as removing smaller samples of lymph nodes). This improvement means that lymphedema is less common now than in the past. Aside from medicine’s technological advances, lymphedema develops in approximately one in four breast cancer patients who have a mastectomy with lymph-node dissection. This risk doubles for patients who also receive radiation treatments to the underarm area.
The first signs of lymphedema can be a change in a patient’s arms or legs or other affected area. Initially, skin will remain soft, but if the problem continues, the limb may become hot and red and the skin hard and stiff. The lymph fluid that collects in the tissues can be very uncomfortable, but pain is not always present. Early symptoms of lymphedema may include:
- A feeling of tightness and decreased flexibility
- Tight fitting of jewelry, clothing or footwear
- Weakness, pain, aching or heaviness in the arm, legs, or feet
- Skin that looks shiny, has fewer folds and feels taut
- Difficulty moving a limb or bending at a joint due to swelling and skin tightness
- Pitting (small indentations left on the skin after pressing on the swollen area)
- Swelling of only one foot or arm
- If the leg is involved, swelling usually begins at the foot, then progresses upward toward the ankle, calf and knee
When to Refer Out
Clients should be encouraged to contact their physician if they have lymphedema in combination with any of the following:
- Previous mastectomy
- Previous lower abdominal surgery
- Previous radiation treatments
- The affected limb becomes red, painful or hot
- The affected limb develops open sores or areas of broken skin
- Fever accompanies any swelling
Additionally, it is suggested that a bodyworker seek permission from the client’s physician prior to performing bodywork if the client has:
- A history of cancer – to make certain massage won’t spread it.
- Full body edema – is usually due to chronic cardiac, kidney, or liver problems and massage may place too much stress on that person’s circulatory system.
How Bodyworkers can Participate in Lymphedema Treatment
Lymphedema can only be managed, not cured. A number of interventions are used for managing lymphedema, including patient education, skin care, compression bandaging, compression garments, compression pumps, exercises and manual lymphatic drainage massage.
Manual lymphatic drainage is a specialized massage technique to help clear edema by facilitating lymph flow through lymph vessel collaterals and collecting ducts. Since the pressure is very low in lymph vessels, lymph drainage techniques are generally administered in a very gentle manner. Stretching of the skin, superficial fascia, and the lymphatic vessels is performed in the direction of lymph flow, and followed by a gentle release.
The basic strokes used in traditional massage styles (e.g., petrissage, effleurage, tapotement, vibration and friction) are generally applied with more pressure than manual lymph drainage techniques. Many massage therapy publications list edema as an indication for these strokes. This is correct as long as edema is being addressed, not lymphedema.
When edema occurs, the lymphatic system is overloaded, yet remains intact. Conventional massage therapy is beneficial for many forms of edema. Consult with a senior practitioner or the client’s physician if you are unsure of your client’s candidacy for massage.
Alternatively, lymphedema is always caused by mechanical insufficiency of the lymphatic system, which is unable to appropriately respond to an increase in lymphatic fluid loads. When applied appropriately to lymphedema, lymph drainage massage increases the activity of lymph vessels and moves interstitial fluid. Lymph drainage massage exerts little pressure on the skin and does not cause any increase in local arterial blood flow. This narrow function makes it ideal for preventing the additional outward force on blood vessels that typically occurs with the enhanced circulation of traditional massage therapy. Increasing the circulation of a mechanically insufficient lymph system can easily increase the swelling.
When working with clients with lymphedema, traditional massage therapy is insufficient and could even exacerbate the problem. Contributing to a client’s lymphedema management requires extra vigilance on the part of the bodyworker as the benefits of understanding lymphedema and mastering lymphatic drainage massage far outweigh the required effort.
Premkumar, Kalyani, Edema and Lymphedema, Massage and Bodywork, December/January 2005.
Rothenbert, Mikel A., MD, Charles F. Chapman, Barron’s Dictionary of Medical Terms, Barron’s Educational Series, Inc., p.140, 1989.
Zuther, Joachim, MT, PT, Traditional Massage Therapy in the Treatment and Management of Lymphedema, Massage Today, June 2002.
www.cancerpage.com, Lymphedema, Rachael Myers Lowe, cancerpage.com, June 2003.
www.vascularweb.com, Lymphedema, VascularWeb, 2006.
www.webmd.com, Swelling, Healthwise, 2006.