lymphedema precautions Archives - Lymphedema Therapy Source

Last month, we began a series on contraindications to MLD. This post will continue that topic, citing a few more contraindications.

3. Heart Failure

Patients with heart failure are at risk for fluid overload, and MLD could further strain their cardiovascular system. The technique’s effects on fluid mobilization may overwhelm the heart’s ability to manage the increased fluid load. Foldi underscores the importance of careful evaluation of a patient’s cardiac function before initiating MLD, especially in those with advanced heart conditions. MLD is not appropriate if heart failure isn’t controlled. And it’s not appropriate if the sole reason for swelling is heart failure as that is a medical condition requiring medical intervention (not lymphedema). Patients with combined edema (from heart failure or other organ dysfunction) and lymphedema require extra caution.

4. Renal Insufficiency

Patients suffering from severe renal insufficiency or kidney failure may experience difficulties in fluid regulation. In such cases, MLD could cause fluid retention and exacerbate symptoms like edema or ascites (according to Ai). (My position is that MLD increases lymphatic flow & ultimately cardiovascular return & renal load. But MLD is primarily not done as it would be of no benefit because lymph vessels are already working at maximum capacity due to the dynamic nature of the edema.) Patients with impaired kidney function should be closely monitored, and MLD should be avoided or used with extreme caution in individuals with compromised renal status. Again, patients with combined edema (from renal disease or other organ dysfunction) and lymphedema require extra caution.

5. Thromboembolic Disorders

Deep vein thrombosis (DVT) or other thromboembolic disorders are a significant contraindication for MLD. Manual lymph drainage can increase blood and lymphatic flow, potentially dislodging clots and causing a pulmonary embolism (PE) or other complications. Foldi’s Textbook emphasizes the critical importance of excluding thrombosis prior to MLD treatment and recommends that patients with active DVT or a history of thromboembolic events within 6 months not undergo MLD (with some exception). DVTs in the acute phase are at risk of dislodging & creating a PE which can kill a person. In the subacute phase (which occurs over the next several weeks), there is typically pain, redness and swelling. The body begins to break down the clot in a process known as fibrinolysis, where enzymes dissolve fibrin and other clot components. As this process happens, part of the clot is reabsorbed, while the remaining structure becomes more organized and fibrous. In the chronic phase (month 3-6), the clot typically becomes firm and organized (restructured with scar tissue) and has little risk of dislodging by month 6.

The exception to waiting 6 months is if a person has a filter and/or receives anticoagulation medication. After stabilization with anticoagulant therapy, MLD may be safely resumed after a 2 to 4-week period (if the physician approves MLD).

Generated by Ai (with edits by author)

References
Foldi’s Textbook of Lymphology

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Is there any science behind it?

There are several recommendations for a person at risk of developing lymphedema and for those who have lymphedema (to prevent an exacerbation episode). But in the past year, I’ve heard some people say there’s no evidence backing up these precautions. Is that true?

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Recommendations

First of all, what are the recommendations? The National Lymphedema Network (NLN) has a page of Position Papers (a summary of their position on topics). They have one called “Risk Reduction.”¹ It was established by their medical committee in 2012. It needs updating but the overall recommendations haven’t changed. If you have lymphedema, the NLN recommends you:

1. Have regular check-ups with a lymphedema specialist (likely to take measurements and assess any problems, garment fitting, etc.)
2. Notify your healthcare provider of any changes in your arm
3. Maintain a healthy body weight (or lose weight if obese)
4. Exercise (see the blog post on exercise here)
5. Wear your compression garments and replace them every 6 month to 1 year
6. Prevent cellulitis infections (and immediately treat any signs or symptoms of infection)
7. Maintain good skin care
8. Avoid trauma of the affected arm (such as needle sticks, bug bites, etc.)
9. Avoid constriction of the affected limb (such as tight bands, restrictive clothing, blood pressures)
10. Avoid extreme heat or cold (such as hot showers, sitting in a sauna)
11. Inform any surgeon of your lymphedema if surgery is planned
12. Avoid stasis (i.e. see exercise above and avoid sitting or standing for long periods)
13. Consider consulting a vein specialist for treatment if you have varicose veins or spider veins
14. Wear your compression and move around during air travel (note it doesn’t say “don’t fly”)

If you are at risk for lymphedema (i.e. if you’ve had lymph nodes removed and/or radiation), the guidelines are nearly the same with a few modifications (such as wearing a compression sleeve). These precautions are backed up by the Foldi Textbook of Lymphology² (a source I often reference).

For NLN guidelines, visit www.lymphnet.org.

(Photo by energepic.com/Pexels)

Rationale behind the recommendations

The NLN explains the rationale behind these precautions. However, it also notes there is limited research backing these recommendations. In theory (and many therapists would say in practice), these precautions make sense. Anything that could increase the blood flow will increase the lymphatic load. And anything that increases lymphatic load can increase your risk of lymphedema development or exacerbation. That doesn’t mean you will experience lymphedema or an exacerbation – just that you could.

My thoughts

Based on the theory and based on my experience of treating patients (and when they first developed symptoms of lymphedema), I recommend patients follow these guidelines. Next month, we’ll look at how to monitor your arm for potential lymphedema development or exacerbation based on symptoms. We’ll also learn how to measure your arm for baseline measurements.

References
1 https://lymphnet.org/position-papers
2 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 268-270. Germany: Urban and Fisher.

Contraindications to Manual Lymph Drainage: Insights from Foldi’s Textbook of Lymphology (part 2 of 3)