Recognition of those at risk of lymphedema, benefits of subclinical detection, and the importance of targeted treatment and management

Abstract

Primary and secondary lymphedemas, irrespective of their cause, remain a significant issue around the world, impacting physical, functional, and psychological well-being, family relationships, and the ability of the affected person to undertake work and household tasks. Often, an accurate, objective differential diagnosis is not (or cannot) be made, sometimes resulting in treatment, which is suboptimal, or which does not achieve expected outcomes due to the impact of a range of comorbidities on lymphatic load or functioning. Diagnosis, Management, and targeted treatment of these comorbidities such as chronic edema, lipedema, and phlebedema will allow improved outcomes for the lymphedemas. To treat and manage lymphedemas well, there is a lifelong cost both to the affected individual, the family, and the health-care system. However, for those with lymphedemas irrespective of its stage, there are significant leverage points for obtaining a good outcome through an accurate differential diagnosis, but it is the group who are at risk of lymphedema where we can have the greatest impact with respect to optimizing their health and well-being. The solution is multifaceted involving three major components: (1) the recognition of those at elevated risk of developing lymphedema and the reduction or management of those risks; (2) the early detection of the subclinical stages of lymphedema; and (3) appropriately targeted and sequenced treatment delivered in a holistic sense within a compassionate caring community environment with appropriate integrated and continuing health professional support. We also need to be aware that high-level technology and equipment is not always needed for an accurate assessment of the lymphedema or its risk, with simple tape measurements and associated volume calculations along with the use of the pitting test and the Stemmer sign being acknowledged as dependable and informative. While the evidence is increasing that lymphovenous or lympho-lymphatic anastomoses, and lymph node transfers are of benefit when created in the earlier stages of lymphedema (and perhaps in those detected as being at a high risk of developing it), complex and invasive treatments are most often not needed when the lymphedema is detected early. In these stages, simple management strategies work well when we employ our knowledge of the importance of weight control, self-management through exercise and activity programs (which can include yoga and tai chi breathing techniques) and skin care, massage with compression provided by bandaging, garments, or wraps, in an environment of integrated professional functioning and advice. In today's COVID environment and when services are not available nearby or what the patient cannot travel, when it is not possible to physically see a therapist or other health professional, telemedicine and its associated information and interactive education programs are of increasing importance. We must together ensure that the information about lymphedema, its risk factors, treatments, and management is made available in clinics and community health facilities, so everyone has access to it and is aware of who to approach for continuous and integrated holistic care.