Worth knowing about edema diseases
Lymphedema is not a rare disease. Worldwide about three percent of all people suffer from chronic lymphedema, in Germany it is more than 5 percent. Permanent lymphostasis triggers fibrotic remodelling of the tissue. Therapy should therefore start early. The most important measure is the complex physical decongestion therapy (MLD/KPE). Worldwide, the number of people with chronic lymphedema is estimated to be at least 200 million. The frequency of lymphedema after tumour treatment in industrialised countries - 4.5 million patients in Germany alone (Földi 2004) - and the frequency of filarial infections in Asian and African countries, which are estimated at 120 million (Rheingans 2004), make this figure realistic.
Frequency of lymphedema. If one reads the literature about lymphedema, one notices contradictory statements because of the lymphedema frequency. On the one hand, there is talk of lymphedema, a stepchild of medicine, which is relatively rare and therefore too little known in the medical profession. On the other hand, it is often written that there are 3 million lymphedema cases in Germany alone, although nowhere does it say how this number has arisen. The highest frequency of lymphedema was published in a paper by U. Schwarz from the Földiklinik in 1990, which found the Stemmer's sign, a thickening of the toe back skin typical for primary lymphedema, in an average of 7% on 1000 test persons.
This would result in about 5.6 million primary lymphedema in a population of 80 million people in Germany. If one additionally considers that secondary lymphedema is twice as frequent as primary lymphedema, this would mean a total of about 15 million lymphedema cases in Germany, a truly utopian number. This work by Schwarz inspired me to do my own study, in which I examined 4000 pupils of lymph drainage schools and found a total of 2 primary lymphedema of the legs. This means a frequency of 0.5 ‰, which would mean 40,000 primary lymphedema cases in Germany. Against my study one can argue that this is not a representative study for the entire population, since the average age of 28 years was relatively young. It is possible that the figures would change somewhat as a result of a representative study, but certainly not significantly.
However, there has been no such study to date. It is known from my clinic statistics that secondary lymphedema is regularly twice as frequent as primary lymphedema. From this I must conclude that secondary lymphedema is twice as frequent in the total population, which would mean about 80,000 secondary lymphedema cases in Germany. This would mean a total of approximately 120,000 lymphedema cases in Germany. From my statistics I also know the distribution within primary and secondary lymphedema. In primary lymphedema 94% are on the legs, 1% on the arms, 0.5% on the head, 0.5% on the genitals and 4% on several body regions. In secondary lymphedema, 66% affect the arms, 31% the legs, 1.5% the genitals and 1% the head and 2% several body regions. In terms of frequency, this results in about 53,000 secondary arm lymphedema, about 38,000 primary leg lymphedema and about 25,000 secondary leg lymphedema in Germany.
Due to the ratio of lymphedema and lipedema in oedema clinics, I estimate the incidence to be 80,000 in Germany. The pure form of lipohypertrophy of the extremities and lipedema without additional obesity is only found in 20% of cases. This means that 80% of lipoedema patients also have obesity, which can worsen the clinical picture. The numbers are a bit older, so the assumption is that the numbers are higher.
Lymphedema can be defined as the accumulation of interstitial fluid caused by disturbed lymphatic drainage. The reduction in lymph flow can result from either congenital or acquired anomalies in lymph drainage. Although lymphedema usually affects one or more extremities, it can also manifest itself in organs. Whatever the pathogenesis, it is often a chronic inexorable condition that poses a long-lasting and psychological problem for the patient and a complex therapeutic challenge for the physician.
Obtrusive glances, whispering, social discrimination and even bullying at school and at work: Liphedema and/or lymphedema are not only associated with severe physical stress, but also with serious psychological stress. As a chronic progressive fat distribution disorder, lipedema is characterized by excessively thick legs and arms with a slender waist and well-proportioned trunk in early stages. It is accompanied by an edema-related symptomatology of complaints, i.e. pressure pain as well as a feeling of heaviness and tension. In late stages, mostly circumscribed bulges form, especially on the inner sides of the thighs and knees.
Since many doctors are only inadequately or not at all familiar with Lipohypertrophia dolorosa, which mainly occurs in women, or often misinterpret it as obesity, patients are often simply treated incorrectly or not at all. Source Pharmaceutical Newspaper online
In many cases of advanced, persistent disease, we find a typical anamnesis with a characteristic body clinical appearance that allows the diagnosis of lymphedema to be made with almost certainty. We speak of the basic diagnosis consisting of anamnesis, inspection and palpation, which gives us the positive sign of Stemmer as proof. Robert Stemmer showed that the skin folds at the base joints of the toes can be lifted from the bone in a healthy patient, whereas this is not possible in a patient with distal lymphedema. A positive Stemmer's sign indicates lymphedema in any case, a negative sign indicates proximal lymphedema. In this case further examinations must follow. The diagnosis is all the more difficult the lower the stage of the edema is. Available examinations include isotopic lymph scintigraphy, direct and indirect lymphography, fluorescence micro-lymphography. Primary lymphedema, magnetic resonance imaging, computer tomography and ultrasound.
We distinguish three types of primary lymphedema:
- congenital - the oedema already exists at birth or occurs within the first two years of life
- praecox- the most common type that occurs either at puberty or up to 35 years of age
- tardum - which occurs only after the 35th life experience, in which extreme care must be taken in the diagnosis in order not to overlook a secondary edema caused by obstruction by the tumor.
Secondary lymphedema develops as a result of destruction of the lymphatic ducts and lymph vessels or lymph nodes, or as a result of external compression, surgical intervention or various disease processes.
Chronic lymphedema often shows complications, and a decade of lymphedema can also cause a variety of neoplastic complications.
Treatment of lymphedema
Lymphedema is a chronic disease that requires lifelong treatment. This does not mean that lymphedema is incurable. It can only be brought into a better state. In the meantime, there are many treatment options that have shown efficient oedema reduction and prevention of fluid accumulation. If, on the other hand, the treatment is discontinued, there will inevitably be an increase in oedema with significant deterioration following recurrent infections resulting from massive oedema, significant additional movement restrictions of the limb functions with physiological impairment of life, up to the occurrence of life-threatening infections such as erysipelas or malignant complications.
The complex physical therapy takes place in 2 phases:
In phase 1 of the decongestion phase, the hygiene regulations must be observed, in particular digital mycosis, minor injuries and skin tears. Furthermore, in phase 1, the patient receives manual whole-body lymphatic drainage, according to the principles described by Winiwarter, Vodder and Földi, up to 5 times a week, followed by compression bandaging with subsequent movement exercises in the sense of physiotherapy exercises and terrain training.
In phase 2 of the decongestion phase, the frequency of manual lymphatic drainage can be reduced to 2 times a week in the outpatient area. The patient is then provided with a compression stocking including the shoulder or compression pantyhose. Occasionally, compression bandaging can also be performed in the outpatient area following manual lymphatic drainage in order to achieve further decongestion.
The maintenance phase tries to maintain the result achieved in the decongestion.
Short-stretch bandages are used during bandaging to reduce edema in the decongestion phase. The short-stretch bandages have a high working pressure and a lower resting pressure, so that decongestion is guaranteed here.
Compression hosiery serves the patient as a relief during the maintenance phase, since compression bandaging with the short-stretch bandages in the system is somewhat problematic and tends to slip even in daily use, there have been clearly positive developments in flat knitting technology by hosiery manufacturers in recent times. Since this compression stocking loses its compressive capacity after 3 to 6 months, it must be replaced accordingly. The compression pressure is in the lighter degree up to 40 mm and in heavier degrees over 59 mm Hg by the compression stocking.
Pharmacological therapy and diet
Coumarin has shown a slow reduction in various types of lymphedema in some studies, both human and animal. Selenium administration is considered to have a positive effect in reducing the incidence of erysipelas. There is no diet for lymphedema. Here only those foods are to be reduced, which cause an increase of the blood capillary pressure like increased consumption of bean coffee, red wine and sparkling wine. Protein reduction does not improve lymphedema, but adds hypoprotinemic edema.
Surgical therapy takes place when medical therapies have failed. There are 2 main application points here. 1. reduction plasty and 2. microsurgical lympholymphatic, lyymphovenous and lymph node venous anastomosis.
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