Reduce the Risk: Guidelines for a Healthy Lifestyle for Lymphedema Management

Few things are more rewarding in our profession than educating a patient on how to help themselves. And you don’t have to be a lymphedema specialist in order to help a patient learn about easy risk reduction practices. Our patients can take an active part in helping decrease their risk of infection or preventing their lymphedema from progressing.

Who Is at Risk for Lymphedema?

All individuals who’ve experienced damage to their lymphatic system are at risk for developing active lymphedema. It doesn’t matter how long it’s been since the injury or surgery; even if they show no signs or symptoms, they can develop them at any time in their life.

Stage 0 lymphedema means that a patient is at risk for lymphedema swelling but has no signs or symptoms. The goal is to keep lymphedema from progressing to the next stage—and you can help them! The worst feeling for me as a lymphedema therapist is seeing a patient who has progressed to stage 2 or 3, educating them on risk reduction practices, and having them ask, “Why didn’t anyone tell me about this?”

Once a patient has progressed to the higher stages, it’s difficult and highly unlikely to reverse progression to a previous stage due to the underlying tissue damage. Knowledge is power, so give your patients with lymphedema—or any type of swelling!—the power to manage their risk.

Risk Reduction Practices for Individuals with Lymphedema

Regular Medical Check-ups

Remind your patients to schedule regular appointments with their medical doctor and Certified Lymphedema Therapist (CLT). If they don’t have one, they can find a CLT through the National Lymphedema Network.

Patients should always report any changes in their swelling, such as:

• Size
• Shape
• Sensation
• Soreness
• Heaviness
• Firmness
• Color
• Temperature
• Tissue texture
• Skin integrity

Maintain a Healthy Body Weight

Patients should eat a healthy and well-balanced diet, stay well-hydrated, and get plenty of exercise. Specific exercises have been shown to benefit individuals with lymphedema; however, patients should consult a CLT before beginning an exercise regimen involving the affected extremity to determine whether compression garments should be worn during exercise and to ensure that they are avoiding exercises that may increase their lymphedema.

Patients with lower extremity lymphedema should avoid stasis (prolonged sitting or standing), which can contribute to the pooling of fluid in the lower extremities due to the lack of muscle pump action.

Wear Compression Garments

If compression garments are prescribed, they should be well-fitting, the correct length, and the appropriate amount of compression. Upper extremity compression garments should start at 20 to 30 mmHg, and lower extremity compression garments should start at 30 to 40 mmHg.

Include the most distal aspect of the involved extremity (the glove or foot piece, for example). Wearing only a sleeve or leg wrap can cause fluid to accumulate in the distal aspect of the extremity, increasing swelling in this area.

Avoid wrinkles in compression garments, and do not fold them over. Folding over or wrinkling a compression garment will exponentially increase the pressure, which can quickly create a tourniquet effect and cause damage to an already compromised system.

Wash the garments as instructed by the manufacturer. This usually means handwashing and hanging dry without fabric softener. Compression garments should be replaced as recommended by the manufacturer, typically every four to six months.

Complete Proper Skin Care

Use lotion on a regular basis. Avoid lotions with fragrances or dyes as they contain alcohol and will dry out the skin. If wearing compression garments, make sure the lotion you use is compatible with the garment and won’t cause it to break down early.

Avoid all kinds of trauma, including:

• Falls
• Fractures
• Burns (Including sunburns—always wear sunscreen.)
• Scratches
• Punctures
• Mosquito and other insect bites (Always wear insect repellent when outdoors.)
• Splinters

All of these can increase the risk of infection or increased swelling. If scratches do occur, wash with soap and water, pat dry, apply a topical antibacterial ointment, cover, and watch for signs and symptoms of infection.

Wear protective clothing such as long sleeves, long pants, socks, shoes, and gloves when washing dishes, using chemicals, gardening, spending time outdoors, or playing with pets.

Nail care should be done professionally. Patients should practice good hand and foot hygiene, ensuring that these areas are kept clean and dry. If problems arise with toenails, the patient should consult a podiatrist. Fungal infections need to be treated promptly. Fingernail cuticles should be kept soft and not cut. Remind patients to be cautious when getting manicures and to make sure the instruments have been properly cleaned prior to use.

When shaving, always use clean razors. If prone to nicks, choose an electric razor to avoid injury. Avoid getting blood draws from the involved extremity. If it is absolutely necessary to use the involved side, ask for the most experienced individual to avoid multiple attempts to search for the vein.

Avoid Constriction and Tourniquets

Anything that is too tight or squeezing can restrict the flow of lymphatic fluid from the area. In fact, anything heavier than the weight of your hand can close the superficial lymphatic vessels!

Sleeves, bras, socks, jewelry, and watches should be well-fitting and not too tight. If a patient has upper extremity lymphedema, they should avoid carrying a heavy bag or purse on the affected side.

When taking blood pressure, medical professionals should use the uninvolved extremity if possible. If you have to take a blood pressure on the involved limb, do so manually, be careful not to overinflate, and only take the blood pressure once.

Know the Signs and Symptoms of Cellulitis

Cellulitis is an infection in the subcutaneous tissue. It is a medical emergency.

Signs of cellulitis include:

• Redness (or tanned appearance)
• Warmth
• Pain
• Fever
• A feeling of overall illness or flu-like symptoms
• Increased swelling

Educate your patient to seek medical attention immediately and be proactive in telling their medical provider that they have lymphedema, they believe they have cellulitis, and that they may need antibiotics. Healthcare professionals may not be familiar with the treatment of lymphedema-related infections. Often the lymphedema swelling is their main concern, the patient is checked for a deep-vein thrombosis, and then sent home. A delay in treatment of cellulitis with oral antibiotics may require hospitalization for IV antibiotics.

Be Proactive When It Comes to Surgery

Medical professionals should consult with a CLT prior to surgery for an individualized approach for management during and after surgery.

Watch Out for Temperature Changes

Before using a sauna or hot tub, the patient should discuss this with a CLT. The general guidelines recommend avoiding exposure for any longer than 15 minutes.

Moist hot packs may be either beneficial or harmful in the management of lymphedema, depending on the individual. This is another case when a CLT should be consulted.

Using ice is not recommended in the management of lymphedema.

Traveling and Flying

Patients should consult with a CLT before flying to determine whether they should wear compression garments. During the flight, they should be sure to move around and also hydrate with non-alcoholic and (preferably) non-caffeinated beverages, which helps to avoid the diuretic effect. Keep a small first aid kit on hand to clean any scratches or scrapes that may occur. Recommend to patients that they discuss prophylactic prescription of antibiotics with their primary care provider if they are traveling out of the country.

These guidelines should be verbally reviewed with all patients who have active lymphedema and those at risk for progressing to stage 1 lymphedema. Many of these guidelines will also be beneficial for patients with low protein swelling (edema) to help decrease their risk of infection.

Before treating a patient with lymphedema, make sure you are aware of the risks! Refer them out if necessary and educate patients about their condition. Providing our patients with a framework for maintaining a healthy lifestyle to reduce their risk for developing stage 1 lymphedema, progressing in stages, or developing an infection can help improve their quality of life for years to come.

For more information, be sure to check out these position papers from the National Lymphedema Network on lymphedema risk reduction practices and healthy habits for patients at risk for lymphedema.