martes, 30 de agosto de 2022

LYMPHEDEMA SIGNS AND SYMPTOMS - STRUCTURAL AND FUNCTIONAL IMPAIRMENT – Long Term Disability - Personal and Social Impact - Health Related Quality of Life (HR-QOL) – Primary Lymphedema - Secondary Lymphedema - Lymphostatic Elephantiasis (Filariasis/Podoconiosis)

Lymphedema is a progressive disfiguring and disabling disease of the skin, classified as a functional, immune, and lymphatic circulatory system disorder. The lymphatics are an active and integrated component of the immune response, and in lymphedema, there is always an increased susceptibility to infection due to the compromised immune system. lymphedema arises when there is a disruption of lymphatic flow, leading to the buildup of lymphatic fluid. Individuals affected by lymphedema may experience difficulties to complete activities of daily living and maintaining employment. Nontreatment and undertreatment of lymphedema are associated with an unfavorable prognosis of disease progression and severity, which are barriers to work and causes of social stigmatization, discrimination, and loss of Quality of Life (QoL).

The ICF (International Classification of Functioning, Disability, and Health, is the international standard to describe and measure health and disability. It includes disfigurement, sensory impairments, nail, and congenital malformations, skin swelling and infections, pain, immunity response, functions of the lymphatic vessels and nodes, and general mobility and functional impairments, which have the potential to interfere with the personal and social levels. Lymphaedema is a disease that may affect arms, legs, fingers, toes, head, neck, abdomen (belly), genitalia, internal organs, or the whole body, which causes chronic inflammation and swelling in the affected area.

Treatment for lymphedema depends on the severity and extent of the condition. Prevention and controlling symptoms are important since there is no cure.

To properly understand and evaluate how lymphedema affects people’s overall health and Quality of Life (QoL), the following questions should be considered:

  1. What is it like to live day by day with lymphedema?
  2. How does lymphatic dysfunction limit an individual?
  3. What is the principal cause of disease progression?
  4. What complications and degrees of disability can lymphedema cause?
  5. What levels of anguish and suffering can be experienced by those affected?


These are some of the symptoms and complications resulting from lymphatic dysfunction (lymphedema) of upper and lower limbs:


SIGNS AND SYMPTOMS (SENSORY FUNCTIONS)

Lymphedema signs and symptoms include:

  • Lymphatic edema (Chronic inflammation).
  • Chronic stasis/stagnant lymphatic flow (Lymphostasis).
  • Progressive swelling (increased edema volume and weight).
  • Skin changes (Structural change of the skin).
  • Loss of hair on the affected limb.
  • The dorsum of the second toe cannot be pinched (Positive Kaposi-Stemmer Sign)
  • Skin dents when pressed in the early initial stages (Pitting edema).
  • Skin does not dents when pressed in late advanced stages (Non-pitting edema).
  • Edema does not subside with limb elevation (only in the mild first stages).
  • Abnormal wound healing (Functions of the Skin and the Immune System).
  • Nail structure disorders (Functions of nails).
  • Visible disfigurement (deformed/enlarged body parts).
  • Fullness sensation (puffiness).
  • Heaviness sensation (feeling of weight).
  • Weakness sensation (debilitation).
  • Fatigue sensation. (urging rest).
  • Burning sensation (warmth and redness).
  • Pins and needles/itching sensation (Paresthesias).
  • Tightness or stiffness sensation.
  • Tenderness and sore to touch.
  • Numbness sensation.
  • Discomfort, aching, or pain sensation.

COMPLICATIONS THAT MAY DEVELOP (BODY STRUCTURE IMPAIRMENTS)

Lymphedema body structure impairments may include the development of:

  • Lymph stasis (precursor of inflammatory plaque progression).
  • Coagulation in the lymph (Lymphatic Thrombosis).
  • Inflammatory episodes involving the skin (Erythema).
  • Soft-tissue changes (Skin structure disorder).
  • Tissue induration-scarring (Fibrosis).
  • Dry, hard, thick, and scaly skin (Hyperkeratosis).
  • Papules often described as frogspawn (Cutaneous Lymphangiectasia).
  • Wart-like lesions/cobblestone appearance (Papillomatosis).
  • Velvety growth with warty projections (Verrucosis).
  • Deformities of the dorsal skin of toes (“square or box “ toes).
  • Upslanting ''ski-jump'' toenails (Dysplastic toenails).
  • Disturbed nail growth/dorsal deviation (Nail Hypoplasia).
  • Ingrown toenails (Onychocryptosis).
  • Yellowing of nails.
  • Skin discoloration.
  • Skin fold/retractions (deepened folds that cannot be widened).
  • Restricted range of flexibility (limited mobility).
  • Difficulties with extreme hot or cold temperatures.
  • Abdominal swelling (Bloating),
  • Genital lymphedema (internal/external genitalia).
  • Disturbed gastrointestinal lymphatic flow (Intestinal lymphangiectasia).
  • Coexisting lymphatic and venous insufficiency (Flebolinfedema).
  • Manifestations of visible disfigurement (Physical deformity).
  • Development of Elephantiasis (Stage III Lymphedema)
  • Aching swelling due to lymph pressure congestion (Sensory nerves).
  • Pain due to the tension forces upon the subcutaneous tissue.
  • Aching joints in the affected limb.
  • Ear pain, nasal congestion, or affected vision (in Head, Face, and Neck Lymphedema).
  • Poor quality of sleep (associated with the symptoms/complications of lymphedema).
  • Cutaneous fungal infections.
  • Bacterial upper dermis skin infections (Erysipelas).
  • Bacterial inner layers of skin infections (Cellulitis/Dermatolymphangioadenitis-DLA).
  • Infection of the lymphatic vessels (Lymphangitis ).
  • Inflammation of lymph nodes (lymphadenitis).
  • Inflammation involving lymph nodes and lymph vessels (Adenolymphangitis -ADL).
  • Poor healing wounds and recurring skin infections (Suppressed Immune Function).
  • Skin abscesses (areas of ulceration and/or tissue damage/necrosis).
  • Skin breakdown (fissures).
  • Lymph fluid leaking from the skin (Lymphorrhoea).
  • Sepsis (Septicemia).
  • Malignant tumors (Lymphangiosarcoma).

FUNCTIONAL PROBLEMS THAT MAY DEVELOP (BODY FUNCTION IMPAIRMENTS)

Lymphedema Body Function Impairments may include experiencing:

  • Difficulties with restricted limb mobility (increased volume and weight).
  • Difficulties with the involvement of limb rotation.
  • Difficulties with standing or sitting for long periods.
  • Difficulties with walking long distances (Walking/gait Disorders).
  • Difficulties with bending or getting up (Functionality Disorders).
  • Difficulties in performing basic daily household activities.
  • Difficulties in self-care.
  • Difficulties in sexual performance (Genital lymphedema/Dyspareunia).
  • Difficulties to engage in some sports or leisure activities.
  • Difficulties with jobs or activities involved in heavy lifting with the affected limb (heavy work).
  • Difficulties with jobs or activities involved in pushing or pulling with the affected limb.
  • Difficulties with jobs or activities involved in constant use of the affected limb (overstressing work).
  • Difficulties with jobs or activities involved in standing or sitting for long periods.
  • Difficulties with jobs or activities involved in the possible trauma/injuries of the affected limb (Immunity deficiency risk).
  • Difficulties with jobs or activities involved in exposure to hot/cold temperatures of the affected limb.
  • Difficulties with jobs or activities involved in precision work with hands and fingers of the affected limb.
  • Difficulties with restrictions in specific occupations due to wearing compression garments.
  • Difficulties with long periods of work without rest (work performance issues).

PERSONAL AND SOCIAL IMPACT ON INDIVIDUALS (PERSONAL AND ENVIRONMENTAL FACTORS)

The personal and social impact of Lymphedema on individuals may include experiencing:

  • Problems in finding well-fitted clothing or footwear.
  • The need to use orthopedic shoes.
  • The need to use compression garments.
  • Problems with time-consuming daily self-management regimes.
  • Hours or days unable to perform usual activities.
  • Appearance-related Social Discrimination (visible Physical Disfigurement).
  • Negative social situations from community/family members (Social Stigmatization).
  • Negative impact on work performance (Functional Impairments).
  • Need of modifying the workspace to accommodate the aching limbs.
  • A disadvantage to access jobs due to the visible disfigurement or physical impairment.
  • Discrimination in the workplace due to the impairment or visible difference.
  • Being worse off in terms of work performance and career.
  • Problems with full-time employment due to requiring more time for complex care.
  • Need of reducing work hours to accommodate the aching limbs.
  • Consequent low-paid employment and productivity losses (limited earning capacity).
  • The need to stop employment (days of work lost).
  • Being a financial burden to the family.
  • Problems to access public financed treatment.
  • Problems with copayments in medical consultations (medical expenses).
  • Problems with direct/indirect out-of-pocket therapy-related expenses.
  • Problems with direct costs for compression garments/orthopedic footwear.
  • Difficulties regarding relationships with family and others.
  • Impaired sexual function (Genital lymphedema-related issues).
  • Inability to get married.
  • Abandonment by their spouse.
  • Needing help to carry out daily activities.
  • Requiring constant care and attention.
  • Requiring recurrent hospitalization (Bacterial infections).
  • Developing the need for continuous antibiotic therapy.
  • Need to depend on other people.
  • Becoming housebound.
  • Loss of Quality of Life (QoL).

CONSEQUENT PSYCHOSOCIAL IMPACT

The consequent psychosocial impact of Lymphedema on individuals may include developing:

  • Distress caused by negative social experiences (Social Stigmatization).
  • Distress caused by disease progression and complications.
  • Distress caused by not having access to proper treatment (nontreatment/undertreatment).
  • Distress caused by a reluctance to participate in public events (Social avoidance).
  • Distress caused by embarrassment to exposing oedematous limbs (Disfigurement/Visible physical difference).
  • Distress caused by negative body image (Self-stigmatization).
  • Distress caused by difficulties finding personal relationships/getting married.
  • Distress caused by a reluctance to engage in sexual activity (Physical and appearance-associated impairments).
  • Distress caused by unsupportive spouse/family.
  • Distress caused by fear of losing the family/spouse.
  • Distress caused by an unsupportive employer.
  • Distress caused by fear of losing their job.
  • Distress caused by having to rely on others to accomplish housework or a job.
  • Distress and being tense, worried, irritable, anxious, and depressed due to disease symptoms, impairments, and environmental factors.

With reference to disability and Quality of Life (QoL) in disorders of the lymphatic circulation, the physical impairments and consequences (the symptom and function domains), are the most important factors and what most conditions individuals, and which consequently may also trigger the psychological and emotional outcome on their personal and social functioning. Read more about disability and lymphedema HERE.

The direct and indirect out-of-pocket expenses of lymphedema management and overall healthcare may include: co-payments for outpatient physician visits; physical therapy visits, complementary and integrative therapy visits; emergency department visits; hospitalizations; labs, X-rays, and tests; lymphedema-specific healthcare needs (compression garments, bandages); medications or other health-related-specific product (antibiotics, antifungal creams, moisturizing ointments); etc.

If the disease is not identified and treated in the earlier stages, the patient prognosis is worse and treatment more costly. Higher costs may delay retirement and increase the inability to access proper health care. Read more about what is the best treatment option for lymphedema HERE.


REFERENCES:

(Pinch on the texts to read the following Research Articles)

SCIENTIFIC SOCIETIES









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