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Is All Edema Lymphedema?

Updated: Mar 11

Summary and additional comments by Margaret Latham, DPT, CLT-LANA, ALM

The following is a more technical article primarily for clinicians and physicians. Dr. Margaret adds her thoughts in several sections and at the end about how these concepts affect aftercare treatment and healing for plastic surgery clients.


This information was provided by Heather Hettrick, PT, PhD, CWS, AWCC, CLT-LANA, CLWT, CORE, Professor for the Physical therapy program at Nova Southeastern University at a webinar sponsored by Lympha Press on February 17, 2022.


Is all Edema Lymphedema?


The short answer is YES! This is because we now know that the lymphatic system is responsible for returning nearly all excess fluid that accumulates in tissues to the venous system, whether temporary or not.


What is Edema?


It is swelling in the tissues related to fluid buildup. This fluid is lymph, which is what makes all edema lymphatic fluid.

Lymphatic load is everything absorbed by the lymphatic capillaries and transported by the lymphatic system which includes (1)

  • All fluid

  • Cancer cells

  • 50%+ of blood plasma proteins

  • Enzymes/Matrix Metalloproteinases (MMPs)

  • Lipids

  • White blood cells

  • Byproducts of wound healing

  • Bacteria, endotoxins

  • Dead and senescent cells

  • Perfumes, dyes, pollutants

lymphorrhea


Stagnant lymph can be toxic to the skin and cause lymphorrhea (leakage of lymph onto the skin) and ultimately lead to denudement or a chemical-like burn of the skin.




Edema Can be Anywhere!

  • Peripheral edema – localized to the feet, ankles, and lower leg

  • Pulmonary edema – lungs

  • Cerebral edema – brain

  • Ascites – edema in the abdominal spaces

  • Anasarca – full body edema

  • Third spacing – an outdated term where fluid moves from the vascular system to spaces between cells or body cavities that normally contain little to no fluid

  • Puffy Head Bird Leg Syndrome – 2-liter fluid shift from lower body to trunk/head due to loss of gravity (astronauts)

Causes of Edema


There are numerous (30+) causes of edema, however all are associated with the lymphatic system as it is all lymph fluid.

  • Severe inflammation

  • Burn injury

  • Trauma

  • Surgery

  • Immobility

  • Obesity/fat disorders

  • Poor nutrition

  • Allergic reaction

  • Medications

  • Congenital vascular malformations

  • Infections (viral, bacterial, parasitic)

  • Various disease states (CHF, CVI)

  • End-stage disorders (e.g., end stage renal disease)

Regardless of the cause, this edema is all still lymphatic fluid that increases our lymphatic load.


Lymphatic System and Circulation


The lymphatic system is a nodal-centric immune-vascular system. The lymphatics are the mortar that manages the interstitial fluid environment and mediates immunity and inflammation. (2)

The lymphatic system is the body’s drainage system. Fluid is taken from the tissues through the lymphatic vessels and lymph nodes.


lymphatic capillaries -> pre-collectors ->

collectors -> lymph nodes


The lymph nodes process molecules and debris in the fluid and the fluid continues through the lymphatic vessels until it returns to the venous system at the attachment of the lymphatic system to vein (venous angle) near the neck.




Classic Functions of the

Lymphatic System

  1. Maintain interstitial fluid / protein balance.

  2. The lymphatic system acts as a safety valve for fluid overload and helps keep edema from forming.

  3. Fat absorption from the intestinal tract.

  4. Immune response to infectious agents.

The homeostasis of the extracellular environment is maintained by the lymphatic system, and it cleanses the interstitial fluid and provides a blockade to the spread of infection or malignant cells in the lymph nodes. Langerhans cells (LCs), maintained in the skin, also serve to prevent unwanted organisms from entering our systems. These cells reside in the epidermis as a dense network of immune system sentinels. These cells determine the appropriate adaptive immune response (inflammation or tolerance) by interpreting the microenvironmental context in which they encounter foreign substances. In a normal physiological, “non-dangerous” situation, LCs coordinate a continuous state of immune tolerance, preventing unnecessary and harmful immune activation. Conversely, when they sense a danger signal, for example during infection or when the physical integrity of skin has been compromised as a result of a trauma, they instruct T lymphocytes of the adaptive immune system to mount efficient effector responses. (3)


Lymphocytes Attacking Cancer Cells
Lymphocytes Attacking Cancer Cells

Newly Appreciated Functions of the Lymphatic System

  1. Reverse cholesterol transport.

  2. Indirect regulation of brain function via cerebral lymphatics and “glymphatics.”

  3. Organ growth and repair (i.e., cardiomyocytes, hair follicles)


Complications associated with the lymphatic system span a wide spectrum, including congenital disorders, cancer and side-effects of cancer treatments, cardiovascular disease, diabetes, and parasitic infections. While some lymphatic disorders are genetically related, lymphatic complications most often arise as a secondary complication following cancer, cardiovascular disease, and immunological diseases.


Lymphatic Vessel Engineering


Specific pathologies and areas that could benefit from improved lymphatic function or engineered lymphatic tissue are summarized in the graphic. Multiple areas of medicine and disease pathologies could benefit from advances in lymphatic tissue engineering. These include rescuing cardiac tissue after MI, clearing macromolecules from the brain to slow or hinder the onset of Alzheimer's disease, further understanding the pathways of cancer metastasis in order to effectively target cancer progression, designing improved organoids which would more accurately model native tissue, simulating lymphedema as an experimental model that could be used to design treatments for lymphedema beyond mechanical pumping, screening potential therapeutic agents to understand how they impact and interact with the lymphatic system, engineering superior skin grafts that incorporate the dermis and associated functionality, and promoting wound healing. (4)


Fluid Imbalance: Dynamic Insufficiency


Edema in the tissues is a symptom of another process such as injury or surgery. Our system becomes temporarily overwhelmed with fluid, but there is no damage to the lymphatic system.


Fluid Imbalance: Mechanical Insufficiency


We develop lymphedema as a disease process. The lymphatic system has some kind of permanent damage that prevents our system from being able to manage fluid accumulation effectively.


Lymphedema as a Disease


Most pathologies associated with the lymphatic system result in the clinical manifestation of edema/lymphedema. It is a chronic, uncurbable condition that is characterized by the abnormal collection of protein-rich fluid as a result of anatomical alterations to the lymphatic system (e.g., lymph node removal). It may lead to impairments in function, integument (skin) disorders, discomfort, and phycological issues.


Lymphedema can be primary (born with an issue, aka congenital) or secondary (acquired). It typically involves the arms or legs but can include the trunk, genitals, and other body locations. It can be on one side or both sides, but if it is on both sides, it is always asymmetrical.


Edema Versus Lymphedema


All edema is lymphatic fluid (must be removed by the lymphatic system).

Edema is the abnormal excess accumulation of serous fluid in the connective tissue. The lymphatic system is temporarily overwhelmed (lymphatic insufficiency), but not permanently damaged. This is low protein edema which has a watery consistency.


Lymphedema is the accumulation of protein rich fluid in an extremity or body part as a result of damage or loss (lymphatic impairment) to part of the lymphatic vessel/node system. Protein rich edema is progressive and permanent, and the fluid is viscous like honey in a Ziploc bag.


Think about lymphatic transport this way:

The lymphatics being temporarily overwhelmed is like going from a pick-up size transport capacity to a Fiat size transport capacity. This is most edema with more than 30 possible causes. It is transient lymphedema caused by processes such as injury, surgery, and congestive heart failure.





If the lymphatics are permanently impaired or damaged, this is the disease of lymphedema. Your Fiat is damaged beyond repair.






Food for Thought from Dr. Margaret


Where does post-op plastic surgery fit in? Off the cuff, as a plastic surgery recipient as well as a certified lymphedema therapist (CLT), I would say that most plastic surgery would result in a combination of normal, temporary post-op edema and a temporary, more prolonged edema caused by lymphatic system damage. We expect any lymphatic system damage to be healed within about 12 weeks, maybe less or maybe more depending on many factors.


Here is my new analogy about lymphatic transport after plastic surgeries:

Because you had surgery you downsized from a truck to a Fiat, but your Fiat gets wrecked as soon as you drive it off the lot. Fortunately, your new Fiat can be repaired by the local body shop with a little help from your CLT. (Pun intended :-) After your Fiat is repaired, you upsize it back to a pickup truck in a few months.

There is a significant component of lymphatic vessel damage with most body procedures (and some facial). The surgical effect of liposuction on the lymphatics is unique. Liposuction disrupts or destroys most lymphatic capillaries within the targeted adipose tissue. Fortunately, lymphatic damage from liposuction is not usually permanent. Lymphatic capillaries regenerate within a few weeks to several months after being damaged by a liposuction cannula. Damage may also occur due to severed vessels by incisions. We expect the lymphatic vessels to be able to be repaired by the body during healing, but this would likely take longer than the usual length of time for just post-op edema to resolve. Lymphatic vessels can regenerate and will normally regrow through scars less than about 3mm in width.


The result would be the likelihood of more prolonged swelling and its possible complications while the lymphatic system heals its “mechanical insufficiency” component as well as catches up from its post-op "dynamic insufficiency" component. In cases of lymphatic system damage from plastic surgery procedures, there is a combination of transient lymphedema caused by both a dynamic insufficiency as well as a (hopefully) temporary mechanical insufficiency of the lymphatic system. It is definitely food for thought in this context.


How does this information affect the answer to the question: "Do I need manual lymph drainage (“lymphatic massage”) after a tummy tuck?" During a typical tummy tuck, lower abdominal skin and tissue (below the belly button) is removed and upper abdominal skin and tissue (above the belly button) is pulled down to be the new lower abdominal skin and tissue. The lymphatics from below the belly button that would normally flow toward the lymph nodes in the groin are now replaced with upper abdominal lymphatics that flow toward the axilla. Without any or much liposuction, the lymphatic system essentially remains intact and does not have the “mechanical insufficiency" component caused by liposuction. If the incision is not extended too far past the mid trunk, it shouldn’t affect the lymph flow from the lower back region to the lymph nodes in the groin. In this case the recovery likely only involves the normal post-op fluid edema with a lesser possibility of more prolonged edema from significant lymphatic system damage. These cases would be much less likely to “need” manual lymph drainage, but it could be helpful in relieving pain and speeding recovery like after any surgery that causes post-op edema. We should also note that the different techniques available for liposuction also play a role in post-op swelling and recovery.


The VAIL Concept & Why?


The venous, arterial, integumentary, and lymphatic systems (VAIL) are interrelated. Anatomically, physiologically and biochemically, these systems work in unison to maintain homeostasis. Dysfunction in one system will lead to dysfunction in the other systems, and this may manifest sub-clinically or be overt. Edema is the clinical manifestation of either an overwhelmed or damaged lymphatic system. One is transient and the other is a disease. Both are part of the lymphedema continuum.

  • All edema is lymphatic fluid

Lymphatic impairment leads to local areas of compromised skin barrier function rending the skin more prone to breakdown and impairments (chronic wounds, infection). (5-7)

  • Called lymphatic dermopathy

Movement enhances VAIL by promoting more optimal functioning (effects on muscle pump, pumping of lymph nodes near joints from ROM, and support for vascular integrity and health).


The venous and lymphatic systems are mutually interdependent. When dysfunctional, the result is a dual outflow system failure.

  • Tri system failure with integumentary impairments (venous leg ulcers, dermatitis, etc.)

Disorders of the lymph system, whether systemic (macro-lymphedema) or localized (micro-lymphedema) produce cutaneous regions susceptible to infection, inflammation, and carcinogenesis (lymphatic dermopathy = skin barrier failure; tri-system failure). (5-7)

The pathophysiology of lymphedema explains the propensity for infections (cellulitis) and hypersensitivity reactions in patients with chronic venous insufficiency (lymphatic dermopathy).


A functional lymphatic system is essential to an organism’s overall health given its role in fluid homeostasis, removal of cellular debris, and mediating immunity and inflammation. (8)

  • Lymph Stasis = Chronic Inflammatory State

Stagnating lymphatic load or lymph fluid results in a pathohistological stage of chronic inflammation resulting in fibrotic changes, thickening, and connective tissue proliferation. “Oxidation & degradation of interstitial proteins attracts monocytes that change into macrophages. Macrophages ingest the proteins and activate fibroblasts that, in turn, form collagen resulting in connective tissue proliferation.” It also triggers adipocytes, leading to fatty tissue proliferation. (1)


  • Macrophages -> Fibroblasts -> Fibrotic Tissue


**There is no re-absorption in the blood capillaries. Fluid is returned to the venous system / vascular compartment by the lymphatics alone. ***


“Arguably, it may be better to consider the presence of chronic edema as synonymous with the presence of lymphedema, inasmuch as all edema represents relative lymph drainage failure.”

- Dr. Stanley Rockson, Stanford Medical Center


“…all edema indicates an inadequacy or failure of lymphatic drainage…” (9)


“…lymphatic failure is responsible for all forms of peripheral edema…” (10)



These statements represent a significant paradigm shift.


How is all Edema Lymphedema? Starlings Law Redefined


What about Starlings Principle of the Microcirculation?

Our previous understanding of Starlings Law regarding capillary fluid exchange is based on hydrostatic pressure which favors filtration of plasma OUT of capillaries and on osmotic pressure which favors osmotic movement of interstitial fluid INTO capillaries with about 90% returned at the venous end and 10% via the lymphatics.


Our new understanding is based on the Endothelial Glycocalyx Layer (EGL). This the the gel-like matrix with hair-like projections extending into the lumen of blood vessels. It acts as a molecular sieve regulating fluid and macromolecule movement. It allows for only a diminishing net filtration across the capillary bed. (11)


EGL
A: Healthy EGL & B: Diseased EGL

In 2010, Levick and Michel mathematically demonstrated that there is no net reabsorption of fluid back into the venous side of the blood capillaries. There is only diminishing net filtration across the capillary bed. (9)

No Net Fluid Movement Back into the Circulatory Vessels

Structure and Function of the Endothelial Glycocalyx

  • Hair-like projections are organized like bushes, with roots communicating with the base layer.

  • EGL is organized into a hexagonal matrix where blood flow shear forces act on the endothelial cells (mechanotransduction).

  • Vascular endothelial cells respond to the mechanical signals, producing and releasing Nitric Oxide which dilates the vessel. (11,13)

  • EGL sheds in response to inflammation, ischemia, sepsis, trauma, atherosclerosis, diabetes, intravenous fluid management as well as prolonged immobility. (11,14)

  • The EGL is dynamic and can “shed” in response to stimuli, such as during inflammation or disease states.

  • Shedding is conceptualized as a dog shedding its fur.

  • During inflammation, this shedding allows more fluid to escape through the EGL. (11,13)

  • The lymphatic system becomes overwhelmed leading to clinical edema. When you see edema, the EGL has been disrupted.

Key Lymphatic Considerations


The dense capsular design of the lymph nodes, placement in joint areas that are mechanically compressed by movement, and role of the EGL all work synergistically to facilitate fluid reabsorption back into the venous system via the lymphatics.

Conversely, immobility and decreased joint movement through the full range of motion, lymph node removal, or venous hypertension can have a significant impact on fluid retention in the dermis and subcutaneous tissues.


All fluid, proteins, and macromolecules are removed from the interstitium by the lymphatics alone (lymph capillaries, vessels, and nodes).


Lymphedema Risk Factors

  • Obesity

  • Chronic venous insufficiency

  • Post-thrombotic syndrome

  • Vein stripping or harvesting

  • Surgery (i.e. revascularization, TKA, THA, abdominal surgery, hysterectomy)

  • Decreased mobility

  • Congestive heart failure

  • Chronic kidney disease

  • Trauma

  • Scars

  • Burns

  • Lymph node dissection or removal

  • Radiation

  • Chronic wounds

  • Recurrent cellulitis

  • Congenital malformation of lymphatic vasculature

  • Tumors obstructing lymphatics

  • Travel to or living in Lymphatic Filariasis epidemic areas

  • Prolonged dependency of a limb or other body part

  • Hyperthyroidism

  • Medication with edema as a side effect

  • Chronic skin disorders and inflammation

  • Arteriovenous shunt (15,16)

  • Nutritional compromise

  • Fat disorders

Link Between Obesity and Lymphedema


There is an increase in multi-causal, obesity-related lymphedema

  • Why? Adipokines

  • Adipose tissue is an endocrine organ. It produces the hormone adipokinase.

  • Obese individuals suffer from greater immobility thereby a reduced muscle-pump which further impairs/impacts lymphatic function.

  • Overhanging abdominal wall can compress lymphatic and venous structures.

Obesity-Induced Lymphedema (OIL)

  • Obesity can cause lymphedema or worsen lymphedema.

  • A BMI threshold of 40 exists at which point lower extremity lymphatic dysfunction can occur.

  • The risk of OIL increases with elevated BMI. 90% of individuals with a BMI > 60 will have the disease (secondary lymphedema).

  • Patients with OIL, or at risk of the disease, are managed with weight loss.

  • Operative intervention to reduce extremity overgrowth is considered after patients have reduced their BMI to less than 40. (17)

CVI Pathophysiology and Phlebolymphedema

  • Etiology: Insufficiency of the venous system due to vascular failure of deep perforating or superficial veins.

  • Results in regurgitation of blood in the veins.

  • Creates dermal backflow of lymphatic fluid.

  • Impairs capillary function due to increased pressure.

  • This causes a dual outflow system failure and a tri-system failure with skin impairment.

  • Lymphatics are damaged from chronic venous insufficiency (CVI) and venous leg ulcers (VLU). (18,19)

All edema, including chronic venous insufficiency, is lymphedema beginning at stage C3:

  • Stage C0: No visible or palpable signs of venous disease

  • Stage C1: Telangiectasias or reticular veins, “spider veins”

  • Stage C2: Varicose (protruding) veins

  • Stage C3: Edema (fluid retention) visible

  • Stage C4: a. Pigmentation and/or eczema b. Lipoermatosclerosis and/or atrophie blanche

  • Stage C5: Healed venous leg ulcers

  • Stage C6: Active venous ulcers

How do we treat edema if it is all lymphedema?

  • Know the etiology or contributing factors for medical management.

  • What is the geography of the edema/lymphedema?

  • What is the patient’s vascular status?

  • What is the patient’s integumentary status (integrity, sensation)?

  • What is the patient’s functional status?

  • What is the patient’s cognition?

  • In other words, do a thorough history and physical related to the edema and determine if it is from lymphatic insufficiency (overwhelmed) or lymphatic impairment (damage).

Lymphatic Insufficiency

  • This is transient lymphedema

  • Rest

  • Ice

  • Compression

  • Elevation

  • Education

  • Manual lymph drainage (MLD) can help


Lymphatic Impairment

  • Disease of lymphedema

  • Treat with complete decongestive therapy (CDT)

  • Skin and nail care

  • Manual lymph drainage (MLD)

  • Compression

  • Exercise (while wearing compression)

  • Patient education

Clinical Relevance

  • Lymphedema is best managed by complete decongestive therapy (CDT).

  1. The chronic disease state of lymphedema requires treatment in 2 phases

  2. Phase 1 is clinician driven decongestion until plateau reached

  3. Phase 2 is patient driven maintenance for life

  4. Both phases involve patient education, skin and nail hygiene, manual lymph drainage (MLD), compression, and exercise.

  • CDT is highly effective on all forms of edema as all edema is the result of lymphatic system failure to some degree.

  • Remember, all edema is lymphatic fluid.

Benefits of Manual Lymph Drainage (MLD)

Because all edema is lymphedema, the benefits of adding MLD to all forms of edema and surgical protocols has been shown to improve outcomes for

  • Total knee replacements (20-22)

  • Orthopedic injuries (23)

  • CVI (24-28)

  • Venous leg ulcers (29-30)

  • Neurological diseases (31)

  • Autoimmune diseases (32)

  • Autism (33-34)

  • MLD is effective when combined with proprioceptive neuromuscular facilitation (PNF) (35)

Recap

  • The venous, arterial, integumentary, and lymphatic systems (think VAIL) are inter-related.

  • Anatomically, physiologically, and biochemically these systems work in unison to maintain homeostasis.

  • Dysfunction in one system can lead to dysfunction in the other systems, and this may manifest sub-clinically or be overt (dual or tri-system failure).

  • All edema is lymphedema given the role of the EGL and because all edema is lymphatic fluid.

  • Lymphedema is a continuum from transient to permanent.

Dr. Margaret’s Two Cents


How do these concepts specifically apply to plastic surgery recovery?

  • Many plastic surgeries, especially those that involve liposuction and/or long incisions damage the lymphatic system to some extent and place the resulting edema somewhere between transient and permanent lymphedema. Not only do we have the normal excess fluid generated by surgery and trauma, but we also have mechanical damage to lymphatic vessels. Fortunately, for most of us, the lymphatic vessels should be able to heal and reroute themselves given enough time (from a few weeks to a few months). Treatment with complete decongestive therapy (CDT) will assist this process.

  • CDT including skin (and possibly wound) care, MLD, and appropriate compression is the treatment of choice to speed recovery, encourage the lymphatic system to heal in an efficient manner, and prevent complications such as fibrosis and skin healing issues.

  • Many factors may affect how quickly someone recovers from plastic surgery including physical characteristics (BMI before and after surgery, history of obesity, presence of excess skin from weight loss (especially an abdominal apron), health status such as hyperthyroid, or unknown/ underlying conditions such as an autoimmune issue, lymphatic system defect, vascular issue (which may include recurrent hemorrhoids), adverse response to medications or anesthesia, or pre-existing inflammatory condition or sensitivity.

  • Other factors may contribute to a slow or abnormal healing such as a history of a sedentary lifestyle prior to surgery, the type of liposuction used, the amount of liposuction received, and the location of the liposuction.

  • Some people will recover more quickly and without significant compression and treatment with CDT or MLD. However, MLD can still help any client with post-op edema and pain and promote a faster recovery and lower risk of complications. It will help most clients significantly.

  • More than just MLD goes into appropriate treatment following any surgery, especially plastic surgery. In my professional opinion treatment should be provided by a healthcare professional who is a certified lymphedema therapist (CLT) and is also well versed in how plastic surgeries affect and change our lymphatic system anatomy and physiology.

  • If someone does not have easy access to their surgeon following their procedures, then receiving treatment from a knowledgeable CLT is even more important.

  • Procedures that will likely benefit the most from treatment by a CLT would be liposuction, especially abdominal liposuction and/or moderate to aggressive liposuction over a larger area such as 360 liposuction, tummy tucks, thigh lifts, and breast reductions. Facial surgeries and arm lifts will also benefit, and to a lesser degree breast augmentation and/or lift.

  • Research and science now show that all edema is lymphedema and that MLD can help anyone with post-surgical or traumatic swelling in addition to persons who have the disease of lymphedema.

  • Prolonged fluid in the tissues following surgery can lead to complications of fibrosis, poor incisional healing, and skin injury.

So, all edema is lymphedema. The principles and techniques used to treat the disease lymphedema can apply to all cases of post-op edema and are especially useful for accelerating recovery, reducing pain, and preventing complications following plastic surgery that involves even temporary damage to the lymphatic system.


To promote good healing and recovery and lower risk of complications (in addition to other factors such as smoking cessation and nutrition...), I advise 1-2 sessions of MLD prior to surgery and then 3-8 sessions following surgery beginning no later than the end of post-op week three but as soon as post-op day 1-3. This helps make sure clients do not have any preexisting issues with lymphatic flow that may hinder progress as well as help get the system moving efficiently again after surgery. The clients I see that are more at risk of issues and complications include clients with a higher BMI prior to surgery, clients with a history of abdominal surgery or endocrine issues, and clients who have had massive weight loss prior to surgery.


Check out my videos demonstrating MLD following tummy tuck and self-MLD, my video on lymphatic system 101, as well as my article on the lymphatic system. As always, feel free to contact me with any questions.


Sources

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