The Impact of Occupational Therapy on Lymphoedema Management

-Lymphoedema: Definition and Prevalence-

Did you know that over 150 million people worldwide suffer from lymphoedema (US 'lymphedema'), a condition that can severely impact daily life? 

Our lymphatic system complements the immune and circulatory systems. It consists of a series of one-way channels that transport lymphatic fluid ('lymph') from the tissues to the bloodstream. Functions of lymph include fluid balance, immunity and fat absorption.

Lymphoedema is an accumulation of protein-rich fluid in the interstitial space, that causes reactive inflammation and fibrosis. It occurs when lymph builds up in tissues, instead of returning to the circulatory system. Protein molecules accumulate, which causes thick, hard tissue; this protein build-up draws more water into the tissues and leads to a heavy, painful and potentially immobile limb.

Physiology of lymphoedema

Lymphoedema affects approximately 15% of all cancer survivors and 30% of all those treated for breast cancer (Manrique et al., 2022)

Lymphoedema can be further classified as primary or secondary:

• Primary lymphoedema is inherited; it may occur at birth but more often later in life

• Secondary lymphoedema is due to a known trauma or injury to the lymphatic system, such as surgical removal of lymph nodes, or radiation therapy

(Showalter et al., 2013)

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-Lymphoedema: The Signs-

• Swelling in the trunk

• Increased limb size

• Heaviness or tightness in a limb

• Aching or discomfort

• Erythema - redness of the skin

• Pitting of the skin when pressed

• Lymphorrhea - an abnormal lymph fluid flow that occurs when the pressure from swelling inside of the tissue is too high for the skin to contain, or there is an opening to the skin's surface

• Positive Stemmer's sign - the inability to pick up a fold of skin at the base of the second toe or middle finger

-Stages of Lymphoedema-

Stage 0

The latent stage, in which the lymphatic system is functioning inadequately, but it is coping by means of compensatory mechanisms. No oedema is present.

Stage 1

The reversible stage. The lymphatic system is overburdened at this point. Protein-rich, soft swelling develops. When the affected limb is elevated, the swelling reduces on its own.

Stage 2

The spontaneously irreversible stage. Excessive connective tissue has formed and begins to harden. Elevating the limb no longer reduces the swelling, due to the fluid becoming richer in protein.

Stage 3

Considered elephantiasis. At this stage, extreme swelling is present, the skin is hardened, wart-like growths develop and cellulitis is commonly correlated. 

Stages of Lymphoedema

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-CDT: A Gold-standard Process-

Complete Decongestive Therapy (CDT) is the gold-standard process for lymphoedema management. It consists of two phases:

• Decongestion and reduction

• Maintenance

Both phases consist of four elements and must be applied together for effectiveness:

1. Skin care

2. Manual Lymph Drainage (MLD)

3. Compression therapy

4. Therapeutic exercise

The treatment phase commences with meticulous skin care. Secondly, it includes MLD - a hands-on technique that uses skin stretching to encourage fluid to move out of an area where there is swelling and into healthy lymph nodes. This allows the body to reabsorb the protein-rich fluid accumulation and move it into the bloodstream.

Phases of the CDT Process 

Third, compression bandaging is donned. The affected limb is wrapped with short-stretch compression bandages, to encourage fluid to move up and out of that limb and to prevent re-accumulation of fluid.

The expectation is to wear compression bandages for approximately 23 hours per day - until the next treatment session - to reduce the size of the swollen limb.

Fourth, therapeutic exercise encourages muscle movement, that helps to move lymph out of an affected limb. It is completed with the compression bandages donned. 

The maintenance phase entails the patient being responsible for self-management. It involves continuation of skin care, self-MLD, therapeutic exercise, hydration and monitoring of symptoms that were taught to the patient in the treatment phase. Instead of donning short-stretch compression bandages, it involves the use of prescribed, custom-fitted compression garments (NLN Medical Advisory Committee, 2010).

Short-Stretch Compression Bandaging of the Arm 

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-The Role of Occupational Therapy-

As a result of lymphoedema, quality of life, functional mobility, range of movement and activities of daily living (ADLs) are negatively impacted.

Occupational therapists (OTs) provide lymphoedema management in a holistic manner, within acute care, inpatient rehabilitation and outpatient settings. This ensures that services are based on the person's goals and preferences, in order to support his or her activities of daily living (Occupational Therapy Board of Australia, 2015).

OTs are best skilled at exploring the impact of swelling and fatigue on one's ability to perform activities of daily living (ADLs), such as showering and dressing (AOTA, 2014). Additionally, instrumental activities of daily living (iADLs) - which involve household chores, driving and social engagement - are more complex. They are based on the interplay between one's physical and social environments, which leads to an overall sense of self-worth (AOTA, 2014).

Occupational therapists provide patients with knowledge regarding lymphoedema - and any potential, corresponding complications, as lymphoedema is complex and multi-faceted. The aim of this education is to empower patients to self-manage their swelling and be aware of any changes to their symptoms. OTs facilitate problem-solving strategies, to allow patients to increase their independence in their daily routine.

One of the biggest things that I have learned as a Certified Lymphoedema Therapist is that occupational therapists play a key role in enabling patients to advocate for themselves. Many of my patients come to me after years of experiencing lymphoedema; they have not received the treatment they need and have given up.

Thus, occupational therapists have the important role of giving patients hope, while utilising evidence-based practice and allowing them to engage in their meaningful occupations again.

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The extent of the impact of lymphoedema on patients' daily routines can be quantified by the Lymphoedema Quality of Life Study. This written questionnaire includes a rating scale of 'not at all' to 'a lot', in relation to the impact of lymphoedema on items such as appearance, donning clothing, mobility, social participation and mental health:

DOWNLOAD: Lymphoedema Quality of Life Study

Lymphoedema Quality of Life Tool (Arm)

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-How to Become a Certified Lymphoedema Therapist-

The first step to becoming a Certified Lymphoedema Therapist (CLT) is to attend a certification course, entailing 135 hours of education. This course includes education on anatomy, physiology, prevalence, case studies and hands-on practice with completing MLD and donning the short-stretch compression bandages.

Upon completion of the training course, therapists earn the credentials 'CLT'. To additionally earn the full credentials of 'CLT-LANA' (Certified Lymphoedema Therapist - Lymphology Association of North America), therapists must pass a standardised, 130-question exam.

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-Conclusion-

Lymphoedema is a build-up of lymph fluid in the fatty tissue just under the skin. As a result, mobility, quality of life and independence are reduced. 

Whilst better treatments for cancer have been developed, the prevalence of lymphoedema has risen by over 30% over the past 10 years. Thus, lymphoedema currently affects approximately five million Americans (Armer et al., 2011).

The efficacy of CDT supports its use in improving oedema, range of motion, quality of life and activities of daily living in patients. However, patients' compliance and carryover of home care recommendations are imperative for successful lymphoedema management.

Support groups and online resources provide valuable information for patients. Organisations such as the National Lymphedema Network offer educational materials and advocacy efforts.

A career as a CLT is rewarding to consider, as it combines science and creativity. It also yields great objective feedback, in the form of circumferential measurements, to quantify the reduction in the size of patients' limbs.

Submitted by:

Chelsea Laur, MSOT, OTR/L, CLT-LANA, CWT 

Certified Lymphedema Therapist - Lymphology Association of North America (CLT-LANA) 

Certified Wound Therapist (CWT)

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-References and Further Resources-

American Occupational Therapy Association (AOTA) (2014) Occupational therapy practice framework: Domain and process (3rd ed). American Journal of Occupational Therapy. 68, S1-S48. Available from: https://doi.org/10.5014/ajot.2014.682006.

Armer, J.M., Brooks, C.W. and Stewart, B.R. (2011) Limitations of self-care in reducing the risk of lymphedema: Supportive-educative systems. Nursing Science Quarterly, 24(1), 57-63. Available from: https://doi.org/10.1177/0894318410389058.

Keeley, V., Crooks, S., Locke, J., Veigas, D., Riches, K. and Hilliam, R. (2010) Lymphoedema Quality of Life Tool. Journal of Lymphoedema. 2010, 5 (1). Available from: https://lymphoedemaeducation.com.au/wp-content/uploads/2019/03/JoL_Quality_of_Life_Measures1.pdf.

Manrique, O.J., Bustos, S.S., Ciudad, P., Adabi, K., Chen, W.F., Forte, A.J., Cheville, A.L., Jakub, J.W., McLaughlin, S.A. and Chen, H.C. Overview of Lymphedema for Physicians and Other Clinicians: A Review of Fundamental Concepts. Mayo Clinic Proceedings. 2022, 97(10): 1920-1935. Available from: https://www.mayoclinicproceedings.org/article/S0025-6196(20)30033-1/fulltext. PMID: 32829905.

National Lymphedema Network (2025) What is Lymphedema? (online). Available from: https://lymphnet.org/page/what-is-lymphedema.

NLN Medical Advisory Committee (2010) Lymphedema risk reduction practices. Position Statement of the National Lymphedema Network.

Occupational Therapy Board of Australia (2015) Position statement: Occupational therapy in oncology. Australian Occupational Therapy Journal. 62, 462-464. doi:10.1111/1440-1630.12265.

Showalter, S.L., Brown, J.C., Cheville, A.L., Fisher, C.S., Sataloff, D. and Schmitz, K.H. (2013) Lifestyle risk factors associated with arm swelling among women with breast cancer. Annals of Surgical Oncology. 20(3), 842-849. Available from: https://doi.org/10.1245/s10434-012-2631-9.