Edema Versus Lymphedema in Chronic Venous Insufficiency (CVI)

Edema (swelling) can be one of the most misunderstood symptoms for medical care providers because it is so common and there are so many causes. Edema can be a benign swelling related to gravity or be a marker for a more serious vascular or malignant disease, and sometimes patients have more than one reason for swelling. As our understanding of the complexity of swelling disorders has advanced, the treatments have become more complex -- from interventional vascular procedures to medicines/ointments for inflammation, to a myriad of stockings, pneumatic devices and decongestive therapy. As people live longer with chronic illnesses, even true Lymphedema can be complicated by other medical conditions that cause or exacerbate swelling. Standard Lymphedema treatment, known as Complete Decongestive Therapy (CDT), was developed for Lymphedema but is effective for many types of swelling. It is important for Lymphedema therapists to know the actual cause of a patient’s swelling and not to label them all as Lymphedema. Patients with many causes of swelling are sent to Lymphedema therapists, and these patients may think they have Lymphedema when they do not. Another problem is patients with swelling that may benefit from decongestive therapy are not sent to Lymphedema therapists because providers do not recognize the benefits of Lymphedema therapy for other forms of swelling. Swelling is a symptom, not a diagnosis. Diagnosis is essential to treatment.

Vascular Malformations and Venous Disorders: The most common form of venous swelling is venous insufficiency, or valvular incompetence in the veins of the legs. Severe venous insufficiency leads to venous hypertension, wounds, infections and pain. Longstanding venous insufficiency can lead to secondary Lymphedema, known as phlebolymphedema. Unless phlebolymphedema has developed, most early venous edemas are best treated with moderate to high compression bandages/stockings and calf exercises. Since high level compression stockings are very difficult for many patients to manage, compression bandages are helpful in this stage.

In Subclinical Stage Zero, the healthy lymphatic system activates its safety factor to protect against swelling. It responds to an increase in water. The therapeutic approach in this stage is compression therapy/bandaging, elevation, and exercise.
In Stage One, the lymphatic system is still healthy but fails to drain the increased water load. Swelling develops during the course of the day and tends to decrease or completely recede during rest at night, but returns the following day. The therapeutic approach in this stage is also compression/bandaging therapy, elevation and exercise.

In Stage Two, blood capillaries and lymph collectors with elevated pressure values that remain without treatment for extended periods of time will eventually suffer damage. The combination of this damage and possible inflammatory process causes the lymphatic system to develop a mechanical insufficiency, which, with the elevated load of water and protein presents as a combined insufficiency. Lymphedema will develop as a result of the Venus pathology and its systems are exacerbated by the symptoms associated with the vericosis pigmentation and pain. It is also referred to as phlebolymphostatic insufficiency. The Lymphedema in the early stage appears initially smooth and is pitting. Without treatment it will progress into a more fibrotic stage. The therapeutic approach is complete decongestive therapy which includes manual lymph drainage, using Vodder techniques and compression bandaging, followed by a compression garment for maintenance.

Regardless of how it originates, Lymphedema is always a progressive condition. So in Stage Three, severe changes in the skin are associated with the phlebolymphostatic swelling. The interstitial fibrin cuff that forms as a result of plasma protein leakage in combination with an increased diffusion distance associated with the swelling decreases oxygen and nutrients delivered to the tissues, this results in local hypoxia and necrosis. Also typical for this stage is lypodermatosclerosis. These characteristic skin changes in the lower extremities include: capillary proliferation, fat necrosis, and fibrosis of skin and subputanious tissue. Pain, especially after moving about, is present. Therapeutic approach in this stage is complete decongestive therapy and wound care. Lymphedema resulting from prolonged CVI, may show signs and symptoms of Elephantiasis (thickening of the skin and underlying tissues).

A complete history, including all other medical conditions, greatly help the Lymphedema therapist in making an effective plan of care for their patients.

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