The lymphatic system is complex, with highly specialised features to manage its multiple functions. The coronavirus pandemic has drawn attention to its role in immune surveillance; equally important in supporting immunity are its key functions of fluid homeostasis and nutrition or gut health (Sneddon and Elwell, 2020). Keeping the lymphatic system healthy and functioning effectively is essential for everyone and crucial for those at risk of, or with, lymphoedema. Health professionals and those they care for have a secret weapon that helps keep the lymphatic system working well, without them even realising it: movement. The lymphatic system relies on the use of small muscle groups to aid the flow of lymph around the body. The British Lymphology Society's (BLS) EveryBodyCan Campaign wants to help patients to mobilise their secret weapons. To support this, there will be free downloadable posters/flyers and leaflets, links to useful resources and educational materials, all available at www.thebls.com/pages/everybodycan/.
Following a brief introduction to the lymphatic system functions, this comment focuses on one aspect-its drainage system and key strategies to improve lymphatic health and function, reduce risk of lymphatic system failure (lymphoedema) and manage lymphoedema should it develop.
The three main components of the lymphatic system responsible for its key functions are:
- Lymphatic organs-the thymus produces T-lymphocytes, while the spleen is a reservoir for maturation and storage of lymphocytes
- Lymphoid tissue-e.g. Peyer's patches in the gut and lymph glands have lymphocytes ready and waiting to protect against infection
- Lymphatic or lymph vessels-these collect harmful particles, for example, bacteria and debris, and fluid for filtering and neutralising in lymphoid tissue before excretion.
Each of the system components and functions works synergistically to defend the body against infection by producing the means to attack and destroy potentially harmful organisms and particles and collecting and draining these away with excess fluid, keeping the gut healthy and able to absorb and transport fat-soluble nutrients. Lymphatic dysfunction compromises immunity, fluid balance in the tissues and peripheral fat mobilisation (Mortimer and Gordon, 2016).
Lymphoedema is a chronic inflammatory condition caused by failure of the lymphatic system to collect and remove fluid and particles that are harmful to the body. It manifests in swelling, usually, but not exclusively, of a limb, with skin changes and increased fat deposition in subcutaneous tissues, as a consequence of retention of the potentially harmful particulate matter and a predisposition to inflammation and infection, which often become recurrent. Any chronic swelling is indicative of relative lymphatic failure (Mortimer and Gordon, 2016).
Normal management of lymphoedema has been challenging during the pandemic, with many face-to-face services being cancelled, creating difficulties with clinical assessment and review of those with lymphoedema and support for them. The emphasis for many has been on facilitating self-care and empowering from a distance via video and phone consultations, supported by online resources to enable individuals to maintain control over their swelling and prevent exacerbation or complications, such as cellulitis. This approach will continue to be important in future care provision.
Self-care strategies for reducing risk and managing lymphoedema
Empowering patients to undertake preventative strategies and support for self-care have never been more important. There are six main elements to reducing the risk of lymphoedema and self-management to keep it under control and prevent complications:
- Skin care-keeping skin clean, soft, supple and intact to maintain it as an effective barrier to infection
- Compression-increasing the interstitial hydrostatic pressure to limit leakage of more fluid into tissue spaces and working with muscles to enhance return through lymphatic vessels to the circulatory system
- Movement-this opens up lymphatic channels, enabling entry of fluid and particles into lymphatic capillaries, which have no muscle and remain inert without movement of the surrounding tissues, and stimulating peristaltic motions within lymphatic vessels for onward movement
- Deep breathing-deep breathing alters the pressures within the abdomen and thorax to stimulate the main thoracic duct of the lymphatic system, which runs parallel to the spinal column. Activity in itself stimulates deeper breathing to provide more oxygen to the heart and muscles (Shields, 1980)
- Healthy eating-being overweight is a risk factor for lymphoedema (BLS, 2020a); positive encouragement to have healthy balanced meals is important and complementary to being more active
- Simple lymphatic drainage (SLD)-this involves specific (self-administered) hand movements and strokes to encourage uptake of fluid into and movement through the lymphatic vessels. This can be helpful for some people, particularly if there is swelling of the midline (head, neck, breast, genitalia or extension of limb oedema to the trunk).
EveryBodyCan campaign
The EveryBodyCan (EBC) campaign aims to highlight the importance of being active for a healthy lymphatic system, for reducing the risk of lymphoedema and for managing it in those who already have lymphoedema or chronic oedema. Guidance and reassurance about the safety of various activities and how to get started in being more active are part of the messaging, based on evidence that exercise is not only safe but also beneficial for those with lymphoedema (Panchik et al, 2019). Following the launch of the 2020 EveryBodyCan Campaign in February 2020, there was considerable interest from individuals and key organisations wanting to get involved, which continued throughout the subsequent weeks and through Lymphoedema Awareness Week in March. Then, COVID-19 struck, and all planned events were cancelled. Resource development and dissemination of key messages of the campaign continued, with social media being an important platform.
Such is the importance of movement and activity for lymphatic drainage and function and support for the campaign that the BLS is extending it into 2021. Development of more online and downloadable resources, which will be valuable through and beyond the pandemic, is the main priority. The BLS website (www.bls.com/pages/everybodycan/) has a host of resources and more information on the campaign.
What's new for 2021
A new theme has been added for 2021: the secret weapon. Talking about exercise may be a real turn off for people, who immediately conjure up negative images of gyms, treadmills, exercise classes and Lycra! Those who have limited ability may feel it is beyond them or pointless. The whole idea of the EBC campaign is that everyone can move a little more and be a little more active in their existing lifestyle, and their lymphatic system will reap the benefits. The campaign is about helping people to build more activity into whatever they do on a daily basis and think about what will support them to do more, more often and feel good about doing it. For example, everyday ‘secret weapons’ might be their radio encouraging dancing (applicable even for the chair-bound) to a couple of tracks every day. It could be the kettle, reminding them to do some ankle stretches, knee lifts or squats (according to abilities and fitness) while waiting for it to boil. It is important for health professionals to tailor these ideas to individuals they are supporting.
Starting a new activity or increasing activity needs support, care and encouragement to make sure it is built up gradually and safely. The impact on swelling should be monitored and adjustments made when required. Those who have been prescribed a compression garment should wear it during any activities. Again, guidance and resources on this are available on the BLS website.
How can you support your patients in adding movement to their day?
Here are some ways in which you can support your patients in incorporating some movement into their daily lives:
- Share information and links to resources about lymphoedema and being active from the EBC campaign page, for example, the Lymph Fact Sheet on Activity and Exercise (BLS, 2020b) with colleagues and patients
- Put up some of the secret weapon posters around clinical areas
- Find out who the BLS Regional Ambassador is in your area and if they can support you in any way
- If you have knowledge or an interest in a particular activity, please consider writing some simple guidance on the activity that could be used as guidance for other health professionals and the public on the website
- If you know of a patient who has faced and overcome challenges in being active with lymphoedema and who would be willing to share their story as inspiration to others, please contact administration at admin@thebls.com to find out more about how their story can be shared
- Register as a Friend of BLS for free information about EBC activities as they are announced
- Keep an eye on BLS social media activity by following the organisation on Facebook and Twitter (@BritishLymph) and help to disseminate information to raise awareness and highlight key messages by re-posting or tagging posts, re-tweeting with the hashtag #EveryBodyCan and including the Twitter handles of key groups or individuals where relevant.