Lymphedema in Multiple Sclerosis
page 2 A Clinical Bulletin from the Professional Resource Center of the National Multiple Sclerosis Society
wound healing, and provides a culture medium for bacteria that can result in lymphangitis(inflammation of the lymph vessels) or cellulitis. This fluid can also predispose the patient tosignificant side effects from minor trauma and infection.
SignS and SyMptoMS
Lymphedema is usually painless, although patients may experience a “tight” feeling in the skin or achronic, dull, heavy sensation in the leg(s). The aected limb will typically be discolored, swollen andhypertrophied; the skin may be thickened and brotic—often causing the individual concern aboutthe cosmetic appearance. Swollen ankles and feet can interfere with activities of daily living andincrease any existing diculty with mobility. The swelling may be severe and constant, making itdicult to wear shoes. The problems increase during the summer because blood vessels and lymphchannels dilate more when the temperature is higher.
It is important to identify the cause of lower extremity edema and to rule out the possible causesother than mobility impairment. A thorough patient history and physical examination are necessary.Lymphangiography and radioactive isotope studies may help in detecting the site of lymphaticobstruction. Generally the latter is not necessary in MS patients, in whom the cause is usually disuseof the lower limbs (Foldi et al., 2003).A lymphedema clinic is the best choice for evaluation and treatment in more complex cases. The patient may also need to be seen by a vascular specialist to rule out other causes of theedema. If swelling occurred rapidly, especially in one leg, and is accompanied by redness andpain, it is imperative to rule out the possibility of phlebitis, which may lead to venous thrombus(Schapiro and Schneider, 2002). In this situation, vascular ultrasound (venous Doppler) isrecommended to rule out deep vein thrombosis. Abdominal and pelvic ultrasound may beordered, and CT scans or MRI may also prove useful.Because extra uid may accumulate in the body and pool in the ankles as the result of cardiacdisease, it is especially important to rule out cardiac problems in patients whose primary sign isankle swelling. In such cases, lymphedema may be accompanied by shortness of breath, coughing,and a general feeling of being unwell.It is important to also rule out possible benign or malignant tumors, as well as liver and kidney disease.Lymphedema is categorized as mild, moderate, or severe, and is progressive in nature (Penzer, 2003):
Stage 1—Pitting (mild):
When the tissue is pressed by the ngertips, the aected areaindents and holds the indentation. Usually upon waking in the morning, the limb or aectedarea is normal or almost normal in size.
Stage 2—Non-pitting (moderate):
The tissue now has a spongy consistency and whenpressed by the ngertips, the tissue bounces back without any indentation. Fibrosis found inStage 2 lymphedema marks the beginning of the hardening of the limbs and increasing size.