Advances in Understanding the Use of Yoga as Therapy in Lymphedema

Introduction

Lymphedema is a disfiguring and disabling, often neglected disease caused by dysfunction of the lymphatic system due to damage/block, hypoplasia due to genetic causes or by lymph overload. Breast Cancer Related Lymphedema (BCRL), elephantiasis due to lymphatic Filariasis (LF) and primary lymphedema of various genetic aberrations are the most prevalent world over. There are two standard yoga protocols for lower limb and upper limb lymphedema described by us previously (Narahari et al., 2007; Narahari et al., 2013). This chapter describes the changes done in yoga protocols incorporating lymphedema patients’ feedback and expert discussions.

Commonly seen mild oedema of over three months duration, which pits when compressed with relatively light pressure represents lymphatic overload could be the result of a failing heart or other systemic illness unrelated to lymphatic block. Some people develop persistent oedema which becomes organized, brawny and non-pitting at least in certain parts of affected area termed lymphedema or elephantiasis, usually found in the tropics. It is acquired following mosquito bites in childhood, transmitting the parasites, Wucheraria bancrofti, Brugia malayi or Brugia timori. Also, it appears some years after therapies for cancer such as surgical removal of lymph nodes with supporting fat pads in adults or following radiotherapy. Several genetic disorders are accounting for rarer presentations, especially but not inevitably in childhood. Lymphedema occurs when lymph vessel function gets impaired due to blockade, gross dilatation or loss. Accumulation of protein-rich interstitial fluid (lymph) stimulating tissue overgrowth and swollen limbs is the hallmark of failure of lymph drainage. There is also the phenomenon of lymphatic overload due to an excess of fluid flow from the capillary bed of the upper dermis as a result of inflammation by cytokines and other inflammatory mediators from the epidermis, dermal mast cells and macrophages. A primary underlying mechanism is the failure epidermal barrier function, which also loads the dermis with inflammatory mediators such as cytokines and growth factors (Ryan, 2016) in an attempt to repair itself. Lymphedema caused by impaired lymphatic flow and the effects of dermal inflammation much worse if there is also venous overload due to the gravitational impacts of an immobile and dependent limb. The role of an overloaded venous system in aggravating lymphatic overload is alleviated by anti-gravitational interventions such as elevation, and ankle movements activating the calf muscle contractions and compressing the calf veins.

There are many causes for the failure of lymph drainage and all lead to lymphedema. But in India, the major cause of lymphedema, and indeed throughout the tropics is LF. It is a neglected disease of the poor, prevalent in 78 countries. In India, there are at least 20 million people with signs and symptoms of LF. The mosquito inoculates the filarial parasites as a microscopic worm. After a prolonged circulation in the bloodstream, the parasite resides as a much more giant ‘worm’ in the lymphatic collecting ducts near their lymph node termination causing dilatation of the vessel (Young et al., 1976) and failure of flow (Witte et al., 1993). Three drugs given once yearly over five years to remove this cause circulating in the blood and consequent transmission. They are albendazole, ivermectin and diethyl carbamazine.