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Climate change and climatic variation impact on chronic edema and lymphedema
Climate change and climatic variation impact on chronic edema and lymphedema
By Susan Witt and Neil Piller
Followinga week of record-breaking heat in Europe and northern America linked to unusual wind patterns and the El Nino climate pattern, human-driven climate change’s growing influence is again brought into focus. We are experiencing increasing issues globally with temperature increases and associated changes in weather patterns, humidity, etc.2. Linked with this has been an increase in the death toll in Europe (and presumably elsewhere) associated with these increases in peak and average temperatures. Especially vulnerable are those with pre-existing cardiovascular and respiratory conditions3 and especially concerning is the potential spread of filarial types of lymphedemas.1
This article is based on three articles recently published in the Journal of Lymphoedema and Wounds International, relating to the impact of climate on those with chronic edemas and lymphedemas and the research being undertaken by Susan Witt, a Ph.D. student with Flinders University who is currently working at the Foeldi Clinic in Germany with Prof Thomas Dieterle. For full details of the findings and proposed activities, we suggest reading the original articles. This summary will give you an indication of where we are, what we know and what we (and you) might be able to do to make a difference!
For all of us, heat and humidity can be an issue, but when you have a damaged or dysfunctional lymphatic system, you can be particularly vulnerable to worsening edema or lymphedema. This could be from the subjective side of tension, pain, heaviness, etc., to the objective side of increased limb volume and size to functional issues determined by those mentioned above.
In a general sense, we ask why? Well, it can be broadly related to both an increased superficial vascular load associated with attempts of the body to maintain temperature homeostasis and an inability of the lymphatic system to deal with the load placed upon it. The result is the accumulation of not only fluid but also its contents, which can include bacteria and their wastes, inflammatory mediators and a range of other molecules, which may promote the development, or progression of lymphedema. Further, due to the slowed lymph flow, we may be at a higher risk of infection due to the inability of the lymphatic system to mount its normal defence against bacteria.
With the impact of climate and climate change predicted to bring increasing temperatures and ongoing adverse weather events, a greater awareness of what might be to come and of its likely impact, and more importantly, what we can all do to minimize the problems for those with conditions like chronic edema and lymphedema, will provide relief to patients in the years to come.
Let’s look at some of those articles and consider where they can lead us and future
research. Some sections of these articles are repeated below (with permission from Omnia Med). You can access the full findings in the original articles in the reference list.
Future research investigating a variety of healthy populations and populations with lymphedema will contribute to a greater understanding of the effect of seasonal climate variation on upper-limb size, volume and fluid distribution.
Chronic edema is a significant problem worldwide and results in a substantial burden on health services and a major impact on individuals’ quality of life. As there is no cure, the primary goal of treatment is to manage the symptoms and prevent deterioration. The gold standard remains the ongoing use of compression therapy via compression garments and bandaging. Other treatments, such as manual lymphatic drainage, skincare, exercise, and laser therapy, are also regularly applied. Rising temperature due to climate change is well documented, with scientists predicting a 1.5–2.5% increase in average temperatures across the globe by 2050. Further, on top of this is the increasing proportion of western populations with obesity and the likely links between weight, body surface area and thermoregulation. It is anticipated this will present significant challenges for the ongoing management of chronic edema. Higher temperatures and increased humidity result in additional discomfort and increased difficulty with compression garment use.
Higher temperatures and increased humidity result in additional discomfort and increased difficulty with compression garment use. This may result in reduced compliance with core treatment recommendations, resulting in increased swelling and poorly managed symptoms.
This may result in reduced compliance with core treatment recommendations, resulting in increased swelling and poorly managed symptoms. In turn, this leads to an increased risk of infection.
In a preliminary study, Witt et al, (2021) searched a range of databases for evidence of the impact of climatic conditions on chronic edema using the PRISMA protocol. Studies were included that examined the general population (adults and/or children) with chronic limb edema because of primary or secondary lymphedema, lipedema, elephantiasis, vascular insufficiency, trauma, or any other condition resulting in chronic edema. A total of 3,536 studies were identified and screened, but only five articles met the inclusion criteria.
Articles fell into three broad categories: compression garment difficulties, physiological changes and seasonal filarial attacks. Despite the broad search terms relating to chronic edema, all included articles related to lymphedema. Populations included breast cancer-related lymphedema, lymphatic filariasis lymphedema, and specifically lower-limb lymphedema. The research results reported were conducted in temperate climates (Sydney, Australia, and Japan), tropical climates (Townsville, Australia, and Ghana) and continental climate (Alberta, Canada). The findings showed a connection between warmer temperatures and symptoms of lymphedema. However, the limited number of studies in this area makes it difficult to draw conclusions about the overall impact. While qualitative indications showed a clear correlation with warmer weather, their physiological measures did not clearly reflect the same. We concluded that there needs to be more quantitative and qualitative evidence relating to climatic variations and chronic edema. Further research in this area is strongly recommended. But what about the influence on people without chronic edema, lymphedema, or other cardiovascular issues? What is it like for the “normal” population? Matthews et al. (2021) undertook a specific study of a healthy population of women living in Townsville, Queensland, Australia. They found significant differences in limb size, with the Sum of the
Anatomical Circumferences being significantly greater in spring than during summer and winter. Also, most circumferential measures at anatomical landmarks were more significant in spring! This change, we believe, may identify that limb size increases when there is a change in climatic conditions and the temperatures and levels of humidity begin to rise.
No significant changes in limb volume or fluid distribution were identified when compared across three different discomfort levels according to Thom’s Discomfort Index.
Again, future research investigating a variety of healthy populations and populations with lymphedema will contribute to a greater understanding of the effect of seasonal climate variation on upper-limb size, volume and fluid distribution.
Further study
Another study was undertaken to test the often anecdotal reports, which suggested that heat and hot weather can cause an exacerbation of breast cancer-related lymphedema (BCRL)5 This study investigated the relationship between seasonal climate variation and limb size, volume, fluid distribution, and diagnosis in women following breast cancer treatment. Women older than the age of 35 years who had undergone treatment for breast cancer were invited to participate. Twenty-five women aged between 38 and 82 years were recruited. Seventy-two percent had received surgery, radiation therapy, and chemotherapy as part of their breast cancer treatment.
Participants completed anthropometric, circumferential, and bioimpedance measures and a survey on three occasions: November (Spring), February (summer), and June (Winter). Diagnostic criteria of >2 cm and >200 mL difference between the affected and unaffected arm and a positive bioimpedance ratio of >1.139 for the dominant arm and >1.066 for the nondominant arm were applied across the three measurement occasions.
Interestingly, no significant correlation between seasonal variation in climate and upper limb size, volume, or fluid distribution was found in women diagnosed with or at risk of developing BCRL.
So, we concluded there was no statistically significant variation in limb size, volume, or fluid distribution in this population across spring, summer, and winter, although there were linked trends in these values.
The diagnosis of lymphedema, however, varied between individual participants throughout the year. This has important implications for the implementation/ commencement of treatment and management.
Again, further research with a larger population in different climates is required to explore the status of women with respect to BCRL. The use of common clinical diagnostic criteria in the study above did not result in consistent diagnostic classification of BCRL for the women involved in this study, so this too can be an issue. It’s one we should all try to address.
So, what’s now being done are further studies engaging not only the patients but also their support groups, lymphedema practitioners, climate change experts, spatial data experts and those from the fields of meteorology, biology, clinical and experimental medicine to utilize a sound methodological approach to study the interplay between climate (and its changes), health and disease.
One of the first steps in the process is the assessment of patients with lymphedema over a year on multiple occasions in each identified season, using a range of subjective tools such as the LYMQOL and objective assessments of fluids using Sozo (a form of bioimpedance measurement), and of fibrous tissues using Indurometry/Fibronometry in a range of countries across the world including Germany, UK, and tropical and temperate Australia. Another of the first steps is to sit down in focus groups with patients affected by lymphedemas and learn more about their personal experiences and the pros and cons of climate concerning their life of living with lymphedema and chronic edemas so we together can help all those with it or at risk of these conditions live better!
All of what we gain can help us better adapt and apply lymphedema management approaches, make us think more about how we can develop new fabrics that provide better ventilation and evaporation and opportunities to educate patients and professionals better, the importance of which was recognized by the award of finalist by the Premiers climate change council in South Australia6 LP
The diagnosis of lymphedema, however, varied between individual participants throughout the year. This has important implications for the implementation/ commencement of treatment and management.
A full set of references can be found at http://www.canadalymph.ca/ pathways-references/
