Lipedema PDF

# Lipedema Lipedema is a frequently overlooked yet fairly common condition and is sometimes confused with lymphedema. Unlike lymphedema, there is a gradual and progressive symmetrical accumulation of fat in the subcutaneous tissue, typically seen in the buttocks and lower extremities. Lipedema was...

# Lipedema Lipedema is a frequently overlooked yet fairly common condition and is sometimes confused with lymphedema. Unlike lymphedema, there is a gradual and progressive symmetrical accumulation of fat in the subcutaneous tissue, typically seen in the buttocks and lower extremities. Lipedema was first described in 1940 as a condition that only affects women and was differentiated from obesity or lymphedema. Lipedema often appears at puberty, pregnancy, or menopause in women, but in contrast, is now known to be extremely rare in men. It is also believed to be an inherited condition, as it often affects more than one woman in a given family. ## Clinical Manifestations and Differential Diagnosis Although lipedema may be challenging for the therapist to identify in its early stages, in later stages, patients with lipedema have characteristic signs that allow for easy differentiation from lymphedema. One of the most important characteristics of lipedema is that it is a bilateral condition usually affecting the lower but rarely the upper extremities; consequently, the upper extremities may look quite normal in lipedema patients. In contrast to lymphedema, lipedema typically affects the proximal areas, such as the buttocks and thighs, but not distal areas, such as the feet. That is why a patient with lipedema shows a negative Stemmer sign (thickened skin folds of the toes). Lipedema also affects the skin by reducing its elasticity, which is the ability of the skin to return to its original size and shape, as well as making the skin sensitive to pressure and touch, which makes it bruise easily and be painful. The clinician should also remember that lipedema, like lymphedema, may be confused with obesity. Although the clinical physical presentation can typically determine the diagnosis of lymphedema and lipedema, diagnostic imaging methods such as lymphoscintigraphy and computed tomography can be helpful with the differential diagnosis of lymphedema and lipedema. ### Table 21-4 Major characteristics distinguishing lipedema from lymphedema | Clinical feature | Lipedema | Lymphedema | |---------------------|----------------------------------------|------------------------------------------------| | Gender | Almost exclusively in women | Women and men | | Commonality | Common | Rare | | Distribution | Bilateral lower extremities (rarely UE) symmetric involvement | Unilateral, or bilateral with one leg affected more severely (asymmetric) | | Family history | Rare | Common | | Cellulitis | Rare | Absent | | Pain on pressure | Present | Present | | Easy bruising | Present (hematoma) | Present (positive) | | Distal edema in the foot | Absent | Present | | Stemmer sign | Absent (negative) | Present | ## Combination Forms of Lipedema and Lymphedema If untreated, lipedema can cause the formation of lymphedema in what is known as lipolymphedema. It is believed that the abnormal subcutaneous fatty tissue distribution that occurs in lipedema compresses the lymph collectors, thus leading to impaired drainage of the lymphatic system. This combination form of lipedema and lymphedema is frequently seen in lymphedema clinics. One study reported that lipolymphedema occurs, on average, 17 years after the initial onset of lipedema in patients who do not receive proper treatment for their lipedema. Thus it is important that the therapist be able to clearly identify lipedema and lymphedema so as to assist in proper patient education and to develop realistic treatment plans and goals. ## Treatment of Lipedema ### Conservative Methods Physical therapists can treat both patients with lymphedema and lipedema with MLD along with the other components of CDT. However, important differences do exist in the anticipated outcomes for each of these conditions. Typically, a patient who has pure primary lymphedema should respond to CDT faster than one who has a combination of lipolymphedema or pure lipedema. Because patients with lipedema or lipolymphedema usually have pain and hypersensitivity in the areas affected by lipedema, the therapist may need to use less pressure during MLD and bandaging while waiting for that hypersensitivity to resolve, which is usually the case. ## Lipedema Education of the Public, Patients, and Health Care Providers Compared with lymphedema, much less has been written about lipedema in lymphology textbooks targeting health care providers. This has led to much confusion in the medical establishment, as illustrated by one study in the United States that determined 9 of the 250 patients with a physician diagnosis of "lymphedema" actually had lipedema. Even though lipedema is a little-known disease, it is likely to be widespread. One study conducted in Germany found that 11% of German women have some form of lipedema, which would imply that, at a minimum, hundreds of thousands of American women may have lipedema. Given that untreated lipedema is likely to cause lymphedema as well, proper public and health care provider education is key in preventing the progression of lipedema to lipolymphedema. ## Case study 21-1 JM is a 58-year-old female who comes to the lymphedema clinic with moderate stage 2 lymphedema of the right upper extremity, secondary to sentinel lymph node biopsy (nodes negative) 6 years prior. Last year she experienced a bad upper-body sunburn while on vacation at Daytona Beach, Florida. A few months later her arm started to feel heavy. JM is a computer programmer and works from home. Her two children are grown, and her husband is a truck driver who is home only on the weekend. Past medical history is significant for diabetes mellitus, high cholesterol, and hypertension. JM has just started an exercise class to help motivate her to lose weight. She is 5'7" in height, weighs 208 pounds (BMI 32.6), and is right-hand dominant. Assessment found no functional limitations in any extremity concerning range of motion or manual muscle testing. Patient complains of general discomfort in the right