2 majerus & company physical therapy vancouver, wa A comprehensive PT clinic offering one on one professional attention from an experienced staff with a wide range of expertise….imagine life squared.Jodie Paschall-Majerus MPT , CLTJohn Majerus PT, OCS, CSCS, CLTLaura Bancroft PTA, CLTRobby Trimbo DPT, CLTTara Socquet MPTBuffy Stinchfield MPTTara Rinhard, DPTKathleen Griffin, PTA, LMT, SI
3 Edema Management- NOT just for breast CA survivors with arm lymphedema!- 75% of our edema patients are treated for LE issues.- Many of the LE patients are referred by their primary care physicians, orthopedists or cardiologists- In the US, CDT seems to be offered as a treatment of last resort..
4 ANATOMY AND PHYSIOLOGY “KEY POINTS” RELATING TO TREATMENT
5 Lymph Production Lymph production Lymph production begins in the terminal lymph vessels, which are located in close proximity to the capillaries.End of the road for circulation, beginning of the road for lymph.
6 Initial Entry Point-Lymph Capillary “Ultrafiltrate” fluid, dead cells, and proteins are resorbed from the interstitial tissues into the lymph capillaries.These finger-like projections are found throughout the body, peripherally just under the epithelium. The pressure and stretch upon the surrounding connective tissue mobilizes the anchoring filaments to open flaps between the flattened endothelial cells to allow uptake of large MW proteins as well as fluid .Intercellular junctionMovable flapAnchoring FilamentThis is the level at which fibrosis becomes an issue.
7 Lymph Transport-Lymphangions Lymphangions - “driving force” for lymph transport in a collecting vessel.Uni-directional valves form segments that respond to filling with contraction of smooth muscle in the vessel walls, moving fluid to the next segment enhanced by the active muscle pump- LymphangiomotoricitySystole; valve closed Diastole; valve openIe breathing and movement
8 Importance of Skin Elasticity / Mechanical External Compression Lymph transportImportance of Skin Elasticity / Mechanical External CompressionRole of fibrosisWith loss of skin elasticity, the muscle pump loses its normal counter-pressure. Adding external, non-elastic compression can improve muscle pump effectiveness.
9 LYMPH NODES 600-700 lymph nodes in the body. Major node groupings: abdomen/intestines, inguinal, axillary, supraclavicular.2-30 mm in length.Functions : filter and concentrate lymph through immune system.MLD takes advantage of these multiple beds.
11 Zones / Watersheds/Anastamoses Each major lymph node grouping receives lymph from a specific body region or tributary zone.The direction of lymphatic flow of each tributary zone is defined by invisible boundaries called watersheds,Anastamoses are areas between zones where vessels physically line up, critical in movement of lymph between adjacent zones during treatment.
12 The lymphatic fluid from right upper quadrant drains into the right lymphatic duct The lymphatic fluid from both legs and the left upper quadrant drains into the thoracic duct
13 - 20 liters of fluid are leaked/drawn off capillary beds each day; normally 90% is reabsorbed through the venous capillaries.Lymphatic load (LL) is the remaining 10% of the volume, about 2 liters per day, that returns to the bloodstream via the lymphatics .Phenotypic differencesTransport capacity LMV LLLow output failure high output failure
14 Transport capacity (TC) - volume of lymph that can be removed by a tributary zone and its regional nodes.-unless compromised, only about 10% of the volume of a normal zone is used, termed the “safety valve”*loss of transport capacity is often asymptomatic and is not easily measuredPossible contributing factors:-surgical incisions crossing major lymphatic channels-pressure on nodes or vessels from obesity or tumors-radiation therapyexcision of lymph nodesCellulitis mediated damage to lymph capillaries
15 Edema ClassificationHigh vs. Low protein edema- guides initial interventions-High protein edema, i.e. lymphedema, develops when transport capacity drops below the lymphatic loadStage 1- reversible- edema goes down overnight, no skin changes evident, typically soft 1+ or 2+ pitting edemaStage 2- broad symptom range with early to advanced Stage 2edema does not fully reduce overnight or with elevationskin becomes hard, brawny, hyperkeratosis, lymph cysts, etc+ Stemmers sign of digits, swelling of dorsum of the footStage 3 – “elephantiasis”, change in limb morphology, more advanced skin changesStages 2 and 3 require lymphatic massage to clear interstitial proteins. Increased risk of cellulitis. Diuretics aren’t helpful.
16 Lymph System Insufficiencies (LSI) Mechanical (low output failure)Compromised lymphatic system with decreased transport capacity (TC)CA/abdominal surgery, radiation, cellulitisDynamic (high output failure)Normally functioning system is unable to clear increased lymphatic load (LL)Longer standing CVI, lymphovenous conversionCombination (safety valve failure)Decreased TC and increased LL overcomes the “safety valve” margin
17 Edema Classification-Low protein edema- lacks the interstitial protein component of the edema, less osmotic pressureExamples: early CVI , stable CHF- Usually responds quickly to bandaging reduction, fewer treatment sessions- Usually requires garments with lower compression- Lymphatic massage is usually not required, especially if the edema is treated early with consistent, adequate compression and diuretics- Watch that the cardiac, pulmonary and renal systems can handle a spike in fluid volume.- Compress one leg at a time- No increased SOB , wet cough, etc.
18 CVI and CHF - CVI - progressive valve failure in the veins - valve damage due to DVT- creates dependent edema due to increased LL with increased venous capillary leakage- superficial /deep varicosities, hemosiderin staining, hairless fragile skin, tissue weeping , venous stasis ulcers- if more severe and prolonged, likely progresses to high protein edema over time if not treated- Cardiac related edema- CHF, etc,- increased venous capillary pressure and leaking- if stable, can treat with compression; proceed with caution
19 Documentation - Digital photography- First visit and after treatments - LE girth measurements – taken at 10cm intervals, MTP and forefoot, toe girths when needed- Body weight- Volumetric algorithms are available
23 Management of Swelling Disorders - Traditional treatments:- “retrograde massage”- elevation- ankle pump exercises- wrapping with long stretch elastic bandages aka ACE wraps- compression garments- pneumatic pumps
24 CDT Therapy - Origins in Germany - Vodder and Foeldi - First offered in the US in 1980- PT is covered by most private insurance and MC- Treatment components:Short stretch bandaging for edema reductionLymphatic massage- central to peripheralRemedial exercisesMeticulous skin careEducation and home management- compression systems, self massage and/or night bandaging
25 Relative Contraindications - Acute DVT – if not yet on anti-coagulation meds or no screen placed- Acute cellulitis - treat after 7-10 days of antibiotic therapy, <warmth/pain in the leg- PAD – ABI of with caution- Extremity paralysis- mechanical pump lost- Complete sensory loss- caution with toes of neuropathic patients- Dementia
26 CDT-Massage principles - Central trunk first- diaphragmatic breathing- Do the proximal portion of extremity first, gradually progressing more distally- Use light pressure – lymphatic system is above muscle fascia layer- Rhythmic and directional skin stretching
27 Push lymph retrograde to an adjacent, intact zone.
28 Terminal Lymph Vessels / Lymph Capillaries Affected by skin stretchPre-collectorsAffected by blood pressure within sheathLymph Collectors or LymphangionsAffected by muscle pump with either good skin or external compressionLymph Trunks and Associated Node BedsAffected by amount of “draw” from more proximal structures
29 Bandaging - Always apply skin moisturizer/ barriers – Eucerin, Aquaphor, antifungals, etc.- Utilize short stretch cotton bandageslow resting pressure, high working pressure- minimal “pulling in” at rest, enhanced muscle pumpthese features are the opposite of Ace/long stretch bandagesA variety of cotton padding and foams are used for creating a proper pressure gradient, protect bony prominences, reshaping the limb, and softening fibrotic tissue- Wear bandages overnight, sequential wraps until not reducing further
30 Bandaging Critical for healing when “wet” venous wounds are present. Not useful for neuropathic “dry” ulcers.Use over wound dressings that maintain the proper healing environment.Watch for areas of skin maceration.
31 Short Stretch Bandaging with Padding and Foam Inserts Garments alone are not designed to reduce or reshape the limb, just maintain the size of the limbGarments are meant to be fitted to an already reduced legCompression bandages should always extend as far as the next large joint above the edema or we get “topping out”, but response does help detecting central blockages.
32 Remedial Exercise- Important, since obesity is a risk factor; this is one reason we favor bandaging over pumps.We want people to walk and move! BUT, patients must wear compression when exercising to:-enhance the LE muscle pump- counteract increased capillary pressures from increased blood flow- create micro-massage of the skin to increase lymph uptake in the terminal lymph vessels
33 Choosing a Compression System EffectiveAffordableManageable to don/doffComfortable to wearCosmetically acceptableEuropean Compression Garment Guidelines
34 Choosing a Compression System - Socks- Circular weave- off the shelf- Flat weave- custom measured- Compression level- Closed toe or open toe, w/ or w/out toe caps- Materials- Latex or Lycra – allergies, use and care- Neoprene garments- CircAids or Ready Wraps
35 Choosing a Compression System Knee or thigh highs? Avoid “topping out” or dumping at the next most proximal limb segment.For high protein edema, apply compression to the whole zone, up to the watershed.Shorts-Bermuda flat weave – combine with flat weave thigh highbiking shortsCapri circular knit legging with knee highsWhen layering garments, many options are available
36 Thank you!majerus & company physical therapyPhone:Web: