4LymphedemaAn abnormal accumulation of protein-rich fluid in the interstitium, causing chronic inflammation and reactive fibrosis of the affected tissuesUsually in an extremity, but can also occur in the head, neck, genitals, and abdomen
5Lymphedema Affects 1% of the American population (2.5 million people) Still poorly understood in the medical communityLargest cause of lymphedema in the world is Filariasis (considered secondary lymphedema)Filariasis is a parasitic infiltration into the lymphatics that is very common in third world countries (affects 90 million people)
6Types of LymphedemaPrimary lymphedema is a result of lymphatic dysplasia.May be present at birthCan develop later in life without known causeSecondary lymphedema is much more common.Result of surgery, radiation, injury, trauma, scarring, or infection of the lymphatic system
7Primary lymphedema Lymphangiodysplasia – general malformation Hypoplasia – fewer than normal # of lymph collectorsAplasia – absences of collectors in a distinct areaMilroy's Disease is congenital lymphedema evident at birthMeige’s Syndrome is primary lymphedema onset at puberty (lymphedema praecox)Lymphedema Tardum is primary lymphedema onset after age 35Most congenital and pubescent edemas also are characterized by other anomalies, retardation87% of primary edemas are in females
10Secondary lymphedema There is a known cause for the presence of edema Surgery: breast cancer, melanoma, prostate/bladder cancer, lymphoma, ovarian cancer, hip replacementsRadiation therapyTrauma – scarring, crush injuryInfectionCVIObesitySelf-induced
14Stages of Lymphedema Latency Stage Transport Capacity is reduced No visible edemaSubjective complaints of heaviness, achinessStage 1Reversible lymphedemaAccumulation of protein-rich edemaPittingReduces w/elevation (no fibrosis)Stage 2Spontaneously Irreversible LymphedemaPitting becomes progressively difficultFibrosisStage 3Lymphostatic ElephantiasisFibrosis, sclerosis, skin changes, papillomas, hyperkeratosis
15Tissue Changes in Lymphedema Connective tissue cells (fibroblasts) proliferateCollagen fibers are producedFibrotic changes, sclerosis and indurationFatty tissue increases
16Angiosarcoma Can develop after long-standing lymphedema “Stewart - Treves Syndrome”Angiosarcoma after mastectomy was first described in 1948 by Stewart and TrevesSigns: reddish-blue and blackish-blue lumps that rapidly increase in size, bleed easily and ulcerate at an early stageVery rare & poor prognosis
18Lymphedema is a disease. All other edemas are symptoms Lymphedema is a disease. All other edemas are symptoms. There is no cure for lymphedema. There is only management.
19Diagnosis of Lymphedema Physical exam and historyare most important.
20Characteristics of Benign Lymphedema Slow onset, progressivePitting in early stagesCellulitis is commonRarely painful but discomfort is commonSkin changes – hyperkeratosis, papillomas, lichenificationUlcerations are unusualStarts distallyToes square, positive Stemmer’s signDorsum of foot “buffalo hump”Loss of ankle contourAsymmetric if bilateral
21History What is the reason for the swelling? How long has the extremity been swollen?How fast did the edema progress/develop?What are the underlying diseases?Is there pain?Other conditions?Other treatments?Medications?
22Inspection Location of swelling (distal or proximal) Any skin changes Lymphatic cysts, fistulasUlcersScars or radiation burnsPapillomasHyperkeratosis
24Palpation Temperature – indicative of infection Stemmer sign is (+) when a thickened cutaneous fold of skin at the dorsum of the toe or finger cannot be lifted or is difficult to lift. Positive Stemmer’s sign is indicative of lymphedema.Skin foldsPittingFibrosisMuscular status
25Diagnostic TestsDirect lymphography: invasive, oily contrast injected into a surgically exposed lymphatic vessel. Damaging. Has been replaced by CT, MRI, US.Lymphoscintigraphy: noninvasive, assesses dynamic process in superficial and deep lymphaticsCTMRIThese tests are often not performed due to lack of clinical importance
32Malignant lymphedema Pain, paresthesia, paralysis Central location, proximal onsetRapid development, continuous progressionSwelling and nodules in supraclavicular fossaHematoma-like discoloration (angiosarcoma)Ulcers and non-healing open woundsRecurrent malignancy
33Filariasis Prevalent in 3rd world countries; Can still be treated successfully with CDT.Most therapists in the US will never encounter Filariasis.
35Pneumatic Compression Pumps Advantages:Can be used at home by patientsFast applicationFinancially lucrative for DME vendors ($4000 per pump)
36Pneumatic Compression Pumps Disadvantages:Disregards the fact that the ipsilateral trunk can be involved in the lymphedemaIn LE edema, the pump can cause genital edema; in UE edema, the pump can cause breast edemaDoes not address tissue fibrosis and extended use can cause additional fibrosisRequires many hours a day with the affected limb elevatedThe pump can traumatize residual, functioning lymphatics, especially of the UE
37Pneumatic Compression Pumps More disadvantages than advantages, but there are times when pumps are an appropriate choiceUse ONLY IF:Teach the patient MLD to clear the trunk firstUse recommended safe settingsUE mmHgLE mmHgCVI patients will benefit from a pump
38Surgery Microsurgical techniques Liposuction Debulking/Reduction proceduresMicrosurgical – transplant collectors, only work in supine, gravity is too much. Only about 20/yearLiposuction – still will need compression, edema can very very easily recur
39Why surgical options do not always succeed… A blocked system must be made intactThe direction of flow must be correctThe inflow of the reconstructed system must be adequate and the outflow must remain openPatency must be lasting
40History of Complete Decongestive Therapy…. Emil Vodder, Ph.D., P.T.discovered that massage therapy boosted people’s immune systems. They began to massage swollen lymph nodes and noticed common colds improving. He created his first publication of this and coined the term MLD (manual lymph drainage).
41History of Complete Decongestive Therapy…. Michael Foeldi, M.D. and Ethel Foeldi, M.D.In the 1980’s, Prof. Foeldi advancedlymphedema considerably by combining MLD,bandaging, exercise,skin and nail care into“Complete Decongestive Therapy.”
42Components of CDT MLD Compression bandaging Exercise Skin and nail careInstructions in self care
43Manual Lymph Drainage MLD is a gentle manual treatment which improves theactivity of the lymph vascular system.In lymphedema, it reroutes the lymph flow around blocked areas into centrallylocated healthy areas which then can drain into the venous system.
45Manual Lymph Drainage Improves lymph production Increases lymphangio-motoricityImproves lymph circulation and increases the volume of lymph transportedSpecial techniques help break down fibrous connective tissuePromotes relaxation and has an analgesic effectThere is research that proves slight stimuli increases the frequency of contraction of lymph vessels
46Compression bandaging Short stretch bandages (Rosidal, Comprilan) are applied to increase the tissue pressure in the edematous extremity.Reduces the ultrafiltration rateImproves efficiency of the muscle and joint pumpsPrevents re-accumulation of evacuated lymph fluidHelps break down fibrous connective tissue that has developed
49ExercisePerformed with the bandages on or while wearing a compression garment.Active ROM, stretching, strengtheningLow exertionDiaphragmatic breathingIncrease muscle and joint pumpingIncrease lymph vessel activityIncrease venous and lymphatic return
50Skin and Nail CareEliminate bacteria and fungal growth by using medicated powders, hydrocortisone cream where indicated.Reduce the risk of infection by avoiding injury, cleaning all injuries immediately, calling MD at first sign of infection.
51Self Care Patients should be instructed in the following: Skin and nail careInfection prevention (cellulitis is very common)Self-bandagingSelf-MLD as neededExerciseDonning and doffing compression garmentRegular follow-up visits
52CDT is a Two-Phase Therapy Phase 1 (Treatment Phase)Meticulous skin/nail careMLDCompression bandagingExerciseSelf care education** lasts as long as necessary
53CDT is a Two-Phase Therapy Phase 2 (Maintenance Phase)Patient wears compression garments during the dayPatient bandages at nightMeticulous skin and nail careDaily exerciseMLD as neededRegular follow-up visits**life long maintenance
54When does CDT fail? Malignant lymphedema Artificial (self-induced) lymphedemaInsufficient treatment (only used MLD or improper bandaging)Deviation from CDT protocolAssociated illnessesLack of complianceActive cancerFaulty diagnosis
55Goals of CDT Volume or size reduction Restore mobility and ROM Infection preventionImprove cosmesisImprove psychosocial morbidityImprove QOL
56Compression garmentsElastic garments are uncomfortable and ineffective if worn while the limb is edematous.Garments do nothing to correct the underlying cause of the edema.Garments are NEEDED after the decongestive phase of CDT to prevent refill.
63What role do medications have? Diuretics: make edema worse; often prescribed, but draw water off protein molecules. Can cause lymphedema to become more fibrotic.Benzopyrones: not FDA approved; stimulate macrophage activity and promote protein proteolysis; theoretically useful; effect is so slow that usefulness is questionable. Includes coumarin, rutosides, diosmin, rutin.
64DIET No specific diet for lymphedema Reducing water and/or protein intake is ineffectiveAvoiding obesity is helpfulGeneral recommendations are low sodium, high fiber, vitamin rich diets.
65What role does obesity play? Increased risk of post-op complications such as infectionReduced muscle pumping efficiency within loose tissuesAdditional fat deposits contribute to arm volumeDeep lymph channels are separated by subcutaneous fat
66Randomized controlled trial comparing a low-fat diet with a weight reduction diet in breast cancer related lymphedemaThis article was published in the medical journal “Cancer” in May 2007.It was also copy-written by the American Cancer Society in 2007
67ResultsThe low-cal group and low-fat group had significant reductions of:body weightBMI% body fat**Significant correlation between weight loss and arm volume reduction regardless of the dietary group**unaffected arm also showed volume reduction
68OverviewThis is the first study to examine the role of diet as a possible treatment for BCRLSignificant correlation of weight loss and loss of swollen arm volumeThe type of diet did not affect arm volume reduction…just losing weight!Weight loss in a healthy mannerHealthy diet and exercise
69Insurance coverage…. Medicare does not pay for products Medicare HMO’s do not payMedicaid does not pay for productsMost Highmark BC/BS, HMO, PPO pay 100% for productsUPMC HMO, PPO plans…as of 1/1/08 started following Medicare guidelines, but this is changing to more coverage
70Insurance obstacles…Frustrating for the therapist because patients need these products to maintain edema and prevent worsening of edema.We recommend products based on what the patient needs or does not need.Often we have to change our recommendations based on what the insurance will reimburse.
71Actual cost for the patient.… Day garments:Patients need 2 garments every 6 monthsCustom fit $ per garmentReady to wear $ per garmentRTW garments only come S, M, L and in a less effective fabric than custom garmentsNight garments: custom only, $
72More cost…Keep in mind that all of these costs are what the DME suppliers charge for “private pay.”Bandaging supplies for treatmentUnilateral UE/LE about $Bilateral LE >$200
73How does this affect you… Most of the DME’s in the area are “out-of-network” with CignaOut of network cost for these products is extremely highImportant to understand how necessary these products are and to consider approval at an “in-network” level.
74Help for patients… Susan G. Komen Foundation Am. Cancer Society Breast cancer patientsAm. Cancer SocietyAny cancer $300/yearNat’l Lymphedema NetworkMarilyn Westbrook FoundationAlso has “Find a Therapist or Treatment Center”
75THANK YOU! email@example.com Phone/Address: Centers for Rehab ServicesMoon Township1600 Coraopolis Heights Rd Coraopolis, PA (412)McCandless9365 McKnight Rd #300 Pittsburgh, PA 15328(412)
76WomensRehab at Centers for Rehab Services Specialists in treating lymphedema as well as urinary incontinence, pelvic pain, interstitial cystitis, vulvadynia, fecal incontinence, constipation and other pelvic floor hyper/hypotonicity disorders.Locations: Cranberry, Moon, Gibsonia, Harmar, St. Margaret’s, South Hills, Oakland, Squirrel Hill, McCandless, Delmont, Monroeville, ChippewaReferral Line CRS