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Treatment of Lymphedema

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1 Treatment of Lymphedema

2 Lymph Anatomy Lymph nodes Lymph vessels Thymus gland Spleen Tonsils
Peyer’s patches

3 Spleen like a large lymph node, helps filter and clean debris.
Pyers Patches: lower intestinal tract, noldels in illieum, screen debris

4 Lymph Vessels Capillaries Pre-collectors Collectors Trunks

5 Lymph no values, flow in and out, can absorb interstitial fluid and are larger than blood capillaries.

6 Lymph Capillaries Larger diameter than blood capillaries No valves
Lymph can flow in any direction Can absorb interstitial fluid

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8 Pre-Collectors & Collectors
Channel lymph fluid into transporting vessels Can absorb fluid Collectors Transporters Resemble veins in structure Passive valves: ever .6-2cm along vessel Lymphangioactivity Contractions caused by Sympathetic Nervous System and lymph volume Superficial and deep

9 Trunks & Ducts Largest lymph vessels
Thoracic duct-largest, pumping by the diaphram. From in cisterna chyle Ducts empty into venous system Lower Body Upper Body R & L Lumbar Trunks Intestinal Trunks R & L Jugular R & L Subclavian R & L Broncho-mediastinal

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11 Lymph Fluid/Lymphatic Load
Consists of: Proteins (1/2 of bodies protien) Water Cells (RBC, WBC, Lymphocytes) Waste Products Fat (intestinal lymph, chyle)

12 Lymph Nodes Filtering station for bacteria, toxins, & dead cells
Produces lymphocytes Regulates the concentration of protein in the lymph Typically thickens the fluid in body

13 Dense connective tissue around, trabecula hold the arties and veins
Dense connective tissue around, trabecula hold the arties and veins. Multiple afferent come in one efferent goes out.

14 Lymphatic Watersheds Median-Sagittal Tranverse Clavical
Spine of Scapula Chaps or Gluteal

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16 Lymph Time Volume & Transport Capacity
LTV= amount of lymph which is transported by the lymphatic system in a unit of time TC=maximum lymph time volume Functional Reserve=the difference between the LTV and the TC

17 Defining Types of Lymphatic Insufficiencies
High Volume or Dynamic Insufficiency Low Volume or Mechanical Insufficiency High Output Failure Leads to Edema Low Output Failure= Lymphedema TC TC Normally Lymph Load volume is 10-12% of total/transport capacity (TC) Lymphendema occurs when Lymph load exceeds the total lymph volume, because the the total capacity of the body has lowered. LL=LTV LL LTV

18 Lymph Propulsion Arterial pulsation Muscle pump Respiration
Contraction of the lymphangion

19 Definition of Lymphedema
Lymphedema is the result of the abnormal accumulation of protein rich edema fluid Primary or secondary Afflicts approximately 1% of the US population (2.5 million people) * A SUDDEN ONSET OF EDEMA MUST BE THOROUGHLY EVALUATED BY A PHYSICIAN

20 Physical Exam History Inspection Palpation
Measurements: weight, circumference Skin assessment: nodules, bumps, discoleration Palpation Temperature: usually a bit warmer Stemmer’s sign: rolls on finger, square and thick skin Skin fold(s) Pitting Fibrosis

21 Other Diagnostic Tests
Lymphography Venous Doppler or Venous Sonography Indirect Lymphography Fluorescence Microlymphography Lymphoscintigraphy CT Scan MRI

22 Types of Lymphedema Primary Secondary Surgery
Radiation Therapy Trauma: blunt trauma Filariasis: parasite, blocks lymph nodes Cancer (Malignant) Infection Obesity Self Induced Hypoplasia (not as many lymph nodes) Hyperplasia Aplasia Inguinal Node Fibrosis (Kineley Syndrome Milroy’s Disease-congentital, males, unilateral typically Meige’s Syndrome: most females around puberty, Bilateral, webbing of fingers and toes, two rows of lashes

23 Stages of Lymphedema Latency Stage Reduced transport capacity
No noticeable edema Stage I Pitting edema Edema reduces with elevation (no fibrosis) Tight sleeve during the day Stage II Pitting becomes progressively more difficult Connective tissue proliferation (fibrosis) Stage III Non pitting Fibrosis and Sclerosis Skin changes (papillomas, hyperkeratosis, etc) Sooner you catch it the lot easier it is to manage.

24 Differential Diagnosis
Lipidema: females, symmetrical (no feet), no pitting, very painful to palpations, bruise easily, tissue is softer. Chronic Venous Insufficiency: gaiter distribution, non-pitting, hemosiderin staining, fibrotic. Acute Deep Venous Thrombophlebitis: swelling, redness, painful, sudden onset Cardiac Edema: bilateral, pitting, complete resolution when legs elevate above heart, no pain. Congestive Heart Failure: pitting, dyspnea, jugular vein distention. Malignancy: Filariasis: Myxedema: decreased ability to sweat, orange skin Complex Regional Pain Syndrome (RSD, Sudeck’s)

25 Chronic Venous Insufficiency

26 Filariasis

27 Lymphedema Interventions
Surgery (Debulking, Liposuction) Taking out all the lymphatic with these surgeries Medication (Diuretics, Benzopyrones) Takes out all the water, but leaves lymphatic's with protein rich lymph fluid. Pneumatic Compression Pump May harden the tissue or destroy lymph collectors, and leave person immobile for a couple of hours. COMPLETE DECONGESTIVE THERAPY Removes proteins from the system.

28 Anti-Edema Medications
Not effective because: Do not allow the proteins to be reabsorbed into the venous system As long as proteins are stagnate in the interstitial space the onconic pressure remains high and lymphedema persists Can worsen Lymphedema in the long run as they increase the concentration of proteins in the interstitial space exacerbating fibrosis

29 Treatment Schools of Thought
Casley-Smith Foldi LeDuc Vodder Norton Klose

30 Complete Decongestive Therapy (CDT)
Skin Care Manual Lymph Drainage Compression Therapy Remedial exercise

31 Purpose of lymphatic treatment
Applied pressure softens fibrotic tissue Excess protein is removed Formation of new tissue channels through anastomoses Provide support Enhance oxygenation by decongesting areas where lymph volume is high Long-term maintenance of improved limb size and shape

32 Contraindications (precautions) to CDT
Acute bacterial or viral infection Wait 24 hours of antibiotic treatment before resuming treatment. Acute CHF h/o CHF treat conservative, 1 limb at a time Kidney malfunction Untreated malignancy The existence of impaired arterial perfusion for compression ABI < 0.50

33 Precaution/ Contraindication Rationale Modification DVT
Do not treat in the area of an acute DVT. Fear is dislodging causing a life threatening emboli Treat adjacent areas Await medical clearance prior to treating affected area Active Infection Do not treat with an active infection. Fear of spreading infection Wait until appropriate antibiotic therapy has been initiated and show signs of resolving Open wound Do not treat areas with breaks in the skin Treat adjacent areas of intact skin Metastatic Disease Fear of spreading cancer Palliative care; Team decision Congestive Heart Failure Fear of systemic fluid overload Must be controlled, then treat conservatively and monitor Asthma Fear that parasympathetic stimulation will provoke an asthma attack AAA, Diverticulitis, IBS, Crohn’s disease Deep abdominal techniques may aggravate or worsen these conditions Do not perform deep abdominal techniques Pregnancy Fear deep abdominal techniques may harm the fetus or uterus

34 Patient education Protect the skin Signs of infection
Gradual return to activity Self management Self massage Compression garments Exercises Weight Management Obesity and body fluid volume fluctuations are beginning to be associated with the development of lymphedema

35 Protect the skin : Individuals that have had lymph nodes removed are at risk for lymphedema. To minimize this risk the following precautions should be followed: Keep arm clean and dry. Apply moisturizer daily to prevent chapping/chaffing of the skin. Balance lotion Attention to nail care; do not cut cuticles. Protected exposed skin with sunscreen and insect repellent. Use care with razors to avoid nicks and skin irritation. Avoid punctures such as injections and blood draws.

36 Wear gloves while doing activities that may cause skin injury
If scratches/punctures to skin occur, keep clean and observe for signs of infection. Gradually build up the duration and intensity of any activity or exercise, and monitor arm during and after for any change in size, shape, firmness or heaviness. Avoid arm constriction from blood pressure cuffs, jewelry and clothing Avoid prolonged (>15 minutes) exposure to heat, particularly hot tubs and saunas Airplane flights: due to decrease pressure in cabin, will need a compression sleeve

37 Signs of infection Red Hot Pain Swelling Fever Generalized Fatigue

38 Exercises Effect of movement on lymphatics - lymph flow; abdominal breathing Development of an effective exercise program 1.) flexibility exercises 2.) strengthening exercises 3.) aerobic exercises 4.) response of limb is important

39 Lymphatic Drainage Exercises
Move fluids through lymphatic channels Active repetitive ROM exercises are performed Follow a specific sequence to move lymph away from a congested area Proximal to distal Avoid static dependent postures

40 Lymphatic Drainage Exercises
20 – 30 minutes each session Twice daily 7 days a week Wear compression bandages or garment during exercises Combine with deep breathing Rest if possible for 30 minutes following exercises Check for redness or increased swelling

41 Sequence of exercises Proximal starting at neck and trunk
Proximal joints moving distally 5 reps – 20 reps

42 Manual Lymph Drainage (MLD)
a manual technique to mobilize fluid in the lymph system, by movement of proteins and fluid into the initial lymphatic vessels. This manual technique is done lightly and slowly.

43 Manual Lymph Drainage (MLD)
Basic Principles: 1. Proximal area is treated first, clearing first the adjacent and unaffected lymphotomes, then proximal sections of the affected lymphotomes. 2. The direction of pressure depends on the areas of edema and the direction should always be towards a cleared lymphotome. 3. Technique and variations are repeated rhythmically. 4. Pressure phase lasts longer than relaxation phase. 5. As a rule there should be no reddening of the skin

44 Manual Lymph Drainage (MLD)
Techniques: 1. Call-up - proximal to edema To clear the collectors proximal to the area Using the Thumb side of hand 2. Reabsorbtion - edematous region Using the 5th digit side of hand Increases protein reabsorption

45 Manual Lymph Drainage (MLD)
1. Mobilize the skin 2. Apply Pressure 3. Relax Technique is done lightly and slowly

46 MLD – Upper extremity 1: Supraclavicular nodes 2: Axillary nodes
3: Inguinal nodes 4: Thigh 5: Popliteal fossa 6: Calf 7: Malleolli 8: Dorsum of foot 9: Toes

47 Upper Extremity mld

48 MLD – Upper extremity 1: Supraclavicular nodes 2: Axillary nodes
3: Anterior chest 4: Back 5: Mascagni Pathway 6: Upper arm 7: Cubital nodes medial/lateral elbow 8: Forearm supination / pronation 9: Dorsum/palm of hand 10: Fingers

49 Lower Extremity mld

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51 Protocol Duration 2 weeks UE 3 – 4 Weeks LE Frequency 5 days a week
Arm minutes Leg minutes Wear Bandages During all awake hours Week 1 Emphasis on Bandages and reduction of Swelling Week 2-3 Facilitate Physician order for Garment Self Management of Edema

52 Abdominal Nodes

53 Treatment Of Abdomen - Deep
Position patient so that hips and knees are flexed Patient performs slow diaphragmatic breathing On exhale apply slow, gentle but firm pressure on area Pressure is toward the cistera chyli On inhale give gentle resistance to promote increased expansion and provide proprioception If you can palpate the aorta  do not apply pressure

54 Treatment Of Abdomen - Deep
Contraindications Pregnancy Endometriosis Hiatal hernia

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56 Compression bandages

57 Compression bandages Compression bandages have been shown to produce a micromassage effect that improves lymph transport. Increase temperature of up to 5 degrees enhances the lymphangion mobility

58 Bandages Resting pressure - Pressure from the outside in the resting position of the muscle. Pressure applied from fascia, bandages Working pressure - Pressure from the inside when the muscles are active. Pressure generated by the muscles

59 Resting Pressure BANDAGE LYMPHATICS MUSCLE

60 Working Pressure BANDAGE LYMPHATICS MUSCLE

61 Types of compression bandages
Elastic high stretch bandage - high resting pressure and low working pressure Not effective for treating lymphedema High resting pressure does not allow the lymphatics to fill And low working pressure does not increase tissue pressure effectively enough to influence the lymphatic pump because it stretches when the muscle contracts

62 Types of Compression bandages
Low stretch bandage - low resting pressure and high working pressure low resting pressure allows the lymphatic to fill High working pressure compresses the lymphatic vessels between the muscle the bandage facilitating lymphatic flow

63 Low Stretch Compression Bandages
Form a semi rigid support which causes an increase in interstitial pressure when the muscle contracts When a patient wears low stretch compression bandages while sleeping or resting the increased interstitial pressure will reduce the amount of fluid and protein leaving the arteriole (ultra filtration) and less edema is formed When a patient wears low stretch compression bandages during activity the increased interstitial pressure not only reduces ultra filtration but increases reabsorbtion into the lymphatic system which decreases lymphedema and well as venous edema

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66 Principles of Bandaging
Must use Low stretch Always start distally and proceed proximally Maintain moderate tension Avoid creases and folds Use tape to secure…not clips or pins Applied with greater pressure distally than proximally Do not extend bandage to maximal length

67 Principles of Bandaging – con’t
Check pressure gradient Place more layers for increase compression rather than applying them more tightly Fill indentations with padding or foam pieces Cover as much of the limb as possible Compression to be worn until next visit Exercise with bandages on to take advantage of muscle pump effect

68 Bandaging Supplies Scissors Tape Lotion – low pH Tubular bandage
Protects the skin, skin hygiene, absorbs perspiration Elastic gauze/finger/toe wraps/Coban Padding – Artiflex or foam Prevents indentations in skin, equalizes pressure, protects tender areas Low stretch compression bandages 6 cm: foot, hand 8 cm: ankle, forearm 10 cm: lower leg, upper arm 12 cm: upper thigh

69 When to instruct the patient to remove the bandages
If the patient gets short of breath or has heart palpations If the fingers/toes are numb, blue or tingling If the wraps fall off If the patient is experiencing too much pain

70 Compression Therapy Compression therapy is the application of external pressure on body tissue to support the elasticity of the skin and its underlying vessels Phase I with Compression Bandages Phase II with medical compression Garments

71 Rationale for using compression therapy:
Compression therapy directly effects the underlying lymphatic vessels, veins and tissue. Improves the efficacy of the muscle pump by creating a semi-rigid support for the muscle to work against Causes a mild increase in total tissue pressure Improves and maintains the shape of the limb

72 Compression Garments Not designed to decrease edema- only to maintain the edema reduced by the treatments Increases reabsorbtion Increases tissue pressure ready made vs. custom ill fitting garment is worse than not wearing one at all

73 Ganlet ends just below knuckles

74 MedaFit garments

75 Donning Compression Garment
For LE : put on in bed Use gloves to don and doff Apply on an “empty” limb

76 Garment Compression Classes
Over the counter -- CC  CC  CC  CC  10-18 mmHg 20-30 mmHg 30-40 mmHg 40-60 mmHg 60+ mmHg

77 Sequential Pneumatic Devices
Mobilizes interstitial fluid into the venous system Single chamber - JOBST vs. sequential Compression (gradient) Use MLD prior to using the pump Studies show that it moves only venous fluid Pump never to exceed 40 mmHg for extended periods of time

78 Sequential Pneumatic Devices

79 Lympha Press Pressure range is 20-180 mmHg.
Pressure is distributed into overlapping air compartments which are contained in a special sleeve. The compartments are sequentially inflated, from distal to proximal, massaging the limb in a proximal direction. The overlapping compartments prevent any gaps in treatment, to achieve a maximal and safe reduction of the lymphedema. The treatment cycle starts by filling the distal compartment first and continues inflating the remaining compartments in sequence during the first 24 seconds until all are full. The pressure is held in all compartments for 2 seconds, then deflates for four seconds which completes the 30 seconds cycle. The cycle then repeats itself.

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82 LASER Another new frontier in the treatment of lymphedema involves using the laser. From various trials lasers appear to help lymph flow, shown to be effective improvement of wound healing, and it has been used effectively in treating edema from DVT’s. The FDA has approved a laser device to be used in the treatment of post-mastectomy arm lymphedema.  Clinical trials are currently underway for leg lymphedema.   Lymphedema and its complications can causing "scarring" of the lymphatic system.  The laser is useful in removing the scar tissue, thereby helping lymph flow.

83 Energy Density - Suggestions
Type of Condition Suggested Treatment Dose Range (J/cm2) Soft Tissue Healing 5-16 Fracture Healing Arthritis – Acute 2-4 Arthritis - Chronic 4-8 Lymphedema 1.5 Neuropathy 10-12 Acute Soft Tissue inflammation 2-8 Chronic Soft Tissue Inflammation 10-20

84 The Short-term Effects Of Low-level Laser Therapy In The Management Of Breast-cancer-related Lymphedema Dirican et al; Supportive Care in Cancer; June 2011 17 BCRL patients referred to program between 2007 and 2009 All patients previously experienced at least one conventional treatment modality Complex physical therapy Manual lymphatic drainage Pneumatic pump therapy LLLT was added to patients’ ongoing therapeutic regimen All patients completed full course of LLLT Two cycles Patients were limited responders to their therapies before LLLT one cycle of LLLT consisted of 3 sessions a week for 3 weeks 300 mJ of total energy was applied for a minute on each of the 17 different points on surgical scar tissue of the axilla second cycle was started after an 8 week break and consisted of 3 weeks of treatment

85 Results Decreased 54% after first cycle
Difference between sums of the circumferences of both affected and unaffected arms Decreased 54% after first cycle Decreased 73% after second cycle Pain score 14 out of 17 experienced decreased pain with motion by an average of 40% after first cycle and 62.7% after second cycle Scar mobility Increased in 13 patients Range of motion Improved in 14 patients May restore drainage through reduction of fibrosis and scarring of tissues in the axillary region may be stimulartory/protective effects of LLlT on the endothelial cells of the vascular system and lymphativ vessels increases lymph vessel diameter and contractibility


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