5LymphedemaAn abnormal accumulation of protein rich fluid in the interstitum, which causes chronic inflammation and reactive fibrosis in the affected tissueLymphedema is classified as either primary or secondary lymphedemaTypically asymmetrical
7Primary LymphedemaThe most likely occurrence of this form is lymphangiodysplasiaHypoplasia- less than normal expected number of lymph collectors in the affected areaAplasia- a distinct absence of lymph collectors in the affected area. May also involve the absence of lymph capillariesHyperplasia- Vessels are characterized by an excessively dilated caliber which renders them less functional due to valvular dysfunction
8Primary LymphedemaPresent at birth or shortly therafter is known as Milroy’s DiseasePrimary Lymphedema that develops during puberty is known as Meige’s Disease.Praecox- Develops before 30Tardum- Develops after 35
9Secondary LymphedemaSecondary lymphedema means there is a known cause for the presence of lymphedemaWorldwide the most common cause is the mosquito born parasite FilariaIn the United States the most common cause is cancer therapyLymph node samplingFull dissection of lymph nodesRadiation therapy
10Secondary Lymphedema (cont) Other causes include any significant trauma to the lymphatic system from accidental or self induced incidents, infectious episodes such as eyrsipelas or cellulitisObesity may also play a role in the development of lymphedema, however, it is more likely due to a secondary co-morbidity (lack of mobility, CVI etc)
11Staging of lymphedemaLymphedema is divided into 4 stages (American Society of Lymphology)Latency stage (subclinical or stage 0)Transport capacity of the lymphatic system is sub-normal but still sufficient to transport the lymphatic loadPatients are “at risk” for developing lymphedemaEducation about subjective complaints and preventative measures is key component of treatment at this stage
12Staging Stage 1 (reversible stage) Accumulation of protein rich fluid No fibrotic alterationsPitting is easily inducedWith proper management of stage 1 patient can expect to have reduction to normal limb sizeStage 1 is often confused with edemas of other geneses
13Staging Stage 2 (spontaneously irreversible) Lymphatic fibrosis Tissue becomes induratedPitting is difficult to inducePositive Stemmer signCommon cellulitic infectionsIncomplete reduction with therapy and good patient compliance
14Stemmer SignSometimes called the Kaposi Stemmer sign
17SymptomsSwelling of an arm or leg, which may include fingers and toes.A full or heavy feeling in an arm or leg.A tight feeling in the skin.Trouble moving a joint in the arm or leg.Thickening of the skin, with or without skin changes such as blisters or warts.A feeling of tightness when wearing clothing, shoes, bracelets, watches, or rings.Itching of the legs or toes.A burning feeling in the legs.Trouble sleeping.Loss of hair.Positive Stemmer Sign (though the absence does not rule out lymphedema)These symptoms may occur very slowly over time or more quickly if there is an infection or injury to the arm or leg.
18Chronic Venous Insufficiency Is an advanced stage of venous disease in which the veins and the muscle pump activity become incompetent causing blood to pool in the legs and feetCan be due to repeated damage from superficial or deep venous pathology, or a variety of vein-related conditions such as the congenital absence of valves
20Pathophysiology of CVI Faulty valves fail to prevent retrograde flow of venous blood during muscle pump activityMay be:IdiopathicPost-thrombotic syndromeGeneticsPelvic tumorsVascular malformations
21SymptomsSwelling in the lower legs and ankles, especially after extended periods of standingAching or tiredness in the legsNew varicose veinsLeathery-looking skin on the legsFlaking or itching skin on the legs or feetStasis ulcers (or venous stasis ulcers)Hemosiderin staining
23Risk factors Deep vein thrombosis (DVT) Varicose veins or a family history of varicose veinsObesityPregnancyInactivitySmokingExtended periods of standing or sittingFemale sexAge over 50
24Early stages of CVI Pitting Edema Corona Phlebectatica Mostly presenting below the kneeCorona PhlebectaticaA myriad of tiny vein branches that are difficult to delineateRed-pink hue to skin that returns immediately after pressure is released
25Advanced stages There may now be a lymphatic component to edema HyperpigmentationDermatologic changesVenous stasis dermatitisLipodermatosclerosisScarring and fibrosis of skin (woody texture to skin)There may now be a lymphatic component to edema
26End Stage CVI Defined by ulcerations of the skin Photo Credit: Charlie Goldberg
27LipedemaA chronic metabolic disorder of the adipose tissue, of unknown etiology.
28Lipedema Predominately in women Bilateral symmetrical swelling from illiac crest to anklesStemmer’s sign negativeNo cellulitic infectionsFoot sparing
29Lipedema“I can never lose weight in my legs no matter how much I diet”Very tender skinBruise easily
30Lipedema Stage 1 Stage 2 Stage 3 Skin surface is normal, tissues exhibit a smooth nodular textureStage 2Skin surface becomes more uneven, large fatty lobules begin to formStage 3Large contour deforming lobular shapes on medial knee, proximal lateral thigh, and above malleoli
32Traumatic Edema Edema due to physical trauma Results in inflammatory reactions accompanied by high protein edema.The majority are temprorary and self resloving. However, it can lead to permanent damage.
33Pathophysiology of traumatic edema The initial step in the inflammatory process causes local vasodilation, followed by an increase in the permebility of blood capillaries toward plasma protein. Macrophages invade and devour damage tissue. These macrophages may injure the lymhpatic system.
38Accurate Pt HxPatient history is crucial in determining the underlying cause of edemaThere are many questions that you can ask that will help guide you down the proper course
39Intake Questions Have you had any lymph nodes removed? Any recent abdominal surgeries?Any history of DVT?Previous cellulitic infection?CHF?Renal Failure?
40Compression Stockings Pneumatic Compression LymphedemaMLDCompression BandageCompression StockingsPneumatic CompressionLipedemaLight MLDCVICompression BandagingTraumatic EdemaMLD above level of injuryCardiac, CHF, RenalCompression bandaging and stockings as tolerated. You MUST consult a physician on these patients prior to initiating any treatment
412 phases to treatment Reduction Maintenance MLD Compression bandaging Pneumatic compressionExercise and skin careCompression StockingsPneumatic CompressionExercise, Skin care
42Manual Lymphatic Drainage A general manual treatment which improves lymph vascular flow. In lymphedema it re-routes the lymph fluid around blocked areas into more centrally located healthy lymph nodesIt is not a massage!Must be done by someone who is properly trained
43Contraindications to MLD CHF if patient is unmedicated or edema is due solely to cardiac failureAcute infectionRenal FailureAcute DVT (seek physician approval for post thrombotic syndrome edema management)
44Compression Bandaging Short stetch bandages are applied to increase the tissue pressure in the swollen extremityImproves the efficiency of the muscle pump and joint pumpsPrevents the reacummulation of evacuated fluidHelps break up deposits of accumulated scar and connective tissues
45Contraindications to compression bandaging Acute DVT (may mobilize thrombus)Acute infectionCardiac edemaAdvanced arterial disease <.7 on the ABIAdvanced renal diseaseMalignancy (relative to severity)
46Bandaging Short stretch- Medium stretch Long Stretch 4-layer Unna, ComprilanMedium stretchCobanCo-PlusLong StretchAce4-layerProfore
47Short stretch Reduce deep venous reflux more effectively High working pressure to low resting pressure. Produce high pressure amplitudes when patient is walking and a decrease in pressure when patient is supineMain disadvantage is the loss of pressure following reduction
51Long Stretch Maintain pressure for longer periods of time A higher pressure of at least 60 mmHg is required to prevent refluxExert a high resting pressure which can constrict the venous and lymphatic systems creating a tourniquet effect
52Helping Patients & Physicians Heal Prairie medical focus only on one therapy. Can you think of patients. I don’t know how you conduct your referral process but you can fill up this referral sheet and Prairie medical will follow up with pre-auth and try to heal your patients Focus of the founder of the company.Helping Patients & Physicians Heal
56Mechanism of ActionA gentle “milking” of lymphatic fluid out of the upper extremity. This distal to proximal motion allows for a clearance of lymphatic fluid to be filtered out of the system via the urinary tract. In essence the Pneumatic Compression pump is designed to ‘do’ what the body is incapable of due to age, damage or disease state.
58Contraindications Inflammatory Phlebitis Episodes of Pulmonary EmbolismInfections in limb without appropriate antibiotic coverage*Presence of LymphangiosarcomaCongestive Heart Failure, Uncontrolled*48 hours
59Pneumatic Compression Therapy Convenient home useComprehensive in-home or office patient trainingEasy to useMedicare and private insurance coverageCustom sizingAdjustableAbility to clean the product-sanitaryPatient dictated time of useLifetime treatment of underlying condition
60Compression garments Class 0 10-20 mmHg Class 1 20-30 mmHg
61Class 0 Preventative only Should not be used for someone with active edema
62Class 1 20-30 mmHg Minimum compression for UE lymphedema Offer support, but NOT sufficient for lower extremity lymphedema or CVI
63Class 2 30-40 Most stage 2 upper extremity lymphedema Minimum compression for LE lymphedmeaOffers good support for LE CVI
64Class 3 40-50 mmHG Rarely used in UE lymphedema Most stage 2 LE lymphedemaMinimum starting point for stage 3 lymphedema
65Consideration for garment selection Patient ability to manage garmentMaterial allergiesPriceInsurance coverage
66Flat knit vs Circular knit Custom onlySlightly easier to donThe thicker fabric offers additional features, such as its massaging effect, which promotes lymph drainage, and its strength, which ensures the stocking does not yield to the edema. In conjunction with movement, it produces a high therapeutic pressure that provides optimum compression of the tissue.Custom or OTSDifficult to donSingle layer of fabricNot appropriate compression for active lymphedema, may not be adequate for sever venous edemaCheaper
67Goals for compression garments MAINTAIN limb volume after decongestion. Compresion garments will NOT decongest limbEasy don/doffing to enhance patient complianceCosmetically appealing
68ReferencesDiseases and Conditions: Chronic Venous Insufficiency (CVI). AccessedGreenlee R, Hoyme H, Witte M, Crowe P, Witte C. Developmental Disorders of the Lymphatic System. Lymphology. 26 (1993):Managing edema to decrease pain and increase range of motion and functional mobility. Loraine Lovejoy-Evans MPT, DPT, CLT-Foldi.Mcdonald J, Sims N, Mayrovitz H. Lymphedema, lipedema, and the open wound. The role of compression therapy. Surgical Clinicals of North America. 83 (2003):
69ReferencesNorton School of lymphatic therapy course manual: Manual Lymphatci Drainage/Complete Decongestive Therapy .Rathbun SW, Kirkpatrick AC. Treatment of chronic venous insufficiency. Curr Treat Options Cardiovasc Med Apr;9(2):Szuba A, Rockson S. Lymphedema: classification, diagnosis and therapy. Vascular Medicine. 1998: 3:Zuther J, Norton S. Lymphedema Management: the comprehensive guide for practitioners. 3rd ed. New York, NY: Thieme Medical Publishers; 2013.
73LE bandaging Lotion Stockinette to calf Toe wraps Cotton (knee, foot) Foam (affix to calf)Foam (affix to ankle and dorsum of foot)Eucerin or other low pHTG or TricofixTranselast/elastomullCellona/Artiflex
74LE bandaging Roman Sandal Ankle sole heel (ASH, Has) Spiral ankle to kneeHerring bone/Figure 8Stockinette to thighAffix foam to thighKnee to mid thighKnee to topDistal thigh to top6cm Comprilan/Rosidal K8cm10 cm12 cm12cm