Transcript 6.10.13 Intervention for Lymphedema

Treatment of Lymphedema
Lymph Anatomy
 Lymph nodes
 Lymph vessels
 Thymus gland
 Spleen
 Tonsils
 Peyer’s patches
Lymph Vessels
 Capillaries
 Pre-collectors
 Collectors
 Trunks
Lymph Capillaries
 Larger diameter than blood capillaries
 No valves
 Lymph can flow in any direction
 Can absorb interstitial fluid
Pre-Collectors & Collectors
 Pre-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
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
Lymph Fluid/Lymphatic Load
 Consists of:
 Proteins (1/2 of bodies protien)
 Water
 Cells (RBC, WBC, Lymphocytes)
 Waste Products
 Fat (intestinal lymph, chyle)
Lymph Nodes
 Filtering station for bacteria, toxins, & dead cells
 Produces lymphocytes
 Regulates the concentration of protein in the lymph
 Typically thickens the fluid
 600-700 in body
Lymphatic Watersheds
 Median-Sagittal
 Tranverse
 Clavical
 Spine of Scapula
 Chaps or Gluteal
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
Defining Types of Lymphatic Insufficiencies
High Volume or Dynamic
Insufficiency
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High Output Failure
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Leads to Edema
TC
Low Volume or
Mechanical Insufficiency
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Low Output Failure=
Lymphedema
TC
LL=LTV
LL
LTV
Lymph Propulsion
 Arterial pulsation
 Muscle pump
 Respiration
 Contraction of the lymphangion
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
Physical Exam
 History
 Inspection
 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
Other Diagnostic Tests
 Lymphography
 Venous Doppler or Venous Sonography
 Indirect Lymphography
 Fluorescence Microlymphography
 Lymphoscintigraphy
 CT Scan
 MRI
Types of Lymphedema
Primary
 Hypoplasia (not as many lymph
nodes)
 Hyperplasia
 Aplasia
 Inguinal Node Fibrosis
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(Kineley Syndrome
Secondary
 Surgery
 Radiation Therapy
 Trauma: blunt trauma
 Filariasis: parasite, blocks
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 Milroy’s Disease-congentital,
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males, unilateral typically
 Meige’s Syndrome: most females
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around puberty, Bilateral, webbing
of fingers and toes, two rows of
lashes
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lymph nodes
Cancer (Malignant)
Infection
Obesity
Self Induced
Stages of Lymphedema
 Latency Stage
Reduced transport capacity
 No noticeable edema
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Stage I
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Pitting edema
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Edema reduces with elevation (no fibrosis)
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Tight sleeve during the day
Stage II
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Pitting becomes progressively more difficult
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Connective tissue proliferation (fibrosis)
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Stage III
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Non pitting
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Fibrosis and Sclerosis
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Skin changes (papillomas, hyperkeratosis, etc)
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Differential Diagnosis
 Lipidema: females, symmetrical (no feet), no pitting, very painful to
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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)
Chronic Venous Insufficiency
Filariasis
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.
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
Treatment Schools of Thought
 Casley-Smith
 Foldi
 LeDuc
 Vodder
 Norton
 Klose
Complete Decongestive Therapy (CDT)
 Skin Care
 Manual Lymph Drainage
 Compression Therapy
 Remedial exercise
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
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
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ABI < 0.50
Precaution/
Rationale
Contraindicatio
n
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
Must be controlled, then treat
conservatively and monitor
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
Do not perform deep abdominal
techniques
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
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.
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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.
 Wear gloves while doing activities that may cause
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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
Signs of infection
 Red
 Hot
 Pain
 Swelling
 Fever
 Generalized Fatigue
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
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
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
Sequence of exercises
 Proximal starting at neck and trunk
 Proximal joints moving distally
 5 reps – 20 reps
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.
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
Manual Lymph Drainage (MLD)
Techniques:
 1. Call-up - proximal to edema
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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
Manual Lymph Drainage (MLD)
 1. Mobilize the skin
 2. Apply Pressure
 3. Relax
 Technique is done lightly and slowly
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
 Upper
Extremity
mld
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
 Lower
Extremity
mld
Protocol
 Duration
2 weeks UE
 3 – 4 Weeks LE
Frequency
 5 days a week
Arm
 30 - 45 minutes
Leg
 45 - 60 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
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Abdomina
l
Nodes
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
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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
Treatment Of Abdomen - Deep
 Contraindications
 Pregnancy
 Endometriosis
 Hiatal hernia
Compression bandages
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
Bandages
 Resting pressure - Pressure from the outside in the
resting position of the muscle.
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Pressure applied from fascia, bandages
 Working pressure - Pressure from the inside when
the muscles are active.
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Pressure generated by the muscles
Resting Pressure
BANDAGE
LYMPHATICS
MUSCLE
Working Pressure
BANDAGE
LYMPHATICS
MUSCLE
Types of compression bandages
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Elastic high stretch bandage
- high resting pressure and low working pressure
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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
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
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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
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
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
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
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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
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
Rationale for using compression therapy:
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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
Compression Garments
 Not designed to decrease edema- only to maintain
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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
MedaFit garments
Donning Compression Garment
 For LE : put on in bed
 Use gloves to don and doff
 Apply on an “empty” limb
Garment Compression Classes
 Over the counter --
 10-18 mmHg
 CC1 -----------------
 20-30 mmHg
 CC2 -----------------
 30-40 mmHg
 CC3 ----------------
 40-60 mmHg
 CC4 ----------------
 60+ mmHg
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
Sequential Pneumatic Devices
Lympha Press
 Pressure range is 20-180 mmHg.
 Pressure is distributed into overlapping air compartments
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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.
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.
Energy Density - Suggestions
Type of Condition
Suggested Treatment Dose Range
(J/cm2)
Soft Tissue Healing
5-16
Fracture Healing
5-16
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
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
 Results
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Difference between sums of the circumferences of both
affected and unaffected arms
 Decreased
54% after first cycle
 Decreased 73% after second cycle
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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
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Scar mobility
 Increased
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in 13 patients
Range of motion
 Improved
in 14 patients