Transcript April 2010 Lymphedema class powerpoint

An Introduction To
Lymphedema Treatment
©2010, Zoltan Bouwhuis, BScPT, CLT
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About Your Presenter
Zoltan Bouwhuis, BScPT, CLT
Born & Raised in Enschede
The Netherlands
PT Training: Hogeschool Enschede, The
Netherlands
Lymphedema clinic SPGH 1998-2005
Lymphedema clinic LMC 2005-2006
Lymphedema clinic SAH 2007-current
Certified Lymphedema Therapist (CLT)
through Academy of Lymphatic Studies
©2010, Zoltan Bouwhuis, BScPT, CLT
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Class Outline
Introduction
Anatomy
(Lymph)edema
Treatment options
Bandaging
Garments
About Certification
Closing
©2010, Zoltan Bouwhuis, BScPT, CLT
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Class Objectives
Demonstrate a basic understanding of
the lymphatic system and lymphedema
Recognize lymphedema
Be able to treat a patient with edema
Be familiar with the certification process
©2010, Zoltan Bouwhuis, BScPT, CLT
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Not Class Objectives
To become a certified lymphedema
therapist
To be proficient in treating complex
edema patients
These will be the objectives of the
lymphedema certification courses
Drum up more business for our clinic
©2010, Zoltan Bouwhuis, BScPT, CLT
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Why this class?
Very little familiarity with lymphedema
Few practitioners
Patients / Physicians / Therapists are
not familiar with lymphedema and its
treatment options
Known treatment options are outdated
©2010, Zoltan Bouwhuis, BScPT, CLT
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DISCLAIMER:
Do not expect a vast amount of
evidence-based practice patterns in this
presentation
This subject matter suffers from a
massive lack of research
Most material presented is based on the
clinical experience of the presenter and
others authors
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Statistics (by estimate)
1 in 8 women will develop breast
cancer during their life time
254,650 new cases of breast cancer in
the US in 2009
About 40,170 women will die from
breast cancer
214,480 new breast cancer survivors in
the US
11% of patients with breast cancer are
< 40 y/o
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Statistics (by estimate)
An estimated 25-30% of breast cancer
patients will develop lymphedema
during their life time
This risk may increase up to 48% after
radiation therapy
An estimated 5-14% of patients who
underwent a sentinel node biopsy will
develop lymphedema
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Statistics (by estimate)
0-60-80% of patients develop leg
lymphedema after genital and
reproductive cancer or after melanoma
in the leg
100 million people world-wide with
lymphatic filariasis
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Commonly known “treatments”
Diuretics
Fluid restriction
TED hoses
Pump
Draining of fluid
De-bulking surgery
Amputation
Samuel Adams 9/27/1722 – 10/2/1803 (founding father & brewer)
©2010, Zoltan Bouwhuis, BScPT, CLT
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ANATOMY
REVIEW
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Circulation
Arteries
Veins
Lymphatics
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The Circulatory System
Arteries:
Carry blood from the heart to
the lungs and the tissues
Supply the tissues with oxygen
and nutrients
Bring 100% of the fluids to the
tissues
Driven by the heart & valves
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The Circulatory System
Veins:
Return blood from the tissues
back to the heart and lungs
Remove CO2 and small waste
products from the tissues
Return 85-90% of the fluids
from the tissues
Driven by the muscle pump &
valves
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The Circulatory System
Lymphatics:
Return fluid from the tissues
back to the heart
Remove fluid, proteins and
large waste products from the
tissues
Return 10-15% of the fluids
from the tissues
Driven by the muscle pump,
valves, breathing and its own
smooth muscles
©2010, Zoltan Bouwhuis, BScPT, CLT
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What’s the difference?
Arteries / Veins
“Closed system”
Circulating system
Dependent on
“external pump”
Fairly set volume
©2010, Zoltan Bouwhuis, BScPT, CLT
Lymphatics
Open ended
One-way
System has its own
pumping mechanism
Can increase
capacity up to 10x
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The Lymphatic System
Lymphatic Vessels
Initial Lymphatics
Precollectors
Lymph Angions
Trunks
Venous Angles
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The Lymphatic System
Organs
Lymph Nodes
Tonsils
Thymus
Spleen
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The Lymphatic System
Initial lymphatics
“Open” ended
Flaps allow entry of large
materials
Function like a pool cleaner
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The Lymphatic System
Initial lymphatics
“Open” ended
Flaps allow entry of large
materials
Function like a pool cleaner
©2010, Zoltan Bouwhuis, BScPT, CLT
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The capillary bed
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The Lymphatic System
Flow of Lymph
Muscle Pump Mechanism
Abdominal Breathing
Longitudinal / Radial Musculature
“Caterpillar-like” movement
Manual Lymph Drainage
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Nodes in Axillary Region
Central Axillary
Subclavian
Supraclavicular
Brachial
Mammary
Subscapular
External Mammary
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Nodes in Neck Region
Subclavian
Occipital
Submental
Retropharyngeal
Posterior Cervical
Spinal Nerve Chain
Supra Clavicular
Thyrolinguofacial
Anterior Deep &
Superficial
Cervical
Posterior Superficial
Cervical
Anterior jugular
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Drainage of Head & Neck
Posterior Auricular
(Mastoid Nodes)
Preauricular Nodes
Occipital Nodes
Sternomastoid Nodes
Parotid
External Jugular
Facial
Retropharyngeal (Tonsillar)
Submandibular
Posterior Cervical
Spinal Nerve Chain
Submental
Sublingual
Posterior Superficial
Cervical Chain
Suprahyoid Node
Supraclavicular Nodes
Anterior Deep &
Superficial Cervical
Internal Jugular Chain
Thyrolinguofacial
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What Is Lymph ?
A protein rich fluid found in the
lymphatic vessels
Derived from interstitial fluid
Honey-like consistency
Mostly clear, sometimes milky color
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What Is Lymph ?
protein molecules
water
cell debris
bacteria
viruses
©2010, Zoltan Bouwhuis, BScPT, CLT
foreign
substances
fatty acids
cancer cells
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LYMPHEDEMA
(and a few other ones)
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Starling’s Hypothesis
"... there must be a balance between the hydrostatic
pressure of the blood in the capillaries and the osmotic
attraction of the blood for the surrounding fluids. “
Starling, E.H. On the adsorbtion of fluid from interstitial spaces. J Physiol. London 19:312-326, 1896.
©2010, Zoltan Bouwhuis, BScPT, CLT
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Starling’s Hypothesis
A thorough understanding of
Starling’s Hypothesis
is the key to understanding the
management of lymphedema.
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Starling’s Hypothesis
Ultra Filtration Pressure = BHP - IHP
Reabsorption Pressure = BCOP - ICOP
BHP
= Blood Hydrostatic Pressure
IHP
= Interstitial Hydrostatic Pressure
BCOP = Blood Colloid Osmotic Pressure
ICOP = Interstitial Colloid Osmotic Pressure
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Colloid Osmotic Pressure
Osmotic
Pressure
Semi-permeable membrane
©2010, Zoltan Bouwhuis, BScPT, CLT
Semi-permeable membrane
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Starling’s Hypothesis
Ultra Filtration Pressure = BHP - IHP
Reabsorption Pressure = BCOP - ICOP
BHP
= Blood Hydrostatic Pressure
IHP
= Interstitial Hydrostatic Pressure
BCOP = Blood Colloid Osmotic Pressure
ICOP = Interstitial Colloid Osmotic Pressure
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Normal Situation
BHP
BCOP
29 mmHg
25 mmHg
IHP ICOP
-2 mmHg
25 mmHg
BHP BCOP
14 mmHg
25 mmHg
IHP
ICOP
-2 mmHg
25 mmHg
Ultra Filtration = Reabsorption  Balance
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Lymphedema
BHP
BCOP
29 mmHg
25 mmHg
IHP ICOP
BHP
BCOP
IHP
ICOP
2 mmHg
14 mmHg
25 mmHg
2 mmHg
30 mmHg
30 mmHg
Ultra Filtration > Reabsorption  Lymphedema
(29-2)-(30-25)
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What Is Lymphedema?
Swelling in a body part due to excess accumulation
of protein rich fluid in the interstitial spaces.
History of insult to lymphatic system
History of congenital lymphedema
Absence of other common causes of edema
©2010, Zoltan Bouwhuis, BScPT, CLT
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Two Forms of Lymphedema
Primary Lymphedema
Secondary Lymphedema
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Primary Lymphedema
Occurs most often in lower extremities
May be present at birth or may develop
later in life
congenital - present at birth
praecox – before age 35
tarda - after age 35
Impaired development of the lymph
system
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Secondary Lymphedema
Caused by damage to the lymph system by
some insult
Infection - cellulitis
Trauma
Radiation - fibrosis
Surgery - lymph node dissection / other surgery
Chemotherapy - scarring
Tumors - “malignant lymphedema”
Lymphatic Filariasis
©2010, Zoltan Bouwhuis, BScPT, CLT
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Occurrence of Lymphedema
after a lymph node dissection
Patient is considered at high risk for
developing lymphedema when 11-13 axillary
lymph nodes are dissected
Lymphedema can occur with as little as 1
axillary node dissected
The chance of developing lymphedema
increases when either chemotherapy or
radiation therapy are added
©2010, Zoltan Bouwhuis, BScPT, CLT
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Stages of Lymphedema
0 - Latency
1 - Spontaneous Reversible
2 - Spontaneous Irreversible
3 - Lymphatic Elephantiasis
©2010, Zoltan Bouwhuis, BScPT, CLT
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Stages of Lymphedema
Stage 0 - latency
Lymphatic system is impaired
No edema noticeable
“Limb-at-risk”
Treatment focus: prevent lymphedema
©2010, Zoltan Bouwhuis, BScPT, CLT
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Stages of Lymphedema
Stage 1 – Spontaneous Reversible
Edema occurs during the day
Edema reduces with rest / elevation
No palpable fibrosis
Treatment focus: control lymphedema to
maintain normal size limb
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Stages of Lymphedema
Stage 2 – Spontaneous Irreversible
Edema worsens during the day
Edema does not reduce (completely ) with
rest / elevation
Palpable fibrosis
Treatment focus: regain control over the
lymphedema to return to a normal size limb
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Stages of Lymphedema
Stage 2 – Fibrosis
Protein starts to clump in
stagnant fluid
Becomes firm with
butter-like consistency
Eventually triggers
connective tissue growth
©2010, Zoltan Bouwhuis, BScPT, CLT
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Stages of Lymphedema
Stage 2 – Spontaneous Irreversible
Edema worsens during the day
Edema does not reduce (completely ) with
rest / elevation
Palpable fibrosis
Treatment focus: regain control over the
lymphedema to return to a normal size limb
©2010, Zoltan Bouwhuis, BScPT, CLT
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Stages of Lymphedema
Stage 3 – Lymphatic Elephantiasis
Edema worsens consistently
Massive limb sizes possible
Structural tissue changes have occurred
Treatment focus: regain control over the
lymphedema to return to a manageable
sized, functional limb
©2010, Zoltan Bouwhuis, BScPT, CLT
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S & S of Lymphedema
Mild to extreme edema
May be pitting or non-pitting
Skin may be indurated and/or
brawny (hardened and
thickened)
Skin color may be darker, and
may be flaky
©2010, Zoltan Bouwhuis, BScPT, CLT
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Pitting Edema
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S & S of Lymphedema
Mild to extreme edema
May be pitting or non-pitting
Skin may be indurated and/or
brawny (hardened and
thickened)
Skin color may be darker, and
may be flaky
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Complicating Factors
Extent of damage to lymph system
Obesity
Age
Infection of an at-risk extremity
Vigorous distal extremity exercises,
particularly with a dependent limb
Poor patient compliance
“Cording” – Axillary Web Syndrome
Supplemental cancer treatments
©2010, Zoltan Bouwhuis, BScPT, CLT
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Complicating Factors
“Cording” – Axillary Web Syndrome
Little understood result of
node dissection
Scarring of remaining
lymphatics?
Treated with sustained
tension in early phase of
stretch
Instant relief after “snap”
©2010, Zoltan Bouwhuis, BScPT, CLT
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Complicating Factors
Supplemental Cancer Treatments
Chemo Therapy
Can cause scarring of lymphatics
General malaise – frequent missed appointments
CDT can reproduce chemo symptoms
“Chemo Brain”
Radiation Therapy
Limits treatment field up to 6 weeks post last EBRT
Causes extensive scarring & fibrosis
Can further limit ROM
Can limit bandaging / garment wearing
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Edema secondary to CHF
Lymphedema
Malignant Lymphedema
Chronic Venous Insufficiency (CVI)
Lipidema/Lipolymphedema
Combinations of the above
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Edema secondary to CHF
Caused by Congestive Heart Failure
Not to be treated as extremity edema
(treatment will cause harm!)
Bilateral edema, often also in trunk
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Edema secondary to CHF
Why not to treat the edema:
Edema is caused by a failing heart
Extremity edema will return into
circulation with treatment
Increased blood volume further strains
the heart
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Lymphedema (primary)
Absence of other causes of edema
No discoloration in early stages
Often unilateral
Palpable fibrosis
Minimal/no reduction with elevation
Starts “for no reason”
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Lymphedema (primary)
Lymphedema Tarda
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Differential Diagnosis
Lymphedema (primary)
Lymphedema Tarda
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Differential Diagnosis
Lymphedema (primary)
Lymphedema Praecox
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Differential Diagnosis
Lymphedema (primary)
Lymphedema Praecox
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Differential Diagnosis
Lymphedema (secondary)
Caused by trauma to lymphatic system
No discoloration in early stages
Often unilateral
Palpable fibrosis
Minimal / no reduction with elevation
Starts right from almost immediately to
much later (>25 yrs) after trauma
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Lymphedema (secondary)
Lymphedema after mastectomy
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Lymphedema (secondary)
Lymphedema after lumpectomy
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Differential Diagnosis
Lymphedema (secondary)
Lymphedema after mastectomy
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Differential Diagnosis
Lymphedema (secondary)
Lymphedema after melanoma
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Differential Diagnosis
Lymphedema (secondary)
Lymphedema after placement of dialysis stent
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Differential Diagnosis
Lymphedema (secondary)
Post Phlebitic Syndrome
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Differential Diagnosis
Lymphedema (secondary)
Post Phlebitic Syndrome with chronic ulcers
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Differential Diagnosis
Lymphedema (secondary)
Lymphedema after mastectomy
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Malignant Lymphedema
Malignant Lymphedema after breast cancer
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Chronic Venous Insufficiency
Gradual onset
Reddish/Brownish discoloration caused
by hemosiderin deposits
Mostly bilateral
Worsens during the day
Often reduction with elevation
Venous stasis ulcers often result
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Chronic Venous Insufficiency
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Differential Diagnosis
Chronic Venous Insufficiency
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Differential Diagnosis
Chronic Venous Insufficiency
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Differential Diagnosis
Chronic Venous Insufficiency
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Differential Diagnosis
Chronic Venous Insufficiency
Now is the time to close your eyes
if you have a sensitive stomach
The next slide will show a patient’s leg
with completely un-managed CVI
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Chronic Venous Insufficiency
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Lipidema / Lipolymphedema
Gradual onset
Patient has excessive fat storage
between hips and ankles
Mostly bilateral
Feet not involved
Can’t be cured. Reduce progression
with compression garments
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Lipidema / Lipolymphedema
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Differential Diagnosis
Lipidema / Lipolymphedema
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Differential Diagnosis
Lymphedema Secondary to CVI
Starts as straight CVI
Initially lymphatics will function as backup for venous system
Eventually lymphatic system will also fail
Fibrosis will become apparent with
resulting tissue changes
©2010, Zoltan Bouwhuis, BScPT, CLT
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Differential Diagnosis
Lymphedema secondary to CVI
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Differential Diagnosis
Lymphedema secondary to CVI
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Differential Diagnosis
Lymphedema secondary to CVI
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Differential Diagnosis
Lymphedema secondary to CVI
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Differential Diagnosis
Lymphedema secondary to CVI
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Differential Diagnosis
Flowsheet
LE1
LE2
M LE
CVI
LIP
LIP/LE
CHF/PE PTS
Side
Unilat
Unilat
Unilat
Bilat
Bilat
Bilat
System
Unilat
Feet Involved
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Hemosiderin
No
No
No
Yes
No
No
No
Yes
Cellulitis
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Pain
No
No
Yes
No
Yes
Yes
Yes
Yes
Sex
F
F/M
F/M
F/M
F
F
F/M
F/M
PM Reduction
Some
Some
No
Yes
No
No
No
No
Fibrosis
Yes
Yes
Yes
No
No
Yes
No
Yes
Ulcers
No
No
No
Yes
No
No
No
Yes
Weeping
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Treatment
CDT
CDT
CDT
CDT
Comp
CDT
Diuretic
Comp
©2010, Zoltan Bouwhuis, BScPT, CLT
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SO,
WHAT IS
THE PROBLEM?
90
So, what’s the problem?
The increased distance between the blood
vessels and the tissues combined with
lymphostasis causes several problems:
#1: Nutritional status is impaired
#2: Immune response is impaired
#3: Mechanical stress
©2010, Zoltan Bouwhuis, BScPT, CLT
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Problem 1: Nutritional State
Relative surface area has increased
Same amount of oxygen and nutrients
are supplying this larger area
Tissue goes into a state of malnutrition
Tissue quality degrades
©2010, Zoltan Bouwhuis, BScPT, CLT
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Problem 1: Nutritional State
SKIN
BLOODVESSEL
nutrition in the “normal” extremity
ample nutrients enter the skin
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Problem 1: Nutritional State
SKIN
BLOODVESSEL
the extremity swells to double its size
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Problem 1: Nutritional State
SKIN
ULCER
BLOODVESSEL
nutrition in the “edematous” extremity
insufficient nutrients enter the skin
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Problem 2: Immune Response
Receptor function is delayed
Antibodies have to travel farther to
reach threat
Antibodies are more spread out
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Problem 2: Immune Response
SKIN
BUG
BLOODVESSEL
a bug enters the “normal” extremity
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Problem 2: Immune Response
the immune system
detects the bugs
the bugs are
identified
x9= 9x
the appropriate response is
taken to eliminate all bugs
©2010, Zoltan Bouwhuis, BScPT, CLT
the appropriate immune
response is determined
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Problem 2: Immune Response
ANTI BODIES
SKIN
BUGS
BLOODVESSEL
the immune response is triggered
and effective
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Problem 2: Immune Response
SKIN
BLOODVESSEL
the extremity swells to double its size
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Problem 2: Immune Response
SKIN
BUG
BLOODVESSEL
a bug enters the edematous extremity
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Problem 2: Immune Response
the immune system
detects the bugs
the bugs are
Identified
(with a slight delay)
x9= 9x
an inappropriate response is
taken to eliminate the bugs
* * infection occurs * *
©2010, Zoltan Bouwhuis, BScPT, CLT
the appropriate immune
response is determined
(based on wrong data)
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Problem 2: Immune Response
ANTI BODIES
SKIN
BUGS
BLOODVESSEL
the immune response is triggered
and ineffective
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Problem 3: Mechanical Stress
Wound bed expands when extremity is
in a dependent position
Wound bed contracts with elevation of
the extremity
The delicate wound bed is torn open
when edema re-occurs
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Problem 3: Mechanical Stress
wound healing in “normal” skin
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Problem 3: Mechanical Stress
wound healing in edematous skin
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So, what’s the problem?
The skin and tissues underneath are in
a state of malnutrition
Wounds heal slower or not at all
Mechanical stresses continuously
damage the wound bed
This allows for opportunistic infections
to occur
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Clinical Impact
Mobility issues
ADL issues
Psychological issues
General health issues
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Clinical Impact
Mobility issues:
Limb can be extremely heavy
Joint restrictions due to soft
tissue approximation
“Michelin Man effect”
Increased stress on joints
©2010, Zoltan Bouwhuis, BScPT, CLT
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Clinical Impact
Mobility issues:
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Clinical Impact
ADL issues:
Clothes may not fit any more
Household tasks may be harder
Functional mobility may be
impaired
Hygiene issues
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Clinical Impact
Psychological issues:
Why me?
Why was I not warned?
Lifelong management
Social isolation
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Clinical Impact
General health issues:
Increased risk for infections
Restrictions on testing
Increased wear of joints
Impaired sensation
Complications with surgery
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Clinical Impact
Surgical recommendations:
Reduce edema prior to surgery
Recommend pre and post-op
antibiotics
Use care with IV-fluids
Recommend post-op CDT
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What not to do
Drain the fluid out of the extremity
Bind the extremity tightly
Attempt to squeeze the fluid out
Stop moving at all
Get any kind of injury to the extremity
Wait for the problem to resolve itself
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Then what is the thing to do?
Treat the edema first:
most of the other problems
will resolve by themselves!
©2010, Zoltan Bouwhuis, BScPT, CLT
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COMPLETE
DECONGESTIVE
THERAPY
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Commonly known “treatments”
Diuretics
Fluid restriction
TED hoses
Pump
Draining of fluid
De-bulking surgery
Amputation
Samuel Adams 9/27/1722 – 10/2/1803 (founding father & brewer)
©2010, Zoltan Bouwhuis, BScPT, CLT
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CDT Components
Meticulous Skin Care
Manual Lymph Drainage
Compression Therapy
Decongestive Exercise
Education
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Meticulous Skin Care
Cleanliness
Protection
Inspection
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Manual Lymph Drainage
Stimulate Flow
Re-route Flow
Time-release effect
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Compression Therapy
Compression bandages
Elastic compression garments
(day-time)
Non-elastic compression garments
(day and/or night-time)
Vaso-pneumatic compression
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Therapeutic Exercise
Promote Circulation
Combine with compression
therapy
Improve overall endurance
Maintain / improve mobility
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Education
Continuum of care
Prevention
Understanding
General knowledge
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COMPRESSION
GARMENTS
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Elastic Compression
Support hose: ≤ 20 mmHg
Medical Compression: ≥ 20 mmHg
Off the shelf / Custom Made
Worn only during the day
Last about 4-6 months
$70 - $600
Variety of compression classes
BSN-Jobst, Juzo, Bauerfind,
Sigvaris, Medi, etc.
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Non-Elastic Compression
Off the shelf / Custom Made
Worn during the night, but also during
the day
Good emergency solution
Lasts several years
$250 - $1800
Variable compression / size
CircAid, ReidSleeve, Tribute, etc.
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MANUAL
LYMPH
DRAINAGE
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Manual Lymph Drainage
Very light skin-technique
Work from proximal to distal with a distal to
proximal technique
Time consuming (30-45 minutes)
Activates lymph nodes
Stimulates lymphatic flow
Stimulate anastosmoses
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Manual Lymph Drainage
Watersheds
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Manual Lymph Drainage
Anastomoses
AAA
PAA
AII
PII
AI
IA
-
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Anterior Axillo-Axillary
Posterior Axillo-Axillary
Anterior Interinguinal
Posterior Interinguinal
Axillo-inguinal
Inguino-axillary
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Manual Lymph Drainage
Anastomoses
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Manual Lymph Drainage
Example: LUE lymphedema
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Manual Lymph Drainage
Example: BLE lymphedema
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Manual Lymph Drainage
Slow, 1 second rhythm
Repeat 5-7 times
Low pressure
Takes 30-45 minutes
Do not attempt to squeeze fluid out of the limb
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LYMPHEDEMA
BANDAGING
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The Effect of Compression
BHP
BCOP
29 mmHg
25 mmHg
IHP ICOP
20 mmHg
30 mmHg
Ultra Filtration
©2010, Zoltan Bouwhuis, BScPT, CLT
BHP
BCOP
IHP
ICOP
14 mmHg
25 mmHg
20 mmHg
30 mmHg
Reabsorption  Balance
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Compression Bandages
At least 50% of treatment effect
Custom-fit with every application
Worn as close to 24/7 as possible
Multi-layered:
Absorption layer
Equalization layer
Compression layer
Short-stretch material
Can be the ideal long term
compression solution
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Short-stretch vs. Long-stretch
Pre Stretch
ACE ®
Comprilan ®
Post Stretch
ACE ®
Comprilan ®
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Bandage Technique
Lower Leg Bandage
Frequently used for mobility
compromised patient
Easy to teach to family members
Effective for venous insufficiency
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Bandage Technique
Lower Leg
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Bandage Technique
Upper Extremity
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Vaso Pneumatic Compression
Gradient-sequential multi-chamber
pump
Actively pumps fluid out of the
affected extremity
Patients pumps at least one hour
each day
Should be done after manual
techniques
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Vaso Pneumatic Compression
“Compression shoes”
3-4 chamber “Medicare” pump
10-12 chamber Lympha Press
Flexitouch®
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Vaso Pneumatic Compression
Different pumps
“Medicare” pump
Approx. $800-$1,200
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Lympha Press
Approx. $5,000
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Vaso Pneumatic Compression
Different pumps
Flexitouch®
Approx $12,500
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Vaso Pneumatic Compression
Patient in Lymphapress
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Education: Who ?
The Patient
The Patient’s Support System
The Patient's Physician
The World
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Education: What ?
The Patient:
Lymphatic Basics
Self-Massage
Self Bandaging
Minimizing the risk of infection
Home exercise program
Use of long-term compression solution
The importance of life-long compliance
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Education: What ?
The Patient’s Support System:
Lymphatic Basics
Massage
Bandaging
Assisting with long-term
compression solution
Reinforcing compliance
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Education: What ?
The Patient’s Physician:
The existence of treatment
How to refer
The impact of treatment
Precautions
Funding issues
Importance of L.M.N.
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Effects of Treatment
Case 1:
61 y/o female
>4 yrs Secondary Lymphedema
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Effects of Treatment
LE secondary to abdominal surgeries
Extreme high soft tissue tension
Severe pain
Weeping lower legs
0-90° knee flexion
Unable to wear shoes
Difficulty walking with walker
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Effects of Treatment
After 30 treatments
Normal soft tissue tension
Minimal pain
0-135° knee flexion
Walks without assistive device
Able to dress self
Lost 23 lbs since start of CDT
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Effects of Treatment
Juzo® 30-40 mmHg custom garments
Reidsleeve® Classic garments
Biocompression vasopneumatic pump
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The Effects of Treatment
Case 2:
19 y/o female
Primary Lymphedema
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The Effects of Treatment
Before treatment
Lymphedema since early age
Worsened after birth of her son 3 years ago
Recently suffered cellulitis and open wounds
Has had fluid drained from lower abdomen
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The Effects of Treatment
After treatment
7 weeks of treatment
Received Juzo & Reidsleeve garments donated by manufacturer
66% reduction of right calf
Patient will return to school to start career
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©2010, Zoltan Bouwhuis, BScPT, CLT
1/27/2009
1/25/2009
1/23/2009
1/21/2009
1/19/2009
1/17/2009
1/15/2009
1/13/2009
1/11/2009
1/9/2009
1/7/2009
1/5/2009
Visit
2/20/2009
2/18/2009
2/16/2009
2/14/2009
2/12/2009
2/10/2009
2/8/2009
2/6/2009
2/4/2009
2/2/2009
1/31/2009
1/29/2009
Girth (cm)
The Effects of Treatment
Measurement Graph
Girth Measurements
80
70
60
50
40
30
Groin
Mid thigh
Knee
Largest Calf
Smallest Ankle
Mid Foot
20
10
0
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The Effects of Treatment
Case 3:
33 y/o male
>3 yrs CVI
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The Effects of Treatment
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Effects of Treatment
Case 3:
76 y/o female
Chronic Venous Insufficiency
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Effects of Treatment
Returning patient
Didn’t wear Circaid® garments 3 days
Severe pain
Extensive ulcerations
Extensive weeping
Minimal ambulator
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The Effects of Treatment
Ulcers all healed
Significant pain reduction
Back to wearing CircAid® garments
Added vasopneumatic compression
No weeping
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The Effects of Treatment
Case 4:
85 y/o male
Chronic Venous Insufficiency
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Effects of Treatment
LE for more than 2 years
Severe pitting edema
Feet increased 2 sizes
Weeping lower legs
Difficulty walking with walker
Extensive cardio-pulmonary history
©2010, Zoltan Bouwhuis, BScPT, CLT
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The Effects of Treatment
After 3 weeks
No palpable edema
Wears regular shoes
Walks with straight cane
Able to dress self, including shoes
Lost 35 lbs since start of CDT
Improved breathing, no side-effects
from treatment
©2010, Zoltan Bouwhuis, BScPT, CLT
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INDICATIONS
CONTRAINDICATIONS
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Indications
Primary lymphedema
Secondary lymphedema
Chronic Venous Insufficiency
Lipolymphedema
Venous stasis ulcers
Subacute local inflammation
post fracture, sprain/strain, etc.
post-operative edema
©2010, Zoltan Bouwhuis, BScPT, CLT
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Contra-Indications
All acute infections
Acute bronchial asthma
Active cancer
Peripheral Vascular Disease
Congestive Heart Failure
Extreme age
Anticoagulant therapy
©2010, Zoltan Bouwhuis, BScPT, CLT
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ABOUT
CERTIFICATION
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Why get certification?
Certification is required for some insurance
coverage
May become required for Medicare coverage
Give structure to lymphedema treatment
Standard vocabulary
Treatment standards
Standard of grading lymphedema
©2009, Zoltan Bouwhuis, BScPT, CLT
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Requirements for
LANA certification
135 (60 minute) hours of CDT training
14 days (= 10 days PTO)
$2850 (+ travel + 2 weeks hotel + 2 weeks
of meals) ≈ $4500
1 year experience after receiving training
$300 LANA exam fee
©2010, Zoltan Bouwhuis, BScPT, CLT
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IN CLOSING
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Ideal World vs. Real World
> 40 min. MLD
> 30 min. rest
> 30 min. exercise
15 min. bandaging
♫ relaxing music
Daily treatment
Daily measurements
Insurance pays……
©2010, Zoltan Bouwhuis, BScPT, CLT
Can anyone say Managed
Care?
Busy clinics
Productivity standards
Cubicles / curtains
Garments are often not a
covered item
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Failure Is An Option……
Patient non-compliance
Lack of motivation
Patient unable to take care of
themselves
Lack of support system
Lack of funding
Patient too sick for program
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Many Schools of Thought…
Training: Vodder, Foldi, LeDuc, Lerner,
Casley-Smith, etc.
Pump / No pump
Personal experience
Market
©2010, Zoltan Bouwhuis, BScPT, CLT
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Information on the Web
The National Lymphedema Network
www.lymphnet.org
North American Vodder Association of Lymphatic Therapy
(NAVALT)
www.navalt.org
Lymphology Association of North America
www.clt-lana.org
Luna Medical, Inc
www.lunamedical.com
Suncoast Lymphedema Group
www.webconceptz.com/lymphedema
©2010, Zoltan Bouwhuis, BScPT, CLT
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Any Questions ?
? ? ? ? ?
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