Lymphedema Therapy

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Lymphedema Therapy

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• majerus company physical therapy
• vancouver, wa

A comprehensive PT clinic offering one on one
professional attention from an experienced staff
with a wide range of expertise.imagine life
squared.
Jodie Paschall-Majerus MPT , CLT John Majerus
PT, OCS, CSCS, CLT Laura Bancroft PTA, CLT Robby
Trimbo DPT, CLT Tara Socquet MPT Buffy
Stinchfield MPT Tara Rinhard, DPT Kathleen
Griffin, PTA, LMT, SI
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Edema Management

• - NOT just for breast CA survivors with arm
  lymphedema!
• - 75 of our edema patients are treated for LE
  issues.
• - Many of the LE patients are referred by their
  primary care physicians, orthopedists or
  cardiologists
• - In the US, CDT seems to be offered as a
  treatment of last resort..

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ANATOMY AND PHYSIOLOGY KEY
POINTS RELATING TO TREATMENT
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Lymph Production
Lymph production
Lymph production begins in the terminal lymph
vessels, which are located in close proximity to
the capillaries.
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Initial Entry Point-Lymph Capillary
Ultrafiltrate fluid, dead cells, and proteins
are resorbed from the interstitial tissues into
the lymph capillaries. These finger-like
projections are found throughout the body,
peripherally just under the epithelium. The
pressure and stretch upon the surrounding
connective tissue mobilizes the anchoring
filaments to open flaps between the flattened
endothelial cells to allow uptake of large MW
proteins as well as fluid .
Intercellular junction
Movable flap
Anchoring Filament
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Lymph Transport-Lymphangions
Lymph transport
Lymphangions - driving force for lymph
transport in a collecting vessel.
Uni-directional valves form segments that
respond to filling with contraction of smooth
muscle in the vessel walls, moving fluid to the
next segment enhanced by the active muscle pump-
Lymphangiomotoricity
Systole valve closed Diastole valve open
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Importance of Skin Elasticity / Mechanical
External Compression
Lymph transport
With loss of skin elasticity, the muscle pump
loses its normal counter-pressure. Adding
external, non-elastic compression can improve
muscle pump effectiveness.
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LYMPH NODES
600-700 lymph nodes in the body. Major node
groupings abdomen/intestines, inguinal,
axillary, supraclavicular. 2-30 mm in length.
Functions filter and concentrate lymph
through immune system.
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LE Lymphatic Vessels
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Zones / Watersheds/Anastamoses
Each major lymph node grouping receives lymph
from a specific body region or tributary zone.
The direction of lymphatic flow of each
tributary zone is defined by invisible boundaries
called watersheds, Anastamoses are areas between
zones where vessels physically line up, critical
in movement of lymph between adjacent zones
during treatment.
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The lymphatic fluid from right upper quadrant
drains into the right lymphatic duct
The lymphatic fluid from both legs and the left
upper quadrant drains into the thoracic duct
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• - 20 liters of fluid are leaked/drawn off
  capillary beds each day normally 90 is
  reabsorbed through the venous capillaries.
• Lymphatic load (LL) is the remaining 10 of the
  volume, about 2 liters per day, that returns to
  the bloodstream via the lymphatics .

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• Transport capacity (TC)
• - volume of lymph that can be removed by a
  tributary zone and its regional nodes.
• -unless compromised, only about 10 of the volume
  of a normal zone is used, termed the safety
  valve
• loss of transport capacity is often asymptomatic
  and is not easily measured
• Possible contributing factors
• -surgical incisions crossing major lymphatic
  channels
• -pressure on nodes or vessels from obesity or
  tumors
• -radiation therapy
• excision of lymph nodes
• Cellulitis mediated damage to lymph capillaries

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Edema Classification

• High vs. Low protein edema- guides initial
  interventions
• -High protein edema, i.e. lymphedema,
  develops when transport capacity drops below the
  lymphatic load
• Stage 1- reversible- edema goes down overnight,
  no skin changes evident, typically soft 1 or
  2 pitting edema
• Stage 2- broad symptom range with early to
  advanced Stage 2
• edema does not fully reduce
  overnight or with elevation
• skin becomes hard, brawny, hyperkeratosis,
  lymph cysts, etc
• Stemmers sign of digits, swelling of dorsum
  of the foot
• Stage 3 elephantiasis, change in limb
  morphology, more advanced skin changes
• Stages 2 and 3 require lymphatic massage to
  clear interstitial proteins. Increased risk of
  cellulitis. Diuretics arent helpful.

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Lymph System Insufficiencies (LSI)

• Mechanical (low output failure)
• Compromised lymphatic system with decreased
  transport capacity (TC)
• CA/abdominal surgery, radiation, cellulitis
• Dynamic (high output failure)
• Normally functioning system is unable to clear
  increased lymphatic load (LL)
• Longer standing CVI, lymphovenous conversion
• Combination (safety valve failure)
• Decreased TC and increased LL overcomes the
  safety valve margin

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Edema Classification

• -Low protein edema- lacks the interstitial
  protein component of the edema, less osmotic
  pressure
• Examples early CVI , stable CHF
• - Usually responds quickly to bandaging
  reduction, fewer treatment sessions
• - Usually requires garments with lower
  compression
• - Lymphatic massage is usually not required,
  especially if the edema is treated early with
  consistent, adequate compression and diuretics
• - Watch that the cardiac, pulmonary and renal
  systems can handle a spike in fluid volume.
• - Compress one leg at a time
• - No increased SOB , wet cough, etc.

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CVI and CHF

• - CVI
• - progressive valve failure in the veins
• - valve damage due to DVT
• - creates dependent edema due to increased LL
  with increased venous capillary leakage
• - superficial /deep varicosities, hemosiderin
  staining, hairless fragile skin, tissue weeping ,
  venous stasis ulcers
• - if more severe and prolonged, likely
  progresses to high protein edema over time if not
  treated
• - Cardiac related edema- CHF, etc,
• - increased venous capillary pressure and
  leaking
• - if stable, can treat with compression proceed
  with caution

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Documentation

• - Digital photography- First visit and after
  treatments
• - LE girth measurements taken at 10cm
  intervals, MTP and forefoot, toe girths when
  needed
• - Body weight
• - Volumetric algorithms are available

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Management of Swelling Disorders

• - Traditional treatments
• - retrograde massage
• - elevation
• - ankle pump exercises
• - wrapping with long stretch elastic bandages
  aka ACE wraps
• - compression garments
• - pneumatic pumps

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CDT Therapy

• - Origins in Germany - Vodder and Foeldi
• - First offered in the US in 1980
• - PT is covered by most private insurance and MC
• - Treatment components
• Short stretch bandaging for edema reduction
• Lymphatic massage- central to peripheral
• Remedial exercises
• Meticulous skin care
• Education and home management- compression
  systems, self massage and/or night bandaging

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Relative Contraindications

• - Acute DVT if not yet on anti-coagulation
  meds or no screen placed
• - Acute cellulitis - treat after 7-10 days of
  antibiotic therapy, ltwarmth/pain in the leg
• - PAD ABI of 0.5-0.8 with caution
• - Extremity paralysis- mechanical pump lost
• - Complete sensory loss- caution with toes of
  neuropathic patients
• - Dementia

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CDT-Massage principles

• - Central trunk first- diaphragmatic breathing
• - Do the proximal portion of extremity first,
  gradually progressing more distally
• - Use light pressure lymphatic system is above
  muscle fascia layer
• - Rhythmic and directional skin stretching

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Push lymph retrograde to an adjacent, intact zone.
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• Terminal Lymph Vessels / Lymph Capillaries
• Affected by skin stretch
• Pre-collectors
• Affected by blood pressure within sheath
• Lymph Collectors or Lymphangions
• Affected by muscle pump with either good skin or
  external compression
• Lymph Trunks and Associated Node Beds
• Affected by amount of draw from more proximal
  structures

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Bandaging

• - Always apply skin moisturizer/ barriers
• Eucerin, Aquaphor, antifungals, etc.
• - Utilize short stretch cotton bandages
• low resting pressure, high working pressure-
  minimal pulling in at rest, enhanced muscle
  pump
• these features are the opposite of Ace/long
  stretch bandages
• A variety of cotton padding and foams are used
  for creating a proper pressure gradient, protect
  bony prominences, reshaping the limb, and
  softening fibrotic tissue
• - Wear bandages overnight, sequential wraps
  until not reducing further

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Bandaging

• Critical for healing when wet venous wounds are
  present.
• Not useful for neuropathic dry ulcers.
• Use over wound dressings that maintain the proper
  healing environment.
• Watch for areas of skin maceration.

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Short Stretch Bandaging with Padding and Foam
Inserts
Garments alone are not designed to reduce or
reshape the limb, just maintain the size of the
limb Garments are meant to be fitted to an
already reduced leg
Compression bandages should always extend as far
as the next large joint above the edema or we get
topping out, but response does help detecting
central blockages.
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Remedial Exercise

• - Important, since obesity is a risk factor
  this is one reason we favor bandaging over pumps.
• We want people to walk and move! BUT, patients
  must wear compression when exercising to
• -enhance the LE muscle pump
• - counteract increased capillary pressures
  from increased blood flow
• - create micro-massage of the skin to increase
  lymph uptake in the terminal lymph vessels

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Choosing a Compression System

• Effective
• Affordable
• Manageable to don/doff
• Comfortable to wear
• Cosmetically acceptable
• European Compression Garment Guidelines
• http//www.lymphormation.org/downloads/position-d
  ocuments/BSN-Template-English.pdf

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Choosing a Compression System

• - Socks
• - Circular weave- off the shelf
• - Flat weave- custom measured
• - Compression level
• - Closed toe or open toe, w/ or w/out toe caps
• - Materials- Latex or Lycra allergies, use and
  care
• - Neoprene garments
• - CircAids or Ready Wraps

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Choosing a Compression System

• Knee or thigh highs? Avoid topping out or
  dumping at the next most proximal limb segment.
• For high protein edema, apply compression to the
  whole zone, up to the watershed.
• Shorts-
• Bermuda flat weave combine with flat weave
  thigh high
• biking shorts
• Capri circular knit legging with knee highs
• When layering garments, many options are
  available

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Thank you!

• majerus company physical therapy
• Phone [phone]
• Web www.majeruspt.com
• Email johnm_at_majeruspt.com