Treatment of Lymphedema

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Treatment of Lymphedema
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Lymph Anatomy

• Lymph nodes
• Lymph vessels
• Thymus gland
• Spleen
• Tonsils
• Peyers patches

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Lymph Vessels

• Capillaries
• Pre-collectors
• Collectors
• Trunks

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Lymph Capillaries

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

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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

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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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Lymph Fluid/Lymphatic Load

• Consists of
• Proteins (1/2 of bodies protien)
• Water
• Cells (RBC, WBC, Lymphocytes)
• Waste Products
• Fat (intestinal lymph, chyle)

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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

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Lymphatic Watersheds

• Median-Sagittal
• Tranverse
• Clavical
• Spine of Scapula
• Chaps or Gluteal

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Lymph Time Volume Transport Capacity

• LTV amount of lymph which is transported by the
  lymphatic system in a unit of time
• TCmaximum lymph time volume
• Functional Reservethe difference between the LTV
  and the TC

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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
LLLTV
LL
LTV
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Lymph Propulsion

• Arterial pulsation
• Muscle pump
• Respiration
• Contraction of the lymphangion

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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

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Physical Exam

• History
• Inspection
• Measurements weight, circumference
• Skin assessment nodules, bumps, discoleration
• Palpation
• Temperature usually a bit warmer
• Stemmers sign rolls on finger, square and thick
  skin
• Skin fold(s)
• Pitting
• Fibrosis

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Other Diagnostic Tests

• Lymphography
• Venous Doppler or Venous Sonography
• Indirect Lymphography
• Fluorescence Microlymphography
• Lymphoscintigraphy
• CT Scan
• MRI

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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
• Milroys Disease-congentital, males, unilateral
  typically
• Meiges Syndrome most females around puberty,
  Bilateral, webbing of fingers and toes, two rows
  of lashes

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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)

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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, Sudecks)

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Chronic Venous Insufficiency
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Filariasis
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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.

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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

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Treatment Schools of Thought

• Casley-Smith
• Foldi
• LeDuc
• Vodder
• Norton
• Klose

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Complete Decongestive Therapy (CDT)

• Skin Care
• Manual Lymph Drainage
• Compression Therapy
• Remedial exercise

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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

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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 lt 0.50

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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 Must be controlled, then treat conservatively and monitor
AAA, Diverticulitis, IBS, Crohns 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
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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

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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.

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• 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 (gt15 minutes) exposure to heat,
  particularly hot tubs and saunas
• Airplane flights due to decrease pressure in
  cabin, will need a compression sleeve

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Signs of infection

• Red
• Hot
• Pain
• Swelling
• Fever
• Generalized Fatigue

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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

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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

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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

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Sequence of exercises

• Proximal starting at neck and trunk
• Proximal joints moving distally
• 5 reps 20 reps

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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.

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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

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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

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Manual Lymph Drainage (MLD)

• 1. Mobilize the skin
• 2. Apply Pressure
• 3. Relax
• Technique is done lightly and slowly

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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

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• Upper Extremity mld

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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

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• Lower Extremity mld

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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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Abdominal Nodes
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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

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Treatment Of Abdomen - Deep

• Contraindications
• Pregnancy
• Endometriosis
• Hiatal hernia

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Compression bandages
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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

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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

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Resting Pressure
BANDAGE
LYMPHATICS
MUSCLE
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Working Pressure
BANDAGE
LYMPHATICS
MUSCLE
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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

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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

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Principles of Bandaging

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

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Principles of Bandaging cont

• 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

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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

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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

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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

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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

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MedaFit garments
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Donning Compression Garment

• For LE put on in bed
• Use gloves to don and doff
• Apply on an empty limb

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Garment Compression Classes

• Over the counter --?
• CC1 -----------------?
• CC2 -----------------?
• CC3 ----------------?
• CC4 ----------------?

• 10-18 mmHg
• 20-30 mmHg
• 30-40 mmHg
• 40-60 mmHg
• 60 mmHg

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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

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Sequential Pneumatic Devices
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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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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 DVTs.
• 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.

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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
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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

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• Results
• 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