lymphedema

Managementof Lymphedema : 

Managementof Lymphedema

Content : 

Content Lymph System: Anatomy/Physiology Lymphedema: Primary Secondary Medical Interventions Therapeutic Interventions: CDT Standard of treatment Phase I Phase II Literature

What is the lymphatic system ? : 

What is the lymphatic system ? Specialized component of the circulatory system. Retrieves fluid (lymph) filtered out of the circulatory system by capillaries and returns it to the venous system for circulation The lymphatic system originates as lymph capillaries in the spaces between cells The capillaries join to form larger vessels called the lymphatics

Lymphatic System (continued) : 

Lymphatic System (continued) smaller diameter and thinner walls than veins or arteries Contain more valves than veins to assist with lymph flow Aided by: Lymph Angion (internal) External adjacent skeletal muscle contractions contractions of the smooth muscles of internal organs pulsatile movements of surrounding blood vessels

Distribution of Lymph Vessels : 

Distribution of Lymph Vessels Originate as “blind-end” vessels

Lymph Vessels : 

Lymph Vessels

Slide 8: 

The lymphatics are joined together by lymph nodes which act as filters and empty into the right lymphatic duct or the thoracic duct

Lymphatic Drainage : 

Lymphatic Drainage An OPEN system Drains 1-3 L / Day Right Subclavian Vein Right Upper Quadrant Thoracic Duct to Left Subclavian Vein Rest of body

The Lymphatic Pump : 

The Lymphatic Pump Inspiration ↓ Descent of the diaphragm ↓ Increased intra-abdominal pressure Decreased intra-thoracic pressure ↓ Thoracic duct lymph “pumped” into the venous system during inspiration

What is Lymphedema ? : 

What is Lymphedema ? Definition “…a subcutaneous accumulation of protein-rich fluid resulting from an insufficient or blocked drainage system…1” Occurs most often in the arm(s) and/or leg(s), and occasionally in other parts of the body such as the trunk and genitalia. 1. Little L, Proche DJ. Manual Lymph Drainage. Journal of the Association of Nurses in AIDS Care. 1998;9:78-82.

How frequently does it occur ? : 

How frequently does it occur ? Affects 1% of the US population – over 2.5 million people – usually from breast cancer treatment Post-mastectomy: 25.5 % Post-mastectomy with axillary lymph node dissection and radiation therapy: 38.3 % Further increased with obesity and/or infection

How frequently does it occur ? (continued) : 

How frequently does it occur ? (continued) May also see with: lymphoma prostate cancer melanoma Hodgkin’s disease ovarian cancer Systemic lupus erythmatosus Even more common in third world countries due to prevalence of parasitic infections

Primary Lymphedema : 

Primary Lymphedema Primary lymphedema is due to a congenital deformity of the lymphatic system: Hypoplasia Hyperplasia Aplasia Primary usually affects the lower extremities.

Primary Lymphedema can: : 

Primary Lymphedema can: Present at birth = Lymphedema congenita Develop in childhood = Lymphedema Praecox Develop in Adulthood = Lymphedema Tarda

Syndactdyly : 

Syndactdyly

Primary Lymphedema can: : 

Primary Lymphedema can: Present at birth = Lymphedema congenita Develop in childhood = Lymphedema Praecox Develop in Adulthood = Lymphedema Tarda

Secondary Lymphedema : 

Secondary Lymphedema Secondary lymphedema usually results from a trauma to the lymphatic system Surgery Breast, gynecological, head/neck, prostate, testicular, bladder, colon Radiation therapy Traumatic injury Seroma Aspiration → Infection Lymphangitis Tumor/cancer involvement Filariasis (200 million people worldwide)

How does Lymphedema occur ? : 

How does Lymphedema occur ? Decreased lymph flow from lymphatic damage results in increased protein concentration in the interstitial fluid With increased protein concentration, fluid is shifted into the interstitial space due to oncotic pressure With fluid accumulation in the interstitial space, swelling/edema occurs in that body part

How does it occur ? (continued) : 

How does it occur ? (continued) Lymphatic damage and fluid stasis also leads to scar tissue/fibrosis development with collagen and fibrin deposition to vessel walls, therefore further blocking lymph flow Fluid stasis increases susceptibility to infection with cycle initiated for further lymphatic damage

Staging Lymphedema : 

Staging Lymphedema Stage 0 – Sub-clinical Lymph transport impaired No obvious signs or symptoms Can last for years

Staging Lymphedema : 

Staging Lymphedema Stage 1 Protein rich fluid present Tissues are soft with no or minimal fibrosis Edema pits on pressure and spontaneously reduces with limb elevation Limb volume difference < 20% Source: International Society of Lymphology, 2003

Staging Lymphedema : 

Staging Lymphedema Stage 2 Substantial fibrosis Tissues feel firm to palpation Does not pit or reduce on elevation Risk of infection increased Limb volume difference 20 – 40 % Source: International Society of Lymphology, 2003

Staging Lymphedema : 

Staging Lymphedema Stage 3 As stage 2 but with elephantine changes Severe hyperkeratosis and papillomatosis Skin loses normal elasticity Skin folds occur Risk of infection increased Limb volume difference > 40 % Source: International Society of Lymphology, 2003

Are diagnostic tools appropriate ? : 

Are diagnostic tools appropriate ? Lymphangiography has been used in past to evaluate, however: rarely is it required due to strong correlation with history and exam for diagnosis anatomical information gained has no impact on treatment can frequently exacerbate the condition If clinical suspicion, venogram or venous doppler can rule out presence of thrombosis Best tools remain detailed history and exam

What are treatment options ? : 

What are treatment options ? Medications: Antibiotics – decrease infection risk Diuretics - decrease interstitial fluid Proteases – break down interstitial proteins Surgical: Not curative Excisional: Charles / Homans procedure debulking of the area to remove excess tissue to decrease volume Study by Kim, D et al Physiological: drainage of the area via lymph to lymph or lymph to venous anastomosis

Manual Lymphatic Treatment : 

Manual Lymphatic Treatment Treatment Goals Improve cosmesis Preserve skin integrity Soften subcutaneous tissues Avoid infection or lymphangitis Decrease limb size Avoid contracture of the involved limb

Manual Lymphatic Treatment- Phase One - CDT : 

Manual Lymphatic Treatment- Phase One - CDT Manual Lymphatic Drainage Antiseptic Moisturizing Cream Low-stretch compression bandages Active Exercise Patient Education (see Phase 2)

Manual Lymph Drainage : 

Manual Lymph Drainage Gentle manual treatment which improves the activity of the lymph vascular system. Re-routes lymph flow around blocked areas into more centrally located healthy lymph vessels.

Compressive Bandaging : 

Compressive Bandaging Minimally elastic bandages applied to increase pressure in extremity. Reduces re-infiltration Improves muscle pump Helps to break up deposits of accumulated scar and connective tissue. Stays in place until next MLD session.

Bandages : 

Bandages

Exercises : 

Exercises Goal: enhance muscle pump activity and promote improved venous and lymphatic return in the involved extremity Employed throughout the span of the CDT treatment program including initial Phase I and Phase II.

Types of Exercise : 

Types of Exercise Flexibility/Stretching minimizing tightness and the effects of scarring which can block lymph flow Resistive improve muscle power, stamina and tone Greatest risk of tears/injury Increases local blood flow and the production of waste products increasing load on the lymphatic system Use in Conjunction with compression Aerobic Conditioning 60% - 75% of the maximum heart rate (target heart rate) Increased deep respiration (deep breathing) enhances venous and lymphatic return Source: National Lymphedema Network

Negative Aspects of Exercise : 

Negative Aspects of Exercise Blood flow is increased, possibly causing an increase in lymphatic load Increased muscle metabolism results in increased metabolic waste Improper exercise may cause inflammation and trauma

Manual Lymphatic Treatment- Phase Two : 

Manual Lymphatic Treatment- Phase Two Compression Stockings/Sleeves Home Exercise Skin Care Patient Education

What types of compression are available in Phase 2 ? : 

What types of compression are available in Phase 2 ? Compression stocking can be used for treatment and maintenance 2 pairs are appropriate to maximize hygiene last from 4 to 6 months can be difficult to don or doff and keep in position Compressive wrapping better flexibility for specific problem areas and for specific patients patients and families can learn technique allow greater activity level than pumps can be time consuming to don

Available compression: Phase 2 : 

Available compression: Phase 2 Compression pumps not adequate for primary therapy do not address proximal edema high cost with decreased compliance less convenient for associated exercise or mobility variable protocols dependent on brand and type but ranges: single chamber/uniform/intermittent compression: 30-60 mm Hg multi-chamber/differential/sequential compression:60-120 mm Hg

Compression Pump : 

Compression Pump

Patient EducationCooperation = Compliance : 

Patient EducationCooperation = Compliance Wear protective garments for appropriate activities: gardening or pruning dishwashing baking/cooking sewing Immediate contact with physician if presence of infection Carry heavy parcels or purses on the opposite limb Sunscreen or long-sleeved garments for sun exposure Sleep with limb elevated

Patient Education (continued) : 

Patient Education (continued) Jewelry should not be worn on affected limb Insect repellent for high risk exposure Utilize electric razor for shaving Check water temperature with other limb or thermometer before immersion Avoid heavy lifting or repetitive movements with involved limb Avoid tight-fitting garments to affected limb Avoid climate temperature extremes

Before / After Photos : 

Before / After Photos

Before / After Photos : 

Before / After Photos

Before / After Photos : 

Before / After Photos

Before / After Photos : 

Before / After Photos

Before / During / After Pictures : 

Before / During / After Pictures

Treatment Research : 

Treatment Research Effectiveness of Lymphedema treatment of the extremities Subjects: 299 patients with lymphedema in the upper (2% primary, 98% secondary) and lower (61% primary, 38.7% secondary) extremity. Intervention: Phase I and Phase II Complete decongestive physiotherapy. Volumetrics taken prior, end of phase I and at 6- to 12-month intervals during phase II Results: Reduction 59% UE, 68% LE. Ave f/up 9 months: compliance retained 90% reduction vs. non-compliant retained 66% reduction. Infections reduced 1.1 infections/pt/yr to 0.65 infections/pt/yr

Treatment Research : 

Treatment Research Comparison of Compression Bandage alone or with Manual Lymph Drainage Johansson et al. examined the effects of low stretch compression bandaging (CB) alone or in combination with manual lymph drainage (MLD) in 38 female patients with arm lymphedema after treatment for breast cancer 2 part test: Part I Compression Garment 2 wks (volume) Part II Compression + MLD or Just Compression Results: Compression Bandage is an effective treatment, and is enhanced with manual lymph drainage

Treatment Research : 

Treatment Research A Comparison of manual lymph drainage with sequential pneumatic compression Johansson et al. examined the effects of manual lymphatic drainage against sequential pneumatic compression for treatment of arm lymphedema in 38 female patients after treatment for breast cancer. 38 females s/p breast cancer 2 part test: Part I Compression Garment x 2 wks (volume maintenance) Part II Sequential Pneumatic Compression or MLD x 2wks Results- Part I: Lymphedema reduced 7%; Part II: MLD decreased 15%, SPC decreased 7%. Only MLD patients reported decreased tension and heaviness in limb during part II

Summary- : 

Summary- Lymph System Lymphedema: Primary / Secondary Medical Interventions Therapeutic Interventions Standard of treatment Phase I Phase II Literature

Questions ? : 

Questions ?

References : 

References Dong K et al. Excisional Surgery for Chronic Advanced Lymphedema. Surgery Today. 2004;34(2):134-137. Didem K, Ufuk Y, Serdar S, Zumre A. The comparison of two different physiotherapy methods in treatment of lymphemema after breast surgery. Breast Cancer Research and Treatment.2005;93:49-54. Johansson K. et al. A randomized study comparing manual lymph drainage with sequential pneumatic compression for treatment of postoperative arm lymphedema. Lymphology. 1998;31(2):56-64. Dicken SC et al. Effective Treatment of Lymphedema of the Extremities. Arch Surg. 1998;133:452-458.

References : 

References Cayuga University faculty pages. Available at: http://www.cayuga-cc.edu/people/facultypages/greer/biol204/lymphatic1/lymphatic1.html. Accessed June 18, 2007 NLN Medical Advisory Committee. Position Statement of the National Lymphedema Network: Topic- Exercise. Approved 7/1/2005. Accessed via the world wide web. Available at: http://www.lymphnet.org/pdfDocs/nlnexercise.pdf. Accessed: June 18, 2007.