Lymphedema Flashcards
Lymphedema - Pathophys
Lymphedema
- Accumulation of protein-rich fluid in the interstitial space due to reduced lymph transport
- Occurs due to damage to the lymph vessels or nodes (typical of cancer) or absence/malformation of lymph vessels (congenital)
- May also occur due to reduced extrinsic compression by skeletal muscles (e.g. in paraplegia)
- Presentation may be delayed by 1-2 years due to slow, progressive fibrosis that occludes lymph vessels and culminates in symptoms
Chronic lymphedema
- Increased protein and colloid osmotic pressure of interstitial fluid leads to more fluid being drawn in from plasma
- Result in high protein edema
- May coexist with edema
- Lymphedema is typically asymettric
Long term impacts of lymphedema
- High protein content leads to fibrosis and increased abnormal fat deposition
- Skin changes may occur later on, including hyperkeratosis, papillomatosis, thickened skin folds, hyperpigmentation, and inflammation
- Fibrosclerosis with enclosure of lymph vessels, blood vessels, and nerves can cause pain
- Lymphedema can be complicated by bacterial infections which can then worsen the lymphedema
Ultimately, issues can result in loss of function of the limb
Risk factors for pymphedema
- Common following breast cancer surgery, followed by melanoma, gyne cancers, prostate ca, and sarcoma
- More extensive surgery
- Radiotherapy
- Obesity
- Infections
Sentinal LN biopsy without dissection lowers risk.
Evaluation of new onset lymphedema
- Rule out cancer recurrence (oncology, likely imaging - either CXR +/- CT)
- Rule out DVT (doppler US)
- Rule out cellulitis (CBC)
Impact of lymphedema
- Difficulty with clothing fit
- Impaired function affecting work, IADLs, BADLs, etc.
- Pain (swelling, aching)
- Impaired sexual function
Self-care to prevent worsening of lymphedema
- Prevention of cellulitis
- Skin hygiene to prevent infection, injury, and further lymphatic decompensation
- low pH, non-allergenic moisturizing cream
- Avoid punctures (injections, acupuncture, insect bites) to the affected limb
- Avoid extremes of heat (sunburn, saunas, etc.) causing hyperemia, and avoiding cold, which may cause rebound swelling, is recommended - Flights
- Reduced cabin pressure on long haul flight may exacerbate lymphedema
- Wear well-fitting compression garments - Lifestyle
- Avoid weight gain (which exacerbates lymphedema) and maintain exercise
- Some exercises may be better than others (eg walking with arm down may worsen, swimming may improve)
Members of a lymphedema specialty team
- Team provides Physical therapy and Patient education
Members:
- PT
- Nurse
- Massage therapist
- Physician
Combined decongestive therapy
- Physical therapy aimed at improving lymphatic drainage through existing lymphatics and encourage collateral circulation.
Phase 1: Reduce lymphedema (intensive)
Phase 2: Maintenance phase (maintain reduction)
Stages and treatment of lymphedema: Stage 1
Stage 1:
- Reverse spontaneously with elevation
Treatment:
- Compression garment
- Skin care
- Exercises
If ineffective, treat as for stage 2
Stages and treatment of lymphedema: Stage 2
Stage 2:
- Does not reverse spontaneously with elevation, will lead to progressive fibrosis if untreated
Treatment:
- Modified, multilayer inelastic bandaging
- Skin care
- Simple lymphatic drainage
- Exercises
If successful after 2-4 weeks, proceed to compression garment for maintenance therapy with ongoing lifestyle changes. If not successful, proceed to stage 3
Stages and treatment of lymphedema: Stage 3
Stage 3
- Does not resolve with elevation, skin changes present (moderate/severe lymphedema)
Treatment:
- Intensive tx with education and psych support
- Low stretch multilayer inelastic bandaging
- Manual lymphatic drainage
- Skin care
- Exercises
Once successful, go to maintenance treatment:
- Compression garment
- Skin care
- Exercises
- Simple lymphatic drainage
Manual lymphatic drainage
- Light massage that requires specialized training as if done improperly, can worsen lymphedema
- Aim is to improve intrinsic contractility of superficial lymph vessels and improve blood flow
- Begins proximally to enhance drainage
- Bandages applied afterwards
A simplified version of the massage (‘simple lymphatic drainage’) can later be taught to patients or their partners as part of the maintenance of lymph edema
Compression bandaging of lymphedema
- Applied after manual lymphatic drainage
- Special, low stretch bandage (e.g. not ACE or tensor bandage, which are too high pressure)
- During intensive phase, stay on for 24 hrs and only removed for lymphatic drainage and skin care
- During maintenance phase, may still be applied during nighttime or while a patient waits for a compression garment
Sequential pneumatic compression pumps for lymphedema
- Inflatable multi-chambered sleeves that squeeze the soft tissues to passively move lymphatic fluid to drainage points
- May be used with compression hosiery or other techniques
- May not be as effect as manual lymphatic drainage (when done properly)
Compression garments for lymphedema
- Prescribed only for mild lymphedema or after intensive phase treatment with edema reduction
- Maintain the size of the limb to prevent further swelling
