Lymphedema and compression Flashcards
Main functions of lymphatic system:
regulate fluid balance
assist with infection control
How much fluid is removed from interstitial space/day?
18 liters
Where is fluid removal from?
80-90% through veins
remaining 2-4 liters thru lymph system
Estimates of lymphedema type:
23–45% of patients after breast cancer
21% of patients after ovarian cancer
28% of patients after endometrial cancer
Up to 70% of patients after prostate cancer
When does lymphedema occur?
when the lymphatics cannot remove the remaining interstitial fluid
Chief complaints of lymphedema?
Limb heaviness, paresthesias, achiness, skin tightness, poor-fitting clothes, altered cosmesis, decreased ADLs and ROM
Lymphatic anatomy:
superficial
deep
perforating
Superficial lymphatics
Drains the skin and subcutaneous tissue
Roughly parallels the veins
Deep lymphatics
Drains all else (deep tissues and organs)
Lymph
fluid made up of water, protein, dead/dying cells/cellular components, fatty acids, foreign material and debris
Lymphangion
functional unit of the lymph system
Smaller lymph anatomy:
capillaries precollectors collectors nodes trunks
Central Lymphatic Flow
Unidirectional valves Skeletal muscle contraction Respiratory pump Aortic pulsations Lymphangiomotoricity
What is fluid movement between capillaries, interstitium, and lymphatic system governed by?
hydrostatic and osmotic pressure
Dynamic insufficiency:
If the lymphatic load exceeds the transport capacity of the lymphatic system, edema will occur
Mechanical insufficiency:
a decrease in the maximal transport capacity of the lymphatic system, mechanical insufficiency can result
Types of lymphedema
primary
secondary
vessel abnormality
age on onset
Primary
10% of all cases
Congenital malformation or impairment of lymphatics
LE affected most often
Secondary:
Acquired
Disruption of or damage to lymphatics
Much more common
What illnesses is secondary lymphedema common in?
Filariasis (parasitic infection)
Cancer treatment
Chronic venous insufficiency
Vessel Abnormality
Aplasia
Hypoplasia
Hyperplasia
Lymph node fibrosis
Age at Onset
Congenital
Praecox
Tarda
Lipedema
Bilateral, symmetrical increase in adipose tissue deposition
What areas does lipedema most commonly affect?
Affects abdomen, buttocks, lower extremities but spares the feet
Causes of lipolymphedema;
Increased compliance of fat allows interstitial fluid to accumulate
Risk Factors for Lymphedema
Lymph node status Radiation therapy Time since surgery Air travel without compression Inflammation/Increased Lymphatic Load Decreased Lymphatic Return
Lymph Node Status
Surgical removal increases risk
More removed, the greater the risk
Sentinel lymph node
the first lymph node to receive lymph from a tumor
Radiation Therapy
Peri-lymphatic and lymph node fibrosis Skin damage Sclerosis/fibrosis Dermal atrophy Decreased sweat glands
What percentage of breast cancer patients who had lumpectomy and axillary radiation developed lymphedema?
26%
Time Since Surgery
Risk increases over time
Possibly due to lymphatic fatigue
Increased Body Mass Index
Air Travel Without Compression
Decreased atmospheric pressure on body while flying allows body to swell
May extrapolate to increased risk when going to areas of high elevation
Compression garment offsets this pressure change
Inflammation/Increased Lymphatic Load
Inflammation and infection increase lymphatic load
Avoiding strenuous activity of at-risk limb may prevent muscle microtrauma and inflammation – increased fluid that the patient’s lymph system may not be able to accommodate
Decreased Lymphatic Return
Constrictive clothing/jewelry
Tourniquets, blood pressure cuffs
Those Prone to Scar Tissue Formation
Trauma from surgical removal of tumor, nodes, and tissue dissection may cause more scar tissue formation in some patients, such as those at risk for keloids
PT Tests and Measures
for Lymphedema
Circumferential Measurements
Weight change with compression
Circulation
Sensory Integrity
Gold standard for lymphedema measurements?
volumetric displacement
Why is volumetric displacement rarely used?
increased time, infection
risk, equipment needs
Circumferential Measurements
Reliable
Can use software programs to convert to volume
Can measure limb every 3, 4, 8, or 12 cm
Include landmarks needed for garments
How can software programs be used to convert to volume?
Compare side-to-side
Compare changes over course of treatment
Compare over time
Pulses
Palpation
Doppler if needed
Other circulation methods to measure for lymphedema?
Capillary refill
Ankle-Brachial Index or Toe-Brachial Index on patients with lower extremity lymphedema
Screen patients with lower extremity lymphedema for DVT
Sensory Integrity
Perform monofilament testing on all patients with lymphedema
What can nerve entrapments be caused by?
tissue distention, edema, and inflammation
Patients at risk for neuropathy
Those with diabetes
Those who received chemotherapy
Stage 0
latent
No edema present
Reduced transport capacity of the lymphatic system
Most commonly due to surgery or radiation
Stage 1
Reversible
Edema that pits when digital pressure is applied
Greatly or completely reduces with elevation
No secondary skin changes
Stage 2
Spontaneously Irreversible
Does not pit when digital pressure is applied
Does not reduce substantially with elevation
Skin becomes fibrotic or brawny
May have frequent skin infections
Stage 3
Lymphostatic Elephantiasis
Extreme increase in limb volume
Deep skin folds and papillomas present
Frequent skin infections
Mild lymphedema
<3 cm interlimb difference
<20% limb volume increase
Moderate lymphedema
3–5 cm interlimb difference
20–40% limb volume increase
Severe lymphedema
> 5 cm interlimb difference
>40% limb volume increase
5PT Method
Pain Position Presentation Periwound Pulses Temperature
Pain
Deep ache or pressure stretch pain neuropathic pain pain from infection or inflammation discomfort, heaviness If patient complains of pain rather than the above sensations, further evaluation or referral is warranted
Position
Distal to area of lymphatic obstruction or damage
Must know:
Normal anatomy and drainage patterns
Surgery/procedures in past medical history
Presentation
lymphorrhea
serous drainage
Drainage can be significant, especially in lower extremity
If infected, drainage may be purulent, seropurulent, and/or copious
Slough-covered wound common
Periwound and Structural Changes
pitting fibrotic peau d'orange Stemmer's sign papillomatosis fungal infection (scaling, thickened nails) Hemosideran deep skin folds hair loss Lichenification Lymphorrhea Dermatitis Ulceration Xerosis
Peau D’Orange
a dimpling of the skin that gives it the appearance of the skin of an orange. Often due to lymphatic obstruction
Pulses
normal
Temperature
Normal May be warm to touch due to: Edema Inflammation Infection
Prognosis for mild lymphedema
will require 5–10 visits
Prognosis for moderate lymphedema
will require 14–24 visits
Prognosis expectations:
Earlier access means faster recovery
Can expect 22–73% volume in 6–36 visits
Lipolymphedema and stage IV cancers make least progress
Proactive education program
For at-risk patients
For providers who deal with at-risk patients
For cancer survivor groups
Do list:
protect from injury, skin checks, how to treat open areas, ideal weight, exercise, garment wear/care
Don’t list
injections/BP/piercings/tattoos in affected area, hot tubs/saunas, walking barefoot
Precautions
Rule out cancer recurrence as cause of lymphedema
Spontaneous lymphedema without prior history of lymphatic trauma should be screened by MD
Screen patients with lower extremity lymphedema
Arterial insufficiency
Deep vein thrombosis
Request for Further Medical Testing
Wound culture and sensitivity if signs and symptoms of infection
Rule out recurrence
If cannot perform an ABI
Skin Care
Keep skin clean and dry
Avoid perfumes, high-alkaline soaps
Use low pH moisturizers
If open wound, wash with soap and water, apply topical antimicrobial, cover
More skin care:
Protect surrounding skin Skin sealant/moisture barrier Lotion to intact skin Absorptive dressing Compression Educate patient/caregivers
Therapeutic Exercise
Patient positioning Active range of motion Flexibility exercise Anaerobic exercise Aerobic exercise Breathing exercise
Manual Therapy
No method is superior but including manual therapy leads to better results
Advanced training or certification is recommended
Manual therapy techniques:
Manual lymphatic drainage
Simple lymph drainage
Lymphatic massage
Benefits of Manual Therapy
Increases lymph formation Propels lymph proximally Increases lymph angiomotoricity Reroutes stagnated lymph Encourages development of collaterals Reduces sympathetic and increases parasympathetic responses Decreases pain/promotes relaxation Decreases fibrosis
Precautions/Contraindications
for Manual Rx
DVT Active infection open wound metastatic disease CHF Asthma Abdominal inflammatory condition/pregnant
Open wound precautions:
treat intact skin only
Metastatic disease precautions:
can use palliatively
CHF precautions:
start slowly, progress slowly
Asthma precautions:
start slowly, monitor asthma
Abdominal inflammatory conditions/pregnant precautions:
do not perform deep abdominal treatment
Manual therapy movement:
Clear (empty/drain) proximally before moving incrementally more distal
Venous angles where lymphatics empty into venous system
Trunk
Affected extremity
Rework often to reclear
Compression Therapy
Reduces ultrafiltration Enhances venous return Improves effectiveness of muscle pump Increases angiomotoricity May reduce fibrosis
Multilayer Compression Bandaging
Skin care: wash, dry, apply lotion Wound care as needed including absorptive dressing Cotton liner Digit bandage Padding: cotton, foam, custom-made Short-stretch compression bandages
Precautions/Contraindications
for Compression Bandaging
Arterial insufficieny
Radiation damage with intact skin
DVT
CHF: start slowly, progress slowly
Open wound: proper infection control, appropriate dressing/skin care
Infection
Patients who are weak, immobile, insensate
Mild lymphedema
Prophylactic UE
10–21 mm Hg
Light
Moderate to severe UE lymphedema
Mild LE lymphedema
15–32 mm Hg
Medium
Moderate to severe LE lymphedema
30–40 mm Hg
Strong
Stage 3 LE lymphedema
<40 mm Hg
Very strong
Compression Pumps
Single or multichamber
Ideally also compresses trunk quadrant
Poor patient adherence
Rarely good intervention strategy
What does a compression pump do?
Remove fluid from the area, but not protein
Once stopped, protein draws fluid back
Residual protein leads to fibrosis
Two phases of intervention
intensive
self-management
Intensive
High frequency of visits over short term
Learn self-care
Self-management
Ongoing
Maintenance of edema reduction
Medical Testing
Rule out serious medical conditions
Cancer/recurrence of cancer
DVT
CHF, etc.
Medical Interventions
Manage risk factors
Pharmacological
Surgical Interventions
Debridement
Microsurgical procedures
Debulking surgeries
Effects of Compression
Enhances calf muscle pump Improves venous return Decreases peripheral edema Reduces venous distension Increases tissue oxygenation Softens lipodermatosclerosis Protects limb from trauma Limits need for prolonged elevation/bed rest
Compression Parameters
30–40 mm Hg at ankle
10 mm Hg at infrapatellar notch
If severe VI, can increase to 40–50 mm Hg
If mild AI, can decrease to 20–30 mm Hg
Contraindications to Compression
ABI < 0.7 Acute infection Pulmonary edema Uncontrolled or severe congestive heart failure Active DVT Claustrophobia (relative)
Types of Compression
Paste bandage Short-stretch compression bandage Multilayer compression bandage system CircAid Tubular bandages Compression garments Vasopneumatic compression devices
Paste Bandages
A nonelastic compression Gauze, in a cloth roll bandage that is impregnated with zinc oxide, calamine, glycerin, and gelatin Hardens into a semi-rigid support Stays on for up to 1 week Used on ambulatory patients
Paste bandage disadvantage:
odor
pruritus
Inability to shower or get the dressing wet
Should not be used in areas of high humidity
Unable to accommodate changes in limb size
Short-Stretch Compression Bandages
Low resting pressure and little distensibility
Ambulatory and nonambulatory patients
Amount of compression determined by Laplace’s law
Need enough to reduce edema without causing ischemia
Short-Stretch Compression Bandages disadvantages
Prone to slippage, causing frequent wrapping
Patients must be trained in correct technique
Inner layer
Absorbs excess wound drainage
Provides padding
Middle layer
short stretch
Outer layer
1–2 layers are long stretch providing increased compression
Multi-layer Bandage
Mimics high working pressure (during standing up to almost 50mmHg) and low resting pressure for tolerance at night
Used mostly in the presence of ulcerations
Velcro Compression Garment
Removable, semi-rigid orthotic compression device
Consists of rows of nonelastic Velcro straps that provide sustained compression
Easy to apply
Velcro Compression Garment Disadvantages:
High one-time cost
Need for patient adherence for daily wear
Tubular Bandages
Off-the-shelf sleeves
Available in several widths and compressions
Allow for graduated compression
Tubular Bandages Disadvantages:
Generic shapes and sizes do not accommodate all patients
Bandages lose shape and compression in a short time
Long Stretch Bandage
Provide mild compression (18-24 mm hg)
Must be applied properly to be effective
Can decrease dependent edema
Elastic-extend beyond 100%
Compression Stockings
Gradient with pressure greatest at the ankle and decreasing superiorly
Flat knit vs. circular
Over the counter vs. custom
8-50mmHg
Compression Hose light support
8-14mmHg- edema prevention for extensive sitting and standing with minimal activity
Compression Hose antiembolism stockings:
16-18mmHg- Deep vein prophylaxis, non- ambulatory patients with edema, includes TED hose
Compression Hose low compression
18-24mm Hg - Non-ambulatory patients with edema failing 16-18mmHg stockings, includes elastic bandages and paste bandages for clients with dependent edema
Compression Hose low to moderate
25-35 mmHg- edema secondary to venous insufficiency, for clients able to participate in exercise, includes 4-layer wraps
Compression Hose moderate
30-40mmHg- Edema with or without ulceration, edema that persists despite lower level compression options, includes four layer bandage
Compression Hose high
40-50mmHg-edema secondary to lymphedema
Compression Class 0
< 20mmHg
non ambulatory patients
Compression Class 1
20-30 mmHg
mild venous insufficiency
VI with mild AI
Compression Class 2
30-40 mmHg
moderate VI
Compression Class 3
40-50 mmHg
severe VI
Compression Class 4
> 50 mmHg
severe VI
