Lymphedema Management

Question 1

what is complete decongestive therapy

Answer 1

• Most common treatment for lymphedema
• Currently recognized as the “gold standard” of care of lymphedema

Question 2

two phases of CDT

Answer 2

intensive phase
maintenance phase

Question 3

intensive phase

Answer 3

• Goal: maximum volume reduction and normalization of tissue texture
• Consists of manual lymphatic drainage (MLD), compression bandaging, patient education, skin care and exercise

Question 4

maintenance phase

Answer 4

• Goal: maintain volume reduction that was achieved in the intensive phase
• Consists of compression garment fitting, exercise, self MLD, possible maintenance MLD by a qualified provider, skin care, and instruction in self care

Question 5

goals of manual lymphatic drainage

Answer 5

• Reduce edema utilizing the anatomy of the lymphatic system
• Direct fluid away from the affected quadrant
• Facilitate uptake in the uninvolved lymphatics
• Break up protein stasis and soften fibrotic tissue

Question 6

is MLD intended to be stand alone treatment?

Answer 6

• no
• often part of CDT
• breast edema shows the most improvement when MLD is performed

Question 7

reduced subjective symptoms after MLD

Answer 7

• tension
• heaviness
• pain
• QOL

Question 8

indications of MLD

Answer 8

• Primary lymphedema
• Secondary lymphedema
• Venous edema
• Post traumatic edema
• post-surgical edema

Question 9

contraindications of MLD

Answer 9

• Untreated acute infecƟons
• Untreated cardiac edema
• Renal edema
• Acute DVT
• Aortic aneurysm
• Neck treatment
• abdominal treatment

Question 10

principles of MLD

Answer 10

*Patient is positioned comfort; treatmentareas supported; body
appropriately draped
*Effleurage over area to be treated is used to begin and end treatment
*Pressure –> generally light, directed to the superficial fascia
tssue layer
*Each stroke has a working “pressure on” and a resting “pressure
off” stage
*Each stroke has a spiral component

Question 11

working stage of MLD

Answer 11

• about 1 second
• repeated 5-7 times
• always directed toward intact lymphatic pathways (towards uninvolved nodes, around involved nodes_

Question 12

what begins and ends MLD and why

Answer 12

abdominal breathing to stimulate thoracic duct

Question 13

MLD general sequence

Answer 13

treat venous angles
regional lymph nodes
appropriate anastomoses
treat extremity from proximal to distal

Question 14

types of compression

Answer 14

*UEand LE short stretch and long stretch bandaging
*Unna boot or paste bandages
*Four layer wrap
*Pneumatic compression/Compression pumps
*Compression garments

Question 15

what does compression therapy do?

Answer 15

*Reduces arterial filtration
*Reduces venous reflux
*Enhances valve competence
*Prevents re-accumulation of fluid
*Increases the calf-muscle pump
*Assists in breakdown of fibrosis
*Provides support for tissues that have lost elasticity

Question 16

compression therapy: phase I

Answer 16

In Phase I of CDT, compression is done using multi-layered short
stretch bandaging

Question 17

compression therapy phase II

Answer 17

In Phase II of CDT, compression is designed to maintain the limb
volume achieved in phase I
* Non-custom or custom compression garments during the day
* Patients requiring nighttime compression will utilize short stretch
bandaged or night time compression garments

Question 18

compression indications

Answer 18

• Upper or lower extremity lymphedema
• Venous edema in the lower extremity
• Edema from post surgery or post trauma
• To shape the residual limb post amputation

Question 19

compression contraindication

Answer 19

• Acute untreated infections
• Acute untreated DVT
• Untreated Cardiac Edema
• Renal edema
• Edema without diagnosis

Question 20

compression precautions

Answer 20

Cardiac edema
* Arterial disease/wounds
* Diabetes: small vessel (arteriole insufficiency)
* Sensory deficits
* Paralysis
* Altered mental status
* Malignancy (relative)
* Sensitivity to compression products
* Inability to perform home management

Question 21

review guidelines for compression therapy slide 19

Question 22

resting pressure

Answer 22

• Constant pressure externally applied by the bandage
• Constant pressure may hinder refill of superficial vessels
• Highest values achieved with strong, very elastic bandages (ace wrap, 4-layer wrap)

Question 23

working pressure

Answer 23

• Temporary pressure that is generated with muscle contraction
• Increases the efficiency of the muscle pump
• Highest values achieved with more rigid dressings (short stretch, Unna boot)

Question 24

short stretch bandage

Answer 24

• Can be elongated 10-100% of resting length
• Low resting pressure and High working pressure
• Minimallyelastic
• Prevent circulatory compromise and tourniquet effect
• Minimize fluid re-accumulation
• loses pressure over time

Question 25

long stretch bandage

Answer 25

* Can be elongated >100% resting length * Low working pressureand High resting pressure * Highly elastic: ACE wraps * May compromise circulation at rest * Poor support when muscles are working * maintain pressure over time

Question 26

determinants of compression

Answer 26

*Elastic component of the bandage *Degree of tension when the bandage is applied ---- Tension on the bandage should approach 50% of the ability of the bandage to stretch *Number bandages applied *Condition of the bandage or garment

Question 27

Law of LaPlace

Answer 27

pressure that is exerted on the tissues from the bandaging system Pressire = tension/radius

Question 28

tension =

Answer 28

is delivered from the bandage system. Each bandage is applied with even tension (same degree of stretch)

Question 29

radius =

Answer 29

the smaller the radius of the limb, the greater the pressure exerted on the tissues

Question 30

padding

Answer 30

* Provides equal compression around the limb * Different forms of padding

Question 31

when does padding need to be applied

Answer 31

* In areas of concavity * In areas to increase the radius of the limb * Any areas of concern for the soft tissues

Question 32

short stretch application

Answer 32

*Apply stockinette over moisturized skin *Pad skin and bony prominences *Apply multiple bandages of varying widths * 6cm, 8cm, 10 cm and 12 cm *Overlap bandages by 50% *Stretch bandage by 50% for even tension

Question 33

pressure gradient

Answer 33

*Pressure should steadily decrease from a distal to proximal direction *Highest pressure is located at the ankle/wrist *Pressure gradient is assessed after application of each bandage *Assess pressure gradient by feeling the stiffness of the bandage system

Question 34

role of compression bandages

Answer 34

to achieve a stable edema reduction of the limb

Question 35

role of compression garments

Answer 35

maintain the treatment results

Question 36

what are compression garments

Answer 36

*Aid in maintaining interstitial fluid homeostasis *Used for management and prevention *Available in custom made or prefabricated varieties *Available in different “classes” (level of compression) *Gradient format design * Distal compression greater than proximal *Should be replaced every 6-9 months

Question 37

compression classes

Answer 37

slide 30

Question 38

exercise

Answer 38

* Aimed specifically at promoting lymphatic flow and reducing swelling * Active, repetitive, resistive or non-resistive motion of the involved body part * Should be performed with compression (bandages or garment) --- Allows the muscle to contract against resistance more effective muscle pump enhancing lymphatic and venous return

Question 39

benefits of exercise

Answer 39

* Reduce fatigue * Increase strength and flexibility * Improve body image * improve overall QoL

Question 40

skin care

Answer 40

*Lymphedema places patients at increased risk ofskin infection *High protein content of lymphatic fluid serves as a medium where bacteria may thrive causing cellulitis *In skin care education, patients learn how to keepthe skin supple and protected from breaks andtears and how and why to use pH-neutral creams or lotions and low pH soaps to discourage bacterial colonization

Question 41

patient education

Answer 41

*Lymphedema is MANAGED, not cured *Lymphedema exacerbations are not uncommon over time *Well managed edema results from adherence withmassage, bandaging, compression and proper skincare *Encourage maintenance of ideal weight *Psychological issues

Question 42

home management

Answer 42

*Self MLD *Self bandaging *Compression garments: day and/or night *Exercise *** lifelong management