Lymphedema Management Flashcards
what is complete decongestive therapy
- Most common treatment for lymphedema
- Currently recognized as the “gold standard” of care of lymphedema
two phases of CDT
intensive phase
maintenance phase
intensive phase
- Goal: maximum volume reduction and normalization of tissue texture
- Consists of manual lymphatic drainage (MLD), compression bandaging, patient education, skin care and exercise
maintenance phase
- 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
goals of manual lymphatic drainage
- 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
is MLD intended to be stand alone treatment?
- no
- often part of CDT
- breast edema shows the most improvement when MLD is performed
reduced subjective symptoms after MLD
- tension
- heaviness
- pain
- QOL
indications of MLD
- Primary lymphedema
- Secondary lymphedema
- Venous edema
- Post traumatic edema
- post-surgical edema
contraindications of MLD
- Untreated acute infecƟons
- Untreated cardiac edema
- Renal edema
- Acute DVT
- Aortic aneurysm
- Neck treatment
- abdominal treatment
principles of MLD
*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
working stage of MLD
- about 1 second
- repeated 5-7 times
- always directed toward intact lymphatic pathways (towards uninvolved nodes, around involved nodes_
what begins and ends MLD and why
abdominal breathing to stimulate thoracic duct
MLD general sequence
treat venous angles
regional lymph nodes
appropriate anastomoses
treat extremity from proximal to distal
types of compression
*UEand LE short stretch and long stretch bandaging
*Unna boot or paste bandages
*Four layer wrap
*Pneumatic compression/Compression pumps
*Compression garments
what does compression therapy do?
*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
compression therapy: phase I
In Phase I of CDT, compression is done using multi-layered short
stretch bandaging
compression therapy phase II
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
compression indications
- 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
compression contraindication
- Acute untreated infections
- Acute untreated DVT
- Untreated Cardiac Edema
- Renal edema
- Edema without diagnosis
compression precautions
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
review guidelines for compression therapy slide 19
resting pressure
- 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)
working pressure
- 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)
short stretch bandage
- 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
long stretch bandage
- 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
determinants of compression
*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
Law of LaPlace
pressure that is exerted on the tissues from the bandaging system
Pressire = tension/radius
tension =
is delivered from the bandage system. Each bandage is applied with
even tension (same degree of stretch)
radius =
the smaller the radius of the limb, the greater the pressure exerted on
the tissues
padding
- Provides equal compression around the limb
- Different forms of padding
when does padding need to be applied
- In areas of concavity
- In areas to increase the radius of the limb
- Any areas of concern for the soft tissues
short stretch application
*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
pressure gradient
*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
role of compression bandages
to achieve a stable edema reduction of the limb
role of compression garments
maintain the treatment results
what are compression garments
*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
compression classes
slide 30
exercise
- 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
benefits of exercise
- Reduce fatigue
- Increase strength and flexibility
- Improve body image
- improve overall QoL
skin care
*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
patient education
*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
home management
*Self MLD
*Self bandaging
*Compression garments: day and/or night
Exercise
** lifelong management
