Lymphedema Management Flashcards
What is CDT?
Most common treatment for lymphedema.
Currently recognized as the gold standard of care of lymphedema.
2 phases - intensive phase and maintenance phase
What are the goals of the CDT phases?
Intensive Phase - maximum volume reduction and normalization of tissue texture.
Maintenance Phase - maintain volume reduction that was achieved in the intensive phase.
What does intensive phase consist of?
Manual Lymphatic Drainage (MLD)
Compression bandaging
Patient education
Skin care and exercise
What does maintenance phase consist of?
Compression garment fitting
Exercise — really important
Self MLD
Possible maintenance MLD by a qualified provider
Skin care
Instructions in self care
What is Manual Lymphatic Drainage?
Light but very specific hands on technique
Occasionally administered alone but is often part of CDT — NOT intended for a stand alone treatment.
*breast edema shows the most improvement when MLD is performed.
*reduction of subjective symptoms including tension, heaviness, and pain as well as improved QOL
What are the goals of MLD?
- 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
Indications for MLD?
Primary Lymphedema
Secondary Lymphedema
Venous edema
Post traumatic edema
Post surgical edema
What are the contraindications to MLD?
Untreated acute infection
Untreated cardiac edema
Renal edema
Acute DVT — need to be anticoagulated for a minimum of 6 weeks.
Aortic aneurysm
Neck treatment
Abdominal treatment
don’t want to push fluid it wont be able to get through
What are the principles of MLD?
- Patient is positioned comfort, treatment areas are supported, body is appropriately draped.
- Effleurage over area to be treated is used to begin and end treatment
- Pressure is generally light, directed to the superficial fascia tissue layer
- Each stroke has a working pressure ON and a resting pressure OFF stage.
- Each stroke has a spiral component.
What is the working stage?
- About 1 second, stroke needs to be repeated 5-7 times in one area.
- Working stage is directed toward intact lymphatic pathways — toward uninvolved nodes around involved nodes.
What typically begins and ends the treatment?
Abdominal breathing — stimulates the thoracic duct.
What is general sequence of MLD?
- Diaphragmatic breathing
- Treat venous angles
- Intact regional lymph nodes
- Appropriate anastomoses
- Treat extremity from proximal to distal
What are the types of compression?
UE and LE short stretch and long stretch bandages
Una boot or paste bandages
Four layer wrap
Pneumatic compression/compression pumps
Compression garments
What are the purposes of compression therapy?
- 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
What is the first phase of compression therapy (CDT)?
INTENSIVE PHASE
Phase 1 of CDT - compression is done using multi-layered short stretch bandaging
* worn around the clock
* considered in-elastic
What is the second phase of compression therapy (CDT)?
MAINTENANCE PHASE
Phase 2 of CDT — compression is designed to maintain the limb volume achieved in phase 1
— non custom or custom compression garments during the day
— if they need nighttime compression will utilize short stretch bandages or night time compression garments.
Indications for compression
UE/LE lymphedema
Venous edema in LE
Edema from post surgery or post trauma
To shape the residual limb post amputation
Contraindications for compression?
Acute untreated infections
Acute untreated DVT
Untreated cardiac edema
Renal edema
Edema without dx
Precautions for compression?
Cardiac edema
Arterial disease/wounds
DM
Sensory deficits
Paralysis
Altered mental status
Malignancy
Sensitivity to compression products
Inability to perform home management
What is involved with resting pressure during bandaging?
Constant pressure externally applied by the bandage even at rest
Constant pressure may hinder refill of superficial vessels
Highest values achieved with strong, very elastic bandages (ace wrap, 4-layer wrap)
What is involved with the working pressure during bandaging?
Temporary pressure that is generated with muscle contraction
Increases the efficiency of the muscle pump
Highest values achieved with more rigid dressings (short stretch, una boot)
What is a short stretch bandage?
Can be elongated 10-100% of resting length
LOW RESTING PRESSURE + HIGH WORKING PRESSURE
Minimally elastic
Prevent circulatory compromise and tourniquet effect
Minimize fluid re-accumulation
Loses pressure over time
What is a long stretch bandage?
Can be elongated >100% resting length
LOW WORKNG PRESSURE + HIGH RESTING PRESSURE
Highly elastic — ace wrap s
May compromise circulation at rest — esp if pulled too tight
Poor support when muscles are working
Maintain pressure over time
What are the 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
What is the law of laplace?
Pressure that is exerted on the tissues from the bandaging system
Pressure = tension/radius
- Tension = is delivered from the bandage system. Each bandage is applied with even tension
- Radius = smaller the radius of the limb, the greater the pressure exerted no the tissues
Why and where do we use padding?
- padding provides equal compression around the limb
Needs to be applied - areas of concavity
- areas to increase the radius of the limb
- any areas of concern for the soft tissues
How do you apply a short stretch application ?
- Apply stockinette over moisturized skin
- Pad skin and bony prominences
- Apply multiple bandages of varying widths — 6cm, 8cm, 10cm, and 12cm
- Overlap bandages by 50%
- Stretch bandage by 50% for even tension
What is the 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
- should feel more firmness in the lower led and gets squishy as we move up the leg
Bandages vs. Garments
- role of compression bandages is to achieve a stable edema reduction of the limb
- the role of compression garments is to MAINTAIN the treatment results
What is the purpose of compression garments?
- Aid in maintaining interstitial fluid homeostasis
- Used for management and prevention
* should be replaced every 6-9months
What is CCL 1?
Compression class level 1 — family history varicose veins, mild lymphedema, prevention of venous ulcers, DVT prophylaxis, mild venous insufficiency
20-30 mmHG!!!
What are the pressure levels for CCL 2 and 3
CCL 2= 30-40 mmHg
CCL 3= 40-50 mmHg
How does exercise help lymphedema treatment?
- aimed specifically at promoting lymphatic flow and reducing swelling
- active, repetitive, resistive OR non resisted motion of the involved body part
- Should be performed with compression — bandages OR garments
— allows the muscle to contract against resistance = therefore more effective muscle pump enhancing lymphatic and venous return.
Why is skin care important with these patients?
Lymphedema places patients at increased risk of skin infection
High protein content of lymphatic fluid serves as a medium where bacteria may thrive causing cellulitis
- patients learn how to keep the skin supple and protected from breaks and tears and how and why to use pH-neutral creams or lotions and low pH soaps to discourage bacterial colonization
Why is patient education important with these patients?
- Lymphedema is managed not cured
- Lymphedema exacerbations are not uncommon over time
- Well managed edema results from adherence with massage, bandaging, compression, and proper skin care
- Encourage maintainence of ideal weight
- Psychological issues
What is included in home management for these patients?
- Self MLD
- Self bandaging
- Compression garments - day and/or night
- Exercise
** LIFELONG MANAGEMENT **
What are patient goals with lymphedema management?
- Independence in self management including self bandaging, self MLD, exercise, and skin care
- Volume reduction
- Independence in donning and doffing compression garments
- Demonstrate knowledge of how to care for garments and proper wear schedule
- Understanding of the etiology, risk, and risk reduction strategies for lymphedema
- Functional limitations
