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
