Lymphedema Part 2+Quiz Flashcards
1
Q
Review: Lymphatic Vessels
Smallest to largest
A
Lymph Caps→ Lymph precollectors→ Lymph collectors→ Lymphatic trunks→ Lymphatic ducts
*Network runs Distal → Proximal
2
Q
Direction of Lymphatic Network
A
Distal → Proximal
3
Q
Lymphatic Vessels
Lymph Capillaries (smallest)
A
small, thin w swinging flaps→ capable of absorbing macromc’s
4
Q
Lymphatic Vessels
Lymph PREcollectors
A
Oriented vertically; connect lymph caps to deeper lymph vessels; may or may not have valves*
5
Q
Lymphatic Vessels
Lymph Collectors
A
Innervated by SNS; contain valves w/ “lymphangions”→ contract to help move lymph fluid proximally
→ Lymhangiomotoricity
6
Q
Lymph Vessels
Lymphatic Trunks
A
Larger; innervated SNS; contain valves
7
Q
Lymph Vessels
Lymphatic Ducts
LARGEST*
A
LARGEST; transport lymph fluid TO R & L venous angles; RETURN fluid into vascular system
8
Q
Lymph Flow====
A
Distal → Proximal
9
Q
Fluid Transport in the Lymphatic System
IMPORTANT PART***
A
-
NORMAL lymphatic system, in absence of patho:
- Working 1/10 as hard as it is MAXIMALLY capable of working***
10
Q
Link bw Lymphatic & Circulatory Systems, and Edema
A
- Edema→ excess accumulation of interstitial fluid
- Edema is prevented if fluid OUT of capillaries EQUALS amt of fluid ABSORBED by venous & lymphatic capillaries
Edema→ inc’d cap hydrostatic pressure, inc interstitial osmotic pressure, incd venule permeability, overwhelmed lymphatic system
11
Q
Link bw Lymphatic System & Edema
A
- Edema→ persists when lymphatic insuff.
- transport capacity SMALLER vs amt fluid needs to be transported
-
3 types:
- Dynamic (most common*), transient maybe
- Mechanical (something wrong w/ parts)
- Combined
12
Q
Lymphatic Insufficiencies:
Dynamic Insuff.
A
- Amt of fluid (H20 or H20+PRO) needing to be transported (lymph load) EXCEEDS transport capacity of anatomically and functionally intact lymph system
13
Q
Lymphatic Insufficiencies:
Dynamic Insuff.
Causes
A
Cardiac Insuff (CHF), Pregnancy, Immobility, Chronic Venous Insuff.
NOTE: Long-term dynamic insuff. can cause damage to lymphatic system===> Mechanical Insuff.
14
Q
Lymphatic Insufficiencies:
Dynamic Insuff.
Treatment*
A
- Geared towards reducing lymphatic load
- Elevation: med clearance for cardiac insuff.
- Compression: med clear for cardiac insuff.
- Exercise*******
15
Q
Acute Edema due to Trauma, Injury, Inflammation
This would be an ex. of ___________ Insuff.
A
DYNAMIC Insuff.
16
Q
Acute Edema due to Trauma, Injury, Inflammation
A
-
Local edema due to trauma or injury→ NORMAL part of inflammatory process
-
Exudation→ incd permeability and vasodilation of blood vessels→ INCd filtration of fluid and PROs into interstitium surrounding injured area
- Goal: bring PROs and circulating cells TO site of injury
-
Exudation→ incd permeability and vasodilation of blood vessels→ INCd filtration of fluid and PROs into interstitium surrounding injured area
- Once cause of injury removed, normal healing takes place, tissues return to normal size and structure, edema resolves
17
Q
Lymphatic Insuff
Mechanical Insuff (something wrong w/ parts)
A
- Reduced transport capacity due to functional or anatomical deficits in the lymphatic system
- cannot manage normal or inc’s in lymph load
18
Q
Lymphatic Insuff
Mechanical Insuff (something wrong w/ parts)
Functional and/or anatomical deficits caused by:
A
- Sx
- lymph node dissection, sx interferes w/ lymph system due to scar tissue or removal lymph caps
- Radiation Tx
- scar/fibrosis of tissue and lymph vessels
- Trauma to lymph vessels
- long term lymphedema, valvular insuff, lymph stasis, lymph fibrosis
- Congenital/Genetic factors, inflammation, infx/parasite
19
Q
Lymphatic Insuff
Mechanical Insuff (something wrong w/ parts)
Treatment:
A
Complete Digestive Therapy (CDT)
20
Q
Lymphatic Insuff’s
CHART*
A
Just know Dynamic and Mechanical***
21
Q
Lymphatic Insuff’s
Dynamic
Broken down into simpler facts
A
- Anatomically and functionally INTACT lymph system
- Lymphatic Load > Transport Capacity (TC)
- Tx: Elevate, Compression, Exercise
- MLD NOT effective*
22
Q
Lymphatic Insuff’s
Mechanical Insuff.
Broken down
A
- Anatomically and/or functionally NON-intact lymph system (structurally different)
- TC < Norm lymphatic load
- Tx: Complete Decongestive Tx, MLD, Compression, Exercise**
- Avoid cond’s that inc net filtration
23
Q
Lymphedema is now considered to be a _____________________
A
Chronic, Inflammatory disease
24
Q
What is Lymphedema?
Def. #1
A
Swelling of soft tissues that results from the accumulation of PRO-rich fluid in the extracellular spaces.
Caused by DEC lymphatic transport capacity and/or INC lymph load and is most commonly see in the extremities, but can occur in head, neck, abdomen, genitals
25
What is Lymphedema?
Def #2:
When collection of PRO-rich fluid persists in specific area, it can attract more fluid and thus worsen swelling.
**In addition to INCd fluid in area, body experiences an inflammatory rxt resulting in _scar tissue_ called _fibrosis_ in the affected area**
***Tell-Tale Sign→ Darker spots (fibrosis/scar tissue)*****\*\*\***
26
Primary vs. Secondary (seen more commonly) Lymphedema
see chart and note highlighted areas
27
Primary Lymphedema
## Footnote
**Etiology and Assocd W/:**
* **Etiology:**
* **“Lymphangiodysplasia”→** developmental abnorm in lymphatic system
* Hypoplasia→ less vessels (# or size)
* Hyperplasia→ greater than normal # or size of vessels
* **Assocd MOST w/:**
* Classified by **age of onset**
28
Secondary Lymphedema (seen more commonly)
## Footnote
**Etiology and Assocd W/:**
* **Etiology:**
* Lymph. sytem develops normally, and lymphedema develops **due to 2\* causes**
* **Assocd MOST w/:**
* CVI
* Lymph node dissection & Cx
* breast, head, neck, melanoma, Genito-urinary
* Under-developed countries, **filariasis infx**
29
**Primary** Lymphedema
## Footnote
**Milroy's Disease (Nonne-Milroy-Syndrome)**
**important stuff**
* **Congenital (appears @ birth)**
* Boys\>girls
* One leg and/or one arm and/or face and/or genitals
* **Type I congenital hereditary lymphedema**
30
**Primary** Lymphedema
## Footnote
**Meige's Syndrome**
* **Presents @ _puberty_**
* Girls \> Boys
* Hormonal?
* **U/L LE**
* **Type II NON-congenital hereditary lymphedema**
* **Lymphedema Praecox (occurs before 35yo)**
31
**Primary** Lymphedema
## Footnote
**Lymphedema Tardum**
* **AFTER 35yo**
* MAYBE B/L
32
**Primary Lymphedema**
**3 types:**
1. Milroy's Disease (Nonne-Milroy-Syndrome)
1. **Congenital (@ birth)**
2. **one leg and/or one arm and/or face and/or genitals**
2. Meige's Syndrome
1. **@ Puberty**
2. **U/L LE**
3. Lymphedema Tardum
1. **AFTER 35yo**
2. **maybe B/L**
33
**Secondary** Lymphedema
## Footnote
**Primary cause?**
Filariasis
\*mosquito-born parasite Filaria
34
**Secondary** Lymphedema
## Footnote
**Primary vs Secondary Causes**
* **Primary→ Filariasis**
* Indigenous peoples
* **Secondary→** Cx and comps from Cx and tx
35
**Secondary** Lymphedema
## Footnote
**Western Hemisphere and Developed Countries**
2\* effect from Sx or radiation due to Cx & lymph node dissection
* Chronic venous insuff.
* Trauma to lymph tissue
* Self-induced lymphedema
36
#1 cause of **LE Edema IN GENERAL……**
VENOUS DISEASES
37
Venous Diseases & Edema
* **#1 Cause of LE edema in general\*\*\*\***
* **Common cause of _Secondary_ Lymphedema**
* DVT, Varicose Veins, Chronic Venous Insuff. w/ Hemosiderin Staining
38
Venous Diseases
## Footnote
**#1 Cause of LE Edema**
**Characteristic Chart**
See Chart
\*Just KEEP READING IT!!!!
39
Venous Diseases→ #1 cause LE edema
* Asymptomatic, dull ache, tight feeling
* U/L, sudden onset
* Tenderness or pain in calf
* Leg or calf swelling
* Dilation of superf. veins
* Pitting edema
* Warm, red
* Hx of trauma, immobility, cx, post-sx, genetic predispo.
DVT
40
Venous Diseases→ #1 cause LE edema
* Asymptomatic, Gradual dull ache
* Heaviness, tension, fatigue
* Sx's INC w/ standing
* Elevation provides relief
* Cramping→ esp @ night
* Skin changes/Hemosiderin staining
* Thinning of skin
* Can result blood clots, phlebitis, ulcers
Varicose Veins
41
Venous Diseases→ #1 cause LE edema
* Sx's INC in standing- painful, burning, throbbing, sudden onset
* Progressive edema may be severe
* Hemosiderin staining→ brown discoloration due to breakdown HgB
* Venous stasis ulcers
* Thinning of skin or thickening
* Fibrosis of tissue
* Dermatitis or cellulitis
* May lead to lymphedema (venous system cannot mng fluid load, and lymph system overwhelmed)
Chronic Venous Insuff
42
**Lymphedema**
## Footnote
**Gen Characteristics→**
* SLOW onset, starts **distally**
* Asymmetrical/U/L
* Cellulitis common SE
* **Early→ Pitting Later→ Fibrosis**
* No pain, but achy, heavy
* Ulcerations not common unless w/ CVI
43
Whats the big deal about swelling?
## Footnote
**SEs acute/chronic edema**
* Impaired mobility of pt and/or body segment→ **impaired function**
* **INCd pain**
44
Whats the big deal about swelling?
## Footnote
**SEs acute/chronic edema**
**Impaired delivery of nutrients to tissue and impaired ability to remove waste products**
More edema in interst. space==\> lg dist bw blood vessels and tissue==\> delivery of nutrients and removal of waste diff.
45
Whats the big deal about swelling?
## Footnote
**SEs acute/chronic edema**
**Risk of converting acute or vascular edema into _lymphedema or phlebolymphedema_**
Skin and tissue fibrosis
Dermato. cond's
INCd risk infx (cellulitis)
46
2\* Tissue Change
## Footnote
**Fibrosis**
**Collagen** produced as norm resp. to inflamm. **In lymphedema→ OVERproduction of collagen**
* Tissue becomes→ firm, indurated, NON-pitting
* May be direct result:
* chronic edema
* radiation
47
2\* Skin Changes
## Footnote
**Hyperkeratosis**
**Overly thickened epidermis**
* Occurs in presence of **lymph stasis**
* Wart like, hard calluses, Lichenization (see pics)
* Starts @ toes
* Meticulous skin care, Rx ointments
48
2\* Effects of Lymphedema: **Cellulitis**
## Footnote
**KNOW THIS ONE!!!!!!**
**Due to:**
* \*Cellulitis **NOT correlated w/ _amt of edema_**
* **Due to:**
* Local bacteria/viral infx (cut/scrape, bug bite)
* Presence of PRO-rich fluid
* Moist warm environ.
* Dmg to lymph. system→ immune syst. deficit
49
2\* Effects of Lymphedema: **Cellulitis**
## Footnote
**KNOW THIS ONE!!!!!!**
**S/S**
* _Expanding_ reddened area, Pain, warm/hot touch, fever, **gen feeling of being sick**
50
2\* Effects of Lymphedema: **Cellulitis**
## Footnote
**KNOW THIS ONE!!!!!!**
**Tx:**
* **Antibx therapy**
* **\*NOTE:** Pts w/ **chronic lymphedema** often provided Rx for antibx, **and are instructed to** ***begin tx immediately upon _suspicion of cellulitis_, and call PCP immediately!***
51
Evaluation of Pt w/ Lymphedema
## Footnote
**Hx of Present Illness**
see pics
52
Evaluation of Pt w/ Lymphedema
## Footnote
**PMH**
see pics
53
Evaluation of Pt w/ Lymphedema
## Footnote
**Social Hx and PLOF**
see pics
54
Evaluation of Pt w/ Lymphedema
## Footnote
**Examination**
**NOTE: NO sharp/dull→ do not want to risk breaking skin\*\*\*\*\***
**Functional status→ Transfers-ESP _sit-to-stand_\*\***
**see pics**
55
Evaluation of Pt w/ Lymphedema
## Footnote
**Examination**
**Integumentary\*\*\* KNOW IT!!!**
* **Tissue texture:**
* Soft/firm/spongy/fibrotic
* **Tissue appearance:**
* Dry/Weeping/Thin/Shiny
* Discoloration/Hemosiderin staining/reddening/cyanotic
* **Presence abnorm tissue:**
* Hyperkeratosis/papillomas/cysts
* **Infx's:**
* Cellulitis/fungal
* **Presence open wounds:**
* Venous/Arterial
* **Redundant tissue:**
* Must remember to examine **beneath/in-bw skin folds\*\*\*\***
56
Pitting Edema Scale
## Footnote
**Characteristics to look @:**
* Some based on **depth of indentation** following fingertip pressure
* Some based on **length of time indentation remains** following fingertip pressure
57
Staging of Lymphedema
\_\_\_\_\_\_\_\_\_\_\_ are the most **distinguishing criteria for _Staging lymphedema_**
Tissue changes\*\*\*
## Footnote
**NOTE: _volume of limb_ DOES NOT determine stage**
58
Staging of Lymphedema
Helps to what?
Classify **progression of dis. process**
59
Staging of Lymphedema
## Footnote
**Applies only to 2 areas: _____ and \_\_\_\_\_**
Arms and Legs
60
Staging Lymphedema
## Footnote
**Stage #s**
* **Stage 0→ Latent Lymphedema**
* **Stage 1**
* **Stage 2**
* **Stage 3**
61
Stages of Lymphedema
## Footnote
**From Patho book**
**ALL FIRST**
* **Stage 0 (Latent or Pre-Clinical Lymphedema)**
* Lymph transport capacity reduced; **no clinical edema present**
* **Stage I→ Spontaneously Reversible**
* Accumulation of pro-rich, pitting edema
* reversible w/ elevation; area affected may be norm size upon waking in morn.
* Incs w/ activity, heat, humidity
* **Stage II→ Spontaneously Irreversible**
* Accumulation of pro-rich NONpitting edema w/ connective scar tissue
* Irreversible; does NOT resolve overnight; inc'ly more difficult to pit
* Clinical fibrosis present
* Skin changes present in **severe stage II**
* **Stage III (Lymphatic Elephantiasis)**
* Accumulation pro-rich edema w/ sig inc in connective and scar tissue
* Severe NONpitting fibrotic edema
* Atrophic changes (hardening of dermal tissue, skin folds, skin papillomas, hyperkeratosis)
62
Staging Lymphadema
## Footnote
**Stage 0 (Latent Lymphedema)**
LTC (lymph transport capacity) reduced; **no clinical edema present**
63
Staging Lymphedema
## Footnote
**Stage I**
* Accumulation pro-rich, **pitting edema**
* **Reversible w/ _elevation_;** area affected may be norm size upon waking up in morning
* INCs w/ activity, heat, humidity
64
Staging Lymphedema
## Footnote
**Stage II (now nonpitting)**
* Accumulation of pro-rich, **NONpitting edema** w/ **connective scar tissue**
* **Irreversible;** does NOT resolve overnight; inc'ly MORE diff to **pit**
* **Clinical fibrosis** present
* Skin changes present in **severe stage II**
65
Staging Lymphedema
## Footnote
**Stage 3 (Lymphostatic Elephantiasis) (more scarring now)**
* Accumulation of pro-rich edema **w/ sig. inc connective and scar tissue**
* Severe **nonpitting fibrotic edema**
* **Atrophic changes→** hardening of dermal tissue, skin folds, skin papillomas, **hyperkeratosis)**
66
Stemmer Sign **typ appears in Stage \_\_\_\_\_\_**
2!!!
67
The Stemmer Sign
## Footnote
**Typ Stage II (nonpitting edema now)**
Try to lift skin on dorsum of fingers/toes
* **(+) Sign:** skin can NOT be lifted, or only lifted w/ **difficulty** compared to uninvolved side
* **Indicates presence of Lymphedema**
* **(-) Sign:** skin CAN be lifted w/out diff.
* **Does NOT R/O lymphedema\*\*\***
68
Stages of Lymphedema
## Footnote
**Simonds Chart from lecture\*\*\***
See chart
69
Stages of Lymphedema
## Footnote
**\*Simonds Chart**
**Stage 0 (Latent or Pre-Clinical Edema)**
* Indicates @ risk for dev. lymphedema
* LTC reduced, but still capable of managing lymph load
* NO edema present
* Bioimpedance MAY detect presence of edema
* May remain in stage 0 indef, or progress
* **Goal→** Risk reduction
70
Stages of Lymphedema
## Footnote
**\*Simonds Chart**
**Stage 1 (Spontaneously Reversible)**
* Swelling→ visible, **pitting**; pro-rich fluid
* **Elevation w/ reverse edema (temporary)**
* **Swelling may go away overnight**
* Swelling returns w/ limb in **dep. pos.**
* Tissue soft and NO fibrotic changes
71
Stages of Lymphedema
## Footnote
**\*Simonds Chart**
**Stage II (Spontaneously Irreversible)**
* **Fibrosis present**
* **Pitting more diff.**
* **Stemmer Sign is (+)**
* Vol. of swelling is INCd
72
Stages of Lymphedema
## Footnote
**\*Simonds Chart**
**Stage III (Lymphostatic Elephantiasis)**
* Giant fibrotic changes\*\*\*, incd fibrosis
* **Thickened, INelastic skin**
* NO PITTING
* Add. skin changes→ hyperkeratosis, papilloma, cysts, skin folds deepen
* Incd chance recurrent **infx**
73
Measures of Edema→ **Circumferential Measures**
Measure in cm, along length of extremity (every 5-10cm)
Involved vs Uninvolved
74
Measures of Edema
## Footnote
**Volumetric/Water Displacement**
* Place known vol. of water in receptacle
* Submerge body part/segment
* Meaure water displacement.
75
Bioimpedance Analysis (BIA)
Non-invasive
* Measures body comp based on electrical conductive props of diff body tissues
* Can detect inc fluid lvls in body part BEFORE visible or measurable
* **early detection of lymphedema**
76
Measures of Edema- Bioelectric Impedance (Bioimpedance)
* Determines electrical impedance, or opposition to flow of electric current thru body tissues which can then be used to calc measure of ECF in limb being assessed
* **Current flows more quickly thru fluid**
* **More liquid→ faster current travels\*\*\***
77
Imagining for Lymphedema
Lymphoscintigraphy
78
Measures of Edema- Perometry (Optoelectronic Volumetry)
Assess size and composition of limb
* Placed into vertically or horizontally oriented frame
* Limb volume, %diff bw selected measurements, contour, cross-sectional area displayed
79
Measures of Edema-
## Footnote
**Photography**
Correlate w/ measurements
Self-explanatory→ take pics
CONSENT\*\*\*\*
80
Treatment for Lymphedema=\_\_\_\_\_\_\_
CDT (Complete Decongestive Therapy)
81
Treatment for Lymphedema
## Footnote
**CDT**
**4 Components:**
1. Skin Care
2. Manual Lymph Drainage (MLD)
3. Compression (Bandaging and/or garments)
4. **Exercise\*\*\***
82
Lymphedema
## Footnote
**Tx Concepts and Approaches**
**2 Notes:**
1. **ANY lymphedema tx tech. can be used for other types of edema**
**BUT….**
2. **Tx techs for other types of edema ARE NOT RECOMMENDED for use w/ lymphedema\*\*\***
83
Complete Decongestive Therapy (CDT)
## Footnote
**2 Phases of Care**
* Phase 1→ **Decongestion**
* Phase 2→ **Maintenance**
## Footnote
**See pics for components of ea.**
84
Complete Decongestive Therapy CDT
## Footnote
**Phase 1: Decongestion**
**GOALS:**
1. Vol. reduction by mob'ing lymph fluid
2. Improve tissue texture
3. Improve ROM and functional ability
4. Pt edu→ skin care, risk reduction, bandaging, exercise
**NOTE: proceed to phase 2 when max. dec in vol./ bennies achieved**
85
Complete Decongestive Therapy CDT
## Footnote
**Phase 2: Maintenance**
**GOALS:**
* Maint. of phase 1 achievements
* Compression garments, Self-MLD
* Further reduction volume
* Further improve. tissue texture
* Pt edu→ all aspects of self care
86
Complete Decongestive Therapy
## Footnote
**Precautions**
* Malignancy
* **may be indicated if palliative**
* Cardiac Hx & HTN
* **avoid MLD to neck**
* Bronchial asthma
* **MLD may induce asthma attack**
* Acute DVT
* **avoid affected limb until therapeutic. anticoag'd**
* Pregnancy/Dysmenorrhea→ CANNOT undergo CDT\*
* Hyperthyoid
* **avoid neck**
* Abdom sx/inflammatory cond's of GI/Abdom Aortic Aneurysm
* **avoid abdomen**
87
Complete Decongestive Therapy (CDT)
## Footnote
**Contraindications (DO NOT DO)**
* Cardiac edema
* Cellulitis (until tx'd)
* Atherosclerosis
* **avoid MLD to neck**
* Renal failure
* **need phys. clear.**
* Arterial Insuff.
88
CDT→ **Skin Care**
## Footnote
**KEEP SKIN:**
Clean, dry, moisturized, intact\*
## Footnote
**CDT can be performed in presence of wounds/skin probs as long as tx'd and monitored\***
89
CDT→ **Manual Lymph Drainage (MLD)**
## Footnote
**What IS it?**
* Lt, manual massage w/ specific strokes to stim. lymph vessels and/or tissue
* Firm/specialized/standard tech's in areas of **fibrosis**
90
MLD
## Footnote
**Effects of MLD**
* INC in **lymph production**
* does not mean inc in edema, means more fluid taken up from tissue into lymph system\*
* INC in **lymphangiomotoricity**
* inc lymph transport into Central venous system
* Reverse or divert **lymph flow**
* circumvent lymph away from and around dmg'd vessels
* INC **venous return**
* **Diuretic effect\***
* inc need to urinate
* **Analgesia**
* transport of noxious subs. AWAY from tissue\*\*\*
91
MLD
## Footnote
**Summary…**
MLD INCs **uptake and transport of….**lymph loads and becomes **primary route for LG mc's to exit involved tissue.** Compression alone does NOT stim lymphatic system. Special techs used in MLD INC interstitial fluid uptake into lymph cap. network. This filling force along w/ **stretch stim of skin traction** raises intravascular pressure and peristalsis of lymph collectors, trunks, and ducts. **Ultimately, lymph fluid empties into blood circulation causing area for more absorption along continuum.**
92
CDT→ **Compression**
## Footnote
**Broken into subtopics**
**Goal/Obtained by use of:**
* **Goal:**
* Facilitate and/or maintain Vol. reduction of the body part
* Prevent **re-accumulation of fluid**
* **Compression obtained by using:**
* Short stretch bandage
* Compression garments
* Compression **pumps**
93
CDT→ **Compression**
## Footnote
**Broken into subtopics**
**Physical Effects:**
* INCd pressure in tissue, INCd pressure on lymph/blood vessels
* DECd cap. filtration
* INCd venous and lymph return
* INCd effect of **muscle pump action** during **exercise/activity**
* Helps break up and soften fibrosis in tissue
* Support for tissues **that have lost elasticity**
94
CDT→ **Compression**
## Footnote
**Broken into subtopics**
**Correct Application:**
* Apply **MORE bandage layers _DISTALLY_ vs proximally\***
* **Pressure→ \> DISTALLY vs proximally\***
* Assists fluid mvmt→ DISTAL to proximal direction\*
* Prevents re-accumulation of fluid in extremity\*\*\*\*\*
95
CDT→ **Compression**
## Footnote
**Broken into subtopics**
**External Support of involved limb (via compression) ALWAYS necessary due to:**
* Loss of elasticity in skin as result of perm. dmg from edema
* Perm dmg to lymph vessels
* Likelihood of lymphedema reoccurrence
96
Compression Pressures
Ex's
* MUST be **GREATEST _Distally_** and gradually **DEC proximally**
* **Incorrect== complications**
97
Compression Bandages
## Footnote
**2 MAIN Types:**
Short Stretch vs. Long Stretch
98
Compression Bandages:
## Footnote
**Short Stretch**
Used for **_management_ of lymphedema**
99
Compression Bandages:
## Footnote
**Long Stretch**
NOT used for mgmt of Lymphedema
100
**Working and Resting Pressures** of Compression Bandages
* **Working→** amt pressure exerted by bandage on the tissue **while mm's and joints _Actively_ moving\***
* **Resting→** amt pressure exerted by bandage on tissue **when mm's and joints are @ _Rest_**
101
Long vs. Short Stretch Compression Bandages
## Footnote
**Which should you try FIRST????**
SHORT-STRETCH!!!
102
**Long vs. Short Stretch Compression Bandages**
**Long Stretch + Ex's**
Ex. ACE bandage
* Elasticity→ provided by weaving latex OR elastic fibers thru bandage
* **Have a LOW _working_ pressure**
* mm contracts→ bandage stretch
* **Have HIGH _resting_ pressure**
* **NOT suitable for lymphedema mgmt\*\*\***
103
**Long vs. Short Stretch Compression Bandages**
**Short-Stretch**
**\*TRY FIRST!!!**
* Elasticity→ occurs as result of cotton weaving method
* **Provide HIGH _Working_ pressure**
* **mm contracts→ bandage does NOT stretch much to accommodate**
* **Very LOW _Resting_ pressure**
* risk dmg to tissue and vessels LOW
* **Suitable for use w/ lymphedema mgmt\*\*\*\***
104
Bandaging Technique and Materials
## Footnote
**GOALS:**
* Create **proper pressure gradient**
* Insure pt can **remain functional** while wearing bandage
* Bandage must be **comfortable**
* Bandage must be **durable** in order to remain **in place bw PT sessions\*\*\***
**See pics for Compression Bandaging Ex's \*\*\***
105
Transitioning to **Compression Garments**
* Once **reduction in limb has been achieved→ bandaging DIScontinued and Garments ordered**
* bandaging may continue when not wearing garments, or during exacerbation
* Most likely worn t/o life
* **Prophylactically to prevent edema e.g. when on airplane**
**Must be _fitted properly_!!!**
106
Compression Garments:
## Footnote
**Things to Consider:**
* Compression lvl needed (mmHg)
* Day/Night time
* Style, Custom vs ready to wear
* Flat knit vs circular
* **Pts ability to don/doff indep.**
* Function when wearing
* Cosmesis, cost, compliance\*
107
Compression Garments:
## Footnote
**Daytime**
* **Need to:** be more cosmetically acceptable, allow full ROM and activity, fit underneath clothes
108
Compression Garments
## Footnote
**Nighttime**
* Alleviates→ need for compressions @ night
* Bulky
* Night time so do not need to be comsetic. pleasing or fit under clothes
109
Compression Garmnents
## Footnote
**Ready to Wear:**
Several sizes/lengths, fit best on proportional and reg. shaped limbs, less $$$, quicker to obtain
110
Compression Garments
## Footnote
**Custom Made**
Best for **irregularly shaped limbs, PRECISE measurements needed\*,** more $$$, easier to don/doff
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Compression Garments
## Footnote
**2 types:**
1. Flat Knit
2. Circular Knit
112
Ex's of Variety of **UE Compression Garments**
Arm sleeve, Glove, Gauntlet
113
Ex's of a Variety of **LE Compression Garments**
Sock, Foot, Knee high, Thigh high, Leggings, Bike shorts, Pantyhose
114
Compression Garments
## Footnote
**Function, Cosmesis, Compliance, Cost**
* **Function**: pt should be able to maint. highest functional lvl
* **Cosmesis:** If not cosmetically acceptable, won't wear (think back to P&O!!!!)
* **Compliance:** Essential for mgmt
* cosmesis, ease don/doff, comfort, functional ability while wear
* **Cost:** Prices vary
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Compression **Pumps**
## Footnote
**AKA: Pneumatic compression, Mech. Compression, and/or Intermittent Pneumatic Compression**
* Utilizes sleeves that fills w/ air to predetermined amt pressure
* NEWER→ mult. chambers inflate sequentially (**distal→proximal) ==\> “milking” type of compression**
* **\*\*\*Mechanical intermittent compression remains controversial**
* lymph may leave distal extremity but pool in prox. segments
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**Exercise and Lymphedema\*\*\***
**In general…**
* Exercise is **key component** in Tx of Lymphedema!!!
* **Regain:** Strength, endurance, ROM
* **Facilitates:** Fluid uptake while wearing compression bandage by INC **working pressure** of bandage, Wt reduction in overWt./Obese pts
* Improves mood, outlet for socialization\*\*\*
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**Exercise and Lymphedema\*\*\***
During **Intensive phase of lymphedema mgmt:**
Ex's generally **remedial in nature** during this phase
118
**Exercise and Lymphedema\*\*\***
**Can progress to _Resistive Exercises\*_**
Undertaken _gradually_ in order to _prevent_ worsening of lymphedema
119
**Exercise and Lymphedema\*\*\***
**Aerobic exercise + Types**
Helps to reduce edema by **INCing flow of lymph\*\*\***
* Swimming/Water walking
* **INCd pressure exerted by water**
* **avoid if skin not intact\***
* Yoga
* **flexibility inc, facilitates: deep breathing, postural alignment**
* Pilates
* **Core strength**
* Return to PLOF is goal for most active pts\*\*\*
* **Self-monitor for improvement/worsening= KEY\***
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**POC→** CDT
## Footnote
**Ideally vs Realistically**
* **Ideally,** pts _should_ be seen for CDT **5x/week**
* compression bandaging worn 24hr/d
* compression bandage removed **daily**
* wash/hang dry
* skin washed daily bw wrapping\*
* **Realistically,** pts are seen for CDT **2-3x/wk**
* compression bandaging worn 24hr/d
* compression bandaging removed **_just before_ next tx session or _during_ tx session**
* Skin washed bw bandaging
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**POC-CDT**
**Delineate time frames and Tx Plan**
**Example Cont'd…**
* Pt will be seen 3x/wk for 4wks
* MLD to RLE towards R. axilla and L inguinal lymph nodes
* Skin care\*
* Compression bandaging→ R. toes, foot, leg, and thigh using gray foam in add. to short-stretch bandage
* TherEx, gait training, stair training
* Assess. for compression garments when volume red. achieved
* Pt Edu→ skin care, risk reduction, self-MLD, self-bandaging, HEP, use and care of compression garments
* Drivers training program prn
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Lymph Caps are _______ in diameter vs blood caps
LARGER
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**Both** lymph caps AND blood caps carry ______ and \_\_\_\_\_\_
RBCs; WBCs
124
Which Stage of lymphedema?
## Footnote
**Elevation of the edematous limb will _alleviate_ or _resolve_ swelling in Stage\_\_\_\_**
Stage 1\*\*
125
Malignancy is NOT a **contraindication of CDT**
## Footnote
**T/F???**
TRUE!!!
## Footnote
**Malignancy is NOT a contraindication of CDT**
126
Reverse or Direct Lymph flow is an effect of \_\_\_\_\_\_\_
MLD
