Modalities

Question 1

What is Complete decongestive therapy?

Answer 1

It is a generalized term for 2 phases of treatment. These phases are composed on Phase 1- Treatment phase (MLD, Compression bandages, exercise, Meticulous skin care) and Phase 2- Self Management phase (Continuous bandaging or compression, exercise, skin care, MLD as needed)

Question 2

What is Manual Lymph Drainage?

Answer 2

Improves lymphatic flow by guiding around blockages for removal. Lie supine with affected side elevated Central areas and uninvolved proximal nodes are cleared first Light and gentle stroke DISTAL TO PROXIMAL starting at the most proximal aspect of extremity first. (Move fluid towards abdomen)

Question 3

What are the 2 kinds of compression?

Answer 3

Short stretch bandages (Comprilan) and Long Stretch Bandages (ACE) Short stretch High working pressure, low resting pressure. Stretches 60% of resting length. Long stretch bandages low working pressure with high resting pressure. Cuts off lymph flow

Question 4

Importance of compression…

Answer 4

50% of edema reduction is equated to proper compression post MLD. Bandages are primarily used in CDT phase 1 but will mostly be used only at night in phase 2. Graded compression (distal>proximal) In Phase 1 use prefab because limb will be changing sizes. In Phase 2, use custom

Question 5

Pneumatic compression

Answer 5

NORMAL RANGE 20-60psi (30-40mmHg UE, 40-50mmHg LE) DANGER ZONE is 70-100mmHg that will damage lymph vessels in as few as 3-5 minutes

Question 6

What are exercise guidelines for patients with Lymphedema?

Answer 6

NEVER perform without compression DO NOT DO isometric holds, overhead resistance, and heavy weight AVOID eccentric based exercises, DOMS, and high impact. Always exercise the proximal musculature first and trunk comes before extremity. Gradual progression Always monitor girth of affected extremities during exercises

Question 7

Stages of edema?

Answer 7

1+=2mm quick rebound

2+=2-4mm and up to 15 sec rebound

3+=4-6mm and up to 30 sec rebound

4+=6-8mm and greater than 30 sec rebound

Question 8

Ankle Brachial Index

Answer 8

>1.2 Falsely elevated, arterial disease, diabetes

0. 95-1.19 Normal
1. 75-0.94- Mild arterial disease+intermittent claud
2. 50-0.74- Moderate arterial disease, pain at rest

<0.5- Severe arterial disease

Question 9

What is Buerger’s Test used for?

Answer 9

Arterial Sufficiency.

Assesses for when the foot becomes when lying down in a supine position.

Up to 90 degrees- Remains pink in color-NORMAL

15-30 degrees (for 30-60 sec) becomes pale- POSITIVE for Ischemic leg

<20 degrees- becomes pale (SEVERE ischemia)

Question 10

What is the rubor of dependency test?

Answer 10

Assesses for arterial insufficiency

Color at the sole of the foot during elevation

When patient is in supine, patient’s leg is brought to 60 degrees for 1 min

Sole should remain pink- but insufficiency= progresses to purple-red or bright red

Also put patient in sitting or dependent position, for color to return to normal, that is a normal result. Color to BRIGHT RED INDICATES AI.

Question 11

Capillary Refill Test

Answer 11

Squeeze and blanch the toe for 5 seconds. Release the pressure and count the seconds.

Normal= Equal or less than 3 seconds

Question 12

Compression with Insufficiency?

Answer 12

No compression when ABI is <0.5

OR

VERY LIGHT compression (12-25mmHg for moderate insufficiency)- close involvement of practitioner

Question 13

Interventions for AI?

Answer 13

Smoking cessation- FIRST THING YOU ADDRESS on NPTE

Regular and Graded Exercise (Basic ACSM guidlines), 3/4 claudication pain scale, 40-60% HRR, 15 min per day progress 5 min biweekly

Weight Control

For wounds- Hydrogels, wet to dry dressings, foam

Question 14

What are venous insufficiency interventions?

Answer 14

Most important therapeutic measure for venous leg ulcers is COMPRESSION. Then mobility exercise, positioning, avoidance of aggravating positions or activities

With mixed arterial/venous disease, the most severe pathology is treated first

Compression includes short stretch bandaging too, but with 20-40mmHg**

Question 15

Venous Wounds Interventions?

Answer 15

Hydrogels - Foam - Calcium Alginates - Silver Impregnated gauze (infection)

Question 16

Wagner Ulcer Classification Scale?

Answer 16

Neuropathic ulcers are staged using Wagner’s.

Grade 0- Preulcerative lesion, healed ulcers, presence of bony deformity

Grade 1- Superficial Ulcer without subcutaneous tissue involvement

Grade 2- Penetration through sub Q tissue. Exposing bone, ligament, etc

Grade 3- Osteitis, abscess, or osteomyelitis

Grade 4- Gangrene of digit

Grade 5- Gangrene of foot requiring disarticulation

Question 17

Skin Cancer Grading System?

Answer 17

ABCD

ASYMMETRY- Uneven edges, lopsided in shape, one half unlike the other

BORDER- irregularity,irregular edges, scalloped or poorly defined edges

COLOR- black, shades of brown, white, blue

DIAMETER- Larger than a pencil eraser

Question 18

Treatment principles for burns:

Answer 18

Basic treatment principles of burn wounds are directed at: 1. Managing or preventing infections 2. Wound closure 3. Ensuring mobility* 4. Preparing patient for surgery*

Question 19

Treatment principles for burns: Superficial Thickness

Answer 19

Application of a moisturizer

Provide an environment that encourages re-epithelialization

Healing 2-5 days

Question 20

Treatment principles for burns: Superficial Partial and Deep Thickness

Answer 20

Prepare patient for primary intention (approximation) by - debriding necrotic or non-viable tissue (blisters?) - tap water can be used to keep the wound clean - If there is concern about infection, we can use antimicrobial or antibacterial ointments/creams

-Cover the wound with mesh gauze impregnated with petroleum jelly with a secondary plain gauze dressing (adaptive wound).

Question 21

Treatment principles for burns: Full thickness

Answer 21

Debridement happens in surgical rooms NOT by PTs.

Prepare patient for surgery by - Controlling/Preventing infection - First wounds are cleaned using anti-microbial (decrease bacterial load) - Using ointments such as Silver Sulfadiazine covered with gauze dressing

Question 22

Treatment principles for Subdermal burns

Answer 22

Apply moisture with wound healing procedures until surgical coverage of wound is completed.

• Petroleum Jelly - Hydrogels - moisture-retentive - Silver impregnated gauze dressings

PT Goals - Keep wound moist - Maintain mobility/function - Prevent Infection

Question 23

What are types of ointments that help with burns?

Answer 23

Silver sulfadiazine (Silver Surfer) - Used for infected burns - Burns up to 3rd degree - Topical Antibacterial - Fight infections - Does NOT treat necrotic tissue

Sulfamylon (Mafenide Acetate) - Used for infected burns & thermal burns - Topical Antibacterial - Fight infections - Treats necrotic tissue*

Bactracin

Question 24

Goals of dressings for surgical treatments:

Answer 24

Prevent: - Shear - Displacement - Infection - Development of hematoma or seroma

• Dressed with soaked gauze that is irrigated frequently to keep a moist wound bed - A splint is incorporated to allow the graft to adhere properly to the wound bed. - Compression bandages are also used as well to prevent hematoma (RBC filled fluid sac) or seroma (WBC filled fluid sac)

Question 25

Contraindications for Volumetrics

Answer 25

DO NOT USE WITH OPEN WOUNDS

Question 26

How do you measure girth with a patient with severe LE edema?

Answer 26

circumferential measurements every centimeter, starting at the floor or weight-bearing surface and progressing to the groin.

Question 27

Is surgical debridement for a non infected, chronic wound appropriate?

Answer 27

Yes. Surgical debridement uses sterile sharp instruments to remove debris and necrotic tissue, as well as viable tissue beyond the wound This converts a chronic wound into an acute wound. The bleeding base afterward is thought to stimulate release of growth factors to speed healing. It is also appropriate for infected wounds in order to make sure there is complete removal of the infection. It is done in an operating room or outpatient setting and is not within the scope of practice for a physical therapist. It is contraindicated in patients with poor vascular supply.