Phases and Components of CDT Flashcards
Phase II - Components
- Also known as the self-management, or improvement phase
- Involved extremity may have reached a normal size if treatment started early Stage 1
- Lymphostatic fibrosis will still be present if CDT started in late Stage 1 or Stage II
- Fibrotic tissue can take several months to resolve.
- The patient must assume responsibility for managing, improving, and maintaining the results achieved in phase I.
- Daily care is vital - skin care, compression garments, bandages at night, MLD, exercises
- Self-management is a lifelong process
Phase I - Components
- Known as the Intensive Phase
- Daily treatment, patient needs to be aware
- Consists of skin care, manual lymph drainage (MLD), compression therapy using short-stretch bandages and padding material, as well as decongestive exercises.
- Duration Upper Extremity 2-3 weeks
- Duration Lower Extremity 2-4 weeks
Goal of Lymphedema Management in Phase I
To decongest the affected limb or area by re-route lymph flow around blocked sites.
Goal of Lymphedema Management in Phase II.
- Self-Management
- Improve and maintain Phase I results
What are the 4 components of CDT?
- Manual Lymph Drainage
- Skin Care
- Compression
- Decongestive Exercise
What are the principles behind MLD strokes on the Lymph System?
- Designed to stretch the walls of the superficial lymph vessels which stimulates an increase in activity.
- Re-route the lymph flow around blocked areas to more centrally located lymph vessels.
What are the effects of Manual Lymph Drainage? (5)
* Increases lymph production
* Increase in the contraction frequency of lymph collectors
* Reverse of lymph flow
* Increase in the local sympathetic response
* Increase in the general parasympathetic effect
How does MLD increase venous return?
- MLD creates a suction effect on the distal lymph collectors
- Superficial - directional stretch of working phase
- Deep - deeper techniques of abdominal strokes
How Does MLD Increase Lymph Production?
Stretch on the anchoring filaments of lymph capillaries stimulates the intake of lymphatic loads into the lymphatic system.
How does MLD Increase Lymphangiomotoricity?
Increase in the contraction frequency of lymph collectors by mild stimuli of the smooth musculature located in the wall of lymph collectors.
How does MLD reverse Lymph Flow?
Moves lymph fluid in superficial lymph vessels opposite to its natural flow patterns. Lymph fluid is re-routed around blocked areas via collateral lymph collectors, anastomoses, or tissue channels
Why do many patients find MLD “soothing” or provides pain relief?
MLD decreases the sympathetic mode and promotes the parasympathetic response.
- accelerates drainage of nociceptive substance from tissues.
What considerations are there in MLD of the trunk?
- ## Even if no apparent involvement treat the trunk for at least 1 day.
When and where does Trunk Lymphedema appear?
- Breast Cancer/reconstructive surgeries 80%
- appears as fullness over shoulder blades or upper back
- fullness across the waistline on right side
- extra rolls of fat along the side of the trunk
- located in the affected breast/chest wall, clavicle scar lines.
Where are healthy lymph nodes/vessels located in relation to the damaged areas?
Adjacent
How is MLD in the extremity treatment carried out?..
In segments starting at the proximal aspect prior to the more distal aspects.
How is the lymph fluid re-routed during MLD in the upper extremity?
Towards
- the Cervical Lymph nodes
- axillary lymph nodes on the contralateral side
- inguinal nodes on the same side
How is the lymph fluid re-routed during MLD in the lower extremity?
Towards
- the deep lymphatic pathways in the abd area
- axillary lymph nodes on the same side
- inguinal nodes on the contralateral side
What is the term for a superficial skin infection of the dermis and upper subcutaneous layer? Presents with a well-defined edge.
Erysipelas
What two microorganisms are the primary cause of Cellulitis?
Group A Streptococcus
Staphlococcus
Why are those with Lymphedema more susceptible to infections of the skin/nails?
- protein-rich fluid serves as an ideal breeding ground
- increased diffusion distance hinders a timely response of defense cells in the affected area
- thick scaly skin increases the risk of cracks and fissures
What are the considerations in effective skincare?
- daily
- with donning/doffing compression
- low pH lotion (pH 5.0-5.5)
- no fragrances
- hypoallergenic
What considerations in treating limbs with fungal infections?
- only start working once medications are started
- can work proximal area
- avoid touching the affected area/use gloves
- nail fungus: do NOT cut cuticles
Why is compression therapy an integral part of CDT?
Maintains the decongestive effect achieved during the MLD session. Without compression therapy successful treatment of lymphedema would be impossible.
What is the Law of LaPlace?
If the radius of a cylinder increases, the tension also needs to increase to achieve the same pressure.
Compression Principles for CDT.
- purpose is to create a cylinder shape of the limb
- if consistent compression (from distal to proximal) a natural gradient will occur (means a change in tension is required)
Necessary in order to prevent tourniquet effect - higher pressure distally
- lower pressure proximally
Why is padding necessary in compression therapy?
- Swollen extremities generally lose their cone shape, making it necessary to use foam/padding to “construct” a cylinder.
- Concave areas (behind ankles)
- use between lobes
Steps when applying compression in Phase 1.
1) Skin Care (cleanse, lotion)
2) Gauze bandages applied to fingers, toes without padding.
3) Cotton stockinet is applied to absorb swear
4) Short-stretch bandages with various widths and applied in layers.
What type of pressure (work vs resting) is found with Short-Stretch Banadages?
HIGH working pressure
LOW resting pressure
What type of pressure (work vs resting) is found with Long-Stretch “Ace” Banadages?
LOW working pressure
HIGH resting pressure
Creates tourniquet effects while resting
What type of pressure is defined as the counter-pressure with the bandage sets against the muscles working underneath?
Working Pressure
What type of pressure is defined as the pressure the bandage exerts on the tissue while resting?
Resting Pressure
When using Short-Stretch Bandages what type of method is used?
- multiple bandages
- spiral wrap
- “Herringbone” pattern
Compression Wrap Therapy Scheduling Considerations?
- Start on Monday to allow for the establishment of routine and teaching of self-application (weekends)
- Patients need to cover wrapped limb when showering
- Must remain on until removed by the therapist
- Measurements once a week
Compression Garment Considerations.
- Pantyhose Style - must cover lower quadrants if groin involvement
- Bandaging at night for fibrous tissue
- Gradient compression from distal to proximal is necessary
Exceptions in Compression Garments
- padding may be required
- Compression < CC II in upper extremities to be considered in arthritic hands, not able to don, paralyzed extremity, age
- Compression > CC II in upper extremities with larger extremities, highly repetitive activities, very active patients, age (young)
- overlap to achieve the desired amount of compression
Compression Levels and Classes.
CC I - 20-30 mm/Hg
CC II - 30-40 mm/Hg
CC III - 40-50 mm/Hg
CC IV - >60 mm/Hg
At what compression is used for most upper extremities?
CC II 30-40mm/Hg
At what compression is used for most lower extremities?
CC III 40-50mm/Hg
What are the considerations regarding ready-made compression wraps?
- can replace bandaging at night
- quick application
- compression wraps are always superior
What are the effects of compression?
- reduce filtration
- increase reabsorption
- improves the efficiency of joint and muscle pump
- prevent re-accumulation of lymph fluid
*break-down of scar tissue and treat fibrosis
Compression increases pressure, how does this affect filtration and reabsorption?
Filtration - reduced
Reabsorption - increased
*Improves exchange of fluids between the blood capillaries and the tissues.
What is the Importance of Exercise in CDT?
* To improve lymph circulation
* To improve/increase venous return
* To optimize joint and muscle pump
* To increase lymphangiomotoricity
* Deep (diaphragmatic) breathing increases the volume of fluid returned via thoracic duct to the venous angle
What type of Exercise is used in CDT?
- 10-15min; 1-2 times a day
- 3-4 light to moderate exercises
- allow for a steady state for a period of time without extreme fatigue
- should be able to engage in light conversation
Why is maintaining compression important during exercise program?
With compression, exercise can increase the uptake of fluid into the initial lymphatics, improve the pumping action of the lymph collectors, and limit filtration.
Example of Upper Extremity Exercise program?
- Pump fist (digit flexion and extension)
- Wrist flexion and extension
- Elbow flexion and extension
- Appropriate shoulder ROM
Example of Lower Extremity Exercise program.
- Walking x 10 minutes
- Supine to perform…
- Abdominal breathing
- Ankle pumps
- Knee flexion/extension
- Hip ab/adduction
- Abdominal breathing (again)
Special considerations with CDT exercise therapy with breast cancer patients?
- weight lifting shown to at the least not increase lymphedema and perhaps even have a role in prevention.
- Lebed Method - exercise/movement program
What are some of the reasons CDT fails in Phase I?
- Lack of compliance
- Improper treatment (MLD only)
- Malignant lymphedema
- Artificial lymphedema (self- induced)
- Associated condition(s)
- Severity of symptoms
