Treatment of Lymphedema

Lymph Anatomy

Lymph nodesLymph vesselsThymus glandSpleenTonsilsPeyer’s patches

Lymph Vessels

CapillariesPre-collectorsCollectorsTrunks

Lymph Capillaries

Larger diameter than blood capillariesNo valvesLymph can flow in any directionCan absorb interstitial fluid

Pre-Collectors & Collectors

Pre-Collectors Channel lymph fluid into transporting vessels Can absorb fluid

Collectors Transporters Resemble veins in structure Passive valves: ever .6-2cm along vessel Lymphangioactivity Contractions caused by Sympathetic Nervous System

and lymph volume Superficial and deep

Trunks & Ducts

Largest lymph vesselsThoracic duct-largest, pumping by the

diaphram. From in cisterna chyle

Ducts empty into venous systemLower Body Upper Body

•R & L Lumbar Trunks•Intestinal Trunks

•R & L Jugular•R & L Subclavian•R & L Broncho-mediastinal

Lymph Fluid/Lymphatic Load

Consists of: Proteins (1/2 of bodies protien) Water Cells (RBC, WBC, Lymphocytes) Waste Products Fat (intestinal lymph, chyle)

Lymph Nodes

Filtering station for bacteria, toxins, & dead cells

Produces lymphocytesRegulates the concentration of protein in the

lymph Typically thickens the fluid 600-700 in body

Lymphatic Watersheds

Median-SagittalTranverseClavicalSpine of ScapulaChaps or Gluteal

Lymph Time Volume & Transport Capacity

LTV= amount of lymph which is transported by the lymphatic system in a unit of time

TC=maximum lymph time volumeFunctional Reserve=the difference between

the LTV and the TC

High Volume or Dynamic InsufficiencyHigh Volume or Dynamic Insufficiency

Low Volume or Mechanical InsufficiencyLow Volume or Mechanical Insufficiency

High Output Failure Leads to Edema

Low Output Failure= Lymphedema

Defining Types of Lymphatic Insufficiencies

TC

LL=LTV

TC

LTV

LL

Lymph Propulsion

Arterial pulsationMuscle pumpRespirationContraction of the lymphangion

Definition of Lymphedema

Lymphedema is the result of the abnormal accumulation of protein rich edema fluid

Primary or secondaryAfflicts approximately 1% of the US

population (2.5 million people)* A SUDDEN ONSET OF EDEMA MUST BE

THOROUGHLY EVALUATED BY A PHYSICIAN

Physical Exam

HistoryInspection

Measurements: weight, circumference Skin assessment: nodules, bumps, discoleration

Palpation Temperature: usually a bit warmer Stemmer’s sign: rolls on finger, square and thick skin Skin fold(s) Pitting Fibrosis

Other Diagnostic Tests

LymphographyVenous Doppler or Venous SonographyIndirect LymphographyFluorescence MicrolymphographyLymphoscintigraphy CT ScanMRI

PrimaryPrimary SecondarySecondary

Hypoplasia (not as many lymph nodes)

Hyperplasia Aplasia Inguinal Node Fibrosis

(Kineley Syndrome Milroy’s Disease-congentital,

males, unilateral typically Meige’s Syndrome: most

females around puberty, Bilateral, webbing of fingers and toes, two rows of lashes

Surgery Radiation Therapy Trauma: blunt trauma Filariasis: parasite, blocks

lymph nodes Cancer (Malignant) Infection Obesity Self Induced

Types of Lymphedema

Stages of Lymphedema

Latency Stage Reduced transport capacity No noticeable edema

Stage I Pitting edema Edema reduces with elevation (no fibrosis)

Tight sleeve during the day Stage II

Pitting becomes progressively more difficult Connective tissue proliferation (fibrosis)

Stage III Non pitting Fibrosis and Sclerosis Skin changes (papillomas, hyperkeratosis, etc)

Differential Diagnosis

Lipidema: females, symmetrical (no feet), no pitting, very painful to palpations, bruise easily, tissue is softer.

Chronic Venous Insufficiency: gaiter distribution, non-pitting, hemosiderin staining, fibrotic.

Acute Deep Venous Thrombophlebitis: swelling, redness, painful, sudden onset

Cardiac Edema: bilateral, pitting, complete resolution when legs elevate above heart, no pain.

Congestive Heart Failure: pitting, dyspnea, jugular vein distention.

Malignancy: Filariasis: Myxedema: decreased ability to sweat, orange skin Complex Regional Pain Syndrome (RSD, Sudeck’s)

Chronic Venous Insufficiency

Filariasis

Lymphedema Interventions

Surgery (Debulking, Liposuction) Taking out all the lymphatic with these surgeries

Medication (Diuretics, Benzopyrones) Takes out all the water, but leaves lymphatic's with

protein rich lymph fluid.

Pneumatic Compression Pump May harden the tissue or destroy lymph collectors,

and leave person immobile for a couple of hours.

COMPLETE DECONGESTIVE THERAPY Removes proteins from the system.

Anti-Edema Medications

Not effective because: Do not allow the proteins to be reabsorbed into the

venous system As long as proteins are stagnate in the interstitial

space the onconic pressure remains high and lymphedema persists

Can worsen Lymphedema in the long run as they increase the concentration of proteins in the interstitial space exacerbating fibrosis

Treatment Schools of Thought

Casley-SmithFoldiLeDucVodderNortonKlose

Complete Decongestive Therapy (CDT)

Skin CareManual Lymph DrainageCompression TherapyRemedial exercise

Purpose of lymphatic treatment

Applied pressure softens fibrotic tissueExcess protein is removedFormation of new tissue channels through

anastomoses Provide supportEnhance oxygenation by decongesting areas

where lymph volume is highLong-term maintenance of improved limb size

and shape

Contraindications (precautions) to CDT

Acute bacterial or viral infection Wait 24 hours of antibiotic treatment before

resuming treatment.

Acute CHF h/o CHF treat conservative, 1 limb at a time

Kidney malfunctionUntreated malignancyThe existence of impaired arterial perfusion

for compression ABI < 0.50

Precaution/Contraindication

Rationale Modification

DVT Do not treat in the area of an acute DVT. Fear is dislodging causing a life threatening emboli

Treat adjacent areasAwait medical clearance prior to treating affected area

Active Infection Do not treat with an active infection. Fear of spreading infection

Wait until appropriate antibiotic therapy has been initiated and show signs of resolving

Open wound Do not treat areas with breaks in the skin

Treat adjacent areas of intact skin

Metastatic Disease

Fear of spreading cancer Palliative care; Team decision

Congestive Heart Failure

Fear of systemic fluid overload Must be controlled, then treat conservatively and monitor

Asthma Fear that parasympathetic stimulation will provoke an asthma attack

Must be controlled, then treat conservatively and monitor

AAA, Diverticulitis, IBS, Crohn’s disease

Deep abdominal techniques may aggravate or worsen these conditions

Do not perform deep abdominal techniques

Pregnancy Fear deep abdominal techniques may harm the fetus or uterus

Do not perform deep abdominal techniques

Patient education

Protect the skinSigns of infectionGradual return to activitySelf management

Self massage Compression garments Exercises

Weight Management Obesity and body fluid volume fluctuations are

beginning to be associated with the development of lymphedema

Protect the skin : Individuals that have had lymph nodes removed are at risk for lymphedema. To minimize this risk the following precautions should be followed:

Keep arm clean and dry.Apply moisturizer daily to prevent

chapping/chaffing of the skin. Balance lotion

Attention to nail care; do not cut cuticles.Protected exposed skin with sunscreen

and insect repellent.Use care with razors to avoid nicks and

skin irritation.Avoid punctures such as injections and

blood draws.

Wear gloves while doing activities that may cause skin injury

If scratches/punctures to skin occur, keep clean and observe for signs of infection.

Gradually build up the duration and intensity of any activity or exercise, and monitor arm during and after for any change in size, shape, firmness or heaviness.

Avoid arm constriction from blood pressure cuffs, jewelry and clothing

Avoid prolonged (>15 minutes) exposure to heat, particularly hot tubs and saunas

Airplane flights: due to decrease pressure in cabin, will need a compression sleeve

Signs of infection

RedHotPainSwellingFeverGeneralized Fatigue

Exercises

Effect of movement on lymphatics - lymph flow; abdominal breathing

Development of an effective exercise program1.) flexibility exercises2.) strengthening exercises3.) aerobic exercises4.) response of limb is important

Lymphatic Drainage Exercises

Move fluids through lymphatic channelsActive repetitive ROM exercises are

performedFollow a specific sequence to move lymph

away from a congested areaProximal to distalAvoid static dependent postures

Lymphatic Drainage Exercises

20 – 30 minutes each sessionTwice daily7 days a weekWear compression bandages or

garment during exercisesCombine with deep breathingRest if possible for 30 minutes

following exercisesCheck for redness or increased

swelling

Sequence of exercises

Proximal starting at neck and trunkProximal joints moving distally5 reps – 20 reps

Manual Lymph Drainage (MLD)

a manual technique to mobilize fluid in the lymph system, by movement of proteins and fluid into the initial lymphatic vessels. This manual technique is done lightly and slowly.

Manual Lymph Drainage (MLD)

Basic Principles: 1. Proximal area is treated first, clearing first the

adjacent and unaffected lymphotomes, then proximal sections of the affected lymphotomes.

2. The direction of pressure depends on the areas of edema and the direction should always be towards a cleared lymphotome.

3. Technique and variations are repeated rhythmically. 4. Pressure phase lasts longer than relaxation phase. 5. As a rule there should be no reddening of the skin

Manual Lymph Drainage (MLD)

Techniques:1. Call-up - proximal to edema

To clear the collectors proximal to the area Using the Thumb side of hand

2. Reabsorbtion - edematous region Using the 5th digit side of hand Increases protein reabsorption

Manual Lymph Drainage (MLD)

1. Mobilize the skin2. Apply Pressure3. Relax

Technique is done lightly and slowly

MLD – Upper extremity

1: Supraclavicular nodes2: Axillary nodes3: Inguinal nodes4: Thigh5: Popliteal fossa6: Calf7: Malleolli8: Dorsum of foot9: Toes

Upper Extremity mld

MLD – Upper extremity

1: Supraclavicular nodes2: Axillary nodes3: Anterior chest4: Back5: Mascagni Pathway6: Upper arm7: Cubital nodes medial/lateral elbow8: Forearm supination / pronation9: Dorsum/palm of hand10: Fingers

Lower Extremity mld

Protocol

Duration 2 weeks UE 3 – 4 Weeks LE

Frequency 5 days a week

Arm 30 - 45 minutes

Leg 45 - 60 minutes

Wear Bandages During all awake hours

Week 1 Emphasis on Bandages and reduction of Swelling

Week 2-3 Facilitate Physician order for Garment Self Management of Edema

Abdominal

Nodes

Treatment Of Abdomen - Deep

Position patient so that hips and knees are flexed

Patient performs slow diaphragmatic breathing On exhale apply slow, gentle but firm pressure on area

Pressure is toward the cistera chyli On inhale give gentle resistance to promote increased

expansion and provide proprioceptionIf you can palpate the aorta do not apply

pressure

Treatment Of Abdomen - Deep

Contraindications Pregnancy Endometriosis Hiatal hernia

Compression bandages

Compression bandages

Compression bandages have been shown to produce a micromassage effect that improves lymph transport.

Increase temperature of up to 5 degrees enhances the lymphangion mobility

Bandages

Resting pressure - Pressure from the outside in the resting position of the muscle. Pressure applied from fascia, bandages

Working pressure - Pressure from the inside when the muscles are active. Pressure generated by the muscles

Resting Pressure

BANDAGEBANDAGE

LYMPHATICSLYMPHATICS

MUSCLE

Working Pressure

BANDAGEBANDAGE

LYMPHATICSLYMPHATICS

MUSCLE

Types of compression bandages

Elastic high stretch bandage- high resting pressure and low working pressure Not effective for treating lymphedema High resting pressure does not allow the

lymphatics to fill And low working pressure does not increase tissue

pressure effectively enough to influence the lymphatic pump because it stretches when the muscle contracts

Types of Compression bandages

Low stretch bandage- low resting pressure and high working pressure

low resting pressure allows the lymphatic to fill High working pressure compresses the lymphatic vessels

between the muscle the bandage facilitating lymphatic flow

Low Stretch Compression Bandages

Form a semi rigid support which causes an increase in interstitial pressure when the muscle contracts

When a patient wears low stretch compression bandages while sleeping or resting the increased interstitial pressure will reduce the amount of fluid and protein leaving the arteriole (ultra filtration) and less edema is formed

When a patient wears low stretch compression bandages during activity the increased interstitial pressure not only reduces ultra filtration but increases reabsorbtion into the lymphatic system which decreases lymphedema and well as venous edema

Principles of Bandaging

Must use Low stretchAlways start distally and proceed

proximallyMaintain moderate tensionAvoid creases and foldsUse tape to secure…not clips or

pinsApplied with greater pressure

distally than proximallyDo not extend bandage to maximal

length

Principles of Bandaging – con’t

Check pressure gradientPlace more layers for increase

compression rather than applying them more tightly

Fill indentations with padding or foam pieces

Cover as much of the limb as possible

Compression to be worn until next visit

Exercise with bandages on to take advantage of muscle pump effect

Bandaging SuppliesScissorsTape Lotion – low pHTubular bandage

Protects the skin, skin hygiene, absorbs perspiration

Elastic gauze/finger/toe wraps/CobanPadding – Artiflex or foam

Prevents indentations in skin, equalizes pressure, protects tender areas

Low stretch compression bandages 6 cm: foot, hand 8 cm: ankle, forearm 10 cm: lower leg, upper arm 12 cm: upper thigh

When to instruct the patient to remove the bandages

If the patient gets short of breath or has heart palpations

If the fingers/toes are numb, blue or tingling

If the wraps fall offIf the patient is experiencing too much pain

Compression Therapy

Compression therapy is the application of external pressure on body tissue to support the elasticity of the skin and its underlying vessels

Phase I with Compression BandagesPhase II with medical compression Garments

Rationale for using compression therapy:

Compression therapy directly effects the underlying lymphatic vessels, veins and tissue.

Improves the efficacy of the muscle pump by creating a semi-rigid support for the muscle to work against

Causes a mild increase in total tissue pressure

Improves and maintains the shape of the limb

Compression Garments

Not designed to decrease edema- only to maintain the edema reduced by the treatments

Increases reabsorbtionIncreases tissue pressureready made vs. customill fitting garment is worse than not wearing

one at all

MedaFit garments

Donning Compression Garment

For LE : put on in bedUse gloves to don and doffApply on an “empty” limb

Garment Compression Classes

Over the counter --CC1 -----------------CC2 -----------------CC3 ----------------CC4 ----------------

10-18 mmHg20-30 mmHg30-40 mmHg40-60 mmHg60+ mmHg

Sequential Pneumatic Devices

Mobilizes interstitial fluid into the venous system

Single chamber - JOBST vs. sequential Compression (gradient)

Use MLD prior to using the pumpStudies show that it moves only venous fluidPump never to exceed 40 mmHg for extended

periods of time

Sequential Pneumatic Devices

Lympha Press

Pressure range is 20-180 mmHg. Pressure is distributed into overlapping air

compartments which are contained in a special sleeve. The compartments are sequentially inflated, from distal

to proximal, massaging the limb in a proximal direction. The overlapping compartments prevent any gaps in

treatment, to achieve a maximal and safe reduction of the lymphedema.

The treatment cycle starts by filling the distal compartment first and continues inflating the remaining compartments in sequence during the first 24 seconds until all are full.

The pressure is held in all compartments for 2 seconds, then deflates for four seconds which completes the 30 seconds cycle. The cycle then repeats itself.

LASER

Another new frontier in the treatment of lymphedema involves using the laser.

From various trials lasers appear to help lymph flow, shown to be effective improvement of wound healing, and it has been used effectively in treating edema from DVT’s.

The FDA has approved a laser device to be used in the treatment of post-mastectomy arm lymphedema.  Clinical trials are currently underway for leg lymphedema.  

Lymphedema and its complications can causing "scarring" of the lymphatic system.  The laser is useful in removing the scar tissue, thereby helping lymph flow.

Energy Density - Suggestions

Type of Condition Suggested Treatment Dose Range (J/cm2)

Soft Tissue Healing 5-16

Fracture Healing 5-16

Arthritis – Acute 2-4

Arthritis - Chronic 4-8

Lymphedema 1.5Neuropathy 10-12

Acute Soft Tissue inflammation 2-8

Chronic Soft Tissue Inflammation 10-20

The Short-term Effects Of Low-level Laser Therapy In The Management Of Breast-cancer-related

Lymphedema

Dirican et al; Supportive Care in Cancer; June 201117 BCRL patients referred to program between

2007 and 2009 All patients previously experienced at least one

conventional treatment modality Complex physical therapy Manual lymphatic drainage Pneumatic pump therapy

LLLT was added to patients’ ongoing therapeutic regimen All patients completed full course of LLLT

Two cycles

Results Difference between sums of the circumferences of

both affected and unaffected arms Decreased 54% after first cycle Decreased 73% after second cycle

Pain score 14 out of 17 experienced decreased pain with

motion by an average of 40% after first cycle and 62.7% after second cycle

Scar mobility Increased in 13 patients

Range of motion Improved in 14 patients