Lymphedema Therapy

majerus & company physical therapy vancouver, wa A comprehensive PT clinic offering one on one professional attention from an experienced staff with a wide range of expertise….imagine life squared. Jodie Paschall-Majerus MPT , CLT John Majerus PT, OCS, CSCS, CLT Laura Bancroft PTA, CLT Robby Trimbo DPT, CLT Tara Socquet MPT Buffy Stinchfield MPT Tara Rinhard, DPT Kathleen Griffin, PTA, LMT, SI

Edema Management - NOT just for breast CA survivors with arm lymphedema! - 75% of our edema patients are treated for LE issues. - Many of the LE patients are referred by their primary care physicians, orthopedists or cardiologists - In the US, CDT seems to be offered as a treatment of last resort..

ANATOMY AND PHYSIOLOGY “KEY POINTS” RELATING TO TREATMENT

Lymph Production Lymph production Lymph production begins in the terminal lymph vessels, which are located in close proximity to the capillaries. End of the road for circulation, beginning of the road for lymph.

Initial Entry Point-Lymph Capillary “Ultrafiltrate” fluid, dead cells, and proteins are resorbed from the interstitial tissues into the lymph capillaries. These finger-like projections are found throughout the body, peripherally just under the epithelium. The pressure and stretch upon the surrounding connective tissue mobilizes the anchoring filaments to open flaps between the flattened endothelial cells to allow uptake of large MW proteins as well as fluid . Intercellular junction Movable flap Anchoring Filament This is the level at which fibrosis becomes an issue.

Lymph Transport-Lymphangions Lymphangions - “driving force” for lymph transport in a collecting vessel. Uni-directional valves form segments that respond to filling with contraction of smooth muscle in the vessel walls, moving fluid to the next segment enhanced by the active muscle pump- Lymphangiomotoricity Systole; valve closed Diastole; valve open Ie breathing and movement

Importance of Skin Elasticity / Mechanical External Compression Lymph transport Importance of Skin Elasticity / Mechanical External Compression Role of fibrosis With loss of skin elasticity, the muscle pump loses its normal counter-pressure. Adding external, non-elastic compression can improve muscle pump effectiveness.

LYMPH NODES 600-700 lymph nodes in the body. Major node groupings: abdomen/intestines, inguinal, axillary, supraclavicular. 2-30 mm in length. Functions : filter and concentrate lymph through immune system. MLD takes advantage of these multiple beds.

LE Lymphatic Vessels

Zones / Watersheds/Anastamoses Each major lymph node grouping receives lymph from a specific body region or tributary zone. The direction of lymphatic flow of each tributary zone is defined by invisible boundaries called watersheds, Anastamoses are areas between zones where vessels physically line up, critical in movement of lymph between adjacent zones during treatment.

The lymphatic fluid from right upper quadrant drains into the right lymphatic duct The lymphatic fluid from both legs and the left upper quadrant drains into the thoracic duct

- 20 liters of fluid are leaked/drawn off capillary beds each day; normally 90% is reabsorbed through the venous capillaries. Lymphatic load (LL) is the remaining 10% of the volume, about 2 liters per day, that returns to the bloodstream via the lymphatics . Phenotypic differences Transport capacity LMV LL Low output failure high output failure

Transport capacity (TC) - volume of lymph that can be removed by a tributary zone and its regional nodes. -unless compromised, only about 10% of the volume of a normal zone is used, termed the “safety valve” *loss of transport capacity is often asymptomatic and is not easily measured Possible contributing factors: -surgical incisions crossing major lymphatic channels -pressure on nodes or vessels from obesity or tumors -radiation therapy excision of lymph nodes Cellulitis mediated damage to lymph capillaries

Edema Classification High vs. Low protein edema- guides initial interventions -High protein edema, i.e. lymphedema, develops when transport capacity drops below the lymphatic load Stage 1- reversible- edema goes down overnight, no skin changes evident, typically soft 1+ or 2+ pitting edema Stage 2- broad symptom range with early to advanced Stage 2 edema does not fully reduce overnight or with elevation skin becomes hard, brawny, hyperkeratosis, lymph cysts, etc + Stemmers sign of digits, swelling of dorsum of the foot Stage 3 – “elephantiasis”, change in limb morphology, more advanced skin changes Stages 2 and 3 require lymphatic massage to clear interstitial proteins. Increased risk of cellulitis. Diuretics aren’t helpful.

Lymph System Insufficiencies (LSI) Mechanical (low output failure) Compromised lymphatic system with decreased transport capacity (TC) CA/abdominal surgery, radiation, cellulitis Dynamic (high output failure) Normally functioning system is unable to clear increased lymphatic load (LL) Longer standing CVI, lymphovenous conversion Combination (safety valve failure) Decreased TC and increased LL overcomes the “safety valve” margin

Edema Classification -Low protein edema- lacks the interstitial protein component of the edema, less osmotic pressure Examples: early CVI , stable CHF - Usually responds quickly to bandaging reduction, fewer treatment sessions - Usually requires garments with lower compression - Lymphatic massage is usually not required, especially if the edema is treated early with consistent, adequate compression and diuretics - Watch that the cardiac, pulmonary and renal systems can handle a spike in fluid volume. - Compress one leg at a time - No increased SOB , wet cough, etc.

CVI and CHF - CVI - progressive valve failure in the veins - valve damage due to DVT - creates dependent edema due to increased LL with increased venous capillary leakage - superficial /deep varicosities, hemosiderin staining, hairless fragile skin, tissue weeping , venous stasis ulcers - if more severe and prolonged, likely progresses to high protein edema over time if not treated - Cardiac related edema- CHF, etc, - increased venous capillary pressure and leaking - if stable, can treat with compression; proceed with caution

Documentation - Digital photography- First visit and after treatments - LE girth measurements – taken at 10cm intervals, MTP and forefoot, toe girths when needed - Body weight - Volumetric algorithms are available

Management of Swelling Disorders - Traditional treatments: - “retrograde massage” - elevation - ankle pump exercises - wrapping with long stretch elastic bandages aka ACE wraps - compression garments - pneumatic pumps

CDT Therapy - Origins in Germany - Vodder and Foeldi - First offered in the US in 1980 - PT is covered by most private insurance and MC - Treatment components: Short stretch bandaging for edema reduction Lymphatic massage- central to peripheral Remedial exercises Meticulous skin care Education and home management- compression systems, self massage and/or night bandaging

Relative Contraindications - Acute DVT – if not yet on anti-coagulation meds or no screen placed - Acute cellulitis - treat after 7-10 days of antibiotic therapy, <warmth/pain in the leg - PAD – ABI of 0.5-0.8 with caution - Extremity paralysis- mechanical pump lost - Complete sensory loss- caution with toes of neuropathic patients - Dementia

CDT-Massage principles - Central trunk first- diaphragmatic breathing - Do the proximal portion of extremity first, gradually progressing more distally - Use light pressure – lymphatic system is above muscle fascia layer - Rhythmic and directional skin stretching

Push lymph retrograde to an adjacent, intact zone.

Terminal Lymph Vessels / Lymph Capillaries Affected by skin stretch Pre-collectors Affected by blood pressure within sheath Lymph Collectors or Lymphangions Affected by muscle pump with either good skin or external compression Lymph Trunks and Associated Node Beds Affected by amount of “draw” from more proximal structures

Bandaging - Always apply skin moisturizer/ barriers – Eucerin, Aquaphor, antifungals, etc. - Utilize short stretch cotton bandages low resting pressure, high working pressure- minimal “pulling in” at rest, enhanced muscle pump these features are the opposite of Ace/long stretch bandages A variety of cotton padding and foams are used for creating a proper pressure gradient, protect bony prominences, reshaping the limb, and softening fibrotic tissue - Wear bandages overnight, sequential wraps until not reducing further

Bandaging Critical for healing when “wet” venous wounds are present. Not useful for neuropathic “dry” ulcers. Use over wound dressings that maintain the proper healing environment. Watch for areas of skin maceration.

Short Stretch Bandaging with Padding and Foam Inserts Garments alone are not designed to reduce or reshape the limb, just maintain the size of the limb Garments are meant to be fitted to an already reduced leg Compression bandages should always extend as far as the next large joint above the edema or we get “topping out”, but response does help detecting central blockages.

Remedial Exercise - Important, since obesity is a risk factor; this is one reason we favor bandaging over pumps. We want people to walk and move! BUT, patients must wear compression when exercising to: -enhance the LE muscle pump - counteract increased capillary pressures from increased blood flow - create micro-massage of the skin to increase lymph uptake in the terminal lymph vessels

Choosing a Compression System Effective Affordable Manageable to don/doff Comfortable to wear Cosmetically acceptable European Compression Garment Guidelines http://www.lymphormation.org/downloads/position-documents/BSN-Template-English.pdf

Choosing a Compression System - Socks - Circular weave- off the shelf - Flat weave- custom measured - Compression level - Closed toe or open toe, w/ or w/out toe caps - Materials- Latex or Lycra – allergies, use and care - Neoprene garments - CircAids or Ready Wraps

Choosing a Compression System Knee or thigh highs? Avoid “topping out” or dumping at the next most proximal limb segment. For high protein edema, apply compression to the whole zone, up to the watershed. Shorts- Bermuda flat weave – combine with flat weave thigh high biking shorts Capri circular knit legging with knee highs When layering garments, many options are available

Thank you! majerus & company physical therapy Phone: 360-253-4020 Web: www.majeruspt.com Email: johnm@majeruspt.com