1. Edema Disorders
Kade Scott DPT, CLT

2. Objectives Understand and recognize different edema disorders
Understand basic treatment options for edema disorders
Explain the differences in compression garments

3. What does the Lymphatic system do?
The lymph system is responsible for transporting
Proteins
Water
Cells
Fat
Waste
WBC, lymphocytes, Bacteria, Virus

5. Lymphedema
An abnormal accumulation of protein rich fluid in the interstitum, which causes chronic inflammation and reactive fibrosis in the affected tissue
Lymphedema is classified as either primary or secondary lymphedema
Typically asymmetrical

6. Copyright © 2014 American Medical Association. All rights reserved.
From: Differential Diagnosis, Investigation, and Current Treatment of Lower Limb Lymphedema
Arch Surg. 2003;138(2): doi: /archsurg
Figure Legend:
Causes of lymphedema.
Date of download: 2/17/2014
Copyright © 2014 American Medical Association. All rights reserved.

7. Primary Lymphedema
The most likely occurrence of this form is lymphangiodysplasia
Hypoplasia- less than normal expected number of lymph collectors in the affected area
Aplasia- a distinct absence of lymph collectors in the affected area. May also involve the absence of lymph capillaries
Hyperplasia- Vessels are characterized by an excessively dilated caliber which renders them less functional due to valvular dysfunction

8. Primary Lymphedema
Present at birth or shortly therafter is known as Milroy’s Disease
Primary Lymphedema that develops during puberty is known as Meige’s Disease.
Praecox- Develops before 30
Tardum- Develops after 35

9. Secondary Lymphedema
Secondary lymphedema means there is a known cause for the presence of lymphedema
Worldwide the most common cause is the mosquito born parasite Filaria
In the United States the most common cause is cancer therapy
Lymph node sampling
Full dissection of lymph nodes
Radiation therapy

10. Secondary Lymphedema (cont)
Other causes include any significant trauma to the lymphatic system from accidental or self induced incidents, infectious episodes such as eyrsipelas or cellulitis
Obesity may also play a role in the development of lymphedema, however, it is more likely due to a secondary co-morbidity (lack of mobility, CVI etc)

11. Staging of lymphedema
Lymphedema is divided into 4 stages (American Society of Lymphology)
Latency stage (subclinical or stage 0)
Transport capacity of the lymphatic system is sub-normal but still sufficient to transport the lymphatic load
Patients are “at risk” for developing lymphedema
Education about subjective complaints and preventative measures is key component of treatment at this stage

12. Staging Stage 1 (reversible stage) Accumulation of protein rich fluid
No fibrotic alterations
Pitting is easily induced
With proper management of stage 1 patient can expect to have reduction to normal limb size
Stage 1 is often confused with edemas of other geneses

13. Staging Stage 2 (spontaneously irreversible) Lymphatic fibrosis
Tissue becomes indurated
Pitting is difficult to induce
Positive Stemmer sign
Common cellulitic infections
Incomplete reduction with therapy and good patient compliance

14. Stemmer Sign
Sometimes called the Kaposi Stemmer sign

15. Staging Stage 3 (Lymphostatic Elephantitis)
Increased skin firmness, other skin alterations including: cysts, fistulas, papillomas, hyperkeratosis, mycotic infections, ulcerations
More prominent Stemmer sign
Recurrent cellulitis
Decreased pitting

17. Symptoms
Swelling of an arm or leg, which may include fingers and toes.
A full or heavy feeling in an arm or leg.
A tight feeling in the skin.
Trouble moving a joint in the arm or leg.
Thickening of the skin, with or without skin changes such as blisters or warts.
A feeling of tightness when wearing clothing, shoes, bracelets, watches, or rings.
Itching of the legs or toes.
A burning feeling in the legs.
Trouble sleeping.
Loss of hair.
Positive Stemmer Sign (though the absence does not rule out lymphedema)
These symptoms may occur very slowly over time or more quickly if there is an infection or injury to the arm or leg.

18. Chronic Venous Insufficiency
Is an advanced stage of venous disease in which the veins and the muscle pump activity become incompetent causing blood to pool in the legs and feet
Can be due to repeated damage from superficial or deep venous pathology, or a variety of vein-related conditions such as the congenital absence of valves

20. Pathophysiology of CVI
Faulty valves fail to prevent retrograde flow of venous blood during muscle pump activity
May be:
Idiopathic
Post-thrombotic syndrome
Genetics
Pelvic tumors
Vascular malformations

21. Symptoms
Swelling in the lower legs and ankles, especially after extended periods of standing
Aching or tiredness in the legs
New varicose veins
Leathery-looking skin on the legs
Flaking or itching skin on the legs or feet
Stasis ulcers (or venous stasis ulcers)
Hemosiderin staining

22. Hemosiderin staining

23. Risk factors Deep vein thrombosis (DVT)
Varicose veins or a family history of varicose veins
Obesity
Pregnancy
Inactivity
Smoking
Extended periods of standing or sitting
Female sex
Age over 50

24. Early stages of CVI Pitting Edema Corona Phlebectatica
Mostly presenting below the knee
Corona Phlebectatica
A myriad of tiny vein branches that are difficult to delineate
Red-pink hue to skin that returns immediately after pressure is released

25. Advanced stages There may now be a lymphatic component to edema
Hyperpigmentation
Dermatologic changes
Venous stasis dermatitis
Lipodermatosclerosis
Scarring and fibrosis of skin (woody texture to skin)
There may now be a lymphatic component to edema

26. End Stage CVI Defined by ulcerations of the skin
Photo Credit: Charlie Goldberg

27. Lipedema
A chronic metabolic disorder of the adipose tissue, of unknown etiology.

28. Lipedema Predominately in women
Bilateral symmetrical swelling from illiac crest to ankles
Stemmer’s sign negative
No cellulitic infections
Foot sparing

29. Lipedema
“I can never lose weight in my legs no matter how much I diet”
Very tender skin
Bruise easily

30. Lipedema Stage 1 Stage 2 Stage 3
Skin surface is normal, tissues exhibit a smooth nodular texture
Stage 2
Skin surface becomes more uneven, large fatty lobules begin to form
Stage 3
Large contour deforming lobular shapes on medial knee, proximal lateral thigh, and above malleoli

31. Lipedema Staging

32. Traumatic Edema Edema due to physical trauma
Results in inflammatory reactions accompanied by high protein edema.
The majority are temprorary and self resloving. However, it can lead to permanent damage.

33. Pathophysiology of traumatic edema
The initial step in the inflammatory process causes local vasodilation, followed by an increase in the permebility of blood capillaries toward plasma protein. Macrophages invade and devour damage tissue. These macrophages may injure the lymhpatic system.

34. Cardiac Edema Greatest distally Always Bilateral Pitting
Complete resolution with elevation
No pain

35. Congestive Heart Failure
Same symptoms as in cardiac edema
Orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion
Jugular venous distension
Cardiac echo, Physical exam

36. Renal Failure and Edema
Increased protein in the urine
Decreased blood protein
Pitting edema in lower extremity

37. How do I differentiate?
And then what?

38. Accurate Pt Hx
Patient history is crucial in determining the underlying cause of edema
There are many questions that you can ask that will help guide you down the proper course

39. Intake Questions Have you had any lymph nodes removed?
Any recent abdominal surgeries?
Any history of DVT?
Previous cellulitic infection?
CHF?
Renal Failure?

40. Compression Stockings Pneumatic Compression
Lymphedema
MLD
Compression Bandage
Compression Stockings
Pneumatic Compression
Lipedema
Light MLD
CVI
Compression Bandaging
Traumatic Edema
MLD above level of injury
Cardiac, CHF, Renal
Compression bandaging and stockings as tolerated. You MUST consult a physician on these patients prior to initiating any treatment

41. 2 phases to treatment Reduction Maintenance MLD Compression bandaging
Pneumatic compression
Exercise and skin care
Compression Stockings
Pneumatic Compression
Exercise, Skin care

42. Manual Lymphatic Drainage
A general manual treatment which improves lymph vascular flow. In lymphedema it re-routes the lymph fluid around blocked areas into more centrally located healthy lymph nodes
It is not a massage!
Must be done by someone who is properly trained

43. Contraindications to MLD
CHF if patient is unmedicated or edema is due solely to cardiac failure
Acute infection
Renal Failure
Acute DVT (seek physician approval for post thrombotic syndrome edema management)

44. Compression Bandaging
Short stetch bandages are applied to increase the tissue pressure in the swollen extremity
Improves the efficiency of the muscle pump and joint pumps
Prevents the reacummulation of evacuated fluid
Helps break up deposits of accumulated scar and connective tissues

45. Contraindications to compression bandaging
Acute DVT (may mobilize thrombus)
Acute infection
Cardiac edema
Advanced arterial disease <.7 on the ABI
Advanced renal disease
Malignancy (relative to severity)

46. Bandaging Short stretch- Medium stretch Long Stretch 4-layer
Unna, Comprilan
Medium stretch
Coban
Co-Plus
Long Stretch
Ace
4-layer
Profore

47. Short stretch Reduce deep venous reflux more effectively
High working pressure to low resting pressure. Produce high pressure amplitudes when patient is walking and a decrease in pressure when patient is supine
Main disadvantage is the loss of pressure following reduction

48. Short Stretch Comprilan Bandage

49. Medium stretch Sustains compression after an initial decrease
Has a fair working to resting pressure ratio

50. 2-layer Wrap

51. Long Stretch Maintain pressure for longer periods of time
A higher pressure of at least 60 mmHg is required to prevent reflux
Exert a high resting pressure which can constrict the venous and lymphatic systems creating a tourniquet effect

52. Helping Patients & Physicians Heal
Prairie medical focus only on one therapy. Can you think of patients. I don’t know how you conduct your referral process but you can fill up this referral sheet and Prairie medical will follow up with pre-auth and try to heal your patients Focus of the founder of the company.
Helping Patients & Physicians Heal

53. Pneumatic Compression Therapy
Before

54. Pneumatic Compression Therapy
Before
After 2 Weeks Pneumatic Compression

55. Pneumatic Compression Pump

56. Mechanism of Action
A gentle “milking” of lymphatic fluid out of the upper extremity. This distal to proximal motion allows for a clearance of lymphatic fluid to be filtered out of the system via the urinary tract. In essence the Pneumatic Compression pump is designed to ‘do’ what the body is incapable of due to age, damage or disease state.

57. Treatment for whole chest wall

58. Contraindications Inflammatory Phlebitis
Episodes of Pulmonary Embolism
Infections in limb without appropriate antibiotic coverage*
Presence of Lymphangiosarcoma
Congestive Heart Failure, Uncontrolled
*48 hours

59. Pneumatic Compression Therapy
Convenient home use
Comprehensive in-home or office patient training
Easy to use
Medicare and private insurance coverage
Custom sizing
Adjustable
Ability to clean the product-sanitary
Patient dictated time of use
Lifetime treatment of underlying condition

60. Compression garments Class 0 10-20 mmHg Class 1 20-30 mmHg

61. Class 0 Preventative only
Should not be used for someone with active edema

62. Class 1 20-30 mmHg Minimum compression for UE lymphedema
Offer support, but NOT sufficient for lower extremity lymphedema or CVI

63. Class 2 30-40 Most stage 2 upper extremity lymphedema
Minimum compression for LE lymphedmea
Offers good support for LE CVI

64. Class 3 40-50 mmHG Rarely used in UE lymphedema
Most stage 2 LE lymphedema
Minimum starting point for stage 3 lymphedema

65. Consideration for garment selection
Patient ability to manage garment
Material allergies
Price
Insurance coverage

66. Flat knit vs Circular knit
Custom only
Slightly easier to don
The thicker fabric offers additional features, such as its massaging effect, which promotes lymph drainage, and its strength, which ensures the stocking does not yield to the edema. In conjunction with movement, it produces a high therapeutic pressure that provides optimum compression of the tissue.
Custom or OTS
Difficult to don
Single layer of fabric
Not appropriate compression for active lymphedema, may not be adequate for sever venous edema
Cheaper

67. Goals for compression garments
MAINTAIN limb volume after decongestion. Compresion garments will NOT decongest limb
Easy don/doffing to enhance patient compliance
Cosmetically appealing

68. References
Diseases and Conditions: Chronic Venous Insufficiency (CVI). Accessed
Greenlee R, Hoyme H, Witte M, Crowe P, Witte C. Developmental Disorders of the Lymphatic System. Lymphology. 26 (1993):
Managing edema to decrease pain and increase range of motion and functional mobility. Loraine Lovejoy-Evans MPT, DPT, CLT-Foldi.
Mcdonald J, Sims N, Mayrovitz H. Lymphedema, lipedema, and the open wound. The role of compression therapy. Surgical Clinicals of North America. 83 (2003):

69. References
Norton School of lymphatic therapy course manual: Manual Lymphatci Drainage/Complete Decongestive Therapy .
Rathbun SW, Kirkpatrick AC. Treatment of chronic venous insufficiency. Curr Treat Options Cardiovasc Med Apr;9(2):
Szuba A, Rockson S. Lymphedema: classification, diagnosis and therapy. Vascular Medicine. 1998: 3:
Zuther J, Norton S. Lymphedema Management: the comprehensive guide for practitioners. 3rd ed. New York, NY: Thieme Medical Publishers; 2013.

70. LE Short Stretch Compression

72. Foam
Open Cell Grey Foam
Komprebinde
Komprex
Rosidal Soft

73. LE bandaging Lotion Stockinette to calf Toe wraps Cotton (knee, foot)
Foam (affix to calf)
Foam (affix to ankle and dorsum of foot)
Eucerin or other low pH
TG or Tricofix
Transelast/elastomull
Cellona/Artiflex

74. LE bandaging Roman Sandal Ankle sole heel (ASH, Has)
Spiral ankle to knee
Herring bone/Figure 8
Stockinette to thigh
Affix foam to thigh
Knee to mid thigh
Knee to top
Distal thigh to top
6cm Comprilan/Rosidal K
8cm
10 cm
12 cm
12cm