Nicole Baldridge, PT, DPT, CLT Certified Lymphedema Therapist Women’sRehab Men’s Health Physical...
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Transcript of Nicole Baldridge, PT, DPT, CLT Certified Lymphedema Therapist Women’sRehab Men’s Health Physical...
Nicole Baldridge, PT, DPT, CLTCertified Lymphedema TherapistWomen’sRehab Men’s Health Physical Therapy Residentfor Centers for Rehab Services
Lymphedema
Diagnosis and
Therapy
Secondary Lymphedema
Primary Lymphedema
Lymphedema
Lymphedema
An abnormal accumulation of protein-rich fluid in the interstitium, causing chronic inflammation and reactive fibrosis of the affected tissues
Usually in an extremity, but can also occur in the head, neck, genitals, and abdomen
Lymphedema
Affects 1% of the American population (2.5 million people)
Still poorly understood in the medical community Largest cause of lymphedema in the world is
Filariasis (considered secondary lymphedema) Filariasis is a parasitic infiltration into the
lymphatics that is very common in third world countries (affects 90 million people)
Types of Lymphedema
Primary lymphedema is a result of lymphatic dysplasia.– May be present at birth– Can develop later in life without known cause
Secondary lymphedema is much more common.– Result of surgery, radiation, injury, trauma,
scarring, or infection of the lymphatic system
Primary lymphedema
Lymphangiodysplasia – general malformation Hypoplasia – fewer than normal # of lymph collectors Aplasia – absences of collectors in a distinct area Milroy's Disease is congenital lymphedema evident
at birth Meige’s Syndrome is primary lymphedema onset at
puberty (lymphedema praecox) Lymphedema Tardum is primary lymphedema onset
after age 35
Secondary lymphedema
There is a known cause for the presence of edema Surgery: breast cancer, melanoma, prostate/bladder
cancer, lymphoma, ovarian cancer, hip replacements Radiation therapy Trauma – scarring, crush injury Infection CVI Obesity Self-induced
Stages of Lymphedema
Latency Stage Transport Capacity is reduced
No visible edema
Subjective complaints of heaviness, achiness
Stage 1
Reversible lymphedema
Accumulation of protein-rich edema
Pitting
Reduces w/elevation (no fibrosis)
Stage 2
Spontaneously Irreversible Lymphedema
Accumulation of protein-rich edema
Pitting becomes progressively difficult
Fibrosis
Stage 3
Lymphostatic Elephantiasis
Accumulation of protein-rich edema
Fibrosis, sclerosis, skin changes, papillomas, hyperkeratosis
Tissue Changes in Lymphedema
Connective tissue cells (fibroblasts) proliferate
Collagen fibers are produced Fibrotic changes, sclerosis and induration Fatty tissue increases
Angiosarcoma
Can develop after long-standing lymphedema “Stewart - Treves Syndrome” Angiosarcoma after mastectomy was first described
in 1948 by Stewart and Treves Signs: reddish-blue and blackish-blue lumps that
rapidly increase in size, bleed easily and ulcerate at an early stage
Very rare & poor prognosis
Stewart-Treves Syndrome
Lymphedema is a disease. All other edemas are symptoms.There is no cure for lymphedema.There is only management.
Diagnosis of
Lymphedema
Physical exam and history
are most important.
Characteristics of Benign Lymphedema
Slow onset, progressive Pitting in early stages Cellulitis is common Rarely painful but discomfort is common Skin changes – hyperkeratosis, papillomas,
lichenification Ulcerations are unusual Starts distally
– Toes square, positive Stemmer’s sign– Dorsum of foot “buffalo hump”– Loss of ankle contour– Asymmetric if bilateral
History
What is the reason for the swelling? How long has the extremity been swollen? How fast did the edema progress/develop? What are the underlying diseases? Is there pain? Other conditions? Other treatments? Medications?
Inspection
Location of swelling (distal or proximal) Any skin changes Lymphatic cysts, fistulas Ulcers Scars or radiation burns Papillomas Hyperkeratosis
Palpation
Temperature – indicative of infection Stemmer sign is (+) when a thickened cutaneous
fold of skin at the dorsum of the toe or finger cannot be lifted or is difficult to lift. Positive Stemmer’s sign is indicative of lymphedema.
Skin folds Pitting Fibrosis Muscular status
Diagnostic Tests
Direct lymphography: invasive, oily contrast injected into a surgically exposed lymphatic vessel. Damaging. Has been replaced by CT, MRI, US.
Lymphoscintigraphy: noninvasive, assesses dynamic process in superficial and deep lymphatics
CT MRI These tests are often not performed due to lack of
clinical importance
Differential Diagnosis
Lipedema Chronic venous insufficiency Acute deep vein thrombosis Cardiac edema Congestive heart failure Malignancy/active cancer Filariasis Myxedema Complex regional pain syndrome
Lipedema
Mainly in women Bilateral, symmetrical edema
from iliac crest to ankles Dorsum of feet never involved (-) Stemmer’s sign Little or no pitting No cellulitis Painful to palpation Bruise easily
CVI
Gaiter distribution Non-pitting Brawny Hemosiderin staining Fibrosis of subcutaneous
tissue Atrophic skin
Acute DVT
Sudden onset Unilateral Painful Cyanosis (+) Homan’s sign Potentially lethal (PE) Diagnosis with venous doppler Not treatable with PT
Cardiac edema
Right heart insufficiency Greatest edema distally Always bilateral Pitting Complete resolution with elevation No pain May treat with PT if cleared by Cardiologist
Congestive Heart Failure
Bilateral heart failure Pitting edema Orthopnea, paroxysmal noctural dyspnea,
DOE Jugular venous distension Diagnosis with physical exam, chest x-ray,
cardiac echo
Malignant lymphedema
Pain, paresthesia, paralysis Central location, proximal onset Rapid development, continuous progression Swelling and nodules in supraclavicular fossa Hematoma-like discoloration (angiosarcoma) Ulcers and non-healing open wounds Recurrent malignancy
Filariasis
Prevalent in 3rd world countries;
Can still be treated successfully with CDT.
Most therapists in the US will never encounter Filariasis.
Lymphedema Treatment Options
Pneumatic compression pump Surgery Complete decongestive therapy (CDT) Elastic support garments Medications
Pneumatic Compression Pumps
Advantages:
1. Can be used at home by patients
2. Fast application
3. Financially lucrative for DME vendors ($4000 per pump)
Pneumatic Compression Pumps
Disadvantages:
1. Disregards the fact that the ipsilateral trunk can be involved in the lymphedema
2. In LE edema, the pump can cause genital edema; in UE edema, the pump can cause breast edema
3. Does not address tissue fibrosis and extended use can cause additional fibrosis
4. Requires many hours a day with the affected limb elevated
5. The pump can traumatize residual, functioning lymphatics, especially of the UE
Pneumatic Compression Pumps
More disadvantages than advantages, but there are times when pumps are an appropriate choice
Use ONLY IF:– Teach the patient MLD to clear the trunk first– Use recommended safe settings
UE 30-40 mmHg LE 50-60 mmHg
CVI patients will benefit from a pump
Surgery
Microsurgical techniques Liposuction Debulking/Reduction procedures
Why surgical options do not always succeed…
A blocked system must be made intact The direction of flow must be correct The inflow of the reconstructed system must
be adequate and the outflow must remain open
Patency must be lasting
History of Complete Decongestive Therapy….
Emil Vodder, Ph.D., P.T. discovered that massage therapy boosted people’s
immune systems. They began to massage swollen lymph nodes and noticed common colds improving. He created his first publication of this
and coined the term MLD (manual lymph drainage).
History of Complete Decongestive Therapy….
Michael Foeldi, M.D. and Ethel Foeldi, M.D.
In the 1980’s, Prof. Foeldi advanced lymphedema considerably by combining MLD,
bandaging, exercise, skin and nail care into
“Complete Decongestive Therapy.”
Components of CDT
MLD Compression bandaging Exercise Skin and nail care Instructions in self care
Manual Lymph Drainage
MLD is a gentle manual treatment
which improves the
activity of the lymph vascular system.
In lymphedema, it reroutes the lymph flow around blocked areas into centrally
located healthy areas which then can drain into the venous system.
Manual Lymph Drainage
Manual Lymph Drainage
Improves lymph production Increases lymphangio-motoricity Improves lymph circulation and increases the
volume of lymph transported Special techniques help break down fibrous
connective tissue Promotes relaxation and has an analgesic
effect
Compression bandaging
Short stretch bandages (Rosidal, Comprilan) are applied to increase the tissue pressure in the edematous extremity.
Reduces the ultrafiltration rate Improves efficiency of the muscle and joint pumps Prevents re-accumulation of evacuated lymph fluid Helps break down fibrous connective tissue that has
developed
Exercise
Performed with the bandages on or while wearing a compression garment.
Active ROM, stretching, strengthening Low exertion Diaphragmatic breathing Increase muscle and joint pumping Increase lymph vessel activity Increase venous and lymphatic return
Skin and Nail Care
Eliminate bacteria and fungal growth by using medicated powders, hydrocortisone cream where indicated.
Reduce the risk of infection by avoiding injury, cleaning all injuries immediately, calling MD at first sign of infection.
Self Care
Patients should be instructed in the following:– Skin and nail care– Infection prevention (cellulitis is very common)– Self-bandaging– Self-MLD as needed– Exercise– Donning and doffing compression garment– Regular follow-up visits
CDT is a Two-Phase Therapy
Phase 1 (Treatment Phase) – Meticulous skin/nail care– MLD– Compression bandaging– Exercise– Self care education
** lasts as long as necessary
CDT is a Two-Phase Therapy
Phase 2 (Maintenance Phase)– Patient wears compression garments during the day– Patient bandages at night– Meticulous skin and nail care– Daily exercise– MLD as needed– Regular follow-up visits
**life long maintenance
When does CDT fail?
Malignant lymphedema Artificial (self-induced) lymphedema Insufficient treatment (only used MLD or
improper bandaging) Deviation from CDT protocol Associated illnesses Lack of compliance Active cancer Faulty diagnosis
Goals of CDT
Volume or size reduction Restore mobility and ROM Infection prevention Improve cosmesis Improve psychosocial morbidity Improve QOL
Compression garments
Elastic garments are uncomfortable and ineffective if worn while the limb is edematous.
Garments do nothing to correct the underlying cause of the edema.
Garments are NEEDED after the decongestive phase of CDT to prevent refill.
Daytime garments
Lymphedema Secondary to Breast Cancer
Primary Lymphedema of the Left Leg
Primary Lymphedema of Scrotum and Leg
Before After resection
Night-time garments
Night-time Garments
What role do medications have?
Diuretics: make edema worse; often prescribed, but draw water off protein molecules. Can cause lymphedema to become more fibrotic.
Benzopyrones: not FDA approved; stimulate macrophage activity and promote protein proteolysis; theoretically useful; effect is so slow that usefulness is questionable. Includes coumarin, rutosides, diosmin, rutin.
DIET
No specific diet for lymphedema Reducing water and/or protein intake is
ineffective Avoiding obesity is helpful General recommendations are low sodium,
high fiber, vitamin rich diets.
Increased risk of post-op complications such as infection
Reduced muscle pumping efficiency within loose tissues
Additional fat deposits contribute to arm volume
Deep lymph channels are separated by subcutaneous fat
What role does obesity play?
Randomized controlled trial comparing a low-fat diet with a
weight reduction diet in breast cancer related lymphedema
This article was published in the medical journal “Cancer” in May 2007.
It was also copy-written by the American Cancer Society in 2007
Results
The low-cal group and low-fat group had significant reductions of: – body weight– BMI– % body fat**Significant correlation between weight loss
and arm volume reduction regardless of the dietary group
**unaffected arm also showed volume reduction
Overview
This is the first study to examine the role of diet as a possible treatment for BCRL
Significant correlation of weight loss and loss of swollen arm volume
The type of diet did not affect arm volume reduction…just losing weight!
Weight loss in a healthy manner Healthy diet and exercise
Insurance coverage….
Medicare does not pay for products– Medicare HMO’s do not pay
Medicaid does not pay for products Most Highmark BC/BS, HMO, PPO pay
100% for products UPMC HMO, PPO plans…as of 1/1/08
started following Medicare guidelines, but this is changing to more coverage
Insurance obstacles…
Frustrating for the therapist because patients need these products to maintain edema and prevent worsening of edema.
We recommend products based on what the patient needs or does not need.
Often we have to change our recommendations based on what the insurance will reimburse.
Actual cost for the patient.…
Day garments: – Patients need 2 garments every 6 months– Custom fit $300-500 per garment– Ready to wear $50-150 per garment
RTW garments only come S, M, L and in a less effective fabric than custom garments
Night garments: custom only, $500-2000
More cost…
Keep in mind that all of these costs are what the DME suppliers charge for “private pay.”
Bandaging supplies for treatment– Unilateral UE/LE about $150-200– Bilateral LE >$200
How does this affect you…
Most of the DME’s in the area are “out-of-network” with Cigna
Out of network cost for these products is extremely high
Important to understand how necessary these products are and to consider approval at an “in-network” level.
Help for patients…
Susan G. Komen Foundation– Breast cancer patients– 800.462.9273
Am. Cancer Society – Any cancer $300/year– 800.227.2345
Nat’l Lymphedema Network– www.lymphnet.org– Marilyn Westbrook Foundation– Also has “Find a Therapist or Treatment Center”
THANK YOU!
[email protected] Phone/Address: Centers for Rehab Services Moon Township
1600 Coraopolis Heights Rd
Coraopolis, PA 15108(412) 269-7062
McCandless
9365 McKnight Rd #300Pittsburgh, PA 15328
(412) 630-9750
WomensRehab at Centers for Rehab Services
Specialists in treating lymphedema as well as urinary incontinence, pelvic pain, interstitial cystitis, vulvadynia, fecal incontinence, constipation and other pelvic floor hyper/hypotonicity disorders.
Locations: Cranberry, Moon, Gibsonia, Harmar, St. Margaret’s, South Hills, Oakland, Squirrel Hill, McCandless, Delmont, Monroeville, Chippewa
Referral Line 1-888-723-4CRS