UPPER  EXTREMITY  LYMPHEDEMA  &  EDEMA  MANAGEMENT

Christa  Newgent  MS,PT,CLT

Presentation  Objectives

• Learn  the  pathophysiology  of  lymphedema  &  edema• Recognize  the  signs  &  symptoms  of  lymphedema  vs.  edema• Understand  the  available  treatment  for  lymphedema  &  

edema• Understand  the  components  of  complete  decongestive  

therapy• Learn  basic  manual  lymph  drainage  techniques• Know  how  to  apply  bandaging  or  taping  to  reduce  swelling• Know  when  &  how  to  recommend  a  compression  garment

Anatomy  &  Physiology• Function• Anatomy• Overview  of  drainage

• Lymph  Flow

Function  of  the  Lymphatic  System

• Transport  fluid  from  the  interstitium  and  transport  it  into  the  venous  circulation

• Transport  fat,  proteins,  and  large  molecules• Produce  lymphocytes• Recognize  and  respond  to  foreign  cells

Anatomy  of  the  Lymphatic  System

Lymphatic  system  is  comprised  of:• Lymphoid  organs• Lymph  vessels• Lymph  nodes

Lymphoid  Organs

• Lymph  nodes:  filter• Spleen:  assists  with  removal  of  old  cells• Thymus  gland:  makes  T-­‐cells;  shrinks  after  puberty

• Tonsils:  assists  with  immunity• Lymphocytes:  circulates  WBC• Intestines:  assists  with  immunity

Lymph  Vessels

Lymph  vessels  are  subdivided  into:• Capillaries• Pre-­‐collectors• Collectors• Trunks

Lymph  Nodes• 600-­‐700  lymph  nodes  in  the  body• Majority  are  in  the  intestines• Functions  include:1. Filtering  station  for  noxious  matter2. Produce  lymphocytes3. Regulate  concentration  of  protein  in  the  lymph• Lymph  nodes  are  generally  located  in  adipose  and  not  

palpable• They  have  more  afferent  vessels  than  efferent• Each  lymph  node  receives  fluid  from  a  specific  region• With  regards  to  the  superficial  system,  these  are  delineated  

by  Watersheds

Lymphatic  Watersheds

Lymph  Drainage

• Rate  of  flow  determined  by  interstitial  fluid  pressure

• Two  factors:   intrinsic  and  extrinsic• Intrinsic:  lymphangion  pumping• Extrinsic:  anything  external  that  intermittently  compresses  a  vessel-­‐mm  contraction,  movement  of  body  part,  arterial  pulsations,  respiration,  tissue  mobilization  (MLD)

Okay,  let’s  get  started  on  this.

• Under  normal  conditions,  all  but  capillary  pressure  tends  to  remain  constant.

• Blood  capillary  pressure  changes  from  30-­‐40  mmHg  (arterial  side)  to  10-­‐15mmHg  (venous  side)

• Capillary  pressure  high  on  arterial  side  leads  to  filtration

• Capillary  pressure  low  on  venous  side  leads  to  resorption

Three  factors  that  can  increase  lymphatic  load:

• Active  hyperemia=  dilation  of  the  precapillary  arteriole-­‐blood  flow  increases-­‐blood  capillary  pressure  increases-­‐filtration  increases-­‐lymphatic  load  increases

• Passive  Hyperemia=  obstruction  of  the  venous  return-­‐blood  backs  up  into  the  capillaries-­‐blood  capillary  pressure  increases-­‐filtration  increases-­‐lymphatic  load  increases

• Hyperproteinemia=reduced  resorption  in  the  venous  capillaries-­‐increase  lymphatic  load

Sufficiency  and  Insufficiency  of  the  Lymphatic  System

• The  lymph  time  volume  is  only  about  10%  of  the  maximum  transport  capacity  =  we  have  a  significant  built  in  functional  reserve

• The  lymph  vessels  respond  to  an  increase  in  water  load  or  protein  load  by  increasing  LTV  =  we  dip  into  our  functional  reserve

Lymphatic  System  Failure

• High  output  failure  is  where  the  lymphatic  load  exceeds  the  transport  capacity  of  a  healthy  lymphatic  system  =  edema

• Low  output  failure  is  where  the  transport  capacity  drops  below  the  physiologic  lymph  load  due  to  organic  or  functional  causes  =  lymphedema

• In  low  output  failure  the  lymph  system  is  unable  to  remove  the  necessary  load  from  the  interstitium,  as  a  result,  the  colloid  osmotic  pressure  will  increase  and  effective  resorption  back  into  the  blood  capillary  will  be  diminished.

Lymphedema

• The  abnormal  accumulation  of  protein  rich  fluid  in  the  interstitium  which  usually  causes  chronic  inflammation  and  reactive  fibrosis  of  the  affected  tissues

Primary  vs.  Secondary• Primary:  imperfect  development  of  lymph  vascular  system:  

aplasia,  hypoplasia,  hyperplasia• Secondary:  lymph  vascular  system  is  damaged

-­‐most  common  cause  in  the  US  is  breast  cancer  

-­‐other  types  of  cancer-­‐in  3rd world  countries-­‐filariasis  is  most  common  cause-­‐surgery-­‐trauma-­‐infection-­‐CVI-­‐obesity

Stages  of  Lymphedema

• Stage  0  – latency  -­‐ feeling  of  heaviness• Stage  1  – reversible  -­‐ better  when  limb  raised  against  gravity

• Stage  2  – spontaneously  irreversible  – gravity  isn’t  doing  anything

• Stage  3  -­‐ Elephantiasis

Usual  signs  and  symptoms• Onset  may  be  slow  or  rapid• Progressive• Pitting  • Often  starts  distally• Cellulitis  is  common• Discomfort  (ache/heavy)• Skin  changes• ulcerations

LYMPHEDEMA  vs.  EDEMA  • Edema  &  lymphedema  are  both  conditions  manifesting  as  swelling,  however  their  etiologies  differ.

• Lymphedema  results  from  inability  of  the  lymph  system  to  remove  sufficient  fluid.

• Edema  is  excess  fluid  as  symptom  of  a  known  disease  (trauma,  infection,  cardiac  origin).

• Means  of  treatment  are  common  to  both  lymphedema  and  edema.

Traumatic  EdemaCaused  by  increased  capillary  permeability.

CHARACTERISTICS

• Localized  edema  at  site  of  trauma

• There  is  a  specific  known  time  of  onset  (surgery  date)

• It  is  temporary• Edema  is  soft,  pitting,  with  

localized  discomfort• Joint  movement  is  limited

KEYS  TO  MANAGEMENT

• Responds  well  to  regional  manual  lymphatic  drainage

• Limit  inflammation  with  ice.• Control  with  compression• Joint  and  muscle  pumping  

assists  with  reducing  edema

Complete  Decongestive  Therapy

CDT  Contraindications  (general)

• Absolute:-­‐acute  infection  -­‐decompensated  CHF-­‐acute  DVT

• Relative:-­‐kidney  disease-­‐caution  on  neck  MLD  in  patients  over  60  y.o.-­‐malignant  disease-­‐osteoporosis

4  Components  to  CDT

• Skin  Care• Exercise• Manual  Lymphatic  Drainage• Compression

Meticulous  Skin  Care

• Decreases  risk  of  infection• Keep  skin  supple  and  clean• Avoid  injury• Clean  injuries  immediately• First  sign  of  infection-­‐call  doc!!!!

Exercise

• Performed  with  compression  bandage/garment  on

• PROM/AROM,  strength,  stretching• Include  diaphragmatic  breathing• Sequential  (proximal  to  distal  to  proximal)

Manual  Lymphatic  Drainage  -­‐MLD

• Increases  lymphangio  activity• Increases  resorption  of  protein  rich  fluid• Promotes  relaxation• Analgesic  effect• 10-­‐15  min.  sessions  for  regional  management  of  edema

MLD  TechniquesCommon  characteristics:• Gentle  &  predominantly  circular  stretching  of  the  skin

• There  is  a  pressure  phase  (promotes  drainage  in  desired  direction)  &  relaxation  phase  (lead  to  refilling  of  lymph  vessels)

• Application  of  technique  is  1/sec  &  5-­‐7  reps  per  “area”

• Stationary  Circles• Pump• Scoop• Rotary

Stationary  Circle

Pump  Technique

Scoop  Technique

Regional  MLD  Pattern

1. Axillary  lymph  nodes  (stationary  circle)2. Upper  arm  (stationary  circles  and/or  pump)3. Elbow  and  cubital  fossa  (stationary  circle)4. Forearm  (pump  and  scoop)5. Back  of  hand  (stationary  circle)6. Fingers  (pump)

Compression

• Reduces  filtration  rate• Improve  efficiency  of  muscle  and  joint  pumps• Prevents  reaccumulation  of  evacuated  edema  fluid

• Breaks  down  deposits  of  indurated  tissue

Compression  Contraindications/Precautions

• Arterial  disease• ABI  0.8  or  below• Acute  infection• Acute  DVT• Neurologic  conditions• Diabetes• Hypertension/cardiac  edema• Must  be  cleared  by  MD

Law  of  Laplace

• Pressure  applies  is  inversely  proportional  to  the  radius.

• Pressure  =  tension/radius• Tension  =  apply  with  even  tension  in  each  bandage

• Radius  =  the  smaller  the  radius,  the  greater  the  pressure

Types  of  BandagesShort  Stretch• Gentle  band,  comprilan,  rosidal• Provide  low  resting  pressure  and  high  working  pressure

• Minimally  elastic  which  prevent  circulatory  compromise  and  tourniquet  effect

Long  Stretch• Ace• Provide  high  resting  pressure  and  low  working  pressure

Principles  &  Goals  of  Bandaging

• Apply  multiple  “snug”  layers• Use  varying  widths• Overlap  about  50%• Even  tension• Increase  tissue  pressure

• Prevent  re-­‐accumulation  of  fluid

• Maintain  functional  mobility• Break  up  fibrosis  (foam  

inserts)• Pressure  needs  to  be  

effective  and comfortable

How  to  apply  Compression  Bandaging

• Goal  is  to  create  a  pressure  gradient  beginning  distally

• Rebandage  daily• Factors  affecting  pressure:  type  of  bandage,  application,  and  number  applied

Bandaging  vs.  Compression  Garments

• Bandaging  is  meant  to  reduce  swelling

• Must  be  reapplied  daily  with  skin  checks

• Patient  typically  cannot  apply  I’ly.

• Bandages  are  uncomfortable  and  aesthetically  unappealing

• Requires  multiple  layers  of  bandages  with  cost  not  covered  by  insurance

• Garments  are  meant  to  maintain  swelling  reduction

• With  mild  lymphedema/edema  a  garment  can  reduce  some  swelling

• Garments  are  more  comfortable  and  aesthetically  pleasing.

• Cost  not  covered  by  insurance

• Pt.  can  typically  apply  I’ly.

Compression  Garments• Garments  are  an  integral  

part  of  treatment-­‐they  are  meant  to  maintain  volume  reduction  achieved  with  CDT

• Selecting  a  garment  is  the  challenge-­‐must  work  and  be  comfortable  enough  for  patient  to  adhere  to  wearing

• Garment  must  be  financially  affordable

• Types  of  garments• Compression  classes• Choosing  a  garment• Fitting  for  a  garment• Ordering  a  garment

Types  of  GarmentsReady  To  Wear-­‐ RTW• Circular  knit• Usually  come  in  several  

sizes• Cheaper• Patient  with  mild  to  

moderate  lymphedema• Relatively  symmetrical  

shape  to  limb• Usually  lighter  and  

thinner  material• Variety  of  colors  available

Custom• Flat  knit• Ideal  for  moderate  

lymphedema• Need  more  containment• Perfect  fit• Must  be  measured  by  a  

fitter• Able  to  add  variety  of  

customization• Expensive

Compression  Classes

RTW

• Edema  glove  and  preventative:  10-­‐20  mmHg

• Class  1:  20-­‐30  mmHg• Class  2:  30-­‐40  mmHg• Class  3:  40-­‐50  mmHg• Class  4:  50-­‐60  mmHg

Custom

• Class  1:  18-­‐21  mmHg  • Class  2:    23-­‐32  mmHg  • Class  3:    34-­‐46  mmHg

Choosing  a  Garment

• Balance  of  cost,  ease  of  care,  effectiveness,  cosmesis

• Better  to  sacrifice  amount  of  compression  for  patient  adherence  – go  lighter  to  ensure  patient  will  wear  vs.  higher  compression  class  with  poor  adherence

• For  UE’s  usually  want  CCL  1  or  2• For  LE’s  usually  want  CCL  2  or  3

Fitting  and  Ordering  Garments

• Measuring  techniques• Insurance  reimbursement• Local  ordering  options• Online  ordering  options

Elastic  Taping

• Improves  blood  and  lymphatic  circulation• Increases  tissue  mobility  to  reduce  scar  formation

• Can  assist  in  releasing  adhered  tissue• Reduced  pain• Facilitates  muscle  activation

Taping  Techniques

Acknowledgments• Foldi M,  Foldi E.  Foldi’s Textbook  of  Lymphology.  2nd ed.  Munich:  Elsevier:   2006.• Guenter  Klose  MLD/CDT  Certified   Instructor,  CLT-­‐LANA.  Lymphedema   Therapy  

Certification   Course.  Presented  by  Klose  Training,  March  2010.• Courneya KS,  Friedenreich CM  (eds)  (2011),  Physical  Activity  and  Cancer,  Recent  

Results   in  Cancer  Research,.  Springer-­‐Verlag   Berlin  Heidelberg.   Chapter  8  Physical  Activity  and  Breast  Cancer  Survivorhip,  Kathryn  Schmitz.

• Fialka-­‐Moser  V,  Crevenna R,  Korpan M,  Quittan M.  Cancer  Rehabilitation.  Particularly  with  Aspects  on  Physical  Impairments.   J  Rehabil Med  2003;  35:  153-­‐162

• Kathryn  Schmitz,  PhD,  MPH,  FACSM.  Beyond  the  PAL  Trial:  Making  Resistance  Exercise   Training  Standard  of  Care  for  Breast  Cancer  Rehabilitation.   Presented   at  the  Klose  Lymphedema   Conference,  October  2011

• Jodi  Winicour,PT,  CMT,  CLT-­‐LANA.  Breast  Cancer  Rehabilitation.   Presented  by  Klose  Training,  September   2012

• Julie  Silver,  MD,  STAR  Program  Certification   Course.  Oncology  Rehab  Partners,  February  2014

• Rodrick  JR,  Poage E,  Wanchai A.    Management   of  lymphedema  with  complimentary,  alternative,   and  other  non  complete   decongestive   therapies:   a  summary  of  the  ALFP.  Lymph  Link.  2013;  26(4).

• Kase K,  Wallis   J,  Kase T.  Clinical   Therapeutic   Applications   of  the  Kinesio   Taping  Method  -­‐ 3rd  Edition.  Kinesio   Taping  Association;2013.

• Netter  F,  Atlas  of  Human  Anatomy.  2nd ed.  Novartis:  1997.