Lymphedema and compression Flashcards
1
Q
Main functions of lymphatic system:
A
regulate fluid balance
assist with infection control
2
Q
How much fluid is removed from interstitial space/day?
A
18 liters
3
Q
Where is fluid removal from?
A
80-90% through veins
remaining 2-4 liters thru lymph system
4
Q
Estimates of lymphedema type:
A
23–45% of patients after breast cancer
21% of patients after ovarian cancer
28% of patients after endometrial cancer
Up to 70% of patients after prostate cancer
5
Q
When does lymphedema occur?
A
when the lymphatics cannot remove the remaining interstitial fluid
6
Q
Chief complaints of lymphedema?
A
Limb heaviness, paresthesias, achiness, skin tightness, poor-fitting clothes, altered cosmesis, decreased ADLs and ROM
7
Q
Lymphatic anatomy:
A
superficial
deep
perforating
8
Q
Superficial lymphatics
A
Drains the skin and subcutaneous tissue
Roughly parallels the veins
9
Q
Deep lymphatics
A
Drains all else (deep tissues and organs)
10
Q
Lymph
A
fluid made up of water, protein, dead/dying cells/cellular components, fatty acids, foreign material and debris
11
Q
Lymphangion
A
functional unit of the lymph system
12
Q
Smaller lymph anatomy:
A
capillaries precollectors collectors nodes trunks
13
Q
Central Lymphatic Flow
A
Unidirectional valves Skeletal muscle contraction Respiratory pump Aortic pulsations Lymphangiomotoricity
14
Q
What is fluid movement between capillaries, interstitium, and lymphatic system governed by?
A
hydrostatic and osmotic pressure
15
Q
Dynamic insufficiency:
A
If the lymphatic load exceeds the transport capacity of the lymphatic system, edema will occur
16
Q
Mechanical insufficiency:
A
a decrease in the maximal transport capacity of the lymphatic system, mechanical insufficiency can result
17
Q
Types of lymphedema
A
primary
secondary
vessel abnormality
age on onset
18
Q
Primary
A
10% of all cases
Congenital malformation or impairment of lymphatics
LE affected most often
19
Q
Secondary:
A
Acquired
Disruption of or damage to lymphatics
Much more common
20
Q
What illnesses is secondary lymphedema common in?
A
Filariasis (parasitic infection)
Cancer treatment
Chronic venous insufficiency
21
Q
Vessel Abnormality
A
Aplasia
Hypoplasia
Hyperplasia
Lymph node fibrosis
22
Q
Age at Onset
A
Congenital
Praecox
Tarda
23
Q
Lipedema
A
Bilateral, symmetrical increase in adipose tissue deposition
24
Q
What areas does lipedema most commonly affect?
A
Affects abdomen, buttocks, lower extremities but spares the feet
25
Causes of lipolymphedema;
Increased compliance of fat allows interstitial fluid to accumulate
26
Risk Factors for Lymphedema
```
Lymph node status
Radiation therapy
Time since surgery
Air travel without compression
Inflammation/Increased Lymphatic Load
Decreased Lymphatic Return
```
27
Lymph Node Status
Surgical removal increases risk
| More removed, the greater the risk
28
Sentinel lymph node
the first lymph node to receive lymph from a tumor
29
Radiation Therapy
```
Peri-lymphatic and lymph node fibrosis
Skin damage
Sclerosis/fibrosis
Dermal atrophy
Decreased sweat glands
```
30
What percentage of breast cancer patients who had lumpectomy and axillary radiation developed lymphedema?
26%
31
Time Since Surgery
Risk increases over time
Possibly due to lymphatic fatigue
Increased Body Mass Index
32
Air Travel Without Compression
Decreased atmospheric pressure on body while flying allows body to swell
May extrapolate to increased risk when going to areas of high elevation
Compression garment offsets this pressure change
33
Inflammation/Increased Lymphatic Load
Inflammation and infection increase lymphatic load
Avoiding strenuous activity of at-risk limb may prevent muscle microtrauma and inflammation – increased fluid that the patient’s lymph system may not be able to accommodate
34
Decreased Lymphatic Return
Constrictive clothing/jewelry
Tourniquets, blood pressure cuffs
Those Prone to Scar Tissue Formation
Trauma from surgical removal of tumor, nodes, and tissue dissection may cause more scar tissue formation in some patients, such as those at risk for keloids
35
PT Tests and Measures
| for Lymphedema
Circumferential Measurements
Weight change with compression
Circulation
Sensory Integrity
36
Gold standard for lymphedema measurements?
volumetric displacement
37
Why is volumetric displacement rarely used?
increased time, infection
| risk, equipment needs
38
Circumferential Measurements
Reliable
Can use software programs to convert to volume
Can measure limb every 3, 4, 8, or 12 cm
Include landmarks needed for garments
39
How can software programs be used to convert to volume?
Compare side-to-side
Compare changes over course of treatment
Compare over time
40
Pulses
Palpation
| Doppler if needed
41
Other circulation methods to measure for lymphedema?
Capillary refill
Ankle-Brachial Index or Toe-Brachial Index on patients with lower extremity lymphedema
Screen patients with lower extremity lymphedema for DVT
42
Sensory Integrity
Perform monofilament testing on all patients with lymphedema
43
What can nerve entrapments be caused by?
tissue distention, edema, and inflammation
44
Patients at risk for neuropathy
Those with diabetes
| Those who received chemotherapy
45
Stage 0
latent
No edema present
Reduced transport capacity of the lymphatic system
Most commonly due to surgery or radiation
46
Stage 1
Reversible
Edema that pits when digital pressure is applied
Greatly or completely reduces with elevation
No secondary skin changes
47
Stage 2
Spontaneously Irreversible
Does not pit when digital pressure is applied
Does not reduce substantially with elevation
Skin becomes fibrotic or brawny
May have frequent skin infections
48
Stage 3
Lymphostatic Elephantiasis
Extreme increase in limb volume
Deep skin folds and papillomas present
Frequent skin infections
49
Mild lymphedema
<3 cm interlimb difference
| <20% limb volume increase
50
Moderate lymphedema
3–5 cm interlimb difference
| 20–40% limb volume increase
51
Severe lymphedema
>5 cm interlimb difference
| >40% limb volume increase
52
5PT Method
```
Pain
Position
Presentation
Periwound
Pulses
Temperature
```
53
Pain
```
Deep ache or pressure
stretch pain
neuropathic pain
pain from infection or inflammation
discomfort, heaviness
If patient complains of pain rather than the above sensations, further evaluation or referral is warranted
```
54
Position
Distal to area of lymphatic obstruction or damage
Must know:
Normal anatomy and drainage patterns
Surgery/procedures in past medical history
55
Presentation
lymphorrhea
serous drainage
Drainage can be significant, especially in lower extremity
If infected, drainage may be purulent, seropurulent, and/or copious
Slough-covered wound common
56
Periwound and Structural Changes
```
pitting
fibrotic
peau d'orange
Stemmer's sign
papillomatosis
fungal infection (scaling, thickened nails)
Hemosideran
deep skin folds
hair loss
Lichenification
Lymphorrhea
Dermatitis
Ulceration
Xerosis
```
57
Peau D’Orange
a dimpling of the skin that gives it the appearance of the skin of an orange. Often due to lymphatic obstruction
58
Pulses
normal
59
Temperature
```
Normal
May be warm to touch due to:
Edema
Inflammation
Infection
```
60
Prognosis for mild lymphedema
will require 5–10 visits
61
Prognosis for moderate lymphedema
will require 14–24 visits
62
Prognosis expectations:
Earlier access means faster recovery
Can expect 22–73% volume in 6–36 visits
Lipolymphedema and stage IV cancers make least progress
63
Proactive education program
For at-risk patients
For providers who deal with at-risk patients
For cancer survivor groups
64
Do list:
protect from injury, skin checks, how to treat open areas, ideal weight, exercise, garment wear/care
65
Don’t list
injections/BP/piercings/tattoos in affected area, hot tubs/saunas, walking barefoot
66
Precautions
Rule out cancer recurrence as cause of lymphedema
Spontaneous lymphedema without prior history of lymphatic trauma should be screened by MD
Screen patients with lower extremity lymphedema
Arterial insufficiency
Deep vein thrombosis
67
Request for Further Medical Testing
Wound culture and sensitivity if signs and symptoms of infection
Rule out recurrence
If cannot perform an ABI
68
Skin Care
Keep skin clean and dry
Avoid perfumes, high-alkaline soaps
Use low pH moisturizers
If open wound, wash with soap and water, apply topical antimicrobial, cover
69
More skin care:
```
Protect surrounding skin
Skin sealant/moisture barrier
Lotion to intact skin
Absorptive dressing
Compression
Educate patient/caregivers
```
70
Therapeutic Exercise
```
Patient positioning
Active range of motion
Flexibility exercise
Anaerobic exercise
Aerobic exercise
Breathing exercise
```
71
Manual Therapy
No method is superior but including manual therapy leads to better results
Advanced training or certification is recommended
72
Manual therapy techniques:
Manual lymphatic drainage
Simple lymph drainage
Lymphatic massage
73
Benefits of Manual Therapy
```
Increases lymph formation
Propels lymph proximally
Increases lymph angiomotoricity
Reroutes stagnated lymph
Encourages development of collaterals
Reduces sympathetic and increases parasympathetic responses
Decreases pain/promotes relaxation
Decreases fibrosis
```
74
Precautions/Contraindications
| for Manual Rx
```
DVT
Active infection
open wound
metastatic disease
CHF
Asthma
Abdominal inflammatory condition/pregnant
```
75
Open wound precautions:
treat intact skin only
76
Metastatic disease precautions:
can use palliatively
77
CHF precautions:
start slowly, progress slowly
78
Asthma precautions:
start slowly, monitor asthma
79
Abdominal inflammatory conditions/pregnant precautions:
do not perform deep abdominal treatment
80
Manual therapy movement:
Clear (empty/drain) proximally before moving incrementally more distal
Venous angles where lymphatics empty into venous system
Trunk
Affected extremity
Rework often to reclear
81
Compression Therapy
```
Reduces ultrafiltration
Enhances venous return
Improves effectiveness of muscle pump
Increases angiomotoricity
May reduce fibrosis
```
82
Multilayer Compression Bandaging
```
Skin care: wash, dry, apply lotion
Wound care as needed including absorptive dressing
Cotton liner
Digit bandage
Padding: cotton, foam, custom-made
Short-stretch compression bandages
```
83
Precautions/Contraindications
| for Compression Bandaging
Arterial insufficieny
Radiation damage with intact skin
DVT
CHF: start slowly, progress slowly
Open wound: proper infection control, appropriate dressing/skin care
Infection
Patients who are weak, immobile, insensate
84
Mild lymphedema
| Prophylactic UE
10–21 mm Hg
| Light
85
Moderate to severe UE lymphedema
| Mild LE lymphedema
15–32 mm Hg
| Medium
86
Moderate to severe LE lymphedema
30–40 mm Hg
| Strong
87
Stage 3 LE lymphedema
<40 mm Hg
| Very strong
88
Compression Pumps
Single or multichamber
Ideally also compresses trunk quadrant
Poor patient adherence
Rarely good intervention strategy
89
What does a compression pump do?
Remove fluid from the area, but not protein
Once stopped, protein draws fluid back
Residual protein leads to fibrosis
90
Two phases of intervention
intensive
| self-management
91
Intensive
High frequency of visits over short term
| Learn self-care
92
Self-management
Ongoing
| Maintenance of edema reduction
93
Medical Testing
Rule out serious medical conditions
Cancer/recurrence of cancer
DVT
CHF, etc.
94
Medical Interventions
Manage risk factors
| Pharmacological
95
Surgical Interventions
Debridement
Microsurgical procedures
Debulking surgeries
96
Effects of Compression
```
Enhances calf muscle pump
Improves venous return
Decreases peripheral edema
Reduces venous distension
Increases tissue oxygenation
Softens lipodermatosclerosis
Protects limb from trauma
Limits need for prolonged elevation/bed rest
```
97
Compression Parameters
30–40 mm Hg at ankle
10 mm Hg at infrapatellar notch
If severe VI, can increase to 40–50 mm Hg
If mild AI, can decrease to 20–30 mm Hg
98
Contraindications to Compression
```
ABI < 0.7
Acute infection
Pulmonary edema
Uncontrolled or severe congestive heart failure
Active DVT
Claustrophobia (relative)
```
99
Types of Compression
```
Paste bandage
Short-stretch compression bandage
Multilayer compression bandage system
CircAid
Tubular bandages
Compression garments
Vasopneumatic compression devices
```
100
Paste Bandages
```
A nonelastic compression
Gauze, in a cloth roll bandage that is impregnated with zinc oxide, calamine, glycerin, and gelatin
Hardens into a semi-rigid support
Stays on for up to 1 week
Used on ambulatory patients
```
101
Paste bandage disadvantage:
odor
pruritus
Inability to shower or get the dressing wet
Should not be used in areas of high humidity
Unable to accommodate changes in limb size
102
Short-Stretch Compression Bandages
Low resting pressure and little distensibility
Ambulatory and nonambulatory patients
Amount of compression determined by Laplace’s law
Need enough to reduce edema without causing ischemia
103
Short-Stretch Compression Bandages disadvantages
Prone to slippage, causing frequent wrapping
| Patients must be trained in correct technique
104
Inner layer
Absorbs excess wound drainage
| Provides padding
105
Middle layer
short stretch
106
Outer layer
1–2 layers are long stretch providing increased compression
107
Multi-layer Bandage
Mimics high working pressure (during standing up to almost 50mmHg) and low resting pressure for tolerance at night
Used mostly in the presence of ulcerations
108
Velcro Compression Garment
Removable, semi-rigid orthotic compression device
Consists of rows of nonelastic Velcro straps that provide sustained compression
Easy to apply
109
Velcro Compression Garment Disadvantages:
High one-time cost
| Need for patient adherence for daily wear
110
Tubular Bandages
Off-the-shelf sleeves
Available in several widths and compressions
Allow for graduated compression
111
Tubular Bandages Disadvantages:
Generic shapes and sizes do not accommodate all patients
| Bandages lose shape and compression in a short time
112
Long Stretch Bandage
Provide mild compression (18-24 mm hg)
Must be applied properly to be effective
Can decrease dependent edema
Elastic-extend beyond 100%
113
Compression Stockings
Gradient with pressure greatest at the ankle and decreasing superiorly
Flat knit vs. circular
Over the counter vs. custom
8-50mmHg
114
Compression Hose light support
8-14mmHg- edema prevention for extensive sitting and standing with minimal activity
115
Compression Hose antiembolism stockings:
16-18mmHg- Deep vein prophylaxis, non- ambulatory patients with edema, includes TED hose
116
Compression Hose low compression
18-24mm Hg - Non-ambulatory patients with edema failing 16-18mmHg stockings, includes elastic bandages and paste bandages for clients with dependent edema
117
Compression Hose low to moderate
25-35 mmHg- edema secondary to venous insufficiency, for clients able to participate in exercise, includes 4-layer wraps
118
Compression Hose moderate
30-40mmHg- Edema with or without ulceration, edema that persists despite lower level compression options, includes four layer bandage
119
Compression Hose high
40-50mmHg-edema secondary to lymphedema
120
Compression Class 0
< 20mmHg
| non ambulatory patients
121
Compression Class 1
20-30 mmHg
mild venous insufficiency
VI with mild AI
122
Compression Class 2
30-40 mmHg
| moderate VI
123
Compression Class 3
40-50 mmHg
| severe VI
124
Compression Class 4
> 50 mmHg
| severe VI
