20131020 03 黃睦升_淋巴水腫


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20131020 03 黃睦升_淋巴水腫

  1. 1. 衛生福利部國民健康署 2013年癌症復健相關人員培訓計畫 2013年癌症復健相關人員培訓計畫 Causes Lymphedema Primary lymphedema: present at birth or onset after puberty. Born without enough lymph nodes, or lymphatic collectors. 淋巴水腫之物理治療 彰化基督教醫療財團法人 鹿港基督教醫院 黃睦升 MS,PT Secondary Lymphedema: developed due to trauma, infection, surgery, tumors, and/ or radiation to the lymph node regions. Can be within days to several years later. 1 2 :↑2~3 times (Mortimer et al., 1997) 3 4 1
  2. 2. The Causation of Edema Lymphedema BLOOD Definition:An abnormal accumulation of tissue proteins , causing edema and chronic inflammation within an extremity. Lymphatic load Tissue Normal HighHigh-flow edema LowLow-flow edema =lymphoedema (high protein) (Grabois M. Phys Med Rehab Rev 1994;8:267-77) SafetySafety-valve insufficiency Lymphatic Transport Capacity Functional overload of the lymphatic system Lymph volume exceeds transport capacities Also occurs in the face, trunk and external genitalia. LYMPH 6 Stages of Lymphedema CTCAE: lymphedema International Society for Lymphology (Casley-Smith et al. 1985) (Common Terminology Criteria for Adverse Events v3.0) Stage 1 : pits on pressure Stage 1 Includes both objective measures (interlimb discrepancy) and subjective assessments. reduced on elevation no or mild fibrosis Stage 2 : non-pitting on pressure not reduced by elevation moderate to severe fibrosis brawny Grade 1: 5%~10% interlimb discrepancy in volume or circumference at point of greatest visible difference; swelling or obscuration of anatomic architecture on close inspection; pitting edema. Grade 2: More than 10%~30% interlimb discrepancy in volume or circumference at point of greatest visible difference; readily apparent obscuration of anatomic architecture; obliteration of skin folds; readily apparent deviation from normal anatomic contour. Grade 3: More than 30% interlimb discrepancy in volume; lymphorrhea; gross deviation from normal anatomic contour; interfering with activities of daily living. Grade 4: Progression to malignancy (e.g., lymphangiosarcoma); amputation indicated; disabling lymphedema. Stage 2 Stage 3 : elephantiasis, warts skin very thick and leathery subcutaneous tissue hypertrophied 7 Stage 3 8 2
  3. 3. Surgical Therapy for Lymphedema Drug Therapy for Lymphedema Debulking or reduction Surgery Antibiotics: for acute or chronic infections (ex: cellulitis and lymphangitis) 1. Microlymphatic-Venous Anastomosis (LVA) 2. lymphatic-venouslymphatic-plasty --Preventive antibiotics for recurrent ALD (acute lymphatic --Preventive dermatitis) (2005,20th International Congress of Lymphology) Lymphology) Diuretics: no effect or even aggravated swelling Benzo-Pyrone (Coumarin): Limitation: 1. few long term good results 2. failure after 2~3yrs --Stimulate proteolysis by macrophages --Increase the number of the macrophages over edematous limb (N Engl J Med 329; 1158-63;1993) -no effect and liver toxicity Functional or physiological surgery Liposuction --Destroy superficial & deep lymphatic pathways --Main complication:cellulitis : (N Engl J Med 340; 346-50;1999) Circumferential liposuction Post-OP + compression may sustained garment improvement in symptoms 9 Lymphatic Venous Anastomosis (LVA) 10 Circumferential Liposuction 0.5mm collecting lymphatic 0.8mm subdermal venule 11 12 3
  4. 4. In later stage, filled with fibrosis and adipose tissue poor result 移植淋巴結 當抽水幫浦 林口長庚醫院副院長鄭明輝: 「嚴重水腫的患肢就像是正在淹 水一樣,已經淹到了好幾層樓 高,淋巴結就像是抽水機,經由 顯微手術將抽水機往最低的一樓 擺,開始抽水,就能逐漸解除淹 水慘狀。」 淋巴結移植手術:從淋巴結較多 的下頷處,將部分淋巴結移植到 右腳背上。 移植後的淋巴結發揮「抽水幫 浦」作用,將堆積的淋巴液慢慢 往上輸送,過了一年多,右腿總 算慢慢恢復原貌。 13 14 15 16 In later stage, filled with fibrosis and adipose tissue surgical intervention 4
  5. 5. 腹大網膜移植手術 早發型下肢淋巴水腫( praecox)的男性患者 許文憲,2008) 的男性患者: 早發型下肢淋巴水腫(lymphedema praecox)的男性患者:(許文憲,2008) 術後7個月後之追蹤結果:其患肢體積、彈性、膝踝關節可彎曲程度及 術後7 個月後之追蹤結果: 其患肢體積、 彈性、 足踝變形程度均恢復正常,但是下肢色素沉著並無顯著改善。 足踝變形程度均恢復正常,但是下肢色素沉著並無顯著改善。 (Goldsmith HS, de los Santos R: Omental transposition for the treatment of chronic lymphedema. Rev Surg 1966;23:303-304.) 術後仍需配合復健 治療,才能使患肢 有機會恢復至接近 正常之大小,時間 約需六至八個月, 甚至更久。 有腎臟病、缺血性 心臟病患者,通常 不建議施行此一移 植手術。 17 腹大網膜移植 18 先天性兩下肢淋巴水腫 (許文憲,2008) 許文憲,2008) 32歲秘魯籍的女子,罹患先天 性兩肢淋巴水腫20年,得長年 臥床。 因為重複感染,造成兩肢嚴重 「垂足」,趾骨併發骨髓炎。 19 動員18個科別、上百名醫護人 員為她進行10餘次手術。 切除她雙腿共15公斤的淋巴纖 維化組織,並且矯正垂足,全 程腿部皮瓣移植。 20 5
  6. 6. Surgical Therapy for Lymphedema The most effective treatment? (2005,20th International Congress of Lymphology) Lymphology) Currently not enough evidence to draw conclusions about the best physical therapy to use in the treatment of lymphoedema. Supplement T’X for poor response to T’ D.L.T. Indication:conservative T’X failure. Indication: T’ (Physical therapies for reducing and controlling lymphoedema of the limbs (Review). 2007 The Cochrane Collaboration) No evidence to suggest the most effective treatment for secondary lymphedema. Surgery+DLT good long-term result longLife long D.L.T. is necessary to keep satisfactory result. (Systematic review:conservative treatments for secondary lymphedema. Oremus et al. BMC Cancer 2012, 12:6) (A Systematic Review of the Evidence for Complete Decongestive Therapy in the Treatment of Lymphedema From 2004 to 2011. Lasinski et al. PM R 2012;4:580-601) Insufficient evidence power: Inconsistencies in defining and measuring lymphedema lack of enough RCT. Small sample sizes. Ethical questions. 21 22 History of Lymphedema The medicine-based evidence is undeniably strong that CDT is an effective way to treat lymphedema. Effective for various degrees of lymphedema: mild, moderate, or severe early or late onset recent or chronic active cancer or palliative situations (Lasinski et al. PM R 2012;4:580-601) 23 15,16th century:lymphedema has been known. 1936, Vodder:manual lymphatic drainage to treat lymphedema 1950-1970, Kinmonth:D/D lymphedema & venous edema 1981, Kubik:concept of lymphatic watersheds. 1975-1980s, M. Foldi (Germany): put all techniques together with his wife (E. Foldi) 1st modern clinic for T’x lymphedema Complex Decongestive Physiotherapy (CDP) 1986, John Casley-Smith:Microcirculation combine Kubik & Foldi methods Complex Lymphatic Therapy (CLT) or Complex Physical Therapy (CPT) 1998, Foldi, Leduc, Vodder school and Casley-Smith et al. agreed: Decongestive Lymphatic Therapy (DLT) 24 6
  7. 7. Decongestive Lymphatic Therapy (DLT) Skin Care Manual Lymphatic Drainage Compression Therapy Decongestive Lymphatic Therapy (DLT) Self Drainage Exercise Intensive phase (2~4 weeks) Goal Maintain phase (6~9 months) Max. reduction in 7~10 times To mobilize the accumulated protein-rich fluid. To initiate the reduction of fibrosclerotic tissues. To maintain and even improve the results achieved in intensive phase. Loosen skin remodelling. ? * Intensive phase: repeated after loose skin remodeling (in maintain phase). *Each repeated DLT course:↓50% preserved ? 25 lymphedema 26 Obstruction of lymph vessels LYMPHOEDEMA Chronic inflammation Excess protein in tissues REPEATED INFECTIONS ↓Lymphatic load Damaged blood vessels Spasms & Thrombosis of Lymphatics Cellular debris 27 Increased Lymphatic Load 28 7
  8. 8. Skin complications of lymphedema Skin Care Education Hyperkeratosis: thickening of the epidermis. 1.Avoid 2.Avoid 3.Avoid 4.Avoid Caused by overproliferation of the keratin layer and produces scaly brown or grey patches. infection and injury pressure on the involved extremity constrictive clothing vigorous activity 重物不宜超過15磅 6.8公斤) 重物不宜超過15磅(約6.8公斤) 15 公斤 5.Avoid heat 6.Keep skin in good condition- moisture lotion 7.Avoid strong massage 29 30 Skin complications of lymphoedema Skin complications of lymphoedema Papillomatosis: multiple benign epidermal tumors Lymphangiectasia(lymphangiomata): excessive dilatation of the lymphatics Treatment: compression with multi-layer short stretch bandage. 31 due to dilatation of lymphatic vessels and fibrosis, and may be accompanied by hyperkeratosis. may be reversible with adequate compression. 32 8
  9. 9. Skin complications of lymphoedema Lymphorrhoea: leakage of lymph from the skin. The surrounding skin should be protected with emollient, and nonadherent absorbent dressings should be applied. Bandages will reduce the underlying lymphoedema, but needs to be changed frequently to avoid maceration of the skin. In the palliative situation, light bandaging may be more appropriate. ↑Lymphatic transport capacity 33 34 Initial lymphatic (2,3) Collecting lymphatic (5) Vascular & Lymphatic System 1-epidermis 6-deep fascia 8,9-two adjacent drainage regions Lymphatic System Lymphotome & Watershed 35 36 9
  10. 10. The Passage of Protein in Normal Tissue Blood capillary Tissue channel Lymphatic system Effect of MLD Vein Mechanically move fluid into initial lymphatic. Make initial lymphatic & collecting lymphatic pumping & being emptied repeatedly. Open valves of collecting lymphatic that crossed watershed. Set up collateral pathway. 37 MLD techniques Casley-Smith: The Strokes Nodal massage Clearing across the watersheds Blocking flow Clearance of deep trunk areas 38 Massage Technique Vodder: four basic strokes Stationary circle: for lymph node Pump technique: for extremities Rotary technique: for trunk Scoop technique: for lower parts of extremities Massage area should be exposed! Stroke pressure : <80 g/cm2 (60 mmHg). gentle, not redness or pain. 20-40 m in diameter 壓力小於30mmHg即可使淋巴液通過微淋巴管,在動物實驗中,過大的力道(壓力大 於60mmHg)會使得微淋巴管塌陷。 Slowly with control: with minimal friction by hands & fingers. Speed: the greater the amount of fluid, the slower the movement. 40 min : 30 (trunk)/10(affected limb) Higher pressure over watershed, lymph node and fibrosis area. Watershed area:6cm (3cm from the midline and crossed over it 3cm) *Ulnar side of hand:vertical to watershed *Bil. thumbs encircle:for lateral trunk 39 40 10
  11. 11. Massage for fibrosis area Drainage pathway & Sequence 對於肢體或體表上很堅硬、纖維化的區域,可加重按摩力道, 創造新的組織通道(tissue channel),即使這些通道已經沒有 瓣膜、也喪失推動淋巴液的功能,卻仍然能提供一個通向含有 正常淋巴管的區域。 另外,外在的壓迫(compression)是必須的,以保持淋巴液在這 些沒有瓣膜的組織通道能抵抗重力的往上回流。 然而在纖維化區域中,微淋巴管的內皮層可能會不正常的被打 開或撕裂,造成更多的淋巴液從微淋巴管滲漏出來,因而需要 馬上纏繞低壓力彈性繃帶。 若因為某種因素,而無法使用低壓力彈性繃帶,則必須省略纖 省略纖 維化區域的按摩,否則將造成淋巴液滲漏、組織間隙的蛋白質 維化區域的按摩 濃度升高、局部皮膚溫度上升、水腫加劇,甚至有感染的可 能。 Posterior Trunk Anterior Trunk 41 42 Drainage pathway & Sequence Face Lymph Pathways 1 43 2 44 11
  12. 12. Respiration Lymphatic Drainage Lymph flows into the sub-clavian veins most rapidly at the peak of inspiration. A one-way drainage:remove protein and excessive fluid Initial lymphatic pre-collector collecting lymphatic lymph node The rate of flow of lymph into venous circulation is proportional to the depth of inspiration. The mechanism of inspiration: Superficial pathway * Intra-thoracic pressure decreases decreased pressure of the thoracic duct in the thoracic portion. lymphatic trunk collecting duct thoracic duct sub-clavian vein vena cava R’t atrium Deep pathway 45 教導患者做腹式呼吸(abdominal breathing),吸氣到最飽最深的程度、 接著吐氣時輔以治療師雙手給予往內 往上的壓力,產生較大的腹壓。 sub-costal MLD practice: External genitalia Pelvic Scoop: M-breathing sub-costal The fingers placed superior the pubic symphsis. Toward the umbilicus. A really deep pressure. Umbilicus Inside the pelvic rim 46 When working on the legs observe the pubis and the genitalia if became edematous, esp. scrotum. 當下肢與生殖器的淋巴水腫合併存 在時,需注意生殖器的皮膚照護、避 免黴菌感染,若只治療下肢淋巴水腫 (如淋巴引流或壓縮療法),則可能會 加重生殖器淋巴水腫症狀,因此軀幹 淋巴區的清空則更加重要! Inside the pelvic rim •若合併有腹水 若合併有腹水(ascites)症狀, 症狀, 若合併有腹水 症狀 則不適合實施M-breathing。 則不適合實施 47 48 12
  13. 13. Past hx:R’t THR (+) 、R’t drop foot : Cervix Ca. S/P with R’t thigh and buttock lymphoedema PT for Post TRAM Procedure Evaluation: – Inspect the flap for color, temperature, capillary refill – Signs of swelling on the involved side – Signs of infection, decreased tissue perfusion, or edema 49 Rehabilitation Goals To reduce stress on the sutures of the abdominal wound closure Prevent subdermal fibrosis and adhesions 1. Positioning the head of the bed at a 450 ↓lymphostasis 2. Lie on the uninvolved side in a fetal position Modulate abnormal sensation 3. May also hug a pillow closely to the chest when coughing and avoid a Valsalva maneuver by exhaling during physical exertion. Restore trunk alignment 4. Use "log-rolling" techniques without disrupting the abdominal sutures. ↓stress on the lumbar spine 5. Maintain trunk flexion during transfers Optimize proprioceptive acuity in residual abdominal m. Encourage normal muscle recruitment patterns – supine to sitting – sitting to standing – ambulation for short distances 6. Ambulation generally begins the postoperative day 1. 13
  14. 14. Post TRAM Exercise One week after: – active and active assistive exercises of upper extremities with achieving full range of motion. – General lower-extremity isometric exercises to prevent deconditioning. Several weeks after – Abdominal strengthening exercises. – Lifting and sit-ups are not permitted until 6 weeks. Trunk strengthening Exercises be for co-contraction of the oblique, transversus abdominis, and multifidus muscles. Examples of exercises: – hook lying with pelvic rotation against resistance at the knee – sitting with isometric trunk rotation against resistance – bridging with isometric pelvic rotation against resistance A home exercise program with self-resistance. This time frame will depend on healing and on an individual basis by the surgeon. 熱敷有助傷口復原及減少莢膜攣縮 低溫燙傷」 「低溫燙傷」 MLD practice: Breast reconstruction 14
  15. 15. Multiple channel pneumatic pump optimal pressure parameters are not been established little or no lasting beneficial effects fail to move lymph into different lymphtic quadrant may damage remaining health lymph vessels need to combine self massage to the neck & trunk ↑Lymphatic transport capacity 58 57 Compression Therapy Effects of compression Multi-layer bandage Reduction in capillary filtration by enhanced tissue pressure Shift of fluid into non-compressed parts of the body Increase in lymphatic re-absorption and stimulation of lymphatic transport Improve rhythmic lymph pulsation Breakdown of fibrosclerotic tissue Suture line & cuff effect 59 Compression garment 60 15
  16. 16. Short stretch bandages (in-elastic) Bandaging Principles low resting pressure & high working pressure Maintain slight tension on bandages, except for wrapping fingers or toes. The bandage should never be stretched to its maximum length. The first bandage is always “light”, then increase pressure slowly over a comfortable period of time. Graded pressure:decreasing from distal to proximal. : Use only tape to fix a bandage.(clamps are dangerous; they can injure the skin and cause serious infections). Check pressure gradient after completing the bandage. 61 Multi-Layer Bandage Cautions with Bandages Padding: Protect the skin and tissue preventing friction and shearing. Reshape the limb to a cylindrical shape provides a smooth surface for an even distribution of cross-sectional sub-bandage pressures, with a decreasing pressure gradient from distal to proximal points. Even pressure by padding. 63 Different radius 62 Very high pressures may be achieved over pressure points. A joint bandage needs to provide adequate pressure to enable reshaping but reduce the potential for shearing and friction. Reducing slippage (may result in a tourniquet effect) Applied pressure should be with uniform tension over the limb. 64 different pressure. 16
  17. 17. Addressing specific problems When to Remove Bandages □ Limb distal part: soreness, numbness, more swelling, pain can’t relive by e’x □Fingers nail: cyanosis, cold ※Bandages should always be adapted to the individual: age, diagnosis, and other condition-DM or peripheral neuropathy. 65 66 Bandaging the Head and Facial area Lymphoedema bandaging for head, breast and genitalia A 12–16cm wide tubular bandage, folded in half Pressure: Hook-and-loop fasteners for easy apply. applied gently and low to prevent paraesthesia or bruising in irradiated regions. No compression on neck. 67 The padding is placed within the tubular bandage. To increase local pressure: by placing several layers of foam.(fig2.) 68 17
  18. 18. Compression of the breast Bandaging the male genitalia-1 A cup shape thick foam(1.5-2.5cm): provide a micro-massage effect(Fig5) Cohesive bandage to prevent slippage. Allow for urination. Gently squeezes the fibrosis. (Fig6: L’t breast) In severe lymphoedema, the penis and scrotum are also padded with 3-4cm thick foam. Foam padding: extended to underneath the armpit and overlap the edges of the bra prevent tourniquet effect.(Fig7) 69 Bandaging the male genitalia-2 70 Bandaging the male genitalia-3 Foam padding: Primary genital lymphoedema with long-term compression and elevated temperatures in the testicles can result in fertility problems. at least 2cm thick anatomically contoured foam. Begin with a low level of compression and depending on the severity and response. Female genital lymphoedema: More complex at least 1cm thick of custom-made anatomically contoured foam Patients or their care-givers must learn self-bandaging skills because excess fluid can rapidly accumulate in the external genitalia if treatment is interrupted. 71 Attention to common cellulitis and fungal infection. 72 18
  19. 19. Compression Garment Contraindications to high compression Acute infection with local and/or systemic symptoms Untreated DVT Untreated cardiac failure or HTN Untreated genital oedema Proven arterial insufficiency (ABPI <0.5–0.8) Class I : 20-30 mmHg hypertrophy scar, mild varicose vein Class II : 30-40mmHg mild arm lymphoedema Class III : 40-50 mmHg severe arm & mild leg lymphoedema Class IV : >50 mmHg. severe leg lymphoedema. 73 74 Self Drainage Exercise Improve muscular contractions and joint mobility. Reduce muscle atrophy. Muscular contractions along with the low-stretch bandages provide constant counter pressure to keep the lymph fluid moving. ↑Lymphatic transport capacity 75 76 19
  20. 20. 消腫運動的基本原則 要求自己每天做以達到最好的效果。 不要穿太緊的衣服,以免阻礙淋巴回流。 需先穿上彈性衣或綁著彈性繃帶時,做消腫運動 才有效果。 一定要按照每項運動的順序,就像按照淋巴引流 的順序一樣。 每項運動不要做太快,慢慢的數1.…2….3….。 運動不可以太累而讓肌肉酸痛,適量就好。 花費的時間:大約是30分鐘,但是一天若只做 10分鐘也總比都沒有做的好。 77 78 FAQ 79 80 20
  21. 21. Avoid heavy lifting and resistance-training exercise for arm lymphoedema? ? 徒手淋巴引流是否加速癌症轉移? 徒手淋巴引流是否加速癌症轉移? 一些學者認為徒手淋巴引流會將惡性癌細胞經由 淋巴結傳輸到血管系統,最後使癌細胞散佈全 身。然而當組織直接接觸到不同的癌細胞,必須 視癌細胞的生物特性及免疫系統的狀況,並不一 定會讓癌細胞散佈全身或形成轉移。 因此,不管患者的癌細胞仍存在或是復發,在先 經過必要的醫療處置後,如化學治療或放射線治 療等,都可接受去腫脹淋巴治療。 •Lawenda BD, Mondry TE, Johnstone PAS. Lymphedema: A primer on the identification and management of a chronic condition in oncologic treatment. CA: A Cancer Journal for Clinicians 2009;59(1):8-24. •Pinell XA, Kirkpatrick SH, Hawkins K, Mondry TE, Johnstone PAS. Manipulative therapy of secondary lymphedema in the presence of locoregional tumors. Cancer 2008;112(4):950-4. 即使文獻指出阻力式訓練或重量訓練可能使上肢淋巴水腫 的症狀惡化,使得臨床上對運動強度的設定仍趨於保留、 使得水腫肢體變的無力。(2006,Markes M) 但仍有學者以隨機控制實驗指出,6個月的重量訓練對上 肢淋巴水腫肢體的周徑及主觀症狀並無影響。(2006, Ahmed RL) 甚至以持續13週、每週兩次、共90分鐘的舉重運動可有效 緩解乳癌術後上肢淋巴水腫的症狀。(2009, Schmitz KH) 81 Predictive factors for DLT effect in lymphedema •Markes M, Brockow T, Resch KL. Exercise for women receiving adjuvant therapy for breast cancer. Cochrane database of systematic reviews (Online) 2006(4). •Ahmed RL, Thomas W, Yee D, Schmitz KH. Randomized controlled trial of weight training and lymphedema in breast cancer survivors. Journal of Clinical Oncology 2006;24(18):2765-72. •Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L et al. Weight lifting in women with breast-cancer-related lymphedema. The New England journal of medicine 2009;361(7):664-73. 82 Predictive factors for DLT effect in lymphedema Baseline PEV was the only predictor of PREV in our study. (including breast cancer related & lower extremity lymphoedema) a lower PEV would predict a better response to DLT. Duration of LE lymphedema was not associated with PREV (DLT effect). Studies on BCRL reported the opposite conclusion PEV=(baseline VL−VH)/VH×100% PEV: percent of excess volume PREV=100%×(post-treatment VL−baseline VL)/excess volume PREV: percent reduction in excess volume (DLT effect) Longer duration of UE lymphedema would induce higher PEV and lead to worse DLT efficacy. early intervention in patients with mild lymphedema would achieve better DLT efficacy. 83 84 21
  22. 22. Treatment Goal A cure is not yet available. T’x is difficult, costly, and time consuming. Aims -to reduce and control the amount of swelling in an affected limb -to restore the function and cosmetics. 86 85 Vicious Circles of Oedema Take Home Message DLT: skin care, MLD(<60mmHg), compression therapy, self drainage exercise. To reduce lymphatic load: skin care. To improve lymphatic transport capacity: MLD compression therapy self drainage exercise. 88 22