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淋巴水腫之物理治療 黃睦升

淋巴水腫之物理治療 黃睦升






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    淋巴水腫之物理治療 黃睦升 淋巴水腫之物理治療 黃睦升 Document Transcript

    • Outline Lymphedema causes & stages 淋巴水腫之物理治療 Conservative therapies for lymphedema Decongestive lymphatic therapy Skin care 彰化基督教醫院鹿基分院 Manual lymphatic drainage 黃睦升 Compression therapy 2012-11-04 Self drainage exercise Benigh & malignant lymphedema Take home messages 1 2Causes Lymphedema Primary lymphedema: present at birth or onset after puberty. Born without enough lymph nodes, or lymphatic collectors. 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. 3 4 The Causation of Edema BLOOD Lymphatic load Low-flow Tissue High-flow edema Safety-valve Normal =lymphoedema edema insufficiency (high protein) Lymphatic Transport LYMPH 5 1
    • Lymphedema Stages of Lymphedema International Society for Lymphology (Casley-Smith et al. 1985) Stage 1 Stage 1 : pits on pressureDefinition:An abnormal accumulation of tissue reduced on elevationproteins , causing edema and chronic inflammation no or mild fibrosiswithin an extremity. (Grabois M. Phys Med Rehab Rev 1994;8:267-77) Stage 2 : non-pitting on pressure Stage 2 not reduced by elevation moderate to severe fibrosisFunctional overload of the lymphatic system brawny Lymph volume exceeds transport capacities Stage 3 : elephantiasis, wartsAlso occurs in the face, trunk and external genitalia. skin very thick and leathery subcutaneous tissue hypertrophied 7 8 Stage 3 CTCAE: lymphedema The most effective treatment? (Common Terminology Criteria for Adverse Events v3.0)Includes both objective measures (interlimb discrepancy) and Currently not enough evidence to draw conclusionssubjective assessments. about the best physical therapy to use in the treatment Grade 1: 5%~10% interlimb discrepancy in volume or of lymphoedema. circumference at point of greatest visible difference; swelling or (Physical therapies for reducing and controlling lymphoedema of the limbs (Review). 2007 The Cochrane Collaboration) obscuration of anatomic architecture on close inspection; pitting edema. No evidence to suggest the most effective treatment for Grade 2: More than 10%~30% interlimb discrepancy in volume secondary lymphedema. or circumference at point of greatest visible difference; readily (Systematic review:conservative treatments for secondary lymphedema. Oremus et al. BMC Cancer 2012, 12:6) apparent obscuration of anatomic architecture; obliteration of (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) skin folds; readily apparent deviation from normal anatomic contour. Grade 3: More than 30% interlimb discrepancy in volume; Insufficient evidence power: lymphorrhea; gross deviation from normal anatomic contour; Inconsistencies in defining and measuring lymphedema interfering with activities of daily living. lack of enough RCT. Grade 4: Progression to malignancy (e.g., lymphangiosarcoma); Small sample sizes. amputation indicated; disabling lymphedema. Ethical questions. 9 10 History of Lymphedema 15,16th century:lymphedema has been known.The medicine-based evidence is 1936, Vodder:manual lymphatic drainage to treat lymphedemaundeniably strong that CDT is an effective 1950-1970, Kinmonth:D/D lymphedema & venous edema 1981, Kubik:concept of lymphatic watersheds.way to treat lymphedema. 1975-1980s, M. Foldi (Germany):Effective for various degrees of put all techniques together with his wife (E. Foldi) 1st modern clinic for T’x lymphedemalymphedema: Complex Decongestive Physiotherapy (CDP) mild, moderate, or severe 1986, John Casley-Smith:Microcirculation combine Kubik & Foldi methods early or late onset Complex Lymphatic Therapy (CLT) recent or chronic or Complex Physical Therapy (CPT) 1998, Foldi, Leduc, Vodder school and Casley-Smith et al. agreed: active cancer or palliative situations (Lasinski et al. PM R 2012;4:580-601) Decongestive Lymphatic Therapy (DLT) 11 12 2
    • Decongestive Lymphatic Therapy Decongestive Lymphatic Therapy (DLT) (DLT) Manual SelfSkin Compression Intensive phase Max. reduction in 7~10 times Lymphatic Drainage To mobilize the accumulated protein-rich fluid.Care Therapy (2~4 weeks) To initiate the reduction of fibrosclerotic tissues. Drainage Exercise Goal Maintain phase To maintain and even improve the results achieved in intensive phase. (6~9 months) Loosen skin remodelling. ? * Intensive phase: repeated after loose skin remodeling (in maintain phase). ? *Each repeated DLT course:↓50% preserved 13 lymphedema 14 Obstruction of lymph vessels LYMPHOEDEMA Chronic inflammation Excess protein in tissues REPEATED INFECTIONS ↓Lymphatic load Damaged blood vessels Spasms & Thrombosis of Lymphatics Cellular debris Increased Lymphatic Load 15 16 Skin complications of lymphedema Skin Care Education Hyperkeratosis: thickening of the epidermis. 1.Avoid infection and injury Caused by overproliferation of the keratin layer and produces scaly brown or grey patches. 2.Avoid pressure on the involved extremity 3.Avoid constrictive clothing 4.Avoid vigorous activity 5.Avoid heat 6.Keep skin in good condition- moisture lotion 7.Avoid strong massage 17 18 3
    • Skin complications of lymphoedema Skin complications of lymphoedema Lymphangiectasia(lymphangiomata): excessive Papillomatosis: multiple benign epidermal tumors dilatation of the lymphatics due to dilatation of lymphatic vessels and Treatment: compression with multi-layer short stretch bandage. fibrosis, and may be accompanied by hyperkeratosis. may be reversible with adequate compression. 19 20Skin 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. ↑Lymphatic transport capacity In the palliative situation, light bandaging may be more appropriate. 21 22 Initial lymphatic Effect of MLD (2,3) Collecting lymphatic (5) 1-epidermis 6-deep fascia 8,9-two adjacentVascular & Lymphatic System drainage regions Lymphatic System Mechanically move fluid into initial lymphatic. Open valves of collecting Lymphotome Make initial lymphatic & lymphatic that crossed & collecting lymphatic pumping watershed. Watershed & being emptied repeatedly. Set up collateral pathway. 23 24 4
    • Massage Technique MLD techniques Slowly with control. Casley-Smith: Vodder: four basic strokes With minimal friction by hands & fingers. The Strokes Stationary circle: for lymph 20-40 µm in diameter node Nodal massage Clearing across the Pump technique: for Massage pressure: <80 g/cm2 (60 mmHg). extremities watersheds Higher pressure over watershed, lymph node and fibrosis area. Rotary technique: for trunk Blocking flow Clearance of deep trunk Scoop technique: for lower Massage area should be exposed! areas parts of extremities When working on the legs observe the pubis and the genitalia if became edematous, esp. scrotum. 25 26 Drainage pathway & Sequence Drainage pathway & SequenceAnterior Trunk Posterior Trunk 27 28 Compression Therapy Multi-layer bandage Compression garment ↑Lymphatic transport capacity 29 30 5
    • Multiple channel pneumatic pump Effects of compressionoptimal pressure parameters are not been Reduction in capillary filtration by enhancedestablished tissue pressurelittle or no lasting beneficial effects Shift of fluid into non-compressed parts of thefail to move lymph into different lymphtic bodyquadrant Increase in lymphatic re-absorption andmay damage remaining health lymph vessels stimulation of lymphatic transportneed to combine self massage to the neck & Improve rhythmic lymph pulsationtrunk Breakdown of fibrosclerotic tissue 31 32 Short stretch bandages (in-elastic) low resting pressure & high working pressure Addressing specific problems Graded pressure:decreasing from distal to proximal. 33 34 Bandaging the Head and Facial areaLymphoedema bandaging for head, breast and genitalia A 12–16cm wide tubular bandage, folded in half Hook-and-loop fasteners for easy apply. Pressure: applied gently and low to prevent paraesthesia or bruising in irradiated regions. No compression on neck. The padding is placed within the tubular bandage. To increase local pressure: by placing several layers of 35 foam.(fig2.) 36 6
    • Compression of the breast Bandaging the male genitalia-1 A cup shape thick Cohesive bandage to prevent foam(1.5-2.5cm): provide a micro-massage slippage. effect(Fig5) Allow for urination. Gently squeezes the In severe lymphoedema, the penis fibrosis. and scrotum are also padded with (Fig6: L’t breast) 3-4cm thick foam. Foam padding: extended to underneath the armpit and overlap the edges of the bra prevent tourniquet effect.(Fig7) 37 38Bandaging the male genitalia-2 Bandaging the male genitalia-3 Foam padding: Primary genital lymphoedema with long-term at least 2cm thick compression and elevated temperatures in the testicles anatomically contoured can result in fertility problems. foam. Begin with a low level of compression and depending Female genital on the severity and response. lymphoedema: More complex at least 1cm thick of Patients or their care-givers must learn self-bandaging custom-made anatomically skills because excess fluid can rapidly accumulate in the contoured foam external genitalia if treatment is interrupted. 39 Attention to common cellulitis and fungal infection. 40Male genital oedema Compression Garment(idiopathic lymphoedema) 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. 41 42 7
    • 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) ↑Lymphatic transport capacity 43 44 Self Drainage Exercise 消腫運動的基本原則Improve muscular contractions and joint mobility. 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。Reduce muscle atrophy. 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Muscular contractions along with the low-stretch 的順序一樣。bandages provide constant counter pressure to 每項運動不要做太快,慢慢的數1.…2….3….。keep the lymph fluid moving. 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。 45 46 47 48 8
    • Benign & Malignant In later stage, filled with fibrosis and lymphedema adipose tissue poor result Benign MalignantOnset slow acuteProgress slow rapidPain (-) (+)Skin color normal cyanosisCentrally No Yespronounced Lower level compresion orTreatment only MLD DLToptions Combine with palliative care. 49 50Take 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. 51 9