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Lymphedema

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Lymphedema program for MMCC PTA program

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Lymphedema

  1. 1. Lymphedema<br />Physical Therapy<br />Treatment & Management<br />
  2. 2. “I wouldn’t want to be a physical therapist – you have to touch people’s feet!”<br />
  3. 3. Overview <br />Theory <br />Anatomy & Physiology<br />Pathology<br />Principles of Management<br />Treatment<br />Manual Lymphatic Drainage Massage<br />Compression Bandaging/Garments<br />Exercise<br />Patient Education<br />
  4. 4. The Lymphatic System<br />Anatomy & Physiology<br />
  5. 5. The big picture<br />Works with venous system for fluid return<br />Removes plasma proteins <br />Filters antigens, bacteria, waste products<br />Produces white blood cells <br />
  6. 6. Initial Lymphatics – “Pickles”<br /><ul><li>Initial Lymphatics
  7. 7. Lymph capillaries
  8. 8. Superficial
  9. 9. Overlapping endothelial cells
  10. 10. Anchoring fibers
  11. 11. Valves prevent fluid backflow</li></li></ul><li>Plumbing – collector sequence<br /><ul><li>Lymphatic Capillaries > Precollectors
  12. 12. Afferent Collectors
  13. 13. Muscular cell walls with valves
  14. 14. Lymphangions – section between the valves
  15. 15. Lymph Nodes </li></li></ul><li>Lymph Nodes<br />600 in body, 300 head/neck<br />Series of sinuses <br />Important immunological functions<br />Offers 100x more resistance to flow than ducts<br />
  16. 16. Collector Sequence – cont. <br />Efferent collectors<br />Lymphatic Trunks<br />Lymphatic Ducts (2)<br />
  17. 17.
  18. 18. Anatomical landmarks<br />Lymphotomes <br />Distinct regions of the body for fluid drainage<br />Watersheds<br />Division areas between lymphotomes where direction of flow changes<br />Anastomoses<br />Collateral vessels offering alternate routes of drainage<br />
  19. 19. Lymph Fluid<br />Transparent, yellowish fluid<br />96% water – more dilute than plasma<br />Also consists of proteins, lipids, minerals, hormones, cells, bacteria, cell waste, etc.<br />Body produces 2.4L of lymph fluid daily, 25L of lymph fluid cycles through the heart <br />
  20. 20. Pathology <br />Lymphedema<br />An excessive accumulation of protein-rich fluid in the tissues caused by a transport failure of the lymphatic system.<br />
  21. 21.
  22. 22. Pathophysiology<br />Mechanical Insufficiency - lymphostatic<br />Low-flow edema, low-volume insufficiency<br />A breakdown in the transport capacity of the lymphatic system<br />Dynamic Insufficiency - lymphodynamic<br />High-flow edema, high-volume insufficiency<br />A high load placed on the lymph system exceeds its capacity<br />Combination – Safety Valve Insufficiency<br />
  23. 23. Causes of Lymphedema<br />Primary<br />Secondary<br />Congenital deficit in number or size of lymph nodes and/or pathways<br />Milroy’s Disease – present at birth<br />Meige’s Disease or Lymphedema praecox – appears at puberty<br />Lymphedema tarda – adult onset<br />Caused by removal or or damage to lymph nodes and/or pathways<br />Cancer/cancer treatments<br />Trauma<br />Chronic Venous Insufficiency<br />Paralysis<br />Filariasis<br />
  24. 24. Sequellae<br />Chronic swelling<br />Excessive tissue proteins<br />Fibrotic changes<br />Chronic inflammation<br />Infections – cellulitis<br />Skin changes – “peau d’ orange”<br />
  25. 25. Signs of Lymphedema <br />Puffiness, heaviness, fullness of limb<br />Stiffness, decreased ROM<br />Weakness, fatigue<br />Skin tension – feeling of “bursting”<br />Pain<br />Numbness, paresthesias<br />
  26. 26. Consequences<br />Functional deficits<br />Loss of mobility<br />Difficulty wearing normal clothing<br />Psychological issues<br />
  27. 27. Stages of Lymphedema<br />Stage 0 <br />Latent, sub-clinical condition<br />Swelling not evident despite impaired lymph transport<br />Stage 1 <br />Completely & spontaneously reversible<br />Soft, pitting edema<br />Little to no fibrosis<br />Skin easily pinched & moved <br />
  28. 28. Stages – cont.<br />Stage 2<br />Spontaneously Irreversible<br />Tissues usually fibrotic<br />Pitting requires strong pressure, or no pitting<br />Can usually be reversed with treatment<br />Stage 3 - Elephantiasis<br />Irreversible<br />No pitting, significant fibrosis<br />Huge size, papillomas, hardening of the skin<br />
  29. 29. Other Types of Edema<br />Acute<br />Venous<br />Lipedema<br />
  30. 30. Principles of Management <br />“If you can help me, I’ll add you to my Christmas card list!”<br />
  31. 31. Goals<br />While the immediate goal of lymphedema therapy is to relieve swelling, the ultimate goal is to enable the patient to self-manage and control this chronic condition.<br />
  32. 32. Complete Decongestive Therapy<br />Manual Lymphatic Drainage (MLD)<br />Compression Bandaging<br />Exercise<br />Skin care – patient education<br />Compression Garments<br />
  33. 33. Adjunct Treatments<br />Myofascial Release<br />Kinesiotaping<br />Aquatic therapy<br />Wound Care<br />Pneumatic pumps<br />
  34. 34. Team Approach<br /><ul><li>Physician/nurses
  35. 35. Other therapists
  36. 36. Certified garment fitter
  37. 37. Nutritionist
  38. 38. Psychologist</li></li></ul><li>Phases of Treatment <br />Phase 1 – Active Intervention<br />Attending therapy 2-5x/week<br />Compression bandaging 23 hrs/day<br />Daily home exercise/self massage<br />Phase 2 – Self-Management <br />Transition to compression garments<br />Maintaining home program<br />Occasional follow-up appointments<br />
  39. 39.
  40. 40. Treatment Techniques<br />“You’re just making that up to make me look stupid!”<br />
  41. 41. Patient Examination<br />History<br />Functional mobility<br />Musculoskeletal<br />Neurological<br />Skin Integrity<br />Edema measurement<br />Cardiovascular<br />
  42. 42. Diagnostic Testing<br />Lymphoscinitigraphy<br />Radiological isotope evaluation<br />Lymphography<br />Direct oil contrast – “blue-dye”<br />Ultrasound<br />Assess presence of filarial worm<br />MRI<br />CT<br />
  43. 43. Red Flags!<br />Contraindications<br />Precautions<br />Any bacterial infection<br />Acute congestive heart failure<br />Acute deep vein thrombosis<br />Acute renal disease<br />Acute pulmonary edema<br />Malignancy<br />Arterial disease<br />Sensation deficits<br />Low blood counts<br />Areas of inflammation<br />Wounds<br />
  44. 44. Skin and Wound Care<br />Prior to treatment, skin should be clean and moisturized<br />Wounds must be addressed<br />
  45. 45. Manual Lymphatic Drainage<br />Goals of technique:<br />Increase peristalsis of lymphangion<br />Break down fibrotic tissues<br />Increase lymph volume in lymph vessels<br />Decrease congestion in interstitium<br />
  46. 46. Basic Principles<br />Treatment begins proximal, to “clear” proximal lymphotomes before moving to affected lymphotomes<br />Massage is directed towards the cleared lymphotome<br />Pressure is very light<br />Strokes are rhythmic<br />
  47. 47. Strokes <br />“Scoops” – massaging lymph nodes<br />Firmer pressure, circular motion<br />“Clearing” <br />Begin furthest from the affected area<br />Clears the way for fluid drainage<br />Moves proximal to distal<br />“Flowing”<br />Begin closest to the affected area<br />Always done after clearing<br />Moves distal to proximal<br />
  48. 48.
  49. 49. MLD Pathways<br />
  50. 50. Medical Compression Bandaging<br />Low stretch bandages<br />Provides low stretch when no contraction<br />Higher compression when muscles contract<br />Prevent re-fill of lymphatics<br />Work with muscle pumping<br />Follow “Law of Laplace” – the smaller the radius the greater the pressure<br />Help break up fibrotic areas<br />
  51. 51. Bandaging Guidelines <br />Worn 23 hrs/ day (off only for bathing)<br />Should re-wrap daily to prevent loosening<br />Should have more compression (more layers) distally<br />Bandages should be washed frequently<br />
  52. 52. Bandaging Techniques<br />
  53. 53. Compression Garments<br />Maintains reduction gained during therapy<br />Transition to garments when reduction plateaus<br />Garments for daytime wear, options for nighttime<br />Insurance coverage varies greatly<br />
  54. 54. Therapeutic Exercise<br />Exercises facilitate muscle pumping <br />Should be done with compression<br />Progress proximally to distally<br />Very low resistance, few repetitions, rests as needed<br />
  55. 55. Patient Education<br />Home exercise<br />Self-massage<br />Skin care<br />Precautions<br />Compression garments<br />
  56. 56. Conclusion<br />Do all the good you can,By all the means you can,In all the ways you can,In all the places you can,At all the times you can,To all the people you can,As long as ever you can<br />-John Wesley<br />
  57. 57. Thank You!<br />Presented by<br />Jennifer K. Root, PT, DPT, CLT<br />Clinical Specialist<br />MidMichigan Medical Center<br />Rehabilitation Services<br />

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