Lymphedema is an excessive accumulation of fluid in tissues caused by a failure of the lymphatic system. Physical therapy uses complete decongestive therapy including manual lymphatic drainage, compression bandaging, exercise, and skin care/patient education to manage lymphedema. Manual lymphatic drainage uses light pressure strokes to increase lymph flow and break down fibrotic tissues. Compression bandaging provides graduated compression to assist lymph transport. A team approach including self-management training helps patients control this chronic condition.

1. Lymphedema Physical Therapy Treatment & Management

2. “I wouldn’t want to be a physical therapist – you have to touch people’s feet!”

3. Overview Theory Anatomy & Physiology Pathology Principles of Management Treatment Manual Lymphatic Drainage Massage Compression Bandaging/Garments Exercise Patient Education

4. The Lymphatic System Anatomy & Physiology

5. The big picture Works with venous system for fluid return Removes plasma proteins Filters antigens, bacteria, waste products Produces white blood cells

7. Lymph capillaries

8. Superficial

9. Overlapping endothelial cells

10. Anchoring fibers

12. Afferent Collectors

13. Muscular cell walls with valves

14. Lymphangions – section between the valves

16. Collector Sequence – cont. Efferent collectors Lymphatic Trunks Lymphatic Ducts (2)

18. Anatomical landmarks Lymphotomes Distinct regions of the body for fluid drainage Watersheds Division areas between lymphotomes where direction of flow changes Anastomoses Collateral vessels offering alternate routes of drainage

19. Lymph Fluid Transparent, yellowish fluid 96% water – more dilute than plasma Also consists of proteins, lipids, minerals, hormones, cells, bacteria, cell waste, etc. Body produces 2.4L of lymph fluid daily, 25L of lymph fluid cycles through the heart

20. Pathology Lymphedema An excessive accumulation of protein-rich fluid in the tissues caused by a transport failure of the lymphatic system.

22. Pathophysiology Mechanical Insufficiency - lymphostatic Low-flow edema, low-volume insufficiency A breakdown in the transport capacity of the lymphatic system Dynamic Insufficiency - lymphodynamic High-flow edema, high-volume insufficiency A high load placed on the lymph system exceeds its capacity Combination – Safety Valve Insufficiency

23. Causes of Lymphedema Primary Secondary Congenital deficit in number or size of lymph nodes and/or pathways Milroy’s Disease – present at birth Meige’s Disease or Lymphedema praecox – appears at puberty Lymphedema tarda – adult onset Caused by removal or or damage to lymph nodes and/or pathways Cancer/cancer treatments Trauma Chronic Venous Insufficiency Paralysis Filariasis

24. Sequellae Chronic swelling Excessive tissue proteins Fibrotic changes Chronic inflammation Infections – cellulitis Skin changes – “peau d’ orange”

25. Signs of Lymphedema Puffiness, heaviness, fullness of limb Stiffness, decreased ROM Weakness, fatigue Skin tension – feeling of “bursting” Pain Numbness, paresthesias

26. Consequences Functional deficits Loss of mobility Difficulty wearing normal clothing Psychological issues

27. Stages of Lymphedema Stage 0 Latent, sub-clinical condition Swelling not evident despite impaired lymph transport Stage 1 Completely & spontaneously reversible Soft, pitting edema Little to no fibrosis Skin easily pinched & moved

28. Stages – cont. Stage 2 Spontaneously Irreversible Tissues usually fibrotic Pitting requires strong pressure, or no pitting Can usually be reversed with treatment Stage 3 - Elephantiasis Irreversible No pitting, significant fibrosis Huge size, papillomas, hardening of the skin

29. Other Types of Edema Acute Venous Lipedema

30. Principles of Management “If you can help me, I’ll add you to my Christmas card list!”

31. Goals 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.

32. Complete Decongestive Therapy Manual Lymphatic Drainage (MLD) Compression Bandaging Exercise Skin care – patient education Compression Garments

33. Adjunct Treatments Myofascial Release Kinesiotaping Aquatic therapy Wound Care Pneumatic pumps

35. Other therapists

36. Certified garment fitter

37. Nutritionist

40. Treatment Techniques “You’re just making that up to make me look stupid!”

41. Patient Examination History Functional mobility Musculoskeletal Neurological Skin Integrity Edema measurement Cardiovascular

42. Diagnostic Testing Lymphoscinitigraphy Radiological isotope evaluation Lymphography Direct oil contrast – “blue-dye” Ultrasound Assess presence of filarial worm MRI CT

43. Red Flags! Contraindications Precautions Any bacterial infection Acute congestive heart failure Acute deep vein thrombosis Acute renal disease Acute pulmonary edema Malignancy Arterial disease Sensation deficits Low blood counts Areas of inflammation Wounds

44. Skin and Wound Care Prior to treatment, skin should be clean and moisturized Wounds must be addressed

45. Manual Lymphatic Drainage Goals of technique: Increase peristalsis of lymphangion Break down fibrotic tissues Increase lymph volume in lymph vessels Decrease congestion in interstitium

46. Basic Principles Treatment begins proximal, to “clear” proximal lymphotomes before moving to affected lymphotomes Massage is directed towards the cleared lymphotome Pressure is very light Strokes are rhythmic

47. Strokes “Scoops” – massaging lymph nodes Firmer pressure, circular motion “Clearing” Begin furthest from the affected area Clears the way for fluid drainage Moves proximal to distal “Flowing” Begin closest to the affected area Always done after clearing Moves distal to proximal

49. MLD Pathways

50. Medical Compression Bandaging Low stretch bandages Provides low stretch when no contraction Higher compression when muscles contract Prevent re-fill of lymphatics Work with muscle pumping Follow “Law of Laplace” – the smaller the radius the greater the pressure Help break up fibrotic areas

51. Bandaging Guidelines Worn 23 hrs/ day (off only for bathing) Should re-wrap daily to prevent loosening Should have more compression (more layers) distally Bandages should be washed frequently

52. Bandaging Techniques

53. Compression Garments Maintains reduction gained during therapy Transition to garments when reduction plateaus Garments for daytime wear, options for nighttime Insurance coverage varies greatly

54. Therapeutic Exercise Exercises facilitate muscle pumping Should be done with compression Progress proximally to distally Very low resistance, few repetitions, rests as needed

55. Patient Education Home exercise Self-massage Skin care Precautions Compression garments

56. Conclusion 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 -John Wesley

57. Thank You! Presented by Jennifer K. Root, PT, DPT, CLT Clinical Specialist MidMichigan Medical Center Rehabilitation Services