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黃睦升 物理治療師

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  1. 1. 1 1 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 衛生福利部國民健康署衛生福利部國民健康署衛生福利部國民健康署衛生福利部國民健康署 2013201320132013年癌症復健相關人員培訓計畫年癌症復健相關人員培訓計畫年癌症復健相關人員培訓計畫年癌症復健相關人員培訓計畫 2 Outline Lymphedema causes & stages The most effective treatment? Decongestive lymphatic therapy Skin care Manual lymphatic drainage Compression therapy Self drainage exercise Take home messages 3 Causes 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. 4
  2. 2. 2 5 ::::↑↑↑↑2~3 times (Mortimer et al., 1997) BLOODBLOODBLOODBLOOD LYMPHLYMPHLYMPHLYMPH NormalNormalNormalNormal HighHighHighHigh----flowflowflowflow edemaedemaedemaedema LowLowLowLow----flowflowflowflow edemaedemaedemaedema ====lymphoedemalymphoedemalymphoedemalymphoedema (high protein)(high protein)(high protein)(high protein) LymphaticLymphatic loadload TissueTissue LymphaticLymphatic TransportTransport CapacityCapacity SafetySafetySafetySafety----valvevalvevalvevalve insufficiencyinsufficiencyinsufficiencyinsufficiency The Causation of EdemaThe Causation of Edema 7 Lymphedema Definition:An abnormal accumulation of tissue proteins , causing edema and chronic inflammation within an extremity. (Grabois M. Phys Med Rehab Rev 1994;8:267-77) Functional overload of the lymphatic system Lymph volume exceeds transport capacities Also occurs in the face, trunk and external genitalia. 8 Stages of Lymphedema International Society for Lymphology (Casley-Smith et al. 1985) Stage 1 : pits on pressure reduced on elevation no or mild fibrosis Stage 2 : non-pitting on pressure not reduced by elevation moderate to severe fibrosis brawny Stage 3 : elephantiasis, warts skin very thick and leathery subcutaneous tissue hypertrophied Stage 1 Stage 2 Stage 3
  3. 3. 3 9 CTCAE: lymphedema (Common Terminology Criteria for Adverse Events v3.0) Includes both objective measures (interlimb discrepancy) and subjective assessments. 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. 10 Drug Therapy for Lymphedema Antibiotics: for acute or chronic infections (ex: cellulitis and lymphangitis) ----Preventive antibiotics for recurrent ALD (acute lymphaticPreventive antibiotics for recurrent ALD (acute lymphatic dermatitis)dermatitis) (2005,20th International Congress of(2005,20th International Congress of LymphologyLymphology)) Diuretics: no effect or even aggravated swelling Benzo-Pyrone (Coumarin): --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 (N Engl J Med 340; 346-50;1999) 11 Surgical Therapy for Lymphedema Debulking or reduction Surgery Liposuction --Destroy superficial & deep lymphatic pathways --Main complication::::cellulitis Functional or physiological surgery 1. Microlymphatic-Venous Anastomosis (LVA) 2. lymphatic-venous- lymphatic-plasty Limitation: 1. few long term good results 2. failure after 2~3yrs Circumferential liposuction Post-OP + compression garment may sustained improvement in symptoms 12 0.5mm collecting lymphatic 0.8mm subdermal venule Lymphatic Venous Anastomosis (LVA)
  4. 4. 4 13 Circumferential Liposuction 14 In later stage, filled with fibrosis and adipose tissue poor result 15 In later stage, filled with fibrosis and adipose tissue surgical intervention 16
  5. 5. 5 17 腹大網膜移植手術 (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。 18 早發型下肢淋巴水腫早發型下肢淋巴水腫早發型下肢淋巴水腫早發型下肢淋巴水腫((((lymphedemalymphedemalymphedemalymphedema praecox)praecox)praecox)praecox)的男性患者的男性患者的男性患者的男性患者::::((((許文憲許文憲許文憲許文憲,2008),2008),2008),2008) 術後術後術後術後7777個月後之追蹤結果個月後之追蹤結果個月後之追蹤結果個月後之追蹤結果::::其患肢體積其患肢體積其患肢體積其患肢體積、、、、彈性彈性彈性彈性、、、、膝踝關節可彎曲程度及膝踝關節可彎曲程度及膝踝關節可彎曲程度及膝踝關節可彎曲程度及 足踝變形程度均恢復正常足踝變形程度均恢復正常足踝變形程度均恢復正常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但是下肢色素沉著並無顯著改善但是下肢色素沉著並無顯著改善但是下肢色素沉著並無顯著改善。。。。 19 腹大網膜移植腹大網膜移植腹大網膜移植腹大網膜移植((((許文憲許文憲許文憲許文憲,2008),2008),2008),2008) 20 先天性兩下肢淋巴水腫先天性兩下肢淋巴水腫先天性兩下肢淋巴水腫先天性兩下肢淋巴水腫 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。 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。
  6. 6. 6 21 Surgical Therapy for Lymphedema Supplement TSupplement T’’X for poor response toX for poor response to D.L.T.D.L.T. IndicationIndication::conservative Tconservative T’’X failure.X failure. Surgery+DLTSurgery+DLT good longgood long--term resultterm result Life long D.L.T. is necessary to keepLife long D.L.T. is necessary to keep satisfactory result.satisfactory result. (2005,20th International Congress of(2005,20th International Congress of LymphologyLymphology)) 22 The most effective treatment? Currently not enough evidence to draw conclusions about the best physical therapy to use in the treatment of lymphoedema. (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. (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. 23 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) 24 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) History of Lymphedema
  7. 7. 7 25 Self Drainage Exercise Compression Therapy Manual Lymphatic Drainage Decongestive Lymphatic Therapy (DLT) Skin Care ? ? 26 To maintain and even improve the results achieved in intensive phase. Loosen skin remodelling. 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. Intensive phase (2~4 weeks) Goal * Intensive phase: repeated after loose skin remodeling (in maintain phase). *Each repeated DLT course:↓50% preserved lymphedema Decongestive Lymphatic Therapy (DLT) 27 ↓↓↓↓Lymphatic load 28 Obstruction of lymph vessels LYMPHOEDEMA Excess protein in tissues REPEATED INFECTIONS Damaged blood vessels Spasms & Thrombosis of Lymphatics Chronic inflammation Cellular debris Increased Lymphatic Load
  8. 8. 8 29 Skin Care Education 1.Avoid infection and injury 2.Avoid pressure on the involved extremity 3.Avoid constrictive clothing 4.Avoid vigorous activity 重物不宜超過重物不宜超過重物不宜超過重物不宜超過15151515磅磅磅磅((((約約約約6.公斤公斤公斤公斤)))) 5.Avoid heat 6.Keep skin in good condition- moisture lotion 7.Avoid strong massage 30 Skin complications of lymphedema Hyperkeratosis: thickening of the epidermis. Caused by overproliferation of the keratin layer and produces scaly brown or grey patches. 31 Lymphangiectasia(lymphangiomata): excessive dilatation of the lymphatics Treatment: compression with multi-layer short stretch bandage. Skin complications of lymphoedema 32 Papillomatosis: multiple benign epidermal tumors due to dilatation of lymphatic vessels and fibrosis, and may be accompanied by hyperkeratosis. may be reversible with adequate compression. Skin complications of lymphoedema
  9. 9. 9 33 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. Skin complications of lymphoedema 34 ↑↑↑↑Lymphatic transport capacity 35 36 Vascular & Lymphatic System Initial lymphatic (2,3) Collecting lymphatic (5) 1-epidermis 6-deep fascia 8,9-two adjacent drainage regions Lymphatic System Lymphotome & Watershed
  10. 10. 10 37 The Passage of Protein in Normal Tissue Blood capillaryBlood capillary Tissue channelTissue channel Lymphatic systemLymphatic system VeinVein 38 Effect of MLD Open valves of collecting lymphatic that crossed watershed. Set up collateral pathway. Mechanically move fluid into initial lymphatic. Make initial lymphatic & collecting lymphatic pumping & being emptied repeatedly. 39 MLD techniques Casley-Smith: The Strokes Nodal massage Clearing across the watersheds Blocking flow Clearance of deep trunk areas Vodder: four basic strokes Stationary circle: for lymph node Pump technique: for extremities Rotary technique: for trunk Scoop technique: for lower parts of extremities 40 Massage Technique Massage area should be exposed! Stroke pressure : <80 g/cm2 (60 mmHg). gentle, not redness or pain. 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 20-40 m in diameter
  11. 11. 11 41 Massage for fibrosis area 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省略纖省略纖省略纖省略纖省略纖省略纖 維化區域的按摩維化區域的按摩維化區域的按摩維化區域的按摩維化區域的按摩維化區域的按摩維化區域的按摩維化區域的按摩,否則將造成淋巴液滲漏、組織間隙的蛋白質 濃度升高、局部皮膚溫度上升、水腫加劇,甚至有感染的可 能。 42 Posterior TrunkAnterior Trunk Drainage pathway & Sequence 43 Drainage pathway & Sequence 44 Face Lymph Pathways 1 2
  12. 12. 12 45 A one-way drainage:remove protein and excessive fluid Initial lymphatic pre-collector collecting lymphatic lymph node lymphatic trunk collecting duct thoracic duct sub-clavian vein vena cava R’t atrium Lymphatic Drainage Superficial pathway Deep pathway 46 Respiration Lymph flows into the sub-clavian veins most rapidly at the peak of inspiration. The rate of flow of lymph into venous circulation is proportional to the depth of inspiration. The mechanism of inspiration: * Intra-thoracic pressure decreases decreased pressure of the thoracic duct in the thoracic portion. 47 M-breathing Pelvic Scoop: The fingers placed superior the pubic bone. Toward the umbilicus. A really deep pressure. 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。 Umbilicus sub-costal sub-costal Inside the pelvic rim Inside the pelvic rim •若合併有腹水若合併有腹水若合併有腹水若合併有腹水(ascites)症狀症狀症狀症狀,,,, 則不適合實施則不適合實施則不適合實施則不適合實施M-breathing。。。。 48 MLD practice: External genitaliaExternal genitalia 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!
  13. 13. 13 49 ↑↑↑↑Lymphatic transport capacity 50 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 51 Effects of compression 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 52 Short stretch bandages (in-elastic) low resting pressure & high working pressure Graded pressure::::decreasing from distal to proximal.
  14. 14. 14 53 Bandaging Principles 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. 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. 54 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. Multi-Layer Bandage Different radius different pressure. Even pressure by padding.Even pressure by padding. 55 Cautions with Bandages 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. 56 Addressing specific problems
  15. 15. 15 57 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. 58 Lymphoedema bandaging for head, breast and genitalia 59 Bandaging the Head and Facial area 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 foam.(fig2.) A 12–16cm wide tubular bandage, folded in half Hook-and-loop fasteners for easy apply. 60 Compression of the breast A cup shape thick foam(1.5-2.5cm): provide a micro-massage effect(Fig5) Gently squeezes the fibrosis. (Fig6: L’t breast) Foam padding: extended to underneath the armpit and overlap the edges of the bra prevent tourniquet effect.(Fig7)
  16. 16. 16 61 Bandaging the male genitalia-1 Cohesive bandage to prevent slippage. Allow for urination. In severe lymphoedema, the penis and scrotum are also padded with 3-4cm thick foam. 62 Foam padding: at least 2cm thick anatomically contoured foam. Female genital lymphoedema: More complex at least 1cm thick of custom-made anatomically contoured foam Bandaging the male genitalia-2 63 Bandaging the male genitalia-3 Primary genital lymphoedema with long-term compression and elevated temperatures in the testicles can result in fertility problems. Begin with a low level of compression and depending on the severity and response. Patients or their care-givers must learn self-bandaging skills because excess fluid can rapidly accumulate in the external genitalia if treatment is interrupted. Attention to common cellulitis and fungal infection. 64 Compression Garment 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.
  17. 17. 17 65 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) 66 ↑↑↑↑Lymphatic transport capacity 67 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. 68 消腫運動的基本原則消腫運動的基本原則消腫運動的基本原則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。
  18. 18. 18 69 70 71 FAQ 72 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。
  19. 19. 19 73 Avoid heavy lifting and resistance-training exercise for arm lymphoedema???? 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) 74 Predictive factors for DLT effect in LE lymphedema PEV was the only predictor of PREV in our study; in other words, a lower PEV would predict a better response to DLT. 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) The same conclusion in treating breast cancer related lymphoedema(BCRL). 75 Predictive factors for DLT effect in LE lymphedema Duration of lymphedema was not associated with PREV (DLT effect). Studies on BCRL reported the opposite conclusion: The progression rate of mild lymphedema to more severe lymphedema was 21% at 1 year and 34% at 3 years. 76
  20. 20. 20 77 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. Vicious Circles of Oedema 79 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.