©2010, zoltan bouwhuis, bscpt, clt 1 an introduction to lymphedema treatment

©2010, Zoltan Bouwhuis, BScPT, CLT 1

An Introduction ToAn Introduction ToLymphedema Lymphedema

TreatmentTreatment


About Your PresenterAbout Your Presenter

Born & Raised in EnschedeBorn & Raised in Enschede

The NetherlandsThe Netherlands

PT Training: Hogeschool Enschede, The PT Training: Hogeschool Enschede, The NetherlandsNetherlands

Lymphedema clinic SPGH 1998-2005Lymphedema clinic SPGH 1998-2005

Lymphedema clinic LMC 2005-2006Lymphedema clinic LMC 2005-2006

Lymphedema clinic SAH 2007-currentLymphedema clinic SAH 2007-current

Certified Lymphedema Therapist (CLT) Certified Lymphedema Therapist (CLT) through Academy of Lymphatic Studiesthrough Academy of Lymphatic Studies

Zoltan Bouwhuis, BScPT, CLTZoltan Bouwhuis, BScPT, CLT


Class OutlineClass Outline

IntroductionIntroductionAnatomyAnatomy(Lymph)edema(Lymph)edemaTreatment optionsTreatment optionsBandagingBandagingGarmentsGarmentsAbout CertificationAbout CertificationClosingClosing


Class ObjectivesClass Objectives

Demonstrate a basic understanding of Demonstrate a basic understanding of the lymphatic system and lymphedemathe lymphatic system and lymphedema

Recognize lymphedema Recognize lymphedema

Be able to treat a patient with edema Be able to treat a patient with edema

Be familiar with the certification processBe familiar with the certification process


NotNot Class Objectives Class Objectives

To become a certified lymphedema To become a certified lymphedema therapist therapist

To be proficient in treating complex To be proficient in treating complex edema patientsedema patients

These will be the objectives of theThese will be the objectives of the

lymphedema certification courseslymphedema certification courses

Drum up more business for our clinic Drum up more business for our clinic


Why this class?Why this class?

Very little familiarity with lymphedemaVery little familiarity with lymphedema

Few practitionersFew practitioners

Patients / Physicians / Therapists are Patients / Physicians / Therapists are not familiar with lymphedema and its not familiar with lymphedema and its treatment optionstreatment options

Known treatment options are outdatedKnown treatment options are outdated


DISCLAIMER:DISCLAIMER:

Do not expect a vast amount of Do not expect a vast amount of evidence-based practice patterns in this evidence-based practice patterns in this presentationpresentationThis subject matter suffers from a This subject matter suffers from a massive lack of researchmassive lack of researchMost material presented is based on the Most material presented is based on the clinical experience of the presenter and clinical experience of the presenter and others authorsothers authors


The Statistics (by estimate)The Statistics (by estimate)

1 in 8 women will develop breast 1 in 8 women will develop breast cancer during their life timecancer during their life time254,650 new cases of breast cancer in 254,650 new cases of breast cancer in the US in 2009the US in 2009About 40,170 women will die from About 40,170 women will die from breast cancerbreast cancer214,480 new breast cancer survivors in 214,480 new breast cancer survivors in the USthe US11% of patients with breast cancer are 11% of patients with breast cancer are < 40 y/o< 40 y/o



An estimated 25-30% of breast cancer patients will develop lymphedema during their life timeThis risk may increase up to 48% after radiation therapyAn estimated 5-14% of patients who underwent a sentinel node biopsy will develop lymphedema



0-60-80% of patients develop leg 0-60-80% of patients develop leg lymphedema after genital and lymphedema after genital and reproductive cancer or after melanoma reproductive cancer or after melanoma in the legin the leg

100 million people world-wide with 100 million people world-wide with lymphatic filariasislymphatic filariasis


Commonly known Commonly known “treatments”“treatments”

DiureticsDiureticsFluid restrictionFluid restrictionTED hosesTED hosesPumpPumpDraining of fluidDraining of fluidDe-bulking surgeryDe-bulking surgeryAmputationAmputation

Samuel Adams 9/27/1722 – 10/2/1803 (founding father & brewer)

12

ANATOMYANATOMY

REVIEWREVIEW


CirculationCirculation

ArteriesArteries

VeinsVeins

LymphaticsLymphatics


The Circulatory SystemThe Circulatory System

Carry blood from the heart to Carry blood from the heart to the lungs and the tissuesthe lungs and the tissues

Supply the tissues with oxygen Supply the tissues with oxygen and nutrientsand nutrients

Bring 100% of the fluids to the Bring 100% of the fluids to the tissuestissues

Driven by the heart & valvesDriven by the heart & valves

Arteries:Arteries:



Return blood from the tissues Return blood from the tissues back to the heart and lungsback to the heart and lungsRemove CORemove CO22 and small waste and small waste products from the tissuesproducts from the tissuesReturn 85-90% of the fluids Return 85-90% of the fluids from the tissuesfrom the tissuesDriven by the muscle pump & Driven by the muscle pump & valvesvalves

Veins:Veins:



Return fluid from the tissues back Return fluid from the tissues back to the heartto the heartRemove fluid, proteins and large Remove fluid, proteins and large waste products from the tissueswaste products from the tissuesReturn 10-15% of the fluids from Return 10-15% of the fluids from the tissuesthe tissuesDriven by the muscle pump, Driven by the muscle pump, valves, breathing and its own valves, breathing and its own smooth musclessmooth muscles

Lymphatics:Lymphatics:


What’s the difference?What’s the difference?

““Closed system”Closed system”

Circulating systemCirculating system

Dependent on Dependent on “external pump”“external pump”

Fairly set volumeFairly set volume

Open endedOpen ended

One-wayOne-way

System has its own System has its own pumping mechanismpumping mechanism

Can increase Can increase capacity up to 10xcapacity up to 10x

Arteries / VeinsArteries / Veins LymphaticsLymphatics


The Lymphatic SystemThe Lymphatic System

Initial LymphaticsInitial Lymphatics

PrecollectorsPrecollectors

Lymph AngionsLymph Angions

TrunksTrunks

Venous AnglesVenous Angles

Lymphatic Vessels



Lymph NodesLymph Nodes

TonsilsTonsils

ThymusThymus

SpleenSpleen

Organs



““Open” endedOpen” endedFlaps allow entry of large Flaps allow entry of large materialsmaterialsFunction like a pool cleanerFunction like a pool cleaner

Initial lymphaticsInitial lymphatics


The capillary bedThe capillary bed



Muscle Pump MechanismMuscle Pump MechanismAbdominal BreathingAbdominal BreathingLongitudinal / Radial Musculature Longitudinal / Radial Musculature “Caterpillar-like” movement“Caterpillar-like” movementManual Lymph DrainageManual Lymph Drainage

Flow of Lymph

Nodes in Axillary RegionNodes in Axillary Region


BrachialBrachial

Central AxillaryCentral Axillary SubclavianSubclavian SupraclavicularSupraclavicular

MammaryMammary

SubscapularSubscapular

External MammaryExternal Mammary

Nodes in Neck RegionNodes in Neck Region


OccipitalOccipital

RetropharyngealRetropharyngeal

SubclavianSubclavian

SubmentalSubmental

Anterior jugularAnterior jugular

Posterior Cervical Posterior Cervical Spinal Nerve ChainSpinal Nerve Chain

Supra ClavicularSupra Clavicular

ThyrolinguofacialThyrolinguofacial

Anterior Deep & Anterior Deep & Superficial Superficial CervicalCervical

Posterior Superficial Posterior Superficial CervicalCervical

Drainage of Head & NeckDrainage of Head & Neck


ThyrolinguofacialThyrolinguofacial

Preauricular NodesPreauricular Nodes

Posterior Auricular Posterior Auricular (Mastoid Nodes)(Mastoid Nodes)

Occipital NodesOccipital Nodes

Posterior Superficial Posterior Superficial Cervical ChainCervical Chain

Anterior Deep & Anterior Deep & Superficial CervicalSuperficial Cervical

Internal Jugular ChainInternal Jugular Chain

Suprahyoid NodeSuprahyoid Node

SublingualSublingual

SubmentalSubmental

FacialFacial

ParotidParotid

SubmandibularSubmandibularPosterior Cervical Posterior Cervical Spinal Nerve ChainSpinal Nerve Chain

Supraclavicular NodesSupraclavicular Nodes

Sternomastoid NodesSternomastoid Nodes

External JugularExternal Jugular

Retropharyngeal (Tonsillar)Retropharyngeal (Tonsillar)


What Is Lymph ?What Is Lymph ?

A A proteinprotein richrich fluid found in the fluid found in the lymphatic vesselslymphatic vessels

Derived from interstitial fluidDerived from interstitial fluid

Honey-like consistencyHoney-like consistency

Mostly clear, sometimes milky colorMostly clear, sometimes milky color


What Is Lymph ?What Is Lymph ?

protein moleculesprotein molecules

waterwater

cell debriscell debris

bacteriabacteria

virusesviruses

foreignforeign

substancessubstances

fatty acidsfatty acids

cancer cellscancer cells

29

LYMPHEDEMALYMPHEDEMA(and a few other (and a few other

ones)ones)


Starling’s HypothesisStarling’s Hypothesis

"... there must be a balance between the hydrostatic pressure of the blood in the capillaries and the osmotic

attraction of the blood for the surrounding fluids. “

Starling, E.H. On the adsorbtion of fluid from interstitial spaces. J Physiol. London 19:312-326, 1896.



A thorough understanding ofA thorough understanding of


is the key to understanding the is the key to understanding the management of lymphedema.management of lymphedema.



Ultra Filtration Pressure = BHP - IHPUltra Filtration Pressure = BHP - IHP

Reabsorption Pressure = BCOP - ICOP Reabsorption Pressure = BCOP - ICOP

BHP = Blood Hydrostatic Pressure

IHP = Interstitial Hydrostatic Pressure

BCOP = Blood Colloid Osmotic Pressure

ICOP = Interstitial Colloid Osmotic Pressure


Colloid Osmotic PressureColloid Osmotic Pressure

Semi-permeable membrane

Osmotic Pressure

Semi-permeable membrane



Ultra Filtration Pressure = BHP - IHPUltra Filtration Pressure = BHP - IHP

Reabsorption Pressure = BCOP - ICOP Reabsorption Pressure = BCOP - ICOP

BHP = Blood Hydrostatic Pressure

IHP = Interstitial Hydrostatic Pressure

BCOP = Blood Colloid Osmotic Pressure

ICOP = Interstitial Colloid Osmotic Pressure


Normal SituationNormal Situation

Ultra Filtration = Reabsorption Balance

BHP29 mmHg

IHP-2 mmHg

BCOP25 mmHg

BHP14 mmHg

BCOP25 mmHg

ICOP25 mmHg

ICOP25 mmHg

IHP-2 mmHg


LymphedemaLymphedema

Ultra Filtration > Reabsorption Lymphedema

BHP29 mmHg

BHP14 mmHg

IHP2 mmHg

IHP2 mmHg

BCOP25 mmHg

BCOP25 mmHg

ICOP30 mmHg

ICOP30 mmHg

(29-2)-(30-25)


What Is Lymphedema?What Is Lymphedema?

History of insult to lymphatic systemHistory of insult to lymphatic system

History of congenital lymphedemaHistory of congenital lymphedema

Absence of other common causes of edemaAbsence of other common causes of edema

Swelling in a body part due to excess accumulation Swelling in a body part due to excess accumulation of protein rich fluid in the interstitial spaces.of protein rich fluid in the interstitial spaces.


Two Forms of LymphedemaTwo Forms of Lymphedema

Primary LymphedemaPrimary Lymphedema

Secondary LymphedemaSecondary Lymphedema


Primary LymphedemaPrimary Lymphedema

Occurs most often in lower extremitiesOccurs most often in lower extremitiesMay be present at birth or may develop May be present at birth or may develop later in lifelater in life

congenital - present at birthcongenital - present at birthpraecox – before age 35praecox – before age 35tarda - after age 35tarda - after age 35

Impaired development of the lymph Impaired development of the lymph systemsystem


Secondary LymphedemaSecondary Lymphedema

Caused by damage to the lymph system by Caused by damage to the lymph system by some insultsome insult

Infection - cellulitis

TraumaTrauma

Radiation - fibrosisRadiation - fibrosis

Surgery - lymph node dissection / other surgery

Chemotherapy - scarring

Tumors - “malignant lymphedema”

Lymphatic FilariasisLymphatic Filariasis

Occurrence of Lymphedema Occurrence of Lymphedema after a lymph node after a lymph node dissectiondissection

Patient is considered at high risk for developing lymphedema when 11-13 axillary lymph nodes are dissected

Lymphedema can occur with as little as 1 axillary node dissected

The chance of developing lymphedema increases when either chemotherapy or radiation therapy are added



Stages of LymphedemaStages of Lymphedema

0 - Latency0 - Latency

1 - Spontaneous Reversible1 - Spontaneous Reversible

2 - Spontaneous Irreversible2 - Spontaneous Irreversible

3 - Lymphatic Elephantiasis3 - Lymphatic Elephantiasis



Lymphatic system is impairedLymphatic system is impaired

No edema noticeableNo edema noticeable

““Limb-at-risk”Limb-at-risk”

Treatment focus: prevent lymphedemaTreatment focus: prevent lymphedema

Stage 0 - latencyStage 0 - latency



Edema occurs during the dayEdema occurs during the day

Edema reduces with rest / elevationEdema reduces with rest / elevation

No palpable fibrosisNo palpable fibrosis

Treatment focus: control lymphedema to Treatment focus: control lymphedema to maintain normal size limbmaintain normal size limb

Stage 1 – Spontaneous ReversibleStage 1 – Spontaneous Reversible



Edema worsens during the dayEdema worsens during the day

Edema does not reduce (completely ) with Edema does not reduce (completely ) with rest / elevationrest / elevation

Palpable fibrosisPalpable fibrosis

Treatment focus: regain control over the Treatment focus: regain control over the lymphedema to return to a normal size limblymphedema to return to a normal size limb

Stage 2 – Spontaneous Stage 2 – Spontaneous IrreversibleIrreversible



Protein starts to clump in Protein starts to clump in stagnant fluidstagnant fluid

Becomes firm with Becomes firm with butter-like consistencybutter-like consistency

Eventually triggers Eventually triggers connective tissue growth connective tissue growth

Stage 2 – FibrosisStage 2 – Fibrosis



Edema worsens during the dayEdema worsens during the day

Edema does not reduce (completely ) with Edema does not reduce (completely ) with rest / elevationrest / elevation


Treatment focus: regain control over the Treatment focus: regain control over the lymphedema to return to a normal size limblymphedema to return to a normal size limb

Stage 2 – Spontaneous Stage 2 – Spontaneous IrreversibleIrreversible



Edema worsens consistentlyEdema worsens consistently

Massive limb sizes possibleMassive limb sizes possible

Structural tissue changes have occurredStructural tissue changes have occurred

Treatment focus: regain control over the Treatment focus: regain control over the lymphedema to return to a manageable lymphedema to return to a manageable sized, functional limbsized, functional limb

Stage 3 – Lymphatic Stage 3 – Lymphatic ElephantiasisElephantiasis


S & S of LymphedemaS & S of Lymphedema

Mild to extreme edemaMild to extreme edema

May be pitting or non-pittingMay be pitting or non-pitting

Skin may be indurated and/or Skin may be indurated and/or brawny (hardened and brawny (hardened and thickened)thickened)

Skin color may be darker, and Skin color may be darker, and may be flakymay be flaky


Pitting EdemaPitting Edema


S & S of LymphedemaS & S of Lymphedema

Mild to extreme edemaMild to extreme edema

May be pitting or non-pittingMay be pitting or non-pitting

Skin may be indurated and/or Skin may be indurated and/or brawny (hardened and brawny (hardened and thickened)thickened)

Skin color may be darker, and Skin color may be darker, and may be flakymay be flaky


Complicating FactorsComplicating Factors

Extent of damage to lymph systemExtent of damage to lymph system

ObesityObesity

AgeAge

Infection of an at-risk extremityInfection of an at-risk extremity

Vigorous distal extremity exercises, Vigorous distal extremity exercises, particularly with a dependent limbparticularly with a dependent limb

Poor patient compliancePoor patient compliance

““Cording” – Axillary Web SyndromeCording” – Axillary Web Syndrome

Supplemental cancer treatmentsSupplemental cancer treatments


Little understood result of node dissection

Scarring of remaining lymphatics?

Treated with sustained tension in early phase of stretch

Instant relief after “snap”


“Cording” – Axillary Web Syndrome



Chemo TherapyChemo TherapyCan cause scarring of lymphaticsCan cause scarring of lymphatics

General malaise – frequent missed appointmentsGeneral malaise – frequent missed appointments

CDT can reproduce chemo symptomsCDT can reproduce chemo symptoms

““Chemo Brain”Chemo Brain”

Radiation TherapyRadiation TherapyLimits treatment field up to 6 weeks post last EBRTLimits treatment field up to 6 weeks post last EBRT

Causes extensive scarring & fibrosisCauses extensive scarring & fibrosis

Can further limit ROMCan further limit ROM

Can limit bandaging / garment wearingCan limit bandaging / garment wearing

Supplemental Cancer TreatmentsSupplemental Cancer Treatments


Differential DiagnosisDifferential Diagnosis

Edema secondary to CHFEdema secondary to CHF

LymphedemaLymphedema

Malignant LymphedemaMalignant Lymphedema

Chronic Venous Insufficiency (CVI)Chronic Venous Insufficiency (CVI)

Lipidema/LipolymphedemaLipidema/Lipolymphedema

Combinations of the aboveCombinations of the above



Caused by Congestive Heart FailureCaused by Congestive Heart Failure

NotNot to be treated as extremity edema to be treated as extremity edema (treatment (treatment willwill cause harm!) cause harm!)

Bilateral edema, often also in trunkBilateral edema, often also in trunk

Edema secondary to CHF



Edema is caused by a failing heartEdema is caused by a failing heart

Extremity edema will return into Extremity edema will return into circulation with treatmentcirculation with treatment

Increased blood volume further strains Increased blood volume further strains the heartthe heart

Edema secondary to CHF

Why not to treat the edema:



Absence of other causes of edemaAbsence of other causes of edema

No discoloration in early stagesNo discoloration in early stages

Often unilateralOften unilateral


Minimal/no reduction with elevationMinimal/no reduction with elevation

Starts “for no reason”Starts “for no reason”

Lymphedema (primary)


Differential DiagnosisDifferential DiagnosisLymphedema (primary)

Lymphedema Tarda



Lymphedema Tarda



Lymphedema Praecox



Caused by trauma to lymphatic systemCaused by trauma to lymphatic systemNo discoloration in early stagesNo discoloration in early stagesOften unilateralOften unilateralPalpable fibrosisPalpable fibrosisMinimal / no reduction with elevationMinimal / no reduction with elevationStarts right from almost immediately to Starts right from almost immediately to much later (>25 yrs) after traumamuch later (>25 yrs) after trauma

Lymphedema (secondary)


Differential DiagnosisDifferential DiagnosisLymphedema (secondary)

Lymphedema after mastectomy



Lymphedema after lumpectomy



Lymphedema after melanoma



Lymphedema after placement of dialysis stent



Post Phlebitic Syndrome



Post Phlebitic Syndrome with chronic ulcers


Differential DiagnosisDifferential DiagnosisMalignant Lymphedema

Malignant Lymphedema after breast cancer



Gradual onsetGradual onsetReddish/Brownish discoloration caused Reddish/Brownish discoloration caused by hemosiderin depositsby hemosiderin depositsMostly bilateralMostly bilateralWorsens during the dayWorsens during the dayOften reduction with elevationOften reduction with elevationVenous stasis ulcers often resultVenous stasis ulcers often result

Chronic Venous Insufficiency


Differential DiagnosisDifferential DiagnosisChronic Venous Insufficiency



Now is the time to close your eyes

if you have a sensitive stomach

The next slide will show a patient’s leg

with completely un-managed CVI



Gradual onsetGradual onsetPatient has excessive fat storage Patient has excessive fat storage between hips and anklesbetween hips and anklesMostly bilateralMostly bilateralFeet not involvedFeet not involvedCan’t be cured. Reduce progression Can’t be cured. Reduce progression with compression garmentswith compression garments

Lipidema / Lipolymphedema


Differential DiagnosisDifferential DiagnosisLipidema / Lipolymphedema



Starts as straight CVIStarts as straight CVIInitially lymphatics will function as back-Initially lymphatics will function as back-up for venous systemup for venous systemEventually lymphatic system will also failEventually lymphatic system will also failFibrosis will become apparent with Fibrosis will become apparent with resulting tissue changesresulting tissue changes

Lymphedema Secondary to CVI


Differential DiagnosisDifferential DiagnosisLymphedema secondary to CVI


Differential DiagnosisDifferential DiagnosisFlowsheet

LE1 LE2 M LE CVI LIP LIP/LE CHF/PE PTS

Side Unilat Unilat Unilat Bilat Bilat Bilat System Unilat

Feet Involved Yes Yes Yes Yes No Yes Yes Yes

Hemosiderin No No No Yes No No No Yes

Cellulitis Yes Yes Yes Yes Yes Yes No Yes

Pain No No Yes No Yes Yes Yes Yes

Sex F F/M F/M F/M F F F/M F/M

PM Reduction Some Some No Yes No No No No

Fibrosis Yes Yes Yes No No Yes No Yes

Ulcers No No No Yes No No No Yes

Weeping Yes Yes Yes Yes No Yes Yes Yes

Treatment CDT CDT CDT CDT Comp CDT Diuretic Comp

90

SO, SO,

WHAT ISWHAT IS

THE PROBLEM?THE PROBLEM?


So, what’s the problem?So, what’s the problem?

The increased distance between the blood The increased distance between the blood vessels and the tissues combined with vessels and the tissues combined with lymphostasis causes several problems:lymphostasis causes several problems:

#1: Nutritional status is impaired#1: Nutritional status is impaired

#2: Immune response is impaired#2: Immune response is impaired

#3: Mechanical stress#3: Mechanical stress

Problem 1: Nutritional StateProblem 1: Nutritional State

Relative surface area has increasedRelative surface area has increased

Same amount of oxygen and nutrients Same amount of oxygen and nutrients are supplying this larger areaare supplying this larger area

Tissue goes into a state of malnutritionTissue goes into a state of malnutrition

Tissue quality degradesTissue quality degrades




SKINSKIN

nutrition in the “normal” extremitynutrition in the “normal” extremityample nutrients enter the skinample nutrients enter the skin

BLOODVESSELBLOODVESSEL



SKINSKIN

the extremity swells to double its sizethe extremity swells to double its size




SKINSKIN

nutrition in the “edematous” extremitynutrition in the “edematous” extremityinsufficient nutrients enter the skininsufficient nutrients enter the skin


ULCERULCER

Problem 2: Immune Problem 2: Immune ResponseResponse

Receptor function is delayedReceptor function is delayed

Antibodies have to travel farther to Antibodies have to travel farther to reach threatreach threat

Antibodies are more spread outAntibodies are more spread out




BUGBUG

SKINSKIN

a bug enters the “normal” extremitya bug enters the “normal” extremity




the immune system the immune system detects the bugsdetects the bugs

the appropriate immune the appropriate immune response is determinedresponse is determined

the bugs arethe bugs areidentifiedidentified

x 9 = 9 x

the appropriate response is the appropriate response is taken to eliminate all bugstaken to eliminate all bugs



BUGSBUGS

SKINSKIN

the immune response is triggeredthe immune response is triggered


ANTI BODIESANTI BODIES

and effectiveand effective



SKINSKIN

the extremity swells to double its sizethe extremity swells to double its size




BUGBUG

SKINSKIN

a bug enters the edematous extremitya bug enters the edematous extremity




the immune system the immune system detects the bugsdetects the bugs

the appropriate immune the appropriate immune response is determinedresponse is determined(based on wrong data)(based on wrong data)

the bugs arethe bugs areIdentifiedIdentified

(with a slight delay)(with a slight delay)

x 9 = 9 x

an an inappropriateinappropriate response is response is taken to eliminate the bugstaken to eliminate the bugs

* * infection occurs * ** * infection occurs * *



BUGSBUGS

SKINSKIN

the immune response is triggeredthe immune response is triggered


ANTI BODIESANTI BODIES

and and ineffectiveineffective

Problem 3: Mechanical Problem 3: Mechanical StressStress

Wound bed expands when extremity is Wound bed expands when extremity is in a dependent positionin a dependent position

Wound bed contracts with elevation of Wound bed contracts with elevation of the extremitythe extremity

The delicate wound bed is torn open The delicate wound bed is torn open when edema re-occurswhen edema re-occurs




wound healing in “normal” skinwound healing in “normal” skin



wound healing in edematous skinwound healing in edematous skin


So, what’s the problem?So, what’s the problem?

The skin and tissues underneath are in The skin and tissues underneath are in a state of malnutritiona state of malnutrition

Wounds heal slower or not at allWounds heal slower or not at all

Mechanical stresses continuously Mechanical stresses continuously damage the wound beddamage the wound bed

This allows for opportunistic infections This allows for opportunistic infections to occurto occur


Clinical ImpactClinical Impact

Mobility issuesMobility issues

ADL issuesADL issues

Psychological issuesPsychological issues

General health issuesGeneral health issues



Limb can be extremely heavyLimb can be extremely heavyJoint restrictions due to soft Joint restrictions due to soft tissue approximationtissue approximation““Michelin Man effect”Michelin Man effect”Increased stress on jointsIncreased stress on joints

Mobility issues:Mobility issues:


Clinical ImpactClinical ImpactMobility issues:Mobility issues:



Clothes may not fit any moreClothes may not fit any moreHousehold tasks may be harderHousehold tasks may be harderFunctional mobility may be Functional mobility may be impairedimpairedHygiene issuesHygiene issues

ADL issues:ADL issues:



Why me?Why me?

Why was I not warned?Why was I not warned?

Lifelong managementLifelong management

Social isolationSocial isolation

Psychological Psychological issues:issues:



Increased risk for infectionsIncreased risk for infections

Restrictions on testingRestrictions on testing

Increased wear of jointsIncreased wear of joints

Impaired sensationImpaired sensation

Complications with surgeryComplications with surgery

General health issues:General health issues:



Reduce edema prior to surgeryReduce edema prior to surgery

Recommend pre and post-op Recommend pre and post-op antibioticsantibiotics

Use care with IV-fluidsUse care with IV-fluids

Recommend post-op CDTRecommend post-op CDT

Surgical Surgical recommendations:recommendations:


What What notnot to do to do

Drain the fluid out of the extremityDrain the fluid out of the extremity

Bind the extremity tightlyBind the extremity tightly

Attempt to squeeze the fluid outAttempt to squeeze the fluid out

Stop moving at allStop moving at all

Get any kind of injury to the extremityGet any kind of injury to the extremity

Wait for the problem to resolve itselfWait for the problem to resolve itself


Then what is the thing to Then what is the thing to do?do?

Treat the edema first:Treat the edema first:

most of the other problemsmost of the other problems

will resolve by themselves!will resolve by themselves!

117

COMPLETECOMPLETE

DECONGESTIVEDECONGESTIVE

THERAPYTHERAPY


Commonly known Commonly known “treatments”“treatments”

DiureticsDiureticsFluid restrictionFluid restrictionTED hosesTED hosesPumpPumpDraining of fluidDraining of fluidDe-bulking surgeryDe-bulking surgeryAmputationAmputation

Samuel Adams 9/27/1722 – 10/2/1803 (founding father & brewer)


CDT ComponentsCDT Components

Meticulous Skin CareMeticulous Skin CareManual Lymph DrainageManual Lymph DrainageCompression TherapyCompression TherapyDecongestive ExerciseDecongestive ExerciseEducationEducation


Meticulous Skin CareMeticulous Skin Care

CleanlinessCleanliness

ProtectionProtection

InspectionInspection


Manual Lymph DrainageManual Lymph Drainage

Stimulate FlowStimulate Flow

Re-route FlowRe-route Flow

Time-release effectTime-release effect


Compression TherapyCompression Therapy

Compression bandagesCompression bandages

Elastic compression garments Elastic compression garments (day-time)(day-time)

Non-elastic compression garments Non-elastic compression garments (day and/or night-time)(day and/or night-time)

Vaso-pneumatic compressionVaso-pneumatic compression


Therapeutic ExerciseTherapeutic Exercise

Promote CirculationPromote Circulation

Combine with compression Combine with compression therapytherapy

Improve overall enduranceImprove overall endurance

Maintain / improve mobilityMaintain / improve mobility


EducationEducation

Continuum of careContinuum of carePreventionPreventionUnderstandingUnderstandingGeneral knowledgeGeneral knowledge

125

COMPRESSIONCOMPRESSION

GARMENTSGARMENTS


Elastic CompressionElastic Compression

Support hose: Support hose: ≤ 20 mmHg≤ 20 mmHg

Medical Compression: Medical Compression: ≥ 20 mmHg≥ 20 mmHg

Off the shelf / Custom MadeOff the shelf / Custom Made

Worn only during the dayWorn only during the day

Last about 4-6 monthsLast about 4-6 months

$70 - $600$70 - $600

Variety of compression classesVariety of compression classes

BSN-Jobst, Juzo, Bauerfind, BSN-Jobst, Juzo, Bauerfind,

Sigvaris, Medi, etc.Sigvaris, Medi, etc.


Non-Elastic CompressionNon-Elastic Compression

Off the shelf / Custom MadeOff the shelf / Custom Made

Worn during the night, but also during Worn during the night, but also during the daythe day

Good emergency solutionGood emergency solution

Lasts several yearsLasts several years

$250 - $1800$250 - $1800

Variable compression / sizeVariable compression / size

CircAid, ReidSleeve, Tribute, etc.CircAid, ReidSleeve, Tribute, etc.

128

MANUALMANUAL

LYMPHLYMPH

DRAINAGEDRAINAGE



Very light skin-techniqueVery light skin-technique

Work from proximal to distal with a distal to Work from proximal to distal with a distal to proximal techniqueproximal technique

Time consuming (30-45 minutes)Time consuming (30-45 minutes)

Activates lymph nodesActivates lymph nodes

Stimulates lymphatic flowStimulates lymphatic flow

Stimulate anastosmosesStimulate anastosmoses


Manual Lymph DrainageManual Lymph DrainageWatershedsWatersheds



AAA -AAA - Anterior Axillo-AxillaryAnterior Axillo-Axillary

PAA -PAA - Posterior Axillo-AxillaryPosterior Axillo-Axillary

AIIAII - - Anterior InteringuinalAnterior Interinguinal

PIIPII - - Posterior InteringuinalPosterior Interinguinal

AIAI - - Axillo-inguinalAxillo-inguinal

IAIA - - Inguino-axillaryInguino-axillary

AnastomosesAnastomoses


Manual Lymph DrainageManual Lymph DrainageAnastomosesAnastomoses


Manual Lymph DrainageManual Lymph DrainageExample: LUE lymphedemaExample: LUE lymphedema


Manual Lymph DrainageManual Lymph DrainageExample: BLE lymphedemaExample: BLE lymphedema



Slow, 1 second rhythmSlow, 1 second rhythm

Repeat 5-7 timesRepeat 5-7 times

Low pressureLow pressure

Takes 30-45 minutesTakes 30-45 minutes

Do Do notnot attempt to squeeze fluid out of the limb attempt to squeeze fluid out of the limb

136

LYMPHEDEMALYMPHEDEMA

BANDAGINGBANDAGING


The Effect of The Effect of CompressionCompression

BHP29 mmHg

BHP14 mmHg

IHP20 mmHg

IHP20 mmHg

BCOP25 mmHg

BCOP25 mmHg

ICOP30 mmHg

ICOP30 mmHg

Ultra Filtration Reabsorption Balance


Compression BandagesCompression Bandages

At least 50% of treatment effectAt least 50% of treatment effectCustom-fit with every applicationCustom-fit with every applicationWorn as close to 24/7 as possibleWorn as close to 24/7 as possibleMulti-layered:Multi-layered:

Absorption layerAbsorption layerEqualization layerEqualization layerCompression layerCompression layer

Short-stretch materialShort-stretch materialCan be the ideal long term Can be the ideal long term compression solutioncompression solution


Short-stretch vs. Long-Short-stretch vs. Long-stretchstretch

Post Stretch

Pre Stretch

ACE ®

Comprilan ®

Comprilan ®

ACE ®


Bandage TechniqueBandage Technique

Frequently used for mobility Frequently used for mobility compromised patientcompromised patient

Easy to teach to family membersEasy to teach to family members

Effective for venous insufficiencyEffective for venous insufficiency

Lower Leg Bandage


Bandage TechniqueBandage TechniqueLower LegLower Leg


Bandage TechniqueBandage TechniqueUpper ExtremityUpper Extremity


Vaso Pneumatic Vaso Pneumatic CompressionCompression

Gradient-sequential multi-chamber Gradient-sequential multi-chamber pumppump

Actively pumps Actively pumps fluidfluid out of the out of the affected extremityaffected extremity

Patients pumps at least one hour Patients pumps at least one hour each dayeach day

Should be done after manual Should be done after manual techniquestechniques



““Compression shoes”Compression shoes”

3-4 chamber “Medicare” pump3-4 chamber “Medicare” pump

10-12 chamber Lympha Press10-12 chamber Lympha Press

FlexitouchFlexitouch®®



Lympha PressLympha Press““Medicare” pumpMedicare” pump

Different pumpsDifferent pumps

Approx. $5,000Approx. $800-$1,200



FlexitouchFlexitouch®®

Different pumpsDifferent pumps

Approx $12,500



Patient in LymphapressPatient in Lymphapress


Education: Who ?Education: Who ?

The PatientThe Patient

The Patient’s Support SystemThe Patient’s Support System

The Patient's PhysicianThe Patient's Physician

The WorldThe World


Education: What ?Education: What ?

Lymphatic BasicsLymphatic Basics

Self-MassageSelf-Massage

Self BandagingSelf Bandaging

Minimizing the risk of infectionMinimizing the risk of infection

Home exercise programHome exercise program

Use of long-term compression solutionUse of long-term compression solution

The importance of life-long complianceThe importance of life-long compliance

The Patient:The Patient:



Lymphatic BasicsLymphatic Basics

MassageMassage

BandagingBandaging

Assisting with long-term Assisting with long-term compression solutioncompression solution

Reinforcing complianceReinforcing compliance

The Patient’s Support System:The Patient’s Support System:



The existence of treatmentThe existence of treatment

How to referHow to refer

The impact of treatmentThe impact of treatment

PrecautionsPrecautions

Funding issuesFunding issues

Importance of L.M.N.Importance of L.M.N.

The Patient’s Physician:The Patient’s Physician:


The Effects of TreatmentThe Effects of Treatment

Case 1:

61 y/o female

>4 yrs Secondary Lymphedema



LE secondary to abdominal surgeries

Extreme high soft tissue tension

Severe pain

Weeping lower legs

0-90° knee flexion

Unable to wear shoes

Difficulty walking with walker



After 30 treatments

Normal soft tissue tension

Minimal pain

0-135° knee flexion

Walks without assistive device

Able to dress self

Lost 23 lbs since start of CDT



Juzo® 30-40 mmHg custom garments

Reidsleeve® Classic garments

Biocompression vasopneumatic pump



Case 2:

19 y/o female

Primary Lymphedema



Before treatment

Lymphedema since early age

Worsened after birth of her son 3 years ago

Recently suffered cellulitis and open wounds

Has had fluid drained from lower abdomen


The Effects of TreatmentThe Effects of TreatmentAfter treatment

7 weeks of treatment

Received Juzo & Reidsleeve garments donated by manufacturer

66% reduction of right calf

Patient will return to school to start career


The Effects of TreatmentThe Effects of TreatmentMeasurement Graph



Case 3:

33 y/o male

>3 yrs CVI



Case 3:

76 y/o female




Returning patient

Didn’t wear Circaid® garments 3 days

Severe pain

Extensive ulcerations

Extensive weeping

Minimal ambulator



Ulcers all healed

Significant pain reduction

Back to wearing CircAid® garments

Added vasopneumatic compression

No weeping



Case 4:

85 y/o male




LE for more than 2 years

Severe pitting edema

Feet increased 2 sizes

Weeping lower legs

Difficulty walking with walker

Extensive cardio-pulmonary history



After 3 weeks

No palpable edema

Wears regular shoes

Walks with straight cane

Able to dress self, including shoes

Lost 35 lbs since start of CDT

Improved breathing, no side-effects

from treatment

168

INDICATIONSINDICATIONS

CONTRA-CONTRA-INDICATIONSINDICATIONS


IndicationsIndications

Primary lymphedemaPrimary lymphedema

Secondary lymphedemaSecondary lymphedema

Chronic Venous InsufficiencyChronic Venous Insufficiency

LipolymphedemaLipolymphedema

Venous stasis ulcersVenous stasis ulcers

Subacute local inflammation Subacute local inflammation

post fracture, sprain/strain, etc.post fracture, sprain/strain, etc.

post-operative edemapost-operative edema


Contra-IndicationsContra-Indications

All acute infectionsAll acute infections

Acute bronchial asthmaAcute bronchial asthma

Active cancerActive cancer

Peripheral Vascular Disease Peripheral Vascular Disease

Congestive Heart FailureCongestive Heart Failure

Extreme ageExtreme age

Anticoagulant therapyAnticoagulant therapy

171

ABOUTABOUT

CERTIFICATIONCERTIFICATION


Why get certification?Why get certification?

Certification is required for some insurance Certification is required for some insurance coveragecoverage

May become required for Medicare coverageMay become required for Medicare coverage

Give structure to lymphedema treatmentGive structure to lymphedema treatmentStandard vocabularyStandard vocabulary

Treatment standardsTreatment standards

Standard of grading lymphedemaStandard of grading lymphedema


Requirements for Requirements for LANA certification LANA certification

135 (60 minute) hours of CDT training135 (60 minute) hours of CDT training

14 days (= 10 days PTO)14 days (= 10 days PTO)

$2850 (+ travel + 2 weeks hotel + 2 weeks $2850 (+ travel + 2 weeks hotel + 2 weeks of meals) of meals) ≈ $4500≈ $4500

1 year experience after receiving training1 year experience after receiving training

$300 LANA exam fee$300 LANA exam fee

174

IN CLOSINGIN CLOSING


Ideal WorldIdeal World

> 40 min. MLD> 40 min. MLD

> 30 min. rest> 30 min. rest

> 30 min. exercise> 30 min. exercise

15 min. bandaging15 min. bandaging

♫ ♫ relaxing musicrelaxing music

Daily treatmentDaily treatment

Daily measurementsDaily measurements

Insurance pays……Insurance pays……

Can anyone say Managed Can anyone say Managed Care?Care?

Busy clinicsBusy clinics

Productivity standardsProductivity standards

Cubicles / curtainsCubicles / curtains

Garments are often not a Garments are often not a covered itemcovered item

vs. Real vs. Real WorldWorld


Failure Failure IsIs An Option…… An Option……

Patient non-compliancePatient non-compliance

Lack of motivationLack of motivation

Patient unable to take care of Patient unable to take care of themselvesthemselves

Lack of support systemLack of support system

Lack of fundingLack of funding

Patient too sick for programPatient too sick for program


Many Schools of Thought…Many Schools of Thought…

Training: Vodder, Foldi, LeDuc, Lerner, Training: Vodder, Foldi, LeDuc, Lerner, Casley-Smith, etc.Casley-Smith, etc.

Pump / No pumpPump / No pump

Personal experiencePersonal experience

MarketMarket


Information on the WebInformation on the Web

The National Lymphedema NetworkThe National Lymphedema Network

www.lymphnet.orgwww.lymphnet.org

North American Vodder Association of Lymphatic Therapy North American Vodder Association of Lymphatic Therapy (NAVALT) (NAVALT)

www.navalt.orgwww.navalt.org

Lymphology Association of North AmericaLymphology Association of North America

www.clt-lana.orgwww.clt-lana.org

Luna Medical, IncLuna Medical, Inc

www.lunamedical.comwww.lunamedical.com

Suncoast Lymphedema GroupSuncoast Lymphedema Group

www.webconceptz.com/lymphedemawww.webconceptz.com/lymphedema


Any Questions ?Any Questions ?

? ? ? ? ?? ? ? ? ?

©2010, zoltan bouwhuis, bscpt, clt 1 an introduction to lymphedema treatment

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