edema disorders kade scott dpt, clt. objectives understand and recognize different edema disorders ...
TRANSCRIPT
Edema DisordersKade Scott DPT, CLT
Objectives Understand and recognize different
edema disorders Understand basic treatment options for
edema disorders Explain the differences in compression
garments
What does the Lymphatic system do? The lymph system is responsible for
transporting Proteins Water Cells Fat Waste WBC, lymphocytes, Bacteria, Virus
Lymphedema An abnormal accumulation of protein
rich fluid in the interstitum, which causes chronic inflammation and reactive fibrosis in the affected tissue
Lymphedema is classified as either primary or secondary lymphedema
Typically asymmetrical
Date of download: 2/17/2014Copyright © 2014 American Medical Association.
All rights reserved.
From: Differential Diagnosis, Investigation, and Current Treatment of Lower Limb Lymphedema
Arch Surg. 2003;138(2):152-161. doi:10.1001/archsurg.138.2.152
Causes of lymphedema.
Figure Legend:
Primary Lymphedema The most likely occurrence of this form is
lymphangiodysplasia Hypoplasia- less than normal expected
number of lymph collectors in the affected area
Aplasia- a distinct absence of lymph collectors in the affected area. May also involve the absence of lymph capillaries
Hyperplasia- Vessels are characterized by an excessively dilated caliber which renders them less functional due to valvular dysfunction
Primary Lymphedema Present at birth or
shortly therafter is known as Milroy’s Disease
Primary Lymphedema that develops during puberty is known as Meige’s Disease.
Praecox- Develops before 30
Tardum- Develops after 35
http://www.sajch.org.za/index.php/SAJCH/article/view/639/453
Secondary Lymphedema Secondary lymphedema means there is a
known cause for the presence of lymphedema
Worldwide the most common cause is the mosquito born parasite Filaria
In the United States the most common cause is cancer therapy Lymph node sampling Full dissection of lymph nodes Radiation therapy
Secondary Lymphedema (cont) Other causes include any significant
trauma to the lymphatic system from accidental or self induced incidents, infectious episodes such as eyrsipelas or cellulitis
Obesity may also play a role in the development of lymphedema, however, it is more likely due to a secondary co-morbidity (lack of mobility, CVI etc)
Staging of lymphedema Lymphedema is divided into 4 stages
(American Society of Lymphology) Latency stage (subclinical or stage 0)
Transport capacity of the lymphatic system is sub-normal but still sufficient to transport the lymphatic load
Patients are “at risk” for developing lymphedema
Education about subjective complaints and preventative measures is key component of treatment at this stage
Staging Stage 1 (reversible stage)
Accumulation of protein rich fluid No fibrotic alterations Pitting is easily induced With proper management of stage 1
patient can expect to have reduction to normal limb size
Stage 1 is often confused with edemas of other geneses
Staging Stage 2 (spontaneously
irreversible) Lymphatic fibrosis Tissue becomes
indurated Pitting is difficult to
induce Positive Stemmer sign Common cellulitic
infections Incomplete reduction
with therapy and good patient compliance
Stemmer SignSometimes called the Kaposi Stemmer sign
Staging Stage 3 (Lymphostatic
Elephantitis) Increased skin firmness,
other skin alterations including: cysts, fistulas, papillomas, hyperkeratosis, mycotic infections, ulcerations
More prominent Stemmer sign
Recurrent cellulitis Decreased pitting
Click icon to add picture
http://www.womenshealthsection.com/content/gyno/gyno005.php3
Symptoms Swelling of an arm or leg, which may include fingers and toes. A full or heavy feeling in an arm or leg. A tight feeling in the skin. Trouble moving a joint in the arm or leg. Thickening of the skin, with or without skin changes such as blisters
or warts. A feeling of tightness when wearing clothing, shoes, bracelets, watches, or
rings. Itching of the legs or toes. A burning feeling in the legs. Trouble sleeping. Loss of hair. Positive Stemmer Sign (though the absence does not rule out
lymphedema) These symptoms may occur very slowly over time or more quickly if there
is an infection or injury to the arm or leg.
Chronic Venous Insufficiency Is an advanced stage of venous disease
in which the veins and the muscle pump activity become incompetent causing blood to pool in the legs and feet
Can be due to repeated damage from superficial or deep venous pathology, or a variety of vein-related conditions such as the congenital absence of valves
Pathophysiology of CVI Faulty valves fail to prevent retrograde
flow of venous blood during muscle pump activity
May be: Idiopathic Post-thrombotic syndrome Genetics Pelvic tumors Vascular malformations
Symptoms Swelling in the lower legs and ankles,
especially after extended periods of standing
Aching or tiredness in the legs New varicose veins Leathery-looking skin on the legs Flaking or itching skin on the legs or feet Stasis ulcers (or venous stasis ulcers) Hemosiderin staining
Hemosiderin staining
Risk factors Deep vein thrombosis (DVT) Varicose veins or a family history of varicose
veins Obesity Pregnancy Inactivity Smoking Extended periods of standing or sitting Female sex Age over 50
Early stages of CVI Pitting Edema
Mostly presenting below the knee
Corona Phlebectatica A myriad of tiny
vein branches that are difficult to delineate
Red-pink hue to skin that returns immediately after pressure is released
http://www.medicographia.com/wp-content/uploads/2011/10/17.JPG
Advanced stages Hyperpigmentation Dermatologic changes Venous stasis dermatitis Lipodermatosclerosis
Scarring and fibrosis of skin (woody texture to skin)
There may now be a lymphatic component to edema http://www.veinsveinsveins.com/app/
webroot/files/lipo.11.jpg
End Stage CVIDefined by ulcerations of the skin
Photo Credit: Charlie Goldberg http://meded.ucsd.edu/clinicalimg/extremities_venous_insuf4.htm
Lipedema A chronic
metabolic disorder of the adipose tissue, of unknown etiology.
http://www.amylhwilliams.com/BEFOREAmyslegsfront1.jpg
Lipedema Predominately in women Bilateral symmetrical swelling from illiac
crest to ankles Stemmer’s sign negative No cellulitic infections Foot sparing
Lipedema “I can never lose weight in my legs no
matter how much I diet” Very tender skin Bruise easily
Lipedema Stage 1
Skin surface is normal, tissues exhibit a smooth nodular texture
Stage 2 Skin surface becomes more uneven, large
fatty lobules begin to form Stage 3
Large contour deforming lobular shapes on medial knee, proximal lateral thigh, and above malleoli
Lipedema Staging
http://www.nature.com/aps/journal/v33/n2/fig_tab/aps2011153f4.html
Traumatic Edema Edema due to physical trauma
Results in inflammatory reactions accompanied by high protein edema.
The majority are temprorary and self resloving. However, it can lead to permanent damage.
Pathophysiology of traumatic edema The initial step in the inflammatory
process causes local vasodilation, followed by an increase in the permebility of blood capillaries toward plasma protein. Macrophages invade and devour damage tissue. These macrophages may injure the lymhpatic system.
Cardiac Edema Greatest distally Always Bilateral Pitting Complete resolution with elevation No pain
Congestive Heart Failure Same symptoms as in cardiac edema Orthopnea, paroxysmal nocturnal
dyspnea, dyspnea on exertion Jugular venous distension Cardiac echo, Physical exam
Renal Failure and Edema Increased protein in the urine Decreased blood protein Pitting edema in lower extremity
How do I differentiate?And then what?
Accurate Pt Hx Patient history is crucial in determining
the underlying cause of edemaThere are many questions that you can ask that will help guide you down the proper course
Intake Questions Have you had any lymph nodes
removed? Any recent abdominal surgeries? Any history of DVT? Previous cellulitic infection? CHF? Renal Failure?
Lymphedema
•MLD•Compression Bandage•Compression Stockings•Pneumatic Compression
Lipedema
•Light MLD•Compression Stockings•Compression Bandage
CVI
•Compression Bandaging•Compression Stockings•Pneumatic Compression
Traumatic Edem
a
•MLD above level of injury•Compression Bandaging
Cardiac,
CHF, Renal
•Compression bandaging and stockings as tolerated. You MUST consult a physician on these patients prior to initiating any treatment
2 phases to treatment
Reduction MLD Compression
bandaging Pneumatic
compression Exercise and skin
care
Maintenance Compression
Stockings Pneumatic
Compression Exercise, Skin care
Manual Lymphatic Drainage A general manual treatment which improves
lymph vascular flow. In lymphedema it re-routes the lymph fluid around blocked areas into more centrally located healthy lymph nodes
It is not a massage! Must be done by someone who is properly
trained
Contraindications to MLD CHF if patient is unmedicated or edema
is due solely to cardiac failure Acute infection Renal Failure Acute DVT (seek physician approval for
post thrombotic syndrome edema management)
Compression Bandaging Short stetch bandages are applied to
increase the tissue pressure in the swollen extremity Improves the efficiency of the muscle
pump and joint pumps Prevents the reacummulation of
evacuated fluid Helps break up deposits of accumulated
scar and connective tissues
Contraindications to compression bandaging Acute DVT (may mobilize thrombus) Acute infection Cardiac edema Advanced arterial disease <.7 on the
ABI Advanced renal disease Malignancy (relative to severity)
Bandaging Short stretch-
Unna, Comprilan Medium stretch
Coban Co-Plus
Long Stretch Ace
4-layer Profore
Short stretch Reduce deep venous reflux more
effectively High working pressure to low resting
pressure. Produce high pressure amplitudes when patient is walking and a decrease in pressure when patient is supine
Main disadvantage is the loss of pressure following reduction
Short Stretch Comprilan Bandagehttp://curept.com/multi-layer-bandaging/
Medium stretch Sustains compression after an initial
decrease Has a fair working to resting pressure
ratio
2-layer Wraphttp://solutions.3m.com/wps/portal/3M/en_EU/Healthcare-Europe/EU-Home/Products/ProductCatalogue/?PC_Z7_RJH9U52300PI40IA1Q602S28E7000000_nid=5W2H1K4LB0be56F5WHWNG2gl
Long Stretch Maintain pressure for longer periods of
time A higher pressure of at least 60 mmHg
is required to prevent reflux Exert a high resting pressure which can
constrict the venous and lymphatic systems creating a tourniquet effect
Helping Patients & Physicians Heal
Pneumatic Compression Therapy
Before
Pneumatic Compression Therapy
Before After 2 Weeks Pneumatic Compression
Pneumatic Compression Pump
Mechanism of ActionA gentle “milking” of lymphatic fluid out of the upper extremity. This distal to proximal motion allows for a clearance of lymphatic fluid to be filtered out of the system via the urinary tract. In essence the Pneumatic Compression pump is designed to ‘do’ what the body is incapable of due to age, damage or disease state.
Contraindications Inflammatory Phlebitis Episodes of Pulmonary Embolism Infections in limb without appropriate
antibiotic coverage* Presence of Lymphangiosarcoma Congestive Heart Failure, Uncontrolled
*48 hours
Pneumatic Compression Therapy
Convenient home use Comprehensive in-home or office patient
training Easy to use Medicare and private insurance coverage Custom sizing Adjustable Ability to clean the product-sanitary Patient dictated time of use Lifetime treatment of underlying condition
Compression garments Class 0 10-20 mmHg Class 1 20-30 mmHg Class 2 30-40 mmHg Class 3 40-50 mmHg
Class 0 Preventative only Should not be used for someone with
active edema
Class 1 20-30 mmHg Minimum compression for UE
lymphedema Offer support, but NOT sufficient for
lower extremity lymphedema or CVI
Class 2 30-40 Most stage 2 upper extremity
lymphedema Minimum compression for LE
lymphedmea Offers good support for LE CVI
Class 3 40-50 mmHG Rarely used in UE lymphedema Most stage 2 LE lymphedema Minimum starting point for stage 3
lymphedema
Consideration for garment selection Patient ability to manage garment Material allergies Price Insurance coverage
Flat knit vs Circular knit
Flat Custom only Slightly easier to don The thicker fabric offers
additional features, such as its massaging effect, which promotes lymph drainage, and its strength, which ensures the stocking does not yield to the edema. In conjunction with movement, it produces a high therapeutic pressure that provides optimum compression of the tissue.
Circular Custom or OTS Difficult to don Single layer of fabric Not appropriate
compression for active lymphedema, may not be adequate for sever venous edema
Cheaper
Goals for compression garments MAINTAIN limb volume after
decongestion. Compresion garments will NOT decongest limb
Easy don/doffing to enhance patient compliance
Cosmetically appealing
References Diseases and Conditions: Chronic Venous Insufficiency
(CVI). http://my.clevelandclinic.org/disorders/venous_insufficiency/hvi_chronic_venous_insufficiency.aspx. Accessed 2-26-14.
Greenlee R, Hoyme H, Witte M, Crowe P, Witte C. Developmental Disorders of the Lymphatic System. Lymphology. 26 (1993): 156-158.
Managing edema to decrease pain and increase range of motion and functional mobility. Loraine Lovejoy-Evans MPT, DPT, CLT-Foldi.
Mcdonald J, Sims N, Mayrovitz H. Lymphedema, lipedema, and the open wound. The role of compression therapy. Surgical Clinicals of North America. 83 (2003): 639-658.
References Norton School of lymphatic therapy course manual:
Manual Lymphatci Drainage/Complete Decongestive Therapy .
Rathbun SW, Kirkpatrick AC. Treatment of chronic venous insufficiency. Curr Treat Options Cardiovasc Med. 2007 Apr;9(2):115-26.
Szuba A, Rockson S. Lymphedema: classification, diagnosis and therapy. Vascular Medicine. 1998: 3:145-156.
Zuther J, Norton S. Lymphedema Management: the comprehensive guide for practitioners. 3rd ed. New York, NY: Thieme Medical Publishers; 2013.
LE Short Stretch Compression
Foam Open Cell Grey Foam Komprebinde Komprex Rosidal Soft
LE bandaging Lotion Stockinette to calf Toe wraps Cotton (knee, foot) Foam (affix to calf) Foam (affix to ankle
and dorsum of foot)
Eucerin or other low pH
TG or Tricofix Transelast/elastomull Cellona/Artiflex
LE bandaging Roman Sandal Ankle sole heel (ASH,
Has) Spiral ankle to knee Herring bone/Figure 8 Stockinette to thigh Affix foam to thigh Knee to mid thigh Knee to top Distal thigh to top
6cm Comprilan/Rosidal K 8cm 10 cm 10 cm
12 cm 12cm 12 cm