EDEMA CONFUSION. Physical Therapy and Lymphedema An Art and A Science. Marta Ostler PT, CWS, CLT

Transcription

1 EDEMA CONFUSION Physical Therapy and Lymphedema An Art and A Science Marta Ostler PT, CWS, CLT

2 OBJECTIVES: 1.Recognize different types of edema 2.Recognize how our fluid transport systems are interwoven 3.Recognize treatment opportunities

3 Organized Approach to Wound Care Offloading Disease Process Controlled Patient Centered Pain Wound Moisture Balance Advanced Modalities Edema BioBurden Debridement Blood Flow 1. Is there adequate perfusion and/or oxygenation? 2. Is non-viable tissue present? 3. Are signs/symptoms of infection and/or inflammation present? 4. Is offloading or pressure relief appropriate? 5. Is edema controlled? 6. Is tissue growth optimized? 7. Is the wound microenvironment conducive to healing? 8. Is pain controlled? 9. Are host factors optimized?

4 VASCULAR MECHANICS VENOUS SYSTEM DEEP VEINS SUPERFICIAL VEINS COMMUNICATING VEINS (PERFORATORS) VALVES CALF PUMP Hegarty M,: Am Overview of Compression Therapy. Today s Wound Clinic vol 4 issue 10-Oct 2010.

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6 CHRONIC VENOUS ULCERS (CVI) Venous Ulcer account for 60-90% of leg ulcers More common in women: 3X Difficult to heal: 50% > 9 months/20% > 2 years High rate of reoccurrence: 60% WHY??? 76% Diagnosed by presentation alone Advances in Skin & Wound Care: August Volume 22 - Issue 8 - p 384

7 What Effects the Pressure?? Directly proportional to persons Height: Distance from head to feet OBESITY: Linear relationship girth and vascular pressure Resting Pressure/supine: ~8 mmhg Standing: mmhg Ambulation: ~ mmhg Hegarty M,: Am Overview of Compression Therapy. Today s Wound Clinic vol 4 issue 10-Oct 2010 Partsch H, Annuals Vascular Disease 2012

8 Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practitioner's guide to treatment and prevention of venous leg ulcers; Wounds International: 2013 VENOUS PRESSURE :Anatomic Failure Ambulatory Venous Hypertension: The elevated pressure in the leg vein during walking Even with intact vessels: 25 mmhg calf pump - 8 mmhg rest = 17 mmhg 1. Venous Wall Physical Properties: Reduced Strength 2. Venous Valves Degenerative damage DVT 3. Calf Pump (.exercise.. ) 90% of venous return is through these 3 Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

9 LYMPHEDEMA An abnormal collection of excessive tissue proteins, edema, chronic inflammation and fibrosis in the interstitial space. The International Society of Lymphology CHRONIC PROBLEM NO CURE TREATMENT: CDT PROGRAM -Manual Lymphatic Drainage -Compression Therapy -Skin Care -Exercise

10 ANATOMY PRECOLLECTORS COLLECTORS LYMPHATIC CAPILLARIES NODES THORACIC DUCT

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13 MECHANICAL INSUFFICIENCY Low Output Failure LYMPHATIC SYSTEM IS DAMAGED AND HAS REDUCED TRANSPORT CAPACITY Structural/Functional Abnormalities

14 DYNAMIC INSUFFICIENCY High Output Failure: OVERLOAD FLUID LOAD EXCEEDS LYMPHATIC TRANSPORT CAPACITY Infection CVI Trauma Cardiac Insufficiency, etc

15 Dr. Wade Farrow: WITHOUT FUNCTIONAL LYMPHATICS, WE WOULD DIE IN ABOUT 24 HOURS. Carlson and Foldi: Lymphatic Failure= infection, inflammation and carcinogenesis Guyton AC: Texbook of Medical Physiology. 8 th ed. Philadelphia. PA: WB Saunders: Carlson JA (2014) Lymphedema and subclinical lymphostasis (microlymphedema) facilitate cutaneous infection, inflammatory dermatoses, and neoplasia: A locus minoris resistentiae. Clin Dermatol32(5): Foldi M, Foldi E (2012) Textbook of Lymphology (3 rd edn.). Elsevier GmbH, Munchen, Germany

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17 PHLEBOLYMPHEDEMA WHAT????? Mixed-etiology swelling. CVI+ lymphatic insufficiency =Phlebolymphedema

18 SOOOOOOOOO. DEFINITION: Phlebolymphedema: is due to insufficiency of the venous or/and lymphatic system, in combination with possible systemic contributors, leading to accumulation of interstitial protein-rich fluid in the interstitial space.

19 What we get.. Hyperemia: Venous Hypertension Increased interstitial fluid Increased sub fascial edema Increased compartment pressure OVERWHELMED LYMPHATIC SYSTEM PROINFLAMMATORY STATE

20 STARLINGS LAW Maybe NOT? 1) Capillaries are semi-porous membranes Fluid moves in and out 2) Increasing capillary hydrostatic pressure, moves fluid into the interstitium 3) Lower capillary hydrostatic pressure+ higher capillary oncotic pressure of proteins= pulls fluid back into the venous system.

21 ENDOTHELIAL GLYCOCALYX LAYER Controls movement of proteins and fluid across the blood capillary wall There is NO reabsorption of fluid, back into the venous side of blood capillaries REABSORPTION OCCURS ONLY THROUGH THE LYMPHATIC CAPILLARIES Photo used with permission

22 The EGL: regulates fluid/protein movement 1. Through the capillary wall to tissue 2. Prevents movement back into venous side of capillaries: even in presence of higher pressures. All fluid/protein existing the blood capillaries into the interstitium MUST be removed by the lymphatics. THEREFORE: Arguably, it may be better to consider the presence of chronic oedema as synonymous with the presence of lympheoedema, in as much all oedema represents relative lymph drainage failure. Mortimer and Rockson (2014)

23 CLINCAL CONSIDERATIONS Consider lymphatic function Recognize lymphedema comes in various forms Use Stemmers sign at various physical locations Consider CDT/MLD program: PT/OT -compression -exercise -manual lymphatic mobilization -skin care

24 WHAT DOES ALL THIS LOOK LIKE??

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28 LYMPHEDEMA RUBRA -CELLULITIS? Lipodermatosclerotic changes (sand paper)

29 FUNCTIONAL CONSIDERATIONS Lymph node locations: joints Joint Movement Mobility Endurance: (Heart rate/breathing) Accountability

30 WHAT MUST WE DO ABOUT IT? COUNTERACT GRAVITY: ELEVATION EXERCISE COMPRESSION THERAPY MANUAL LYMH DRAINAGE SKIN CARE SELF MANAGEMENT

31 EXERCISE!! CALF RAISES CALF STRETCHES MARCHES DAILY WALKING UP AND DOWN STAIRS SWIMMING 75 % adherence 24% improved healing rates Obrien J, Finlayson K, Kerr G, Edwards H; Evaluating the effectiveness of a self management exercise intervention on wound healing, functional ability and health-related quality of life outcomes in adults with venous leg ulcers: a randomized controlled trial. Int Wound, 2016 Jan 27.

32 PURPOSE OF COMPRESSION 1.Counteract the force of gravity and promote the normal flow of venous blood up the leg 2.Acts on the venous and lymphatic systems to improve venous and lymph return and reduce edema 3.Causes narrowing of the superficial veins Meissner,M, Lower Extremity Venous Anatomy, Interventional Radiology, Sept. 2005, ; 22(3):

33 Elevated MMP-1 in Venous Ulcers Beidler et al, Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy. Wound Rep Regen 16: , 2008.

34 TYPES COMPRESSION WRAPS COMPRESSION HOSIERY INTERMITTENT PNEUMATIC COMPRESSION (IPC) MIXED TEXTILES

35 HOW DO WE DEFINE THIS IN PRACTICE?????? Types of Compression ELASTIC INELASTIC STATIC DYNAMIC WRAPS HOSE LONG STRETCH, SHORT STRETCH NON-STRETCH HELP!!!!! PARTNER WITH A LYMPHATIC THERAPIST

36 WHAT IS ADAQUATE COMPRESSION Overcomes intravenous pressure Exerts a sub-bandage resting pressure that is well tolerated in a resting position Provides a pressure increase when the patient rises to a standing position: (50-70mmHG) Provides external compression improving venous reflux during walking Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practitioner's guide to treatment and prevention of venous leg ulcers; Wounds International: 2013 Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

37 IT S THE LAYERS La Places Law: Lymphatic Principles A formula that defines the pressures exerted on curved surfaces Pressure = T x N C xw N= number of layers applied T= bandage tension C= limb circumference W= Bandage Width World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008

38 Non-Stretch ZINC PASTE BANDAGES

39 Short Stretch Bandages that stretch to less than 100% of their original length: minimal extensibility High Working Pressure/Low Resting Pressure

40 Long Stretch Expands over 100% of its original length Low Working Pressure/High Resting Pressure Contains Elastomeric Fibers: fibers that are able to stretch and return to almost their original size. World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008

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43 Combining Textiles

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48 ULCER X 7 YEARS 3 YEARS ACTIVE TREATMENT 3 X PER WEEK NO FINAL CLOSURE STARTED PHYSICAL THERAPY - EXERCISE -NODE MASSAGE -INELASTIC MULTILAYER COMPRESSION

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51 TAKE HOME PEARLS THINK ABOUT THE WHOLE PATIENT.. REMEMBER OTHER SPECIALITIES THAT MAY BE ABLE TO HELP EDEMA IS NOT DIAGNOSIS SPECIFIC: ALWAYS, NEVER ETC EXERCISE/MOBILITY LYMPHATIC CARE/EDUCATION COMPRESSION TOOLS/TRICKS

52 BIBLIOGRAPHY Brenner E, Putz D.MorigglB: Stemmer (Kaposi-Stemmer-sign-30 years later. Phlebologie.2007: 36(6): Farrow W, Phlebolymphedema-A common Underdiagnosed and Undertreated problem in the wound Care clinic. Journal fo the Am. College of certified Wound specialists (2010) 2: Valencia IC, Falabella A, Kirsner RS, Eaglstein WH: chronic venous insufficiency and venous leg ulceration. J am Acad, Dermatol (3): Guyton AC: texbook of Medial Physiology. 8 th Ed. Philadelphia PA: WB Saunders: FoldiE, Foldi M, Chronic venous insufficiency and venous-lymphostatic insufficiency. In: Foldi s texbook of lymphlogy. 2 nd ed. Munich, Germany; Elsevier, 2006 p Fugman SL, Clar, RA, Stasis dermatitis. Available at Medscape,com/article/ overview. Accessed april 26, 2010 Goldman MP: Lipodermatosclerosis: review of ases evaluated at the Mayo clinic H Am Acad Dermatol. 2002:46: Blankfield RP, Finkelhor RS, AlexanderJJ, et al: Etiology and diagnosis of bilateral leg edema in primary care. Am J Med. 1998: 105: Beidler, S. K., Douillet, C. D., Berndt, D. F., Keagy, B. A., Rich, P. B., & Marston, W. A. (2009). Inflammatory cytokine levels in chronic venous insufficiency ulcer tissue before and after compression therapy. Journal of Vascular Surgery, 49(4), Bjork R, Hettrick H; Endothelial glycocalyx layer and interdependence of lymphatic and integumentary systems, Wounds International 2018, Vol 9 Issue 2. Best Practice for the Management of Lymphoedema - 2nd edition,