Presented By Dorothy Purtell OTR Mary Ognenoff, OTR

Transcription

1 Presented By Dorothy Purtell OTR Mary Ognenoff, OTR

2 Introduction Course Objectives: at the completion of this course attendees will be able to: Identify different types of edema, and various treatment approaches Identify precautions, contraindications, and complications related to treating edema in medically complex patients Have a working knowledge of fluid/edema dynamics and related anatomy and physiology

3 Introduction Course Objectives: (Continued) Perform basic wrapping techniques, manual edema/lymph drainage, and apply compression garments Perform objective tests and measures, document progress, and establish goals with edema patients Identify appropriate candidates for treatment and understand precautions and contraindications related to edema management Establish functional carry over/maintenance programs for patients and provide patient education for long-term edema management

4 Introduction Course Outline for Day One: History of the Lymphatic System Anatomy and Physiology of the Lymphatic System Fluid Dynamics Edema Treatment Overview Clinically Complex Patients Manual Edema Mobilization for the Lower Extremity Lab (Edema Evaluation and MEM for the LE) Compression Wrapping for the Lower Extremity Lab (Compression Wrapping for the LE)

5 Introduction Course Outline Day Two: Edema Treatment Indications and Applications Manual Edema Mobilization for the Upper Extremity Lab (MEM for the UE) Compression Wrapping for the Upper Extremity Lab (Compression Wrapping for the UE) Compression Garments Edema Evaluation Documentation, Treatment Strategies, and Goals Patient Self-Management Case Studies, Q& A, and Quiz

6 Presented By Dorothy Purtell OTR Mary Ognenoff, OTR

7 History Early anatomists did not differentiate between the circulatory and lymph systems Gasparo Asseli, an Italian physician is credited with making the first documented differentiation between lymph vessels and veins in 1622 (western history) Gong Tingxian ( ), a Chinese physician, is credited for using various herbs to treat edema. His treatment formed the basis for the Casely-Smiths use of benzopyrenes. Anatomy of the Body of Man (1653) contained the first illustrations of human lymphatics discovered by Johann Vesling in 1624

8 History Olaf Rudbeck of Sweden, through his research is credited as the first scientist to consider the lymph system as a complete system in 1652 Antonio Nuck established the structure of the lymph system through scientific experiments involving injections of mercury (1692)

9 History- Edema Drainage Esmarch & Kuhlenkampf had already determined in 1885 that the results of drainage techniques would be transitory in non-compliant patients who failed to recognize the chronic nature of their condition Manual drainage techniques and external compression were first introduced by Winiwarter ( ) a surgeon from Belgium

10 History-Edema Drainage Emil Vodder, PhD is credited with developing techniques for lymph drainage in the 1930 s but because of his limited medical background his ideas received little attention In the 1960 s Johannes Asdonk, a German physician established the safety and veracity of Vodder s techniques by treating 20,000 patients in his clinic using MLD techniques

11 History-Modern Edema Treatment Foldi, a German physician performed extensive clinical research and formed the first large clinic to specifically address lymphedema in the 1970 s & 80 S. Technique is known as Complex Decongestive Therapy

12 History-Modern Edema Treatment Leduc & Caplan have done extensive cadaver research and published information about lymphatic pathways in 1970 s to present day Casley Smiths of Australia have done extensive work with electron microscope & use of chemicals to aid in the breakup of interstitial proteins. This unique treatment approach is known as Complex Physical Therapy (CPT)

13 History-References Artzberger, S. & Schrauth, R. (2004). Comprehensive Lymphedema and Venous Edema Management Certification Course. Course and materials presented at Cedar Haven Rehabilitation Center, West Bend, WI. Artzberger, S. & Schrauth, R. (2008). Lymphedema: The Next Level. Course and materials presented at UW-Milwaukee Extension, Milwaukee, WI. Chickly, Bruno. (2002). Silent Waves: The Theory and Practice of Lymph Drainage Therapy. Scottsdale, AZ: International Health & Healing, Inc. Publishing. Chickly, Bruno Who Discovered the Lymphatic System Lymphology Dec 1997,30,4 pp

14 Presented By Dorothy Purtell, OTR Mary Ognenoff, OTR Anatomy and Physiology

15 Lymphatic A & P Overview Lymphatic system is part of the body s circulatory system Blood leaves the heart through one route: the arterial system Blood returns to the heart through two routes: the venous and lymphatic pathways The lymphatic system is composed of unique structures to allow it to perform its function in the body Johnson & Purtell, 2014

16 Anatomy of Lymphatic System Initial lymphatics (capillaries and pre collectors) Collectors Lymph trunks Thoracic duct Lymph nodes Johnson & Purtell, 2014

17 Initial Lymphatic Anatomy Fragile net like structures that are described as feather fine (diameters of 0.1 to 10 microns) Directly or indirectly cover every part of body Located in superficial dermis layer One layer endothelial cell Connector filaments extend from lymphatic to connective tissue to hold the net like structure in place Johnson & Purtell, 2014

18 Johnson & Purtell, 2014

19 Initial Lymphatic Function Stretching and relaxation of net like structure opens and closes the endothelial cells to admit water or other large molecule substances. Pressure in the connective tissue opens junctions by light massage, light compression, muscle contraction, etc. to propel lymph towards collectors Too much pressure can collapse this fragile structure and prevent flow of lymph Johnson & Purtell, 2014

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21 Pre-Collectors Anatomy & Function Similar to lymph capillaries Gradually increasing in size with one to three layers of endothelial cells One way bicuspid valves that help prevent back flow Moves lymph in one direction towards collectors Johnson & Purtell, 2014

22 Johnson & Purtell, 2014 (Powsner, Patriquin & Beazley, 2002)

23 Collector Anatomy Main transporting vessels of lymphatic system-large vessels with valves and muscular units Conducts the lymph proximally toward the surrounding lymph nodes on its way to the heart Three layers of cells consisting of initima, media, aventitia Initima: Made up of flat edothelial cells Media: smooth muscle layer Aventitia: connective tissue Johnson & Purtell, 2014

24 Collector Function Composed of lymphangions which are the specific intervalular units of the lymph collectors The border of one lymphagion forms the valve base of the next one. Valves are every 6 to 20mm. Together they look like a string of pearls. Lymph enters a lymphagion causing stretch of smooth muscle layer and reflexive contraction moving lymph through the valve to next lymphagion. Rate of contraction is typically 10x per minute Contractions can increase up to 30 x per minute with exercise or heat (37 to 41C) Johnson & Purtell, 2014

25 (Chikly, 2002) Johnson & Purtell, 2014

26 Lymph Trunk and Thoracic Duct Biggest lymph collectors in the body Structure similar to that of the lymph collectors Carries lymph to the terminal pathways in the deep venous system. The largest of these is the thoracic duct. It extends from L2-T4 and parallels the spine. It starts at the Csterna Chyli and flows into the L subclavian at the base neck. Lymphatic-venous anastomosis provides fluid with alternative pathways back to the circulatory system. Johnson & Purtell, 2014

27 Lymphatic Physiology Lymphatic system is similar in some ways to a complex highway system Johnson & Purtell, 2014

28 Johnson & Purtell, 2014

29 Lymph Fluid or Lymph The mechanism of lymph formation is still a mystery Originates in the connective tissue spaces of the body Once fluid enters lymph capillaries it is called lymph Constituents of blood filter out as a natural part of the circulatory process into the interstitial space between cells and are reabsorbed in the lymph capillaries Johnson & Purtell, 2014

30 Lymph Fluid or Lymph This clear yellowish sticky substance consists of: excess plasma protein, bacteria, hormone cells, fat cells, tissue waste products, minerals, ions and water Lymph is 96% water vs. blood plasma which is 90% water Lymphatic system plays an important role in transporting protein away from the interstitial space-a large part of which the venous system cannot recover In extreme cases of protein overload in tissues, could lead to massive swelling and possibly death. Johnson & Purtell, 2014

31 Lymph Nodes Greek word meaning ganglion or little tumor Most are bean-shaped ranging in size from 2 to 25mm. (Pin head to a large olive) 400 to 700 nodes in body with nearly half in the abdomen. Main groups of nodes located at major articulation folds of the body (i.e., elbow, knee) and cervical region. Function as filtration and purification stations for lymph fluid Johnson & Purtell, 2014

32 Lymph Node Areas Johnson & Purtell, 2014 (Ellis, 2005)

33 Lymphatic Physiology The lymphatic system is a second pathway back to the heart, parallel to the blood system Lymphatic circulation is a slow rhythm, low velocity, and low pressure process vs. blood circulation. Lymph fluid contains components of blood that have filtered out of the capillaries and into the interstitium. Johnson & Purtell, 2014

34 Lymphatic Physiology cont. 90% of the fluid that filters out of the interstitium is reabsorbed by the venous capillaries and the other 10% by lymphatics. Lymphatics absorb the majority of large molecules such as plasma proteins, fat cells, hormone molecules, and cellular waste products. Along the way back to the heart, there are anastamoses, or alternative routes, for fluid jump back into the venous system or other components of the lymphatic system If lymphatics cannot carry enough protein away the result is edema. Johnson & Purtell, 2014

35 Edema Johnson & Purtell, 2014

36 Track Lymph From Digit to Heart Fluid from interstitium enters the initial lymphatics (it is now considered lymph) Moves from initial lymphatics to pre collectors and then to collector lymphatics Lymph fluid travels through lymph nodes at the elbow & axilla and enters lymphatic trunks Johnson & Purtell, 2014

37 Track Lymph From Digit to Heart All along this route there are frequent anastomoses where fluid returns to the circulatory system or continues on the lymphatic pathways The lymphatic ducts eventually drain into the thoracic duct, which empties into the L subclavian Now mixed with the blood it travels to the heart and through the circulatory system Johnson & Purtell, 2014

38 References Artzberger, S. & Schrauth, R. (2004). Comprehensive Lymphedema and Venous Edema Management Certification Course. Course and materials presented at Cedar Haven Rehabilitation Center, West Bend, WI. Artzberger, S. & Schrauth, R. (2008). Lymphedema: The Next Level. Course and materials presented at UW- Milwaukee Extension, Milwaukee, WI. Chickly, Bruno. (2002). Silent Waves: The Theory and Practice of Lymph Drainage Therapy. Scottsdale, AZ: International Health & Healing, Inc. Publishing. Ellis, S. (2005). What is the Lymphatic System? Retrieved from Mader, S. (1997). Inquiry Into Life. Wm. C. Brown Publishers. Powsner, R., Patriquin, L. & Beazley, R. (2002). Sentinel Node Lymphoscintigraphy in Cutaneous Malignant Melanoma: The Internet Journal of Radiology, 2(2). Johnson & Purtell, 2014

39 Presented By Dorothy Purtell OTR Mary Ognenoff, OTR

40 Fluid Dynamics Diffusion is the movement of atoms and molecules from a higher concentration to areas of lower concentration Osmosis happens in a situation (such as living tissues) where a barrier prevents molecules from diffusing, but allows water to move in an attempt to achieve homeostasis or equal concentration Johnson & Purtell, 2014

41 Fluid Dynamics Filtration is the movement of fluid against, or in the opposite direction, of osmosis. This can be caused by hydrostatic pressure Starling s Law explains the movement of fluids in and out of the circulatory system as a result of osmosis and filtration Johnson & Purtell, 2014

42 Fluid Dynamics Example of Starling s Law: At the capillary level as blood enters the arteriole end of the capillary the hydrostatic pressure on the blood pushes fluid (filtration) into the interstitial space. As the fluid leaves, the hydrostatic pressure has decreased, and the osmotic pressure in the interstitial space pushes fluid back into the circulatory system on the venous end of the capillary. Johnson & Purtell, 2014

43 Fluid Dynamics There is some debate as to the amount of fluid that returns directly to the circulatory system. Conventional thinking from Starling s era has been that up to 98% of fluid returned to the venous system. More recent studies indicate that the lymphatics may play a role in the return of up to 80% of fluid to the circulatory system Johnson & Purtell, 2014

44 Johnson & Purtell, 2014 (Ellis, 2005)

45 Fluid Dynamics-Edema When the dynamic fluid system becomes unbalanced edema is often the result Elevated blood hydrostatic pressure (hypertension) Decreased blood osmotic pressure (malnutrition) Increase in tissue osmotic pressure (sprain/fracture) Johnson & Purtell, 2014

46 Fluid Imbalance-Edema Johnson & Purtell, 2014

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49 Fluid Dynamics-Edema Edema can be the result of: Injury (sprain, fracture, burn) Systemic illness (renal failure, cirrhosis, CHF) Allergic/Immune response Electrolyte imbalance Phlebitis/venous insufficiency Lymphostatic edema (lymphedema) Lymphodynamic edema (overload edema) Johnson & Purtell, 2014

50 Fluid Dynamics-Edema But the important thing to remember is.. The presence of any edema, no matter what the cause, is a sign that the lymphatic system has been overwhelmed Foldi M The Kitchen Sink Example Johnson & Purtell, 2014

51 Fluid Dynamics-Edema Johnson & Purtell, 2014

52 Fluid Dynamics-Edema Johnson & Purtell, 2014

53 Fluid Dynamics-Edema Johnson & Purtell, 2014

54 Fluid Dynamics-Edema Johnson & Purtell, 2014

55 Fluid Dynamics Our job as therapists is to intervene in appropriate cases to prevent damage from prolonged tissue overload, and assist patients with acute or chronic edema to reduce and manage their condition. Johnson & Purtell, 2014

56 Fluid Dynamics- References Artzberger, S. & Schrauth, R. (2004). Comprehensive Lymphedema and Venous Edema Management Certification Course. Course and materials presented at Cedar Haven Rehabilitation Center, West Bend, WI. Artzberger, S. & Schrauth, R. (2008). Lymphedema: The Next Level. Course and materials presented at UW-Milwaukee Extension, Milwaukee, WI. Chickly, Bruno. (2002). Silent Waves: The Theory and Practice of Lymph Drainage Therapy. Scottsdale, AZ: International Health & Healing, Inc. Publishing. Ellis, S. (2005). What is the Lymphatic System? Retrieved from Johnson & Purtell, 2014

57 Presented by Steve Johnson PT Dorothy Purtell OT

58 Lymphedema Treatment Widely performed in Europe, becoming more widely practiced in the rehab field in the U.S. Patients once told to live with it are having positive and lasting outcomes Therapists receiving general and specialized training in the field Johnson & Purtell, 2014

59 Goals of Lymphatic Treatment Allow fluid and plasma proteins to move out of the interstitial space and back into the circulatory system to be excreted out of the body. Stimulate the lymphatic system to increase the speed and efficiency of fluid transport to restore balance in the body systems Create a program that meets the individual s needs and lifestyle for long term edema management Johnson & Purtell, 2014

60 Johnson & Purtell, 2014

61 Facets of Lymphedema Treatment Manual Edema Mobilization (MEM) Compression Wrapping Techniques Garment Wear Patient Education and Self-Management Exercise Ongoing Assessment/Critical Thinking * Because of the dynamic nature of edema management, the frequency and duration of these facets will vary depending on the patient s needs and goals for treatment Johnson & Purtell, 2014

62 Manual Edema Mobilization Hands-on technique used to stimulate the smooth muscle contractions of the lymphatic system Gentle and slow technique that facilitates the movement of fluid instead of actually physically moving the fluid Johnson & Purtell, 2014

63 Compression Wrapping Techniques Graded compression applied with low stretch bandages Low stretch bandages used to provide a resistive force, not compressive, to avoid collapsing the lymphatics Bandages are used in the reduction stage of treatment and also in some long-term management programs Johnson & Purtell, 2014

64 Garment Wear Utilized to provide compression to limb to avoid edema refill More comfortable and practical for daily wear than bandages Generally applied after edema reduction had been accomplished Type of garment depends on patient s edema, lifestyle, and comorbidities Variety of products available both from the pharmacy and over-the-counter Johnson & Purtell, 2014

65 Patient Education and Self- Management Critical aspect of all ongoing edema programs to ensure carry over and longterm success Education needs to start early to invest the patient in the process and increase their accountability and compliance Patient will be expected to carry out practical aspects of the edema program Johnson & Purtell, 2014

66 Exercise Important to be incorporated regularly into lifestyle to ensure lymphatic flow Important to maintain safe and independent mobility and ADL s The success of MEM and compression will be limited without exercise Johnson & Purtell, 2014

67 Critical Thinking Continual assessment and adjustment of the techniques employed is critical to the success of the edema program It is important to remember that your assessment and critical thinking skills are equally as important as your ability to apply the treatment techniques Johnson & Purtell, 2014

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72 References Artzberger, S. & Schrauth, R. (2004). Comprehensive Lymphedema and Venous Edema Management Certification Course. Course and materials presented at Cedar Haven Rehabilitation Center, West Bend, WI. Artzberger, S. & Schrauth, R. (2008). Lymphedema: The Next Level. Course and materials presented at UW-Milwaukee Extension, Milwaukee, WI. Chickly, Bruno. (2002). Silent Waves: The Theory and Practice of Lymph Drainage Therapy. Scottsdale, AZ: International Health & Healing, Inc. Publishing. Johnson & Purtell, 2014

73 Presented By Dorothy Purtell, OTR Mary Ognenoff, OTR

74 Clinical Implications of Treatment Although edema management and Manual Lymph Therapy (MLT) are minimally invasive, there are some critical precautions and contraindications that must be observed to protect our patients

75 Clinical Implications of Treatment- Precautions Venous insufficiency Arterial insufficiency Mixed insufficiency

76 Clinical Implications of Treatment- Precautions Venous insufficiency- swelling as the result of failure of the venous return system Relief with elevation Dusky colored Superficial wounds shin area /weeping

77 Venous Signs

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79 Clinical Implications of Treatment- Precautions Arterial insufficiency- swelling and symptoms as a result of occlusion of small arteries and arterioles Relief with lowering legs/ decrease activity Deep circular wounds over bony areas rubor of dependency Hair loss ABI <.8

80 Arterial Signs

81 Arterial Signs

82 Rubor of Dependency Elevated Limb Dependent Limb

83 Arterial Insufficiency ABI: Highest systolic pressure of the dorsalis pedis and posterior tibial arteries divided by the highest systolic pressure of the brachial artery For example: 130 (leg systolic pressure) = (arm systolic pressure)

84 Clinical Implications of Treatment- Precautions Mixed insufficiency- some patients will exhibit a mixture of both conditions Fibrous tissue and lymphedema can result from years of untreated swelling/edema

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87 Clinical Implications of Treatment- Precautions DM movement of lymph can alter glucose uptake Carotid Stenosis- care should be taken to avoid edema Tx or routing of fluid in the neck Menstruation/ pregnancy- treating in the abdominal area should be avoided

88 Clinical Implications of Treatment- Precautions Orthostatic Hypotension Minimally controlled or controlled CHF, Renal Disease, Hepatic Disease Active Chemo agents or steroid use

89 Clinical Implications of Treatment- Contraindications Active infection/fever- could spread systemically DVT/Phlebitis- pulmonary embolism Nutrapenia- risk is too great for infection Uncontrolled CHF, Renal Disease, Hepatic Disease Active/Untreated foot fungus or eczema

90 Clinical Implications of Treatment Prior to engaging in treatment of patients with any of these conditions or symptoms it is important: Consult appropriate physician/specialist Carefully review proposed POC, weighing carefully potential benefit vs. risk of exacerbating the underlying conditions

91 Clinical Implications of Treatment If you elect to proceed with treatment: Care must be taken to closely monitor signs & symptoms Make every effort to educate your patient/caregivers of the importance of compliance with instructions and selfmonitoring Keep physicians/other health care providers updated of progress

92 Clinical Presentations

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94 References Artzberger, S. & Schrauth, R. (2004). Comprehensive Lymphedema and Venous Edema Management Certification Course. Course and materials presented at Cedar Haven Rehabilitation Center, West Bend, WI. Artzberger, S. & Schrauth, R. (2008). Lymphedema: The Next Level. Course and materials presented at UW-Milwaukee Extension, Milwaukee, WI. Chickly, Bruno. (2002). Silent Waves: The Theory and Practice of Lymph Drainage Therapy. Scottsdale, AZ: International Health & Healing, Inc. Publishing.

95 Presented by Dorothy Purtell OTR Mary Ognenoff, OTR

96 Common Treatment Applications Acute injury Post-surgical Wound care Venous and arterial problems Post-Cancer CVA Obesity Congenital

97 Acute Injury Acute swelling can overload the lymphatic system Acute swelling can exacerbate an underlying condition Trauma can cause damage to lymphatic structures and the development of fibrotic tissue can prevent re-growth of lymph structures Goal of treatment is to prevent excess fluid accumulation in the tissue with R.I.C.E. (rest, ice, compression, elevation)

98 Post-surgical Surgical trauma and systemic effects of surgery and recovery can result in excessive fluid accumulation in the tissues Edema reduces ROM and lengthens time for achieving desired ROM Edema increases pain Edema puts pressure on incision sites Edema reduces incision healing rate Edema can increase complications as DVT/clots and can slow progression of mobility Work with the medical team to determine opportunities for post surgical edema management

99 Wound care Poor fluid dynamics negatively effects circulation and oxygenation tissues Edema reduces wound healing rate by impairing proper vascular flow to allow healing Exacerbates dermatitis and other skin conditions

100 Venous Problems Conditions can develop over time, often related to lifestyle and heredity Fluid system will be 30% overcapacity before showing any clinical signs of swelling Swelling often presents with gradual nature over time Superficial wounds often develop as well as chronic infections Condition often managed with diuretics with limited success

101 Arterial Problems Problems with adequate blood flow to the extremity can lead to tissue and nerve death Wounds often present over bony prominences Condition must be treated with extra caution for patient safety

102 Post-Cancer Cancer treatment can lead to removal of lymph nodes (through mastectomies and other radical surgeries) Cancer treatment can cause damage to lymphatic structures (such as radiation and chemotherapy) This can result in the patient developing a lymphedema secondary to treatment Metastases and neoplasms can block the lymphatics and cause sudden swelling

103 CVA Loss of normal nervous regulatory function and lack of muscle pump action in the extremity often leads to the development of edema Edema adds another complicating factor to an already complex condition Appropriate positioning at all times and use of NMES/ROM to move fluid are critical Decreased physical activity can lead to lymphatic overload, dependent edema, and skin breakdown, etc.

104 Obesity Obesity can cause a stretch on the lymphatic structures, resulting in damage Lack of physical activity due to weight can result in edema issues Lipidema-excessive deposits of fat on legs and buttocks-compromises lymphatics Edema problems in obese patients are often overlooked Pitting edema in the extremities is not fat!

105 Congenital Individuals can be born with deficits in the number or size of the lymph nodes and/or lymphatic pathways Some individuals will tell you they have always had swelling in their legs out of proportion with their body type Some females will not experience symptoms until first or subsequent pregnancies This can occur in just one limb or in the entire body Most begin in the lower legs (Milroy s and Meige s Diseases)

106 Adjunctive Treatments Myofascial Release Kinesiotaping AquaticTherapy Modalities

107 Alternative & Adjunctive Treatments-Aquatic therapy Why choose the pool? Weight displacement allowing obese, weak, or deconditioned patients the capacity to exercise External pressure of water has a positive effect on fluid movement in the body Need to consider: risk/benefit to your population logistics of operating a program if you do not have pool access

108 Alternative & Adjunctive Treatments-Aquatic therapy Precautions Open wounds or potential infection through injury Heart/ lung conditions that are irritated with exertion Heated or excessively warm pool temperature Incontinence

109 Alternative & Adjunctive Treatments-Kinesiotaping Why choose Kinesio tape? Reportedly stimulates lymphatics and uptake of fluid in the extremity and reduces pain/swelling Active movement combined with kinesio tape provides continuous movement of fluid Tape can be left on for 2+ days which eliminates the cumbersome process of dressing changes on part of the limb Helpful with: very large or hypersensitive limbs arthritic or immobile patients

110 Alternative & Adjunctive Treatments-Myofascial Release Why choose Myofascial release? MFR is a low pressure technique that releases bound fascia Produces deep relaxation and in theory promotes homeostatic flow of lymph and energy

111 Alternative & Adjunctive Treatments-Myofascial Release Precautions Is a specific technique that requires skills training beyond the scope of this course Malignancy, RA, infection, hypersensitive skin, cardiopulmonary conditions

112 Alternative & Adjunctive Treatments-Modalities Why choose modalities? Serve as an adjunct to MLT techniques and wrapping Ice can reduce inflammatory response in acute edema as well as reduce pain for wrapping tolerance Heat producing modalities can soften tissue, relax tissue, and increase flow/circulation Phototherapy uses light energy to increase cellular metabolism and active transport to move fluid

113 Alternative & Adjunctive Treatments-Modalities Precautions Avoid use of heat producing modalities in acute phases of edema/swelling Infection, cancer, implants, open wounds, DM, or other specific medical conditions may preclude the use of certain modalities

114 References Artzberger, S. & Schrauth, R. (2004). Comprehensive Lymphedema and Venous Edema Management Certification Course. Course and materials presented at Cedar Haven Rehabilitation Center, West Bend, WI. Artzberger, S. & Schrauth, R. (2008). Lymphedema: The Next Level. Course and materials presented at UW-Milwaukee Extension, Milwaukee, WI. Chickly, Bruno. (2002). Silent Waves: The Theory and Practice of Lymph Drainage Therapy. Scottsdale, AZ: International Health & Healing, Inc. Publishing.

115 Presented By Dorothy Purtell OTR Mary Ognenoff, OTR

116 Introduction Manual Lymphatic Therapy (MLT) is a generic term for lymph drainage massage Manual Edema Mobilization (MEM) is another term for lymph drainage massage

117 Theory Gentle manual manipulation facilitates lymphangion smooth muscle contraction, resulting in increased speed of fluid transport, thus a reduction of edema Manual manipulation moves congested lymph from the lymphostatic area to a healthy functioning lymphatic quadrant Analogous to the circulatory system

118 MLT for the Lower Extremity Keys to effective edema treatment: Remember the two S s slow and soft Start proximal (i.e. where you want the edema to go) remember to uncork the bottle Always remember effective treatment is stimulating the body to actively transport fluid vs. physically moving/pushing the fluid

119 MLT for the Lower Extremity Keys to effective edema treatment:(continued) Always take into account patient comfort and privacy Maintain awareness of body postures and positioning to protect yourself from strain and injury Always observe universal precautions to protect both you and your patient

120 MLT for the Lower Extremity Techniques: The basic U Clearing - always done prior to flowing, starts where you want the fluid to end up (generally proximal to distal) Flowing performed after clearing, always preformed in the direction you want the fluid to move (generally distal to proximal) Lymph node massage-blocked lymph nodes can cause a dam that prevents fluid flow; they require firm pressure in an inward circular motion

121 MLT for the Lower Extremity Getting started: Diaphragmatic Breathing Flow the Cistern

122 MLT for the Lower Extremity Lower Extremity Flow Inguinal to Cistern

123 MLT for the Lower Extremity Flow Upper Leg

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125 MLT for the Lower Extremity Flow Lower Leg Flow Ankle & Foot Add Pump points in areas of concentrated lymph nodes to increase fluid movement *

126 Anterior View Posterior View

127 MLT for the Lower Extremity- Exercise Exercise is an important adjunct to MLT Exercises should be performed througout the process of flowing Exercises should follow the process of flowing body sections from proximal to distal There is no magic set of exercises, use your creativity and critical thinking! Exercise is important in making the patient an active participant in the process

128 Now let s get to it!!!

129 Lower Extremity Compression Wrapping

130 Lower Extremity-Wrapping Basics of wrapping: Utilize low stretch bandage which provides resistive force vs. compression Wraps must be reapplied whenever they become loose and should be worn 23 hours/day Therapeutic compression is achieved through layering and not by increasing the stretch on the bandage!!!

131 Lower Extremity-Wrapping Basics of wrapping:(continued) Typically will require two sets of bandages for hygiene Selection of bandage sizes is variable depending on the patients size and wrapping needs Use padding material to protect bony prominences in areas susceptible to skin breakdown or at major joints to increase comfort

132 Lower Extremity-Wrapping Law of Laplace- The smaller the radius (i.e. ankle/wrist) the greater the pressure exerted by the compression wrap Using chip bags and padding over the ankle/wrist will increase the circumference and equalize the pressure across the limb

133 Lower Extremity-wrapping Wrapping Lower Extremity: Start with stockinette which should cover the entire area to be wrapped Apply foam inserts over dorsum of foot, and any bony prominences that require it Add chip bags as needed Apply foam base layer or Artiflex in circular pattern focusing on even application with >50% overlap

134 Lower Extremity-wrapping Wrapping Lower Extremity: (continued) Apply low stretch brown bandage by rolling onto the limb vs. pre-stretching Complete top of wrap with either a basket weave to hold bandage or cut excess bandage and secure with tape

135 Lower Extremity-wrapping Choosing the wrap: Low stretch with Artiflex- good choice for initial intervention the artiflex provides buffer to the compression wrap. Can be difficult for patient to apply themselves Low stretch with Foam- good choice for densely packed edematous limb because of its ability to generate heat and soften the limb. Very cumbersome limiting mobility and ability to wear certain clothing/ shoes

136 Lower Extremity-wrapping Choosing the wrap: Low stretch with KT wrap- good for ease of application and with active populations due to the dual layers of compression wraps acting to support the limb. Patient maintains the ability to wear traditional shoes/clothes

137 Lower Extremity-Exercise Exercise is an essential adjunct to any successful edema management program AROM, AAROM, or PROM following the clearing of each area will stimulate the lymphatics Encourages patient participation and ownership of the process vs. passive participation Can be continued as a home program

138 References Artzberger, S. & Schrauth, R. (2004). Comprehensive Lymphedema and Venous Edema Management Certification Course. Course and materials presented at Cedar Haven Rehabilitation Center, West Bend, WI. Artzberger, S. & Schrauth, R. (2008). Lymphedema: The Next Level. Course and materials presented at UW-Milwaukee Extension, Milwaukee, WI. Chickly, Bruno. (2002). Silent Waves: The Theory and Practice of Lymph Drainage Therapy. Scottsdale, AZ: International Health & Healing, Inc. Publishing.