IPC Use in Lymphedema: Physiological Considerations

Transcription

1 IPC Use in Lymphedema: Physiological Considerations Harvey N. Mayrovitz PhD, Professor of Physiology College of Medical Sciences, Nova Southeastern University Ft. Lauderdale Florida ICC meeting Boston 9/8/2013

2 Brief Excursion into Normal Physiological Process Consideration

3 Capillary Tissue Lymph Capillary P T Interstitium Lymphatic Capillary Lumen junction P L Lymphatic EC Leak 1971 P L Leak 1971

4 Capillary Tissue Lymph Capillary Blind Lymphatic Capillary Lumen EC P L P L > P T Lymphatic Capillary Lumen junction Anchoring Filaments P T Blood Capillary Leak 1971 Lumen P L P L < P T EC Fluid and Protein enter Lymphatic Capillaries P T

5 Collection Propulsion Lymph taken up by lymphatic capillaries enters lymph collectors valve Grimaldi et al Lymph Capillary Lymphangion (lymph micro heart) Walls have a muscular media Valve

6 Collection Propulsion Peristaltic like contractions propel lymph to next segment valve Grimaldi et al Lymph Capillary Lymphangion (lymph micro heart) Walls have a muscular media Valve Contraction force & frequency is preload & afterload dependent analogous to heart

7 Normal Lymphatic Function capillary Fluid + Protein Excess > Lymphatics

8 Normal Lymphatic Function capillary Fluid + Protein Excess > Lymphatics If Net Filtration Exceeds Lymphatic Transport Capacity Overload = Edema + [Protein] = Lymphedema

9 Lymphatic Drainage Pathways LN Veins NORMAL LN Veins LYMPHEDEMA Transverse Watershed Vertical Watershed Transverse Watershed Vertical Watershed Lymph flow and drainage determined by normal physiological processes and lymphatic pathways Lymph flow through normal pathways reduced or absent due to node or lymph vessel obstruction or dysfunction

10 Therapeutic Strategy Use Alternate Pathways Stimulate Lymphatics and Optimize Conditions for IPC related pumping Lymph LN P LV Veins IPC Related Augmentation Treatment Related Lymph Flow LN P T1 P LV P T2 LN Lymphatic Flow Stimulated Lymphatics P L Lymphatic Pressure Q L Q L ~ P L -P LV R NORMAL Q L P L Treatment Related Lymph Flow in LYMPHEDEMA Lymph flow depends on pathway pressure gradient and resistance

11 Adjunctive IPC Lymphedema Therapy ROLE Phase I Component of in clinic therapy Phase II At home maintenance therapy TYPES Basic: Few Adjustments Not Programmable Advanced: Calibrated Sequential Programmable With Truncal Clearance Capability No Truncal Clearance Capability

12 Physiological Considerations IPC Compression Pattern Progression Pressure Not independent considerations

13 Compression Pattern Examples Skin Interface Pressure (mmhg) Work & Release Flexitouch System Drainage Peristaltic like Progression Lympha Press System Squeeze & Hold seconds Mayrovitz HN Physical Therapy 2007;87: G1 G2 G3 G4 G5 G1 G2 G3 G4 G5

14 Physiological Considerations Proximal/Central clearance prior to forward propulsion Distal Central progressive propulsion

15 Advanced IPC Progression Approach Clear 2 affected trunk areas 1 Clear normal adjacent trunk areas LN Veins LN Prepare abdominal region LN Inguinal Nodes A. First sequentially treat lymph receiving regions (1 5) to optimize gradient and minimize resistance for subsequent limb drainage procedures Mayrovitz et al. Home Health Care Management & Practice 2009;21(5) Hammond & Mayrovitz Home Health Care Management & Practice 2010;22(6)

16 Advanced IPC Progression Approach Clear 2 affected trunk areas 1 Clear normal adjacent trunk areas LN Veins LN Prepare abdominal region LN Inguinal Nodes B. Then progressive treatment of limb and trunk with suitable pump pressure starting at the most peripheral region ( 5 1)

17 Physiological Considerations Proximal/Central clearance prior to forward propulsion Distal Central progressive propulsion with minimal inhibition of: Distal lymphatic capillary interstitial fluid uptake Lympho venous flow

18 Pattern Considerations

19 ~ 30s ~ 3s P 0 P 0 P = P 0 Blood Capillary * Filtration Lymphatic Capillary Uptake Arteriole P = P P pump max ~40 mmhg Arm: Modi et al Leg: Unno et al Venule reabsorption Lympho Venous Shunt * Olszewski & Engesgt 1980

20 Pressure Considerations

21 Lower Pressure vs. Higher Pressure Lower Pressures Facilitate lymph movement in functioning lymphatics Minimize inhibition of lymph filling during compression Minimize potential injury due to higher pressures Provide a comfortable treatment experience for patients Higher Pressures Facilitate directional interstitial fluid movement especially if low interstitial hydraulic conductance

22 Summary View IPC use in lymphedema should be consistent with Physiological considerations of Initial Central Clearance Subsequent Progressive Propulsion

23 Summary View IPC use in lymphedema should be consistent with Physiological considerations of Initial Central Clearance Subsequent Progressive Propulsion Using Compression Pressures and Patterns that during compression minimally inhibit lymph capillary uptake lymphatic intrinsic active pumping lymph venous uptake and drainage

24 Summary View IPC use in lymphedema should be consistent with Physiological considerations of Initial Central Clearance Subsequent Progressive Propulsion Using Compression Pressures and Patterns that during compression minimally inhibit lymph capillary uptake lymphatic intrinsic active pumping lymph venous uptake and drainage And facilitate lymph vessel and tissue lymph flow via Impulse like progressive compression arterial lymphatic interactions that tend to occur at lower compression pressures

25 Examples of Some Research Study Outcomes

26 Research Study Outcomes Author Muluk, et al (2013) European J of Vasc Endovasc Surg Outcomes Legs: Significant Limb volume; significantly improved patient reported outcomes

27 Research Study Outcomes Author Muluk, et al (2013) European J of Vasc Endovasc Surg Fife, et al (2012) Supportive Care in Cancer Outcomes Legs: Significant Limb volume; significantly improved patient reported outcomes BCRL: 29% Limb volume vs 16% limb volume with standard pump use

28 Research Study Outcomes Author Muluk, et al (2013) European J of Vasc Endovasc Surg Fife, et al (2012) Supportive Care in Cancer Adams, et al (2010) Biomedical Optics Express Outcomes Legs: Significant Limb volume; significantly improved patient reported outcomes BCRL: 29% Limb volume vs 16% limb volume with standard pump use Increased propulsion rates in healthy and BCRL patients; improved lymphatic function systemically

29 Research Study Outcomes Author Muluk, et al (2013) European J of Vasc Endovasc Surg Fife, et al (2012) Supportive Care in Cancer Adams, et al (2010) Biomedical Optics Express Ridner, et al (2010) Lymphatic Research & Biology Outcomes Legs: Significant Limb volume; significantly improved patient reported outcomes BCRL: 29% Limb volume vs 16% limb volume with standard pump use Increased propulsion rates in healthy and BCRL patients; improved lymphatic function systemically BCRL of the trunk: Significant improvement in truncal symptoms and sleep

30 Research Study Outcomes Author Muluk, et al (2013) European J of Vasc Endovasc Surg Fife, et al (2012) Supportive Care in Cancer Adams, et al (2010) Biomedical Optics Express Ridner, et al (2010) Lymphatic Research & Biology Wilburn, et al (2006) BMC Cancer Outcomes Legs: Significant Limb volume; significantly improved patient reported outcomes BCRL: 29% Limb volume vs 16% limb volume with standard pump use Increased propulsion rates in healthy and BCRL patients; improved lymphatic function systemically BCRL of the trunk: Significant improvement in truncal symptoms and sleep BCRL: Significant Limb volume but no improvement with self massage

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