LYMPHEDEMA the more you know GOALS FOR TODAY WELL-INTENTIONED, BUT TEDS Recognize full Continuum of Lymphedema stages Identify Range of Lymphedema Diagnoses Differentiate Effective Treatment Options from less Effective Expand Understanding of Compression Garments Diuretics Prescribe compression garments without first reducing edema Don t treat edema until it is clinically significant Is the dx just, LE Edema - 782.3, or is it a form of, Lymphedema Other - 457.1?
LYMPHEDEMA DEFINITION FORMATION OF LYMPH An abnormal accumulation of protein-rich fluid in the interstitial due to a mechanical insufficiency in lymphatic transport resulting in reactive fibrosis in the affected tissues in addition to progressively accumulating edema in the impacted lymphatic territory Starling s Equilibrium Hydrostatic Pressure/Filtration Oncotic Pressure/Reabsorbtion Lymph Capillary - 10% of Filtrate Functions as Safety Valve Returns proteins to circulation LYMPHATIC TERRITORIES DR. MICHAEL FOELDI: All types of lymphatic failure lead to edema every edema represents a failure of the lymphatic system because the safety valve function of of functioning lymphatics would otherwise prevent the formation of edema. Therefore: all edemas represent an overwhelming of lymphatic transport capacity but not all edemas are lymphedema.
FAILURES OF LYMPH TRANSPORT FAILURES OF LYMPH TRANSPORT FAILURES OF LYMPH TRANSPORT LYMHEDEMA DEFINITION An abnormal accumulation of protein rich fluid in the interstitial space due to a failure of the lymphatic safety valve resulting in mechanical insufficiency, leading to chronic inflammation, progressive fibrosis and edema in the affected lymphatic territory
STAGES OF LYMPHEDEMA STAGES OF LYMPHEDEMA Continuum of Disease Stage 0: Transport capacity is reduced, risk of lymphedema but lymphatic load remains less than the reduced transport capacity Latency Stage Stage 1: Transport capacity exceeded, edema may come and go, reduces with elevation Spontaneously Reversible Stage 2: edema does not reduce with elevation, fibrotic skin changes begin to accumulate Spontaneously Irreversible CAUSES OF LYMPHEDEMA REMEMBER: ITS ALL ABOUT LYMPHATIC IMPAIRMENT Chronic Venous Insufficiency Breast and other Cancer Txs Malignancy Trauma & Surgery (non-ca) Chronic Infections Primary TREATMENT: WHAT ABOUT PUMPS AND SURGERY? Pumps: don t remove interstitial proteins, ignore trunk portion of ipsilateral territory, damage functioning lymphatics Surgery: minimal success, ignore safety valve function of full lymph transport Filariasis
COMPRESSION BANDAGING Short-Stretch Bandages: high working pressure & low resting pressure - best per research Law of LaPlace: P = t/r skilled construction of bandage focused on layers and radius COMPLETE DECONGESTIVE THERAPY GOLD STANDARD OF TREATMENT Customized per patient, therefore a skilled intervention MANUAL LYMPH DRAINAGE TRAINING OF THERAPISTS Physiologically & Anatomically correct Stimulates lymph vessel pump Removes proteins Light stretching of skin NLN/LANA Standard - 135 hr course in CDT Provides minimum skill set to allow for comprehensive treatment Partial training yields partial treatments
TREATMENT STANDARD CDT - 2 Phases Intensive Phase - 1st phase 3-5 x week, 1-2 hrs per visit Partial treatment schedule is like administering partial dose of medication Expect 50-70% edema reduction SECOND PHASE OF TREATMENT Optimization Phase Continue the 4 components: Compression - Garments MLD - self or with MT Exercise Skin Care COMPRESSION GARMENTS: PRESERVING CLINICAL OUTCOMES SOME COMMENTS ON COMPRESSION GARMENTS Garments are holding devices, not reducing devices Most patients need 24 hour compression Stockings - not best for everyone and only to be used for daytime Alternative compression - Various Velcro-type options for daytime and nighttime
SUMMARY - LYMPHEDEMA Many causes - CVI, Cellulitis, Primary, Cancer Treatment - yet all have in common a mechanical failure of lymph transport Continuum of Disease - Latency to Elephantiasis, needs intervention as soon as possible, yet treatable at all levels CDT - Gold Standard of treatment, seems simple, yet very effective Training and Treatment should both be comprehensive Garments - Please take time to consider which will provide the best control over the long term - help build the Compression Toolbox