Nicole Baldridge, PT, DPT, CLT Certified Lymphedema Therapist Women ’ sRehab Men ’ s Health

1. Nicole Baldridge, PT, DPT, CLT Certified Lymphedema Therapist Women’sRehab Men’s Health Physical Therapy Resident for Centers for Rehab Services

2. Lymphedema Diagnosis and Therapy

3. Lymphedema Secondary Lymphedema Primary Lymphedema

4. Lymphedema • An abnormal accumulation of protein-rich fluid in the interstitium, causing chronic inflammation and reactive fibrosis of the affected tissues • Usually in an extremity, but can also occur in the head, neck, genitals, and abdomen

5. Lymphedema • Affects 1% of the American population (2.5 million people) • Still poorly understood in the medical community • Largest cause of lymphedema in the world is Filariasis (considered secondary lymphedema) • Filariasis is a parasitic infiltration into the lymphatics that is very common in third world countries (affects 90 million people)

6. Types of Lymphedema • Primary lymphedema is a result of lymphatic dysplasia. • May be present at birth • Can develop later in life without known cause • Secondary lymphedema is much more common. • Result of surgery, radiation, injury, trauma, scarring, or infection of the lymphatic system

7. Primary lymphedema • Lymphangiodysplasia – general malformation • Hypoplasia – fewer than normal # of lymph collectors • Aplasia – absences of collectors in a distinct area • Milroy's Disease is congenital lymphedema evident at birth • Meige’s Syndrome is primary lymphedema onset at puberty (lymphedema praecox) • Lymphedema Tardum is primary lymphedema onset after age 35

10. Secondary lymphedema • There is a known cause for the presence of edema • Surgery: breast cancer, melanoma, prostate/bladder cancer, lymphoma, ovarian cancer, hip replacements • Radiation therapy • Trauma – scarring, crush injury • Infection • CVI • Obesity • Self-induced

14. Stages of Lymphedema

15. Tissue Changes in Lymphedema • Connective tissue cells (fibroblasts) proliferate • Collagen fibers are produced • Fibrotic changes, sclerosis and induration • Fatty tissue increases

16. Angiosarcoma • Can develop after long-standing lymphedema • “Stewart - Treves Syndrome” • Angiosarcoma after mastectomy was first described in 1948 by Stewart and Treves • Signs: reddish-blue and blackish-blue lumps that rapidly increase in size, bleed easily and ulcerate at an early stage • Very rare & poor prognosis

17. Stewart-Treves Syndrome

18. Lymphedema is a disease. All other edemas are symptoms.There is no cure for lymphedema.There is only management.

19. Diagnosis of Lymphedema Physical exam and history are most important.

20. Characteristics of Benign Lymphedema • Slow onset, progressive • Pitting in early stages • Cellulitis is common • Rarely painful but discomfort is common • Skin changes – hyperkeratosis, papillomas, lichenification • Ulcerations are unusual • Starts distally • Toes square, positive Stemmer’s sign • Dorsum of foot “buffalo hump” • Loss of ankle contour • Asymmetric if bilateral

21. History • What is the reason for the swelling? • How long has the extremity been swollen? • How fast did the edema progress/develop? • What are the underlying diseases? • Is there pain? • Other conditions? • Other treatments? • Medications?

22. Inspection • Location of swelling (distal or proximal) • Any skin changes • Lymphatic cysts, fistulas • Ulcers • Scars or radiation burns • Papillomas • Hyperkeratosis

24. Palpation • Temperature – indicative of infection • Stemmer sign is (+) when a thickened cutaneous fold of skin at the dorsum of the toe or finger cannot be lifted or is difficult to lift. Positive Stemmer’s sign is indicative of lymphedema. • Skin folds • Pitting • Fibrosis • Muscular status

25. Diagnostic Tests • Direct lymphography: invasive, oily contrast injected into a surgically exposed lymphatic vessel. Damaging. Has been replaced by CT, MRI, US. • Lymphoscintigraphy: noninvasive, assesses dynamic process in superficial and deep lymphatics • CT • MRI • These tests are often not performed due to lack of clinical importance

26. Differential Diagnosis • Lipedema • Chronic venous insufficiency • Acute deep vein thrombosis • Cardiac edema • Congestive heart failure • Malignancy/active cancer • Filariasis • Myxedema • Complex regional pain syndrome

27. Lipedema • Mainly in women • Bilateral, symmetrical edema from iliac crest to ankles • Dorsum of feet never involved • (-) Stemmer’s sign • Little or no pitting • No cellulitis • Painful to palpation • Bruise easily

28. CVI • Gaiter distribution • Non-pitting • Brawny • Hemosiderin staining • Fibrosis of subcutaneous tissue • Atrophic skin

29. Acute DVT • Sudden onset • Unilateral • Painful • Cyanosis • (+) Homan’s sign • Potentially lethal (PE) • Diagnosis with venous doppler • Not treatable with PT

30. Cardiac edema • Right heart insufficiency • Greatest edema distally • Always bilateral • Pitting • Complete resolution with elevation • No pain • May treat with PT if cleared by Cardiologist

31. Congestive Heart Failure • Bilateral heart failure • Pitting edema • Orthopnea, paroxysmal noctural dyspnea, DOE • Jugular venous distension • Diagnosis with physical exam, chest x-ray, cardiac echo

32. Malignant lymphedema • Pain, paresthesia, paralysis • Central location, proximal onset • Rapid development, continuous progression • Swelling and nodules in supraclavicular fossa • Hematoma-like discoloration (angiosarcoma) • Ulcers and non-healing open wounds • Recurrent malignancy

33. Filariasis Prevalent in 3rd world countries; Can still be treated successfully with CDT. Most therapists in the US will never encounter Filariasis.

34. Lymphedema Treatment Options • Pneumatic compression pump • Surgery • Complete decongestive therapy (CDT) • Elastic support garments • Medications

35. Pneumatic Compression Pumps Advantages: • Can be used at home by patients • Fast application • Financially lucrative for DME vendors ($4000 per pump)

36. Pneumatic Compression Pumps Disadvantages: • Disregards the fact that the ipsilateral trunk can be involved in the lymphedema • In LE edema, the pump can cause genital edema; in UE edema, the pump can cause breast edema • Does not address tissue fibrosis and extended use can cause additional fibrosis • Requires many hours a day with the affected limb elevated • The pump can traumatize residual, functioning lymphatics, especially of the UE

37. Pneumatic Compression Pumps • More disadvantages than advantages, but there are times when pumps are an appropriate choice • Use ONLY IF: • Teach the patient MLD to clear the trunk first • Use recommended safe settings • UE 30-40 mmHg • LE 50-60 mmHg • CVI patients will benefit from a pump

38. Surgery • Microsurgical techniques • Liposuction • Debulking/Reduction procedures

39. Why surgical options do not always succeed… • A blocked system must be made intact • The direction of flow must be correct • The inflow of the reconstructed system must be adequate and the outflow must remain open • Patency must be lasting

40. History of Complete Decongestive Therapy…. Emil Vodder, Ph.D., P.T. discovered that massage therapy boosted people’s immune systems. They began to massage swollen lymph nodes and noticed common colds improving. He created his first publication of this and coined the term MLD (manual lymph drainage).

41. History of Complete Decongestive Therapy…. Michael Foeldi, M.D. and Ethel Foeldi, M.D. In the 1980’s, Prof. Foeldi advanced lymphedema considerably by combining MLD, bandaging, exercise, skin and nail care into “Complete Decongestive Therapy.”

42. Components of CDT • MLD • Compression bandaging • Exercise • Skin and nail care • Instructions in self care

43. Manual Lymph Drainage MLD is a gentle manual treatment which improves the activity of the lymph vascular system. In lymphedema, it reroutes the lymph flow around blocked areas into centrally located healthy areas which then can drain into the venous system.

44. Manual Lymph Drainage

45. Manual Lymph Drainage • Improves lymph production • Increases lymphangio-motoricity • Improves lymph circulation and increases the volume of lymph transported • Special techniques help break down fibrous connective tissue • Promotes relaxation and has an analgesic effect

46. Compression bandaging Short stretch bandages (Rosidal, Comprilan) are applied to increase the tissue pressure in the edematous extremity. • Reduces the ultrafiltration rate • Improves efficiency of the muscle and joint pumps • Prevents re-accumulation of evacuated lymph fluid • Helps break down fibrous connective tissue that has developed

49. Exercise • Performed with the bandages on or while wearing a compression garment. • Active ROM, stretching, strengthening • Low exertion • Diaphragmatic breathing • Increase muscle and joint pumping • Increase lymph vessel activity • Increase venous and lymphatic return

50. Skin and Nail Care • Eliminate bacteria and fungal growth by using medicated powders, hydrocortisone cream where indicated. • Reduce the risk of infection by avoiding injury, cleaning all injuries immediately, calling MD at first sign of infection.