2013 Consensus Document of

the International Society of

Lymphology defines lymphedema

as :

“an external (or interal)

manifestation of lymphatic

system insufficiency and

deranged lymph transport.”

“In its purest form, the central

disturbance is a low output

failure of the lymphvascular

system, that is, overall lymphatic

transport is reduced.”

The most common cause of secondary lymphedema in

Canada is cancer or cancer treatment (s).

Lymphedema can result from any

cancer if the tumor or

cancer treatment compromises

the lymphatic drainage routes.

If the lymphatic

system fails,

swelling occurs in

the skin

and

subcutaneous

tissues

of the affected

body part.

• The lymphatic system

is an open-

ended,one-way fluid

transportation system.

Lymphatic Vessels • Vascular network comprised

of: – initial lymphatics – collecting vessels – lymphatic trunks – lymphatic ducts

• present throughout the body with a few exceptions

• lymph fluid moves from the

superficial to deep via a series of progressively larger transporting-type vessels.

Lymph Node

• 600 - 700

• Vary in shape and size

• Clusters or chains

• Major lymph node stations

include: neck, axilla, groin,

gut

• all the lymph passes through the nodes for inspection and cleansing

Movement of fluid to and from

the tissue spaces

Transportation Systems

Blood vessel to interstitium

Blood vessels are leaky structures

Pressures acting on either side of the blood vessel wall influence the rate at which fluid

flows in or out of the blood vessel.

The direction and rate of flow depends on the size of the

pushing and pulling forces within the vessel versus the

pushing and pulling forces in the tissue.

Formation of Lymph

Particulate matter (macromolecules, pathogens and migrating cells), too large for venous uptake, enters the initial lymph vessel.

The formation of lymph

Interstitium to lymphatics

•Structure of initial

lymph vessel makes it

easily accessible to

interstitial fluid

•Fluid flows through

gaps between the

endothelial cells

High output failure edema can

happen if:

Lymphedema is a low output

failure edema,

resulting from a decrease in the

overall

transport capacity of the lymphatic

system.

Tissue composition

changes (fat, muscle,

bone) occur

depending on stage

of lymphedema not

duration.

Why are cancer patients particularly

at risk?

Surgery

Radiation Therapy

Obstruction

• History

– Lymphedema is a diagnosis, swelling is a

symptom

– Need to know :

• Medical history

• Lymphedema history

• Social history

• Subjective Symptoms

• Observation

• Physical Assessment

• Edema Volume Assessment

• Special Tests

• Outcome Measures

• Patient Goals

Severity of Lymphedema

Mild < 20%

Moderate: 20 – 40%

Severe: > 40%

2003 ISL Staging of Lymphedema

Why is lymphedema

management important?

Over time, if left

untreated, lymphedema

has been shown to have

the propensity to

increase in edema

volume and with tissue

composition changes

(fibrosis, excess

adipose tissue)

http://www.lympho.org/

Treatment Goals:

1) Reduce and then maintain limb size to

restore function

2) Reduce pain

3) Improve physical appearance

Principles of treatment:

1) Increase lymph flow from the limb

2) Minimize the formation of new lymph

3) Encourage resorption of fluid into the

venous capillaries

Common conservative treatments: Education

Elevation

Compression therapies

• Compression bandaging

• Compression garments

• Pumps

• Compression systems

Manual lymph drainage (MLD)

Complete Decongestive Therapy (CDT)

Exercise

Self-management – chronic disease model

Education - Management rather than cure

– chronic disease model of care

- Basic understanding of the condition and

its treatment is essential

- Risk reduction strategies

- Maintenance and self-management are

important

http://www.lymphnet.org/pdf

Docs/nlnriskreduction.pdf (National Lymphedema Network)

Key risk reduction strategies

body weight

Skin care – infection risk reduction

Trauma – inflammation risk reduction

Constriction

Elevation

- useful in stage 0 or stage 1 lymphedema

- Lower extremity lymphedema

- Has not been shown to be effective in

stage 2 or stage 3 lymphedema

Treatment Goals

Reduce edema volume

Improve cosmesis of the limb

Improve overall health of the limb

Symptom control

Comfort

Maintain limb size

Many Treatment Options

•Compression bandaging

•Compression garments

•Compression systems

•Compression pumps

•Other

Treatment Options

Considerations:

• Goals of care

• Access to active treatment

• Independence of patient

• Social Supports

• Financial Supports

Multi-layered Compression

Bandaging

• A bandaging technique that applies

gradient pressure to the limb.

Principles of Compression

Bandaging

• Each compression bandage is applied with even tension

• Gradient compression is achieved with layering

• Most compression (layers) distally and gradually less compression as you move up the limb proximally

• In order to adjust to daily girth changes and to ensure good skin care, bandages should be removed and reapplied on a daily basis

http://www.3m.com/intl/ca/english/market/health/

Coban/Coban_landing.html?WT.mc_id=www.3m.

ca/coban2giraffe

Compression Bandaging

• Can be applied in a supportive or

compressive manner

• Can be used to reduce and/or contain

the swelling

• Reported reductions: 30 - 38%

REMOVE BANDAGES IF:

an infection is suspected

pain develops under

bandages

shortness of breath

Swelling occurs or

increases above or below

the level of the bandaging

CONSIDERATIONS

C U S TO M

•Tailor-made to exact measurements

•Can accommodate unique needs

•Many options ie. Zippers, inserts, extra padding

•Expensive

•Takes a long time to get the garment

R E A DY M A D E

•Off the shelf fit

•Many companies now, all fit slightly differently

•Limited flexibility to accommodate individual needs

•Tend to be less expensive

•Can usually be obtained quickly

Fit most important!

Benefit items on AADL program for eligible

clients with chronic lymphedema

• Fabric

• Style

• Options

• Silver

• Compression

COMPRESSION

How much compression is appropriate?

• Medically optimal vs what’s practical

• Class one: 20 – 30 mmHg (preventative and mild LE)

• Class two: 30 – 40 mmHg

• 40 – 60mmHg (legs only)

• Donning and doffing

• Skin integrity

ABI – normal range 1.0 – 1.2

Grade 2 compression stockings may be applied safely if the ABPI is between 0.8 and 1.2.

ABI < 0.5 severe arterial insufficiency - ALL COMPRESSION IS CONTRA- INDICATED

Toe Brachial Index (Toe PPG) – normal = 1.0

Arterial Status and Compression

30 – 40 mmHg

• ABI must be 0.8 – 1.2

• Toe Pressure > 80mmHg

• Toe BI > 0.6

20 – 30 mmHg

• ABI > 0.6

• Toe Pressure > 50mmHg

• Toe BI > 0.4

ABI < 0.5 severe arterial insufficiency - ALL COMPRESSION IS CONTRA- INDICATED

TBI < 0.5 – ALL COMPRESSION IS CONTRAINDICATED

REIDSLEEVE

Compression systems

MEASURE UP

2001 by Circaid

MEDAFIT by

BiaCare

Compression systems

• Advantages

– Simple to use & apply

– Saves time

– Eliminates the task of

laundering and rolling

bandages

• Disadvantages

– Expensive

– Some patients find

them difficult to sleep

with

– Can be difficult to

launder, taking days to

dry

• Replaces night time bandaging

• Growing number of products on the market

Lymphapress

Pump

Other considerations

shaped and sewn tubigrip

Products on the market with lycra or spandex

o bike or exercise shorts with/without suspenders

o body shaping camisoles

o sports bras

o tube tops

o spanx

o UnderArmour products

o isotoner gloves

Manual Lymph Drainage • Specialized gentle massage technique

• Stimulates lymph flow

• Access collateral lymphatic vessels to draw

fluid from impaired regions to areas of normal

lymphatic functioning

Complete Decongestive Therapy

Combination of treatment techniques:

1) MLD

2) CB

3) Exercise

4) Skin care

Program is usually 4 weeks long, followed by a maintenance period.

Considered the “Gold Standard” treatment

Exercise!

Decades of controversy – what is research

telling us?

• Most studies have been with BCRL

• Resistance exercise does not increase the extent of

swelling or severity of symptoms

• Exercise may in fact be helpful in reducing edema

• Improves strength, muscular endurance and QOL

• Considerations:

– Trauma and over-use injury

– Wear compression garment (except in pool)

– Cuffed weights/constricting clothing

– Avoid over heating

– Stay hydrated

Self management is the active

participation by people in their own

health care.

• Motivation

• Knowledge of condition

• Knowledge of symptom

management plan

• Other health problems

• Health beliefs

• Confidence to self manage

• Social factors

• Knowledge and support of health

professionals.

Complications

• Pain

• Infection

• Lymphorrhea “weeping edema”

• DVT

• Emotional distress

• Edemas of mixed etiology

• Quality of Life