Edema DisordersKade Scott DPT, CLT

Objectives Understand and recognize different

edema disorders Understand basic treatment options for

edema disorders Explain the differences in compression

garments

What does the Lymphatic system do? The lymph system is responsible for

transporting Proteins Water Cells Fat Waste WBC, lymphocytes, Bacteria, Virus

Lymphedema An abnormal accumulation of protein

rich fluid in the interstitum, which causes chronic inflammation and reactive fibrosis in the affected tissue

Lymphedema is classified as either primary or secondary lymphedema

Typically asymmetrical

Date of download: 2/17/2014Copyright © 2014 American Medical Association.

All rights reserved.

From: Differential Diagnosis, Investigation, and Current Treatment of Lower Limb Lymphedema

Arch Surg. 2003;138(2):152-161. doi:10.1001/archsurg.138.2.152

Causes of lymphedema.

Figure Legend:

Primary Lymphedema The most likely occurrence of this form is

lymphangiodysplasia Hypoplasia- less than normal expected

number of lymph collectors in the affected area

Aplasia- a distinct absence of lymph collectors in the affected area. May also involve the absence of lymph capillaries

Hyperplasia- Vessels are characterized by an excessively dilated caliber which renders them less functional due to valvular dysfunction

Primary Lymphedema Present at birth or

shortly therafter is known as Milroy’s Disease

Primary Lymphedema that develops during puberty is known as Meige’s Disease.

Praecox- Develops before 30

Tardum- Develops after 35

http://www.sajch.org.za/index.php/SAJCH/article/view/639/453

Secondary Lymphedema Secondary lymphedema means there is a

known cause for the presence of lymphedema

Worldwide the most common cause is the mosquito born parasite Filaria

In the United States the most common cause is cancer therapy Lymph node sampling Full dissection of lymph nodes Radiation therapy

Secondary Lymphedema (cont) Other causes include any significant

trauma to the lymphatic system from accidental or self induced incidents, infectious episodes such as eyrsipelas or cellulitis

Obesity may also play a role in the development of lymphedema, however, it is more likely due to a secondary co-morbidity (lack of mobility, CVI etc)

Staging of lymphedema Lymphedema is divided into 4 stages

(American Society of Lymphology) Latency stage (subclinical or stage 0)

Transport capacity of the lymphatic system is sub-normal but still sufficient to transport the lymphatic load

Patients are “at risk” for developing lymphedema

Education about subjective complaints and preventative measures is key component of treatment at this stage

Staging Stage 1 (reversible stage)

Accumulation of protein rich fluid No fibrotic alterations Pitting is easily induced With proper management of stage 1

patient can expect to have reduction to normal limb size

Stage 1 is often confused with edemas of other geneses

Staging Stage 2 (spontaneously

irreversible) Lymphatic fibrosis Tissue becomes

indurated Pitting is difficult to

induce Positive Stemmer sign Common cellulitic

infections Incomplete reduction

with therapy and good patient compliance

Stemmer SignSometimes called the Kaposi Stemmer sign

Staging Stage 3 (Lymphostatic

Elephantitis) Increased skin firmness,

other skin alterations including: cysts, fistulas, papillomas, hyperkeratosis, mycotic infections, ulcerations

More prominent Stemmer sign

Recurrent cellulitis Decreased pitting

Click icon to add picture

http://www.womenshealthsection.com/content/gyno/gyno005.php3

Symptoms Swelling of an arm or leg, which may include fingers and toes. A full or heavy feeling in an arm or leg. A tight feeling in the skin. Trouble moving a joint in the arm or leg. Thickening of the skin, with or without skin changes such as blisters

or warts. A feeling of tightness when wearing clothing, shoes, bracelets, watches, or

rings. Itching of the legs or toes. A burning feeling in the legs. Trouble sleeping. Loss of hair. Positive Stemmer Sign (though the absence does not rule out

lymphedema) These symptoms may occur very slowly over time or more quickly if there

is an infection or injury to the arm or leg.

Chronic Venous Insufficiency Is an advanced stage of venous disease

in which the veins and the muscle pump activity become incompetent causing blood to pool in the legs and feet

Can be due to repeated damage from superficial or deep venous pathology, or a variety of vein-related conditions such as the congenital absence of valves

Pathophysiology of CVI Faulty valves fail to prevent retrograde

flow of venous blood during muscle pump activity

May be: Idiopathic Post-thrombotic syndrome Genetics Pelvic tumors Vascular malformations

Symptoms Swelling in the lower legs and ankles,

especially after extended periods of standing

Aching or tiredness in the legs New varicose veins Leathery-looking skin on the legs Flaking or itching skin on the legs or feet Stasis ulcers (or venous stasis ulcers) Hemosiderin staining

Hemosiderin staining

Risk factors Deep vein thrombosis (DVT) Varicose veins or a family history of varicose

veins Obesity Pregnancy Inactivity Smoking Extended periods of standing or sitting Female sex Age over 50

Early stages of CVI Pitting Edema

Mostly presenting below the knee

Corona Phlebectatica A myriad of tiny

vein branches that are difficult to delineate

Red-pink hue to skin that returns immediately after pressure is released

http://www.medicographia.com/wp-content/uploads/2011/10/17.JPG

Advanced stages Hyperpigmentation Dermatologic changes Venous stasis dermatitis Lipodermatosclerosis

Scarring and fibrosis of skin (woody texture to skin)

There may now be a lymphatic component to edema http://www.veinsveinsveins.com/app/

webroot/files/lipo.11.jpg

End Stage CVIDefined by ulcerations of the skin

Photo Credit: Charlie Goldberg http://meded.ucsd.edu/clinicalimg/extremities_venous_insuf4.htm

Lipedema A chronic

metabolic disorder of the adipose tissue, of unknown etiology.

http://www.amylhwilliams.com/BEFOREAmyslegsfront1.jpg

Lipedema Predominately in women Bilateral symmetrical swelling from illiac

crest to ankles Stemmer’s sign negative No cellulitic infections Foot sparing

Lipedema “I can never lose weight in my legs no

matter how much I diet” Very tender skin Bruise easily

Lipedema Stage 1

Skin surface is normal, tissues exhibit a smooth nodular texture

Stage 2 Skin surface becomes more uneven, large

fatty lobules begin to form Stage 3

Large contour deforming lobular shapes on medial knee, proximal lateral thigh, and above malleoli

Lipedema Staging

http://www.nature.com/aps/journal/v33/n2/fig_tab/aps2011153f4.html

Traumatic Edema Edema due to physical trauma

Results in inflammatory reactions accompanied by high protein edema.

The majority are temprorary and self resloving. However, it can lead to permanent damage.

Pathophysiology of traumatic edema The initial step in the inflammatory

process causes local vasodilation, followed by an increase in the permebility of blood capillaries toward plasma protein. Macrophages invade and devour damage tissue. These macrophages may injure the lymhpatic system.

Cardiac Edema Greatest distally Always Bilateral Pitting Complete resolution with elevation No pain

Congestive Heart Failure Same symptoms as in cardiac edema Orthopnea, paroxysmal nocturnal

dyspnea, dyspnea on exertion Jugular venous distension Cardiac echo, Physical exam

Renal Failure and Edema Increased protein in the urine Decreased blood protein Pitting edema in lower extremity

How do I differentiate?And then what?

Accurate Pt Hx Patient history is crucial in determining

the underlying cause of edemaThere are many questions that you can ask that will help guide you down the proper course

Intake Questions Have you had any lymph nodes

removed? Any recent abdominal surgeries? Any history of DVT? Previous cellulitic infection? CHF? Renal Failure?

Lymphedema

•MLD•Compression Bandage•Compression Stockings•Pneumatic Compression

Lipedema

•Light MLD•Compression Stockings•Compression Bandage

CVI

•Compression Bandaging•Compression Stockings•Pneumatic Compression

Traumatic Edem

a

•MLD above level of injury•Compression Bandaging

Cardiac,

CHF, Renal

•Compression bandaging and stockings as tolerated. You MUST consult a physician on these patients prior to initiating any treatment

2 phases to treatment

Reduction MLD Compression

bandaging Pneumatic

compression Exercise and skin

care

Maintenance Compression

Stockings Pneumatic

Compression Exercise, Skin care

Manual Lymphatic Drainage A general manual treatment which improves

lymph vascular flow. In lymphedema it re-routes the lymph fluid around blocked areas into more centrally located healthy lymph nodes

It is not a massage! Must be done by someone who is properly

trained

Contraindications to MLD CHF if patient is unmedicated or edema

is due solely to cardiac failure Acute infection Renal Failure Acute DVT (seek physician approval for

post thrombotic syndrome edema management)

Compression Bandaging Short stetch bandages are applied to

increase the tissue pressure in the swollen extremity Improves the efficiency of the muscle

pump and joint pumps Prevents the reacummulation of

evacuated fluid Helps break up deposits of accumulated

scar and connective tissues

Contraindications to compression bandaging Acute DVT (may mobilize thrombus) Acute infection Cardiac edema Advanced arterial disease <.7 on the

ABI Advanced renal disease Malignancy (relative to severity)

Bandaging Short stretch-

Unna, Comprilan Medium stretch

Coban Co-Plus

Long Stretch Ace

4-layer Profore

Short stretch Reduce deep venous reflux more

effectively High working pressure to low resting

pressure. Produce high pressure amplitudes when patient is walking and a decrease in pressure when patient is supine

Main disadvantage is the loss of pressure following reduction

Short Stretch Comprilan Bandagehttp://curept.com/multi-layer-bandaging/

Medium stretch Sustains compression after an initial

decrease Has a fair working to resting pressure

ratio

2-layer Wraphttp://solutions.3m.com/wps/portal/3M/en_EU/Healthcare-Europe/EU-Home/Products/ProductCatalogue/?PC_Z7_RJH9U52300PI40IA1Q602S28E7000000_nid=5W2H1K4LB0be56F5WHWNG2gl

Long Stretch Maintain pressure for longer periods of

time A higher pressure of at least 60 mmHg

is required to prevent reflux Exert a high resting pressure which can

constrict the venous and lymphatic systems creating a tourniquet effect

Helping Patients & Physicians Heal

Pneumatic Compression Therapy

Before

Pneumatic Compression Therapy

Before After 2 Weeks Pneumatic Compression

Pneumatic Compression Pump

Mechanism of ActionA gentle “milking” of lymphatic fluid out of the upper extremity. This distal to proximal motion allows for a clearance of lymphatic fluid to be filtered out of the system via the urinary tract. In essence the Pneumatic Compression pump is designed to ‘do’ what the body is incapable of due to age, damage or disease state.

Contraindications Inflammatory Phlebitis Episodes of Pulmonary Embolism Infections in limb without appropriate

antibiotic coverage* Presence of Lymphangiosarcoma Congestive Heart Failure, Uncontrolled

*48 hours

Pneumatic Compression Therapy

Convenient home use Comprehensive in-home or office patient

training Easy to use Medicare and private insurance coverage Custom sizing Adjustable Ability to clean the product-sanitary Patient dictated time of use Lifetime treatment of underlying condition

Compression garments Class 0 10-20 mmHg Class 1 20-30 mmHg Class 2 30-40 mmHg Class 3 40-50 mmHg

Class 0 Preventative only Should not be used for someone with

active edema

Class 1 20-30 mmHg Minimum compression for UE

lymphedema Offer support, but NOT sufficient for

lower extremity lymphedema or CVI

Class 2 30-40 Most stage 2 upper extremity

lymphedema Minimum compression for LE

lymphedmea Offers good support for LE CVI

Class 3 40-50 mmHG Rarely used in UE lymphedema Most stage 2 LE lymphedema Minimum starting point for stage 3

lymphedema

Consideration for garment selection Patient ability to manage garment Material allergies Price Insurance coverage

Flat knit vs Circular knit

Flat Custom only Slightly easier to don The thicker fabric offers

additional features, such as its massaging effect, which promotes lymph drainage, and its strength, which ensures the stocking does not yield to the edema. In conjunction with movement, it produces a high therapeutic pressure that provides optimum compression of the tissue.

Circular Custom or OTS Difficult to don Single layer of fabric Not appropriate

compression for active lymphedema, may not be adequate for sever venous edema

Cheaper

Goals for compression garments MAINTAIN limb volume after

decongestion. Compresion garments will NOT decongest limb

Easy don/doffing to enhance patient compliance

Cosmetically appealing

References Diseases and Conditions: Chronic Venous Insufficiency

(CVI). http://my.clevelandclinic.org/disorders/venous_insufficiency/hvi_chronic_venous_insufficiency.aspx. Accessed 2-26-14.

Greenlee R, Hoyme H, Witte M, Crowe P, Witte C. Developmental Disorders of the Lymphatic System. Lymphology. 26 (1993): 156-158.

Managing edema to decrease pain and increase range of motion and functional mobility. Loraine Lovejoy-Evans MPT, DPT, CLT-Foldi.

Mcdonald J, Sims N, Mayrovitz H. Lymphedema, lipedema, and the open wound. The role of compression therapy. Surgical Clinicals of North America. 83 (2003): 639-658.

References Norton School of lymphatic therapy course manual:

Manual Lymphatci Drainage/Complete Decongestive Therapy .

Rathbun SW, Kirkpatrick AC. Treatment of chronic venous insufficiency. Curr Treat Options Cardiovasc Med. 2007 Apr;9(2):115-26.

Szuba A, Rockson S. Lymphedema: classification, diagnosis and therapy. Vascular Medicine. 1998: 3:145-156.

Zuther J, Norton S. Lymphedema Management: the comprehensive guide for practitioners. 3rd ed. New York, NY: Thieme Medical Publishers; 2013.

LE Short Stretch Compression

Foam Open Cell Grey Foam Komprebinde Komprex Rosidal Soft

LE bandaging Lotion Stockinette to calf Toe wraps Cotton (knee, foot) Foam (affix to calf) Foam (affix to ankle

and dorsum of foot)

Eucerin or other low pH

TG or Tricofix Transelast/elastomull Cellona/Artiflex

LE bandaging Roman Sandal Ankle sole heel (ASH,

Has) Spiral ankle to knee Herring bone/Figure 8 Stockinette to thigh Affix foam to thigh Knee to mid thigh Knee to top Distal thigh to top

6cm Comprilan/Rosidal K 8cm 10 cm 10 cm

12 cm 12cm 12 cm