Nicole Baldridge, PT, DPT, CLTCertified Lymphedema TherapistWomen’sRehab Men’s Health Physical Therapy Residentfor Centers for Rehab Services

Lymphedema

Diagnosis and

Therapy

Secondary Lymphedema

Primary Lymphedema

Lymphedema

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

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)

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

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

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

Stages of Lymphedema

Latency Stage Transport Capacity is reduced

No visible edema

Subjective complaints of heaviness, achiness

Stage 1

Reversible lymphedema

Accumulation of protein-rich edema

Pitting

Reduces w/elevation (no fibrosis)

Stage 2

Spontaneously Irreversible Lymphedema

Accumulation of protein-rich edema

Pitting becomes progressively difficult

Fibrosis

Stage 3

Lymphostatic Elephantiasis

Accumulation of protein-rich edema

Fibrosis, sclerosis, skin changes, papillomas, hyperkeratosis

Tissue Changes in Lymphedema

Connective tissue cells (fibroblasts) proliferate

Collagen fibers are produced Fibrotic changes, sclerosis and induration Fatty tissue increases

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

Stewart-Treves Syndrome

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

Diagnosis of

Lymphedema

Physical exam and history

are most important.

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

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?

Inspection

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

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

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

Differential Diagnosis

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

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

CVI

Gaiter distribution Non-pitting Brawny Hemosiderin staining Fibrosis of subcutaneous

tissue Atrophic skin

Acute DVT

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

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

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

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

Filariasis

Prevalent in 3rd world countries;

Can still be treated successfully with CDT.

Most therapists in the US will never encounter Filariasis.

Lymphedema Treatment Options

Pneumatic compression pump Surgery Complete decongestive therapy (CDT) Elastic support garments Medications

Pneumatic Compression Pumps

Advantages:

1. Can be used at home by patients

2. Fast application

3. Financially lucrative for DME vendors ($4000 per pump)

Pneumatic Compression Pumps

Disadvantages:

1. Disregards the fact that the ipsilateral trunk can be involved in the lymphedema

2. In LE edema, the pump can cause genital edema; in UE edema, the pump can cause breast edema

3. Does not address tissue fibrosis and extended use can cause additional fibrosis

4. Requires many hours a day with the affected limb elevated

5. The pump can traumatize residual, functioning lymphatics, especially of the UE

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

Surgery

Microsurgical techniques Liposuction Debulking/Reduction procedures

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

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).

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.”

Components of CDT

MLD Compression bandaging Exercise Skin and nail care Instructions in self care

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.

Manual Lymph Drainage

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

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

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

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.

Self Care

Patients should be instructed in the following:– Skin and nail care– Infection prevention (cellulitis is very common)– Self-bandaging– Self-MLD as needed– Exercise– Donning and doffing compression garment– Regular follow-up visits

CDT is a Two-Phase Therapy

Phase 1 (Treatment Phase) – Meticulous skin/nail care– MLD– Compression bandaging– Exercise– Self care education

** lasts as long as necessary

CDT is a Two-Phase Therapy

Phase 2 (Maintenance Phase)– Patient wears compression garments during the day– Patient bandages at night– Meticulous skin and nail care– Daily exercise– MLD as needed– Regular follow-up visits

**life long maintenance

When does CDT fail?

Malignant lymphedema Artificial (self-induced) lymphedema Insufficient treatment (only used MLD or

improper bandaging) Deviation from CDT protocol Associated illnesses Lack of compliance Active cancer Faulty diagnosis

Goals of CDT

Volume or size reduction Restore mobility and ROM Infection prevention Improve cosmesis Improve psychosocial morbidity Improve QOL

Compression garments

Elastic garments are uncomfortable and ineffective if worn while the limb is edematous.

Garments do nothing to correct the underlying cause of the edema.

Garments are NEEDED after the decongestive phase of CDT to prevent refill.

Daytime garments

Lymphedema Secondary to Breast Cancer

Primary Lymphedema of the Left Leg

Primary Lymphedema of Scrotum and Leg

Before After resection

Night-time garments

Night-time Garments

What role do medications have?

Diuretics: make edema worse; often prescribed, but draw water off protein molecules. Can cause lymphedema to become more fibrotic.

Benzopyrones: not FDA approved; stimulate macrophage activity and promote protein proteolysis; theoretically useful; effect is so slow that usefulness is questionable. Includes coumarin, rutosides, diosmin, rutin.

DIET

No specific diet for lymphedema Reducing water and/or protein intake is

ineffective Avoiding obesity is helpful General recommendations are low sodium,

high fiber, vitamin rich diets.

Increased risk of post-op complications such as infection

Reduced muscle pumping efficiency within loose tissues

Additional fat deposits contribute to arm volume

Deep lymph channels are separated by subcutaneous fat

What role does obesity play?

Randomized controlled trial comparing a low-fat diet with a

weight reduction diet in breast cancer related lymphedema

This article was published in the medical journal “Cancer” in May 2007.

It was also copy-written by the American Cancer Society in 2007

Results

The low-cal group and low-fat group had significant reductions of: – body weight– BMI– % body fat**Significant correlation between weight loss

and arm volume reduction regardless of the dietary group

**unaffected arm also showed volume reduction

Overview

This is the first study to examine the role of diet as a possible treatment for BCRL

Significant correlation of weight loss and loss of swollen arm volume

The type of diet did not affect arm volume reduction…just losing weight!

Weight loss in a healthy manner Healthy diet and exercise

Insurance coverage….

Medicare does not pay for products– Medicare HMO’s do not pay

Medicaid does not pay for products Most Highmark BC/BS, HMO, PPO pay

100% for products UPMC HMO, PPO plans…as of 1/1/08

started following Medicare guidelines, but this is changing to more coverage

Insurance obstacles…

Frustrating for the therapist because patients need these products to maintain edema and prevent worsening of edema.

We recommend products based on what the patient needs or does not need.

Often we have to change our recommendations based on what the insurance will reimburse.

Actual cost for the patient.…

Day garments: – Patients need 2 garments every 6 months– Custom fit $300-500 per garment– Ready to wear $50-150 per garment

RTW garments only come S, M, L and in a less effective fabric than custom garments

Night garments: custom only, $500-2000

More cost…

Keep in mind that all of these costs are what the DME suppliers charge for “private pay.”

Bandaging supplies for treatment– Unilateral UE/LE about $150-200– Bilateral LE >$200

How does this affect you…

Most of the DME’s in the area are “out-of-network” with Cigna

Out of network cost for these products is extremely high

Important to understand how necessary these products are and to consider approval at an “in-network” level.

Help for patients…

Susan G. Komen Foundation– Breast cancer patients– 800.462.9273

Am. Cancer Society – Any cancer $300/year– 800.227.2345

Nat’l Lymphedema Network– www.lymphnet.org– Marilyn Westbrook Foundation– Also has “Find a Therapist or Treatment Center”

THANK YOU!

baldridgena@upmc.edu Phone/Address: Centers for Rehab Services Moon Township

1600 Coraopolis Heights Rd  

Coraopolis, PA 15108(412) 269-7062

McCandless

9365 McKnight Rd #300Pittsburgh, PA 15328

(412) 630-9750

WomensRehab at Centers for Rehab Services

Specialists in treating lymphedema as well as urinary incontinence, pelvic pain, interstitial cystitis, vulvadynia, fecal incontinence, constipation and other pelvic floor hyper/hypotonicity disorders.

Locations: Cranberry, Moon, Gibsonia, Harmar, St. Margaret’s, South Hills, Oakland, Squirrel Hill, McCandless, Delmont, Monroeville, Chippewa

Referral Line 1-888-723-4CRS