Nicole Baldridge, PT, DPT, CLT

Certified Lymphedema Therapist
Women’sRehab Men’s Health
Physical Therapy Resident
for Centers for Rehab Services

Lymphedema

Diagnosis
and
Therapy

Lymphedema

Secondary Lymphedema

Primary Lymphedema

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

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) .

injury. trauma. radiation. scarring. – May be present at birth – Can develop later in life without known cause  Secondary lymphedema is much more common.Types of Lymphedema  Primarylymphedema is a result of lymphatic dysplasia. – Result of surgery. 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 .

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

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papillomas. Elephantiasis hyperkeratosis . sclerosis. achiness Stage 1 Accumulation of protein-rich edema Reversible Pitting lymphedema Reduces w/elevation (no fibrosis) Stage 2 Accumulation of protein-rich edema Spontaneously Pitting becomes progressively difficult Irreversible Fibrosis Lymphedema Stage 3 Accumulation of protein-rich edema Lymphostatic Fibrosis. Stages of Lymphedema Latency Stage Transport Capacity is reduced No visible edema Subjective complaints of heaviness. skin changes.

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

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 .Angiosarcoma  Can develop after long-standing lymphedema  “Stewart .

Stewart-Treves Syndrome .

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

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

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

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 .

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Positive Stemmer’s sign is indicative of lymphedema.  Skin folds  Pitting  Fibrosis  Muscular status .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.

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

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 .

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

paralysis  Central location. paresthesia.Malignant lymphedema  Pain. 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. Most therapists in the US will never encounter Filariasis. Can still be treated successfully with CDT. .

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

Can be used at home by patients 2. Fast application 3.Pneumatic Compression Pumps Advantages: 1. Financially lucrative for DME vendors ($4000 per pump) .

the pump can cause breast edema 3. Requires many hours a day with the affected limb elevated 5. Disregards the fact that the ipsilateral trunk can be involved in the lymphedema 2. functioning lymphatics. The pump can traumatize residual. In LE edema. Does not address tissue fibrosis and extended use can cause additional fibrosis 4.Pneumatic Compression Pumps Disadvantages: 1. especially of the UE . the pump can cause genital edema. in UE edema.

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

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

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

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

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

 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 .Compression bandaging Short stretch bandages (Rosidal. Comprilan) are applied to increase the tissue pressure in the edematous extremity.

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

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

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 .

 Garments do nothing to correct the underlying cause of the edema.  Garments are NEEDED after the decongestive phase of CDT to prevent refill.Compression garments  Elastic garments are uncomfortable and ineffective if worn while the limb is edematous. .

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 .

often prescribed. Can cause lymphedema to become more fibrotic. rutosides. diosmin. effect is so slow that usefulness is questionable. Includes coumarin. . but draw water off protein molecules. rutin.  Benzopyrones: not FDA approved.What role do medications have?  Diuretics: make edema worse. stimulate macrophage activity and promote protein proteolysis. theoretically useful.

vitamin rich diets.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. .

What role does obesity play? 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 .

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…. HMO. PPO pay 100% for products  UPMC HMO. but this is changing to more coverage .  Medicare does not pay for products – Medicare HMO’s do not pay  Medicaid does not pay for products  Most Highmark BC/BS. PPO plans…as of 1/1/08 started following Medicare guidelines.

Insurance obstacles…  Frustratingfor the therapist because patients need these products to maintain edema and prevent worsening of edema.  Often we have to change our recommendations based on what the insurance will reimburse.  We recommend products based on what the patient needs or does not need. .

L and in a less effective fabric than custom garments  Night garments: custom only. M.…  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.Actual cost for the patient. $500-2000 .

”  Bandaging supplies for treatment – Unilateral UE/LE about $150-200 – Bilateral LE >$200 .More cost…  Keepin mind that all of these costs are what the DME suppliers charge for “private pay.

.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.

462.227.Help for patients…  Susan G.9273  Am. Cancer Society – Any cancer $300/year – 800.2345  Nat’l Lymphedema Network – www.lymphnet.org – Marilyn Westbrook Foundation – Also has “Find a Therapist or Treatment Center” . Komen Foundation – Breast cancer patients – 800.

PA 15328 (412) 630-9750 .edu  Phone/Address: Centers for Rehab Services  Moon Township 1600 Coraopolis Heights Rd Coraopolis. PA 15108 (412) 269-7062  McCandless 9365 McKnight Rd #300 Pittsburgh.THANK YOU!  baldridgena@upmc.

pelvic pain. Monroeville. Margaret’s.WomensRehab at Centers for Rehab Services  Specialists in treating lymphedema as well as urinary incontinence. Squirrel Hill. constipation and other pelvic floor hyper/hypotonicity disorders. South Hills.  Locations: Cranberry. McCandless. interstitial cystitis. vulvadynia. Chippewa  Referral Line 1-888-723-4CRS . Gibsonia. Oakland. Harmar. Delmont. fecal incontinence. Moon. St.