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
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 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, sclerosis, skin changes, papillomas,
Elephantiasis 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.
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….

 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 #300
Pittsburgh, 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