1. Outline Lymphedema causes & stages Conservative therapies for lymphedema Decongestive lymphatic therapy Skin care Manual lymphatic drainage Compression therapy 2012-11-04Self drainage exercise Benigh & malignant lymphedema Take home messages 1 2Causes Lymphedema Primary lymphedema: present at birth or onset after puberty. Born without enough lymph nodes, or lymphatic collectors. Secondary Lymphedema: developed due to trauma, infection, surgery, tumors, and/ or radiation to the lymph node regions. Can be within days to several years later. 3 4The Causation of EdemaBLOOD Lymphatic load Low-flow Tissue High-flow edema Safety-valveNormal =lymphoedemaedema insufficiency (high protein) LymphaticTransport LYMPH 51

2. Lymphedema Stages of LymphedemaInternational Society for Lymphology (Casley-Smith et al. 1985)Stage 1Stage 1 : pits on pressureDefinitionAn abnormal accumulation of tissuereduced on elevationproteins , causing edema and chronic inflammation no or mild fibrosiswithin an extremity.(Grabois M. Phys Med Rehab Rev 1994;8:267-77)Stage 2 : non-pitting on pressure Stage 2 not reduced by elevation moderate to severe fibrosisFunctional overload of the lymphatic systembrawnyLymph volume exceeds transport capacities Stage 3 : elephantiasis, wartsAlso occurs in the face, trunk and external genitalia. skin very thick and leathery subcutaneous tissue hypertrophied 78Stage 3 CTCAE: lymphedemaThe most effective treatment? (Common Terminology Criteria for Adverse Events v3.0)Includes both objective measures (interlimb discrepancy) and Currently not enough evidence to draw conclusionssubjective assessments.about the best physical therapy to use in the treatment Grade 1: 5%~10% interlimb discrepancy in volume orof lymphoedema. circumference at point of greatest visible difference; swelling or (Physical therapies for reducing and controlling lymphoedema of the limbs (Review). 2007 The Cochrane Collaboration) obscuration of anatomic architecture on close inspection; pitting edema.No evidence to suggest the most effective treatment for Grade 2: More than 10%~30% interlimb discrepancy in volumesecondary lymphedema. or circumference at point of greatest visible difference; readily(Systematic review:conservative treatments for secondary lymphedema. Oremus et al. BMC Cancer 2012, 12:6) apparent obscuration of anatomic architecture; obliteration of (A Systematic Review of the Evidence for Complete Decongestive Therapy in the Treatment of Lymphedema From 2004 to 2011. Lasinski et al.PM R 2012;4:580-601) skin folds; readily apparent deviation from normal anatomic contour. Grade 3: More than 30% interlimb discrepancy in volume; Insufficient evidence power: lymphorrhea; gross deviation from normal anatomic contour; Inconsistencies in defining and measuring lymphedema interfering with activities of daily living. lack of enough RCT. Grade 4: Progression to malignancy (e.g., lymphangiosarcoma);Small sample sizes. amputation indicated; disabling lymphedema.Ethical questions. 9 10History of Lymphedema 15,16th century:lymphedema has been known.The medicine-based evidence is 1936, Vodder:manual lymphatic drainage to treat lymphedemaundeniably strong that CDT is an effective 1950-1970, Kinmonth:D/D lymphedema & venous edema 1981, Kubik:concept of lymphatic watersheds.way to treat lymphedema. 1975-1980s, M. Foldi (Germany):Effective for various degrees ofput all techniques together with his wife (E. Foldi) 1st modern clinic for Tx lymphedemalymphedema:Complex Decongestive Physiotherapy (CDP) mild, moderate, or severe 1986, John Casley-Smith:Microcirculationcombine Kubik & Foldi methods early or late onset Complex Lymphatic Therapy (CLT) recent or chronicor Complex Physical Therapy (CPT) 1998, Foldi, Leduc, Vodder school and Casley-Smith et al. agreed: active cancer or palliative situations(Lasinski et al. PM R 2012;4:580-601)Decongestive Lymphatic Therapy (DLT)11 12 2 3. Decongestive Lymphatic TherapyDecongestive Lymphatic Therapy (DLT) (DLT) Manual SelfSkin CompressionIntensive phase Max. reduction in 7~10 times LymphaticDrainage To mobilize the accumulated protein-rich fluid.Care Therapy(2~4 weeks) To initiate the reduction of fibrosclerotic tissues.DrainageExercise Goal Maintain phaseTo maintain and even improve the results achieved inintensive phase.(6~9 months) Loosen skin remodelling. ? Intensive phase: repeated after loose skin remodeling(in maintain phase).? Each repeated DLT course:50% preserved 13 lymphedema 14Obstruction of lymph vesselsLYMPHOEDEMAChronic inflammation Excess protein in tissuesREPEATED INFECTIONSLymphatic load Damaged blood vesselsSpasms & Thrombosisof LymphaticsCellular debrisIncreased Lymphatic Load 1516Skin complications of lymphedema Skin Care EducationHyperkeratosis: thickening of the epidermis.1.Avoid infection and injuryCaused by overproliferation of the keratin layer and producesscaly brown or grey patches.2.Avoid pressure on the involved extremity3.Avoid constrictive clothing4.Avoid vigorous activity5.Avoid heat6.Keep skin in good condition- moisture lotion7.Avoid strong massage 17183 4. Skin complications of lymphoedemaSkin complications of lymphoedemaLymphangiectasia(lymphangiomata): excessive Papillomatosis: multiple benignepidermal tumorsdilatation of the lymphatics due to dilatation of lymphatic vessels and Treatment: compression with multi-layer short stretch bandage.fibrosis, and may be accompanied by hyperkeratosis. may be reversible with adequate compression. 19 20Skin complications of lymphoedema Lymphorrhoea: leakage of lymph from the skin.The surrounding skin should beprotected with emollient, andnonadherent absorbent dressingsshould be applied.Bandages will reduce the underlyinglymphoedema, but needs to be changedfrequently to avoid maceration of theskin. Lymphatic transport capacityIn the palliative situation, lightbandaging may be more appropriate. 21 22Initial lymphaticEffect of MLD(2,3)Collectinglymphatic (5) 1-epidermis 6-deep fascia 8,9-two adjacentVascular & Lymphatic Systemdrainage regionsLymphatic System Mechanically move fluid into initial lymphatic. Open valves of collectingLymphotomeMake initial lymphatic & lymphatic that crossed&collecting lymphatic pumpingwatershed. Watershed & being emptied repeatedly. Set up collateral pathway. 23 244 5. Massage Technique MLD techniques Slowly with control.Casley-Smith:Vodder: four basic strokes With minimal friction by hands & fingers. The StrokesStationary circle: for lymph20-40 m in diameternode Nodal massage Clearing across thePump technique: for Massage pressure: 50 mmHg.severe leg lymphoedema.41 427 8. Contraindications to high compression Acute infection with local and/or systemic symptoms Untreated DVT Untreated cardiac failure or HTN Untreated genital oedema Proven arterial insufficiency (ABPI