A Comprehensive Approach to Managing Swelling, Edema, and Lymphedema - - PowerPoint PPT Presentation

A Comprehensive Approach to Managing Swelling, Edema, and Lymphedema

Effective Assessment and Rehabilitation Strategies Across Patient Populations

Lisa Berman Sylvestri MSPT, CLT‐LANA

1

LEARNING OBJECTIVES

• 1. Apply knowledge of the lymphatic system to treat

edema/lymphedema in various patient populations

• 2. Identify high risk patients to prevent lymphedema during

procedures

• 3. Utilize manual techniques and compression to mobilize fluid and

decongest a swollen area

• 4. Objectively measure and grade edema
• 5. Create appropriate treatment plans to maximize function,

reduce swelling and promote tissue healing

• 6. Explain to patients the importance of a HEP for edema

management for faster recovery 2

WHAT IS SWELLING?

Dictionary.com: An abnormal enlargement of a part of the body, typically as a result of an accumulation of fluid. Healthline.com: Swelling occurs whenever the organs, skin, or other parts

• f your body enlarge. It is typically the result of

inflammation or a buildup of fluid. Swelling can occur internally, or it can affect your outer skin and muscles. Wikipedia.com: A transient, abnormal enlargement of a body part or area not caused by proliferation of cells. It is caused by accumulation of fluid in tissues.

3

WHAT IS SWELLING…REALLY??

• The body’s normal response to injury.
• It’s the action of increased blood flow, white blood

cells, and fluid to an injured area to promote healing.

• Congenital or acquired
• Congenital – present at birth
• Acquired – due to injury or tissue damage
• Acute or chronic
• Acute – occurs 2‐24 hours following injury
• Chronic – occurs within weeks to months

4

DIFFERENT TYPES OF SWELLING

• Edema ‐ is an abnormal accumulation of fluid in

the interstitium.

• Usually named by its location – peripheral edema,

pulmonary edema, ascites, thrombophlebitis, etc.

• Lymphedema ‐ is a condition of localized, high

protein fluid retention and tissue swelling caused by a compromised lymphatic system.

• Effusion – an accumulation of fluid in an anatomic

space

• Hemarthrosis – an effusion due to blood into a joint

space

5

THE UNKNOWN

“It is disheartening to learn that the average American medical school graduate receives an exposure to the lymphatic curriculum for less than 30 minutes within a four‐year medical education.” “Creating a better world for lymphatic patients is not an idle dream. The tools already exist. In a future world of ideal medical practice, clinicians will receive the same exposure to the lymphatic system that they currently receive for cardiac, renal, endocrine, and other bodily functions.”

• Dr. Stanley Rockson, 2017

6

FACTS

• Our body is about 2/3 FLUID with blood, water, and

intracellular and extracellular components

• Blood makes up the smallest portion of fluid

extracellular fluid  intracellular fluid makes up largest portion

• Extracellular fluid is composed of interstitial fluid and

blood plasma

• The blood CARRIES the nutrients and oxygen the body

requires to body organs

• Interstitial fluid TRANSPORTS nutrients and oxygen into

cells and body organs at the capillary level through connective tissue and removes waste

7

NORMAL LYMPHATIC AND CIRCULATORY ANATOMY

• CIRCULATORY ‐ closed system
• LYMPHATIC ‐ open system
• Superficial
• Deep
• Separated by fascia
• 2 separate systems working together
• Both systems are innervated by our autonomic nervous

system

8

THE LYMPHATIC SYSTEM

• Body’s immune system
• Maintains homeostasis
• Cleans, filters and moves lymph fluid and is then

returned to the circulatory system

• Most interstitial fluid will return to circulatory system via

venous system, however some particles are too big

• Lymph fluid is another name for the interstitial fluid
• nce it enters the lymph system
• Lymph fluid is made up of the lymphatic load:
• Water
• Proteins
• Cellular components/WBC and lymphocytes
• Fatty acids
• Cellular debris, cancer cells, bacteria, dirt and particles

from outside 9

CIRCULATORY SYSTEM

10

11

LYMPH COLLECTORS AND REGIONAL LYMPH NODES

12

WATERSHEDS AND QUADRANTS

13

LYMPH NODE

14

LYMPH COLLECTOR

15

DRAINAGE AND TERMINUS

16

DIAPHRAGM BREATHING

17

HOW DOES LYMPH MOVE?

• Pressure differential at the capillary level
• Diffusion of molecules
• Osmosis of water
• Filtration and reabsorption
• Contractile properties of lymph angion
• Contractile properties of surrounding structures
• Blood pressure
• Diaphragmatic breathing
• Musculoskeletal contractions/muscle pump

18

MUSCLE PUMP ACTION

Muscle Pump and Valves. This figure is used, with permission, from The Lymphoedema Support Group of NWS, http://www.lymphoedemasupport.com/muscle.php.

19

NORMAL LYMPHATIC FUNCTION

• Mobilization of fluid and particles that are too large

to return to the venous system; approximately 10%

• f fluid
• Approximately 2‐4 liters/day
• Approximately 500‐700 lymph nodes throughout
• ur body, with largest concentration in head and

neck and abdomen

20

21

ABNORMAL LYMPHATIC FUNCTION

Occurs because of:

• 1. Damage to lymph vessels
• 2. Damage to lymph nodes
• 3. Medical comorbidities
• 4. Congenital abnormalities

22

WHAT IS LYMPHEDEMA?

• Abnormal accumulation of high protein lymph fluid

in the interstitium and subcutaneous tissue due to lymphatic dysfunction or pathology

• It usually occurs in the extremities, but can also
• ccur in the trunk, breast, head and neck,

abdomen, and genitalia

• Diagnosis made by difference in limb size of 5%

23

LYMPHEDEMA

• Primary Lymphedema
• Congenital abnormalities
• Secondary Lymphedema
• Removal of lymph nodes/lymph node biopsy
• Radiation
• Trauma
• Malignancy
• Infection (acute or chronic)
• DVT – Deep Vein Thrombosis
• CVI ‐ Chronic Venous Insufficiency

24

STAGES OF LYMPHEDEMA

• STAGE 0 – pre‐lymphedema, latent or subclinical

lymphedema

• Most likely no symptoms, but there is known damage to the

system

• STAGE 1 – reversible
• Visible swelling that comes and go, pitting edema, elevation is

helpful

• STAGE 2 – spontaneously irreversible
• Visible swelling, visible skin changes, fibrosis of skin and

underlying tissue

• Will not reduce on its own, but can still respond to treatment
• STAGE 3 – lymphostatic elephantiasis
• Severe edema and fibrosis, will respond mildly to treatment,

especially compression 25

LYMPHEDEMA

• May occur gradually or acute onset
• Usually develops slowly and progressively
• Sudden and painful onset may be a sign of malignant

lymphedema

• Most commonly develops within the first two years following

breast cancer surgery

• Important to treat early for maximal benefit
• The exact pathology remains unknown (in the absence
• f a known injury to lymphatic system)
• Lymphedema may result in a chronic, progressive

inflammatory reaction, or may be caused by inflammatory cells and reactions. 26

LYMPHEDEMA

• Signs and symptoms
• Pressure or heaviness of a limb
• Visible swelling
• Peau d’orange
• Change in fit of clothing
• Pain
• Tingling
• Infections (cellulitis)
• Fibrosis
• Decreased quality of life

***THERE IS NO CURE FOR A TRUE LYMPHEDEMA!! ***WE MUST FOCUS ON MANAGEMENT

27

INFLAMMATION

• Is part of the complex biological response of body

tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molecular mediators.

• The function of inflammation is to eliminate the initial

cause of cell injury, clear out necrotic cells and tissues damaged from the original insult and the inflammatory process, and initiate tissue repair.

• The signs of inflammation are heat, pain, redness,

swelling, and loss of function

• The signs of infection are heat, pain, redness/rash,

swelling, fever

28

INFECTIONS

• With lymphedema there is a higher risk of infection

due to the inability of the lymphatic system to remove proteins, cellular debris and skin irritants

• Recurrent swelling and infections can also cause

long term changes to the lymph vessels and nodes, causing further fibrosis and further potential for infection

• Cellulitis (bacterial skin infection) is very common

with lymphedema

29

INFECTIONS

• Signs of cellulitis:
• Redness or rash like symptoms
• Irregular borders and fast expansion
• Increased skin temperature
• Visible swelling at site
• Fever
• Pain

***Skin care education!!!*** ***Go see your doctor immediately!!***

30

FIBROSIS

• Fibrosis, or scarring, of tissue and skin is an

important factor that must be addressed with all types of edema

• Increased protein accumulation underneath the skin

causes scarring

• Decreased elasticity and mobility of the skin causes an

increase of collagen production

• All of this excess connective tissue makes it harder for

tissue to move and fluid to flow, leading to more problems

31

QUESTIONS?

• Does this help us understand that there are often

multiple types of “swelling” present following injury and surgery?

• Treatment beyond RICE or PRICE
• Protection from further injury/Pressure
• Rest
• Ice
• Compression
• Elevation

32

COMPLETE DECONGESTIVE THERAPY

TREATMENT GOLD STANDARD

• Four components:
• 1. Manual Lymph Drainage (MLD) – manual therapy to

decongest swollen area

• 2. Compression – either with multi layer bandaging or

garments

• 3. Exercise – now proven in prevention and to decrease

lymphedema progression

• 4. Education – skin and nail care, infection prevention,

long term management

33

STAGES OF TISSUE HEALING

• INFLAMMATORY
• UP TO 5 DAYS
• Body produces white

blood cells, plasma proteins and cytokines into tissue

• Very basic exercises
• FIBROBLASTIC

REPAIR/

• PROLIFERATION
• 5 DAYS – 2 MONTHS
• New collateral blood

and lymph vessels form

• Fibroblasts are laying

down immature collagen

• Most important

phase of rehab

• Prevent atrophy and

begin exercise

• REMODELING AND

MATURATION

• MONTHS TO YEARS
• Collagen matures and

becomes firm and fibrotic

• Goal is to optimize

tissue function through exercise and manual therapy 34

MANUAL THERAPIES

• Manual Lymph Drainage (MLD)
• Scar management
• Stretching/trigger point work
• Joint mobilizations
• Compression (multi‐layer) bandaging

35

MANUAL LYMPH DRAINAGE

• Manual technique that is NOT massage
• Goal is to mobilize fluid
• Decreasing sympathetic nervous system

activity(pain)

• Increasing parasympathetic nervous system activity

(relaxation)

• Increase in venous return of the superficial venous

system

36

MANUAL LYMPH DRAINAGE: CONTRAINDICATIONS

• ABSOLUTE:
• CHF
• Acute infection
• DVT (acute)
• Renal failure
• Acute UNKNOWN

inflammation

• Acute malignancy
• RELATIVE:
• Bronchial asthma
• Hyperthyroidism
• Hyper/Hypotension
• Treated/active cancer
• Patient tolerance

37

MANUAL LYMPH DRAINAGE

• Very gentle, light manual technique
• Composed of two phases:

1. Active/working phase

• Applying a STRETCH to the lymph vessels and underlying

subcutaneous tissues

• Moving the skin over underlying tissue; NOT moving

the hands on the skin

• Moving fluid in the proper direction

2. Rest phase

• “snap back” of the tissue allowing fluid absorption and

propulsion centrally

• Clear system proximally first
• Mobilize fluid distal to proximal

38

MANUAL LYMPH DRAINAGE

• Used on body areas that are very congested; at or

proximal to surgical area

• Used around, and later over, incisions to promote

scar mobility and decrease pain

• Sometimes use of SLIGHTLY HEAVIER pressure is

warranted if an area is very fibrotic and stiff

• Repetition is key with fluid mobilization
• At least 5 repetitions at each site before moving to

next hand position

39

STATIONARY CIRCLES

• Used to stimulate regional lymph nodes and can be

performed over all aspects of the body

• Very relaxing stroke
• It is a stationary stroke: Start at proximal area, then lift

and move hands to next position distally for clearing

• Working phase – therapist places palmar aspect of

fingers and distal palm flat on skin surface. Light pressure stretches perpendicular to lymph collectors (to open capillaries) and then parallel to the collectors to move fluid towards regional lymph nodes

• Resting phase – do not release hands from skin, but

pressure is completely released allowing skin to ‘snap back’ to starting position, completing the circular motion

40

STATIONARY CIRCLES

Action phase = dark arrow Rest phase = lighter arrow Whole motion appears circular, however the arrow should be pointing straight up towards inguinal regional lymph nodes because that’s where the action portion ends. **Do not pull the skin back up! 41

PUMPS

• Used to move fluid on larger areas of the body
• It is a dynamic stroke; begin distally and move

proximally

• Working phase – the palm and web space between the

thumb and second finger are contacting skin and performing the work. Action comes from the wrist pushing the skin proximally

• Resting phase – the release comes from the wrist

pivoting up and removing the palm from the skin allowing the ‘snap back’ underneath the palm. The fingertips maintain contact, and now pointing downward establishing the next starting position.

42

PUMPS

Action phase = dark arrow Rest phase = light arrow The web space is directing the motion

• f the fluid.

43

Effect of Physical Methods of Lymphatic Drainage on Postexercise Recovery of Mixed Martial Arts Athletes.

• Eighty MMA athletes were allocated to 4 groups: MLD, the

BF (Bodyflow) device, DOT (deep oscillation therapy), and the control group.

• The application of MLD reduced the post‐exercise blood

lactic acid concentration and post‐exercise muscle tension.

• Findings indicate that lymphatic drainage methods,

whether manual or using electro‐stimulation and DOT, improve post‐exercise regeneration of the forearm muscles

• f MMA athletes.

***These methods can be used optimize training effects and reducing the risk of injuries of the combat sports athletes.

44

SCAR MASSAGE

• Perform MLD on both sides of the scar, inward

towards scar

• Perform stationary circles over incision
• Myofascial work beginning superficially and

progressing to deeper work per patient tolerance and lack of reflexive pain and/or swelling

• Cross friction only if necessary

45

TRIGGER POINT WORK

• NECESSARY type of manual treatment due to significant

guarding, fibrosis and shortening of muscles

• Very poor patient tolerance, and often leads to MORE

reflexive guarding

• Use length of thumb or lateral aspect of palm at fifth

metatarsal

• Start with minimal pressure and stop BEFORE increased

pain of patient

• Hold 10‐60 seconds, gently release, repeat as necessary
• Start work proximally and progress distally, but

promote fluid movement distal to proximal

46

TRIGGER POINTS

47

ASSESSMENT AND TREATMENT OF LYMPHEDEMA RISK AND TREATMENT ACROSS VARIOUS PATIENT POPULATIONS

• Post surgery patients
• Oncology
• Joint Replacement
• Arthroscopy/Repairs
• Orthopedic patients
• Acute or chronic inflammatory disorders and arthritis
• Casting/immobility
• Diabetes/Wounds/Chronic Venous Insufficiency
• Chronic pain patients

48

EVIDENCE BASED MEDICINE: WHAT IS IT AND WHAT IT ISN’T

Best Available Research EBM Clinical Individual Expertise Patient Needs

Sackett, et al.

49

PATIENT POPULATION

• Why is this patient being referred?
• How does this patient present to us?
• What does treatment consist of?

50

WHAT DOES ANY TREATMENT LOOK LIKE?

• Get patient to relax and trust you
• Manual therapy
• ROM exercises
• Muscle pump/Isometric exercises
• Strengthening exercises
• EDUCATION!
• Avoid soreness and lactic acid build up!

51

THE ONCOLOGY PATIENT

• Breast cancer
• Pelvic cancers
• Melanomas
• Head and neck cancers
• Radiation therapy patients

52

BREAST CANCER:

WHY IS THIS PATIENT BEING REFERRED?

• Pain
• General Deconditioning
• Postural Dysfunction
• ROM issues
• Frozen shoulder
• Needs to get into RT position
• Post‐op swelling/Lymphedema Stage 0
• Sentinel Lymph Node Biopsy (SLNB) = 5‐17%
• Axillary Lymph Node Dissection (ALND) = 15‐53%
• ALND and RT and/or Chemo = >50%
• BMI < 25 kg/m2 = 8% at 5 years post treatment; BMI >

35 kg/m2 = 17% at 5 years post treatment

53

BREAST CANCER:

PATIENT PRESENTATION

• Incision at breast
• Incision at axilla
• Expander placement
• Drains
• May be very red/burnt from radiation
• Instructed not to raise arms above 90 degrees
• Significant protective posturing and pain
• Swelling at breast, chest wall to scapula, axilla, upper

arm to full arm

• Seromas
• Cording within affected quadrant

54

CORDING

• Axillary web syndrome
• Thick and rope like
• Thin like a guitar string
• Believed to be scarring and inflammation of the

connective tissue that surrounds lymph vessels, as well as blood vessels and nerves

• Location anywhere from site of surgery at axilla to

hand or chest wall

• Painful and restricts motion

55

CORDING

56

BREAST CANCER:

PATIENT TREATMENT

• Get patient to relax and trust you
• Diaphragmatic breathing
• Gentle touch with MLD
• Manual Therapy
• MLD – where is the swelling?
• We may avoid affected axilla
• Start proximally and slowly move distally, but move fluid

distal to proximal

• Gentle scapular PNF
• Trigger Point Work – Gently!!
• Scar massage

57

BREAST CANCER:

TREATMENT FOR CORDING

• Soft tissue work at distal most aspect of palpable

cord

• MLD
• Gentle mobilization of cord 
• PROM into painful range with more aggressive mobility
• AAROM
• Foam roll – snow angels, butterfly wings, UE flexion
• Seated stretches on table
• Wand exercises
• Standing stretches – multi angle pec stretch
• AROM
• Neural/lymphatic vessel glides
• “bye bye” exercise

58

BREAST CANCER:

PATIENT TREATMENT (CONTINUED)

• ROM exercises
• PROMAAROMAROM
• Perform supine for scapular stabilization or seated/standing in

front of a mirror

• Wand exercises, pulley exercises, seated next to table exercises
• Muscle pump exercises/isometrics
• Shoulder isometrics ‐ ENTIRE KINETIC CHAIN
• Also wrist, elbow, scapula, trunk, etc
• Strengthening exercises
• Have patient generate her own resistance
• Theraband
• Weight training – starting very light and progressing slowly
• CKC exercises of upper quarter?
• Patient may resume whatever exercise they prefer if guided

properly and slowly

***Encourage patient to wear compression sleeve!!! 59

BREAST CANCER: PATIENT TREATMENT (CONTINUED)

• EDUCATION – National Lymphedema Network

(NLN) Position Papers.

• Healthy habits
• Air travel
• Risk reduction
• BCRL screening and early detection
• Consider cardiotoxicity due to chemo, lowered

immune response, fatigue, chemo induced neuropathy, chemo brain, radiation related changes, etc

60

BREAST CANCER:

PATIENT TREATMENT

• Be careful regarding the use of modalities
• Ice
• Moist heat
• Ultrasound
• Electric Stimulation
• Laser

61

RADIATION THERAPY

• External Beam Radiation Therapy (EBRT)
• Brachytherapy
• Targeted treatments (gamma knife/cyberknife)
• Traditional EBRT is high energy rays used to kill

lingering cancer cells

• Side effects described as a sunburn

***INFLAMMATION!!!!!!

Laying down more collagen causing fibrosis and scar tissue

62

Physical Activity and Lymphedema (the PAL Trial): Assessing the safety of progressive strength training in breast cancer survivors.

• Strength training 2x/week reduced the incidence of

lymphedema exacerbations that required further treatment by HALF!

• The number and severity of lymphedema

symptoms were reduced by self, subjective report, with improvements in quality of life.

63

Weight lifting in women with breast‐cancer‐related lymphedema.

• 1 year weight training program
• 13 weeks of supervised instruction at a gym, then 9 months

unsupervised

• The proportion of women who had an increase of 5% or

more in limb swelling was similar in the weight‐lifting group (11%) and the control group (12%). As compared with the control group, the weight‐lifting group had greater improvements in self‐reported severity

• f lymphedema symptoms and upper and lower body

strength and a lower incidence

• f lymphedema exacerbations as assessed by a

certified lymphedema specialist.

• In breast‐cancer survivors with lymphedema, slow

progressive weight lifting had no significant effect on limb swelling and resulted in a decreased incidence of exacerbations of lymphedema, reduced symptoms, and increased strength.

64

A Randomized Trial on the Effect of Exercise Mode on Breast Cancer‐related Lymphedema.

• Exercise mode of resistance training and aerobic training.

Lymphedema remained stable in both groups, with no significant differences between groups noted in lymphedema status. The resistance‐based exercise group increasing strength compared with the aerobic‐based exercise group. The aerobic‐based exercise group reported a clinically relevant decline in number of symptoms postintervention and women in both exercise groups experienced clinically meaningful improvements in lower‐body endurance, aerobic fitness.

• Participating in resistance‐ or aerobic‐based exercise did not

change lymphedema status but led to clinically relevant improvements in function and quality of life. As such, personal preferences, survivorship concerns, and functional needs are important and relevant considerations when prescribing exercise mode to those with secondary lymphedema. 65

Long term effects of manual lymphatic drainage and active exercises on physical morbidities, lymphoscintigraphy parameters and lymphedema formation in patients

• perated due to breast cancer: A clinical trial
• 106 women undergoing radical BC surgery. Women

were allocated to perform AE or MLD, 2 weekly sessions during one month after surgery.

• Age ≤39 years was the factor with the greatest

association with lymphedema. In women with age ≤39 years, BMI >24Kg/m2 was significantly associated with lymphedema.

• In younger women, obesity seems to be the major

player in lymphedema development and, in older women, improving muscle strength through AE can prevent lymphedema. In essence, MLD is as safe and effective as AE in rehabilitation after breast cancer surgery.

66

Combining Manual Lymph Drainage with Physical Exercise after Modified Radical Mastectomy Effectively Prevents Upper Limb Lymphedema.

• In the PE group, patients started to undertake remedial

exercises and progressive weight training after recovery from anesthesia. In the MLD group, in addition to receiving the same treatments as in the PE group, the patients were trained to perform self‐MLD on the surgical incision for 10 min/session, 3 sessions/day, beginning after suture removal and incision closure

• Compared to those in the PE group, patients in MLD

group experienced significant improvements in scar contracture, shoulder abduction, and upper limb circumference.

• Self‐MLD, in combination with physical exercise, is

beneficial for breast cancer patients in preventing postmastectomy scar formation, upper limb lymphedema, and shoulder joint dysfunction.

67

PELVIC CANCER:

WHY IS THIS PATIENT BEING REFERRED?

• Pain
• Impaired ROM
• Gait dysfunction
• Fatigue and general deconditioning
• Post‐op swelling

68

PELVIC CANCER:

PATIENT PRESENTATION

• Large abdominal incision vs laparoscopic incision,

and possible inguinal incision

• Protective posturing and pain/muscle guarding
• Antalgia
• Balance dysfunction
• Swelling throughout abdomen, genitals, proximal

LEs

69

PELVIC CANCER:

TREATMENT

• Diaphragmatic breathing
• Manual therapy and scar massage
• MLD towards axilla, avoid inguinal regional lymph nodes

and bypassing abdomen

• ROM
• Prone lying
• Hip flexor stretches
• Muscle pump and isometric exercises
• Quad, HS, glut sets and ankle pumps
• Abdominals
• Kegels

70

PELVIC CANCER:

TREATMENT

• Strength training
• PREs
• Begin with bilateral work, slowly progressing towards

unilateral work if necessary

• Avoid plyometrics
• Gait and balance training
• Education/HEP

***Compression garments for trunk or LEs

71

Incidence, risk factors and estimates of a woman’s risk of developing secondary lower limb lymphedema and lymphedema‐specific supportive care needs in women treated for endometrial cancer.

• 13% of women developed lymphedema. Risk varied

markedly with the number of lymph nodes removed and, to a lesser extent, receipt of adjuvant radiation or chemotherapy treatment, and use of nonsteroidal anti‐ inflammatory drugs (pre‐diagnosis).

• The absolute risk of developing lymphedema was 30%‐

50% for women with 15+ nodes removed and additional risk factors

• Lymphedema is common; experienced by one in eight

women following endometrial cancer. Women who have undergone lymphadenectomy have very high risks

• f lymphedema and should be informed how to self‐

monitor for symptoms.

72

Lower‐extremity lymphedema following management for endometrial and cervical cancer.

• We identified 165 (135 endometrial cancer and 30

cervical cancer) subjects. In the entire population, 3.6% subjects developed post‐

• perative lymphedema.
• Supplementary analyses revealed that a BMI

>35 kg/m(2) and possessing numerous (≥3) co‐ morbidities significantly correlated with the manifestation of lower‐extremity lymphedema.

73

Low rate of lymphedema after extended pelvic lymphadenectomy followed by pelvic irradiation of node‐ positive prostate cancer.

• 22 patients treated with surgery, EBRT,

brachytherapy, hormone therapy. 6 patients (27%) experienced grade 1 lymphedema, 2 patients (9%) had grade 2 lymphedema, and none had grade 3 or 4 based on the CTC Common Toxicity Criteria Scale 4.0. 3 patients required treatment with compression stockings.

• There is a low incidence of lymphedema in prostate

cancer patients who have high risk positive nodes and have undergone pelvic lymph node dissection

74

MELANOMA:

WHY IS THIS PATIENT BEING REFERRED?

• Pain
• ROM and strength deficits
• Fatigue and general deconditioning
• Post‐op swelling

PATIENT PRESENTATION:

• Incision at tumor site and regional lymph nodes
• Guarding and ROM protective posturing

TREATMENT: to include MLD to proximal lymph nodes and for scar management

75

Prospective Assessment of Lymphedema Incidence and Lymphedema‐associated Symptoms following Lymph Node Surgery for Melanoma.

• Twelve months after axillary surgery, 9% had Limb Volume

Change (LVC) 5‐10%, and 13% had LVC >10%.

• Twelve months after inguino‐femoral surgery, 10% had LVC

5‐10%, and 13% had LVC >10%.

• There was a significant 7‐ to 9‐fold increase in symptoms for

patients with LVC greater than >10% compared to those with LVC <5%, lymph node dissection versus SLN biopsy

• LVC greater than 5% is common at 12 months following

nodal surgery for melanoma and is associated with symptoms.

76

THE JOINT REPLACEMENT PATIENT/ SURGERY INTO JOINT CAPSULE: WHY IS THIS PATIENT BEING REFERRED?

• ROM deficits
• Strength training
• Gait and balance training
• Post‐op pain and swelling

77

THE JOINT REPLACEMENT PATIENT: PATIENT PRESENTATION

• Significant soft tissue damage and damage of

lymph vessels

• Swelling, which is dependent in nature
• Usually significant and grossly affects entire extremity
• Impaired ROM and contractures
• Strength deficits
• Gait and balance deficits

78

THE JOINT REPLACEMENT PATIENT:

TREATMENT

• Diaphragm breathing
• Manual Therapy – begin gently and progressively

increase pressure

• Massage and MLD
• Scar mobility
• Trigger point work
• Joint mobilizations
• PROM
• Compression bandaging?
• AAROM and AROM exercises
• Muscle pump exercises/isometrics
• LE – full kinetic chain
• UE – full kinetic chain
• Keep isometrics as part of HEP for long term muscle

pump activity

79

THE JOINT REPLACEMENT PATIENT:

TREATMENT

• Strength training
• PREs – be cognizant of weight and theraband placement
• Begin with bilateral and progress to unilateral work
• OKC vs CKC
• Gait and balance training
• Return to sport
• HEP and long term education
• Does this patient need a compression stocking?

80

Randomized trial investigating the efficacy of manual lymphatic drainage to improve early outcome after total knee arthroplasty.

• A significantly greater active knee flexion was

achieved in the MLD group when compared with the control (no MLD) group at the final measure prior to hospital discharge (day 4 post surgery) and at 6 weeks post surgery.

• MLD in the early postoperative stages after TKA

appears to improve active knee flexion up to 6 weeks post surgery, in addition to conventional care.

81

STICKS study – Short‐sTretch Inelastic Compression bandage in Knee Swelling following total knee arthroplasty – a feasibility study

• No complications noted
• Improved Oxford knee scores
• There was no significant difference

between groups regarding knee swelling, knee range of motion, visual analogue pain score, complications and length of stay.

82

THE ARTHRITIC/ORTHOPEDIC/CHRONIC PAIN PATIENT: WHY IS THIS PATIENT BEING REFERRED?

• Pain
• Loss of function

PATIENT PRESENTATION:

• Strength deficits and muscle atrophy
• Impaired ROM
• Antalgia or compensatory gait strategy

TREATMENT: OA/RA related pain and swelling would benefit from MLD as part of clinical and home program

83

DIABETES/WOUNDS/CVI:

WHY IS THIS PATIENT BEING REFERRED?

• Gait and balance dysfunction
• Deconditioning
• Peripheral neuropathy
• Wound care
• Swelling

PATIENT PRESENTATION:

• Swelling of LEs that is not symmetrical
• SYMMETRICAL SWELLING IS AN INDICATION OF CARDIAC

DISEASE

• Chronic inflammation and skin breakdown/wounds due to

decreased ability to remove excess fluid

• Long term dilation of venous and lymph vessels continue to

make valves insufficient

84

COMPRESSION

• REBECCA ELWELL
• The use of compression bandaging in the intensive

phase of treatment is indicated to reduce distortion, lymphorrhea, and achieve wound healing.

• CVI specific

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DIABETES/WOUNDS/CVI:

TREATMENT

• Teach diaphragmatic breathing for improved fluid

return with leg elevation

• Exercise
• Walking is best for long term muscle pump action
• Compression important for these patients for long

term management (remain aware of DVT)

• Manual therapy as BASIC part of clinical treatment

but more for a HEP ***SKIN CARE***

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Venous flow during manual lymphatic drainage applied to different regions of the lower extremity in people with and without chronic venous insufficiency: a cross‐ sectional study.

• MLD was applied by a certificated physical therapist to

the medial and lateral aspects of the thigh and leg. Blood flow velocities in the femoral vein, great saphenous vein, popliteal vein and small saphenous vein at baseline and during MLD, measured by duplex ultrasound.

• Flow volume in the femoral vein increased from

baseline when MLD was applied to the medial and lateral aspects of the thigh. MLD had a positive effect

• n venous blood flow regardless of whether it was

applied to the medial or the lateral aspect of the leg.

• MLD increases blood flow in deep and superficial veins.

MLD should be applied along the route of the venous vessels for improved venous return.

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OTHER DIAGNOSES

• RSD/CRPS
• Stroke
• Fibromyalgia
• High impact sports
• Headaches and migraine
• Amputation

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LBS MLD TREATMENT PROTOCOL

Non‐oncology patients Determine treatment area and regional lymph nodes (RLN) Stimulate RLN with stationary circles Clear the limb by performing stationary circles at most proximal area of injury towards RLNmove hands distally and perform stationary circles towards RLN continue moving distally until you reach the end of the limb/treatment area Mobilize fluid distal to proximal now with pumps or stationary circles back towards RLN

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LBS MLD TREATMENT PROTOCOL

Oncology Patients Determine treatment area, RLN, and secondary RLN – the closest group of lymph nodes that have NOT been affected by treatment Stimulate the affected RLN (assuming no skin breakdown) AND secondary RLN with stationary circles Perform stationary circles STARTING at affected RLN and move TOWARD secondary/unaffected RLN Clear the limb by performing stationary circles at proximal area of swelling move hands distally covering entire swollen area Perform pumps or stationary circles to mobilize fluid from distal to proximal towards UNAFFECTED RLN, BYPASSING affected RLN 90

EXERCISES

• Diaphragmatic breathing
• ROM – begin proximally and move distally
• Posture and Stretching – want to have good muscle

and tissue flexibility to promote fluid movement

• Foam roll for posture
• Isometrics for muscle pump activity
• Proximal stability
• Peripheral strengthening
• Open chain vs. closed chain
• Lymphatic and neural mobilization exercise
• “Bye Bye” exercise
• Sciatic/femoral nerve glide

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PHARMACOLOGICAL CONSIDERATIONS

• Diuretics – removing fluid only. There is no removal
• f proteins.
• Not indicated for long term use
• May help for very short time in an incredibly swollen

limb or with lymphorrhea

• Benzopyrones – increase macrophage activity for

protein breakdown

• Cause liver toxicity
• Not FDA approved

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CASE STUDIES

• SK ‐ 62 y/o female
• B breast CA ER+ PR+ HER2‐
• Treated with B lumpectomy and R SLNB (5) and L SLNB

(3) followed by Canadian RT protocol

• Presented with 4 incisions, post operative B breast

swelling and referred for lymphedema education and sleeves

• Very active; flies and hikes at altitude annually, yoga,

TRX, weight training

• Benefitted from MLD for chest swelling with use of B

axilla and inguinal LNs

• Wears B sleeves for activity and night garments when

staying at altitude; does not wear compression bra

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CASE STUDIES

• JH – 55 y/o female
• R breast CA ER‐ PR‐ HER2‐
• Treated with R mastectomy and ALND (7, 2+) and chemo; no

reconstruction

• R UE post surgical swelling and L UE swelling secondary to

port placement

• Had prophylactic L mastectomy
• Wore B compression sleeves
• Recurrence 6 months later, large tumor deep in chest wall.

Surgery to remove tumor, part of pectoral mm and ALND (7, 1+) followed by RT

• Severe burn, had to stop all PT, able to resume 6 weeks later

to work on scar tissue, fibrosis, mild R upper arm lymphedema

• Wears B sleeves to fly, R UE sleeve intermittently with

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CASE STUDIES

• MH – 74 y/o female
• Congenital L LE lymphedema x30 years with history of

cellulitis (x3) which she self managed for years with self MLD, self bandaging, compression pump use and thigh high compression stocking 40/50 mmHg

• Increased swelling and lower abdominal redness

following air travel 1 year prior

• L THR approx. 3 year ago and begins having increased

pain and girth after 3 months treatment

• Has L TH revision, cleared to resume CDT after 4 weeks,

has not yet begun PT. Just resumed wearing stocking and pump

• Progressive, significant L LE weakness and antalgia; and

progressive swelling

• Discharge to begin aquatic PT

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COMPRESSION: BANDAGES AND GARMENTS

• Necessary component of treatment due to the

change in elasticity of lymphatic vessels

• Improves the effectiveness of muscle pump activity
• Stronger distally and decreases gradually proximally
• Continues to promote lymphatic and venous return

by improving effectiveness of valve function

• Helps maintain decongestive effect of MLD and

prevents re‐accumulation of fluid

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COMPRESSION BANDAGES

• Multi‐layer bandages required to treat a true

lymphedema

• Short stretch bandages preferred due to the higher

working pressure (allows 60% elasticity) and low resting pressure vs ACE bandage (140% elasticity) which has a high resting pressure and low working pressure

• 1‐2 layers in a temporary lymphedema MAY be

sufficient

• Longer wear time = better results
• Part of HEP – involve caregiver if able

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COMPRESSION GARMENTS

• Better long term option
• Compression classes:
• CCI: 20‐30 mmHg
• CCII: 30‐40 mmHg
• CCIII: 40‐50 mmHg
• CCIV: >60 mmHg
• Graded compression – stronger distally
• Anything that is available OTC is non‐medical

strength

• Usually anywhere from 8‐12, 12‐15, or even 15‐20

mmHg

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COMPRESSION GARMENTS

• Most likely recommend CCI for prevention in oncology

patients

• For performing exercises and HEP
• For air travel
• For strenuous or repetitive activity
• Recommended for daily wear for at least 4 weeks for

subclinical swelling

• CC1 for treatment in orthopedic patients
• Long term wear for those who present with clinical

lymphedema

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DOCUMENTATION

• SUBJECTIVE REPORT
• HPI/PMH – especially infection history
• Time of onset?
• Pain scale
• Altered sensation
• Social history
• Questionnaire
• SF‐36
• LLIS – Lymphedema Life Impact Scale
• Offers a subjective scale for physical, psychosocial,

and functional concerns on a scale of 1‐5

• Any swelling self management?

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ICD‐10 codes

• Secondary lymphedema = I89.0
• Post mastectomy lymphedema = I97.2
• Localized edema = R60.0
• Edema, unspecified = R60.9
• Effusion, unspecified joint = M25.40

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DOCUMENTATION

• OBJECTIVE (SEE HANDOUT)
• Edema circumferential measurements with measuring

tape

• Pitting edema grading
• Stemmer sign
• Testing for skin changes and thickening of skin at the base
• f the toe or finger
• “Can the skin easily be pinched and lifted”?
• Wounds
• Skin integrity/fibrosis
• Scars and scar tissue
• Homan’s sign
• Pulses
• ROM and strength measurements

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CIRCUMFRENTIAL MEASUREMENTS

• Measure same way and place each time
• Measure frequently, but not each visit

1. Base of MCP/MTP joints 2. Mid foot/hand 3. Ulnar styloid/Medial Malleoli 4. 2 points forearm/leg (find distinguishing mark) 5. Elbow/knee joint 6. Mid upper arm/thigh 7. Proximal most part of limb (axilla and groin)

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PITTING EDEMA SCALE

O’Sullivan, S.B. and Schmitz T.J. (Eds.). (2007). Physical rehabilitation: assessment and treatment (5th ed.). Philadelphia: F. A. Davis Company. p.659

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DOCUMENTATION

• “UTILIZING TECHNIQUE”

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DOCUMENTATION: ASSESSMENT AND PLAN

• Is the patient getting better? Subjectively and
• bjectively
• Is swelling changing? Is it moving?
• Is skin integrity changing?
• Is patient compliant?
• Is swelling affecting function?
• Are we changing the way we’re addressing swelling

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LONG TERM MANAGEMENT AND PREVENTION

• How do we prevent future exacerbations?
• Remind patients that even if they do everything right,

exacerbations happen

• Manage expectations
• Infection prevention
• Optimize patient compliance
• Make sure a treatment plan includes all 4 aspects of

treatment

• Have oncology patients keep a measurement diary to

monitor subtle changes and trends

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SKIN CARE

• Keep area clean and dry thoroughly
• Any cuts or abrasions should be washed, dried, and

covered with antibacterial cream and bandage

• Cut toenails professionally
• Avoid limb constriction and punctures
• Use sunscreen
• Use insect repellent
• Use electric razors
• Avoid extremes in temperature for prolonged periods
• f time
• Moisturize – no added dyes, perfumes, chemicals

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REFERENCES

LYMPHOLOGY ASSOCIATION OF NORTH AMERICA

• www.clt‐lana.org

NATIONAL LYMPHEDEMA NETWORK

• www.lymphnet.org

AMERICAN CANCER SOCIETY

• www.cancer.org

LYMPH NOTES

• www.lymphnotes.com
• LYMPHATIC EDUCATION AND RESEARCH NETWORK
• www.lymphaticnetwork.org

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LYMPHEDEMA CERTIFICATION PROGRAMS

• THE VODDER SCHOOL INTERNATIONAL
• THE ACADEMY OF LYMPHATIC STUDIES
• THE NORTON SCHOOL
• KLOSE TRAINING
• CASLEY‐SMITH INTERNATIONAL
• INT’L LYMPHEDEMA AND WOUND TRAINING

INSTITUTE

• LEDUC METHOD

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Role of physiotherapy and patient education in lymphedema control following breast cancer surgery.

• The patients were divided into three groups: Group A who received

neither education nor physiotherapy post surgery; Group B, who received an educational program on BCRL between Days 0 and 7 post surgery; and Group C, who received an educational program on BCRL between Days 0 and 7 post surgery, followed by a physiotherapy program.

• During the follow‐up 15.4% developed lymphedema, 18.6% in Group A,

15.0% in Group B, and 7.7% in Group C. The independent risk factors for BCRL included positive axillary lymph node invasion, a higher (>20) number of dissected axillary lymph nodes, and having undergone radiation therapy, whereas receiving an educational program followed by physiotherapy was a protective factor against BCRL

• Patient education that begins within the first week post surgery and is

followed by physiotherapy is effective in reducing the risk of BCRL in women with breast cancer!

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QUESTIONS?

THANK YOU! lisa@oasisptwellness.com

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