1. Outline
Lymphedema causes & stages
淋巴水腫之物理治療 Conservative therapies for lymphedema
Decongestive lymphatic therapy
Skin care
彰化基督教醫院鹿基分院
Manual lymphatic drainage
黃睦升 Compression therapy
2012-11-04 Self drainage exercise
Benigh & malignant lymphedema
Take home messages
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Causes 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.
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The Causation of Edema
BLOOD
Lymphatic
load
Low-flow
Tissue High-flow edema Safety-valve
Normal =lymphoedema
edema insufficiency
(high protein)
Lymphatic
Transport
LYMPH
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2. Lymphedema Stages of Lymphedema
International Society for Lymphology (Casley-Smith et al. 1985)
Stage 1
Stage 1 : pits on pressure
Definition：An abnormal accumulation of tissue reduced on elevation
proteins , causing edema and chronic inflammation
no or mild fibrosis
within 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 fibrosis
Functional overload of the lymphatic system brawny
Lymph volume exceeds transport capacities Stage 3 : elephantiasis, warts
Also occurs in the face, trunk and external genitalia. skin very thick and leathery
subcutaneous tissue hypertrophied
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Stage 3
CTCAE: lymphedema The most effective treatment?
(Common Terminology Criteria for Adverse Events v3.0)
Includes both objective measures (interlimb discrepancy) and Currently not enough evidence to draw conclusions
subjective assessments. about the best physical therapy to use in the treatment
Grade 1: 5%~10% interlimb discrepancy in volume or of 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 volume secondary 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.
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History of Lymphedema
15,16th century:lymphedema has been known.
The medicine-based evidence is 1936, Vodder:manual lymphatic drainage to treat lymphedema
undeniably 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 of put all techniques together
with his wife (E. Foldi) 1st modern clinic for T’x lymphedema
lymphedema: Complex Decongestive Physiotherapy (CDP)
mild, moderate, or severe 1986, John Casley-Smith:Microcirculation
combine Kubik & Foldi methods
early or late onset Complex Lymphatic Therapy (CLT)
recent or chronic or 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)
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3. Decongestive Lymphatic Therapy Decongestive Lymphatic Therapy
(DLT) (DLT)
Manual Self
Skin Compression Intensive phase
Max. reduction in 7~10 times
Lymphatic Drainage To mobilize the accumulated protein-rich fluid.
Care Therapy (2~4 weeks)
To initiate the reduction of fibrosclerotic tissues.
Drainage Exercise
Goal Maintain phase
To maintain and even improve the results achieved in
intensive phase.
(6~9 months)
Loosen skin remodelling.
?
＊ Intensive phase: repeated after loose skin remodeling
(in maintain phase).
? ＊Each repeated DLT course:↓50% preserved
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Obstruction of lymph vessels
LYMPHOEDEMA
Chronic
inflammation
Excess protein in tissues
REPEATED INFECTIONS
↓Lymphatic load Damaged blood vessels
Spasms & Thrombosis
of Lymphatics
Cellular debris Increased Lymphatic Load
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Skin complications of lymphedema
Skin Care Education
Hyperkeratosis: thickening of the epidermis.
1.Avoid infection and injury Caused by overproliferation of the keratin layer and produces
scaly brown or grey patches.
2.Avoid pressure on the involved extremity
3.Avoid constrictive clothing
4.Avoid vigorous activity
5.Avoid heat
6.Keep skin in good condition- moisture lotion
7.Avoid strong massage
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4. Skin complications of lymphoedema Skin complications of lymphoedema
Lymphangiectasia(lymphangiomata): excessive Papillomatosis: multiple benign
epidermal tumors
dilatation 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.
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Skin complications of lymphoedema
Lymphorrhoea: leakage of lymph
from the skin.
The surrounding skin should be
protected with emollient, and
nonadherent absorbent dressings
should be applied.
Bandages will reduce the underlying
lymphoedema, but needs to be changed
frequently to avoid maceration of the
skin. ↑Lymphatic transport capacity
In the palliative situation, light
bandaging may be more appropriate.
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Initial lymphatic
Effect of MLD
(2,3)
Collecting
lymphatic (5)
1-epidermis
6-deep fascia
8,9-two
adjacent
Vascular & Lymphatic System drainage
regions
Lymphatic System
Mechanically move fluid
into initial lymphatic.
Open valves of collecting
Lymphotome Make initial lymphatic & lymphatic that crossed
& collecting lymphatic pumping watershed.
Watershed
& being emptied repeatedly.
Set up collateral pathway.
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5. Massage Technique MLD techniques
Slowly with control. Casley-Smith: Vodder: four basic strokes
With minimal friction by hands & fingers. The Strokes Stationary circle: for lymph
20-40 µm in diameter node
Nodal massage
Clearing across the Pump technique: for
Massage pressure: <80 g/cm2 (60 mmHg). extremities
watersheds
Higher pressure over watershed, lymph node and fibrosis area. Rotary technique: for trunk
Blocking flow
Clearance of deep trunk Scoop technique: for lower
Massage area should be exposed! areas parts of extremities
When working on the legs observe the pubis and the
genitalia if became edematous, esp. scrotum.
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Drainage pathway & Sequence Drainage pathway & Sequence
Anterior Trunk Posterior Trunk
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Compression Therapy
Multi-layer bandage
Compression garment
↑Lymphatic transport capacity
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6. Multiple channel pneumatic pump Effects of compression
optimal pressure parameters are not been Reduction in capillary filtration by enhanced
established tissue pressure
little or no lasting beneficial effects Shift of fluid into non-compressed parts of the
fail to move lymph into different lymphtic body
quadrant Increase in lymphatic re-absorption and
may damage remaining health lymph vessels stimulation of lymphatic transport
need to combine self massage to the neck & Improve rhythmic lymph pulsation
trunk Breakdown of fibrosclerotic tissue
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Short stretch bandages (in-elastic)
low resting pressure & high working pressure
Addressing specific problems
Graded pressure：decreasing from distal to proximal.
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Bandaging the Head and Facial area
Lymphoedema bandaging for
head, breast and genitalia A 12–16cm wide tubular bandage,
folded in half
Hook-and-loop fasteners for
easy apply.
Pressure:
applied gently and low to prevent paraesthesia or bruising in
irradiated regions.
No compression on neck.
The padding is placed within the tubular bandage.
To increase local pressure: by placing several layers of
35 foam.(fig2.) 36
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7. Compression of the breast
Bandaging the male genitalia-1
A cup shape thick
Cohesive bandage to prevent
foam(1.5-2.5cm): provide
a micro-massage
slippage.
effect(Fig5) Allow for urination.
Gently squeezes the In severe lymphoedema, the penis
fibrosis. and scrotum are also padded with
(Fig6: L’t breast) 3-4cm thick foam.
Foam padding: extended
to underneath the armpit
and overlap the edges of
the bra prevent
tourniquet effect.(Fig7)
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Bandaging the male genitalia-2 Bandaging the male genitalia-3
Foam padding: Primary genital lymphoedema with long-term
at least 2cm thick compression and elevated temperatures in the testicles
anatomically contoured can result in fertility problems.
foam.
Begin with a low level of compression and depending
Female genital on the severity and response.
lymphoedema:
More complex
at least 1cm thick of Patients or their care-givers must learn self-bandaging
custom-made anatomically skills because excess fluid can rapidly accumulate in the
contoured foam external genitalia if treatment is interrupted.
39 Attention to common cellulitis and fungal infection. 40
Male genital oedema Compression Garment
(idiopathic lymphoedema)
Class I : 20-30 mmHg
hypertrophy scar, mild varicose vein
Class II : 30-40mmHg
mild arm lymphoedema
Class III : 40-50 mmHg
severe arm & mild leg lymphoedema
Class IV : >50 mmHg.
severe leg lymphoedema.
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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 <0.5–0.8)
↑Lymphatic transport capacity
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Self Drainage Exercise 消腫運動的基本原則
Improve muscular contractions and joint mobility. 要求自己每天做以達到最好的效果。
不要穿太緊的衣服，以免阻礙淋巴回流。
Reduce muscle atrophy. 需先穿上彈性衣或綁著彈性繃帶時，做消腫運動
才有效果。
一定要按照每項運動的順序，就像按照淋巴引流
Muscular contractions along with the low-stretch 的順序一樣。
bandages provide constant counter pressure to 每項運動不要做太快，慢慢的數1.…2….3….。
keep the lymph fluid moving.
運動不可以太累而讓肌肉酸痛，適量就好。
花費的時間：大約是30分鐘，但是一天若只做
10分鐘也總比都沒有做的好。
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9. Benign & Malignant In later stage, filled with fibrosis and
lymphedema adipose tissue poor result
Benign Malignant
Onset slow acute
Progress slow rapid
Pain (-) (+)
Skin color normal cyanosis
Centrally
No Yes
pronounced
Lower level
compresion or
Treatment only MLD
DLT
options
Combine with
palliative care. 49 50
Take home Message
DLT: skin care, MLD(<60mmHg),
compression therapy, self drainage
exercise.
To reduce lymphatic load: skin care.
To improve lymphatic transport capacity:
MLD
compression therapy
self drainage exercise.
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