Introduction to Lymphedema Management
PTA 205L Complex Medical Dysfunctions Lab

Instructional Use Statement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment.

Contact howardc@lanecc.edu for permissions

Overview of Lymphedema

Anatomy and Physiology Review

What is the lymphatic system - tutorial (requires flash player)

Video Summary of Lymphedema and Treatment

1. Fluid, proteins, fat and other cellular debris is transported to the venous system via the lymphatic system
2. Lymphatic fluid is transferred from the periphery to centrally-located ducts for filtration prior to entering the venous system
3. If the water and protein content load exceeds capacity of the lymphatic system, then edema results. (Volume > transport capacity)
4. High protein fluid accumulation in interstitial spaces = lymphedema

Classifications of Lymphedema

Primary = congenital. Defects in the system at birth result in chronic fluid accumulation

Secondary = acquired. Common precursors are lymph node resection, hx of radiation therapy, trauma, venous insufficiency and infection.

Severity of lymphedema is graded and documented in stages:

• Stage 0: subjective reports of limb heaviness/aching; no increase limb volume detected
• Stage I: reversible, sxs decrease with elevation of the affected extremity, pitting edema
• 1+ pitting = slight edema
• 2+ pitting = slight indentation is visible from finger pressure
• 3+ pitting = deep fingerprint is visible from finger pressure for 5-30 seconds
• 4+ pitting = limb swelling 1-2 x normal size
• Stage II: irreversible, no change in sxs with elevation, tissue fibrosis, decreased pitting edema from finger pressure
• Stage III: irreversible, elephantitis

Lymphedema Signs and Symptoms

• mild warmth
• swelling
• pain
• trophic changes (skin darkening)
• venous ulceration (skin infection)
• decreased ROM
• loss of functional mobility/decreased independence with ADLs (dressing, grooming, etc)

Interventions for Lymphedema

Also referred to as Complete Decongestive Therapy (CDT)

• Manual lymph drainage (MLD)
• Compression Bandages
• Vasopneumatic Compression
• Patient education (skin care, therapeutic exercise, self-massage, compression garment wear and care)

General Contraindications for CDT

• acute infection
• active cancer
• congestive heart failure (risk fluid overload into circulatory system)
• DVTor hx/risk of thrombus (clot) formation
• hx radiation therapy without MD clearance for CDT

Role of the PTA

• Treatment of lymphedema is considered a clinically complex. PTs and PTAs seek additional continuing education, supervised clinical experience, study group and/or mentoring when providing treatment to this population
• Speciality certifications (CDT) are available to PT and PTAs through nationally-recognized organizations
• With proper training and collaboration with a supervising PT, PTAs can
• apply compression bandages
• measure and document limb girth (pre-post bandaging/pneumatic compression, size for compression garments)
• measure and document volumetric displacement
• perform manual lymphatic drainage
• apply intermittent compression using pneumatic compression devices
• instruct, monitor, and modify therapeutic exercises to facilitate lymphatic flow
• educate patients on effective skin and nail care, activity and environmental restrictions, garment wear and care, and self-massage
• collaborate with the medical team for optimal treatment outcomes
• physician
• nurse
• occupational therapist
• wound care specialist

Complete Decongestive Therapy Overview

Manual Lymph Drainage

• specialized soft tissue mobilization which stimulates lymphatic vessels
• approach is a systematic, mild manual stretching to facilitate flow to main lymphatic vessels. Excessive manual pressure and stretching can strain and damage affected lymphatic vessels.
• strokes are in the direction of lymph flow and/or toward intact lymph pathways
• strokes start proximally to clear the way for drainage from more distal areas
• stroke descriptions include:

• pressure smoothly increases (working phase) and decreases (resting phase)
• Rx sessions typically last 40-90 minutes
• goals of MLD: increase lymphatic flow, increase extensibility of soft tissues, increase collateral lymph vessel formation
• frequency of treatment is 2-5x/week for 2-8 weeks until limb size stabilizes/plateaus

Intermittent Pneumatic Compression

• compressive sleeve is applied to limb; can be single chamber or multiple chamber
• chambers within sleeve are filled with air which provides distal-proximal external compression
• Treatment time, on/off cycle, and amount of pressure is set by the treating PT
• general guidelines are 30-60 mmHg for the UE, 40-80 mmHg for the LE
• extremity is positioned above the heart to facilitate fluid return and to decrease strain to venous system
• close monitoring of the patient for adverse reactions (numbness, tingling, increased edema above sleeve, changes in skin texture at base of sleeve
• contraindicated for patients with hx of nerve disease, abdominal or genital swelling, infection, renal disease/uncontrolled HTN, and/or DVT risk.

Compression Bandaging

• goals of bandaging are
• increase hydrostatic pressure within tissues (push fluid back in)
• increase absorption of fluid by veins
• increase absorption of protein by lymphatics
• principles of compression bandaging follows LaPlace's Law
• Sub-bandage pressure/compression (mmHg) =
• (tension x layers) ÷ (circumference of leg [cm] x width of bandage [cm])
• increase in leg circumference ==> decreased compression (mmHg)
• increase in bandage width ==> decreased compression (mmHg); bandage width typically increases from distal to proximal
• consistently applied tension in the bandage, from distal to proximal, will result in greatest compression at the smallest diameter (e.g., greatest compression is at the most distal/dependent component of the extremity
• bandages are selected which provide low resting, high working pressure (e.g., pressure increases when the limb is moving
• bandages are applied in layers for optimal external pressure
• bandage application approaches include figure-8 and concentric circles
• multiple types of materials are used in bandaging to protect skin and increase working pressure during compression (stockinette, short stretch, foam padding)
• excessive pressure should be avoided: monitor for numbness, tingling, increased swelling/indentation distal to bandage
• sufficient pressure should be applied so that bandage does not shift/move considerably during active movement

Compression Garments

• patients are measured for a compression garment once limb girth measurements are stabilized
• custom and off-the-shelf options are available
• reimbursement, patient compliance (comfort, esthetics, ability to donn/doff) directly influences garment selection
• lifespan of a garment is typically 3-4 months

Exercise

• light ROM exercises while compression is applied to facilitate lymphatic flow
• includes breathing exercises to stimulate proximal lymphatic channels
• movements are proximal to distal so lymph channels may open an allow for flow

Patient Education

• skin care, UV protection/sunburn prevention, monitoring for infection
• skin extensibility - low pH lotions
• patient/family training in self-massage, exercises, compression wrapping
• demonstration and practice donning/doffing garments
• light exercise activity for weight management; no heavy lifting with involved extremity and avoid heat/overheating with exercise
• avoiding tight jewelry or other constricting clothing
• prompt health care providers so compression/trauma from blood pressure/draws on affected side is avoided.
• wear gloves when working on activities where skin is at risk for tears/abrasions

Lab Preparation

Dress in lab clothing which will allow full access to the UE to the axilla and full access to the LE to the groin. Lycra tights/shorts (e.g., UnderArmor) is recommended for students who require extra warmth/layers during lab practice.

Skills to refresh prior lab include:

• vital sign assessment: particularly BP
• girth measurements: choose a bony landmark as a reference point and document the distance from the landmark as you take measurements. Be consistent with units of measure (cm/inches)
•  s/sxs of excessive compression: numbness, tingling, decreased active motion, increased swelling/discoloration distally
• manual contact with lumbrical grip

End of Pre-Lab Preparation