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LYMPHEDEMA

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prostate cancer. melanoma. Hodgkin's disease. ovarian cancer. Cushing's disease ... manual lymph drainage/massage. compression garments to reduce and control edema ... – PowerPoint PPT presentation

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Title: LYMPHEDEMA


1
LYMPHEDEMA
  • Eden Wheeler, M. D.
  • ROCKHILL ORTHOPAEDICS
  • Physical Medicine and Rehabilitation

2
What is Lymphedema ?
  • Swelling of a body part, usually a limb, due to
    accumulation of lymph fluid from obstructed flow
    of the lymphatics
  • Primary lymphedema is due to a congenital
    deformity of the lymphatic system
  • Lymphedema congenita present at birth
  • Lymphedema praecox develops in childhood or
    adolescence
  • Lymphedema tarda develops in adulthood

3
Secondary Lymphedema
  • Secondary lymphedema usually results from a
    trauma to the lymphatic system
  • Surgery
  • Radiation therapy
  • Tumor compression/obstruction
  • Traumatic injury
  • Infection
  • Lymphoproliferative disease
  • Tumor/cancer involvement

4
What is the lymphatic system ?
  • Retrieves proteins filtered out of the
    circulatory system by capillaries and returns
    them to the venous system for circulation
  • The lymphatic system originates as lymph
    capillaries in the spaces between cells
  • The capillaries join to form larger vessels
    called the lymphatics

5
Lymphatic System (continued)
  • The lymphatics are joined together by lymph nodes
    which act as filters and empty into the right
    lymphatic duct or the thoracic duct
  • Lymphatics
  • smaller diameter and thinner walls than veins or
    arteries
  • contain valves like veins to assist with lymph
    flow
  • also are aided by skeletal muscle contractions
    and pulsatile movements of surrounding blood
    vessels to assist with lymph flow

6
How does it occur ?
  • Decreased lymph flow from lymphatic damage
    results in increased protein concentration in the
    interstitial fluid
  • With increased protein concentration, fluid is
    shifted into the interstitial space due to
    oncotic pressure
  • With fluid accumulation in the interstitial
    space, swelling/edema occurs in that body part

7
How does it occur ? (continued)
  • Lymphatic damage and fluid stasis also leads to
    scar tissue/fibrosis development with collagen
    and fibrin deposition to vessel walls, therefore
    further blocking lymph flow
  • Fluid stasis increases susceptibility to
    infection with cycle initiated for further
    lymphatic damage

8
How frequently does it occur ?
  • Affects 1 of the US population over 2 million
    people usually from breast cancer treatment
  • Post-mastectomy 25.5
  • Post-mastectomy with axillary lymph node
    dissection and radiation therapy 38.3
  • Further increased with obesity and/or infection

9
How frequently does it occur ? (continued)
  • May also see with
  • lymphoma
  • prostate cancer
  • melanoma
  • Hodgkins disease
  • ovarian cancer
  • Cushings disease
  • Systemic lupus erythmatosus
  • Even more common in third world countries due to
    prevalence of parasitic infections

10
Types of lymphedema
  • Acute
  • mild, transient form
  • occurring within days of surgery
  • resolving within first weeks
  • Painful
  • occurs 4 to 6 weeks after surgery
  • frequently associated with phlebitis or
    lymphangitis
  • Erysipeloid
  • occurs with chronic form after local trauma

11
Types of lymphedema (continued)
  • Chronic
  • more insidious and painless form
  • occurs 18 to 24 months after surgery after
    gradual development of fibrous tissues
  • Dependent
  • occurs with fluid overloading conditions such a
    renal failure or cardiovascular diseases
  • more involving dependent or inactive extremities

12
Physiologic consequencesfrom lymphedema
13
What is seen clinically ?
  • Edema of the involved anatomy
  • Pain can, but not always may be, present
  • more common with infection
  • Usually no skin ulcerations are seen
  • if present, more consistent with chronic venous
    insufficiency
  • If erythema, must consider infection
  • Thickening, hardening or doughiness of the
    subcutaneous tissue
  • Seldom are skin changes seen

14
Are diagnostic tools appropriate ?
  • Lymphangiography has been used in past to
    evaluate, however
  • rarely is it required due to strong correlation
    with history and exam for diagnosis
  • anatomical information gained has no impact on
    treatment
  • can frequently exacerbate the condition
  • If clinical suspicion, venogram or venous doppler
    can rule out presence of thrombosis
  • Best tools remain detailed history and exam

15
What happens if not treated ?
  • A cycle of fibrosis, stasis and protein
    accumulation begins with progression and
    worsening of edema
  • Increased incidence of infection
  • Elephantiasis may develop in final stages
  • In severe cases, rare complication of
    lymphangiosarcoma may occur

16
When is treatment appropriate ?
  • ALWAYS in the presence of painless swelling,
    especially if greater than 2 cm
  • If swelling occurs after the 6 week period
    following completion of treatment
  • ALWAYS with swelling in the months or years after
    treatment, but first must rule out cancer
    recurrence or metastatic disease

17
What are goals of treatment ?
  • Improve cosmesis
  • Preserve skin integrity
  • Soften subcutaneous tissues
  • Avoid infection or lymphangitis
  • Decrease limb size
  • Avoid contracture of the involved limb
  • Most importantly patient and family education

18
What are treatment options ?
  • Medications
  • Antibiotics
  • should always have on hand to begin treatment
    with first signs of infection
  • should cover Gram positive organisms with most
    common pathogen Group A Strep
  • Diuretics
  • can decrease water and sodium in the interstitial
    fluid, but have no impact on protein status
  • risks usually outweigh benefits
  • Benzopyrones / Coumarin
  • stimulate proteolysis
  • not available in United States or FDA approved

19
What are treatment options ?
  • Mechanical interventions
  • elevation
  • protection of limb
  • manual lymph drainage/massage
  • compression garments to reduce and control edema
  • exercise, especially of distal musculature, to
    facilitate lymph flow
  • Surgery Not curative
  • Excisional Charles / Homans procedure
  • debulking of the area to remove excess tissue to
    decrease volume
  • Physiological
  • drainage of the area via lymph to lymph or lymph
    to venous anastomosis

20
What can Physiatry provide for treatment ?
  • Education regarding factors contributing to
    lymphedema and therefore increased compliance
  • Early treatment for initial or recurrent
    infection
  • Emphasize proper care of the extremity
  • Determination of appropriate therapy and/or
    long-term compression needs

21
What are measures to be taken for protection ?
  • Make every attempt to avoid
  • cuts scratches insect bites
  • hangnails punctures burns
  • Do not irritate or handle these injuries if they
    occur
  • No blood pressures or venipunctures in involved
    limb
  • Liberal use of moisturizer to avoid dryness or
    cracking

22
Measures to take (continued)
  • Wear protective garments for appropriate
    activities
  • gardening or pruning
  • dishwashing
  • baking/cooking
  • sewing
  • Immediate contact with physician if presence of
    infection
  • Carry heavy parcels or purses on the opposite
    limb
  • Sunscreen or long-sleeved garments for sun
    exposure
  • Sleep with limb elevated

23
Measures to take (continued)
  • Jewelry should not be worn on affected limb
  • Insect repellent for high risk exposure
  • Utilize electric razor for shaving
  • Check water temperature with other limb or
    thermometer before immersion
  • Avoid heavy lifting or repetitive movements with
    involved limb
  • Avoid tight-fitting garments to affected limb
  • Avoid climate temperature extremes

24
What types of compression are available ?
  • Compression stocking
  • can be used for treatment and maintenance
  • 2 pairs are appropriate to maximize hygiene
  • last from 4 to 6 months
  • can be difficult to don or doff and keep in
    position
  • Compressive wrapping
  • better flexibility for specific problem areas and
    for specific patients
  • patients and families can learn technique
  • allow greater activity level than pumps
  • can be time consuming to don

25
Available compression (continued)
  • Compression pumps
  • not adequate for primary therapy
  • do not address proximal edema
  • high cost with decreased compliance
  • less convenient for associated exercise or
    mobility
  • variable protocols dependent on brand and type
    but ranges
  • single chamber/uniform/intermittent compression
    30-60 mm Hg
  • multi-chamber/differential/sequential
    compression60-120 mm Hg
  • Reid sleeve
  • markets as being less expensive, less cumbersome
    and more effective than traditional pump
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