Agents - Lymphedema

What is lymphedema?

Abnormal accumulation of protein-rich fluid in a part of the body; can occur anywhere

What causes primary lymphedema? What are some examples of conditions?

Being born with lymphatic hypofunction; swelling is progressive due to abnormal development. Examples include Milroy’s, Meige’s, lymphedena tarda, malformation

What causes secondary lymphedema? Name some examples of conditions

Damage or ongoing strain to the lymphatic system, e.g. cancer treatment (node removal, fluid backup), phlebo-lymphedema (chronic venous insufficiency), filarosis (parasitic inf d/t mosquito bite), obesity

What is the pathway of lymph through the body, starting in the lymph vessels?

Vessels → nodes (filters) → circulatory system. Processed by the kidneys

How is lymphedema diagnosed?

Clinical observation: swelling (especially dorsally), skin change, Stemmer sign (can’t pinch skin away), PMH, family history. R/o DVT, cardiac insufficiency

What are some tests and measures for lymphedema performed by a CLT?

Circumferential measurements, bioelectrical spectroscopy (most reliable), water displacement, or an MD-ordered diagnostic test

What is stage 0?

“Latency stage”, not evident despite impairment. Diagnosed via bioimpedance

What is stage 1?

Early accumulation of fluid, subsides with elevation, fluctuating circulation

What is stage 2?

Moderate swelling, not resolved with elevation, a 2cm difference in circumference. This is the stage where most CLT intervention is

What is stage 3?

Severe swelling, skin changes are evident - fibrotic changes, papillomas, peau d’orange, hyperkeratosis

Name some symptoms of lymphedema

Atypical swelling, heaviness/tightness, aching or discomfort, recurring infection, hardening or thickening of skin

Name some risk factors for lymphedema

A history of cancer removal surgery (removal of lymph nodes), history of radiation, history of multiple cellulitis infection, obesity, inflammatory comorbidities (RA, psoriatic arthritis)

What are the two phases of Complete Decongestive Therapy (CDT)?

Decongestion and maintenance

How often and how long is the decongestion phase?

2-5d/wk for 1-3 weeks

How often and long is the maintenance phase?

Follow up annually and daily maintenance; lifelong

What are the components of the decongestion phase?

Skincare, exercise, manual drainage, gradient compression

What are some components of skincare in the maintenance phase? Why is this done?

Wash daily with soap and water, moisturize daily, attention to nail care, don’t cut cuticles, caution w razors, use sunscreen and bug repellant, gloves in certain activities, monitor scratches. This is done to prevent infection and reduce fibrotic skin changes

What types of exercise are done in the maintenance stage? Why?

Progressive cardiovascular and strength exercise. This is to increase lymphatic circulation rate, stretch skin, maintain mobility and tone, and to move fluid proximally

What is compression?

Inward directed mechanical force measured in mmHg

What is containment?

The hold a garment provides against pressure; how much it stretches; rigidity

What kind of wrapping is used in the decongestion phase and for what goal? Describe

Compression bandaging using a short-stretch bandage, sometimes with foam. Done to reduce limb volume

What is inelastic compression?

It is an alternative wrapping during the decongestive phase; used when there are underlying wounds or mobility issues or in the interim

What two kinds of wrapping are used in the maintenance phase? Why?

1 - day maintenance; custom or ready made, difficult to don/doff, requires mobility

2 - night maintenance; have less compression and more containment, foam and soft

What can a non-CLT physical therapist (me) do to help patients with lymphedema?

Ask the patient about their management and CDT implementation, assist with any mobility issues they have, assess risk factors, refer a CLT early if lymphedema is suspected