Edema Disorders

Kade Scott DPT, CLT

Objectives

   Understand and recognize different edema disorders Understand basic treatment options for edema disorders Explain the differences in compression garments

What does the Lymphatic system do?

 The lymph system is responsible for transporting  Proteins      Water Cells Fat Waste WBC, lymphocytes, Bacteria, Virus

Lymphedema

   An abnormal accumulation of protein rich fluid in the interstitum, which causes chronic inflammation and reactive fibrosis in the affected tissue Lymphedema is classified as either primary or secondary lymphedema Typically asymmetrical

From:

Differential Diagnosis, Investigation, and Current Treatment of Lower Limb Lymphedema

Arch Surg. 2003;138(2):152-161. doi:10.1001/archsurg.138.2.152

Figure Legend :

Causes of lymphedema.

Date of download: 2/17/2014 Copyright © 2014 American Medical Association. All rights reserved.

Primary Lymphedema

 The most likely occurrence of this form is lymphangiodysplasia  Hypoplasia- less than normal expected number of lymph collectors in the affected area   Aplasia- a distinct absence of lymph collectors in the affected area. May also involve the absence of lymph capillaries Hyperplasia- Vessels are characterized by an excessively dilated caliber which renders them less functional due to valvular dysfunction

Primary Lymphedema

    Present at birth or shortly therafter is known as Milroy’s Disease Primary Lymphedema that develops during puberty is known as Meige’s Disease.

Praecox- Develops before 30 Tardum- Develops after 35 http://www.sajch.org.za/index.php/SAJCH/arti cle/view/639/453

Secondary Lymphedema

   Secondary lymphedema means there is a known cause for the presence of lymphedema Worldwide the most common cause is the mosquito born parasite Filaria In the United States the most common cause is cancer therapy  Lymph node sampling   Full dissection of lymph nodes Radiation therapy

Secondary Lymphedema (cont)

  Other causes include any significant trauma to the lymphatic system from accidental or self induced incidents, infectious episodes such as eyrsipelas or cellulitis Obesity may also play a role in the development of lymphedema, however, it is more likely due to a secondary co morbidity (lack of mobility, CVI etc)

Staging of lymphedema

 Lymphedema is divided into 4 stages (American Society of Lymphology)  Latency stage (subclinical or stage 0)    Transport capacity of the lymphatic system is sub-normal but still sufficient to transport the lymphatic load Patients are “at risk” for developing lymphedema Education about subjective complaints and preventative measures is key component of treatment at this stage

Staging

 Stage 1 (reversible stage)  Accumulation of protein rich fluid     No fibrotic alterations Pitting is easily induced With proper management of stage 1 patient can expect to have reduction to normal limb size Stage 1 is often confused with edemas of other geneses

Staging

 Stage 2 (spontaneously irreversible)       Lymphatic fibrosis Tissue becomes indurated Pitting is difficult to induce Positive Stemmer sign Common cellulitic infections Incomplete reduction with therapy and good patient compliance

Stemmer Sign

Sometimes called the Kaposi Stemmer sign

Staging

 Stage 3 (Lymphostatic Elephantitis)     Increased skin firmness, other skin alterations including: cysts, fistulas, papillomas, hyperkeratosis, mycotic infections, ulcerations More prominent Stemmer sign Recurrent cellulitis Decreased pitting

http://www.womenshealthsection.com/content/gyno/gyno005.php3

Symptoms

            Swelling of an arm or leg, which may include fingers and toes.

A full or heavy feeling in an arm or leg.

A tight feeling in the skin.

Trouble moving a joint in the arm or leg.

Thickening of the skin, with or without skin changes such as blisters or warts.

A feeling of tightness when wearing clothing, shoes, bracelets, watches, or rings.

Itching of the legs or toes.

A burning feeling in the legs.

Trouble sleeping.

Loss of hair.

Positive Stemmer Sign (though the absence does not rule out lymphedema) These symptoms may occur very slowly over time or more quickly if there is an infection or injury to the arm or leg.

Chronic Venous Insufficiency

  Is an advanced stage of venous disease in which the veins and the muscle pump activity become incompetent causing blood to pool in the legs and feet Can be due to repeated damage from superficial or deep venous pathology, or a variety of vein-related conditions such as the congenital absence of valves

Pathophysiology of CVI

  Faulty valves fail to prevent retrograde flow of venous blood during muscle pump activity May be:  Idiopathic     Post-thrombotic syndrome Genetics Pelvic tumors Vascular malformations

Symptoms

       Swelling in the lower legs and ankles, especially after extended periods of standing Aching or tiredness in the legs New varicose veins Leathery-looking skin on the legs Flaking or itching skin on the legs or feet Stasis ulcers (or venous stasis ulcers) Hemosiderin staining

Hemosiderin staining

Risk factors

         Deep vein thrombosis (DVT) Varicose veins or a family history of varicose veins Obesity Pregnancy Inactivity Smoking Extended periods of standing or sitting Female sex Age over 50

Early stages of CVI

 Pitting Edema  Mostly presenting below the knee  Corona Phlebectatica   A myriad of tiny vein branches that are difficult to delineate Red-pink hue to skin that returns immediately after pressure is released http://www.medicographia.com/wp content/uploads/2011/10/17.JPG

Advanced stages

     Hyperpigmentation Dermatologic changes Venous stasis dermatitis Lipodermatosclerosis  Scarring and fibrosis of skin (woody texture to skin) There may now be a lymphatic component to edema http://www.veinsveinsveins.com/app/webro ot/files/lipo.11.jpg

Photo Credit: Charlie Goldberg http://meded.ucsd.edu/clinicalimg/e xtremities_venous_insuf4.htm

End Stage CVI

Defined by ulcerations of the skin

Lipedema

 A chronic metabolic disorder of the adipose tissue, of unknown etiology.

http://www.amylhwilliams.com/BEFOREAmyslegsfront1.jpg

Lipedema

     Predominately in women Bilateral symmetrical swelling from illiac crest to ankles Stemmer’s sign negative No cellulitic infections Foot sparing

Lipedema

   “I can never lose weight in my legs no matter how much I diet” Very tender skin Bruise easily

Lipedema

   Stage 1  Skin surface is normal, tissues exhibit a smooth nodular texture Stage 2  Skin surface becomes more uneven, large fatty lobules begin to form Stage 3  Large contour deforming lobular shapes on medial knee, proximal lateral thigh, and above malleoli

Lipedema Staging

http://www.nature.com/aps/journal/v33/n2/fig_tab/aps2011153f4.html

Traumatic Edema

 Edema due to physical trauma   Results in inflammatory reactions accompanied by high protein edema.

The majority are temprorary and self resloving. However, it can lead to permanent damage.

Pathophysiology of traumatic edema

 The initial step in the inflammatory process causes local vasodilation, followed by an increase in the permebility of blood capillaries toward plasma protein. Macrophages invade and devour damage tissue. These macrophages may injure the lymhpatic system.

Cardiac Edema

     Greatest distally Always Bilateral Pitting Complete resolution with elevation No pain

Congestive Heart Failure

    Same symptoms as in cardiac edema Orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion Jugular venous distension Cardiac echo, Physical exam

Renal Failure and Edema

   Increased protein in the urine Decreased blood protein Pitting edema in lower extremity

How do I differentiate?

And then what?

Accurate Pt Hx

 Patient history is crucial in determining the underlying cause of edema There are many questions that you can ask that will help guide you down the proper course

Intake Questions

      Have you had any lymph nodes removed?

Any recent abdominal surgeries?

Any history of DVT?

Previous cellulitic infection?

CHF?

Renal Failure?

Lymphedema •MLD •Compression Bandage •Compression Stockings •Pneumatic Compression Lipedema •Light MLD •Compression Stockings •Compression Bandage CVI •Compression Bandaging •Compression Stockings •Pneumatic Compression Traumatic Edema •MLD above level of injury •Compression Bandaging Cardiac, CHF, Renal •Compression bandaging and stockings as tolerated. You MUST consult a physician on these patients prior to initiating any treatment

2 phases to treatment

   

Reduction

MLD Compression bandaging Pneumatic compression Exercise and skin care

Maintenance

 Compression Stockings  Pneumatic Compression  Exercise, Skin care

Manual Lymphatic Drainage

   A general manual treatment which improves lymph vascular flow. In lymphedema it re routes the lymph fluid around blocked areas into more centrally located healthy lymph nodes It is not a massage!

Must be done by someone who is properly trained

Contraindications to MLD

    CHF if patient is unmedicated or edema is due solely to cardiac failure Acute infection Renal Failure Acute DVT (seek physician approval for post thrombotic syndrome edema management)

Compression Bandaging

 Short stetch bandages are applied to increase the tissue pressure in the swollen extremity  Improves the efficiency of the muscle pump and joint pumps   Prevents the reacummulation of evacuated fluid Helps break up deposits of accumulated scar and connective tissues

Contraindications to compression bandaging

      Acute DVT (may mobilize thrombus) Acute infection Cardiac edema Advanced arterial disease <.7 on the ABI Advanced renal disease Malignancy (relative to severity)

Bandaging

    Short stretch  Unna, Comprilan Medium stretch  Coban  Co-Plus Long Stretch  Ace 4-layer  Profore

Short stretch

   Reduce deep venous reflux more effectively High working pressure to low resting pressure. Produce high pressure amplitudes when patient is walking and a decrease in pressure when patient is supine Main disadvantage is the loss of pressure following reduction

Short Stretch Comprilan Bandage

http://curept.com/multi-layer bandaging/

Medium stretch

  Sustains compression after an initial decrease Has a fair working to resting pressure ratio

2-layer Wrap

http://solutions.3m.com/wps/portal/3M/en_EU/Healthcare Europe/EU Home/Products/ProductCatalogue/?PC_Z7_RJH9U52300PI40IA

1Q602S28E7000000_nid=5W2H1K4LB0be56F5WHWNG2gl

Long Stretch

   Maintain pressure for longer periods of time A higher pressure of at least 60 mmHg is required to prevent reflux Exert a high resting pressure which can constrict the venous and lymphatic systems creating a tourniquet effect

Helping Patients & Physicians Heal

Pneumatic Compression Therapy

Before

Pneumatic Compression Therapy

Before After 2 Weeks Pneumatic Compression

Pneumatic Compression Pump

Mechanism of Action

A gentle “milking” of lymphatic fluid out of the upper extremity. This distal to proximal motion allows for a clearance of lymphatic fluid to be filtered out of the system via the urinary tract. In essence the Pneumatic Compression pump is designed to ‘do’ what the body is incapable of due to age, damage or disease state.

Contraindications

     Inflammatory Phlebitis Episodes of Pulmonary Embolism Infections in limb without appropriate antibiotic coverage* Presence of Lymphangiosarcoma Congestive Heart Failure, Uncontrolled *48 hours

Pneumatic Compression Therapy

         Convenient home use Comprehensive in-home or office patient training Easy to use Medicare and private insurance coverage Custom sizing Adjustable Ability to clean the product-sanitary Patient dictated time of use

Lifetime treatment of underlying condition

Compression garments

    Class 0 10-20 mmHg Class 1 20-30 mmHg Class 2 30-40 mmHg Class 3 40-50 mmHg

Class 0

  Preventative only Should not be used for someone with active edema

Class 1 20-30 mmHg

  Minimum compression for UE lymphedema Offer support, but NOT sufficient for lower extremity lymphedema or CVI

Class 2 30-40

   Most stage 2 upper extremity lymphedema Minimum compression for LE lymphedmea Offers good support for LE CVI

Class 3 40-50 mmHG

   Rarely used in UE lymphedema Most stage 2 LE lymphedema Minimum starting point for stage 3 lymphedema

Consideration for garment selection

    Patient ability to manage garment Material allergies Price Insurance coverage

Flat knit vs Circular knit

  

Flat

Custom only Slightly easier to don The thicker fabric offers additional features, such as its massaging effect, which promotes lymph drainage, and its strength, which ensures the stocking does not yield to the edema. In conjunction with movement, it produces a high therapeutic pressure that provides optimum compression of the tissue.     

Circular

Custom or OTS Difficult to don Single layer of fabric Not appropriate compression for active lymphedema, may not be adequate for sever venous edema Cheaper

Goals for compression garments

   MAINTAIN limb volume after decongestion. Compresion garments will NOT decongest limb Easy don/doffing to enhance patient compliance Cosmetically appealing

References

    Diseases and Conditions: Chronic Venous Insufficiency (CVI). http://my.clevelandclinic.org/disorders/venous_insufficienc y/hvi_chronic_venous_insufficiency.aspx. Accessed 2-26-14 .

Greenlee R, Hoyme H, Witte M, Crowe P, Witte C. Developmental Disorders of the Lymphatic System. Lymphology. 26 (1993): 156-158.

Managing edema to decrease pain and increase range of motion and functional mobility. Loraine Lovejoy-Evans MPT, DPT, CLT-Foldi. Mcdonald J, Sims N, Mayrovitz H. Lymphedema, lipedema, and the open wound. The role of compression therapy. Surgical Clinicals of North America. 83 (2003): 639-658.

References

    Norton School of lymphatic therapy course manual: Manual Lymphatci Drainage/Complete Decongestive Therapy .

Rathbun SW, Kirkpatrick AC. Treatment of chronic venous insufficiency. Curr Treat Options Cardiovasc Med. 2007 Apr;9(2):115-26.

Szuba A, Rockson S. Lymphedema: classification, diagnosis and therapy. Vascular Medicine. 1998: 3:145-156.

Zuther J, Norton S. Lymphedema Management: the comprehensive guide for practitioners. 3 rd ed. New York, NY: Thieme Medical Publishers; 2013.

LE Short Stretch Compression

Foam

    Open Cell Grey Foam Komprebinde Komprex Rosidal Soft

LE bandaging

      Lotion Stockinette to calf Toe wraps Cotton (knee, foot) Foam (affix to calf) Foam (affix to ankle and dorsum of foot)     Eucerin or other low pH TG or Tricofix Transelast/elastomull Cellona/Artiflex

LE bandaging

         Roman Sandal Ankle sole heel (ASH, Has) Spiral ankle to knee Herring bone/Figure 8 Stockinette to thigh Affix foam to thigh Knee to mid thigh Knee to top Distal thigh to top     6cm Comprilan/Rosidal K 8cm 10 cm 10 cm    12 cm 12cm 12 cm