Nicole Baldridge, PT, DPT, CLT
Certified Lymphedema Therapist
Women’sRehab Men’s Health
Physical Therapy Resident
for Centers for Rehab Services
Lymphedema
Diagnosis
and
Therapy
Lymphedema
Secondary Lymphedema
Primary Lymphedema
Lymphedema
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An abnormal accumulation of protein-rich
fluid in the interstitium, causing chronic
inflammation and reactive fibrosis of the
affected tissues
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Usually in an extremity, but can also occur in
the head, neck, genitals, and abdomen
Lymphedema
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Affects 1% of the American population (2.5
million people)
Still poorly understood in the medical
community
Largest cause of lymphedema in the world is
Filariasis (considered secondary
lymphedema)
Filariasis is a parasitic infiltration into the
lymphatics that is very common in third world
countries (affects 90 million people)
Types of Lymphedema
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Primary lymphedema is a result of lymphatic
dysplasia.
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May be present at birth
Can develop later in life without known cause
Secondary lymphedema is much more
common.
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Result of surgery, radiation, injury, trauma,
scarring, or infection of the lymphatic system
Primary lymphedema
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Lymphangiodysplasia – general malformation
Hypoplasia – fewer than normal # of lymph
collectors
Aplasia – absences of collectors in a distinct area
Milroy's Disease is congenital lymphedema evident
at birth
Meige’s Syndrome is primary lymphedema onset
at puberty (lymphedema praecox)
Lymphedema Tardum is primary lymphedema
onset after age 35
Secondary lymphedema
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There is a known cause for the presence of edema
Surgery: breast cancer, melanoma, prostate/bladder
cancer, lymphoma, ovarian cancer, hip replacements
Radiation therapy
Trauma – scarring, crush injury
Infection
CVI
Obesity
Self-induced
Stages of Lymphedema
Latency Stage
Transport Capacity is reduced
No visible edema
Subjective complaints of heaviness, achiness
Stage 1
Reversible
lymphedema
Accumulation of protein-rich edema
Pitting
Reduces w/elevation (no fibrosis)
Stage 2
Spontaneously
Irreversible
Lymphedema
Accumulation of protein-rich edema
Pitting becomes progressively difficult
Fibrosis
Stage 3
Lymphostatic
Elephantiasis
Accumulation of protein-rich edema
Fibrosis, sclerosis, skin changes, papillomas,
hyperkeratosis
Tissue Changes in Lymphedema
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Connective tissue cells (fibroblasts)
proliferate
Collagen fibers are produced
Fibrotic changes, sclerosis and induration
Fatty tissue increases
Angiosarcoma
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Can develop after long-standing lymphedema
“Stewart - Treves Syndrome”
Angiosarcoma after mastectomy was first described
in 1948 by Stewart and Treves
Signs: reddish-blue and blackish-blue lumps that
rapidly increase in size, bleed easily and ulcerate at
an early stage
Very rare & poor prognosis
Stewart-Treves Syndrome
Lymphedema is a disease.
All other edemas are symptoms.
There is no cure for lymphedema.
There is only management.
Diagnosis
of
Lymphedema
Physical exam and
history
are most important.
Characteristics of Benign
Lymphedema
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Slow onset, progressive
Pitting in early stages
Cellulitis is common
Rarely painful but discomfort is common
Skin changes – hyperkeratosis, papillomas,
lichenification
Ulcerations are unusual
Starts distally
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Toes square, positive Stemmer’s sign
Dorsum of foot “buffalo hump”
Loss of ankle contour
Asymmetric if bilateral
History
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What is the reason for the swelling?
How long has the extremity been swollen?
How fast did the edema progress/develop?
What are the underlying diseases?
Is there pain?
Other conditions?
Other treatments?
Medications?
Inspection
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Location of swelling (distal or proximal)
Any skin changes
Lymphatic cysts, fistulas
Ulcers
Scars or radiation burns
Papillomas
Hyperkeratosis
Palpation
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Temperature – indicative of infection
Stemmer sign is (+) when a thickened cutaneous
fold of skin at the dorsum of the toe or finger cannot
be lifted or is difficult to lift. Positive Stemmer’s sign
is indicative of lymphedema.
Skin folds
Pitting
Fibrosis
Muscular status
Diagnostic Tests
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Direct lymphography: invasive, oily contrast injected
into a surgically exposed lymphatic vessel.
Damaging. Has been replaced by CT, MRI, US.
Lymphoscintigraphy: noninvasive, assesses
dynamic process in superficial and deep lymphatics
CT
MRI
These tests are often not performed due to lack of
clinical importance
Differential Diagnosis
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Lipedema
Chronic venous insufficiency
Acute deep vein thrombosis
Cardiac edema
Congestive heart failure
Malignancy/active cancer
Filariasis
Myxedema
Complex regional pain syndrome
Lipedema
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Mainly in women
Bilateral, symmetrical edema
from iliac crest to ankles
Dorsum of feet never involved
(-) Stemmer’s sign
Little or no pitting
No cellulitis
Painful to palpation
Bruise easily
CVI
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Gaiter distribution
Non-pitting
Brawny
Hemosiderin staining
Fibrosis of subcutaneous
tissue
Atrophic skin
Acute DVT
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Sudden onset
Unilateral
Painful
Cyanosis
(+) Homan’s sign
Potentially lethal (PE)
Diagnosis with venous doppler
Not treatable with PT
Cardiac edema
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Right heart insufficiency
Greatest edema distally
Always bilateral
Pitting
Complete resolution with elevation
No pain
May treat with PT if cleared by Cardiologist
Congestive Heart Failure
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Bilateral heart failure
Pitting edema
Orthopnea, paroxysmal noctural dyspnea,
DOE
Jugular venous distension
Diagnosis with physical exam, chest x-ray,
cardiac echo
Malignant lymphedema
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Pain, paresthesia, paralysis
Central location, proximal onset
Rapid development, continuous progression
Swelling and nodules in supraclavicular fossa
Hematoma-like discoloration (angiosarcoma)
Ulcers and non-healing open wounds
Recurrent malignancy
Filariasis
Prevalent in 3rd world countries;
Can still be treated successfully with CDT.
Most therapists in the US will never encounter Filariasis.
Lymphedema Treatment Options
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Pneumatic compression pump
Surgery
Complete decongestive therapy (CDT)
Elastic support garments
Medications
Pneumatic Compression Pumps
Advantages:
1.
Can be used at home by patients
2.
Fast application
3.
Financially lucrative for DME vendors ($4000 per pump)
Pneumatic Compression Pumps
Disadvantages:
1.
Disregards the fact that the ipsilateral trunk can be
involved in the lymphedema
2.
In LE edema, the pump can cause genital edema;
in UE edema, the pump can cause breast edema
3.
Does not address tissue fibrosis and extended use
can cause additional fibrosis
4.
Requires many hours a day with the affected limb
elevated
5.
The pump can traumatize residual, functioning
lymphatics, especially of the UE
Pneumatic Compression Pumps
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More disadvantages than advantages, but
there are times when pumps are an
appropriate choice
Use ONLY IF:
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Teach the patient MLD to clear the trunk first
Use recommended safe settings
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UE 30-40 mmHg
LE 50-60 mmHg
CVI patients will benefit from a pump
Surgery
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Microsurgical techniques
Liposuction
Debulking/Reduction procedures
Why surgical options do not always
succeed…
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A blocked system must be made intact
The direction of flow must be correct
The inflow of the reconstructed system must
be adequate and the outflow must remain
open
Patency must be lasting
History of Complete Decongestive
Therapy….
Emil Vodder, Ph.D., P.T.
discovered that massage therapy boosted people’s
immune systems. They began to massage swollen
lymph nodes and noticed common colds improving.
He created his first publication of this and coined
the term MLD (manual lymph drainage).
History of Complete Decongestive Therapy….
Michael Foeldi, M.D. and Ethel Foeldi, M.D.
In the 1980’s, Prof. Foeldi advanced
lymphedema considerably by combining MLD,
bandaging, exercise,
skin and nail care into
“Complete Decongestive Therapy.”
Components of CDT
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MLD
Compression bandaging
Exercise
Skin and nail care
Instructions in self care
Manual Lymph Drainage
MLD is a gentle manual treatment
which improves the
activity of the lymph vascular system.
In lymphedema, it reroutes the lymph flow
around blocked areas into centrally
located healthy areas which then can drain
into the venous system.
Manual Lymph Drainage
Manual Lymph Drainage
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Improves lymph production
Increases lymphangio-motoricity
Improves lymph circulation and increases the
volume of lymph transported
Special techniques help break down fibrous
connective tissue
Promotes relaxation and has an analgesic
effect
Compression bandaging
Short stretch bandages (Rosidal, Comprilan) are
applied to increase the tissue pressure in the
edematous extremity.
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Reduces the ultrafiltration rate
Improves efficiency of the muscle and joint pumps
Prevents re-accumulation of evacuated lymph fluid
Helps break down fibrous connective tissue that has
developed
Exercise
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Performed with the bandages on or while
wearing a compression garment.
Active ROM, stretching, strengthening
Low exertion
Diaphragmatic breathing
Increase muscle and joint pumping
Increase lymph vessel activity
Increase venous and lymphatic return
Skin and Nail Care
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Eliminate bacteria and fungal growth by
using medicated powders, hydrocortisone
cream where indicated.
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Reduce the risk of infection by avoiding
injury, cleaning all injuries immediately,
calling MD at first sign of infection.
Self Care
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Patients should be instructed in the following:
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Skin and nail care
Infection prevention (cellulitis is very common)
Self-bandaging
Self-MLD as needed
Exercise
Donning and doffing compression garment
Regular follow-up visits
CDT is a Two-Phase Therapy
Phase 1 (Treatment Phase)
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Meticulous skin/nail care
MLD
Compression bandaging
Exercise
Self care education
** lasts as long as necessary
CDT is a Two-Phase Therapy
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Phase 2 (Maintenance Phase)
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Patient wears compression garments during the
day
Patient bandages at night
Meticulous skin and nail care
Daily exercise
MLD as needed
Regular follow-up visits
**life long maintenance
When does CDT fail?
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Malignant lymphedema
Artificial (self-induced) lymphedema
Insufficient treatment (only used MLD or
improper bandaging)
Deviation from CDT protocol
Associated illnesses
Lack of compliance
Active cancer
Faulty diagnosis
Goals of CDT
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Volume or size reduction
Restore mobility and ROM
Infection prevention
Improve cosmesis
Improve psychosocial morbidity
Improve QOL
Compression garments
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Elastic garments are uncomfortable and
ineffective if worn while the limb is
edematous.
Garments do nothing to correct the
underlying cause of the edema.
Garments are NEEDED after the
decongestive phase of CDT to prevent refill.
Daytime garments
Lymphedema Secondary to Breast Cancer
Primary Lymphedema of the Left Leg
Primary Lymphedema of Scrotum and Leg
Before
After resection
Night-time garments
Night-time Garments
What role do medications have?
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Diuretics: make edema worse; often prescribed,
but draw water off protein molecules. Can cause
lymphedema to become more fibrotic.
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Benzopyrones: not FDA approved; stimulate
macrophage activity and promote protein proteolysis;
theoretically useful; effect is so slow that usefulness
is questionable. Includes coumarin, rutosides,
diosmin, rutin.
DIET
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No specific diet for lymphedema
Reducing water and/or protein intake is
ineffective
Avoiding obesity is helpful
General recommendations are low sodium,
high fiber, vitamin rich diets.
What role does obesity play?
Increased risk of post-op complications such as
infection
Reduced muscle pumping efficiency within loose
tissues
Additional fat deposits contribute to arm volume
Deep lymph channels are separated by
subcutaneous fat
Randomized controlled trial
comparing a low-fat diet with a
weight reduction diet in breast
cancer related lymphedema
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This article was published in the medical
journal “Cancer” in May 2007.
It was also copy-written by the American
Cancer Society in 2007
Results
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The low-cal group and low-fat group had
significant reductions of:
body weight
– BMI
– % body fat
**Significant correlation between weight loss
and arm volume reduction regardless of the
dietary group
**unaffected arm also showed volume reduction
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Overview
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This is the first study to examine the role of
diet as a possible treatment for BCRL
Significant correlation of weight loss and loss
of swollen arm volume
The type of diet did not affect arm volume
reduction…just losing weight!
Weight loss in a healthy manner
Healthy diet and exercise
Insurance coverage….
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Medicare does not pay for products
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Medicare HMO’s do not pay
Medicaid does not pay for products
Most Highmark BC/BS, HMO, PPO pay
100% for products
UPMC HMO, PPO plans…as of 1/1/08
started following Medicare guidelines, but
this is changing to more coverage
Insurance obstacles…
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Frustrating for the therapist because patients
need these products to maintain edema and
prevent worsening of edema.
We recommend products based on what the
patient needs or does not need.
Often we have to change our
recommendations based on what the
insurance will reimburse.
Actual cost for the patient.…
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Day garments:
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Patients need 2 garments every 6 months
Custom fit $300-500 per garment
Ready to wear $50-150 per garment
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RTW garments only come S, M, L and in a less effective
fabric than custom garments
Night garments: custom only, $500-2000
More cost…
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Keep in mind that all of these costs are what
the DME suppliers charge for “private pay.”
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Bandaging supplies for treatment
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Unilateral UE/LE about $150-200
Bilateral LE >$200
How does this affect you…
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Most of the DME’s in the area are “out-ofnetwork” with Cigna
Out of network cost for these products is
extremely high
Important to understand how necessary
these products are and to consider approval
at an “in-network” level.
Help for patients…
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Susan G. Komen Foundation
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Am. Cancer Society
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Breast cancer patients
800.462.9273
Any cancer $300/year
800.227.2345
Nat’l Lymphedema Network
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www.lymphnet.org
Marilyn Westbrook Foundation
Also has “Find a Therapist or Treatment Center”
THANK YOU!
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baldridgena@upmc.edu
Phone/Address: Centers for Rehab Services
Moon Township
1600 Coraopolis Heights Rd
Coraopolis, PA 15108
(412) 269-7062
McCandless
9365 McKnight Rd #300
Pittsburgh, PA 15328
(412) 630-9750
WomensRehab
at Centers for Rehab Services
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Specialists in treating lymphedema as well
as urinary incontinence, pelvic pain,
interstitial cystitis, vulvadynia, fecal
incontinence, constipation and other pelvic
floor hyper/hypotonicity disorders.
Locations: Cranberry, Moon, Gibsonia,
Harmar, St. Margaret’s, South Hills, Oakland,
Squirrel Hill, McCandless, Delmont,
Monroeville, Chippewa
Referral Line 1-888-723-4CRS