Lymphedema Therapy
majerus & company physical therapy
vancouver, wa
A comprehensive PT clinic offering one on one professional
attention from an experienced staff with a wide range of
expertise….imagine life squared.
Jodie Paschall-Majerus MPT , CLT
John Majerus PT, OCS, CSCS, CLT
Laura Bancroft PTA, CLT
Robby Trimbo DPT, CLT
Tara Socquet MPT
Buffy Stinchfield MPT
Tara Rinhard, DPT
Kathleen Griffin, PTA, LMT, SI
Edema Management
- NOT just for breast CA survivors with arm
lymphedema!
- 75% of our edema patients are treated for
LE issues.
- Many of the LE patients are referred by
their primary care physicians, orthopedists
or cardiologists
- In the US, CDT seems to be offered as a
treatment of last resort..
ANATOMY AND PHYSIOLOGY
“KEY POINTS” RELATING TO TREATMENT
Lymph Production
Lymph
production
begins in the
terminal lymph
vessels, which
are located in
close
proximity to
the capillaries.
Initial Entry Point-Lymph Capillary
“Ultrafiltrate” fluid, dead cells,
and proteins are resorbed from
the interstitial tissues into the
lymph capillaries.
Intercellular junction
These finger-like projections
are found throughout the body, Movable flap
peripherally just under the
epithelium. The pressure and
stretch upon the surrounding Anchoring Filament
connective tissue mobilizes the
anchoring filaments to open
flaps between the flattened
endothelial cells to allow uptake
of large MW proteins as well as
fluid .
Lymph Transport-Lymphangions
Lymphangions - “driving
force” for lymph
transport in a collecting
vessel.
Uni-directional valves
form segments that
respond to filling with
contraction of smooth
muscle in the vessel
walls, moving fluid to
the next segment
enhanced by the active
muscle pumpLymphangiomotoricity
Systole; valve closed Diastole; valve open
Importance of Skin Elasticity /
Mechanical External Compression
With loss of skin elasticity, the muscle pump loses its
normal counter-pressure. Adding external, nonelastic compression can improve muscle pump
effectiveness.
LYMPH NODES
600-700 lymph nodes in the body.
Major node groupings:
abdomen/intestines, inguinal,
axillary, supraclavicular.
2-30 mm in length.
Functions : filter and concentrate
lymph through immune system.
LE Lymphatic Vessels
Zones / Watersheds/Anastamoses
Each major lymph node
grouping receives lymph
from a specific body region
or tributary zone.
The direction of lymphatic
flow of each tributary zone
is defined by invisible
boundaries called
watersheds,
Anastamoses are areas
between zones where
vessels physically line up,
critical in movement of
lymph between adjacent
zones during treatment.
The lymphatic fluid from
right upper quadrant
drains into the right
lymphatic duct
The lymphatic fluid from
both legs and the left upper
quadrant drains into the
thoracic duct
- 20 liters of fluid are
leaked/drawn off capillary
beds each day; normally
90% is reabsorbed through
the venous capillaries.
-Lymphatic load (LL) is
the remaining 10% of the
volume, about 2 liters per
day, that returns to the
bloodstream via the
lymphatics .
Transport capacity (TC)
- volume of lymph that can be removed by a tributary
zone and its regional nodes.
-unless compromised, only about 10% of the volume of
a normal zone is used, termed the “safety valve”
*loss of transport capacity is often asymptomatic
and is not easily measured
Possible contributing factors:
-surgical incisions crossing major lymphatic channels
-pressure on nodes or vessels from obesity or tumors
-radiation therapy
-excision of lymph nodes
-Cellulitis mediated damage to lymph capillaries
Edema Classification
High vs. Low protein edema- guides initial interventions
-High protein edema, i.e. lymphedema, develops when transport
capacity drops below the lymphatic load
Stage 1- reversible- edema goes down overnight, no skin
changes evident, typically soft 1+ or 2+ pitting edema
Stage 2- broad symptom range with early to advanced Stage 2
edema does not fully reduce overnight or with elevation
skin becomes hard, brawny, hyperkeratosis, lymph cysts, etc
+ Stemmers sign of digits, swelling of dorsum of the foot
Stage 3 – “elephantiasis”, change in limb morphology, more
advanced skin changes
Stages 2 and 3 require lymphatic massage to clear interstitial
proteins. Increased risk of cellulitis. Diuretics aren’t helpful.
Lymph System Insufficiencies (LSI)
-
-
-
Mechanical (low output failure)
Compromised lymphatic system with decreased
transport capacity (TC)
– CA/abdominal surgery, radiation, cellulitis
Dynamic (high output failure)
Normally functioning system is unable to clear
increased lymphatic load (LL)
– Longer standing CVI, lymphovenous conversion
Combination (safety valve failure)
Decreased TC and increased LL overcomes the
“safety valve” margin
Edema Classification
-Low protein edema- lacks the interstitial protein component
of the edema, less osmotic pressure
Examples: early CVI , stable CHF
- Usually responds quickly to bandaging reduction, fewer
treatment sessions
- Usually requires garments with lower compression
- Lymphatic massage is usually not required, especially if the
edema is treated early with consistent, adequate
compression and diuretics
- Watch that the cardiac, pulmonary and renal systems can
handle a spike in fluid volume.
- Compress one leg at a time
- No increased SOB , wet cough, etc.
CVI and CHF
- CVI
- progressive valve failure in the veins
- valve damage due to DVT
- creates dependent edema due to increased LL with
increased venous capillary leakage
- superficial /deep varicosities, hemosiderin staining,
hairless fragile skin, tissue weeping , venous stasis ulcers
- if more severe and prolonged, likely progresses to high
protein edema over time if not treated
- Cardiac related edema- CHF, etc,
- increased venous capillary pressure and leaking
- if stable, can treat with compression; proceed with caution
Documentation
- Digital photography- First visit and after
treatments
- LE girth measurements – taken at 10cm
intervals, MTP and forefoot, toe girths
when needed
- Body weight
- Volumetric algorithms are available
Management of Swelling Disorders
- Traditional treatments:
- “retrograde massage”
- elevation
- ankle pump exercises
- wrapping with long stretch elastic
bandages aka ACE wraps
- compression garments
- pneumatic pumps
CDT Therapy
- Origins in Germany - Vodder and Foeldi
- First offered in the US in 1980
- PT is covered by most private insurance and MC
- Treatment components:
– Short stretch bandaging for edema reduction
– Lymphatic massage- central to peripheral
– Remedial exercises
– Meticulous skin care
– Education and home management- compression
systems, self massage and/or night bandaging
Relative Contraindications
- Acute DVT – if not yet on anti-coagulation
meds or no screen placed
- Acute cellulitis - treat after 7-10 days of
antibiotic therapy, <warmth/pain in the leg
- PAD – ABI of 0.5-0.8 with caution
- Extremity paralysis- mechanical pump lost
- Complete sensory loss- caution with toes of
neuropathic patients
- Dementia
CDT-Massage principles
- Central trunk first- diaphragmatic
breathing
- Do the proximal portion of extremity first,
gradually progressing more distally
- Use light pressure – lymphatic system is
above muscle fascia layer
- Rhythmic and directional skin stretching
Push lymph
retrograde to
an adjacent,
intact zone.
Movement through the
Lymph Vascular System




Terminal Lymph Vessels / Lymph Capillaries
 Affected by skin stretch
Pre-collectors
 Affected by blood pressure within sheath
Lymph Collectors or Lymphangions
 Affected by muscle pump with either good skin
or external compression
Lymph Trunks and Associated Node Beds
 Affected by amount of “draw” from more
proximal structures
Bandaging
- Always apply skin moisturizer/ barriers –
Eucerin, Aquaphor, antifungals, etc.
- Utilize short stretch cotton bandages
– low resting pressure, high working pressure- minimal
“pulling in” at rest, enhanced muscle pump
– these features are the opposite of Ace/long stretch
bandages
– A variety of cotton padding and foams are used for
creating a proper pressure gradient, protect bony
prominences, reshaping the limb, and softening fibrotic
tissue
- Wear bandages overnight, sequential wraps until not
reducing further
Bandaging
-
Critical for healing when “wet” venous wounds are
present.
Not useful for neuropathic “dry” ulcers.
Use over wound dressings that maintain the proper
healing environment.
Watch for areas of skin maceration.
Short Stretch Bandaging with
Padding and Foam Inserts
Garments alone are not designed to reduce or reshape the limb, just
maintain the size of the limb
Garments are meant to be fitted to an already reduced leg
Compression
bandages should
always extend as far
as the next large
joint above the
edema or we get
“topping out”, but
response does help
detecting central
blockages.
Remedial Exercise
- Important, since obesity is a risk factor; this is
one reason we favor bandaging over pumps.
We want people to walk and move! BUT, patients
must wear compression when exercising to:
-enhance the LE muscle pump
- counteract increased capillary pressures
from increased blood flow
- create micro-massage of the skin to increase
lymph uptake in the terminal lymph vessels
Choosing a Compression System
-
-
Effective
Affordable
Manageable to don/doff
Comfortable to wear
Cosmetically acceptable
European Compression Garment Guidelines
http://www.lymphormation.org/downloads/position
-documents/BSN-Template-English.pdf
Choosing a Compression System
- Socks
- Circular weave- off the shelf
- Flat weave- custom measured
- Compression level
- Closed toe or open toe, w/ or w/out toe caps
- Materials- Latex or Lycra – allergies, use and
care
- Neoprene garments
- CircAids or Ready Wraps
Choosing a Compression System
-
Knee or thigh highs? Avoid “topping out” or dumping at the
next most proximal limb segment.
-
For high protein edema, apply compression to the whole zone,
up to the watershed.
-
Shorts- Bermuda flat weave – combine with flat weave thigh high
- biking shorts
- Capri circular knit legging with knee highs
When layering garments, many options are available
Thank you!
majerus & company physical therapy
Phone: 360-253-4020
Web: www.majeruspt.com
Email: johnm@majeruspt.com