Lymphedema; causes, symptoms, treatment, physiotherapy managment

Lymphedema

Location

 When lymphedema develops, it is most often apparent in the distal extremities, particularly over the dorsum of the foot or hand. The term dependent edema describes the accumulation of fluids in the peripheral aspects of the limbs, particularly when the distal segments are lower than the heart. In contrast, lymphedema also can manifest more centrally, for example in the axilla, groin,or even the trunk.

Lymphedema


Severity

 The severity of lymphedema may be described quantitatively or qualitatively. Lymphedema is described by the severity of changes that occur in skin and subcutaneous tissues. Although all three types reflect a significant degree of lymphedema they are listed in order of severity, from least severe to

most severe. Descriptors such as mild, moderate, and severe sometimes are based on how much larger the size of the edematous limb is compared with the noninvolved limb. However, there are no standard definitions associated with size and severity.

Increased Size of the Limb

As the volume of interstitial fluid in the limb increases, so does the size of the limb (weight and girth).

Increased volume, in turn, causes tautness of the skin and susceptibility to skin breakdown.

Sensory Disturbances

Paresthesia (tingling, itching, or numbness) or occasionally a mild aching pain may be felt particularly in the fingers or toes. In many instances the condition is painless, and the patient perceives only a sense of heaviness of the limb. Fine finger coordination also may be impaired as the result of the sensory disturbances.

Stiffness and Limited Range of Motion

Range of motion (ROM) decreases in the fingers and wrist or toes and ankle or even in the more proximal

joints, leading to decreased functional mobility of the involved segments.

Decreased Resistance to Infection

Wound healing is delayed; and frequent infections (e.g., cellulitis) may occur.

Examination and Evaluation

of Lymphatic Function

A patient’s history, a systems review, and specific tests and measures provide information to determine impairments and functional limitations that can arise from lymphatic disorders and the presence of lymphedema. Other tests and measurements, such as vital signs, ROM, strength, posture, and sensory, functional, and cardiopulmonary testing, also are appropriate.

History and Systems Review

Note any history of infection, trauma, surgery, or radiation therapy. The onset and duration of lymphedema, delayed wound healing, or previous treatment of lymphedema are pertinent pieces of information. Identify the occupation or daily activities of the patient and determine if long periods of standing or sitting are required.

Examination of Skin Integrity

Visual inspection and palpation of the skin provide information about the integrity of the skin. The location of the edema should be noted. When the limb is in a dependent position, palpate the skin to determine the type and severity of lymphedema and changes in skin and subcutaneous tissues. Areas of pitting, brawny, or weeping edema should be noted The presence of wounds or scars and the color and appearance of the skin, which often is shiny and red in an edematous limb, should be noted. Photographic documentation is convenient in the clinical or home setting and provides visual evidence of changes in skin integrity. If a wound or scar is identified, its size should be noted, as should scar mobility or the presence of inflammation or infection in a wound.

Girth Measurements

Circumferential measurements of the involved limb should be taken and compared with the noninvolved limb if the problem is unilateral. Identify specific intervals or landmarks at which measurements are taken so measurements during subsequent examinations are reliable. Use of circumferential measurements at anatomical landmarks has been shown to be a valid and reliable method of calculating limb volume.

Volumetric Measurements

An alternative method of measuring limb size is to immerse the limb in a tank of water to a predetermined anatomical landmark and measure the volume of water displaced.

Lymphedema


Prevention of Lymphedema

If a patient is at risk of developing lymphedema secondary to infection, inflammation, obstruction, surgical removal of lymphatic structures, or chronic venous insufficiency, prevention of lymphedema should be the priority.

Comprehensive management of lymphedema involves a combination of appropriate medical management and direct therapeutic intervention by a therapist combined with self-management by the patient. Treatment also includes appropriate pharmacological management for infection control and prevention or removal of excessive fluid and proteins.

The overall goal of management when lymphedema has developed is to improve drainage of obstructed areas and theoretically to channel fluids into unobstructed, collateral vessels. The following must be accomplished to increase lymphatic drainage. The hydrostatic pressures on edematous tissues must be increased. This is accomplished by external compression of tissues with manual lymphatic drainage, sequential pneumatic compression machines, or compressive garments. Lymphatic and venous return also is enhanced by elevating the involved limb. Lymphedema caused by infection or inflammation of the lymphatic system (e.g., lymphangitis or cellulitis) does not diminish as readily with elevation as does edema secondary to chronic venous insufficiency.

 In some situations, such as after removal of lymph nodes or vessels, preventive measures may be needed for a lifetime. Even when a patient takes every measure to prevent edema, it still may develop at some time, particularly after trauma to or surgical removal of lymph vessels.

Management of Lymphedema

Background and Rationale

Comprehensive management of lymphedema involves a combination of appropriate medical management and direct therapeutic intervention by a therapist combined with self-management by the patient. Treatment also includes appropriate pharmacological management for infection control and prevention or removal of excessive fluid and proteins.

The overall goal of management when lymphedema has developed is to improve drainage of obstructed areas and theoretically to channel fluids into unobstructed, collateral vessels. The following must be accomplished to increase lymphatic drainage. The hydrostatic pressures on edematous tissues must be increased. This is accomplished by external compression of tissues with manual lymphatic drainage, sequential pneumatic compression machines, or compressive garments. Lymphatic and venous return also is enhanced by elevating the involved limb. Lymphedema caused by infection or inflammation of the lymphatic system (e.g., lymphangitis or cellulitis) does not diminish as readily with elevation as does edema secondary to chronic venous insufficiency.

 

Comprehensive Regimens and Components

A comprehensive approach to the management of lymphedema is referred to in the literature by a variety of terms, including complex lymphedema therapy, complete or complex decongestive physical therapy, or decongestive lymphatic therapy. All of these regimens combine manual lymphatic drainage through light, superficial massage and compressive bandaging with active ROM, low-intensity resistance exercises, cardiopulmonary conditioning exercises, and good skin hygiene.

Manual lymphatic drainage

 Manual lymphatic drainage involves slow, very light repetitive stroking and circular massage movements done in a specific sequence with the involved extremity elevated whenever possible. Proximal congestion in the trunk, groin, buttock, or axilla is cleared first to make room for fluid from the more distal areas. The direction of the massage is toward specific lymph nodes and usually involves distal to proximal stroking. Fluid in the involved extremity then is cleared, first in the proximal portion and then in the distal portion of the limb. Because manual lymphatic drainage is extremely labor- and time-intensive, methods of selfmassage are taught to the patient as soon as possible in a treatment program.

Exercise

 Active ROM, stretching, and low-intensity resistance exercises are integrated with manual drainage techniques. Exercises are performed while wearing a compressive garment or bandages and in a specific

sequence, often with the edematous limb(s) elevated. A low-intensity cardiovascular/pulmonary endurance activity, such as bicycling, often follows ROM and strengthening exercises.

Elevation

 The involved limb is elevated during use of a sequential compression pump, while sleeping or resting, or even during sedentary activities. The compressive bandages or garment are worn during periods of elevation.

Compressive bandages, garments, or pumps

 No-stretch, nonelastic bandages or low-stretch elastic bandages or garments are recommended because they provide relatively low compressive forces on the edematous extremity at rest. In addition, they provide a higher working pressure with active muscular contractions because of their less yielding nature than high-stretch bandages. High-stretch sports bandages, such as Ace wraps, are not recommended for treating lymphedema.  Daily use of a sequential, pneumatic compression pump also may be advisable during the early stages of treatment of substantial lymphedema.

Skin care and hygiene

 Lymphedema predisposes the patient to skin breakdown, infection, and delayed wound healing. Meticulous attention to skin care and protection of the edematous limb are essential elements of self management of lymphedema.

Management Guidelines

Guidelines for the management of lymphatic disorders are essentially the same as those already described for the management of chronic venous insufficiency and associated lymphedema. As with chronic venous insufficiency, management of lymphatic disorders initially involves direct interventions by a therapist and an emphasis on patient education, followed by lifelong prevention and self-management by the patient.

Precautions and Self-Management of Lymphedema

Precautions that patients should take to prevent lymphedema

and skin breakdown or infection are an important

aspect of self-management .

Use of Community Resources

A valuable resource for patients and health care professions

is the National Lymphedema Network (www.

lymphnet.org). This nonprofit organization provides

education and guidance about lymphedema. Another

resource is the Lymphedema Internet Network (http://

www.lymphedeoften with the ma.org).

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