Nicole Baldridge, PT, DPT, CLT
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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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Nicole Baldridge, PT, DPT, CLT

Certified Lymphedema Therapist

Women’sRehab Men’s Health

Physical Therapy Resident

for Centers for Rehab Services


Lymphedema
Lymphedema

Diagnosis

and

Therapy


Lymphedema

Secondary Lymphedema

Primary Lymphedema


Lymphedema1
Lymphedema

  • An abnormal accumulation of protein-rich fluid in the interstitium, causing chronic inflammation and reactive fibrosis of the affected tissues

  • Usually in an extremity, but can also occur in the head, neck, genitals, and abdomen


Lymphedema2
Lymphedema

  • 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
Types of Lymphedema

  • Primary lymphedema is a result of lymphatic dysplasia.

    • May be present at birth

    • Can develop later in life without known cause

  • Secondary lymphedema is much more common.

    • Result of surgery, radiation, injury, trauma, scarring, or infection of the lymphatic system


Primary lymphedema
Primary lymphedema

  • 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
Secondary lymphedema

  • 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



Tissue changes in lymphedema
Tissue Changes in Lymphedema

  • Connective tissue cells (fibroblasts) proliferate

  • Collagen fibers are produced

  • Fibrotic changes, sclerosis and induration

  • Fatty tissue increases


Angiosarcoma
Angiosarcoma

  • 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



Lymphedema is a disease. All other edemas are symptoms.There is no cure for lymphedema.There is only management.


Diagnosis of lymphedema

Diagnosis of Lymphedema

Physical exam and history

are most important.


Characteristics of benign lymphedema
Characteristics of Benign Lymphedema

  • 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

    • Toes square, positive Stemmer’s sign

    • Dorsum of foot “buffalo hump”

    • Loss of ankle contour

    • Asymmetric if bilateral


History
History

  • 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
Inspection

  • Location of swelling (distal or proximal)

  • Any skin changes

  • Lymphatic cysts, fistulas

  • Ulcers

  • Scars or radiation burns

  • Papillomas

  • Hyperkeratosis


Palpation
Palpation

  • 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
Diagnostic Tests

  • 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
Differential Diagnosis

  • Lipedema

  • Chronic venous insufficiency

  • Acute deep vein thrombosis

  • Cardiac edema

  • Congestive heart failure

  • Malignancy/active cancer

  • Filariasis

  • Myxedema

  • Complex regional pain syndrome


Lipedema
Lipedema

  • 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

  • Gaiter distribution

  • Non-pitting

  • Brawny

  • Hemosiderin staining

  • Fibrosis of subcutaneous

    tissue

  • Atrophic skin


Acute dvt
Acute DVT

  • Sudden onset

  • Unilateral

  • Painful

  • Cyanosis

  • (+) Homan’s sign

  • Potentially lethal (PE)

  • Diagnosis with venous doppler

  • Not treatable with PT


Cardiac edema
Cardiac edema

  • 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
Congestive Heart Failure

  • Bilateral heart failure

  • Pitting edema

  • Orthopnea, paroxysmal noctural dyspnea, DOE

  • Jugular venous distension

  • Diagnosis with physical exam, chest x-ray, cardiac echo


Malignant lymphedema
Malignant lymphedema

  • 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
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
Lymphedema Treatment Options

  • Pneumatic compression pump

  • Surgery

  • Complete decongestive therapy (CDT)

  • Elastic support garments

  • Medications


Pneumatic compression pumps
Pneumatic Compression Pumps

Advantages:

  • Can be used at home by patients

  • Fast application

  • Financially lucrative for DME vendors ($4000 per pump)


Pneumatic compression pumps1
Pneumatic Compression Pumps

Disadvantages:

  • Disregards the fact that the ipsilateral trunk can be involved in the lymphedema

  • In LE edema, the pump can cause genital edema; in UE edema, the pump can cause breast edema

  • Does not address tissue fibrosis and extended use can cause additional fibrosis

  • Requires many hours a day with the affected limb elevated

  • The pump can traumatize residual, functioning lymphatics, especially of the UE


Pneumatic compression pumps2
Pneumatic Compression Pumps

  • More disadvantages than advantages, but there are times when pumps are an appropriate choice

  • Use ONLY IF:

    • Teach the patient MLD to clear the trunk first

    • Use recommended safe settings

      • UE 30-40 mmHg

      • LE 50-60 mmHg

  • CVI patients will benefit from a pump


Surgery
Surgery

  • Microsurgical techniques

  • Liposuction

  • Debulking/Reduction procedures


Why surgical options do not always succeed
Why surgical options do not always succeed…

  • 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
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
Components of CDT

  • MLD

  • Compression bandaging

  • Exercise

  • Skin and nail care

  • Instructions in self care


Manual lymph drainage
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 drainage2
Manual Lymph Drainage

  • 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
Compression bandaging

Short stretch bandages (Rosidal, Comprilan) are applied to increase the tissue pressure in the edematous extremity.

  • 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
Exercise

  • 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
Skin and Nail Care

  • Eliminate bacteria and fungal growth by using medicated powders, hydrocortisone cream where indicated.

  • Reduce the risk of infection by avoiding injury, cleaning all injuries immediately, calling MD at first sign of infection.


Self care
Self Care

  • Patients should be instructed in the following:

    • 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
CDT is a Two-Phase Therapy

Phase 1 (Treatment Phase)

  • Meticulous skin/nail care

  • MLD

  • Compression bandaging

  • Exercise

  • Self care education

    ** lasts as long as necessary


Cdt is a two phase therapy1
CDT is a Two-Phase Therapy

  • Phase 2 (Maintenance Phase)

    • 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
When does CDT fail?

  • 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
Goals of CDT

  • Volume or size reduction

  • Restore mobility and ROM

  • Infection prevention

  • Improve cosmesis

  • Improve psychosocial morbidity

  • Improve QOL


Compression garments
Compression garments

  • 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.








What role do medications have
What role do medications have?

  • Diuretics: make edema worse; often prescribed, but draw water off protein molecules. Can cause lymphedema to become more fibrotic.

  • 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

  • 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
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 aweight reduction diet in breast cancer related lymphedema

  • 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
Results

  • 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


Overview
Overview

  • 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
Insurance coverage….

  • Medicare does not pay for products

    • 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
Insurance obstacles…

  • 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
Actual cost for the patient.…

  • Day garments:

    • Patients need 2 garments every 6 months

    • Custom fit $300-500 per garment

    • Ready to wear $50-150 per garment

      • RTW garments only come S, M, L and in a less effective fabric than custom garments

  • Night garments: custom only, $500-2000


More cost
More cost…

  • Keep in mind that all of these costs are what the DME suppliers charge for “private pay.”

  • Bandaging supplies for treatment

    • Unilateral UE/LE about $150-200

    • Bilateral LE >$200


How does this affect you
How does this affect you…

  • Most of the DME’s in the area are “out-of-network” 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
Help for patients…

  • Susan G. Komen Foundation

    • Breast cancer patients

    • 800.462.9273

  • Am. Cancer Society

    • Any cancer $300/year

    • 800.227.2345

  • Nat’l Lymphedema Network

    • www.lymphnet.org

    • Marilyn Westbrook Foundation

    • Also has “Find a Therapist or Treatment Center”


Thank you
THANK YOU!

  • [email protected]

  • 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
WomensRehab at Centers for Rehab Services

  • 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


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