Weiss, Jan- Lymphedema...5/2/2017 1 Jan Weiss, PT, DHS, CLT-LANA CoxHealth Venous Symposium June 2,...
Transcript of Weiss, Jan- Lymphedema...5/2/2017 1 Jan Weiss, PT, DHS, CLT-LANA CoxHealth Venous Symposium June 2,...
5/2/2017
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Jan Weiss, PT, DHS, CLT-LANA
CoxHealth Venous Symposium
June 2, 2017
IS IT LYMPHEDEMA?
DIFFERENTIATING BETWEEN LYMPHATIC AND OTHER ORIGINS
OF EDEMA&
IMPLICATIONS FOR TREATMENT
Is it lymphedema?
Venous Edema
LE edema resulting from venous hypertension
Often develops the “reverse champagne bottle” appearance
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Diagnosis- CVI• History
• Risk factors: DVT, heredity, obesity
• Gradual onset and slow progression
• Orthostatic edema
• Clinical Exam• Usually bilateral
• Classic hemosiderin staining
• Usually involves ankle-knee- rarely the thigh; can include feet
• c/o aching, heaviness, tightness
• Pitting edema early in disease
• Progressive lipodermatosclerosis, ulceration as condition advances
• Imaging• Duplex Ultrasonography
• Saph-fem US
• Iliac vein IVUS
Lymphedema
• LE edema resulting from impairment in the lymphatic drainage system
• Loss of normal visible anatomical architecture
Diagnosis- Lymphedema
• History• Risk factors: Hereditary (primary); Lymph node dissection, injury to lymphatic
vessels, obesity (secondary lymphedema)
• Onset usually gradual but may be rapid
• Often considered a diagnosis of “exclusion”
• Patients have increased likelihood of cellulitis
• Clinical Exam• May be unilateral or bilateral, but will always be asymmetrical
• Usually is distal involving the foot, but may include entire leg
• Soft pitting edema early, then progressive induration
• In contrast to CVI, the skin remains elastic much longer, and ulceration is atypical; no hemosiderin staining; little or no lipodermatosclerosis
• Typically have minimal discomfort or tenderness, but always “heaviness”
• Imaging• Lymphoscintigraphy
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Lymphoscintigraphy
NIRFLNear-Infrared Lymphatic Imaging
• Injection of Indocyanine Green (ICG) into dermal tissue
• Fluorescent signal eminates from ICG laden subdermal lymph vessels
• Image collected by customized camera using night vision technology
• Only penetrates ~1.5 cm into tissue
• Measures lymphatic flow in real time
NIRFLI imagingNear-Infrared Lymphatic Imaging
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NIRFLI imaging
ICG-Arm-Comparison
Researchgate.net
Comparison of lymphatic flow: normal to impaired
Lipedema
� Symmetrical appearanceof „swelling“ of both legsdue to abnormal production of adiposetissue
� Disproportionate size ofhips/legs to upper body
� Diet and exerciseresistance (?)
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Diagnosis- Lipedema
• History• Affects mainly women; often hereditary
• Often begins in childhood, puberty or after pregnancy
• Clinical Exam• Bilateral and symmetrical from pelvic girdle to ankles
• Spares the feet, unless accompanied by lymphedema • Tissues very soft, almost “fluffy”, no pitting, unless accompanied by
lymphedema• Marked tenderness and pain
• Bruise easily
• Imaging• No imaging necessary, but could identify CVI or lymphedema with
respective imaging for those conditions
Is Lipedema a Disease?
•No ICD-10 code exists for lipedema. However, the following pathological findings are well described in the literature:
� Micro-angiopathy in the adipose tissue
� Elasticity of the skin is decreased
� Weakness of the venous leg pump
� Pre-lymphatic channels abnormal
� Initial lymphatics abnormal
� Lymph collectors: cork screw
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May vary in severity, but always worse when accompanied by obesityMild Severe
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Patient with Lipo-lymphedema
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Before CDT After CDT
Lipedema
• The problem is NOT primarily edema, but is fat accompanied by some edema
• Compression and MLD helps with pain and capillary fragility
• Tissues are very soft, and tender
• Typical high elastic compression stockings are POORLY tolerated due to pain and tissue texture
Treatment similarities; different rationale
• Chronic Venous Insufficiency
• Compression to enhance venous return, reduce venous edema and risk of ulceration
• Lymphedema
• Compression and manual lymphatic drainage to reduce lymphatic edema, risk of infection, and promote tissue health
• Lipedema
• Compression to reduce pain, tenderness, and any orthostatic or lymphatic edema present
• These patients will NOT display the great size reductions noted with lymphedema or some venous edemas
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Klippel-Trenaunay-Weber Syndrome
• Congenital condition consisting of a triad of vascular/lymphatic/soft &boney tissue abnormalities
• Varicose Veins
• Boney and soft tissue hypertrophy
• Port wine stain
• Commonly has DVT and lymphatic impairment
• Limb is enlarged beyond that solely due to edema
• Pre-treatment Post-treatment
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Compression stockings
• Your typical OTC compression stocking
• High elasticity
• Readily cuts into tissues, especially if poorly fitting
• Usually a custom garment
• Lower elasticity
• Lays much flatter/smoother on skin
Circular knit Flat knit
CIRCULAR KNIT VS. FLAT KNIT GARMENTS
Problem: When used for lymphedema and lipo-lymphedema, circular knit garments tend to migrate into tissue creases and create a tourniquet.
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Latex Lycra
Stretch and size tolerance of circular vs flat knit garments
Stretch tolerance of aflat-knit garment with high working pressure
Size tolerance of aflat-knit garment
Size tolerance of acircular-knit garment
Stretch
Pre
ssure
CCL2
Stretch tolerance of acircular-knit garment
Custom flat knit can accommodate any size or shape
Indications for use of flat knit compression
• When body size or contour doesn’t permit fit with OTC garment
• When tissues are very soft
• When edema is poorly controlled with circular knit garment
• When circular knit garments are painful; poorly tolerated
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Assistive donning/doffing devices
Alternative compression
• Velcro-style
• Non-elastic compression
• Eases problem with donning
• Allows for some fluctuation in edema
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Compression therapy options
Ready Wrap
(Solaris)
Tribute
(Solaris)
Farrow Wrap
(BSNmedical)
Juxta Fit
(CircAid)
Compression pumps
Non-segmental or segmental without calibrated gradient compression
Applies compression to limb only
• Segmental calibrated gradient compression
• May apply compression to trunk and limb
Basic Pneumatic Pump Advanced Pneumatic Pump
Benefits of pneumatic compression
• Augment blood and lymphatic flow
• Reduction of swelling and pain
• Prophylaxis against DVT
• Assist in wound healing by improving circulation
• Convenience of treatment at home
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Considerations when recommending pneumatic compression
• When possible a pump should NEVER be considered as a sole means of controlling/reducing edema
• Does the patient actually need edema reduction treatment first, then a pump for home management?
• What else is the patient doing for edema control?
• Are they actively participating in their care?
• Wearing compression garments, elevation, diet, exercise
• Is there lymphatic insufficiency which requires proximal lymphatic drainage?
Would your patient benefit from a referral to Cox Outpatient Lymphedema Clinic?
Services offered
• Individualized patient evaluation
• With physician diagnosis and input, differential diagnosis helps ascertain etiology of edema to guide appropriate treatment
• Rule out contraindications for therapy
• Application of appropriate materials/treatments to assist with edema reduction and wound healing when appropriate
• Individualized fitting of compression garments – there is NO ONE SIZE FITS ALL
• Education in self care for their chronic condition
• Case management for patients with special needs
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When to refer to Cox Lymphedema Clinic?
• When there is chronic edema
• Edema reduction is essential for proper fit and success
with compression garments
• Anytime unsure of compression garment fitting
• When the patient has body contour, size, or tissue texture will not tolerate OTC circular knit garments
• Anytime education will be essential to donning
• Contact Jan Weiss, PT for questions 269-7168
• Contact Sarah West for scheduling 269-9681
• Fax 269-5542
Thank you for your time and attention
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References• Educational materials/photos provided with consent of Klose Training and
Consulting, LLC. Lafayette, CO
• Compression garment slides provided with permission of BSN Medical. www.BSNmedical.US
• Compression pump slides used with permission from Tactile Medical
• Morris RJ, Woodcock JP. Evidence-Based Compression; Prevention of Venous Stasis and Deep Vein Thrombosis. Ann Surg. 2004;239(2):162-171
• Suami H, Chang D, et al. Using indocyanine green fluorescent lymphography to demonstrate lymphatic architechture. J Lymphoedema. 2012;7(2)
• Sevick-Muraca E. Translation of Near-Infrared Flourescence Imaging Technologies: Emerging Clinical Application. Ann Rev Med. 2012;63:217-231