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Edema:ComprehensiveManagement
LisaCabralPT,DPT,CLT,CWSWPTAFallConference2016
Disclosures
• ThespeakerhasnofinancialconflictofinterestforcontentofthispresentaIon.
• ThespeakerisnotendorsinganyparIcularproductortypeofequipment.
CourseObjecIves
• TorecognizetheanatomyandfuncIonofthelymphaIcsystem
• ToidenIfydifferenttypesofedema• Todescribethebesttreatmentapproachesforlowproteinversushighproteinedema
• Tounderstandthebasicsofgeneralwoundcaremanagement
Whyedemamanagement?
• YoucanfinditinallseTngsofphysicaltherapypracIce
• ComplicatededemacanlimitfuncIon,mobility,andoveralloutcomeofcare
• ItiswithinourscopeofpracIceasphysicaltherapypracIIoners
THELYMPHATICSYSTEMWhatisit?Whatdoesitdo?
RoleoftheLymphaIcSystem
• Conductimmunesystemsurveillance– Immediateandlongtermresponsetopathogens
• Assistthecardiovascularsystemtomaintainfluidhomeostasis
• AidthedigesIvesysteminthebreakdownoflong-chainfaXyacids
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AnatomyoftheLymphaIcSystem
• Lymphfluid:clearandtransparentsemifluidmedium
• LymphaIcloads:protein,water,cellularcomponentsandparIcles,andfat
ComponentsoftheLymphaIcSystem
• IniIallymphaIcs(capillaries)andpre-collectors–absorb
• CollectorlymphaIcs–conduct• Lymphnodes–filterandconduct• Lymphtrunks–deeper,conduct• Thoracicduct–deepest,largest,conducts
NormalLymphFlow
Lymphcapillaries➔ Pre-collectors➔Collectors➔Lymph
Nodes➔LymphaIcTrunks➔
Thoracic/RightLymphaIcDuct➔ Le^orRightSubclavianVein➔Heart
LymphCapillaries
• AlsoknownastheiniIallymphaIcs• “Mesh”likecomplexthroughoutthebody
• ResponsibleforlymphformaIon• AnchoringfilamentsfacilitateopeningandclosingofcapillaryjuncIons
• MobilizaIonofso^IssuefromtheoutsidecanfacilitatechangeinpressureandsImulateanchoringfilaments
Pre-CollectorsandCollectors
• Pre-collectors– ConnecIonbetweenlymphcapillariesandcollectors
• Collectors– MovesfluidtolymphnodesandontolymphaIctrunks
– Similarstructuretoveins– Containsvalves(pair=lymphangion,every6-20mm)– Contracts10-12Imesperminute(smoothmuscle)
LymphNodes• Regionalandcentral,600-700inthebody
• ProtecIvefuncIon:filters,phagocytosisofpathogens,wasteproductsanddeadcells
• ImmunefuncIon:makeanIbodies• Thickeningofthelymphfluid:bloodcapillariesreabsorbwater
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• Lymphotomes:superficialanatomicalsegmentsthatdividethebodyintospecificareas/territoriesdrainedbythesamegroupofnodes
• Watersheds:divisionareasbetweentwolymphotomesthatallowlymphtomoveagainstthenormalflow
LymphaIcTrunksandDucts• LymphaIcTrunks
– Similartothecollectorsbuthavemoredevelopedmusclestructure
– Aresultofwhensuperficialanddeepcollectorsmerge– Sendsfluidtovenousangles
• ThoracicDuct– FromL2toT4– LymphfrombilateralLE,le^arm,andle^quadrantofface– EmpIesintothele^venousangle
• RightlymphaIcDuct– Lymphfromrightarm,upperrightquadrant,andface– EmpIesintotherightvenousangle
Return of Lymph Fluid
• Venoussystem:le^andrightvenousanglesbetweenthesubclavianandjugularveinsattheleveloftheclavicles
• OnlydirectconnecIonwithlymphandvenoussystems
• Feedsbackintothecirculatorysystem(heart).
Physiology:StarlingEquilibriumEquaIon
Jv=Kf[Pc-Pif–σ(πp–πif)]
Capillaryfiltrate=Permeabilityofwaterandsmallsolutes[HydrostaIcpressuregradient–Permeabilityofplasmaprotein
(ColloidosmoIcpressuregradient)]
Physiology:StarlingEquilibriumEquaIon
– DescribeshowtheosmoIcandhydrostaIcpressuresinthecapillariesandintersIIalIssuedeterminethedirecIonoffluidmovement– Fluidisconstantlybeingfiltratedandreabsorbedatthecapillarybed– HydrostaIcpressure:pressureexertedbythebloodonthecapillarywalls– OsmoIcpressure:forcecreatedbylargemoleculessuchasplasmaproteins(opposeshydrostaIcpressure)
When the fluid flows from the interstitial space into the capillary, it is termed reabsorption When the fluid flows from the capillary into the interstitial space, it is termed filtration
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Physiology
• Func1onalreserveofthelympha1csystem:ThetransportcapacityofthelymphaIcsystemis10xgreaterthan(>)thephysiologicamountoflymphloads(normalfuncIon)
• Ifneeded,thelymphaIcsystemcanassistwhenthethereanoverloadofvenousfluidpresent.
• Dynamicinsufficiency=Lymphload>Transportcapacity.Thus,edemaisnoted.
AbnormalPhysiology:Lymphedema
• Lymphedema/Lymphosta1cedema=mechanicalinsufficiencyorlow-volumeinsufficiencyofthelymphaIcsystem– Highproteincontentisthehighlightoflymphedemacomparedtootheredemas.
LymphaIcFailureTransport Capacity Lymphatic Load
Dynamic (edema)
Normal Increased
Mechanical (lymphedema)
Decreased Normal
Combination (lymphedema)
Decreased Increased
Hemodynamic (cardiac edema)
Normal/Decreased Increased due to right ventricular failure
Evalua1onandAssessmentConsidera1ons
WhatdoIask?WhatdoIlookat?
SubjecIve
• Anyrecenthealthchanges?
• Didtheswellingoccurfastorslow?
• DoestheswellingimprovewithelevaIon?
• DoestheswellingimprovewithdiureIcs?
SubjecIve
• HaveyouhadanyrecentinfecIonorbloodclot?
• Wheredoyousleep?
• Isthereanypainassociatedwiththeswelling?
• DoestheswellinglimityourfuncIon?
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PastMedicalHistory
• Fullsystemsreview• Canceranditstreatments• InfecIons• Surgeriesortraumas• FuncIonalstatusandacIvitylevel• Historyofsmokingandalcoholuse• Socialhistory
ObjecIve
• GeneralPTassessment• Skinintegrity(palpaIon,texture,color,temperature,piTng,scars)
• Volumeorgirthmeasurementsoftheinvolvedareasofthebody
– IfpresentintheextremiIes,symmetricorasymmetric
• Pain
ClassifyingPiTngEdema
• 1+=2mmorless,disappearsrapidly• 2+=2-4mm,disappearsin10-15seconds• 3+=4-6mm,maylastmorethan1minute• 4+=6-8mm,lastsaslongas2-5minutes
ObjecIve
• Stemmersign:theonlyclinicaltestthatisareliableandvalidmethodtodiagnoselymphedema
– Thickeningoftheskinoftheproximalphalangesofthetoesorfingeroftheinvolvedlimb
– Can’t“tent”orpickuptheskinwhenpinched– PosiIve=definiteindicaIonoflymphedema– NegaIve=absenceofthediagnosisisnotcertain
DifferenIalDiagnosisforTypesofEdema
HowdoIputallthepiecestogether?
Lymphedema
• Lymphedemaisachronic,incurablecondiIonthatischaracterizedbyanabnormalcollecIonoffluidowingtoananatomicalalteraIonofthelymphaIcsystem(Macdonald,JM.2002)
• Highproteintypeedema• Canclassifiedasaprimaryorsecondarylymphedema
• StagedfromStage0toStage3
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EIologyofLymphedema:Primary
• Milroy’sdisease(congenIallymphedema)• Meige’sdiease(lymphedemapraecox)• LymphedemaTarda
EIologyofLymphedema:Secondary
• Damagetolymphnodesand/orlymphvesselsthatresultsinmechanicalinsufficiency
• Possiblecauses:Trauma,RadiaIontherapy,TumorobstrucIon,InfecIon,CVI,Surgery,InfecIon
StagesofLymphedema
• Stage0/Subclinical:PaIentfeels“heaviness”ininvolvedlimb.FibroIcchangesandfluidaccumulaIoncanoccurbeforevisibleswellingorpiTng
• Stage1:Reversiblelymphedema.AccumulaIonofprotein-richfluid,elevaIonreducesswelling.Tissuepitsonpressure.
StagesofLymphedema
• Stage2:Spontaneouslyirreversiblelymphedema.ProteinssImulatefibroblastformaIon(fibrosis).ConnecIveIssueandscarIssueproliferate.MinimalpiTng,evenwithmoderateswelling.
• Stage3:LymphostaIcelephanIasis.HardeningofdermalIssues,papillomasoftheskin,Issueappearanceiselephant-like(notallprogresstothisstage).
VenousHypertensionRelatedEdema
• Chronic“venousinsufficiency”
• PostthromboIcsyndromecanleadtothis
• IncreaseinbloodcapillarypressureresultsinanincreaseinnetfiltraIoncausinganincreaseinlymphaIcload
• Hemosiderinstainingisthekeyindicator
Phlebolymphedema
• EndstagevenousinsufficiencyrelatededemacancausesignificantoverloadtothelymphaIcsystemcausingpermanentchanges
• Thisiswhenonewouldseelipodermatosclerosis
• LimbsizemaybesmallrelaIvetotheendstagesoflymphedemabutdemonstratesulceraIons,varicosis,andpain
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Lipedema
• “LipedemaisachronicmetabolicdisorderoftheadiposeIssue,ofunknowneIology,andismarkedbyabilateralandsymmetricalswellingofthelowerextremiIes,causedbyextensivedepositsofsubcutaneousfaXyIssue.”AllenandHines,1940
Lipedema
• O^enmisdiagnosedasbilateralprimarylymphedema,extreme“celluliIs,”ormorbidobesity
• Sparesthefeet,bilateralandsymmetrical,negaIvestemmerssign
• Almostexclusivelywomen• Canleadtolymphedema(lipolymphedema)andvenousdisorders
• Doesnotimprovewithexercise
EdemaDuetoMalignancy
• GrowthofthetumorcanplacepressureonandlimitthelymphaIcsystem
• Symptomsincludepain,paresthesias,paralysis,rapiddevelopmentofswelling
• CanleadtoIssuebreakdownandwounds
TraumaIcEdema
• PhysicaltraumacancauseatemporarydisrupIonofthetransportcapacity
• Significantscarringwithtraumacanleadtoasecondarylymphedema
• Surgery,blunttrauma,andburnscanresultininflammatoryreacIons
• Typicallyreturnsbacktonormal
FluidRetenIonStates
• Endocrine,cardiac,renal,hepaIc,andothermedicalcondiIonscanresultinthebodyretainingfluids
• Typicallyfullbodyandbilateralinvolvementtothelimbsisnoted
• So^“marshmallow”like,lowproteinedema• CanbetreatedwithdiureIcs• Ifpoorlymanaged,canturnintoalymphedema
OtherInflammatoryProcesses
• InflammaIoncausesproteindumpingfromthecapillaries
• InflammatoryrheumaIsm/rheumatoidarthriIs:inflammaIonofthesynovialmembraneofjoints
• ReflexsympatheIcdystrophy:pain,edema,autonomicdysfuncIon,movementdisorderandtrophicchanges
• OsteoarthriIs
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DependentEdema
• O^enseeninthosethataresedentaryorhavelimitedmobility
• ImpairedlymphaIcflowduetoposiIoning,mostcommonlytheinguinalandpoplitealregion
• DecreasedmusclepumpacIvaIon• Typicallyresolves/improveswithelevaIonandposiIoning
CelluliIs
• A.K.A.Erysipelas• PainfulinflammaIonoftheso^IssueduetoacuteinfecIon
• Expandinglocalerythema,palpablelocallymphnodesinsomecases,feverandchills
• MostcommoncomplicaIonoflymphedema
LymphangiIs
• InflammaIonofoneormoreofthelymphaIcvessels,usuallyduetoaninfecIon
• StreptococcalinfecIonmostcommon• Fineredstreaksfrominfectedareathatspreadsproximallyonthelimb
• Canpresentwithfever,chills,headacheandmyalgia
• Treatedbypenicillinandhotsoaks
TreatmentOp1ons
NowthatIhaveanideaofwhattypeofedemaitis,whatdoIdonow?
TreatmentStrategies:LowProteinEdemas
• Lowproteinedema=alledemasexceptforlymphedema
• TreattheunderlyingmedicalcomplicaIon• ElevaIon/PosiIonalchanges• MusclepumpacIvaIon• Compressionmanagement• Kinesiotaping®• ElectricalSImulaIon
TreatmentStrategies:HighProteinEdemas
• FulldecongesIvetherapy• Lymphedema/vasopneumaIcpumps• ElectricalSImulaIon• Kinesiotaping®
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FullDecongesIveTherapy
• ManuallymphaIcdrainage• Compressionwraps• TherapeuIcexercise
GoalofDecreasingLymphaIcLoad
• RemovestagnantwasteproductsfromIssue• IncreaseoxygenIssuetopromotewoundhealing
• Decreasecycletofibrosis
ManualLymphaIcDrainage
• PosiIonpaIentwithheadslightlyelevated
• Workingphase(“onphase”):stretchingtheso^Issue/subcutaneousIssue• ResIngphase(“offphase”):elasIcityoftheskinmovesthetherapist’shandpassivelytoallowabsorpIonfromtheintersIIum
KeyConceptswithMLD
• Lightpressureapplied• Morefirmpressureoverareasoffibrosis• Each“workingphase”shouldlastabout1secondandrepeat5-7Imes• Clearproximallyfirstandthenflowdistaltoproximal
KeyConceptswithMLD
• Clearandflowbetweengroupsoflymphnodes
• Pumppoints:useoftwobundlesofnodestofacilitateimprovedlymphaIcmobilizaIon
-Ex.Medialkneeandlateralhip• HEPforselfmobilizaIontechniques
EffectsofMLD
• IncreaselymphproducIon• Increaselymphangiomotoricity• Reverseoflymphflow
– Deepcollectorsdon’tcrossbetweenwatershedsbutsuperficialcollectorsdo
• Increaseinvenousreturn• Soothing• Analgesic
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ContraindicaIonsforMLD
• AcuteCardiacedema• Renalfailure• AcuteinfecIons• AcutebronchiIs
• AcuteDVT• Malignancies• Bronchialasthma• Hypertension
PrecauIonsforMLD
• Pregnantwomen• Abdominalsurgeries• Hyperthyroidism(limitneckduetoincreasehormonerelease)
• AorIcaneurysm• InflammatorycondiIons• RadiaIonfibrosis
ExampleMLDPlanforLymphedema
• 1sttreatmentsession:MLDtotrunk• 2ndtreatment:MLDtotrunk,plusbilaterallimbs
• 3rdtreatment:MLDtotrunk,plusbilaterallimbs,instrucIononHEP
• Followingsessions:focusonareasofinduraIon,scarIssue,etc.
ExampleRouIneforEdemaPost-OpTotalKneeReplacement
1. Tummyrubsx10anddeepbreathingx52. Inguinalnodechopsx10followedbykneeto
chest3. Poplitealnodeclearingx10followedby
sweepsfrominsideandoutsidekneetowardLATERALhip(alwaysdistaltoproximal)
4. x10kicksandx20anklepumps5. Tummyrubsx10anddeepbreathingx5
Compression Therapy
• Elastic fibers of the cutaneous tissues are damaged in lymphedema
• Goal = maintain the decongestive effect during the MLD session
EffectsofCompressionTherapy
• ImprovesvenousandlymphaIcreturn• ReducesnetfiltraIon• Improveseffectofthemusclepumps• Preventsre-accumulaIonofevacuatedfluidpostMLD
• Helpsbreakupandso^endepositsofconnecIveIssueandscarIssue
• ProvidessupportforthenowinelasIcfibers
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Bandaging
• Shortstretchisthebandageofchoice• MulIplelayersused• PaIentsshouldmaintaintheiracIvitylevels
• Criteriaforstabilizededema:reducIonincludesremodelingofthesubcutaneousfibrosis,pliableIssuewithnoinduraIon,andnofurtherdecreaseingirthfor7–10days.
BandageApplicaIon
• Dresswound(s)asappropriate• StockineXefirsttocollectsweat• CoXonorfoampadding• Typically3rollsofshortstretchbandageused:smallesttolargestwidth.SpiralapplicaIon,nevercircumferenIal
Bandaging
HammandPerdomo.
CompressionGarments
• Longtermcompressionmanagement
• UsedtopreservetreatmentsuccessduringdecongesIvetherapies
• CompressiongarmentsmeanttoMAINTAINcurrentedemanotreduceittobaseline
• IllfiXedandineffecIvecompressiongarmentsmaycauseharmtoapaIent
CompressionGarments
• Differentlevelsofcompressiondependentuponmanufacturers
• <20mmHgcompressionisnotsuitableinmanagementoflymphedema
• Usually20-40mmHgcompressiongarmentsareused
TherapeuIcExercise:Benefits
• Improvedstrength• DecreaseinresIngheartrate• Improvedstrengthinbone,tendonandligaments
• Decreaseinbodyfat• Physiologicaleffects:increasesbloodcapillarypermeability,filtraIon,andlymphaIcloadofwater
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ExerciseandEdema
• Mostbeneficialwhencompressionisused• Appropriatecompressionprovidesresistancetopromotethemusclepump
• NospecificexercisethatisbeXerorworseforedemamanagement
• DoNOToverstressthepaIentwithexcessiveexerciseasthiscancausemicroswelling
Lymphedema/VasopneumaIcPumps
• Improperuseofthepumpcancomplicatelymphedemamanagement
• Lymphedemapumpsclearproximallyfirst• TypicallybestuIlizedformaintenanceorinconjuncIonwithtreatment
• Goodforvenoushypertension
TapingObjecIves
• Neurosensory:assistinrestoringmotorpathwaysanddisruptpain
• Structural:assisttoimproveso^IssueorjointimpairmentsbyinhibiIngorfacilitaIng
• Microcirculatory:promotemovementofstagnantsuperficialfluid,removeirritantsandimproveoxygenaIon
KinesiotapingCorrecIveTechniques
• Mechanical:improvestabilityorbiomechanics• Fascial:directmovementoffasciaanddecreasefascialimitaIons
• SpaceCorrecIon:decreasepressureovertargetIssue
• Ligament/tendon:reducestressonaligamentortendon
• FuncIonal:providesensorysImulaIontoinhibitorfacilitateamoIon
• Circulatory/lymphaIc:toreduceedemaandpromotemovementoflymph
ApplicaIonandUse
• CanusevarioustypesoftapingtoaddressparIcularneeds
• ScarandfascialmobilizaIon• Edemaandbruisingmanagement• Forlymphedema,typicallyinconjuncIonwithfulldecongesIvetherapies
SpecificTechniques
• SpacecorrecIonli^ing– 10-35%tension– DecreasepressureontargetIssue
– Createrecoilandli^overtargetIssue
– I,donuthole,webcut
• CirculatoryandlymphaIccorrecIon
– 0-20%tension– Fancut– Anchorproximallytowardhealthylymphnode
– Fantailsovercongestedarea
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PrecauIonsforTaping
• Tapeallergies• GeriatricandcondiIonsthatcauseprematureaging
• CongesIveheartfailure• Diabetes• Kidneydisease
ContraindicaIonsforTaping
• Tapeallergies• FragileorhealingIssue• Openwounds• CelluliIsorinfecIon• Malignancysite• Coronaryarterydisease• Deepveinthrombosis• Pregnancy
ConsideraIonsbeforetheapplicaIon
• Skinshouldbecleaned,dry,andfreeofoilsormoisturebeforeapplicaIon.
• Removehairifneeded• Roundedges• AcIvateadhesivewithrubbing• EducatepaIentonwearImeandcareoftape
OtherTips
• Ifapplicable,documentthenumberof“blocks”used
• TheobjecIveofthetape• Targetedmuscleormusclegroup• CorrelatebacktofuncIon• Discussperformancewithandwithouttape
EvidenceforEdemaManagement
• Bialoszewskietal2009,RCT– 24parIcipantswithlowerextremityedema– Kinesiologytaping+PTvsPTonly– Decreasesnotedinthethighwithkinesiologytaping
• Han-JeTsai2009– 41parIcipantswithBCRL– Bandagingvskinesiologytaping– Nodifferenceinvolume– AcceptanceandadherencewasbeXerwithkinesiologytaping
ElectricalSImulaIonParameters
• Goal:TreaIngforedemareducIon– Muscle“milking”– Bipolarsetuponmuscleproximaltoedema– Lowfrequency(1-10pps)– Visible,comfortablemusclecontracIon– Elevatelimb– 15-30minuteswithorwithoutcoldapplicaIon
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Parameters
• Goal:producetetanicmusclecontracIons
– Frequency:arbitrary30-60pps– Mode:pulsed,on/off1-5or1-3– Amplitude:arbitrary1-500V– DuraIon/width:arbitrary5-30min
ElectrodePolarity
• NegaIve– Increases:Vascularity,SImulaIonoffibroblasIcgrowth,CollagenproducIon,EpidermalcellmigraIon
– InhibitsBacterialgrowth
• PosiIve– Increasesmacrophages
– Promotesepithelialgrowth
ApplicaIon
• Treatmentshouldbe30-60minutes• Electrodetype
– rubbercarbon,electro-meshglove/sock• Electrodearrangement
– Largedispersiveelectrodewith:• one,two,orfouracIveelectrodes(bifurcated)• Equalsize(ifmorethanoneacIveelectrode)
• Couplingmedia– gelorsalinesoakedsponge– ConducIvespray
PrecauIons
• Burn– Excessiveelectricaldensity
• IntensitytoohighforsizeoftheacIveelectrode• Directmetalcontact
GeneralRehabConsideraIons
• ImpairedmobilityandfuncIonduetosizeoflimbs
• GaitdeviaIons
• LimitedcardiovascularenduranceanddecondiIoning
ApproachesforPrevenIon
• EducaIon,educaIon,educaIon• ProtectskinandperforminspecIons• AppropriateprogressionofacIviIes• AvoiduseofbloodpressurecuffandneedlesIcksoninvolvedlimb
• Monitorandpreventrapidweightgain• Managephysicalchangeswithaging• Avoidsystemicorlocaleventscausinghyperemia• TakecauIonwithpressurechanges
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AROM/ joint
mobs
compression muscle strengthening
gait training
MLD breathing exercises
CP endurance
skin care patient education
CVI X X X X X X
secondary lymph
X X X X X X X X X
lipedema X X X X X X X
orthopedic conditions
with edema
X X X X X X X
CVI/lymphedema
X X X X X X X X X
AdaptedfromHammandPerdomo.
CommonEdemaDiagnosisandRecommendedInterven1ons
SkinandNailCare
• EdematousIssuebecomethickenedandscaly,increasingriskforskincracksandfissures
• PaIentswithlymphedemaaresuscepIbletoinfecIonofskinandnails• StreptococcusbacteriamostcommoncauseforinfecIonsinpaIentswithlymphedema
GeneralSkinCareRecommendaIons
• Soaps,moisturizers,andointments:Nofragrances,Hypoallergenic,NeutraloracidicpHscale
• Protectfromtrauma,keepskincleanandusebugsprayandsunscreen
• BasicmoistwoundhealingtechniquesinconjuncIonwithlymphedemamanagement
GeneralWoundCareManagementWhatifthereisawound?
Wounddepth
Par1althickness:skinlossinvolvingtheepidermisandupperlayerofthedermis.• Healsthroughre-epithelializaIon• TissueregeneratedtooriginalfuncIonFullthickness:skinlossextendingpastpapillarydermis.MayincludesubcutaneousIssue,tendon,muscle,andbone.• HealsbygranulaIonIssueformaIon,contracIonand
eventualepithelializaIonfromwoundmargin.• ResultsinscarformaIon(70-80%strengthoforiginal)• Tissuedoesnotregenerate
Time to heal dependent on: VascularityTissueDepth
Full thickness: Distal Full thickness: Proximal
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Time to heal dependent on…
Geometric shape
Linear < Rectangular/Square < Circular
Implications for Mobility?
Full thickness Sacral Pressure Ulcer
Wound Healing Phases
SussmanC;Bates-JensenBM.
Hemostasis
Minutes Inflammation
Days Proliferation
Weeks Remodeling
Year(s)
“TreatthewholepaIent,nottheholeinthepaIent.”
Characteristics of Lower Extremity Ulcers Type Cause Pain Location Appearance
Arterial Arteriosclerosis Pain can be severe due to lack of blood flow.
Toes/fingers. Lower third of leg.
Defined borders. Dry/necrotic. Little to no granulation. Hairless, cooler skin.
Venous Venous Hypertension
Mild Proximal to the medial malleolus
Irreg. borders, red wound base, heavy drainage, hemosiderin staining
Pressure Prolonged pressure/Shear
Varies on structures involved.
Over bony prominences
Varies depending on location/depth. May note discoloration Non-blanching erythema
Neuropathic Diabetes (neuropathies)
None. Patients with an infection may experience pain.
Plantar Foot Pale, pink base, moderate drainage, callus tissue, atrophy, hammer toes.
Adapted from Hamm R. (2015)
Wound Bed Preparation (WBP)
WoundbedpreparaIonisthemanagementofawoundinordertoaccelerateendogenoushealingortofacilitatetheeffecIvenessofothertherapeuIcmeasures.Falanga,2003
PrincipalsofWBP:• IdenIfythecause• PaIentcenteredapproach• Assessthewound• Debridement• BacterialControl• MoistureBalance• Monitorrateofhealing
Sibbald, G. Et al., 2011
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TIME Principles of Wound Bed Preparation (International Advisory Panel on WBP)
Tissue non viable or deficient
Infection or inflammation
Moisture imbalance
Edge of wound non advancing or undermining
Defective matrix & cell
debris
High bacterial counts or prolonged
inflammation
Desiccation or excess
fluid
Non-migrating keratinocytes
Non-responsive wound cells
↓ Debridement
↓
↓ Antimicrobials
↓
↓ Dressings,
compression ↓
↓ Biological agents, adjunct therapies,
debridement
Restore wound base & ECM proteins
Low bacterial counts and controlled
inflammation
Restore cell migration,
avoid maceration
↓ Stimulate
keratinocyte migration K
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and
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ullo
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on
Objec1ve:Necro1cTissueTypes
• NonviableTissue:necroIcIssue,cellulardebris,senescentnonfuncIonalcellsandbacterialbiofilms
• Eschar:composedofdeadskinorsubcutaneouscellsvariesincolorandtexture.Notsynonymouswitha“scab”
• Slough:non-viablesubcutaneousIssueandisaresultofthebody’sautolyIcprocesstophagocytosedeadcells
MoistWoundHealing
• Necessaryforwoundstoheal• Useofappropriatedressingshelpsfacilitatethisbalance
• Constantmonitoring/re-assessmentnecessarytomeetneedsofchangingwoundenvironment
Great Reference!
Ovington, L. Hanging Wet-to-Dry Dressings Out to Dry. Advances in Skin & Wound Care: The Journal for
Prevention and Healing. March/April 2002. 15:2; 79-84.
ConsideraIonsWhenSelecIngaDressing
• Drywound→Moistenit
• Excessivedrainage→Absorbit
• NecroIcwound→Debrideit
• GranulaIngwound→Protectit
DressingFunctions
• Absorbdrainage• Providemoisture(hydrate)
• ProtectIssue• Obliteratedeadspace
• Actasabarriertobacteria
• Minimize/controlodor
• Decreasepain• Offerbacterialcontrol
AbsorbencySpectrum
Gauze Foam Alginate Hydrofiber
Less Absorbent More Absorbent
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Let’sreview
• HowmuchdrainageistypicallyassociatedwitheIologylisted?
– DiabeIc/Neuropathic
– Venous– Arterial
• UsetheseopIons:– LiXle/Scant– Moderate– Heavy
“WhatDressingShouldIUse?”
• Variousstudieshavedonedressingcomparisons
• Weakevidence• NostandardtargetpopulaIonsused• Mostdomorethanbasicwettodry• Somestudiesdidshowthatthereweredifferencesinfrequencyofchanges,financialburdenandpainwithdressings
IsThereaRightAnswer?
• KnowthewoundpresentaIonandeIology• Whatisthegoalathand?• Whatisavailableatyourfacility?• Whowillbedoingthedressingchange• Frequency?• Pain?• Finances(insuranceandCMSlimitaIons)
WoundDressingsCategorizedbyFuncIonality
Adaptedfrom
Kloth,L.C.,McCulloch,J.M
.(2010)
Wound Dressing Function Dressing Category
Moisture maintenance Transparent Films Hydrocolloids
Moisture absorption Foams Alginates Hydrofibers
Moisture addition Hydrogels
Reduce bacterial levels (antimicrobial) Silver-containing dressings Iodine containing dressings
Reduce protease levels Collagen dressings Collagen-ORC dressings
Reduce odor Activated charcoal additive Cyclodextrin additive
Reduces pain Ibuprofen-containing dressing Soft silicone dressings
ImportanceofMonitoring
• Onedressing/combinaIonofdressingswillNOTbeappropriatefromstarttofinish
• DocumentaIonisEXTREMELYimportantsowecanrecognizechangesassoonastheyoccur
• Woundchangesnotedin2weekswillhelpyoudecide
DocumentaIonandBilling
• Policy:facility,NaIonalandlocalcoveragedeterminaIons,conservaIvetreatmentconsideraIons
• Billing:appropriateCPT,EnsurethepolicycoverstheparIcularwoundcarebeinguIlized
• DocumentaIon:outcomemeasures(funcIonalandself-report),photos,paIentorcaregivereducaIon
10/2/16
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CommonWoundCareCPTs
Sitetoaccessmostcommonlyusedcodesforwoundandedemacare:
www.apta.org/Payment/Coding/FAQs/AcIveWoundMgmt/
SitetoreferenceforuptodatechangesonCPTsingeneral:www.apta.org/Payment/Coding/CPTChanges/
CaseStudiesAllthatinfoisgreat!But,canIreallyapplyit?
References• BaranoskiS.,Ayello,E.A.(2015).WoundCareEssenIals3rdEdiIon
• BeXanyJA,FishDr,MendelFC.InfluenceofhighvoltagepulseddirectcurrentonedemaformaIonfollowingimpactinjury.PhysTher.1990.70;219-224.
• Casley-Smith, JR and Gaffney, R.M. (1981). Excess plasma proteins as a cause of chronic inflammation and lymphoedema: quantatative electron microscopy. Journal of Pathology, 133, 245-272.
• Chikyl, B. Lymphedema: An overview. Silent Waves: Theory and Practice of Lymph Drainage Therapy. Scottsdale, AZ, International Health & Healing, 2001
• Hamm and Perdomo. Lymphedema. Text and Atlas of Wound Diagnosis and Treatment. McGraw and Hill. 2015. 143-164.
• Kloth,L.C.,McCulloch,J.M.(2010).WoundHealing:EvidenceBasedManagement4thed
References• Lymphnotes.com. Last updated 2013. Accessed March 2014.
• Macdonald, JM. Wound healing and lymphedema: A new look at an old problem. Ostomy Wound Mange 2002; 47; 52-57.
• Zuther, Joachim. Lymphedema Management: The Comprehensive Guide for Practitioners. 2nd Edition. New York. 2009.
• Reed BV. Effect of high voltage pulsed electrical stimulation on microvascular permeability to plasma proteins. A possible mechanism in minimizing edema. Physical Therapy. 1988;68(4):491-5.
• Robinson, AJ, Mackler, LS. Clinical Electrophysiology, 2nd ed. Lippincott Williams & Wilkins, Philadelphia. 1995.
• Prentice WE. Therapeutic Modalities for Allied Health Professionals. McGraw-Hill. St. Louis. 2005.
References
• Taylor K, et al. Effects of electrically induced muscle contraction on posttraumatic edema formation in frog hind limbs. Phys Ther. 1992. 72; 127-132.
• Sibbald, G et al. Special Considerations in Wound Bed Preparation. Advances in skin and wound care. 2011;24;415-36.
• Snyder AR, Perotti AL, Lam KC, Bay RC. The influence of high-voltage electrical stimulation on edema formation after acute injury: a systematic review. J Sport Rehabil. 2010;19(4):436-51.
• SussmanC.,Bates-JensenB.(2012).WoundCare:ACollaboraIvePracIceManualforHealthProfessionals.4thediIon.
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