EDEMA CONFUSION

Marta Ostler PT, CWS, CLT

Physical Therapy and Lymphedema

An Art and A Science

OBJECTIVES:

1.Recognize different types of edema

2.Recognize how our fluid transport

systems are interwoven

3.Recognize treatment opportunities

Organized Approach to Wound Care1. Is there adequate perfusion

and/or oxygenation?

2. Is non-viable tissue present?

3. Are signs/symptoms of infection and/or inflammation present?

4. Is offloading or pressure relief appropriate?

5. Is edema controlled?

6. Is tissue growth optimized?

7. Is the wound microenvironment conducive to healing?

8. Is pain controlled?

9. Are host factors optimized?

Offloading

Disease Process

Controlled

BioBurden

Advanced Modalities

Wound Moisture Balance

Debridement

Blood Flow

Patient Centered Pain

Edema

VASCULAR MECHANICS

VENOUS SYSTEM

■ DEEP VEINS

■ SUPERFICIAL VEINS

■ COMMUNICATING VEINS (PERFORATORS)

■ VALVES

■ CALF PUMP

Hegarty M,: Am Overview of Compression Therapy. Today’s Wound Clinic vol 4

issue 10-Oct 2010.

CHRONIC VENOUS ULCERS (CVI)

Venous Ulcer account for 60-90% of leg ulcers

More common in women: 3X

Difficult to heal: 50% > 9 months/20% > 2 years

High rate of reoccurrence: 60% WHY???

76% Diagnosed by presentation alone

Advances in Skin & Wound Care: August 2009 - Volume 22 - Issue 8 - p 384

What Effects the Pressure??

Directly proportional to persons Height: Distance from head to feet

OBESITY: Linear relationship girth and vascular pressure

■ Resting Pressure/supine: ~8 mmHG

■ Standing: + 100 mmHG

■ Ambulation: ~25-100 mmHg

Hegarty M,: Am Overview of Compression Therapy. Today’s Wound Clinic vol 4 issue 10-Oct 2010

Partsch H, Annuals Vascular Disease 2012

VENOUS PRESSURE :Anatomic Failure

Ambulatory Venous Hypertension:

The elevated pressure in the leg vein during walking

Even with intact vessels:

25 mmHg calf pump - 8 mmhg rest = 17 mmHg

1. Venous Wall Physical Properties: Reduced Strength

2. Venous Valves

Degenerative damage DVT

3. Calf Pump (….exercise…..☺)

90% of venous return is through these 3

Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practitioner's guide to treatment and prevention of venous leg

ulcers; Wounds International: 2013

LYMPHEDEMA

An abnormal collection of excessive tissue

proteins, edema, chronic inflammation and fibrosis

in the interstitial space. The International Society of Lymphology

CHRONIC PROBLEM

NO CURE

TREATMENT: CDT PROGRAM

-Manual Lymphatic Drainage

-Compression Therapy

-Skin Care

-Exercise

ANATOMY

■ PRECOLLECTORS

■ COLLECTORS

■ LYMPHATIC CAPILLARIES

■ NODES

■ THORACIC DUCT

MECHANICAL INSUFFICIENCY

LYMPHATIC SYSTEM IS DAMAGED AND HAS REDUCED

TRANSPORT CAPACITY

Structural/Functional Abnormalities

Low Output Failure

DYNAMIC INSUFFICIENCY

FLUID LOAD EXCEEDS LYMPHATIC TRANSPORT CAPACITY

Infection

CVI

Trauma

Cardiac Insufficiency, etc

High Output Failure: OVERLOAD

Dr. Wade Farrow:“WITHOUT FUNCTIONAL LYMPHATICS, WE

WOULD DIE IN ABOUT 24 HOURS.”

Guyton AC: Texbook of Medical Physiology. 8th ed. Philadelphia. PA: WB Saunders: 1991.

Carlson JA (2014) Lymphedema and subclinical lymphostasis (microlymphedema) facilitate cutaneous

infection, inflammatory dermatoses, and neoplasia: A locus minoris resistentiae. Clin Dermatol32(5): 599–

615

Foldi M, Foldi E (2012) Textbook of Lymphology (3rd edn.). Elsevier GmbH, Munchen, Germany

Carlson and Foldi:

Lymphatic Failure= infection,

inflammation and carcinogenesis

“PHLEBOLYMPHEDEMA”

WHAT?????

Mixed-etiology swelling…….

CVI+ lymphatic insufficiency

=Phlebolymphedema

SOOOOOOOOO…….

DEFINITION:

Phlebolymphedema:

is due to insufficiency of the venous or/and lymphatic system, in combination with

possible systemic contributors, leading to accumulation of interstitial

protein-rich fluid in the interstitial space.

What we get…..

▪ Hyperemia: Venous Hypertension

▪ Increased interstitial fluid

▪ Increased sub fascial edema

▪ Increased compartment pressure

▪ OVERWHELMED LYMPHATIC SYSTEM

▪ PROINFLAMMATORY STATE

STARLINGS LAW

1) Capillaries are semi-porous membranes Fluid moves in and out

2) Increasing capillary hydrostatic pressure , moves fluid into the interstitium

3) Lower capillary hydrostatic pressure+ higher capillary oncotic pressure of

proteins= pulls fluid back into the venous system.

Maybe NOT?

ENDOTHELIAL GLYCOCALYX LAYER

Controls movement of

proteins and fluid across

the blood capillary wall

There is NOreabsorption of fluid,

back into the venous

side of blood capillaries

REABSORPTION OCCURS

ONLY THROUGH THE

LYMPHATIC CAPILLARIESPhoto used with permission

The EGL: regulates fluid/protein movement

1. Through the capillary wall to tissue

2. Prevents movement back into venous side of

capillaries: even in presence of higher pressures.

All fluid/protein existing the blood capillaries

into the interstitium MUST be removed by the

lymphatics.

THEREFORE:

“ Arguably, it may be better to consider the presence of chronic oedema

as synonymous with the presence of lympheoedema, in as much all

oedema represents relative lymph drainage failure.” Mortimer and

Rockson (2014)

CLINCAL CONSIDERATIONS

Consider lymphatic function

Recognize lymphedema comes in various forms

Use Stemmers sign at various physical locations

Consider CDT/MLD program: PT/OT

-compression

-exercise

-manual lymphatic mobilization

-skin care

WHAT DOES ALL THIS LOOK LIKE??

LYMPHEDEMA RUBRA Lipodermatosclerotic changes (sand

paper) -CELLULITIS?

FUNCTIONAL CONSIDERATIONS

Lymph node locations: joints

Joint Movement

Mobility

Endurance: (Heart rate/Breathing)

Accountability

WHAT MUST WE DO ABOUT IT?

COUNTERACT GRAVITY: ELEVATION

EXERCISE

COMPRESSION THERAPY

MANUAL LYMH DRAINAGE

SKIN CARE

SELF MANAGEMENT

EXERCISE!!CALF RAISES

CALF STRETCHES

MARCHES

DAILY WALKING

UP AND DOWN STAIRS

SWIMMING

• 75 % adherence

• 24% improved healing rates

Obrien J, Finlayson K, Kerr G, Edwards H; Evaluating the effectiveness of a self –management exercise intervention on wound healing, functional ability and

health-related quality of life outcomes in adults with venous leg ulcers: a randomized controlled trial. Int Wound , 2016 Jan 27.

PURPOSE OF COMPRESSION

1.Counteract the force of gravity and promote the normal flow of venous blood up the leg

2.Acts on the venous and lymphatic systems to improve venous and lymph return and reduce edema

3.Causes narrowing of the superficial veins

Meissner,M, Lower Extremity Venous Anatomy, Interventional Radiology, Sept. 2005, ; 22(3): 147-158

Beidler et al, Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression

therapy. Wound Rep Regen 16:642-648, 2008.

Elevated MMP-1 in Venous Ulcers

TYPES

■ COMPRESSION WRAPS

■ COMPRESSION HOSIERY

■ INTERMITTENT PNEUMATIC COMPRESSION (IPC)

■ MIXED TEXTILES

HOW DO WE DEFINE THIS IN PRACTICE??????

Types of Compression

■ ELASTIC

■ INELASTIC

■ STATIC

■ DYNAMIC

■ WRAPS

■ HOSE

■ LONG STRETCH, SHORT STRETCH

■ NON-STRETCH

HELP!!!!!

PARTNER WITH A LYMPHATIC THERAPIST

WHAT IS ADAQUATE COMPRESSION

■ Overcomes intravenous pressure

■ Exerts a sub-bandage resting pressure that is well tolerated

in a resting position

■ Provides a pressure increase when the patient rises to a

standing position: (50-70mmHG)

■ Provides external compression improving venous reflux

during walking

Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practitioner's guide to treatment and prevention of venous leg ulcers; Wounds

International: 2013

Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

La Places Law:

A formula that defines the pressures exerted on curved surfaces

Pressure = T x N

C xW

N= number of layers applied

T= bandage tension

C= limb circumference

W= Bandage Width World Union of Wound Healing societies (WUWHS). Principles of best practice:

Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008

Lymphatic PrinciplesIT’S THE LAYERS

Non-Stretch

ZINC PASTE BANDAGES

Short Stretch

■ Bandages that stretch to less than 100% of their

original length: minimal extensibility

■ High Working Pressure/Low Resting Pressure

Long Stretch

■ Expands over 100% of its original length

■ Low Working Pressure/High Resting Pressure

■ Contains Elastomeric Fibers: fibers that are able to stretch and return to almost their original size.

World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensusdocument. London: MEP Ltd,2008

Combining Textiles

ULCER X 7 YEARS3 YEARS ACTIVE TREATMENT3 X PER WEEKNO FINAL CLOSURESTARTED PHYSICAL THERAPY- EXERCISE-NODE MASSAGE-INELASTIC MULTILAYER COMPRESSION

TAKE HOME PEARLS

■ THINK ABOUT THE WHOLE PATIENT…..

■ REMEMBER OTHER SPECIALITIES THAT MAY BE

ABLE TO HELP

■ EDEMA IS NOT DIAGNOSIS SPECIFIC: ALWAYS,

NEVER…ETC

■ EXERCISE/MOBILITY

■ LYMPHATIC CARE/EDUCATION

■ COMPRESSION TOOLS/TRICKS

BIBLIOGRAPHY

■ Brenner E, Putz D.MorigglB: Stemmer (Kaposi-Stemmer-sign-30 years later. Phlebologie.2007: 36(6):320-324.

■ Farrow W, Phlebolymphedema-A common Underdiagnosed and Undertreated problem in the wound Care clinic. Journal fo the Am. College of certified Wound specialists (2010) 2: 14-23

■ Valencia IC, Falabella A, Kirsner RS, Eaglstein WH: chronic venous insufficiency and venous leg ulceration . J am Acad, Dermatol. 2001 44(3):401-421.

■ Guyton AC: texbook of Medial Physiology. 8th Ed. Philadelphia PA: WB Saunders: 1991.

■ FoldiE, Foldi M, Chronic venous insufficiency and venous-lymphostatic insufficiency. In: Foldi’s texbook of lymphlogy . 2nd ed. Munich, Germany; Elsevier, 2006 p. 434-447.

■ Fugman SL, Clar, RA, Stasis dermatitis. Available at Http://emedicine . Medscape,com/article/1084813-overview. Accessed april 26, 2010

■ Goldman MP: Lipodermatosclerosis: review of ases evaluated at the Mayo clinic H Am Acad Dermatol. 2002:46: 187-192.

■ Blankfield RP, Finkelhor RS, AlexanderJJ, et al: Etiology and diagnosis of bilateral leg edema in primary care. Am J Med. 1998: 105: 192-197.

■ Beidler, S. K., Douillet, C. D., Berndt, D. F., Keagy, B. A., Rich, P. B., & Marston, W. A. (2009). Inflammatory cytokine levels in chronic venous insufficiency ulcer tissue before and after compression therapy. Journal of Vascular Surgery, 49(4), 1013–1020. http://doi.org/10.1016/j.jvs.2008.11.049

■ Bjork R, Hettrick H; Endothelial glycocalyx layer and interdependence of lymphatic and integumentary systems, Wounds International 2018, Vol 9 Issue 2 .

■ Best Practice for the Management of Lymphoedema - 2nd edition, www.lympho.org