Lymphoedema - Physiotherapy Management

BPT
MPT

1. Lymphoedema : PT Management Dr. Shreya Monpara Guide: Dr. D. N. Bid

2. INTRODUCTION Lymphoedema is a chronic disease marked by the increased collection of lymphatic fluid in the body, causing swelling, which can lead to skin and tissue changes The chronic, progressive accumulation of protein-rich fluid within the interstitium and the fibroadipose tissue exceeds the capacity of the lymphatic system to transport the fluid

3. LYMPHATIC SYSTEM Initial lymphatics Larger lymph vessels Lymph nodes Lymph

4. The lymphatic system is a one-way drainage system leading fluid from the tissues of the body to the veins in the neck. FUNCTION OF LYMPHATICS Waste Disposal Immunological Maintenence of tissue fluids

5. PHSIOLOGICAL CAUSE OF OEDEMA An equilibrium is normally maintained between tissue fluid formation and reabsorption in the body which is dependent upon hydrostatic and osmotic pressures, known as Starling’s forces, across the capillary wall.

6. FACTORS RESPONSIBLE FOR CAUSING OEDEMA Increased permeability of capillary walls. Decreased plasma osmotic pressure. Increased plasma hydrostatic pressure. Reduced lymphatic system transport capacity. TYPES OF LYMPHOEDEMA PRIMARY LYMPHOEDEMA Primary lymphoedema arises from an abnormality occuring within the lymphatic system

7. Classification according to age Classification of according to lymphographic appearance

8. SECONDARY LYMPHOEDEMA It arises from the influence of an external factor which affects the function of lymphatic system. CAUSES: Infection Inflammation Trauma Cancer and its treatment

9. STAGES OF LYMPHOEDEMA

10. CLINICAL FEATURES Swelling in an arm or a leg Can be fibrosis and pitting oedema. Limbs can feel heavy and achy. There is altered sensation. Reduced mobility and range of movement. Pain and joint discomfort. Skin changes, for example redness and increased temperature. Nail discoloration Hyperkeratosis and lymphangiectasia. Hardening, thickening, or tightness of the skin 

11. COMPLICATIONS Chronic lymphoedema Compression therapy complication Lymphorrhoea Malignant disease Psychological morbidity Venous complications CHRONIC LYMPHOEDEMA Lymphorrhoea

12. INVESTIGATION Lymphoscintigraphy Lymphoangiography MRI CT scan

13. ASSESSMENT Assessment of the condition of the skin Assessment of the shape of the swollen limb Assessment of the degree and extent of the swelling Assessment of limb function and discussion of the influence of the lymphoedema on the patient’s limb movement, their day-to-day roles, hobbies, social activities and occupation.

14. MEASURING LYMHOEDEMA Simple surface measurement Limb volume measurement

15. CALCULATING LIMB VOLUME Once all the measurements of the limb have been recorded, the volume of the limb can be determined. The mathematical formula for calculating the volume of a cylinder is used as it considers the limb as a series of cylinders, each with a height of 4 cm. The formula is : circumference 2 / ∏. By totalling the volumes of all the cylinders, the total limb volume can be reached. If the limb volume of the opposite limb is also calculated, the excess volume in the swollen limb can be estimated. The following is an example of how this can be done. Swollen left arm limb volume 2701.5 ml minus Normal right arm limb volume 2394.8 ml equals 306.7 ml. 100 ÷ Normal limb volume × volume difference between the two arms 100 ÷ 2394.8 × 306.7 = 13% . The swollen left arm is 13% bigger than the normal right arm

16. PITTING EDEMA SCALE Grade 0: No clinical edema Grade 1: Slight pitting (2 mm depth) with no visible distortion that rebounds immediately. Grade 2: Somewhat deeper pit (4 mm) with no readily detectable distortion that rebounds in fewer than 15 seconds. Grade 3: Noticeably deep pit (6 mm) with the dependent extremity full and swollen that takes up to 30 seconds to rebound. Grade 4: Very deep pit (8 mm) with the dependent extremity grossly distorted that takes more than 30 seconds to rebound.

17. MANAGEMENT The best global treatment Of lymphoedema, according to the international guidelines of the International Society of Lymphology is CDT. MLD(manual lymphatic drainage) Compression therapy Exercise Skin care Self care management

18. MANUAL LYMPHATIC DRAINAGE MLD is a light, skin-stretching massage that helps promote the movement of lymphatic fluid out of the swollen limb. MLD is composed of four main strokes: stationary circles, scoop technique, pump technique, rotary technique. TECHNIQUE Usually performed with the patient in the lying position Starts and ends with deep diaphragmatic breathing.

19. The unaffected lymph nodes and region of the body are treated first. Moves proximal to distal to drain the affected areas. Slow and rhythmical movements . Uses gentle pressure. CONTRAINDICATIONS Cardiac insufficiency Acute inflammation caused by pathogenic germs (bacteria, fungi, viruses). Deep venous thrombosis (DVT) Acute renal failure

20. COMPRESSION THERAPY Products used for compression therapy are low-stretch bandages and elastic garments.  Even when MLD is performed correctly, swelling does not decrease without compression. Compression bandages should remain on the extremities until the next session of MLD.

21. Principles : The size and shape of the swollen limb This principle forms part of the Law of laplace . The construction and type of compression material. COMPRESSION GARMENTS Construction : Circular, seamless knitted garments. : Flat-knit garments Style of garments Measuring for compression garments Application and removal of compression garments

22. CONTRAINDICATIONS Arterial insufficiency Deep vein thrombosis Poorly controlled cardiac failure

23. EXERCISES It consist of gentle stretching and range of motion exercises. Wear your compression garment or bandages when exercising to get the best out of the muscle pump action.

24. SKIN CARE Wash the skin daily Treat any cuts or breaks in the skin antiseptically. Keep the skin moist Wear well-fitting, comfortable shoes if the feet are affected Pay attention to care of the nails on the hands or feet: do not cut or tear cuticles – use a cuticle stick covered with cotton wool.

25. SELF CARE MANAGEMENT Avoid chemical hair removers when removing unwanted hair. Avoid extremes of temperature such as hot baths and cold showers. Wear loose clothing that does not constrict the limb. Make sure that any jewellery does not constrict the limb. Put on and care for their compression sleeves and garments.

26. ADDITIONAL TREATMENT CircAid Kinesiotaping Low-level laser therapy Pneumatic compression pumps Reid sleeve

27. REFRENCES Lymphoedema care- Mary woods Physiopedia Validation of the lymphoedema life impact scale version-2 : A condition specific measurement tool for persons with lymphoedema

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