Lymphatic facilitation for upper extremety injuries

http://www.nwata.org/storage/2011d10meeting/Lymphatic%20Facilitation%20-%20Pat%20Archer.pdf

National Lymphedema Network

LymphLink Question Corner

January-March 2011
Catherine Tuppo, PT, MS, CLT-LANA

Q:  Can you tell me if there are any new treatment techniques (discussed at the conference) that are being investigated for lymphedema?

A:  While the standard of care remains Complete Decongestive Therapy (CDT) which incorporates skin care, manual lymph drainage, compression bandaging, compression garments, and exercise, presentations highlighted research investigating pneumatic compression, low level laser therapy (LLLT), aqua therapy, acupuncture, and surgery such as liposuction.

Researchers are studying the optimal design for pneumatic compression devices as well as protocols for application. Speakers discussed utilizing multi-chamber devices with varied methodologies. Several presented papers which utilized compression devices with both trunk and limb components for upper limb and lower limb edema, at lower compression settings. Another discussed tissue response at various compression settings for lower limb edema. Benefits were noted by each speaker based on the study methods presented.

The positive and negative effects of LLLT were debated in a pro and con session. Another speaker described a pilot study investigating the effects of treatment with LLLT and MLD. This pilot study (n=5) noted short-term improvements in tissue water and hardness with LLLT, but no long-term effects. The speaker clearly defined limitations of the study discussing that a more rigorous research protocol is needed with a larger subject population, before clinical inferences can be made.

One speaker discussed a study incorporating aqua therapy (pool exercise) for Phase 2 lymphedema treatment. Aqua therapy, in this context, was noted to improve adherence during the self management phase when compared to a conventional self management regime.

The use of acupuncture for lymphedema treatment has been considered somewhat controversial due to concerns for tissue injury and/or infection when the lymphadematous region (or area at risk) is utilized for insertion of the acupuncture needle(s). One paper investigated the rate of infection when acupuncture is applied to the involved or at risk lymphadematous segments. The speaker discussed that in this study (n=29), no incidents of infection were noted.

Several papers addressed the current state of surgical interventions for lymphedema management. One speaker reviewed liposuction as a treatment option for chronic lymphedema. The presenter noted that before an individual is considered a candidate for this type of surgery, he/she must have undergone the standard of care for lymphedema, CDT. After liposuction surgery, the speaker noted it is imperative that the patient wear custom compression garments at all times (24 hours a day, 7 days a week) in order for the limb reduction to be maintained. The patient may continue MLD and CDT after liposuction. More widely performed in Europe, liposuction for lymphedema management in the United States is less available.

It is exciting to see that research is moving forward in many areas. However, we must understand that additional research is needed in all of these areas before potential benefits and potential harms can be reliably demonstrated. Long-term follow up, case-control design, and larger subject populations will assist in bringing the rigor of the research forward.

Q:  Have there been any further advances in the factors which may influence the development of breast cancer-related lymphedema?

A:  Factors related to the development of breast cancer-related lymphedema continue to be studied in long-term research protocols. The influence of genetics on the development of secondary lymphedema is now being investigated. Specifically, researchers are interested in determining if there is a genetic predisposition for lymphedema in individuals who develop lymphedema after treatment for breast cancer.

Q:  Is CDT or MLD (manual lymph drainage) effective for conditions other than lymphedema?

A:  Therapists have been successfully applying the principles of CDT and MLD to other diagnoses. One presenter discussed the utilization of modified MLD, elastic taping and compression bandages, along with traditional modalities, for a patient after total knee replacement, noting improvements in edema, range of motion and pain. Another speaker discussed the beneficial application of MLD along with deep tissue massage (DTM) in the post-operative care of patients undergoing a variety of cosmetic surgeries involving different areas of the body (face, breast, abdomen, buttocks and thighs).

Q:  Are there any new diagnostic imaging tests for lymphedema?

A:  Lymphoscintigraphy and lymphangiography remain the primary diagnostic imaging techniques for lymphedema; however several studies discussed the use of NIR (Near Infrared Fluorescence Imaging) for visualization of lymphatic flow. NIR may have promise moving forward; however it is a costly test, and requires the injection of the imaging medium into the limb. Nonetheless, it does provide a dynamic view of lymphatic flow and may prove beneficial for use in investigational studies looking at the impact of various treatment techniques on lymphatic function.

Catherine Tuppo, PT, MS, CLT-LANA

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Manual lymphatic drainage therapy in patients with breast cancer related lymphoedema

http://www.biomedcentral.com/content/pdf/1471-2407-11-94.pdf

Course Comments

Hi Carmen,
I took your continuing ed class in Saddle Brook, NJ last month. I have been curious about lymphatic drainage and wanted to learn some more about it to see if it would be something I should pursue further. I've decided I want to become certified. I wish I could come down to Virginia and take your course, but unfortunately that's not feasible.
Thank you Carmen for making my first exposure to lymphatic therapy such a positive one....it was a great class and it has inspired me.
Sincerely,
Laurie

Carmen,
I hope you are doing well.  My legs are doing great. 
 
I have a question.  When traveling instead of taking bandages to wrap or my overnight compression garments, can I just sleep in compression stockings?  I’m going to visit my sister in California for a week.  I don’t want to pack my overnight compression garments in  my checked in luggage because of the cost of the garments in case they are lost and don’t want to stuff them in a carry- on bag because they are so heavy.  I just wanted to make sure that compression stockings would work the same overnight to keep swelling down.  If I’m traveling and in a car, I’ll take my overnight garments.  
 
Thanks again for all the tips and products you educated me on.  My legs feel better than they have in years.
 
Julie

Treatment of RIBP/Lymphedema by Joachim Zuther

Treatment of RIBP in the Presence of Lymphedema

By Joachim Zuther, on March 1st, 2011

This is the second part of  Radiation-Induced Brachial Plexopathy (RIBP) and Lymphedema. The last blog entry covered the causes and symptoms. This entry covers the treatment and how it relates to the presence of lymphedema.
How is RIBP treated?
Although surgical procedures to decompress the brachial plexus and re-vascularize the nerves and surrounding tissues have been described in the literature, the results are often unsatisfactory.
Unfortunately, RIBP is essentially an incurable condition and with the absence of satisfactory treatment, emphasis is placed on symptom control and therapeutic exercises specifically addressing the maintenance of movement in the paralyzed extremity for as long as possible. Physical and Occupational therapists work as part of a multi-professional team to address loss of function and flexibility, weakness, pain and lymphedema. Special adaptive equipment and techniques address basic functions of daily living and suggest ways to modify the home and workplace.
Special considerations to address RIBP in the presence of lymphedema:
Lymphedema management in patients with RIBP is more challenging, but absolutely necessary to help control pain and to decrease the volume of the extremity. Volume reduction lessens the impact of excess weight on the shoulder joint, prevents the build-up of additional fibrotic (scar) tissue and significantly lowers the risk of infections commonly associated with lymphedema. It is often necessary to adapt compression and exercise protocols to accommodate the special circumstances associated with RIBP.
Compression Bandaging: Many patients affected by RIBP experience impaired sensation on the skin and are often unable to provide accurate feedback related to their individual tolerance to pressure. Therapists applying compression bandages to the affected extremity during the initial sessions of Complete Decongestive Therapy should be very conservative with application pressure and use ample padding to avoid pressure sores; application pressure may be gradually increased in the absence of side effects.
Effective compression therapy for lymphedema partially depends on the extent of the interaction between the bandage layers and the musculature working against the resistance of the bandages; this is also known as the working pressure. With partial or complete loss of muscle activity, the working pressure of the bandage is reduced, making the bandage less effective. However, even if compression bandages are applied with less pressure and the day-to-day results of these bandages are not as noticeable, they are still effective in promoting lymphatic return by increasing the pressure in the tissues.
It is also important to consider that some RIBP patients wear arm slings to reduce the degree of subluxation and discomfort of the shoulder joint. In these cases, the elbow should be kept in 90 degrees of flexion during the application of compression bandages.
The possible presence of joint contractures caused by muscular atrophy and immobilization should be addressed with special bandage application techniques.
Compression Garments: The wearing of compression garments is essential to prevent lymphatic fluid from accumulating in the tissues and conserves the results achieved with Manual Lymphatic Drainage.
Compression sleeves and gauntlets are available in a number of compression classes. The level of compression within the different classes is determined by the value of pressure the garments produce on the skin; these pressure values are measured in units of millimeters of mercury (mmHg). For a compression garment to work effectively, the pressure needs to gradually decrease from the wrist to the shoulder. This gradient is necessary to avoid tourniquet effects and subsequent obstruction of lymph flow.
In general, compression levels provided by class 2 garments (30-40 mm/Hg) will be sufficient to prevent swelling in most patients affected by

Donning Device

lymphedema of the upper extremity. However, if lymphedema is combined with RIBP and partial or complete immobility with subsequent loss of normal muscle tone, a lower compression may be required in order to avoid tourniquet effects.
Patients need to be thoroughly educated in the use of donning devices for compression sleeves and alternatives for night bandaging (Solaris, CircAid, etc).
Exercises: Immobility is detrimental to the lymphatic return. In addition to support the return of lymph fluid, the main goal of the exercise protocol is to focus on mobility. Modifications to the usual decongestive exercise program may be necessary to address impaired motor function.

Arm Bike

Exercise protocols for RIBP with partial or complete loss of mobility are geared towards the development of strategies that compensate for lost muscle function by using those muscles that still have function. Specific exercises also help to maintain and develop any strength and control that remain in the affected musculature. This also helps to prevent further shortening of muscle fibers (contracture) and to maintain and regain range of motion in the arm. Elevating the arm as often as possible to promote lymphatic return is even more important in patients affected by RIBP.
Therapists and doctors may also suggest adaptive equipment that helps the patient to maintain a normal life. For a very comprehensive list if adaptive devices and coping tips, I would like to refer you to the RIBP page of the “Step Up – Speak Out” website.
Additional Resources:
BreastCancer.org Discussion Forum
Step Up – Speak Out
Medscape
Lymphedema People