Nicole Baldridge, PT, DPT, CLT

Certified Lymphedema Therapist

WomensRehab Mens Health
Physical Therapy Resident
for Centers for Rehab Services
Lymphedema

Diagnosis
and
Therapy
Lymphedema

Secondary Lymphedema

Primary Lymphedema
Lymphedema

An abnormal accumulation of protein-rich

fluid in the interstitium, causing chronic
inflammation and reactive fibrosis of the
affected tissues

Usuallyin an extremity, but can also occur in

the head, neck, genitals, and abdomen
Lymphedema

Affects 1% of the American population (2.5

million people)
Still poorly understood in the medical community
Largest cause of lymphedema in the world is
Filariasis (considered secondary lymphedema)
Filariasis is a parasitic infiltration into the
lymphatics that is very common in third world
countries (affects 90 million people)
Types of Lymphedema

Primarylymphedema is a result of lymphatic

dysplasia.
May be present at birth
Can develop later in life without known cause
Secondary lymphedema is much more
common.
Result of surgery, radiation, injury, trauma,
scarring, or infection of the lymphatic system
Primary lymphedema

Lymphangiodysplasia general malformation

Hypoplasia fewer than normal # of lymph collectors
Aplasia absences of collectors in a distinct area
Milroy's Disease is congenital lymphedema evident
at birth
Meiges Syndrome is primary lymphedema onset at
puberty (lymphedema praecox)
Lymphedema Tardum is primary lymphedema onset
after age 35
Secondary lymphedema

There is a known cause for the presence of edema

Surgery: breast cancer, melanoma, prostate/bladder
cancer, lymphoma, ovarian cancer, hip replacements
Radiation therapy
Trauma scarring, crush injury
Infection
CVI
Obesity
Self-induced
 Stages of Lymphedema
Latency Stage Transport Capacity is reduced
No visible edema
Subjective complaints of heaviness, achiness
Stage 1 Accumulation of protein-rich edema
Reversible Pitting
lymphedema Reduces w/elevation (no fibrosis)
Stage 2 Accumulation of protein-rich edema
Spontaneously Pitting becomes progressively difficult
Irreversible Fibrosis
Lymphedema

Stage 3 Accumulation of protein-rich edema

Lymphostatic Fibrosis, sclerosis, skin changes, papillomas,
Elephantiasis hyperkeratosis
Tissue Changes in Lymphedema

Connective tissue cells (fibroblasts)

proliferate
Collagen fibers are produced
Fibrotic changes, sclerosis and induration
Fatty tissue increases
Angiosarcoma

Can develop after long-standing lymphedema

Stewart - Treves Syndrome
Angiosarcoma after mastectomy was first described
in 1948 by Stewart and Treves
Signs: reddish-blue and blackish-blue lumps that
rapidly increase in size, bleed easily and ulcerate at
an early stage
Very rare & poor prognosis
Stewart-Treves Syndrome
Lymphedema is a disease.
All other edemas are symptoms.
There is no cure for lymphedema.
There is only management.
 Diagnosis
of
Lymphedema

Physical exam and

history
are most important.
Characteristics of Benign
Lymphedema

Slow onset, progressive

Pitting in early stages
Cellulitis is common
Rarely painful but discomfort is common
Skin changes hyperkeratosis, papillomas, lichenification
Ulcerations are unusual
Starts distally
Toes square, positive Stemmers sign
Dorsum of foot buffalo hump
Loss of ankle contour
Asymmetric if bilateral
History

What is the reason for the swelling?

How long has the extremity been swollen?
How fast did the edema progress/develop?
What are the underlying diseases?
Is there pain?
Other conditions?
Other treatments?
Medications?
Inspection

Location of swelling (distal or proximal)

Any skin changes
Lymphatic cysts, fistulas
Ulcers
Scars or radiation burns
Papillomas
Hyperkeratosis
Palpation

Temperature indicative of infection

Stemmer sign is (+) when a thickened cutaneous fold
of skin at the dorsum of the toe or finger cannot be
lifted or is difficult to lift. Positive Stemmers sign is
indicative of lymphedema.
Skin folds
Pitting
Fibrosis
Muscular status
Diagnostic Tests

Direct lymphography: invasive, oily contrast injected

into a surgically exposed lymphatic vessel.
Damaging. Has been replaced by CT, MRI, US.
Lymphoscintigraphy: noninvasive, assesses
dynamic process in superficial and deep lymphatics
CT
MRI
These tests are often not performed due to lack of
clinical importance
Differential Diagnosis

Lipedema
Chronic venous insufficiency
Acute deep vein thrombosis
Cardiac edema
Congestive heart failure
Malignancy/active cancer
Filariasis
Myxedema
Complex regional pain syndrome
Lipedema

Mainly in women
Bilateral, symmetrical edema

from iliac crest to ankles

Dorsum of feet never involved
(-) Stemmers sign
Little or no pitting
No cellulitis
Painful to palpation
Bruise easily
CVI

Gaiter distribution
Non-pitting
Brawny
Hemosiderin staining
Fibrosis of subcutaneous
tissue
Atrophic skin
Acute DVT

Sudden onset
Unilateral
Painful
Cyanosis
(+) Homans sign
Potentially lethal (PE)
Diagnosis with venous doppler
Not treatable with PT
Cardiac edema

Right heart insufficiency

Greatest edema distally
Always bilateral
Pitting
Complete resolution with elevation
No pain
May treat with PT if cleared by Cardiologist
Congestive Heart Failure

Bilateral heart failure

Pitting edema
Orthopnea, paroxysmal noctural dyspnea,
DOE
Jugular venous distension
Diagnosis with physical exam, chest x-ray,
cardiac echo
Malignant lymphedema

Pain, paresthesia, paralysis

Central location, proximal onset
Rapid development, continuous progression
Swelling and nodules in supraclavicular fossa
Hematoma-like discoloration (angiosarcoma)
Ulcers and non-healing open wounds
Recurrent malignancy
Filariasis

Prevalent in 3rd world countries;

Can still be treated successfully with CDT.
Most therapists in the US will never
encounter Filariasis.
Lymphedema Treatment Options

Pneumatic compression pump

Surgery
Complete decongestive therapy (CDT)
Elastic support garments
Medications
Pneumatic Compression Pumps

Advantages:
1. Can be used at home by patients
2. Fast application
3. Financially lucrative for DME vendors ($4000 per pump)
Pneumatic Compression Pumps

Disadvantages:
1. Disregards the fact that the ipsilateral trunk can be
involved in the lymphedema
2. In LE edema, the pump can cause genital edema; in UE
edema, the pump can cause breast edema
3. Does not address tissue fibrosis and extended use can
cause additional fibrosis
4. Requires many hours a day with the affected limb elevated
5. The pump can traumatize residual, functioning lymphatics,
especially of the UE
Pneumatic Compression Pumps

More disadvantages than advantages, but there

are times when pumps are an appropriate choice
Use ONLY IF:
Teach the patient MLD to clear the trunk first
Use recommended safe settings
UE 30-40 mmHg
LE 50-60 mmHg

CVI patients will benefit from a pump

 Surgery

Microsurgical techniques
Liposuction
Debulking/Reduction procedures
Why surgical options do not always
succeed

A blocked system must be made intact

The direction of flow must be correct
The inflow of the reconstructed system must
be adequate and the outflow must remain
open
Patency must be lasting
 History of Complete Decongestive
Therapy.

Emil Vodder, Ph.D., P.T.

discovered that massage therapy boosted peoples
immune systems. They began to massage swollen
lymph nodes and noticed common colds improving.
He created his first publication of this and coined
the term MLD (manual lymph drainage).
History of Complete Decongestive Therapy.

Michael Foeldi, M.D. and Ethel Foeldi, M.D.

In the 1980s, Prof. Foeldi advanced

lymphedema considerably by combining MLD,
bandaging, exercise,
skin and nail care into
Complete Decongestive Therapy.
Components of CDT

MLD
Compression bandaging
Exercise
Skin and nail care
Instructions in self care
 Manual Lymph Drainage

MLD is a gentle manual treatment

which improves the
activity of the lymph vascular system.
In lymphedema, it reroutes the lymph flow
around blocked areas into centrally
located healthy areas which then can drain
into the venous system.
Manual Lymph Drainage
Manual Lymph Drainage

Improves lymph production

Increases lymphangio-motoricity
Improves lymph circulation and increases the
volume of lymph transported
Special techniques help break down fibrous
connective tissue
Promotes relaxation and has an analgesic
effect
Compression bandaging

Short stretch bandages (Rosidal, Comprilan) are

applied to increase the tissue pressure in the
edematous extremity.

Reduces the ultrafiltration rate

Improves efficiency of the muscle and joint pumps
Prevents re-accumulation of evacuated lymph fluid
Helps break down fibrous connective tissue that has
developed
Exercise

Performed with the bandages on or while wearing

a compression garment.
Active ROM, stretching, strengthening
Low exertion
Diaphragmatic breathing
Increase muscle and joint pumping
Increase lymph vessel activity
Increase venous and lymphatic return
Skin and Nail Care

Eliminatebacteria and fungal growth by

using medicated powders, hydrocortisone
cream where indicated.

Reduce the risk of infection by avoiding

injury, cleaning all injuries immediately,
calling MD at first sign of infection.
Self Care

Patients should be instructed in the following:

Skin and nail care
Infection prevention (cellulitis is very common)
Self-bandaging
Self-MLD as needed
Exercise
Donning and doffing compression garment
Regular follow-up visits
CDT is a Two-Phase Therapy

Phase 1 (Treatment Phase)

Meticulous skin/nail care
MLD
Compression bandaging
Exercise
Self care education

** lasts as long as necessary

CDT is a Two-Phase Therapy

Phase 2 (Maintenance Phase)

Patient wears compression garments during the day
Patient bandages at night
Meticulous skin and nail care
Daily exercise
MLD as needed
Regular follow-up visits

**life long maintenance

When does CDT fail?

Malignant lymphedema
Artificial (self-induced) lymphedema
Insufficient treatment (only used MLD or
improper bandaging)
Deviation from CDT protocol
Associated illnesses
Lack of compliance
Active cancer
Faulty diagnosis
Goals of CDT

Volume or size reduction

Restore mobility and ROM
Infection prevention
Improve cosmesis
Improve psychosocial morbidity
Improve QOL
Compression garments

Elastic garments are uncomfortable and

ineffective if worn while the limb is
edematous.
Garments do nothing to correct the
underlying cause of the edema.
Garments are NEEDED after the
decongestive phase of CDT to prevent refill.
Daytime garments
Lymphedema Secondary to Breast Cancer
Primary Lymphedema of the Left Leg
Primary Lymphedema of Scrotum and Leg
Before After resection
Night-time garments
Night-time Garments
What role do medications have?

Diuretics: make edema worse; often prescribed,

but draw water off protein molecules. Can cause
lymphedema to become more fibrotic.

Benzopyrones: not FDA approved; stimulate

macrophage activity and promote protein proteolysis;
theoretically useful; effect is so slow that usefulness
is questionable. Includes coumarin, rutosides,
diosmin, rutin.
DIET

No specific diet for lymphedema

Reducing water and/or protein intake is
ineffective
Avoiding obesity is helpful
General recommendations are low sodium,
high fiber, vitamin rich diets.
What role does obesity play?

Increased risk of post-op complications such as

infection

Reduced muscle pumping efficiency within loose

tissues

Additional fat deposits contribute to arm volume

Deep lymph channels are separated by

subcutaneous fat
Randomized controlled trial
comparing a low-fat diet with a

weight reduction diet in breast

cancer related lymphedema

This article was published in the medical journal

Cancer in May 2007.
It was also copy-written by the American Cancer
Society in 2007
Results

The low-cal group and low-fat group had

significant reductions of:
body weight
BMI
% body fat
**Significant correlation between weight loss
and arm volume reduction regardless of the
dietary group
**unaffected arm also showed volume reduction
Overview

This is the first study to examine the role of

diet as a possible treatment for BCRL
Significant correlation of weight loss and loss
of swollen arm volume
The type of diet did not affect arm volume
reductionjust losing weight!
Weight loss in a healthy manner
Healthy diet and exercise
Insurance coverage.

Medicare does not pay for products

Medicare HMOs do not pay
Medicaid does not pay for products
Most Highmark BC/BS, HMO, PPO pay 100%
for products
UPMC HMO, PPO plansas of 1/1/08 started
following Medicare guidelines, but this is
changing to more coverage
Insurance obstacles

Frustratingfor the therapist because patients

need these products to maintain edema and
prevent worsening of edema.
We recommend products based on what the
patient needs or does not need.
Often we have to change our
recommendations based on what the
insurance will reimburse.
Actual cost for the patient.

Day garments:
Patients need 2 garments every 6 months
Custom fit $300-500 per garment
Ready to wear $50-150 per garment
RTW garments only come S, M, L and in a less effective
fabric than custom garments

Night garments: custom only, $500-2000

More cost

Keepin mind that all of these costs are what

the DME suppliers charge for private pay.

Bandaging supplies for treatment

Unilateral UE/LE about $150-200
Bilateral LE >$200
How does this affect you

Most of the DMEs in the area are out-of-

network with Cigna
Out of network cost for these products is
extremely high
Important to understand how necessary
these products are and to consider approval
at an in-network level.
Help for patients

Susan G. Komen Foundation

Breast cancer patients
800.462.9273
Am. Cancer Society
Any cancer $300/year
800.227.2345
Natl Lymphedema Network
www.lymphnet.org
Marilyn Westbrook Foundation
Also has Find a Therapist or Treatment Center
THANK YOU!

baldridgena@upmc.edu
Phone/Address: Centers for Rehab Services
Moon Township
1600 Coraopolis Heights Rd
Coraopolis, PA 15108
(412) 269-7062
McCandless
9365 McKnight Rd #300
Pittsburgh, PA 15328
(412) 630-9750
WomensRehab
at Centers for Rehab Services

Specialists in treating lymphedema as well as

urinary incontinence, pelvic pain, interstitial
cystitis, vulvadynia, fecal incontinence,
constipation and other pelvic floor
hyper/hypotonicity disorders.
Locations: Cranberry, Moon, Gibsonia, Harmar,
St. Margarets, South Hills, Oakland, Squirrel Hill,
McCandless, Delmont, Monroeville, Chippewa
Referral Line 1-888-723-4CRS