EDEMA CONFUSION - apwca.org TEXAS 2018/Presentations/1020 Edema... · EDEMA CONFUSION Marta Ostler...
Transcript of EDEMA CONFUSION - apwca.org TEXAS 2018/Presentations/1020 Edema... · EDEMA CONFUSION Marta Ostler...
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