Lymphedema Stage 0 and 1

Water-drop for Lymph drainageSynergy Healthcare is pleased to let you know that we now have 2 certified lymphedema practitioners to assist your patients with their recovery and attainment of optimal function. Here follows a brief summary of stage zero and stage one lymphedema. It is important to recognize these early stages as this condition is still reversible if addressed early. Without proper care, the vast majority of stage one cases progress to stage two, which can be managed but not cured.

Lymphedema is a very common and serious condition, affecting at least 3 million Americans. Estimated incidence of lymphedema in the United States includes 1-2 million cases of primary lymphedema and 2-3 million cases of secondary lymphedema. In these cases, the swelling may affect limbs, face, genitals and trunk. The highest incidence of secondary lymphedema in the United States is observed following breast cancer surgery, particularly among those patients who underwent radiation therapy following the removal of axillary lymph nodes.

Primary lymphedema is caused by a developmental abnormality of the lymphatic system, which is either congenital or hereditary. Swelling in primary lymphedema generally affects the lower extremities. Complete Decongestive Therapy (CDT) is a non-invasive, multi-component approach to effectively treat and manage lymphedema and related conditions. Numerous studies have proven the effectiveness of this therapy, which has been well established in European countries since the 1970’s and in the United States since the 1990’s.

Currently there is no cure, or permanent remedy for lymphedema once it reaches stage two. If lymphedema is present, the lymphatic system is mechanically insufficient, which means that the transport capacity has fallen below the normal amount of lymphatic load. The transport capacity in the damaged lymph vessels cannot be restored to its original level.

Although the swelling may recede somewhat during the night in some early stage cases, lymphedema is a progressive condition. Regardless of the cause, lymphedema will in most cases gradually progress through its stages if left untreated

Stage 0 

This stage is also known as the sub clinical, pre-stage, or latency stage of lymphedema.

In this stage the transport capacity of the lymphatic system is subnormal, yet remains sufficient to manage normal lymphatic loads. However, this situation results in a limited functional reserve of the lymphatic system.

Stage I

This stage, also known as the reversible stage, is characterized by soft tissue pliability without any fibrotic changes. Pitting is easily induced and the swelling retains the indentation produced by the (thumb) pressure for some time. In early stage I, it is possible for the swelling to recede overnight. With proper management in this early stage, the patient can expect a reduction of the extremity to a normal size (compared to the uninvolved limb). Without proper care, progression into stage II in the vast majority of the cases is inevitable. It is difficult to distinguish stage I lymphedema from edemas of other origins. The clinician needs to rely upon the history and whether or not the swelling resolves with conventional management such as compression and elevation.

Anyone who had a surgery involving the lymphatic system or trauma and DOES NOT develop visible lymphedema, is considered to be in a latency stage (hidden lymphedema). Notably, 42% of women present with some degree of visible lymphedema one year post-mastectomy; the other 58% are considered to be in a latency stage.

Patients in a pre-stage are “at risk” to develop lymphedema. The reduction in functional reserve results in a fragile balance between the subnormal transport capacity and the lymphatic loads. Any added stress put on the lymphatic system, such as extended heat, or cold, injuries, or infections may cause the onset of lymphedema. Patient information and education, especially following surgical procedures, can dramatically reduce the risk for developing lymphedema.

The importance of having early preventative treatment during this phase shouldn’t be understated. We have discussed the relevance of manual lymphatic therapy, but Synergy also has the skills to mediate scar tissue, lack of range, and weakness that patients experience post surgically. Education and self-lymphatic techniques are provided to patients to teach them to maintain their health and prevent further progression.

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Lymphedema treatment

Lymphatic Therapy touches the waters of the body

How is Lymphedema Treated?

Complete Decongestive Therapy (CDT) is the therapy of choice for most patients suffering from primary and secondary lymphedema. CDT is a non-invasive, multi-component approach to treat lymphedema and related conditions. Numerous studies have proven the scientific basis and effectiveness of this therapy, which has been well established in European countries since the 1970s. The goal in lymphedema management is to reduce the swelling and to maintain the reduction by removing excess plasma proteins and water from the tissues, utilizing remaining lymph vessels and other lymphatic pathways. Additional goals are prevention and elimination of infections and the reduction and removal of fibrotic tissues. CDT with its four components Manual Lymph Drainage (MLD), compression therapy, decongestive exercises and skin care, is designed to achieve this goal.
CDT is applied in two phases. In phase one (intensive phase), the patient is treated by a skilled and specially trained therapist on a daily basis until the swollen extremity is reduced to a normal or near normal size. The end of phase one is determined by the results of circumferential or volumetric measurements on the affected extremity. Depending on the stage of lymphedema, the involved extremity or body part may have reached a normal size at the end of the intensive phase, or there may still be a circumferential difference between the involved and the uninvolved limb. If treatment is initiated in the early stage of lymphedema (stage one), which is characterized by a soft tissue consistency without any fibrotic alterations, limb reduction can be expected to a normal size (compared to the uninvolved limb). If intervention starts in the later stages of lymphedema (stages two and three), where lymphostatic fibrosis in the subcutaneous tissues is present, the edematous fluid will recede, and fibrotic areas may soften. However, in most cases the hardened tissue will not completely regress during the intensive phase of CDT. Reduction in fibrotic tissue is a slow process, which can take several months or longer and is achieved mainly in the second phase of CDT.
In the second phase of CDT (self-management phase), the patient assumes responsibility for managing, improving and maintaining the results achieved in the first phase. To reverse the symptoms associated with later stages of lymphedema, good patient compliance is indispensable. Compression garments have to be worn daily and bandages have to be applied during the night. This self-management phase is a lifelong process and includes self- Manual Lymph Drainage, self-bandaging (during the night) and decongestive exercises; regular check-ups with the physician and the lymphedema therapist are necessary.

Nora Graebner is a certified Lymphedema therapist who can assist you with this issue.

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Lymphedema Therapy

Lymph gland example of Lymphedema

Example of the lymphatic glands normal and affected by Lymhedema

Lymphedema is an abnormal accumulation of protein-rich fluid in the interstitium, which causes chronic inflammation and reactive fibrosis of the affected tissues. Primary lymphedema is congenital and is the result of lymphatic dysplasia that may present at birth but more often develops later in life (peri-pubertal onset). Secondary lymphedema is the result of lymphatic system failure secondary to a trauma or injury to the system.  In this country, it most often occurs after surgery or radiation therapy to treat cancer and results in a mechanical insufficiency. The lymphatic system itself is damaged and cannot keep up with the demands of the additional fluid and proteins in the interstitium.  Secondary lymphedema can also occur due to obesity, chronic venous insufficiency, cardiac edema, cardiac bypass, orthopedic surgery, liposuction, etc. and begins initially with a dynamic insufficiency (fluid overload but intact lymphatics). Over time, this progresses to a combined dynamic and mechanical insufficiency when the lymphatic system has been overtaxed to the point where permanent damage begins to occur.

Dynamic insufficiencies are low protein edemas consisting mostly of water and typically reverse with elevation. Mechanical insufficiencies are high protein edemas and will not respond as well, or at all, to elevation or pneumatic pumps because neither causes the proteins in the interstitium to be reabsorbed. This is when complete decongestive therapy (CDT) is needed, which consists of manual lymph drainage (MLD), multi-layer compression bandaging,  long term use of compression garments, remedial exercise, skin/nail care, and patient education for prevention and maintenance since lymphedema is a chronic condition and there is no cure.

We can help people with mechanical, dynamic, or mechanical/dynamic insufficiency but the course of treatment will be different and we will expect different outcomes based on the patient’s type of edema. Those who have a dynamic insufficiency (fluid overload) with no damage to the lymphatic system will respond very well to compression garments, exercise, and education and may be able to skip the MLD and bandaging.  However, for those with a high protein or mixed edema, the gold standard of treatment is CDT.

Early Treatment is Important

Lymphedema progresses at different unpredictable rates. Some limbs may stay in the congested state without developing fibrosis for quite a while and others develop fibrosis more quickly. Once fibrosis develops, it becomes more difficult to achieve good outcomes, so early treatment is crucial.

Patient education: patients are instructed to contact a healthcare provider immediately if they begin to experience feelings of heaviness, tightness, notice that clothing or jewelry are fitting more tightly, or if the at-risk area becomes hot or red. A patient who has no visible edema may still be in the initial stage 0 of lymphedema and referral for treatment is important even in early stages.
Signs and Symptoms of Various Edemas

Chronic venous insufficiency:  Without appropriate therapy, venous edema triggers a lymphatic failure (mechanical insufficiency) and results in a combined phlebolymphostatic edema.

Traits: Gaiter distribution, non-pitting (indentation occurs but quickly refills), brawny (leathery or woody texture), hemosiderin staining (dark blue, brown or purple discoloration of the gaiter distribution), fibrosis of the subcutaneous tissue, ulcers are common.

Cardiac Edema: (Caused by Right Heart Failure) CHF creates hypertension in the venous limb of the system, continued circulation increases blood capillary pressure at the microcirculation level resulting in back pressure and edema.

Traits: Most fluid builds up distally, always bilateral, pitting (but will refill quickly), complete resolution with elevation, no pain,  jugular venous distention, orthopnea, paroxysmal nocturnal dyspnea, or dyspnea on exertion.

Acute Deep Vein Thrombosis: Sudden onset, usually unilateral, pain, cyanosis, swelling, distention of surface veins and pulmonary embolism.

Malignant lymphedema: May be an indication of new onset or recurrent cancer.

Traits: Pain, paresthesia, paralysis, proximal onset, rapid development and continuous progression, shiny tight skin, swelling in nodules in supraclavicular fossa, hematoma-like discoloration, ulcers, non-healing open wounds.

Stages of Lymphedema:

Stage 0: the latency stage, no visible or palpable edema, subjective complaints possible.
Stage 1: accumulation of protein-rich edema fluid, pitting edema, reduces with elevation, no fibrosis.
Stage 2: accumulation of protein-rich edema fluid, pitting becomes progressively more difficult, connective tissue proliferation (fibrosis).
Stage 3: accumulation of protein-rich edema fluid, non-pitting, fibrosis and sclerosis, skin changes (papillomas, hyperkeratosis etc.).

Lymphedema stages

 

 

 

 

 

 

How does CDT reduce and manage chronic edema?

Intensive phase:
Manual lymphatic drainage (MLD) decongests the limb. Stretching of skin causes anchoring filaments attached to lymph capillaries to open the endothelial junctions and absorb proteins in interstitial fluid. The slow wave-like rhythm speeds the contractions and transport of the lymphatic fluid while also promoting relaxation and an increase in parasympathetic activity.

MLD is followed by multi layer compression bandaging, which provides an external force increasing interstitial pressure and promoting reabsorption to cause further volume reduction and maintain progress.

Remedial exercise with compression bandages in place further decreases fluid through muscle pumping action, while the limb is surrounded by short stretch bandages that offer a high working pressure during activity and low resting pressure when the muscles are not being used.

Maintenance phase:
When the patient’s decongestive phase reaches a plateau, they are fit for long-term compression garments to maintain progress made during the intensive phase. At this time, the patient is educated in self MLD, exercises, prevention and management as well as meticulous skin/nail care to prevent complications such as cellulitis.

Efficacy: CDT will render a 50-70% reduction in limb volume during the intensive phase and is capable of reducing recurrent cellulitis by one-half.

Contraindications to treatment:
Uncontrolled CHF, renal failure, cardiac edema, acute DVT and active infection (cellulitis, erysipelas) are all contraindications. If the patient does not currently have cellulitis but fungus is present, they may need an anti fungal regime prescribed by the doctor prior to treatment.
There is no evidence of CDT expediting the spread of cancer but the patient must be monitored by physician. For those with active cancer, MLD is highly recommended as an analgesic modality.

Meeting the Needs of Our Patients:

The first consideration should always be: who is qualified to offer the best care? There is very little lymphedema education given in schools. Valerie Anderson, DPT, CLT has undergone 135 hours of additional training to become a certified lymphedema therapist. She will soon take the Lymphology Association of North America (LANA) exam and become nationally recognized as a LANA certified therapist.

CDT is the gold standard of care but people may not be able to commit to the time, expense and full-time compression garments required. Currently, most insurances do not cover bandages and compression garments, which can present a severe financial burden to the patient. We will thoroughly evaluate the patient and discuss with them the options of treatment. Together, we will formulate a plan to give the best course of treatment while still remaining in their budget and time constraints.

Before and after Lymphedema wrapping treatment

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Lymphatic Drainage Therapy

 

Lymph, the water of life

Lymph, the water of life

WHAT IS THE LYMPHATIC SYSTEM?

The lymphatic system is a second pathway back to the heart, parallel to the venous system. Lymph is a fluid that originates in the connective tissue spaces of the body. Once it is in the first lymph capillaries, the interstitial fluid is called lymph. This systems transports large proteins, foreign bodies, pathogenic substances (germs, toxins, etc) and many other components in its pathway through the lymphatic nodes which act as an active purification center. The nodes break down and destroy those particles so they can eventually be flushed out of the body through the eliminary tract. There are 400-700 nodes in the body, half in the abdomen.

 

What is the function of a lymph node?

It is a filtration and purification station for the lymph circulation. It capture and destroy toxins of the body. They concentrate the lymph, reabsorbing about 40% of the liquids present in the lymph. They produce lymphocytes (The production is increased when the flow of lymph is increased through the nodes. The use of manual techniques such as Lymph Drainage Therapy (LDT) increases the production of lymphocytes.)

Systems Affected by LDT  

Fluid System: circulation, reabsorption, detoxification.

Lymphatic System: amplitude, frequency of contraction. Capacity and reroute.

Blood Circulatory System: increased filtration and absorbtion

The Immune System: White Blood Cell (WBC)

Nervous System: Increase relaxation and decrease spasms with analgesic effect. C-fiber mechano-receptors has a pain inhibitory effect. Gate Control Theory.

Visceral System: Improved fluid movement to and from tissues.

MAIN FUNCTIONS OF THE LYMPHATIC SYSTEM      

Absorb excess fluid. Recover and return substances to the blood. Regulates the fluid volume and pressure in the tissue (equilibrium). Helps transport Immunocompetent cells (lymphocytes, hormones). Carries food components absorbed from small intestine to blood circulation.

MAIN ACTION OF LDT

  1. In the liquid/blood. Activates lymph function and circulation. Indirectly stimulates the circulation of the body (i.e. dilates blood capillaries and enhances reabsorption, activates venous circulation) Lymph drainage reduces edema through these effects.
  2. In the immune system: The passage of lymph into the lymph nodes stimulates the immune system by increasing lymphocytes.
  3. In the nervous system: Decreases the sympathetic response and stimulates the parasympathetic tone- relaxation.

We offer lymphatic classes for you learn about how to treat yourself and we have 2 certified lymphedema therapists Nora and Val to help if you have lymphedema diagnosis.

 

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