Lymphedema Prevention and Therapy Pere

1. LymphedemaPrevention and TherapyPere� M. Summers, OTR/L, CLT HEALTHSOUTH Rehabilitation Institute of Tucson 2650 N. Wyatt DriveTucson, Arizona Phone 520-322-3669

3. A. Skin Weighs about 15% of body weight DERMIS is the underlying layer of skin and contains blood and lymphatic vessels as well as nerves and nerve endings, glands and hair follicles EPIDERMIS is the top layer of skin and contains a network of valveless prelymphatics as well as a capillary blood supply

4. B. Blood Circulatory System 1. Arteries contain approximately 20% total circulating blood and transports oxygen and nutrients to the cells 2. Veins remove small waste products and approximately 90% of the waste fluid from the interstitium

5. Therapy Application A light touch on the skin is required to maximize the lymph vessel dilation and transportation of lymph fluid It is the valveless prelymphatics in the epidermis that are engaged in mobilization of fluid

6. C. Lymph Circulatory System Initial lymphatics primary function is to drain the skin of waste fluid and micromolecules The fluid is carried from the initial lymphatics through the adipose tissue

7. Lymph Circulatory System Deeper system is a series of segments bordered by valves and each segment has its own nerves Lymph propulsion occurs when a reflex is triggered by the filling lymphangion.

8. Lymph Circulatory System Lymph nodes are interspersed throughout the lymph circulatory system and are the size of a head of a pin to the size of a lima bean. They filter the lymph fluid and fight infection. There are between 400 and 1000 nodes in the human body The lymph vessels usually parallel veins except in the gut. They partner the veins in garbage pickup

9. Lymph Circulatory System The lymph circulatory system is designed to be responsible to specific areas of the body: the head/neck, the right upper quadrant, the left upper quadrant, the right lower quadrant and the left lower quadrant. The quadrants of the body have regional node sites: in the axillas and groins

10. Therapy Application The lymphedema therapist should do manual therapy around or away from regional node sites that have been damaged through node dissection

11. PATHOPHYSIOLOGY

12. Definition of Lymphedema Swelling from an accumulation of interstitial fluid due to a breakdown of the lymph circulatory system

13. B. Forms of Lymphedema Mechanical which is a structural or functional impairment of the lymph system. Lymphedema as a result of breast cancer treatment is this form Dynamic which is the result of too much fluid for the healthy lymph system to carry out. Chronic Venous Insufficiency is an example of this type

14. Forms of Lymphedema Combined, which is both the mechanical and dynamic types when they occur together. An example of this type is the person who has Chronic Venous Insufficiency with repeated infections that in turn damage the lymph system.

15. C. Classification of Lymphedema 1-Primary: birth defect 2-Secondary: caused by an interruption of a normal lymph system In the U.S. and western Europe cancer treatment is the largest population of secondary lymphedema

16. Prevention of Lymphedema Can Lymphedema be prevented? Restricting activity after breast cancer surgery will not assure that the individual will not get lymphedema

17. Activities that MIGHT Aggravate an Existing Lymphedema Condition Tennis Racquetball Golf Water skiing Aggressive aerobic exercise Rock climbing

18. Activities that MIGHT Aggravate an Existing Lymphedema Condition Vacuuming Picking up children or carrying groceries Flying Taking a trip to the mountains Yard work Working at the computer for long periods (over 45 minutes) Counting money Knitting or crocheting

19. Activities that MIGHT Aggravate an Existing Lymphedema Condition Quilting Writing letters Walking the dog Driving a car a distance (45 minutes to one hour) Preparing meals Pulling a slot machine handle repeatedly Playing the piano

20. THERAPY

21. Assessment of Lymphedema Measurements of the involved arm Visual comparison of the involved trunk to the uninvolved trunk Bra strap indentations Patient report of a sense of fullness of heaviness in the trunk, arm

22. Manual Therapy Dilate lymph vessels to increase the amount of lymph fluid transport, increase the speed of transport, influence the direction of lymph fluid transport to areas that are not at risk

23. Compression Multilayered compression bandaging Medical compression sleeves and hand pieces to maintain the effects of therapy Alternative compression items (CircAids, Flexitouch, Reid Sleeve

24. Complications of Lymphedema Acute Inflammatory episodes Pain Orthopedic problems related to weight of the involved limb Cosmetic issues Clothing issues

25. Appropriate Exercises Myth regarding lymphedema exercises Quality of life issues It is critical to assess the degree of cancer surgery prior to establishing a therapeutic exercise program for the post breast cancer surgery patient

26. Assessment of Functional Limitations The first step is to assess strength and range of motion Pain is an important issue in designing a remedial exercise program

27. Endurance Activity level prior to the incident that caused lymphedema Upper body involvement in a 7 minute task with minimal resistance The person�s interest in an exercise program

28. Goals for Therapeutic Exercise Strength Activities of daily living Job requirements Child care, household tasks

29. Goals for Therapeutic Exercise Endurance Muscular endurance: the ability of a muscle to contract repeatedly or general tension and sustain that tension over a prolonged period of time General endurance: the ability to sustain lo-intensity exercise such as walking over an extended period of time

30. General Principles of an Exercise Program Never exercise to the point of pain or exhaustion Stop doing an exercise if it creates pain Stop exercises if you get short of breath. If shortness of breath continues after you have stopped exercising, call your doctor

31. General Principles of an Exercise Program Never do exercises that cause loss of balance. Be sure that any household furniture you�re holding onto is sturdy. Do not hold onto furniture that has wheels. The kitchen or dining room table, or the kitchen countertops are usually safe

32. General Principles of an Exercise Program Start your exercise program slowly and build up in number of repetitions and sets All movements should be done slowly. Rapid, jerky movements might cause muscle and tissue strain Try to do the exercises the same time each day to help make it become a part of your daily routine

33. General Principles of an Exercise Program Always make sure there is a period of �down � time after the exercises. Do not rush to work immediately after exercising The person who have lymphedema should do land exercises with compression on the involved limb

34. Problems/Special Considerations If joints are involved with damage due to chemotherapy or radiation, joint protection principles must be included

35. Problems/Special Considerations Use the strongest or largest joint possible to accomplish an exercise Distribute the load over several joints Use each joint in its most stable and functional position Use good body mechanics

36. Problems/Special Considerations Reduce the effort required to do the exercise Avoid prolonged periods of maintaining the same joint position Avoid positions and exercises leading to possible joint deformity Avoid excessive pressure against the back of the fingers, the pads of the thumb and fingers, and the thumb side of each finger

37. Problems/Special Considerations Avoid tight grasps on exercise equipment and keep the hand open whenever possible Take recovery periods as needed during the exercises