since we are not meeting in person to discuss this material you will see a large variety of materials I've placed for you on canvas the first of these obviously is this lymphadema PowerPoint show there are videos on manual lymphatic drainage videos that show you the lymphadema related Strokes as well well as videos on bandaging of the lower and upper extremities last there are some questionnaires and scales commonly used with patients that have lymphadema lymphadema is a very common and serious condition affecting at least 3 million Americans estimated rates reported in the literature on the incidents of lymphadema vary widely worldwide 140 million to 250 million cases of lymphadema are estimated to exist with filariasis a parasitic infection being the most common cause estimated incidents of lymphadema in the United States includes 2 to 3 million cases of secondary lymphadema in these cases the swelling may affect limbs face genitals and trunk the highest incidence of secondary lymp epidemia 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 there's one to two million cases of primary lymphadema in the United States primary lymphadema is caused by a developmental abnormality of the lymphatic system which is either congenital or hereditary swelling and primary lymphadema generally affects the lower extremities complete decongestive therapy or CDT is a non-invasive multi-component approach to effectively treat and manage lymphadema and related conditions numerous Studies have proven the effectiveness of this therapy which has been well established in European countries since the 1970s and in the United States since the 1990s the lymphatic system is not a closed system like the cardiovascular system it represents a one-way system which serves as an accessory route by which the lymphatic fluid is returned from the tissue spaces back to the bloodstream the system starts in the interstitial tissue areas with the so-called initial lymph vessels or lymph capillaries and ends in the Venus part of the blood circulatory system and route to the Venus circul ation the lymphatic fluid travels through a number of successive lymph nodes thereby filtering impurities from the lymphatic fluid the main purpose of the lymphatic system in addition to its important role in the immune defense is to drain substances from the interstitial tissues the fluid carried by the lymphatic system is known as the lymphatic load within the lymphatic load there are substances and these substances include protein water cells and in the digestive system fat protein and water play a very important role in The Case of lymphadema Dr foldy a world renowned lymphologist created the collective term lymphatic loads for these substances the following slides will provide a brief anatomical overview on the lymphatic system to start with a brief historical overview it was hypocrates that talked about vessels containing what he referred to as white blood Aristotle described vessels containing a colorless fluid or as well white blood the French anatomist Marie sappy used subcutaneous Mercury injections to graphically represent the anatomy of the lymphatic system Thomas barlin a Danish physician and anatomist called the vessels vaza lymphatica in 1652 and officially gave the lymphatic system its name this slide shows a cross-section through a lymph capillary in relation to blood vessels and the connective tissues number seven represents the interstitial space lymph capillaries also called initial lymph vessels represent the beginning of the lymphatic system note the lymphatic system is not a closed circulatory system the single layered lymph capillaries lined with endothelial cells which are number three and four in the picture are arranged adjacent to each other or overlapping each other to make up lymph capillaries there are no connections between these endothelial cells each cell is connected with the surrounding connective tissue by anchoring filaments which enable the lymph capillar Aries to stay open even under high pressure in the tissues this is in the case of swelling for example if interstitial fluid accumulates and the tissue pressure increases the stretched anchoring filaments will cause a pull on the endothelial cells resulting in open Junctions between these cells through these openings or Inlet valves excess interstitial fluid and other lymphatic loads will be able to enter the initial lymphatic system this slide shows a horizontal cross-section of a lymph capillary arrows represent openings between endothelial cells which are open Junctions or Inlet valves also shown are connective tissue fibers and anchoring filaments as mentioned in the previous slide lymph capillaries are made up by a single layer of endothelial cells once more an overview on the close relationship between blood capillaries and lymphatic capillaries on the left hand side the right side depicts a crosssectional view of a lymphatic capillary this demonstrates the opening and closing mechanism of the lymphatic capillary High interstitial pressure opens the inlet valves of the lymphatic capillaries by means of pole on the anchoring filaments lymphatic loads are able to enter the lymphatic capillary from the interstitial space this process is also known as lymph formation once the intra lymphatic pressure which is the pressure inside the lymphatic capillaries increases to the an equal Val value to the interstitial pressure the inlet valves will close the lymph fluid absorbed by the initial lymph vessel system reaches the lymph collectors via pre collectors the anatomical structure of the larger lymph collectors is similar to that of blood vessels with an inner wall a layer of smooth musculature in the middle layer and an outer layer lymph collectors also have valves which which allow the flow of lymph in One Direction only the the section between a distal and proximal pair of valves is called the lymph angon lymph collectors transport the lymph towards groups of lymph nodes also known as Regional lymph nodes from the lymph nodes the lymphatic fluid is then transported by larger lymph collectors known of known as lymphatic trunks back to the Venus part of the blood circulatory system this slide shows a cross-section of a lymphatic collector with a number of lymph anons the smallest functional units of lymphatic collectors lymphatic fluid is transported through the lymphatic collectors by means of contraction of the smooth musculature within the walls of the the lymph angion remembering the lymph angon is the region of the lymph vessels between valves once lymphatic fluid enters a lymph angon the smooth muscles are stretched this stretch causes the smooth musculature in the wall of the angon to contract thus injecting the lymph fluid into the lymph angon located further proximally this process is also known as ly lymph angom MotorCity lymphatic fluid enters the lymph nodes via aeren lymphatic collectors the inner Lumen of lymph nodes contains a large number of Chambers which cause the flow of lymph to considerably slow down inside the lymph nodes the lymph nodes have three primary functions first they are protective by filtering out harmful materials contained in the lymph second they have an immune function lymph nodes produce lymphocytes and third they thicken the lymphatic fluid many lymph nodes are strategically located on the neck the digestive system the axela and the groin the these lymph nodes are part of the first line of defense for the body lymph fluid leaves the lymph nodes via eant collectors and then is transported to the lymphatic trunks which are larger collectors these lymphatic trunks return the lymph fluid back to the blood the regional lymph nodes include axillary lymph nodes inguinal lymph nodes and cervical lymph nodes axillary lymph nodes receive lymph from the upper extremity and skin of the thorax both anteriorly and posteriorly the abdominal Lumbar and Glu areas as well as the external genitalia in both males and females and the lower extremity drain into the inguinal lymph nodes cervical lymph nodes receive lymph fluid from the head and neck areas as mentioned in some of the previous slides the lymph fluid is transported from the regional lymph nodes back to the Venus part of the blood circulatory system via lymphatic trunks which are very large lymph collectors the largest lymphatic trunk in the body is the thoracic duct which starts between the 11 th thoracic and the second lumbar vertebrae just anterior to the vertebral column the thoracic duct is between 10 and 18 in long and contains a large number of valves it perforates the diaphragm and continues to run upward to connect to the left Venus angle the left Venus angle is an area located behind the left clavicle and is made up by the connection of the left sub iian and internal jugular veins approximately 2 to 3 l of lymphatic fluid are returned to the Venus blood via the thoracic duct within a 24-hour period of time the lymphatic fluid coming from the mamary gland drains for the most part into the axillary lymph nodes this is the reason why breast cancer usually causes metastases in the the axillary lymph nodes other drainage areas are the parisal which is number seven and supraclavicular lymph nodes which are not visible on this slide metastases in the axillary or supraclavicular lymph nodes or radiation in these areas may affect the brachial plexis resulting in paresthesia paresis or paralysis in the upper extreme ity the lymph coming from the upper extremity drains for the most part into the axillary lymph nodes which is number five on the slide on the right part of the lateral upper arm may also drain into supraclavicular lymph nodes which is number seven in the case of breast cancer with dissection or radiation or a combination of both of the lymph nodes the drainage of lymph from the upper extremity will be impaired this could cause an accumulation of lymph in this case protein and water in the arm resulting in secondary lymphadema the lymph coming from the lower extremities drains into the inguinal lymph nodes which are number one on the slide inguinal lymph nodes are located in the medial femoral triangle which is outlined by the inguinal ligament proximally the sartorious muscle laterally and the gillus muscle medially dissection and or radiation of these lymph nodes could result in secondary lymphadema of the lower extremity the more common reason for the onset of lymphadema in the lower extremity are congenital malformations which we will discuss later uh resulting in what is known as primary lymphadema the next part of the presentation will cover the physiology of the lymphatic system the transport capacity abbreviated TC of the lymphatic system is equal to the maximum amount of lymph fluid the healthy lymphatic system is able to transport in a given length of time the actual transport capacity of the lymphatic system is much higher than the amount of lymph it has to be able to transport under normal conditions for example as discussed earlier under normal conditions the thoracic duct transports between 2 and 3 lers of lymph fluid in 24 hours back to the Venus blood system in certain pathologies volumes of more than 20 20 L of lymph per day returning to the Venus angle via the thoracic duct were measured the fact that the actual transport capacity of the lymphatic system is much higher than the amount of lymph it has to be able to transport under normal conditions enables the lymphatic system to react to an increase in lymphatic load which includes water or protein and water with an increase in the contraction frequency of the lymph collectors as an increase in lymphatic loads may result from many factors such as sedentary lifestyle exercise or other conditions such as infections or Venus insufficiencies the ability of the lymphatic system to re react to an increase of lymphatic loads by increasing its contraction frequency is also known as the functional reserve of the lymphatic system as seen in the previous slide an increase in the lymphatic water load or protein and water load results in an increase in the contraction frequency of lymph collectors this is what's known as functional Reserve should the lymphatic load exceed the transport capacity of of the healthy lymphatic system lymphatic fluid will accumulate in the interstitial tissue causing edema Dynamic insufficiency is often caused by insufficient Venus return which can be caused by congestive heart failure Venus insufficiency sitting or standing too long pregnancy and other pathologies manual lymph drainage and complete decongestive therapy is not indicated in the case of dynamic insufficiency the appropriate therapeutic approach would be ambulation elevation exercise and if indicated a compression garment if Dynamic insufficiency is left untreated over an extended period of time secondary damage to lymphatic system may occur due to the strain on the lymph collect s lymph collectors work on their maximum capacity in cases of dynamic insufficiency in the case of a mechanical insufficiency of the lymphatic system the lymphatic system is diseased the transport capacity in a diseased or damaged lymphatic system is reduced to such an extent that it can no longer cope with the normal amount of lymp lymphatic load the lymphatic system is unable to activate its functional Reserve in case of a mechanical insufficiency mechanical insufficiency can be caused by trauma surgery radiation infection and congenital malformations of the lymphatic system mechanical insufficiency causes lymphadema well why lymphadema lymp EMA is defined as a high protein swelling in the interstitial tissues in the case of mechanical insufficiency the lymphatic system is unable to remove the protein and water molecules from the tissues resulting in an accumulation of these substances lymphadema is caused by a mechanical insufficiency of the lymphatic system it can be classified as either primary or secondary based on an underlying ideology however this classification has little significance in determining the method of treatment primary lymphadema is caused by congenital malformations of the lymphatic system and can be present at birth or develop sometime during the course of Life the most common common malformation of the lymphatic system is known as hypoplasia in hypoplasia the number of lymph collectors is reduced and the diameter of existing lymph vessels is smaller than normal this results in a decrease in the transport capacity if transport capacity is reduced to such a level that normal amounts of lymphatic loads can't be drained anymore lymphadema develops and this lymphadema is known as primary lymphadema primary lymphadema generally affects the lower extremities to a greater rate than the upper extremities the mechanical insufficiency present in secondary lymphadema is caused by a known insult to the lymphatic system most common causes for secondary lymphadema include surgery and radiation trauma infection malignant tumors and others surgery and radiation is by far the most common cause for secondary lymphadema in the United States surgical procedures in cancer therapy commonly include the removal or dissection of lymph nodes the goal of these procedures is generally to eliminate the cancer cells and to save the the patient's life a side effect in lymph node dissection or removal and radiation is the disruption in the lymph transport if the remaining lymphatics are unable to manage the lymphatic load secondary lymphadema will develop trauma insults involving the lymphatic system may cause a significant reduction in lymph flow resulting in secondary lymphadema this can involve Burns and larger skin abrasions Scar Tissue hinders regeneration of lymph collectors which further exacerbates the problem posttraumatic secondary lymphadema develops from a mechanical insufficiency of the lymphatic system as a result of tissue lesions and should not be confused with postraumatic edema post-traumatic edema is a local result due to trauma which usually recedes after a few days infections including recurrent acute or chronic inflammatory processes involving the lymphatic system may result in mechanical insufficiency the most common cause for inflammation of lym of the lymphatic system and lymphadema in general is filariasis lymphatic filariasis is endemic in more than 80 countries in the tropics and subtropics and is caused by threadlike parasitic ferial worms that's hard to say lymphatic filariasis is transmitted when an infected mosquito bites a person then goes on to bite others thus infecting them with the parasites the worms live for 4 to six years lodged in the lymphatic system where they reproduce the tox the toxicity of the waste products produced by these worms results in inflammation and obliteration of the lymphatic system leading to often extreme swelling of the lower extremities and genitalia malignant tumors May mechanically blocked block the lymph Flow by pressing against lymphatic structures from the outside malignant cells may also infiltrate the lymphatic system and proliferate in either lympha lymphatic vessels or in lymph nodes thus blocking the flow of lymph currently there is no cure or permanent remedy for lymphadema if lymphadema is present the lymphatic system is mechanically insufficient which means that the transport capacity has fallen below the normal amount of 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 lymphadema is a progressive condition regardless of the cause lymphadema in most cases will gradually progress through its stages if left untreated there is no specific period of time for a patient to remain in a particular stage for example a patient will not be in stage one for 4 months and then progress to stage two for 6 months before moving to stage three the following slides will present the stages of lymphadema stage zero this stage is also known as the subclinical pre-stage or latency stage of lymphadema in this stage the transport capacity of the lymphatic system is subnormal yet remains sufficient to manage the quote unquote normal lymphatic loads however this situation results in a limited functional reserve of the lymphatic system anyone who had a surgery involving the lymphatic system or trauma and does not develop Vin visible lymphadema is considered to be in a latency stage also known as hidden lymphadema approximately 42% of women present with some degree of visible lymphadema onee postmastectomy and the other 58% are considered to be in a latency stage patients in a pre-stage are at risk to develop lymphadema the reduction in functional Reserve results in a fragile balance between 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 lymphadema patient information and education especially following surgical procedures can dramatically reduce the risk for developing lymphadema stage one one 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 one 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 the progression into stage two in the vast majority of the cases is inevitable it is difficult to distinguish stage one lymphadema from edemas of other Genesis the clinician needs to rely upon the history and whether the swelling resolves with conventional management including compression and elevation or the swelling remains with conventional management this slide shows a 19-year-old female with stage one lymphadema before and after two weeks or 10 treatments of complete decongestive therapy as you can see lymphad has reduced the involved limb back to its normal size stage two stage two also known as spontaneously irreversible is primarily identified by tissue proliferation and subsequent fibrosis also known as lymphostatic fibrosis tissue prolif eration is caused by longstanding accumulation of protein Rich fluid over time the tissue becomes harder and pitting is difficult to induce as you can see in the slide pitting is visible on the dorsum of the hand in many cases the volume of swelling increases which exacerbates the already compromised local immune defense because of this infection such as cellulitis is common in this stage this in turn leads or tends to increase the volume of the affected area volume reduction can be affect can be expected if proper treatment is initiated in this stage of lymphadema in most cases the Harden tissue will not completely recede in the Intensive phase of complete decongestive therapy reduction of fibrotic tissue is achieved mainly in the second phase of complete decongestive therapy with compression and good patient compliance lymphadema often stabilizes in stage two in those patients suffering from recurrent infections the lymphodema May develop into stage three which is known as lymphostatic elephantiasis what do I mean by spontaneously irreversible the fluid component in this stage can be removed spontaneously while it will take more time to remove the increased tissue component which is initially irreversible this slide shows a 69-year-old female with Stage 2 lymph edema before and after 2 weeks or 10 treatments of con complete decongestive therapy as you can see lymphadema is reduced with some fibrotic tissue still being present again with good patient compliance fibrotic tissue can be addressed and will recede stage three stage three is also known as lymphostatic elephantiasis typical for this stage is an increase in volume of the lymphadema and further progression of the tissue changes lymphostatic fibrosis increases in firmness and other skin alterations such as papilomas cysts fistual hyper caratos fungal infections of the nails and skin and ulcerations of the skin frequently develop pitting at this stage may or may not be present the natural skin folds especially on the dorsum of the wrist and Ankle deepen in many cases cellulitis is re urrent if lymphadema management starts in this stage reduction can still be expected to achieve good results it is necessary to extend the duration of the Intensive phase of complete decongestive therapy also known as CDT in many cases the Intensive phase has to be repeated several times even extreme cases of lymphostatic elephantiasis can be reduced to a normal or nor near normal size with proper care and patient compliance this slide shows a 51-year-old male with stage three bilateral lymphadema before and after a total of five weeks or 48 treatments of complete decongestive therapy as you can see lymphadema is reduced however some fibrotic tissue is still present fibrotic tissue again will continue to recede with good patient compliance here's another slide depicting stage three lymphadema before treatment on the left and two years later on the right the patient received a series of 40 treatments over four weeks of complete decongestive therapy as you can see lymphadema was reduced but some fibrotic tissue was still present the picture on the right shows the patient 2 years after discharged due to excellent compliance the patient was able to reduce the fibrotic tissue considerably complete decongestive therapy is the gold standard for lymphadema care in the next few slides lymphadema and its treatment with complete decongestive therapy will be discussed complete decongestive therapy or CDT is a non-invasive multi-component approach to effectively treat and manage lymphadema and related conditions CDT consists of a combination of manual lymphatic drainage compression therapy decongestive exercises and Skin Care manual lymphatic drainage also known as MLD is a gentle manual treatment technique this technique is based upon Vaders which is Dr Amil voder his basic techniques consisting of four basic Strokes these Strokes are designed to stretch the walls of superficial lymph vessels which increases their activity MLD techniques reroute the lymph flow around the blocked areas into more centrally located lymph vessels that drain into the Venus system the most important effects of manual lymphatic drainage are the following to increase lymph production by Stretch on the anchoring filaments of the lymphatic capillaries this stimulates the intake of lymphatic loads into the lymphatic system MLD will increase the contraction frequency of lymph collectors this is known of as lymph angom MotorCity this is achieved by mild stimuli of the smooth muscular found in the walls of lymph collectors MLD has been shown to reverse the lymph flow in the treatment of lymphadema MLD moves lymph fluid in superficial lymph vessels opposite to its natural flow patterns lymph fluid is rerouted around blocked areas via collateral lymph collectors anastomoses or tissue two channels MLD increases Venus return the directional pressure of MLD Strokes increases the Venus return in The Superficial Venus system deeper and more specialized techniques of MLD especially in the abdominal area affect the Venus return in the Deep Venus system an increased Venus return produces additional decongestive effects last MLD is soothing the light pressures used in MLD decreases the sympathetic mode and promotes the parasympathetic response based on the phase of treatment compression therapy is either applied by specific bandage materials these are called short stretch bandages or by compression garments or a combination of both in some cases alternative to bandaging and compression garments have been used these alternative include custommade adjustable compression devices such as Circ Reed sleeves and others the following effects are achieved with compression bandages and garments they prevent the reaccumulation of evacuated lymph fluid and conserves the decongestive results achieved during manual lymphatic drainage or MLD they increase the pressure in the tissue itself and on the blood and lymph vessels contained in these tissues the tissue pressure plays an essential role in the exchange of fluids between the blood capillaries and the tissues The Beneficial effects of increased tissue pressure are especially important during airplane travel compression therapy improves Venus and lymphatic return external compression forces these fluids in the proximal Direction They also improve the fun function of the valves contained in the lymphatic and Venus vessels compr compression therapy improves the effectiveness of the muscle and joint pumps during activity activity of the skeletal muscu is an important factor in the return of fluids within the Venus and lymphatic system together with other supporting mechanisms the muscle and joint pump activity propels these fluids back to the heart and ensures an uninterrupted circulation external compression provides a sufficient counter Force to the working musculature thus improving its efficiency compression therapy helps to break up and soften deposits of connective tissue and Scar Tissue this effect is especially beneficial in the treatment of lymphostatic fibrosis and can be increased by the use of special foam materials in combination with compression therapy compression therapy compensates for the elastic insufficiency of the affected tissue this will be shown on the next two slides due to the constant overstretch in longstanding lymp edema the elastic fibers of the skin tissues are damaged this slide shows a 52-year-old female patient with stage three postmastectomy lymphadema overstretched skin as you can see in this photo is evident this slide shows the same patient as on the previous slide post decongestion damaged skin elasticity due to overstretched tissue is evident although lymphadema may be reduced to a normal or near normal size when proper treatment techniques are utilized the skin elasticity may never be regained completely the affected bodyby part is always at risk for a reaccumulation of fluid external support of the affected extremity or body part is there therefore an essential component of lymphadema management the primary goal in compression therapy is to maintain the decongestive effect achieved during the manual lymphatic drainage session that is to prevent reaccumulation of fluid into the tissues without the benefits provided by compression therapy successful treatment of lymphadema would be impossible exercise is most beneficial for patients with lymphadema when compression which includes bandages or garments is utilized on the affected limb during periods of exercise compression provides a slight forgiving resistance so that the muscular can act as an internal pumping mechanism the rhythmic contraction and relaxation of the muscles against the garments or bandages will increase the activity of the lymph vessels and limit filtration by providing an increase in tissue pressure with compression exercise can increase the uptake of fluid into the initial lymphatics and improve the pumping action of the lymph collectors there are no specific exercises that are quote unquote better for lymphadema in fact all patients with lymphadema can benefit from some form of decongestive exercise the patient's constraints and ability levels determined by an orthopedic evaluation will govern exercise prescription an important or appropriate intensity to perform exercise could be described as the level where the activity can be easily sustained allowing the patient to simultaneously engage in conversation light to moderate exercise allows the individual to reach a steady state and continue the activity for a given period of time with less risk of reaching fatigue strenuous exercise will cause fatigue and the patient is less likely con to continue that exercise patients suffering from lymphadema are susceptible to infections of the skin and Nails meticulous care of these areas is essential to the success of complete decongestive therapy lymph emitus tissues are saturated with protein Rich fluid which serves as an ideal breeding ground for pathogens in addition the local immune defense is low due to the swelling and increased diffusion distance which Hind ERS a timely response of the defense cells in the affected area lymph emitus skin can also become thickened and scaly which increases the risk of skin cracks and fissures the basic consideration in skin and Nail Care is the prevention and control of infections and injuries patients are instructed in proper cleansing and moisturizing techniques to maintain the health and integrity of the skin this educational process includes how to inspect the skin for any wounds or signs of infection or inflammation suitable ointments or lotions formulated for sensitive skin and lymphadema should be applied before the application of compression bandages and garments ointments as well as soaps and other skin cleansers used in lymphadema management should have good moisturizing qualities contain no fragrences be hypoallergenic and should be formulated to be in either the neutral or acidic range of the pH scale which is around a pH of five to identify possible allergic reactions to skin care products they should all first be tested on healthy skin before the initial application to the affected areas successful lymphadema management is performed in two phases those phases will be discussed on the upcoming slides in Phase One also known as the intensive or decongestive phase the patient is seen on a daily basis which generally means Monday through Friday and treatments are given until the affected body part is decongested it is imperative for the success of the therapy that treatments are given daily and that the patient is Thoroughly informed about all components of CDT before treatment is initiated again compliance is key phase one consists of skin care manual lymphatic drainage compression therapy using short stretch bandages and padding material as well as decongestive exercises patient instruction is also an imperative component of the Intensive phase self manual lymphatic drainage and self- bandaging proper exercises skin care proper care of bandages and garments as well as dos and don'ts are part of the patient instruction and education the duration of the Intensive phase varies with the severity of the condition and averages two to 3 weeks for patients with upper extremity lymphadema and two to four weeks for patients with lymphadema of the lower extremity or extremities in extreme cases the decongestive phase May last up to six to even 8 weeks and may have to be repeated several times the end of the first phase of treatment is determined by the results of circumferential or volumetric measurements of or on the affected extremity once measurements approach a plateau the end of phase one is reached and the patient progresses seamlessly into phase 2 of CDT phase 2 of CDT is also known as the self management phase depending on the stage of lymphadema the involved extremity or body part may have reached a normal size at the end of the Intensive phase or there still may be a circumferential difference between the involved and the uninvolved limb if the treatment was initiated in the early stage one of lymphadema which is car characterized by a soft tissue consistency without any fibrotic alterations limb reduction can be expected to be to a normal size compared to the uninvolved limb if intervention started in the later stages of lymphadema with lymphostatic fibrosis present the fibrotic tissue will not completely regress during the Intensive phase of CDT reduction in fi iotic tissue is a slow process which can take several months or longer and is achieved mainly in the second phase of CDT in phase two of CDT the patient assumes responsibility for managing improving and maintaining the results achieved in Phase One to reverse the symptoms associated with later later stages of lymphadema good patient compliance is indispensable proper daily skin care is necessary compression garments have to be worn daily in many cases bandages have to be applied during the night self manual lymphatic drainage and decongestive exercises should be formed daily this self-management phase is a lifelong process regular checkups with the physician and the lymphadema therapist are often necessary a multi-layered application of padded short stretched bandages is applied daily until the extremity is decongested bandages must remain on until the next day of treatment so the therapist is able to inspect the bandages and the extrem examples of upper extremity and lower extremity bandaging have been supplied to you in separate videos on the course platform short stretched bandages are primarily used in the decongestive phase of lymphadema management also known as phase one these bandages are textile elastic providing a High working pressure and a low resting pressure working pressure is defined as the counter pressure the bandage sets against the muscles working underneath resting pressure is the pressure the bandages exert on the tissue while the patient rests the pressure quality of short stretch bandages pres prevents reaccumulation of fluid and improves the lymphatic and Venus return long stretch bandages generally known as Ace bandages are known to have a low working pressure providing minimal resistance while exercising the high resting pressure in these bandages May produce tourniquet effects while resting long stretch bandages es should not be used in the treat treatment and management of lymphadema gauze bandages are often applied to fingers and toes to avoid constriction of Venus and lymphatic vessels and to achieve a compression gradient it is necessary to apply compression bandages in layers following the application of a suitable moisturizer on on the skin a cotton stocking at is applied to absorb sweat and to protect the skin from padding materials special soft foam materials or synthetic cotton bandages are used for this purpose short stretch bandages of various widths are then applied in layers on the extremity tape should be used to affix the bandage material and not Clips or pins sharp bandaging Clips or pins may cut into the patient's skin and provide an Avenue for infection once the extremity is decongested the patient is fitted for compression garments compression garments are available as compression gauntlets sleeves and stockings and these are made for specific specific body parts like brasseries or vests they are manufactured in a number of sizes and variations to include circular knit and flat knit varieties compression garments also provide different compression levels or compression classes the compression levels establish the compression value the garments produce on the skin surface and are measured in millimeters of mercury to ensure the benefits of compression a gradient from distal to proximal is necessary the pressure values within the different levels of compression are measured on the distal circumference of the extremity for example on the leg at the ankles where the pressure gradient is highest most manufacturers in the United States use the following F in values compression level one is 20 to 30 mm of mercury compression level 2 30 to 40 mm of mercury compression 3 40 to 50 mm of mercury and compression level four anything that is more than 60 mm of mercury compression classes 1 2 and three are available ready made made as well as customade compression class 4 is available as customade only upper extremity lymphadema generally requires a compression compression Class 2 whereas a lower extremity lymphadema in most cases requires a compression class 3 garment the appropriate style and compression class is determined by the referring physician in cooperation with the lymphadema therapist patients with lymphadema graduate from bandages into elastic compression garments once the limb is decongested which is in phase two of lymphadema management to preserve the treatment success achieved during the decongestion of the emitus limb compression garments have to be worn lifelong compression garments will not by themselves reduce swelling therefore they must not be worn on an untreated swollen extremity to ensure the lifelong benefits of compression garments it is important that only trained individuals with a full understanding of the pathology of lymp feda take the appropriate measurements and make an educated Choice regarding the Garment selection compression garments become a part of the patient's life much like hearing aids or eyeglasses ill fitted and ineffective compression garments produce not only poor results but can be dangerous to the patient many potential problems and special needs of the patients must be addressed and solved in order to arrive at a comfortable yet supportive garment solution as you can see on this slide there are examples of both the Bad and the good as well as the two short where it comes to compression related garments the main goal in lymphatic management is to decongest the affected body part heart and return the lymphadema back to a stage of latency stage zero also known as the subclinical stage the normal or near normal size of the limb should be maintained and reaccumulation of lymph fluid should be prevented additional goals include prevention of infections and reduction of fibrotic tissues to achieve the goal of decongestion manual lymph drainage techniques are utilized to reroute the lymph flow around the blocked areas into more centrally located healthy lymph vessels which drain into the Venus system the healthy lymph nodes and lymph vessels which are generally located adjacent to the area with insufficient lymphatic drainage are manipulated with manual lymphatic drainage or MLD the resulting increase in lymph angom MotorCity is the healthy area creates a suction effect this suction effect enables accumulated lymph fluid to move from an area with insufficient lymph flow into an area with normal lymphatic drainage the extremity itself is treated in segments the proximal aspect of the affected extremity is decongested prior to expanding the treatment into the more distal aspects in case of uncomplicated upper extremity lymphadema which is pictured on the left the lymph is rerouted toward towards the cervical lymph nodes the axillary lymph nodes on the contralateral side and the inguinal leg lymph nodes on the same side in case of uncomplicated lower extremity lymphadema seen on the right the lymph is rerouted towards the axillary lymph nodes on the same side and the inguinal ligament lymph nodes on the contralateral side in addition deep lymphatic Pathways in the abdominal area are used as well to decongest the lower extremity obviously parts of the body other than the upper and lower extremity can be affected by lymphadema the next series of slides discusses the various other parts of the body that may be affected by lymphadema swelling of the trunk or trunkal swelling may be present as a standalone condition or in combination with upper and or lower extremity lymphadema trunkal swelling usually develops following dissection of axillary or inguinal lymph nodes the swelling of male and female genit Alia is often associated with lower extremity lymphadema to include both primary and secondary lymphodema swelling is more common in males due to the greater tissue elasticity of the scrotum and penis the slide shows a male patient with genital and lower extremity lymphadema following surgery and radiation for prostate cancer the picture on the right shows the patient following a series of 10 treatments with some residual swelling remaining genital lymphadema is obviously a challenging condition which often causes longstanding physical emotional and social problems for the affected patients treatment of this condition may be included in the treatment sequence for lower extremity lymphadema or it may be performed as a stand alone treatment if lower extremity lymphadema swelling is present the treatment of the genital swelling should precede the treatment sequence for leg or lower extremity lymphadema head and or neck lymphadema is often the result of cancer treatment for malignancies in the neck to include the larynx ferx thyroid gland and tonsils or the head region to include the bottom of the mouth tongue lips and salivary glands cancers in the head and neck region commonly metastasized to cervical lymph nodes in the case of cervical metastases all or part of the cervical lymph nodes are removed this surgical procedure is referred to as neck dissection this is often combined with radiation therapy of the area depending on the extent of the C surgical procedure additional damage to the facial nerves diaphragm brachial plexus and vocal cords may be observed the swelling which is usually more pronounced in the morning may involve the neck submandibular area cheek nose and or eyelids forehead and scalp are generally not involved the therapeutic benefits of complete decongestive therapy can often be considered enhanced by facial exercises chewing gum and meticulous oral hygiene the patient should be fitted with a compression garment for the face and neck shown at the right these garments are available in different sizes and can be ordered in either standard or custommade sizes this compression or compression masks should be worn at night drainage areas in the post neck dissection conditions are the cranial portions of the upper quadrants to include anterior and posterior and the axillary lymph node groups as mentioned previously to date there is no cure for lymphadema the goal of any treatment must be to reduce the swelling and to maintain that reduction the only physiological way to achieve this goal is to remove the excess plasma proteins from the tissues via lymph vessels and tissue channels for a majority of patients this can be achieved by the skillful application of complete decongestive therapy CDT shows good long-term results in both primary and secondary cases of lymphadema and is the current gold and international standard for care for lymphadema numerous other therapeutic interventions have been offered to treat this condition some of these approaches have been used used to supplement complete decongestive therapy While others have been proven to be unsuccessful often treatment options are selected individually based upon past medical history amount of Edema Lifestyle Insurance and financial situation newer devices to treat lymphadema consist of a multi-chambered sleeve applied to the arm or the leg that uses rubber tubing to connect to a pump the pump moves compressed air into the chambers of the sleeve which inflate one at a time while moving up the arm or leg pumps are effective in removing water from interstitial spaces but do not remove proteins it must be stressed that lymphadema is a high protein edema and the primary goal in lymphadema treatment is the removal of excess plasma proteins from the interstitial tissues proteins that remain in the tissues continue to attract fibro blasts and generate new connective tissue which creates more Scar Tissue there are a number of documented disadvantages of compression pump therapy for lymphad management these include remaining and intact functioning limb lymph collectors may be destroyed by these pumps trunk quadrants previously not swollen may fill with fluid pumps can cause swelling of external genitalia pumps move water from the distal to the proximal extremity where it accumulates pneumatic compression pumps move water but not protein pumps have no effect on softening of fibrotic tissue and may worsen fibrosis application time is long and questionable by long I mean a minimum of 4 hours and some protocols suggest up to eight hours patients are immobile during pump sessions and there are currently no standardized settings intermittent compression pumps are not considered a component of complete decongestive therapy the following should be observed if pumps are used in the treatment of lymphadema they must not be used to decongest an extremity in other words pumps cannot be used or should not be used in Phase One pumps may be used in phase two once the affected limb is decongested if these devices are used in the self-management phase the treatment should be combined with manual lymphatic drainage there are two basic types of surgical procedures used in the attempt to treat lymphadema the first type of procedure is an aisal procedure to include debulking and liposuction the second surgical procedure involves lymphatic reconstruction in general surgical approaches are associated with significant risks and do not eliminate the need for compression garment for those of you that are interested in the debulking procedures the excess skin and the subcutaneous tissues of the affected limb by lymphadema are surgically removed together with the tissue the subcutaneous lymph vessels are removed as well this seriously interferes with any later attempt to treat the limb with CDT the picture shows a patient 6 months following a debulking procedure on both lower extremities CDT was not initiated for treatment massive swelling is present just above the area where the procedure was performed affecting the proximal thighs genital area and lower trunk portions debulking procedures do not prevent the reaccumulation of lymph fluid and do nothing to repair or improve the function of a compromised lymphatic system the Cosmetic results are also fairly unsatisfactory in most cases today these operations are not as common as they were in the late 1980s and early 1990s it must be added that in some cases redundant skinfold following unsuccessful treatment with CDT may require excision the surgical removal of these excess skin folds should only be performed after successful decongestion of the swollen limb lipos section is another procedure used in the treatment of lymphadema in this procedure the subcutaneous fat tissue is is removed with a blunt tipped canula which is introduced into the fatty area through a small incision suction is then applied which removes the fatty tissues and destroys any remaining intact lymph collectors which are embedded in the fatty tissue following this procedure the lymphatic microcirculation is significantly Disturbed the technique of lipos suction has improved in recent years however major complications may still result from these procedures and the Cosmetic results are often unsatisfactory the fact that fatty tissue cannot be removed without causing additional damage to the lymphatic system makes it understandable that these invasive procedures can worsen existing lymphadema and possibly trigger the onset of lymphadema micro surgery is another surgical approach in the treatment of lymphadema these approaches attempt to restore the lymphatic continuity by either replacing the collectors with segments of a vein or prosthetic material or by connecting lymph collectors directly into the Venus system the various surgical attempts to quote unquote repair the compromised lymphatic system in lymphadema have failed so far the pharmaceutical approach to managing lymphadema includes the use of diuretics benzopyrones antibiotics and diet most experts agree that the use of diuretics for the treatment of uncomplicated lymphadema is in effective and may lead to the worsening of symptoms diuretics are able to remove the water content of the edema while the protein molecules remain in the tissue spaces these proteins continue to draw water to the emitus area as soon as the drug loses its Effectiveness diuretics result in a higher concentration of proteins in the edema fluid which leads to an increase in the swelling and may cause the tissue to become more fibrotic diuretics may also be indicated in those cases where lymphadema is associated with other conditions that necessitate the application of these drugs benzopyrones these include cumarin and flavenoids that have been tested in research studies these drugs are not used any longer in the United States Europe and Australia due to their liver toxicity and inconsistent efficacy antibiotics are used to treat infections such as cellulitis and lymphangitis and are common in lymphadema in particular if left untreated infections are typic Ally characterized by redness pain and high fever again antibiotics are administered in these cases fungal infections are another common complication of extremity lymphadema and can be treated with antimycotic and antifungal drugs in most cases washing the skin using a mild disinfectant followed by antibiotic antifungal cream is helpful diet there is no special diet for lymphadema there is also no vitamins food supplements or herbs that have been proven to be effective in the reduction of lymphadema it is important to understand that lymphadema cannot be reduced by the limitation of protein ingestion an accepted approach is to follow a low salt and lowfat diet which positively contributes to weight control it is also important not to limit fluid intake good hydration with water is essential for basic cellular function obesity generally worsens the symptoms of lymphadema reducing calorie intake combined with a supervised exercise program in case of obesity is essential in decreasing limb bulk in cases of lymphadema in conclusion lymphadema may appear as a simple or complicated swelling and should never be neglected accurate diagnosis and effective therapy is available lymphadema usually affects one extremity in bilateral involvement the swelling is always asymmetrical complete decongestive therapy or CDT is the current International standard and the therapy of choice for treatment of lymphadema CDT is the treatment endorsed by the American Cancer Society as well as the National Cancer Institute complete decongestive therapy is not only proven to be effective with excellent long-term results it is also non-invasive and safe without any known side effects to the patient provided the patient is an appropriate candidate for CDT CDT is also cost effective in that it transfers the care from the medical professional to the patient and family CDT significantly reduces the risk factors of developing infections and improves complications associated with lymphadema such as papilomas lymphatic cysts lymphatic fistulas vericose lymphatics and fungal infections