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Lymphedema and its treatment


Autor: mr sc. med. dr Bratislav Cvetković   

lymphedema-and-its-treatment

Lymphedema represents a progressive swelling of the intercellular tissue, certain part of the body, mostly the progresive swelling of one or two extremities, the trunk, the head, genitals where the lymph accumulates as it cannot pour off by the lymph or vein circulation.  Lymphedema is a difficult, chronic, long-standing and incurable disease.

Human body is watery solution of electrolites dissolved in three sections – intravascular, interstitial, and intercellular. The excess of liquid which has a tendency to accumulate in the interstitial vein system of the circulation 90 per cent is drained and by the lymph circulation the 10 per cent of the liquid is drained in the normal circumstances of the healthy body, only by the lymph great molecules of interstitial are drained. The lymph system contains the high concentration of proteins ( 1g %) and it is called ’highprotein’ edema.  The lymph system from the interstitial removes the following: the excess of water, electrolites (which do not return in the circulation by the vein capilars), macromolecules, proteins, the cells of inflammation and tumors and their fragments. The lymph system, beside its main function, the lymph circulation, has the filter against the antigens invasion, the function of protein protectors (75 – 150 gr proteins per day return to the veins) and the function of the cleansing lipoproteins from the intima of blood vessels ( antiatherosclerosis function).  So, the lymph system keeps the homeostasis of the extracellular space of the interstitium, it is important in the prevention of the infections and releases the bacteria, water, and proteins. The lymph system in the chronic stadium is characterised by the excess of proteins which withdraw water with them and strengthen the edema, but they activate the macrophages causing the inflammatory reaction which classifies the lymph as the regional nonsystematic collagenosis.  

The lymph system damages the quality of life and the patient is unable to function, not only physically, but also mentally as the great financial expenses for treatments become the real problem.
 
The frequency of the lymphedema – the primary lymphedema manifests among 1 per cent of population, 2, 5 – 5 per cent in the world has some kind of the lymphedema.
Epidemiology according to WHO – is that one of 20 – 25 persons in the world has a kind of lymphedema, and 30 millions have primary lymphedema, and 20 millions is postmastectomy lymphedema. (John Casley- Smith, 1993).

Lymphedema is frequent during many years (even after 30 years) after the initial damage of the lymph vessels or noduses for normal functioning of a person.

The history facts about the lymphedema

  • Hippocrates ( 460-377 B.C) wrote about the vessels with white blood
  • Aristotel ( 383-322 B.C.) described the vessels with clear liqud
  • Aselli ( 1581-1626 ) studied the lymph system from the aspect of modern medicine
  • Bertholin was the first who used the term ’vasa lymphatica’ and gave the name to the lymph system 

Anatomy

The lymph system consists of the lymph vessels, lymph nodes, lymph organs and the group of the lymph tissue, which is added to the immune system, its main purpose is maintaining the homestasis of the interior part of a body and the defense of a body from infections.
The lymph contents are equal to the intercellular liquid from the part of a body which is rich in proteins (around 20 g/l or more), the oil drops of the gastrointestine tract region, electrones.

The lymph system consists of

  • The lymph capilars
  • The lymph vessels are created by the capilar links and they can be:
    • Aferrent or prenodal, and they bring the lymph from the periphery to the lymph knots
    • The lymph stems or postnodal which carry the lymph from the lymph knots
  • The lymph stems or truncuses
    • Subphrenic ( truncus intestinalis i truncus lumbalis  dexter et sinister )
    • Upperphrenic ( truncus subclavius,truncus jugularis,truncus bronchomediastinalis )
  • The lymph canals or ductuses (ductus thoracicus,ductus lymphaticus dex) 
  • The lymph knot

The lymph circulation is globally divided into: surface and deep lymph system. The superficial is above the fascia of the muscles (epifascial), draining the lymph from the skin and hypodermic tissue which form 15 per cent of the complete lymph net.

The deep lymph system is subfacial, following the magistral blood vessels; drain the lymph from the body excluding the skin.

The lymphedema manifests in the superficial system of the lymph circulation.

The lymph system

The main function is the liquid withdrawal from the interstitium in the systematic circulation. The lymph system controls: the concentration of proteins in the interstitial liquid, the volume and pressure of interstitial liquid. The amount of plasma and plasma proteins which are filtrated from the capillary bed is equal to the amount of plasma which returns by the lymph circulation into the systematic circulation. 

The lymph circulation

The greatest circulation of the lymph is at the atmospheric pressure of 0 mmHg and normal pressure of the lymph is – 3 mmHg.

The lymph circulation increases with the increasing of the capillary pressure, increasing the coloid-osmatic pressure of the interstitial liquid and increasing the permeablility of capillars.

The increasing of the lymph circulation is enabled by the contraction of surrounding sceletal muscles, the body movements, the pulsation of surrounding artheries, the exterior compression, the contraction of interior organ muscles,  the great depth of breathing and massage.

The lymph circulation is probably the finest mechanism in a human body.

The causes of creation the lymphedema

  • The reduction of lymph circulation (loss, interruption)
  • Hyperthrophy or hyperplasia of the lymph circulation
  • The obstruction of lymphatics (malignant disease, the scar of lymphadenectomia, radiotherapy or infection)
The lymph system is the protective factor against the overcharge of the liquids and prevents the edema.

  • Dynamic insufficiency due to increasing of the volume. So, the lymph overcharge surpasses the transport capacity and liquid is accumulated in the interstitials causing the edema.
  • Mechanic insufficiency – means that the lymph transport system is damaged which damages the normal lymph circulation. The lymph circulation cannot solve the normal overcharge of the lymph. The lymph protective factor cannot be activated in the mechanical insufficiency.
The lymph system maintains homeostasis of extracellular space and insufficiency of this system with the normal or larger creation of interstitial liquid causes the lymphedema.

The lymphedema is the consequence of surgical blockade of the lymph circulation, and then the postirradiation of the fibrosis of tissues.

The lympedema has a characteristic abnormal high concentration of tissue proteins, chronic inflammation, thickness of the hypodermis, at serious cases it can alter into lymphangioma. The incidence of the secundary lymphedema after surgical or radiation therapy of the carcinoma of the breast is from 6 to 30 per cent, after the treatment of the carcinoma in the epelvis 1 – 47 per cent, the treatment of the head and neck of 22 – 56 per cent.

Pathophysiology of the lymphedema

The lymphedema is the result of the functional overcharge of the lymph system, and the lymph volume surpass the capacity of the lymph transport. The lymph circulation causes the accumulation of proteins, cell metabolites such as macromolecular proteins and hyaluronic acid in extracellular space. It causes the increasing of tissue of colloid pressure and it causes the water accumulation and increasing of interstitial hydrostatic pressure; both factors increase the lymphedema. Hystopathological finding is the thickness of the basic membrane of the lymph vessel, fragmentation and degeneration of elastic fibres, the great number of fibroplast and inflammatory cells with pathological accumulation of colagen. The old concept – the lymphedema is the clinical manifestation of the mechanical damage of the lymph transport. The new concept – the lymphedema is degenerative and inflammatory process in the skin, lymphatices and lymphoduses with the  fibrosis changes during episodes of  dermatolymphadenitisa (DLA), and not only in the assimilation of the lymph. The lymphedema is the part of pathology and clinic picture of the vein insufficiency maintaining the degree and extend of the vein blockage. 

The symptoms of lymphedema

The swelling, the feeling of weightness, slow movements of extremities and ankles, slight uneasiness with manifestation of pain and itching, the repetitive episodes of infection as lymphedema is the chronic inflammatory process (the skin is warm and red) with cellulities or lymphangitis and serious cases are followed with the skin and extremities thickness, pouring of the lymph (lymphorea) and extremely great swellings – elephantiasis.  

Specific criterions of diagnosis do not exist; the lymphedema is a chronic state which can be controlled under the adequate therapy.

There are many extremity swellings and can be divided into general and central (heart, kidney, systematic, nutritive, diabetes, alergic, neuropathic); they cause clammy periphery swellings of acute circulation which do not last for long; periphery or local causes (vein - phleboedema, lymph – congenitial, posttrauma - M. Sudek and Volkman’s contractions, systematic, infective, ’malignant’ – due to the progress of malignancy, lypoedema, postperfusion, haemangioma, arteriovascular fistulas) cause the chronic swellings.  Lymphedema is frequently mixed with flebedema and lypodema. Due to different etiological factors and treatment approaches there are rare proximal or ’downward’ lymphedema or frequent ’upward’. 

The clinical division of lymphodema can be:
  • Acute
  • Transitory
  • Chronic
There are four types of chronic lymphedema:

The most frequent type manifests with the uneasiness in the extremity, pain in the proximal parts and the feeling of weightness. It is evident two years after the surgical and radiation treatments and may manifest 30 years after the operation.

Transitorory lymphedema manifest after acute lymphedema, the latent period of different duration follows, and the transitory lymphedema manifests in the proximal parts and frequently spreads; it manifests by the clammy swellings, the loss of elasticity of the skin and frequently alters into the chronic stadium. 

The chronic lymphedema is irreversible ’highprotein’ and it is controlled by the therapy. At the beginning it is soft, clammy, and pale on the pressure of the finger and leaves the traces in the skin and, after the night rest, by different elevations, exercises and placing the elastic supportive devices. The interstitial liquid and proteins cause the inflammation and permanent fibrosclerotic tissue change, the skin loses its elasticity and look like the orange skin, becomes thin and form the blisters (hylodermia) filled with the lymph and by bursting they cause lymphorrhea; the swelling becomes spoongy, the skin does not form hollows after the finger pressure, extremities enlarge, losing the basic form. The secundary changes are eczema, pigmentation, ulcers or wartlike condylomas.

The classification of the chronic lymphedema – the international

Stadium I – early accumulation of the liquid rich in proteins, during the elevation of extremities the swelling decreases (reversible) and the region of disease is of normal shape and size.

Stadium II – the elevation of extremities does not reduce the swelling, it becomes clammy under the finger pressure, leaving the traces under the finger pressure, after some time the swelling is not clammy any more, but hard due to fibrosis and the finger pressure does not leave the trace.

Stadium III – the swelling is spoongy with trophic changes on the skin for example the deposits of oils, wartlike condillomas, the loss of the extremity functions, at the end the elephantiasis. The so-called stadium ’’0’’ manifests after the treatment for example Ca of the breast when the lymphangioscintigraphy can show the latent shape.

Etiological classification

Primary (congenital, praecox, late – tarda and familiar) and secundary or aquired (parasitic infection – filariasis, infection – erysipelas, postsurgical, malignant – obstruction or complication of vein insufficiency, after radiotherapy, trauma adenoid, TBC...), lymphedema.

Primary limphedema manifests due to primary disease of the lymph system, hereditary or, as aplasia, hypoplasia or hyperplasia and represents the rare clinical entity among women usually on the extremities (on the legs).

There are three types of primary lymphedema -
  • Classical congenital, which manifests after the birth and causes the dysfunction of the lymph system by the bad diagnosis
  • Praecox ( early) frequently manifests before puberty from 14 – 16 years at teenegers
  • Tarda (late) manifests after 35 years of age and it are always unilateral.  
The classification according to the degree of manifestation:
  • Mild uncomplicated lymphedema – the increasing to 2 centimeters or 20 per cent great volume in comparison with the healthy side; edema is limited to extremities which keeps its shape, the skin is healthy and intact, normal and subjectively soft and clammy.
  • Moderate to expressed – of great volume, from 2 – 6 centimeters, and volume is less than 40 per cent in comparison with healthy side, it spreads to the hip, the diseased extremity loses its shape with the manifestation of skin changes (skin folds, fibrosis and hypercaterosis).
  • Extremely expressed lymphedema – elephantiasis, the swelling in the range of 6 centimeters and over 40 per cent of the great volume in comparison with the healthy side, with trophic changes of the skin and in the last stadium the manifestation of the lymph and in the pleura 0 hielotofax. The swelling is irreversible, and extremities become great and swelled.

The estimation and diagnosis (the recognition of lymphedema)

It is not complicate and case hystory with clinical examination are sufficient.
Diagnostic methods find the cause of lymphedema, and do not establish a diagnosis.
They are used for – differential diagnosis, the stadium degree of lymphadema, observing the reduction of lymphedema. The research definition – the increasing of volume by 10 per cent in comparison with the state before the operation is represented by lymphedema.

Subjectively

It is important to know if surgery of the breast is done after the diagnosis is established. It is also preferable to know if the dissection of the lymph knots is performed as well as radiation therapy after the surgery, and the consequences such as post operative infections, swellings after the operation, celullitis, or the swellings after the operation and its duration, the skin changes and the complication of the lymphedema, the temporary medicament therapy and allergy of the patients, and the state of the patients is also very important. Precipitate factors are trauma and physical extremity or the whole body shock, the skin damage, the extreme heat, overweight, tight clothes or jewellery, the position of the extremities, a difficult prosthesis. The important data is the previous breast treatment.

The objective

Inspection extremities, the basic lymph knots, body quadrants, the skin changes
Such as hyperpigmentation, fibrosis, the skin integrity and hydratation
The span of extremity movements – it is usually reduced in the ankle segments.
The pain – subjectively it does not exist but if a strong and sharp pain manifests it would be good to further examine DD.

The diagnostic tests

The measuring of extremities on every 8 – 12 centimeters and comparison with the healthy extremities – the difference is 2 centimeters in the span regarding the increasing of the lymphedema indication.

HAND is measured three times over the letheral epicondylomas and 10 – 12 centimeters distally and proximally from it, over the metacarpus.

THE LEG is measured over the knee and in many levels proximally and distally, the span is over the malleus, malleol of the heel, the dorsum of the foot. The body weight is important and Body – mas index.

The volume measuring is very precise and should be used when it is possible. The increasing of the volume extremities is 150 – 200 ml indicative for the lymphedema.

The skin tonometry quantifies the elasticity of the skin

The diagnosis test with 99 per cent accuracy is Shtemmer’s sign, the skin pinched between the II and III finger on the foot, if the skin does not fold the test is positive. The skin is thick and swelled at the beginning, later fibrosis manifests, as the lymphedema manifests suprafascially above the muscle fascia, and other swellings may manifest in the muscles. 

The additional diagnosis:

  • Lymphangioscintigraphy
  • The Contrast Lymphography
  • The Color Doppler
  • Ultrasonography
  • The Computerized tomography
  • The Nuclear Magnetic Resonance
Other techniques – fluoroscent microlymphafanfiography for example vitamin B12,  
  • Subscutane scan C – scan
  • Lymphoxerography – the detection of the soft tissue is in the phase of examination
  • Immunehystochemic examinations  
  • Electronic microscopy
  • The biopsy of the lymphedema tissue
  • Genetic researches, carried out at the primary lymphadema.

The complication of the lymphedema

If it is not treated, the extremity extension enlarges, the movements of the ankles decrease, the weight of extremities with the change of configuration and shapes, the trombosis of the lymphatics manifests, cellulitis, lymphangitis, erysipelas (red wind), hylodermia (the lymph blisters), the trophic changes with the ulcers, the wartlike condillomas, chronic wounds, tissue necrosis, gangrene with the amputation and lymphangiosarcom manifests at 1%.

Lipedemia

Lipedemia manifests as the problems with the symmetric division of the oily tissue, especially on the legs and rarely on the hands and must not be replaced with lymphedema. It manifests only at women, bilateral and symmetrically around the legs, from the pelvis to the ankles and never manifests on the feet.

Shtemmer’s sign is negative

Characteristics: the lymphedema - the skin is smooth, during time it becomes stiff and without therapy, the swelling is not clammy, it hurts on the pressure, and has daily rhythm – it is bigger at noon, sensitive to traumas, and bruises manifest after small injuries, with the accumulation of the oil on the hips and knees. KDFT does not give the adequate results, the real therapy is surgical.

The treatments of the lymphedema

- Is the interdisciplinary problem which occupies a great number of doctors and therapists and it is necessary that many who treat lymphedema accept one document (the same treatment with pathology and treating lymphedema) – consensus document. Consensus document is a dynamic document, and changes with the new concepts and has the basic principles of the lymphedema treatment. It allows that one principle manifests in different ways, which depends on the individual patient’s state, technical and other work circumstances. 

International Society of Lymphology-ISL was decided on the Concensus for the diagnosis documents and the therapy of lymphedema in 1995.

As lymphedema is treated but is not cured, it is better to pay attention to the treatment of lymphedema or help than about curing it.

If the treatment begins early, the result of the therapy is better. As a five-day therapy KDFT has a right effect of the lymphedema releasing, the final result of the therapy is better.

All methods of the lymphedema treatments can be divided into: conservative (nonoperative) and surgical (operative methods).

Conservative methods of the treatment

Conservative methods of the treatment showed success at lymphedema I and II phases. The main diasadvantages of applying it The physical classic procedures are that the edema releasing only water without proteins, developing fibrosis. Conservative methods include – hygienic and diet measures, medicament therapy, the elevation of extremities, the compressive bandage and clothes, the manual lymph drainage  MLD, exercises, the use of classic physical procedures and pneumatic lymphdrainage. KDFT – The complex decongestive physical therapy   
The complex decongestive physical therapy is nowadays the most accepted method of treating lymphedema, including a combination of several methods: the skin treatment, centripetal MLD, short-elastic bandage (with the consequences of wearing the elastic pieces of clothes when the edema is reduced), the therapeutic exercise such as kinesiotherapy with the bandage or elastic clothes.

KDFT includes three phases:

Phase I or decongestive (acute) phase consists of giving information and education about the lymphedema, the patient training classes for the use of KDFT, (self-massage, self-bandage, the exercises and the skin treatment), the application of KDFT, the hygienic dietetic regime for the correction of TT, psychologic treatment with the psychosocial instructions.

It is preferable to have the elevation of extremities for 30* from the heart, as well as the prevention and therapy of fibrosis in the corium, the lasers, the pneumatic compressive lymphdrainages, hyperbaric treatments. This phase lasts approximately 4 – 6 weeks till the decongestion of extremities such as the reduction of extremity volume for 70 – 75 per cent that is the reduction of the span for 3 centimeters in comparison with healthy persons or achieving the individual decongestion.

The phase II or the maintaining phase starts after the decongestion of extremities. According to the measuring the span extremities, an adequate sock or elastic sleeve is necessary for wearing during the day. It includes the application of KDFT in the home circumstances, MLD, wearing the elastic pieces of clothes, regular bandages during the night and every day exercises with elastic supportive devices for extremities, with the skin hygiene). It is important to mention that the therapy is permanent and it can be controlled by these procedures.

Phase III – the repetition of the first phase after six months or repetition of the therapy due to the patient state.

The surgical treatments

The physiological reconstruction and recessive operations did not show the good results.
And they usually result in complications (long-lasting lymphorreia, the infection of the wound, the skin necrosis, trombosis, the scars and scar contractures or amputation.)

They are divided into: resecting, lymphosuction, lymph-lymph anastomosis) and drainage operations as well as the combination of them. Numerous operations show their unsuccessfulness.

The aims of operative treatments are the function improvement, the reduction of extremities, the patients’ problems with  reduction, the prevention of the complications of the lymphedema such as cellulities, lymphangitis, lymphorea, hylodermia, lymphangiosarcom and better estetic extremity function.

Nowadays there are 100 kinds of the surgical interventions and none gives the satisfactory results:
  • Resecting – includes the extension of the lymph tissue, the eye-sight is the most frequently used, and they are followed with the frequent and significant complications.
  • Lymphosuction – is the reduction operation of the lymphedema and it is always followed by the postoperative exterior compression.
  • The drainage – surpasses the ’lymph blockage’ and the blockage or replace the lymph from the diseased extremity without the direct interventions on the diseased lymph vessels. Reconstructive – the reconstruction of the lympha by the direct intervention on the lymph vessels, are actual with the development of microsurgery.
  • Combined – includes the application of several methods. The central lymph blockage that is the reflux is the unsoluble surgical problem.

The aims of the treatments

  • The education of the patients about the lymphedema and encouragement regarding the treatment methods in the home circumstances
  • The stimulation of the lymph system; the faciality of the lymph swellings
  • The preventions of the accumulation swellings
  • The prevention of the repetitive or recurrence of infection
  • The patient’s help to live with the psychological lymphedema sequels
  • If it is possible involve the family and friends into the treatments

The risk factors for the lymphedema development

  • Surgical intervention and post-operative radiation therapy
  • The post-operative complications– Cellulitis or Erysipelas
  • Extensive disection of the lymph noduses
  • The old age with the overweight

The contraindications for the therapy (relative contraindications)

  • Congestive heart weakness (the inflammation of the face or dyspnea during the therapy and if the drainage is adequate the patient should urinate after it)
  • Acc. DVT – the deep vein trombosis and acc. threatening trombosis
  • Acc. the infection which is not cured in time or the inflammation of the extremity tissue
  • Avoid the massage and bandage over the tissue which was radiated
  • The active malignancy

The influence of the lymphedema on the patient

  • The extremity swelling or the body parts with the tendency of deteriorating if it is not treated
  • The difficulties at the patient’s movements
  • The repetetive infection episodes
  • The thickness of the skin, the lymph releasing through the skin
  • The cosmetic problems and problems with finding adequate shoes and clothes
  • The changed way of life – without sunshine, heat and limited everyday activities
  • The constant medical help, money expense and numerous hospitalisation

The complex decongestive physical therapy (KDFT)

The use of four methods in the treatments of the lymphedema – can be applied to patients without the actual metastatic diseases!

  • THE SKIN PROTECTION  
  • MLD – MANUAL LYMPH DRAINAGE
  • THE COMPRESSIVE BANDAGE
  • EXERCISES

The hygiene and skin protection

The hygiene of the skin is necessary in order to prevent and eliminate the bacteria and fungi, the development of repetitive cellulite attacks and lymphangitises. The patient should be thought how to treat the skin and nails with the treatments of the inspection of the interdigital spaces and skin folders as they are especially vulnerable on the micotic and erysipeloid infection.  The skin protection is necessary with the losions of the ph 5-5, 5 with the lanolin base twice daily before putting the bandages and after taking them off.   The skin damage can be the base for microorganisms which grow on the tissue rich in proteins as the ideal base for the growth of bacteria and the infection development. If the infection develops, go to your dentist and begin the therapy with the antibiotics; meanwhile stop the treatment of   KDFT as the extremities do not move and rest with the evaluation.

Manual lymph drainage (MLD)

Is the technique of the lymph decompression massage which stimulates the lymph circulation by releasing and decompression of the obstruction of adenoids and directing the lymph into the surrounding, functional lymph regions. From the pathological point of view MLD maintains the lymph circulation, strengthening the function of the capilary lymph pump and stimulating the fagocit activity of the tissue macrophages. The aim is stimulating the movements of the excessive liquid from the swollen area by the normal lymph circulation and by the activating the collaterals. The drainage begins with the stimulation of the lymph knots and nodulus of the surrounding basin. The treatment is performed to the diseased extremity, from the proximal releasing to the distal end.  MLD is based on the concept of releasing the central regions; adenoids are released in the surrounding area, then in the two surrounding-adjacent quadrants, with the drainage of the lymph knots if they exist and, in the end, the drainage of the extremities proximally and distally.  There are four techniques MLD –according to Vodder, Fold, Leduc or Casley-Smith. The wall of the epifascial adenoids is stretched and increased the activity, but the lymph is directed toward the adequate side. The movements are circular and have:  
  • The intensity of hand pressure, which must be pleasant and it is 30 mmHg; it must not be greater because of the danger of the lymph bursting,  
  • The direction of the movement is always in the direction of the lymph vessels
  • The movements must be in proximal segments first then distal
  • The rhythm or the duration is 1 secund and the phase of resting lasts about 5 secunds. It causes the pump effect and the repetition of 5 – 7 times is the most effective. During MLD the patient behaviour must be observed.

Indications for MLD  

  • The primary and secundary lymphedema
  • The paresis of fascial and hemyplegy as the begining of the therapy
  • Chr. Reumathism of ankles
  • Algodistrophic sy,
  • The great  contusions and haematomas  
  • The scars as the consequence of burns,
  • The distorsion of ankles

Contraindications for MLD

Absolute - acc. infections, acc. DVT, acc. bronchitis, heart and kidney edema.
Relative - malignity and bronchial astma. 

The basic movements during MLD

  • Standing (circular) movement,
  • The movement of pumping
  • The movement of giving ,
  • The circular movement,
  • The movement of smoothing.
Self-massage – is the simple version of MLD and can be performed at home and it is called the lymph drainage JLD. It is done with the fingers of the patient.

The compressive therapy (KT)

Is used as  
  • Elastic several-level therapy with the bandages,
  • The compressive clothes parts
The bandage of the diseased extremity follows after each MLD, due to the decongestion of MLD which is manifested and optimalized by the compressive bandage. The compressive therapy increases the interstitial pressure as the balance is optimalized in the functional capilary unit, interstitial or the lymph capilary.

For the bandage the several-level short-elastic bandages are used. The bandage prevents the complete diseased extremity by the lymph.

The aims of KT are

  • It reduces the amount of the interstitial liquid producing the efficiency of the ’muscle pump’.
  • It prevents the skin extension,
  • The protection- prevention of the extremities from injuries, trauma and infections.

The effects of the compressive bandages

  • The reduction of filtrations
  • The increasment of the muscle efficiency and the ankle pump
  • The prevention of the accumulation of evacuated lymph liquid
  • MLD and compressive bandage destroys the accumulated deposites in the connective tissue.

The principles of the lymph bandage - Why is ti used?

In order to achieve the impression in the lymphoedema tissue the several-level bandage should be used in order to treat the surface and deep blood vessels. By the correct application of the bandage from the distal to proximal part of the extremities, with increasing the great, moderate hard distal pressure (the proximal pressure is lower), the decreased pressure in coordination with the muscle activity forms the strong support – the high pressure. At the beginning of the treatments, the bandage is placed after MLD and stays there for 24 hours – it is one-day bandage. It is recommanded that the patient sleeps with its elastic bandage whenever it is possible.
The bandage is more efficient than other elastic clothes pieces and is frequently recommanded. The correct use of the elastic bandage does not influence the circulation. The bandage of the lymphedema must not cause the pain, itching, colour change around the toes. If it happens the bandage takes off, especially if other disease develop meanwhile – the arthery diseases, the heart and kidney edema, irregular TA, acc. infections (cellulitis, erysipelas),
malignant edema, the muscle dysfunction which are the absolute K.I. for bandage.
As relative K.I. for the use of bandage: regular hypertension, the sclerosis of coronary artheries, that is coronary disease, the heart arrhythmia, paresis and paralyses, age, diabetes, bronchial astma. 

The compressive (elastic) clothes pieces

The elastic sleeve or sock is made in several sizes. They are used after the plato or the swelling reduction for 70 per cent or the reduction of the span for more than 2 centimetres. By wearing the elastic sleeves or socks, the accumulation or reaccumulation is reduced, and the adequate function of the muscle pump is provided toward the preventing of the muscle injuries and infection development.
The compressive parts of the clothes are available in four classes

Class I -  20 -30 mmHg , low compression
Class II  - 30 – 40 mmHg,
Class III – 40 - 50mmHg ,
Class IV over 50 mmHg , high compression to 70 mmHg and it is done in sizes. For the lymphedema of the hand the class II or III are recommanded, and for the leg class III is preferable. They are taken off at night, when the patient lies in bed and rests. The compressive clothes are worn during work, exercising and travelling, especially during the plane flight, and it must be taken off when some infection manifests on the extremity which is diseased. 

For the use of class IV, the skin should be intact and of the preserved integrity without any small wounds, and the patient must be younger and active ready to cooperate with the doctor.

Exercises

The therapeutic exercises of the bandaged extremities and elevation are prescribed to each patient.

The exercise activates all muscle groups and ankles which result in better lymph circulation and dilate all lymph vessels. Every day kinesiotherapy is the part of the regime of a patient’s life with lymphedema, and the aim is the increasment of the vein and lymph circulation. The lymph circulation is greater for 5 – 15 times. Kinesiotherapy consists of the rhythmic flexions and extensions of the extremities.

The activity of the muscle pump reflects in the change of the tissue pressure which stimulates the lymph capillaries to open and close which enables the liquid creation. The use of adequate exercising is ideal as it does not create the additional creating of the interstitial liquid. (Cohen et al 2001). The exercise should be performed once daily and they include the exercise of flexibility – elasticity, power and aerobcs. (Board 2002).        

The diaphragmal kind of breathing, the diaphragm has contractions and creates the negative pressure, and during exporium the diaphragm relaxes and creates the positive pressure, so that the experium creates the pumping effect of the central adenoids.

The prevention of the lymphedema

The prevention of the lymphedema has a special significance, by which we prevent or prolong the lymphedema, alleviate the discomforts and improve the quality of patient’s life. The education is very important for the performing of drainage, self-bandage, correct exercises, hygiene of the skin and nails, and the lymphedema development.

The prevention of the lymphedema is difficult – the prenatal diagnosis of congenital dysfunction is possible. They cause the lymphedema or screening of the family with the familiar dysfunction. The specific measures, the change of life, the prevention and protection of the skin from infections, the specific exercising, the outdoor compression by elastic holders (socks or sleeve ccl II, the medicament therapy.

The prevention of the secundary lymphedema is simpler. The right choice and the use of methods and surgical interventions, the change of routine of iridatory treatment, the postoperative education and rehabilitation of the patients and the prevention of the first signs of the lymphedema and the beggining conservative therapy.

In early recognising of the first changes which can be manifested at the lymphedema it is necessary to pay attention to the following: the comparison of actual body weight with the ideal body weight, the weight of the arms and legs, the level of proteins in blood, the ability for doing everyday activities, the swellings, the surgical interventions and radiation therapy of patients, the diseases as diabetes, hypertension, the kidney disease, heart and vein disease.

The medicament therapy

The most frequently used therapy of the lymphedema, if doctors cannot do anything; at chronic lymphedema can have only psychological effect.

As specific medicines in a therapy there are three groups of medicines – benzopirones, flavonoides and rutosaides group of medicines did not prove in the clinical routine. DIURETICS are not indicated in the therapy of lymphedema, they are used occasionally during the initial phase of complex decongestive therapy of lymphedema. The longstanding therapy can cause the disbalanse of liquid and electrolites. They temporarily mobilise liquid, by the increasing the pressure during the accumulation of proteins in the interstitial area causing the rapid reaccumulation of edema and the increased concentration of proteins on the other hand accelerate fibrosis. ANTIBIOTICS are used in the treatments of lymphedema with antimitotic if they are necessary.  ANALGESICS The patients may suffer pain due to the accumulated liquid in the nerve endings or the muscle atrophy and contractures during movements. It is preferable to use analgetics, tricyclic antidepressants.  

The dietetic regime at noncomplicated periphery lymphedema is not of importance. The dietetics regime must be carried out and the approximate weight must be achieved TT. The level of proteins (albumines) in blood should be controlised and the diet based on the balanced diet with the limited amount of salts is preferable. The amount of 3 – 5 grammes of salt is adequate.

Psychosocial rehabilitation is an integral part of the treatment of lymphedema.
  • The swelling of extremity or any body part damages the anatomic configuration and causes the limits in activities of everyday life.
  • The state deteriorates in time.
  • It causes the difficulties in movements
  • The repetitive episodes of infections
  • Hospitalisation
  • The coarse skin, the lymph pouring off through the skin (lymphorrhea)
  • The cosmetic problem, difficulties at buying shoes and clothes
  • The different way of life – the patient should avoid the sun exposure, limited physical activities
  • The constant medical help and treatment expenses

Pneumatic lymphdrainage

are mechanical devices which are filled with air and consist of turn-ups for the extremity, arm or leg as well as the area around the pelvis and abdomenon.

The turn-ups are filled with the air in sequences, which provide the pump effects of the lymph towards the heart. The positive pressure is used and it is not recommanded to be greater than 40 mmHg on the level of distal turn-ups.   The duration of the pressure in chambers is 15 – 20 secunds, and the duration of the daily therapy on the lymphdrainage is 2 hours per day when the state of extremities is satisfactory. ; The therapy is then 1 – 2 times per week and lasts 1 hour. The lymphdrainages mobilise the liquid movements through adenoids and it can happen that the lymph accumulate in great amounts, which is the reason for a therapy of pneumatic pumps added to the concept KDFT; it is not regarded as the singular therapy.
 

Cvetkovic  Bratislav, PhD
The Clinic for Physical Medicine, rehabilitation and protetics in Nis
Kanjuh  Zeljko, PhD
The Clinic for Rehabilitation " Dr M.Zotovic " Belgrade


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