Know Your Nodes, Part IV

By Riva Preil

So, how does physical therapy help treat lymphedema?  Great question, I am glad you asked.  The gold standard of care to treat lymphedema is COMPLETE DECONGESTIVE THERAPY (CDT).  CDT consists of four components:

  1. Manual Lymphatic Drainage (MLD)
  2. Compression
  3. Exercises
  4. Skin Care

MLD was pioneered by Dr. Emil Vodder in the early 1900s, and it is series of various manual techniques (including “pump,” “rotaries,” “scoop,” “and pump-push,” to name several) which promote moving the excess lymph fluid from the distal extremities towards proximal, healthy open lymph channels.  Another way to think about lymphedema due to lymph node removal is that there is congestion on one “road”.  Therefore, the certified lymphedema therapist (CLT) seeks to open up and create new channels on uncongested “roads,” thereby creating detours for the lymph to return to the venous system through alternate routes.  MLD allows the CLT to direct the lymph along healthy, open lymphatic pathways.

In addition, appropriate compression must be applied to promote the return of lymphatic fluid and to prevent it from improperly pooling in affected areas.  Therefore, compression is an appropriate component of CDT.  During the acute first phase of treatment, bandaging should ideally be worn 23 hours during the day and removed only for showering or bathing.  CLT therapists bandage patients with short stretch bandages and they teach patients how to perform self-wrapping.  During the chronic second phase of treatment, compression garments can be substituted for bandages during the day, either custom made or over the counter.  Bandaging is continued for nighttime usage in most cases.

No physical therapy experience would be complete without some exercise, right?  Exercises are important in treatment of lymphedema because the musculoskeletal system helps with venous return and promoting fluid movement by acting as a pump mechanism.  That’s why ankle pumps (ankle dorsiflexion and plantarflexion) are recommended after ankle surgeries, in treatment of postsurgical edema (swelling).  So too, similar upper extremity and lower extremity “pump-like” exercises help return lymphatic fluid to the venous system.  Depending on the type of lymphedema (upper vs. lower extremity) several examples of lymphedema appropriate exercises include ankle pumps, knee and hip flexion and extension, shoulder flexion and abduction, elbow flexion and extension, and wrist flexion and extension.

Finally, skin care is a huge component of CDT.  The reason for this is that increased swelling of any extremity increases the DIAMETER of the extremity.  This increases the distance that gases (ex. oxygen) and nutrients must travel to reach the surface of the skin.  This is referred to as increased diffusion distance.  Oxygen is a necessary component in skin healing after any injury, even simply a paper cut!  It is harder for oxygen to travel long distances compared to short distances, therefore increased diffusion distance (as in the case of lymphedema) SLOWS the healing process.  Slower healing rate increases the likelihood of developing an infection through the open wound.  Therefore, it is crucial for all patients with lymphedema to be vigilant about skin care and inspection.  Their wounds heal slower than those of other individuals, and it is important to minimize the chance of developing infection by keeping wounds clean and covered.

So there you have it!  That was a brief overview of “How I Spent My Summer Vacation.” I could not think of a better way to spend my time this summer.  Don’t get me wrong, a week in Italy or an Alaskan cruise are trips that I look forward to hopefully taking one day, but I am grateful that I had the opportunity to take this incredible course his past summer.  This course is rarely offered in New York, so I had to jump on my chance when I saw it advertised. Thank you to Amy for supporting my continuing education and to my co-workers for helping to treat my patients while I was at the course. Italy and Alaska can wait for me, because my patients are more important!

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