Today's Wound Clinic - Winter 2008 - (Page 26) coverstory Stages of lymphedema12 Stage 1 – is spontaneously reversible, pitting edema is noted, and upon waking in the morning, the affected area is normal or almost normal in size. Stage 2 – is spontaneously irreversible, the tissue is spongy in consistency and non-pitting, fibrotic changes begin. Stage 3 – is referred to as lymphostatic elephantiasis. The affected area is very large, fibrotic, and unresponsive to intervention; the area becomes a medium for bacterial invasion and subsequent lymphangitis. changes in the subcutaneous tissues of the thighs, buttocks, and hips. DIAGNOSTIC EVALUATION Appropriate management requires a correct diagnosis and an understanding of the underlying pathophysiology.7 Imaging techniques such as lymphography and lymphscintography that allow visualization of the lymphatics are available but seldom used in clinical practice. Other imaging techniques such as ultrasound or CT scans are most helpful in ruling out other causes of edema such as venous insufficiency, deep vein thrombosis (DVT), or pelvic mass. Lymphedema is most commonly diagnosed by case history and physical exam. The Stemmer sign (thickened skin folds on the dorsum of the digits that are difficult to pinch) is considered proof of lymphostatic edema.8 Other common findings are asymetrical lower extremity swelling, increased natural skin folds, subcutaneous fibrosis, and skin alterations such as hyperkeratosis, pachydermia, and papillomatosis. The degree to which these findings are present depends on the severity and duration of the lymphedema. begin. Complete decongestive therapy (CDT) is a safe, reliable, non-invasive technique considered the gold standard for care. It comprises a fourstep process: Step 1. Manual lymph drainage (MLD) Step 2. Graduated compression Step 3. Therapeutic exercise Step 4. Scrupulous skin care. Manual lymph drainage. Complete decongestive therapy is provided in two steps. The first step includes strategies to move the lymphatic fluid from the affected region and reduce the swelling using MLD techniques and compression bandaging. The former stimulates the activity of the lymphatic vessels and manually moves lymphatic fluid. Applied correctly, a series of MLD treatments will generally decrease the volume of the affected extremity to normal or near-normal size. Ideally, these treatments are performed daily, 5 days a week for 2 to 4 weeks, depending of the severity. Bandages are applied during this time to retain the achieved reduction. Compression. Once the swelling is reduced, the patient is fitted with a graduated compression garment. The compression garment is essential to maintaining the reduced limb—ie, to prevent re-accumulation of fluid in the limb—and is designed to replace bandages used earlier in treatment process. CLINICAL IMPLICATIONS Complete decongestive therapy. Once the condition has been definitively diagnosed and the patient understands the chronicity of lymphatic challenges, treatment procedures can 26 Winter 2007 Today’s Wound Clinic The compression bandage utilized in the treatment of lymphedema has several unique qualities. First, it is a short-stretch bandage—ie, less than 100% extensible. Fully stretched, it is less than twice its resting length. This property allows the bandage to provide a high working pressure.The less stretch available in the applied bandage, the more resistance to fluid reaccumulation. Also, during ambulation or exercise, the muscle bulge that occurs with contraction places pressure on the tissues between the muscle and semi-rigid wall of the bandage. This pumping action enhances both venous and lymphatic flow. Second, bandages used for lymphedema are textile elastic—ie, they are 100% cotton and their stretch comes from the weave in the fabric, not from elastic fibers. Because very little energy is stored in the fabric, the pressure against the limb at rest is lower than that exerted by elastic bandages. This lower pressure allows the lymphatics to fill more readily. As in venous disease, compression garments are worn during the day; however, in lymphedema compression is also frequently required during sleep since inactivity reduces lymphatic function. Nighttime compression can be achieved through self-bandaging or a second compression garment frequently of lower pressure than the daytime garments. (Old daytime garments often make good sleep garments.) For the
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