Today's Wound Clinic - Winter 2008 - (Page 27) coverstory lymphedema patient, this usually requires working pressures higher than are generally needed for successful management of venous disease only. Historically, this need has been met by utilizing Class IV or higher compression garments.Today, most of the compression garment companies offer a line of lymphedema garments designed along the principles of short-stretch bandages.The garments are more resistant to stretch—thereby, creating high working pressures—but have less elasticity allowing lower resting pressures. Compression bandaging utilized in the treatment of lymphedema differs in several additional ways from the bandaging typically used to manage venous insufficiency. The first difference is that compression must be applied from the digits to the root of the limb. The next variation is the types of materials utilized. Digits are individually wrapped with-soft, elasticized gauze. Although most multilayered compression bandaging systems utilized in the treatment of venous disease start with cotton padding, material lymphedema bandaging utilizes synthetic padding. The padding protects the underlying skin and also shapes the limb. In lymphedema, it is not unusual for the ankle to be as large or even larger than the calf; therefore, the limb must be reshaped before applying compression bandages to ensure a gradient compression. The synthetic bandaging material does not become matted in the presence of moisture and generally becomes fluffier with repeated use. Reimbursement. Although MLD is reimbursed under the manual therapy code, most payors do not directly reimburse for the bandaging supplies. Quality short-stretch bandages are more expensive than the various multilayer bandaging products on the market for managing venous insufficiency; however, over the course of treatment they are cost effective. Because the bandages are re-usable, two sets of bandages (one to wear and one to wash) are sufficient to meet the patients needs for the entire course of treatment. Multilayer systems are replaced at each office/clinic visit. In addition to compression garments, meticulous skin care, self-manual lymphatic drainage, and therapeutic exercise will promote treatment success. impedes diffusion to the tissues. Compression bandaging applied in this situation should be re-applied in 2 to 3 days with reduction in limb size and increased ability to assess diminishing symptoms. LIFELONG CHANGES Because lymphedema is a chronic condition that must be addressed everyday, ongoing therapy can be taxing for patients and lifelong changes must be made. 11 Once a differential diagnosis (lymphedema or lipedema) has been made, the role of the clinician is to support the patient, not only within the context of managing the lymphedema and related physical issues, but also in addressing the emotional, social, and spiritual aspects of care. ■ LOWER LEG INFECTION The patient with lymphedema is at particular risk for cellulitis of the lower leg. Cellulitis is an infection of the dermis and subcutaneous tissue and is usually caused by Streptococcus or Staphylococcus organisms. It is characterized by warmth, edema, erythema, and advancing borders. Clinically, patients may develop a fever and elevated white blood cell count, progressing to local tissue death and systemic infection. Cellulitis can develop in seemingly healthy skin but usually develops in the presence of a break in the skin. Hygiene, friction to the skin surface, and the inability to examine and clean the lower extremity places the patient at risk. Cellulitis usually results in blistering of the epidermis; superficial necrosis might be present. The extent of the injury can range from acute erythema, with or without blisters, to extensive epidermal necrosis with exudate. Treatment is aimed at resolving the acute infection and preventing recurrent episodes of cellulitis. The mainstay of treatment is antibiotic therapy. Antibiotics often are required intravenously in the initial stages of infection and changed to oral once the infection begins to resolve.9 A 4 to 6week course of treatment may be necessary because of impaired circulation to the area.10 The general practice is not to compress the red swollen limb. This certainly should be followed if acute DVT is involved. However, compression to reduce edema should enhance systemic treatment of cellulitis. Systemic antibiotics are dependent on blood circulation for distribution. Edema reduces circulation and REFERENCES 1. Gallagher SM. Lymphedema and lipedema. In: Gallagher SM. The Challenges of Caring for the Obese Patient. Edgemont Pa: Matrix Medical Communications; 2005. 2. Siegren M, Kline R. Current concepts in lymphedema management. Adv Skin Wound Care 2004;17:174-180. 3. Lymphedema.Available At: www.emedicine.com/ MED/topic2722.htm.Accessed January 14, 2008. 4. Petrek JA, Heelan MC. Incidence of carcinomarelated lymphedema. Cancer 1998; 83(S12B): 2776-2781. 5. Lymphedema: system interrupted. Available at: http://www.lymphdoc.com. Accessed December 10, 2007. 6. Lipedema.Accessed at: http://lymphedema.com/ lipedema.htm.Accessed December 10, 2007. 7. King M, DiFalco E. Lymphedema: Skin and wound care in an aging population. Ostomy Wound Manage 2004;50(5):10–12. 8.Weissleder H, Schuchhardt, C. Lymphedema Diagnosis and Therapy 3rd edition;Viavital Verlag GmbH:Koln; 2001. 9. Baxter H, McGregor F. Understanding and managing cellulitis. Nurs Standard 2001;15(44): 50-55. 10. Sulberg D, Penrod M, Blatny R. Common bacterial skin infections American Family Physician. 2002;66(1):119–124. 11. Davis CM. Complementary Therapies in Rehabilitation. Thorofare, NJ: Slack Inc; 2004. 12. DeTurk WE, Cahalin LP. Physical therapy associated with lymphatic system disorders. In: Cardiovascular and Pulmonary Physical Therapy:An Evidence-Based Approach. McGraw-Hill; New York, NY;2004. Today’s Wound Clinic Winter 2008 27 http://www.emedicine.com/MED/topic2722.htm http://www.emedicine.com/MED/topic2722.htm http://www.lymphdoc.com http://lymphedema.com/lipedema.htm http://lymphedema.com/lipedema.htm
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