Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3628_Библиотеки_им_академика_М_И_Перельмана
.pdf
6.2 Complete Decongestive Therapy
https://t.me/medicina_free
Table 6.4 Absolute and relative contraindications for
compression therapy
Part of the evaluation process is to scan for potential
contraindications and/or precautions for compression therapy
to avoid adverse outcomes.
The application of compression on an extremity is absolutely
contraindicated in the following cases:
●
Cardiac edema.
●
Peripheral arterial diseases: Compression therapy is
contraindicated with an ankle/brachial index (ABI) of less than
0.8. Normal ABI values range from 0.95 to 1.3; in mild to
moderate arterial disease, the values range from 0.5 to 0.8.
ABI values of less than 0.5 are interpreted as severe arterial
insufficiencies.
ABI compares the systolic blood pressure of the ankle to that
of the arm. These measurements are useful in the assessment, follow-up, and treatment of patients with peripheral
vascular disease.
●
Acute infections (cellulitis, erysipelas).
Relative contraindications:
●
Hypertension.
●
Cardiac arrhythmia.
●
Decreased or absent sensation in the extremity.
●
Partial or complete paralysis, flaccid limbs.
●
Age.
●
Congestive heart failure.
●
Mild to moderate arterial occlusive disease (ABI values 0.8–1.0).
●
Diabetes.
●
Malignant lymphedema.
A normal extremity can be compared to a cylinder. If
compression therapy is applied on a leg using the same
tension on the distal and the proximal ends of the extremity, the pressure in the ankle area (smaller radius)
would be greater than the pressure on the calf (greater
radius), and the pressure on the thigh would be lower
than the pressure on the calf.
4
This principle can be applied in a true cylindrical or
cone-shaped extremity. In the area of bony prominences
(ankles, wrists, or the medial and lateral circumferences
of the hand and foot), the pressure is higher due to the
smaller radius and the greater tension of the compression
material used, whereas in concave areas (behind the
ankles), the applied pressure is lower.
These issues and the fact that swollen extremities generally lose their cone shape make it necessary to use foam
materials for padding in combination with compression
bandages to construct a more cylindrical shape.
During the manufacturing process of compression garments a compression gradient is already built into the
garments, generally eliminating the need of additional
padding.
Compression Bandages
Correctly applied compression bandages are safe and
effective and represent an indispensable part of CDT.
Only trained therapists or patients and their caregivers
who have received instruction in the application of shortstretch bandages from a trained individual should apply
compression bandages in the treatment of lymphedema.
The application of bandage materials can be bulky and
are used primarily during the initial phase, also known as
the decongestive phase of CDT. Various types of elastic
bandages are available; the preferred types of bandage
material used in lymphedema management are shortstretch compression bandages. The braided cotton fibers
used in the production process are woven in a way to
achieve a certain degree of textile-elasticity. This interwoven pattern allows for about 30% to 60% extensibility
of the bandage’s original length. To understand the effects
of various bandage materials on the tissues and the vascular systems embedded within the tissues, it is important to discuss the difference between short-stretch and
long-stretch compression bandages.
Two different qualities of sub-bandage pressure can be
distinguished in compression therapy: the working pres-
sure and the resting pressure. Relevant in the determination of these pressure qualities are the type of bandage
(long-stretch or short-stretch) used, the tension employed during the application of the bandage, the number
of layers, and the condition of the material (age); bandages lose some of their elasticity over time and with
repetitive use and cleaning.
Working pressure: The resistance the bandage provides
against the working musculature determines the working
pressure. This pressure is temporary and only active during muscle expansion, and its value depends on the extent of muscle contraction. The active working pressure
results in an increase of the tissue pressure in the area
where the bandages are applied; in addition, the venous
and lymphatic vessels in the superficial and in the deep
systems are compressed, thus improving the return of
fluids within these vessel systems.
The lower the elasticity of a compression bandage, the
higher the working pressure. Short-stretch bandages
exert a high working pressure on the tissues and form a
strong support during muscle contraction.
Long-stretch bandages contain elastic fibers and retain
a low working pressure. Newly manufactured longstretch bandages allow for an extensibility of more than
140% to 300% of the bandage’s original length. This relatively high elasticity exerts a low resistance against the
working musculature, and the decongestive effect on the
venous and lymphatic system is minimal, especially in
the deep systems.
Resting pressure: This is the sub-bandage pressure exerted on the tissues at rest, i.e., without muscle contraction.
The resting pressure is a permanent pressure, and its value
depends on the amount of tension used during the application of the bandage. The higher the tension (or stretch), the
higher the pressure the bandage exerts on the tissues. A
bandage with a high extensibility will therefore result in
increased pressure on the tissues during rest.
Integrative, Multiprofessional Conservative Treatment
https://t.me/medicina_free
Long-stretch vs short-stretch bandages
in the treatment of lymphedema
Long-stretch bandages exert a relatively high resting
pressure during which the venous and lymphatic vessels
in the skin are compressed. This permanent compression
may cause a tourniquet effect on the bandaged
extremity. Long-stretch bandages may constrict veins
and lymphatic vessels at rest and provide minimal
support of the tissues during muscle contraction.
Short-stretch bandages employ a very low resting
pressure on the tissues and the vascular systems. The
risk of a tourniquet effect is therefore relatively low if a
specially trained individual applies the compression
bandages correctly.
Note: Long-stretch bandages are therefore not
suitable for the treatment of lymphedema.
The high working and low resting pressure qualities of
short-stretch bandages make them the preferred choice
in the management of lymphedema and swellings of
other geneses.
If significant short-term changes of the limb volume
after lymphoreconstructive surgery are expected, e.g.,
after lymphovenous anastomosis (LVA), the characteristics of short-stretch bandages in the postsurgical “new”
decongestive phase are preferable. After achieving a
“new” steady state after successful LVA treatment, compression garments are recommended again, but in general
require re-sizing and replacing garments.
How to apply a short-stretch bandage
correctly?
To avoid constriction of venous and lymphatic vessels
and to achieve a compression gradient in the treatment
of lymphedema, it is necessary to apply compression
bandages in layers. Following the application of a suitable
moisturizer on the skin (see the section on Skin and Nail
Care later in this chapter), a cotton stockinette is applied
to absorb sweat and to protect the skin from the padding
materials. The goal in the use of padding is to protect
bony prominences and to create a cylindrical shape
around the extremity. Special soft foam materials or
synthetic cotton bandages are used for this purpose. For
the padding of concave areas (behind the malleoli, palm)
or to increase the pressure over lymphostatic fibrosis or
wounds, a denser foam material is suitable. Short-stretch
bandages of various widths are then applied in layers on
the extremity. Tape should be used to affix the bandage
material; sharp bandaging clips or pins are to be avoided
as these materials may cut into the patient’s skin and
cause infection.
Most patients adjust to and tolerate the compression
bandage well after a few applications. Patients should
maintain their normal activity level and perform the decongestive exercise program while wearing the bandages
(see the section on Exercises later in this chapter).
Compression Garments
The primary role of compression garments in lymphedema management is to preserve the success achieved with
treatment during the decongestion of the edematous
body part. In patients with lymphedema bandages are replaced with elastic compression garments once the limb
is decongested (see the section on Two-Phase Approach
of CDT later in this chapter).
Note:
Compression garments by themselves do not reduce
swelling and should not be worn on untreated swollen
extremities or body parts.
To ensure maximum long-term benefits of compression
garments, it is imperative that only trained individuals
with a full understanding of the pathology of lymphedema and its related conditions take the required measurements for the garment and, together with the patient,
decide on the compression class, style, and length of the
garment. Ill-fitting and ineffective compression garments
not only produce poor results but also can be dangerous
to the patient. A number of potential limitations and specific needs of the individual patient must be addressed
and resolved to arrive at a comfortable yet supportive
garment. Compression garments become a part of the patient’s life, much like hearing aids or eyeglasses; they
must be worn on a daily basis and applied first thing in
the morning.
Compression garments are available as compression
gauntlets, sleeves, and stockings and are made for specific
body parts (e.g., brassieres or vests). They are manufactured in several sizes, variations (circular knit, flat knit),
styles, compression classes, and materials, and are available in standard sizes or be custom-made.
Note:
Compression garments should be replaced every
6 months or sooner if the garments have lost their
elasticity.
Donning and doffing of compression garments may be a
challenge for patients who have mobility issues, whose
hands are weak, or who have pain because of osteoarthritis;
72
6.2 Complete Decongestive Therapy
https://t.me/medicina_free
this is most challenging for patients living alone. Some patients, despite their best efforts, may not be able to reach
their feet adequately in order to don elastic garments or
may have limited assistance at home. Education and practice are crucial to helping patients and/or caregivers achieve
independence in this skill.
Donning aids can be useful to assist in the application of
compression garments. Rubber gloves, slip-on/off aids, and
nonslip mats are examples of donning systems, which also
help to protect the garment from damage (▶ Fig. 6.11).
Rubber gloves are an important tool for all patients as
they allow for “massaging” of the garment into place and
avoid pinching and pulling of the gar ment and damage
from fingernails or jewelry.
Elastic garments, which offer effective daytime compression, are not appropriate for nighttime use because
they can restrict adequate blood flow while the limb is
elevated and may bunch up when worn in bed.
Circular-Knit and Flat-Knit Garments
Compression garments are produced using two main
knitting methods—seamed flat-knit (▶ Fig. 6.12) and
seamless circular-knit. Both types are knitted by using
threads made of some form of rubber (elastomer). Cotton
or a synthetic material generally covers the elastomeric
thread, providing the garment with additional qualities.
Covered compression threads are more durable in that
they limit or regulate stretch of the elastic fiber and protect it from sweat and skin ointments (▶ Fig. 6.13). The
covered fibers make the garments softer, more breathable, and easier to apply. The manufacturing process provides compression garments with a two-way elasticity
(▶ Fig. 6.14); the more two-way stretch a compression
garment provides, the more comfortable it is to wear.
Flat- or circular-knit compression
garments?
The choice between flat- or circular-knit compression
garments involves various considerations. Circularknitted materials are less expensive and cosmetically
more attractive than flat-knit garments because they
have no seam and are produced using finer and sheerer
materials. Based on the manufacturing process of flatknit garments, these items are usually denser and more
costly to produce. However, they produce a more
tailored fit since the number of meshes is determined
by the patient’s circumferential measurements, which
may be a determining factor for patients with
excessively deformed extremities.
Aesthetic considerations are an important aspect in
choosing the right garment. Compression garments
are effective only if they are worn consistently; if the
patient is unhappy with the garment and does not
want to wear it, the therapeutic benefit is lost. Lower
extremity stockings can be disguised by wearing a
sheer (preferably dark) nylon stocking on top of them.
Fig. 6.11 Donning aid for open-toe compression stockings (Juzo
Slippie; with permission from Juzo USA, Inc.).
Styles of Compression Garments
Compression garments are manufactured in different styles
and lengths and are available with a variety of fastening
systems and integrated pressure pads (▶ Fig. 6.15a,b).
Fastening systems are designed to prevent the garments
from sliding, which may create a tourniquet effect that
may cause additional swelling and make the compression
garment uncomfortable to wear for the individual. Fastening systems consist of garter belts, hip attachments
(▶ Fig. 6.16), or fasteners that attach to shoulder straps.
Other systems include synthetic polymers (usually silicone
dots or stripes) on the inside of the proximal end of the
garments (▶ Fig. 6.17). Special adhesive lotions that are
available from most garment manufacturers can be used
as well to prevent the garment from slipping.
Built-in pressure pads constructed of dense foam materials ensure an even distribution of pressure in concave
areas, such as behind the malleoli or the palmar surface
of the hand.
Integrative, Multiprofessional Conservative Treatment
https://t.me/medicina_free
Fig. 6.12 Flat-knit thigh-high compression garment (with permission from Juzo USA, Inc.).
Fig. 6.13 Covered compressio n threads used in compression
garments (Juzo USA Fibersoft) (with permission from Juzo
USA, Inc.).
Fig. 6.14 Two-way elasticity in compression garments (with
permission from Juzo USA, Inc.).
Compression Classes
Graduated compression garments are available in four
main compression classes, which establish the compression value the garment produces on the skin surface and
are calculated in millimeters of mercury (mmHg). The
pressure values within the different classes of compression garments are measured on the distal circumference
of the extremity (wrist, ankle), where the pressure is
highest. To ensure the benefits of compression and promote sufficient circulation, a gradient from distal to proximal is necessar y.
For seamless circular-knit garments there is no current
international consensus for compression values within
the different compression classes.
Compression levels for lymphedema
treatment
The following values represent the compression ranges
most manufacturers adhere to (▶ Fig. 6.18):
●
20 to 30 mmHg (Compression class I)
●
30 to 40 mmHg (Compression class II)
●
40 to 50 mmHg (Compression class III)
Compression levels for seamed flat-knit garments lean
more toward international standards:
●
18 to 21 mmHg (Compression class I)
●
23 to 32 mmHg (Compression class II)
●
34 to 46 mmHg (Compression class III)
●
Over 50 mmHg (Compression class IV)
Pressure values below 20 mmHg are generally not
suitable for the management of lymphedema and are
used only if a higher compression cannot be tolerated
or is contraindicated.
74
6.2 Complete Decongestive Therapy
https://t.me/medicina_free
Fig. 6.15 (a) Compression styles for the lower extremity: 1, Knee-high stocking; 2, thigh-high stocking; 3, pantyhose; 4, pantyhose with
highly elastic body part; 5, thigh-high stocking with fastening border (silicone dots); 6, thigh-high stocking with hip attachment; 7, thighhigh stocking with garter belt; 8, toe caps. (b) Compression styles for the upper extremity: 1, Compression gauntlet; 2, compression
gauntlet with finger stubs; 3, arm sleeve; 4, arm sleeve with shoulder cover and strap (with permission from Juzo USA, Inc.).
Fig. 6.17 Compression glove with finger stubs (with permission
Fig. 6.16 Thigh-high compression stocking with fastening border
made of silicone dots (with permission from Juzo USA, Inc.).
from Juzo USA, Inc.).
In some cases of lower extremity lymphedema, a compression of more than that available in compression class
Many factors, such as age, activity level, skin integrity,
mobility issues, congestive heart failure, partial or complete paralysis, diabetes, and wound care factors, must be
considered to determine the correct compression class
for a patient.
IV may have to be used. In these cases, a compression
level II or III knee-high stocking may be worn in addition
to a compression level III thigh-high stocking (or pantyhose). It is important to understand that the individual
compression values of garments worn on top of each
Integrative, Multiprofessional Conservative Treatment
https://t.me/medicina_free
Fig. 6.18 Compression levels (with permission from Juzo USA, Inc.).
other do not double the values. Two level III stockings, for
example, do not add up to a level VI; the resulting pressure would be somewhere between compression classes
IV and V.
Physical limitations of the patient could be a rationale
for a decision to combine two stockings. For example, an
arthritic patient who requires a lower extremity garment
of a higher compression level may have less difficulty
donning a compression class III thigh-high with a compression class II knee-high stocking.
In most cases of upper extremity lymphedema, patients are adequately served by a compression class II arm
sleeve, provided there are no contraindications that would
require the use of a lower compression class, such as in the
case of a partially or completely paralyzed, or flaccid limb. A
patient with upper extremity lymphedema may require a
compression class III arm sleeve if she or he is involved in
a high-intensity and repetitive activity. For example, if a
patient wishes to return to playing golf, a class III arm sleeve
canbeusedontheinvolvedextremityduringplayanda
class II arm sleeve for daily activities.
Patients with lower extremity involvement usually require a compression class III garment; however, contraindications may be present that may necessitate the use of
a lower level, and certain situations may require a higher
level of compression.
If the patient has tolerated compression well during the
decongestive phase, she or he may easily fit into the standard compression levels for the upper and lower extremities.
It is important to consider the physical ability of the patient,
as well as the patient’s home support system when choosing a compression garment. A 70-year-old patient with
lower extremity lymphedema may not be physically able to
don a class III garment; thus, a class II garment may serve
the patient’s needs better.
The reduction of compression class is a relevant therapeutic aim to be discussed during patient education in the
modern surgical management of lymphedema, as it will
help to define potential phases to pause wearing compression garments without harming the overall results.
Custom-Made and Standard Compression
Garments
Compression garments with a compression level of more
than 50 mmHg are available only in custom-made materials. The high degree of compression requires the garment
to be manufactured to the patient’s exact circumferential
measurements. As discussed earlier, custom-made garments may also be a better choice for those individuals
with extremely deformed extremities. Some manufacturers provide custom garments with zippers, which can
be a choice for patients who may be physically unable to
don a closed compression garment.
Standard or ready-made garments are available in
compression classes I–III; these garments can be obtained
from most manufacturers in many predetermined sizes
and styles that can accommodate a vast majority of
extremities.
Custom-made garments are expensive, and the production time for these garments is longer. Although some
lymphedema patients benefit from custom-made garments, they are certainly not requisite for all patients.
The availability of a large variety of standard g arments
helps to reduce the cost and allows patients to wear
cosmetically more attract ive compression garments.
76
6.2 Complete Decongestive Therapy
https://t.me/medicina_free
Alternative Compression Materials
Multilayered sho rt-stretch compression bandaging remains the most adaptable compression modality for
lymphedema. The application of short-stretch bandage
materials in combination with appropriate padding
allows customization of the compressi on in virtually
unlimited variations. However, some patients are either
unable or unwilling to apply bandages for nighttime
compression, in which case alternative materials may
provide the solution to counter a lack of adherence to
the self-care and self-bandaging regimen.
Several adjustable elastic and nonelastic compression
devices are available for patients with lymphedema and
venous disorders. These devices provide gradient compression by use of adjustable bands. Some of these devices use foam pads underneath the nonelastic material to
provide additional padding, others may be combined
with traditional compression garments (▶ Fig. 6.19).
There is a broad consensus between clinicians that
these devices should not be used to decongest a swollen
limb (▶ Table 6.4). Nonelastic, adjustable compression
may be used as an alternative to nighttime bandaging to
balance daytime compression supplied by elastic compression garments when the extremity has decongested
to a normal or near-normal size.
Alternative devices can also be utilized as a supplement
to elastic garments in the daytime when elastic compression is insufficient to control edema in a limb with flaccid
skin due to massive reduction or very aggressive forms of
edema.
Exercises
Well-tailored regular exercise programs can have a positive impact on a healthy lifestyle, improve general wellbeing, increase energy level, and contribute to stress and
weight management. Additional benefits of exercises for
those individuals at risk of, or have, lymphedema include
improved limb flexibility and range of movement, and
most importantly increased lymphatic and venous return
from the swollen areas, which can result in reduction of
limb size and subjective limb symptoms.
Research indicates that the transport of lymphatic fluid
and proteins from swollen areas increases during and
after exercises. Studies show that lymph flow increased
fivefold in the first 15 minutes and two- to threefold during the remaining time of a 2-hour exercise protocol.
addition to the benefits to the lymphatic system, it is
known that muscle activity and diaphragmatic breathing
also have a considerable impact on venous blood returning from the extremities back to the heart, which in turn
also positively affects fluid management within the interstitial spaces; increased venous return is of particular
importance for those individuals affected by lower extremity lymphedema.
5
In
Decongestive Exercises
The goal of the exercise program during the intensive
phase of CDT is to improve lymphatic circulation and to
maximize functional ability. Exercises are performed at
least twice a day for 10 to 15 minutes wearing the compression bandages. To promote patient’s compliance, it is
important to create an exercise protocol that is easy to
learn and to perform. The therapist should monitor the
exercise program regularly and the patient should assume the primary responsibility for the exercise as early
as possible in the treatment program. A balanced program of recreational activities supports general wellbeing, improves lymphatic drainage, and controls weight.
High-risk activities that could trigger a further decrease
in lymphatic transport capacity should be avoided or kept
at a minimum. High-risk activities for lymphedema include running, tennis and other racquet sports, soccer,
wrestling, kickboxing, step aerobics, weight lifting with
the affected extremity, or intense horse riding.
Fig. 6.19 Padded gradient compression with nonelastic adjustable bands (CircAid Measure-Up; with permission from CircAid
Medical Products, Inc.).
Abdominal Breathing Exercises
Diaphragmatic breathing exercises are a valuable tool in
stimulating deep lymphatic structures, such as the cisterna
chyli, the abdominal part of the thoracic duct, lumbar
trunks and lumbar lymph nodes, pelvic lymph nodes, and
certain organ systems.
Stimulation of these deep lymphatic structures, in
particular the thoracic duct, accelerates the transport of
lymphatic fluid toward the venous angles through which
the lymphatic fluid is returned into the blood circulatory
system.
The considerable decongestive effects on the lymphatic
and venous systems also make abdominal breathing exercises a valuable tool for the treatment of upper extremity
lymphedema.
Integrative, Multiprofessional Conservative Treatment
https://t.me/medicina_free
Resistive Exercises
Resistive or strength exercises increase the strength in
ligaments, tendons, and bones, improve muscular power,
and positively contribute to weight control. Strength exercises are typically performed in a repetitive fashion
against an opposing load. Improved strength assists in
the prevention of overuse syndrome and restores intramuscular balance and normal biomechanics in the involved limb and surrounding joints. Resistive exercises
using weights may present possible problems in regard
to injury or overuse; however, with appropriate precautions resistive exercises using weights can be beneficial
for patients affected by lymphedema. Negative effects in
terms of accumulation of fluid in the affected limb (or the
limb at risk) are unlikely if exercises are pe rformed
with compression in place on the involved extremity.
More research is needed to determine whether weighttraining and other forms of exercise help reduce the
risk of lymphedema.
Liftingheavyweightsisnotthebestwaytostarta
lymphedema exercise regimen; an exercise program
should start gradually to avoid sprains and injury to
muscles and should be followed by a warm down after
active exercises. Studies have shown that a 10 to
15 mi nutes warming down per iod a ssists the lymphatic system in the removal of excess f luid and metabolites, which have accumulated in the interstitial
space.
Aerobic Exercises
Aerobic exercises are generally performed in a repetitive
fashion using large muscle groups. Some long-term benefits include decrease in resting heart rate, improved muscular strength, weight control, and increased return of
venous and lymphatic fluids.
It is important to understand that certain aerobic exer-
6
cises and recreational activities could trigger an increase
in swelling or have higher risks of injury. Ideally, such
high-risk activities (listed earlier under the section Decongestive Exercises) should be avoided or modified for
patients affected by lymphedema.
Beneficial activities for upper and lower extremities
Beneficial activities for upper and lower extremity lymphedema include (but are not limited to):
Swimming or water aerobics: With the body weight reduced by approximately 90% in chest-deep water, exercises
improve mobility, make movement more comfortable, and enhance strength and muscle tone. In addition, the
hydrostatic pressure acts like a “ full-body” compression garment and helps to reduce edema by contributing to
lymphatic and venous return. Hot water (temperatures above 35 °C [94 °F]), usually found in hot tubs and Jacuzzis, must
be avoided; high water temperature has a negative impact on lymphedema. Patients should be cautious with hot tubs
and lakes during the summer (in warmer climates any time of the year) as they present an increased risk for various
types of infections caused by bacteria. Range of motion and flexibility are increased when in a warm water pool and the
cardiovascular system is working more effectively, so aerobic workout is possible.
Walking: A 20-minute walk outdoors or on a treadmill (10–15 minutes, slow walking speed), while wearing the
compression garment, will stimulate the circulatory system and contribute to the individual’s general well-being.
Easy biking: Easy biking for 20 to 25 minutes either outdoors or at the gym, using a comfortable and wide saddle. Legs
are placed in a higher position on recumbent bikes, which makes them a better choice for individuals affected by lower
extremity lymphedema.
Yoga: Several studies
easily adapted to the individual’s particular health status, abilities, and limitations, and therefore may be preferable to
more strenuous forms of exercise for some patients. In addition to increasing flexibility, muscle strength, and range of
motion, yoga beneficially impacts breathing and increases venous and lymphatic circulation, both important aspects in
the management of lymphedema. Some forms of yoga are fast-paced and intense, others are gentle and relaxing;
techniques like “ Hatha” and “Iyengar” yoga are gentle and slow, “Bikram,”“Hot,” and “Power” yoga are faster. The
gentler forms of yoga combined with breathing exercises are preferable; challenging techniques should be avoided by
those affected by lymphedema. More advanced poses, and most of the inverted poses, should be avoided as well—
including headstand (too much weight on the arms and neck), shoulder stand (too much weight and pressure on the
neck and shoulders), and downward facing dog (too much weight on the arms). Many cancer centers and support
groups provide contacts for yoga classes specifically tailored to cancer survivors and lymphedema patients.
Lebed Method: This exercise and movement program is designed for people with lymphedema and cancer survivors.
The program incorporates music and dance to focus on overall wellness, range of motion, balance, strength, and
endurance.
7,8
indicate that yoga can have positive effects for those affected by lymphedema. Yoga can be
78
6.3 The Two-Phase Approach in Lymphedema Management
https://t.me/medicina_free
There is no real consensus on the type of exercise regimen that can be incorporated into the patient’s selfmanagement regimen. Research suggests that a program
of progressive exercises, i.e., starting with gentle exercises
and increasing intensity moderately over time, tailored to
each patient ’s needs and abilities, is not likely to increase
the risk of lymphedema.
Although research has shown that strenuous exercises
can be undertaken by those individuals at risk of, or already having, lymphedema without negative effects, it is
advisable to start the exercise regimen slowly, which
avoids the risk of increased swelling, strains, and injury
to muscles, and allows the individual to observe how the
edematous extremity responds to exercise.
In some cases, it is not an easy task to draft a list of exercises that should be avoided in individuals with lymphedema. Many patients find it important to continue
their prelymphedema activities, even if these activities are
considered high-risk for lymphedema. However, for many
individuals engaging in these activities, the exercise plays
such a vital role in their daily routine, and is so ingrained in
their personality, that giving up these high-risk activities
could have a serious impact on their well-being.
Nobody knows better than the lymphedema patient
what is good for her or his body and spirit. As long as the
patients are careful and under the care of a trained lymphedema therapist or health care professional with experience in lymphedema, wear their compression garment
during physical activities, and the exercise regimen does
not cause discomfort or pain, continuing with these
activities sho uld not have any negat ive impact. However,
if the affected limb hurts, feels strained, or increases in
volume during and after the activity, the patient should
adjust as necessary and consult with the treating lymphedema therapist or physician. The key here is caution
and moderation; gradual progression is imperative
while trying to accomplish an improved return of lymphatic fluid without adding further stress to an impaired
lymphatic system.
Skin and Nail Care
Before compression bandages are applied, appropriate
moisturizers or lotions are used to cover the aff ected
body part. During the intensive phase of CDT, patients are
continuously instructed by the therapist on proper
cleansing and moisturizing techniques to maintain the
health and integrity of the skin and to prevent infections.
This educational process includes how to inspect the skin
for any wounds or signs of infection or inflammation. Patients affected by lymphedema are susceptible to infections of the skin and nails. Meticulous care of these areas
is essential to the success of CDT. Skin is usually impermeable to bacteria and other pathogens, but any defect in
the skin, whether from trauma, heat, or other causes, can
present an entry site for pathogens or infectious agents.
Lymphedematous skin can also become thickened and
scaly, increasing the risk of skin cracks and fissures.
The basic consideration in skin and nail care is there-
fore prevention and control of infection.
Suitable ointments or lotions formulated for sensitive
skin, radiation dermatitis, and lymphedema should be
applied prior to lymphedema bandaging while the patient is in the decongestive phase of CDT. After the limb is
decongested and the patient wears compression garments, moisturizing ointments should be applied twice
daily. Ointments, as well as soaps or other skin cleansers
used in lymphedema management, should have good
moisturizing qualities, contain no fragrances, be hypoallergenic, and be formulated to be in either the neutral or
acidic range of the pH scale (around pH 5.0).
Tight-fitting compression sleeves or stockings, as well
as materials used in compression bandaging, may cause
skin irritation.
In mosquito-infested areas, it is necessary to apply insect repellents to the affected extremity (some moisturizers contain natural repellents) to avoid bites, which
could cause infections.
6.3 The Two-Phase Approach in
Lymphedema Management
The vast majority of lymphedema patients benefit from
CDT, which is performed in two phases; in phase 1,also
known as the intensive or decongestive phase, CDT is
administered on a daily basis until the limb is decongested. Once the end of phase one is reached, the patient progresses seamlessly into phase 2 of CDT, also
known as the self-management or improvement phase,
in which the patient assumes responsibility for managing, improving, and maintaining the results achieved in
phase one.
6.3.1 Intensive Phase
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. Patient’s adherence to the treatment program
and compliance are indispensable components to ensure
treatment success.
The severity of the condition is a determining factor for
the duration of the intensive phase, which averages 2 to 3
weeks for patients with upper extremity lymphedema
and 2 to 4 weeks for patients with lymphedema of the
leg. In extreme cases the decongestive phase may last up
to 6 to 8 weeks and may have to be repeated several
times. Depending on the stage of lymphedema, the involved extremity or body part may have reached a nor-
Integrative, Multiprofessional Conservative Treatment
https://t.me/medicina_free
mal size at the end of the intensive phase, or there may
still be a circumferential difference bet ween the involved
and the uninvolved limb. If treatment is initiated in the
early stage of lymphedema, which is characterized by a
soft tissue consistency without any fibrotic alterations,
limb reduction can be expected to a normal size (compared with the uninvolved limb). If intervention starts in
the later stages of lymphedema, in which lymphostatic
fibrosis in the subcutaneous tissues has developed, the
edematous fluid will recede, and fibrotic areas may soften. However, in most cases the indurated tissue will not
completely regress during the intensive phase of CDT. Reduction in fibrotic tissue is a slow process, which can take
several months or longer, and is achieved mainly in the
second phase of CDT.
MLD in the first phase of therapy is applied at least
once a day, 5 days a week. The MLD portion of the treatment generally requires 30 to 60 minutes; the duration of
individual treatments is contingent on the number of involved limbs and body parts, as well as on the severity of
the symptoms.
The most important aspect of MLD in the intensive
phase is to identify drainage areas with sufficient and
healthy lymphatics. Lymphatic pathways (lymphatic
capillaries, precollec tors, and collectors) as well as
lymph nodes are then used to reroute the accumulated
protein-rich lymphatic fluid around blocked or damaged areas from the swollen extremity or body part to
areas with sufficient lymphatic drainage, and then back
to the venous system.
How to practically treat an extremity with lymphedema
The basic procedural pat tern of treatment in the example of a unilateral, secondary, upper extremity lymphedema.
Swelling in upper extremit y lymphedema in many cases involves the ipsilateral truncal quadrant. Healthy
lymphatics are generally found in adjacent truncal lymphatic territories (e.g., the contralateral upper quadrant and
the ipsilateral lower quadrant) as well as in the lymphatic vessels and lymph nodes in the supraclavicular area of the
same side. To maxi mize the therapeuti c effect of MLD, the method of procedure can be broken down into the
following steps:
Manipulation of lymph nodes and collectors located in the healthy adjacent quadrants as well as in the supraclavicular
area on the ipsilateral side will increase lymphangiomotoricity and result in a “suction effect” on the protein-rich
lymphatic fluid in the congested area. Following this initial preparation, the congested body quadrant is included in the
treatment. The protein-rich lymphatic fluid located in this area is carefully moved toward the previously manipulated
adjacent truncal quadrants, using primarily superficial lymphatic capillaries (initial lymphatic vessel plexus) and
lymphatic collectors, which connect adjacent truncal quadrants (lymphatic anastomoses). Even though MLD is not
directly applied to the swollen extremity during this period of the treatment, a volume reduction occurs, which can be
noted in a decrease of circumferential measurements in the affected extremity. This volume reduction is generally
observed following a series of two to four treatments.
When the extremity starts to decongest, the initial preparation is reduced to the relevant lymph nodes (in this case,
axillary lymph nodes on the contralateral side and inguinal lymph nodes on the ipsilateral side) and anastomoses. The
treatment area is now expanded to include the affected extremity on a step-by-step basis. To avoid overload of the
healthy lymphatics in the drainage areas, it is suggested to initially include only the upper arm in the treatment protocol.
In severe cases of lymphedema, it may be necessary to treat only parts of the upper arm. In the following treatments,
the forearm then the hand and fingers are carefully included.
Patients should be instructed early in the course of treatment how to perform simple self-MLD techniques, which are
used to stimulate lymphatic drainage during the weekends in the intensive phase as well as in the self-management
phase.
Compression therapy during the intensive phase of the treatment is provided using short-stretch bandages in
combination with appropriate padding materials as described earlier in this chapter.
Depending on the number of bandages and padding materials used, it may take experienced lymphedema therapists
10 to 20 minutes (in extreme cases, even longer) to apply a compression bandage.
An important aspect in this stage of the treatment is to instruct the patient, and preferably a family member or care
giver, in self-bandaging techniques. This requires a lot of practice, which makes it necessary to initiate the patient
instruction early in the intensive phase.
The end of the first phase of treatment is determined by the results of circumferential or volumetric measurements of
the affected extremity. When the measurements approach a plateau, the end of the intensive phase is reached, and the
patient progresses seamlessly into phase two of CDT.
80
Соседние файлы в папке Библиотека им академика М.И. Перельмана