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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3954_Библиотеки_им_академика_М_И_Перельмана.pdf
Lymphedema Management
The Comprehensive Guide for Practitioners
Joachim E. Zuther
Founder
Academy of Lymphatic Studies
Sebastian, Florida
USA
245 illustrations
Thieme
Stuttgart · New York
© 2009 Georg Thieme Verlag,
Rüdigerstrasse 14, 70469 Stuttgart, Germany
http://www.thieme.de
Thieme New York, 333 Seventh Avenue,
New York, NY 10001, USA
http://www.thieme.com
Cover design: Thieme Publishing Group
Typesetting by Primustype Hurler,
Notzingen, Germany
Printed by Replika Press Pvt Ltd, Sonipat, India
ISBN 978−3−13−139482−8 1 2 3 4 5 6
Library of Congress Cataloging-in-Publication Data
Zuther, Joachim E.
Lymphedema management : the comprehensive
guide for practitioners /
Joachim E. Zuther. -- 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-3-13-139482-8 (alk. paper)
1. Lymphedema. I. Title.
[DNLM: 1. Lymphedema--physiopathology. 2.
Lymphedema--therapy. WH 700 Z96L 2009]
RC646.3.Z88 2009
616.4'2--dc22
2009006645
This book, including all parts thereof, is legally pro-
tected by copyright. Any use, exploitation, or com-
mercialization outside the narrow limits set by copy-
right legislation, without the publisher’s consent, is
illegal and liable to prosecution. This applies in par-
ticular to photostat reproduction, copying, mimeo-
graphing, preparation of microfilms, and electronic
data processing and storage.
Some of the product names, patents, and registered
designs referred to in this book are in fact registered
trademarks or proprietary names even though
specific reference to this fact is not always made in
the text. Therefore, the appearance of a name
without designation as proprietary is not to be con-
strued as a representation by the publisher that it is
in the public domain.
Important note: Medicine is an ever-changing
science undergoing continual development. Re-
search and clinical experience are continually ex-
panding our knowledge, in particular our knowledge
of proper treatment and drug therapy. Insofar as this
book mentions any dosage or application, readers
may rest assured that the authors, editors, and pub-
lishers have made every effort to ensure that such
references are in accordance with the state of
knowledge at the time of production of the book.
Nevertheless, this does not involve, imply, or ex-
press any guarantee or responsibility on the part of
the publishers in respect to any dosage instructions
and forms of applications stated in the book. Every
user is requested to examine carefully the manu-
facturers’ leaflets accompanying each drug and to
check, if necessary in consultation with a physician
or specialist, whether the dosage schedules men-
tioned therein or the contraindications stated by the
manufacturers differ from the statements made in
the present book. Such examination is particularly
important with drugs that are either rarely used or
have been newly released on the market. Every
dosage schedule or every form of application used is
entirely at the user’s own risk and responsibility. The
authors and publishers request every user to report
to the publishers any discrepancies or inaccuracies
noticed. If errors in this work are found after pub-
lication, errata will be posted at www.thieme.com
on the product description page.
V
Contents in Brief
쐽 1 Anatomy ................................................................. 1
쐽 2 Physiology ................................................................ 31
쐽 3 Pathology ................................................................. 47
쐽 4 Complete Decongestive Therapy ............................................. 111
쐽 5 Treatment ................................................................ 143
쐽 6 Administration ............................................................ 237
Sample Forms and Templates ............................................... 244
쐽 Appendix ................................................................... 257
쐽 Glossary .................................................................. 258
쐽 Index ..................................................................... 274
VI
List of Contributors
Teresa Conner-Kerr, PhD, PT, CWS, CLT
Associate Professor and Coordinator
Anatomy Laboratory
Department of Physical Therapy Education
Elon University
Elon, North Carolina
USA
Michael J. King, MD, FACP, FACC
Board Certified Cardiologist
Lymphedema Specialist
Lauderhill, Florida
USA
Linda A. Koehler, PT, CLT-LANA
Lymphedema Therapist
Lymphedema Program
Fairview Medical Center
Minneapolis, Minnesota
USA
Kimberly D. Leaird, M. Ed, PT, CLT
Clinical Lymphedema Therapist
Clinical Rehab Solutions
Melbourne, Florida
USA
Joachim E. Zuther
Founder
Academy of Lymphatic Studies
Sebastian, Florida
USA
VII
Contents
쐽 1 Anatomy ........................ 1
Circulatory System ..................... 2
Lymphatic System ..................... 4
Topography ........................... 4
Components ........................... 4
Lymphatic Watersheds ................. 14
Interterritorial Anastomoses ............ 17
Lymphatic Drainage and Regional
Lymph Node Groups of Different Body
Parts .................................. 18
쐽 2 Physiology ...................... 31
Heart and Circulation .................. 32
Blood Pressure ........................ 35
Capillary Exchange .................... 35
Physiology of the Lymphatic System .... 42
Insufficiencies of the Lymphatic System . 43
쐽 3 Pathology ....................... 47
Lymphedema .......................... 48
Chronic Venous and Lymphovenous
Insufficiency ........................... 78
Wounds and Skin Lesions .............. 84
Lipedema ............................. 95
Traumatic Edema ...................... 98
Inflammatory Rheumatism ............. 101
Reflex Sympathetic Dystrophy .......... 103
Cyclic Idiopathic Edema ................ 105
쐽 4 Complete Decongestive Therapy . 111
History and Background ................ 112
Goal of Complete Decongestive
Therapy ............................... 113
Components of Complete Decongestive
Therapy ............................... 114
Compression Therapy .................. 122
Decongestive Exercises ................. 130
Skin and Nail Care ..................... 133
The Two-Phase Approach in
Lymphedema Management ............. 133
Documentation Techniques for
Lymphedema .......................... 137
쐽 5 Treatment ...................... 143
General Considerations ................ 144
Application of Basic MLD Techniques
on Different Parts of the Body .......... 144
Treatment Sequences .................. 157
Application of Compression Bandages . . . 179
Measurements for Compression
Garments ............................. 202
Patient Education ...................... 209
쐽 6 Administration ................. 237
Setting Up a Lymphedema Clinic ....... 238
Suggested Materials to Start Up a
Lymphedema Program ................. 240
Reimbursements and Billing ............ 241
Sample Forms and Templates ......... 244
Patient Information
.................... 244
Lymphedema Evaluation ............... 245
Physical Examination .................. 247
Measurement of the Upper Extremity . . . 248
Measurement of the Lower Extremity . . . 249
Progress Notes ........................ 250
Photography Release
................... 251
Privacy Rules Notification .............. 252
Health Information Consent ............ 253
Example of Letter of Medical
Necessity .............................. 254
Information on Lymphedema for
Patients ............................... 255
쐽 Appendix .......................... 257
Glossary .............................. 258
Index ................................. 274
VIII
Foreword to the Second Edition
As Executive Director and Founder of the
National Lymphedema Network (NLN
®
), it is
with sincere pleasure that I write the foreword
to the second edition of “Lymphedema Man-
agement: The Comprehensive Guide for Practi-
tioners.”
Joachim E. Zuther (Joe) and I first met in
1995 during a bandaging workshop in San
Francisco. Intrigued with the lymphatic sys-
tem, but puzzled by the lack of knowledge on
the subject, we clearly had a coincidental vi-
sion: to create awareness and educate pro-
fessionals in this fascinating field of medicine;
to support and help the untold number of
patients with swollen limbs from various un-
derlying causes; and, most importantly, to
offer adequate treatment for this often debili-
tating condition.
Since then, we have seen much of our vision
achieved: specifically, several thousand
certified lymphedema therapists, noticeable
interest from physicians in various disciplines,
and tremendous progress in both basic and
clinical research—performed in academic in-
stitutions and now published in peer-reviewed
medical journals.
Joe has played a pivotal role in creating lym-
phedema awareness through the dissemina-
tion of current information, in addition to the
education of professionals through his estab-
lishment of the Academy of Lymphatic Stu-
dies, training thousands of physical and occu-
pational therapists, nurses, massage ther-
apists, and physicians. As a result, we now have
hundreds of established lymphedema clinics
in universities, hospitals, and rehabilitation
centers throughout the USA. Numerous physi-
cians have chosen to include the lymphatic
system into their existing practice.
However, Joe recognized that the teaching on
the subject of the lymphatic system in US
medical schools is minimal, at most. He knew
that the publishing of a textbook was an abso-
lute prerequisite to the education of all discip-
lines.
Joe published his first edition in 2005, which
soon became a tremendous asset to the
lymphedema community, widely used in
lymphedema clinics, training courses and
other medical practices worldwide. The text is
well written and superbly organized, with
color-coded tabs identifying each chapter for
quick reference. The chapters are constructed
in a logical manner, beginning with anatomy,
followed by physiology and pathophysiology
of the lymphatic system, co-morbidities and
treatment, as well as administrative and docu-
mentation issues. Illustrations, photographs,
and tables throughout the book authenticate
and support the text. An excellent glossary
adds ease to locating specific terminology.
In the four years since publication of the first
edition, there has been a huge movement
toward more sophistication among therapists
and researchers—studying the lymphatic sys-
tem in greater depth and identifying additional
co-morbidities which affect the lymph system
and cause swelling; new and important infor-
mation that needed to be included in the edu-
cation of the lymphatic system.
Acknowledging the need for updating and
revising some of the first edition chapters, as
well as adding new topics and current infor-
mation on various subjects, Joe set to the task
of editing in preparation of the publishing of
the second edition.
There is an informative new chapter cover-
ing axillary web syndrome that describes the
anatomy, physiology, evaluation, and treat-
ment for this obscure phenomenon. Klippel-
Trenaunay and Parkes Weber syndrome have
also been included in the new edition. Klippel-
Trenaunay syndrome is an often-misunder-
stood and under-treated vascular and lym-
phatic anomaly, seen more frequently in lym-
phedema clinics. The chapter on wounds has
been revised and covers, in depth common
skin changes and wound types associated with
chronic lymphedema.
I applaud and admire my friend and col-
league, Joe Zuther, for the years of his dedica-
tion, unwavering belief in his vision, and for
authoring the second edition of his lifetime
work.
Saskia R. J. Thiadens, RN
IX
Foreword to the First Edition
I am a board-certified internist and cardiolo-
gist who became interested in lymphedema
ten years ago. I have been involved with the
clinical aspects of lymphology since that time.
Initially, I knew very little about the pathology
of the lymphatic system. The subject was not
taught to me in medical school. Lymphedema
is a real medical problem that has been ig-
nored in this country. As a result, I found that
most of my peers looked upon lymphedema
treatment as an alternative form of therapy,
outside the mainstream of conventional medi-
cine. I, being academically oriented, with
teaching experience, at first felt the same way.
In Europe, the basic principles for the treat-
ment of lymphedema were described decades
ago.
As medicine advances, people are living
longer, and more patients are presenting with
edema and lymphedema. The need for proper
evaluation and diagnosis of the edematous
patient has become increasingly important.
The pathophysiology of edema varies depend-
ing on the etiology, and an understanding of
this is essential to choose the appropriate
course of intervention. In all cases, a thorough
evaluation of the patient’s overall medical con-
dition is necessary.
Several articles and books have been written
on this subject. The book written in the format
Mr. Zuther has chosen is needed. It is not, for
the most part, written in prose, and the reader
does not have to pour through entire para-
graphs and chapters to find the desired infor-
mation. The book is a complete and compre-
hensive discussion of lymphedema, and is pre-
sented and organized in a way so that facts are
readily obtainable. It serves as a reference
source and text both to individuals who know
little about lymphedema and to those knowl-
edgeable about the condition who want to re-
view specific topics. It is a valuable source of
information and instruction to lay persons,
students, therapists, and physicians. Unlike
many other books on the subject, this book is
not a “cookbook” or “how to” manual. It con-
tains the complete anatomy and physiology of
the lymphatic system, discusses treatment op-
tions, and also covers patient education and
administrative issues.
This textbook is a valuable addition to the
literature dealing with the field of lymph-
edema.
Michael J. King, MD, FACP, FACC
Lauderhill, Florida