The Clinician`s Role In Compression

Lymphedema, a disorder of the lymphatic system, affects at least 3 million Americans.1 The lymphatic system plays a role in both immune function and circulation. The system is comprised of lymphatic vessels located just under the skin and lymph nodes in areas around the neck, axilla, and groin. As the vessels transport fluid away from the tissues, waste products, bacteria, and large protein molecules are collected. The fluid is carried to the lymph nodes where the water products are degraded and eliminated, while the remaining protein-rich fluid is transported to the heart and back into circulation.2

When the normal lymphatic channels are disrupted, abnormal amounts of protein-rich lymphatic fluid collects in the interstitial tissue and causes swelling, most often in the arm and/or legs, and occasionally in other parts of the body. When the disruption becomes profound, the volume of lymphatic fluid exceeds the lymphatic transport capacity, leading to lymphedema.

Primary lymphedema is caused by connatal malformations of the lymphatic system, such as missing or impaired lymphatic vessels. This can affect any or all parts of the body but is usually seen in the legs. Secondary lymphedema, sometimes referred to as acquired lymphedema, occurs when lymphatic vessels are damaged or lymph nodes are removed. The lymphatic vessels can become damaged as a result of trauma, surgery, radiation, severe chronic venous insufficiency, morbid obesity, or infection. Without appropriate intervention, the protein-rich fluid increases the size and number of the tissue channels. This contributes to a reduction in the oxygen availability in the transport system, which interferes with wound healing and provides a culture medium for bacteria. This increased bacterial load can result in lymphangitis. When lymphedema continues unchecked, the protein-rich fluid continues to accumulate, swelling increases, and tissue becomes fibrotic. Untreated lymphedema can lead to a decrease or loss of limb function, skin breakdown, or chronic infections.

Risk Factors
Approximately 250 million people acquire lymphedema every year.3 Most commonly around the world, lymphedema is the result of a mosquito-born microfilia parasitic infection originating in the tropics. However, in industrialized nations, the onset of lymphedema is most commonly associated with complications following cancer treatment. Women are particularly at risk for lymphedema in the arm following surgery or radiation for breast cancer and in the legs following treatment for cervical or uterine cancer. Men are at risk of developing lymphedema in their legs following surgery for prostrate or testicular cancer. Both men and women are at risk following treatment for malignant melanoma or any other surgery or radiation affecting the lymph nodes or requiring lymph node dissection. For example, about 50% to 70% of patients having axillary lymph node dissection develop lymphedema. Of the 2 million breast cancer survivors alive today, 15% to 30% cope daily with lymphedema.4

Understanding the Differences between Lymphedema and Lipodema
Lymphatic accumulation and congestion—the clinical manifestation of lymphedema5—should not be confused with edema that results from venous insufficiency. However, untreated venous insufficiency can progress into a combined venous/lymphatic disorder that is treated in ways similar to treatment of lymphedema. Also, lipedema must be differentiated from lymphedema; however, treatment overlap also can occur.

Lipedema is characterized by a bilateral, symmetrical increase in stored fat. This condition usually affects the hips, buttocks, and thighs. Although the swelling can be extensive it seldom involves the feet. Lipedema often develops at the time of puberty, can be familial, and affects women. This hormone-driven condition is usually controllable as long the woman remains thin and active. Unfortunately, once the patient begins to gain weight the condition can progress rapidly. Many women with lipedema become morbidly obese because of weight gain coupled with difficulty comfortably achieving an adequate level of activity.6

One of the primary problems with lipedema is that it leads to inactivity. Physical fatigue can develop with a corresponding need for rest. Women with lipedema are likely to gain weight for a number of reasons. For example, many women avoid sports because they feel tired much of the time. It becomes difficult to climb stairs, wear regular clothing, or even walk. Others fail to engage in vigorous activity because they are embarrassed by the appearance of their body. Each of these factors works together to contribute to progressive weakness, additional weight gain, compulsive eating, increased reclusivity, and further development of lymphedema.

Another problem is the widespread misunderstanding of lipedema. Clinicians tend to misunderstand lipedema and its role in lymphedema. Lipedema often is confused with morbid obesity. Others fail to recognize the difference between cellulite and lipedema. Panniculopathia edematicosclerotica, often referred to as cellulite, is a related but different condition that occurs in young women and causes 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.

Clinical Implications
Complete decongestive therapy. Once the condition has been definitively diagnosed and the patient understands the chronicity of lymphatic challenges, treatment procedures can begin. Complete decongestive therapy (CDT) is a safe, reliable, non-invasive technique considered the gold standard for care. It comprises a four-step 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.
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 re-accumulation. 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 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.

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 6-week 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 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.