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Toronto,
ON—
Compression is the gold standard therapy for phlebolymphedema. The
rationale for compression and decompression therapies was discussed
by Brian Kunimoto, MD, Catherine Cotton, BScPT, and Mary Engel,
RN, ET, at the annual meeting of the Canadian Association of Wound
Care.
Phlebolymphedema is the accumulation of excess intercellular fluid
in the legs and feet due to lymphatic obstruction that is the result
of chronic venous insufficiency.
The collection of protein-rich fluids compromises the microvascular
and lymphatic systems, reducing cellular oxygen and nutrients and
interfering with wound healing, said Ms. Cotton, patient care director,
orthopaedics and rehabilitation, The Scarborough Hospital, Toronto,
ON.
Diagnosis
Swollen and tired feet and legs are a sign of phlebolymphedema.
The swelling is usually bilateral and worse in the evening. A patient
history may reveal that the onset of the condition coincided with
pregnancy, an accident, or a long car/plane trip, Ms. Cotton said.
A clinical exam may find white atrophy, crural ulcers, aberrations
of normal vein patterns, skin temperature changes, general or localized
edema, tender veins, local thrombophlebitis, and enlarged lymph
nodes. An early sign of phlebolymphedema is a positive Stemmer’s
sign. (Stemmer’s sign is a test in which the thickened folds
at the dorsum of the toes cannot be or are very difficult to lift.
This indicates lymphostasis, which has caused a thickening of the
skin.)
In the later stages of the disease, the limb “hardens”
(due to excessive connective tissue deposition) and the skin becomes
thick and wartlike (elephantiasis verrucosa nostra), said Dr. Kunimoto,
clinical assistant professor, division of dermatology, University
of British Columbia, and a dermatologist at the Wound Healing Clinic
at Vancouver General Hospital.
Pathogenesis
In healthy people, excess fluid filters through capillary walls
to the interstitial space. Increasing interstitial pressure pulls
on filaments, and opens endothelial slits, allowing the fluid to
enter the lymph vessels.
“In phlebolymphedema, we have dynamic or mechanical insufficiency,”
Dr. Kunimoto said.
Whereas dynamic insufficiency (via venous hypertension or inflammation)
increases the interstitial fluid, mechanical insufficiency impedes
absorption of the interstitial fluid by the lymph vessels. “The
filtration rate is greater than the reabsorption rate,” Ms.
Cotton said.
“There is a lot of fibrosis in and around these lymphatics,
so you can imagine that what used to work perfectly encased in a
fluid medium now doesn’t work because it is encased in a gel.
This gel doesn’t allow the anchoring filaments to work properly,”
Dr. Kunimoto said.
Furthermore, the collection of protein-rich fluid causes collagen
deposition and a scarring process (lipodermatosclerosis) that permanently
reduces the permeability of the lymph vessels.
Management
“Compression therapy is the mainstay of treatment for phlebolymphedema,”
Ms. Cotton said.
Low-stretch bandages create low resting pressures, but during activity/movement
they work with the muscles to create more pressure. (Pressure varies
between 30 and 60 mmHg.) Correct wrapping technique involves direction,
overlap, and pressure. The bandage should be spiral distally to
proximally to help pump the fluid from a distal to proximal direction.
The overlap is usually between one-half and two-thirds of the previous
layer. The distal layers are greater to create more distal pressure,
Ms. Cotton said. Bandages should be changed every six hours or they
will begin stretching and slipping. Short-stretch, not four-layer,
bandages are used to improve patient compliance.
While bandages are usually used in the first stages, compression
garments can be used after the swelling is reduced. Like compression
bandages, compression garments create distal to proximal pressure.
They may be either custom- or ready-made. “Compliance is directly
proportional to the fit. If it’s not comfortable, it’s
going to sit in the cupboard. So you need to negotiate with your
clients what they’re going to wear and how they’re going
to wear it,” Ms. Cotton said. Garments must be replaced when
they begin to stretch (between four and six months). Stockings and
garments may be machine-washed and laid flat to dry.
Research into the use of compression devices is quite limited, and
not many insurance companies cover them. She noted that pumps inflate
distally to proximally, but can create problems if proximal fluid
overload or tissue fibrosis is pre-existing in the limb. “From
a physiological point of view, you need to clear the proximal region
before you can clear the distal region.” Thus, the distal fluid
may run into a wall of proximal fluid. The swelling would be reduced
more easily if the proximal fluid was cleared first. Nevertheless,
pumps do provide pressure, and they tend to work best if the limb
does not have proximal fibrosis, Ms. Cotton said.
Decompression therapy is achieved through four steps (hygiene and
skin care, manual lymph drainage, bandaging and compression, and
exercises andelevation), said Ms. Engel, Osotomy Wound and Compression
Management, Kitchener, ON.
During a specialized form of massage, manual lymph drainage therapists
use a light touch—about 30mmHg—working the proximal subcutaneous
vessels first. Some therapists start at the eyes and end at the
toes, she said. “Manual decompression therapy can be as much
as twice a day or as little as yearly if the fluid levels are stable,”
she said. Obese patients who have a poor body image may be reluctant
to try massage therapy. However, massage therapy is much less painful
than (improperly applied) compression bandages and garments, she
said.
Phlebolymphedema management combines treatment of the underlying
cause with compression/decompression therapy, elevation, exercise,
nutrition, weight management, skin care, and the wearing of nonrestrictive
clothing and jewellery. Venolymphatic reconstructive surgery is
controversial, Ms. Cotton said.
“Do not take blood samples or blood pressure, or inject anything
into the affected limb,” Ms. Engel said.
She noted that the management of phlebolymphedema involves several
multidisciplinary healthcare providers. The patient requires education
and information to co-ordinate the team members. “Patients
who are knowledgeable about their lymph deficiencies have almost
normal limbs with few problems,” she said.
Patient information:
www.lymphovenous-canada.ca
www.lymphnet.org
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