Lymphedema management : the comprehensive guide for practitioners

394 Pages·2013·38.27 MB·English

by  Norton

Lymphedema
Management
The Comprehensive Guide
for Practitioners
Joachim E. Zuther, MLD
Founder,EducationalDirector
AcademyofLymphaticStudies
Sebastian,FL,USA
Co-founder,NorthAmericanLymphedema
EducationAssociation(NALEA)
Steve Norton, CDT Certified Instructor,
CLT-LANA
ExecutiveDirector,NortonSchoolofLymphaticTherapy
Matawan,NJ,USA
Co-founder,NorthAmericanLymphedema
EducationAssociation(NALEA)
Withthecollaborationof
JaneM.Armer,JohnBeckwith,MichaelBernas,JoyC.Cohn,
TeresaConner-Kerr,JaniceN.Cormier,KateD.Cromwell,
LindaA.Koehler,MargaF.Massey,MaureenMcBeth,
LindaMcGrathBoyle,JudithNudelman,NicolleSamuels,
BradSmith,SarahA.Stolker
3rdedition
423illustrations
Thieme
Stuttgart·NewYork
IV
LibraryofCongressCataloging-in-PublicationData Importantnote:Medicineisanever-changingscienceundergoing
continualdevelopment.Researchandclinicalexperiencearecon-
Zuther,JoachimE. tinuallyexpandingourknowledge,inparticularourknowledgeof
Lymphedemamanagement:thecomprehensiveguideforpracti- propertreatmentanddrugtherapy.Insofarasthisbookmentions
tioners/JoachimE.Zuther,SteveNorton;withthecollaborationof anydosageorapplication,readersmayrestassuredthattheau-
JaneM.Armer...[etal.].--3rded. thors,editors,andpublishershavemadeeveryefforttoensurethat
p.;cm. suchreferencesareinaccordancewiththestateofknowledgeat
Includesbibliographicalreferences. thetimeofproductionofthebook.
ISBN978-3-13-139483-5(hardcover:alk.paper)--ISBN978-3- Nevertheless,thisdoesnotinvolve,imply,orexpressanyguarantee
13-146813-0(eISBN) orresponsibilityonthepartofthepublishersinrespecttoanydos-
I.Norton,Steve,1962-II.Armer,JaneM.III.Title. ageinstructionsandformsofapplicationsstatedinthebook.Every
[DNLM: 1. Lymphedema--physiopathology. 2. Lymphedema- userisrequestedtoexaminecarefullythemanufacturers’leaflets
-therapy. WH700] accompanyingeachdrugandtocheck,ifnecessaryinconsultation
withaphysicianorspecialist,whetherthedosageschedulesmen-
616.4’2--dc23 tionedthereinorthecontraindicationsstatedbythemanufacturers
2012041980 differfromthestatementsmadeinthepresentbook.Suchexami-
nationisparticularlyimportantwithdrugsthatareeitherrarely
used or have been newly released on the market. Every dosage
scheduleoreveryformofapplicationusedisentirelyattheuser’s
ownriskandresponsibility.Theauthorsandpublishersrequestev-
eryusertoreporttothepublishersanydiscrepanciesorinaccura-
ciesnoticed.Iferrorsinthisworkarefoundafterpublication,errata
IllustrationsbyAnthonyPazos,AZ,USA willbepostedatwww.thieme.comontheproductdescriptionpage.
©2013GeorgThiemeVerlagKG,
Rüdigerstrasse14,70469Stuttgart,Germany
http://www.thieme.de Someoftheproductnames,patents,andregistereddesignsreferred
ThiemeMedicalPublishers,Inc.,333SeventhAvenue, to in this book are in fact registered trademarks or proprietary
NewYork,NY10001,USA nameseventhoughspecificreferencetothisfactisnotalwaysmade
http://www.thieme.com inthetext.Therefore,theappearanceofanamewithoutdesigna-
tionasproprietaryisnottobeconstruedasarepresentationbythe
Coverdesign:ThiemePublishingGroup publisherthatitisinthepublicdomain.
TypesettingbyprimustypeHurlerGmbH,Notzingen,Germany
PrintedinItalybyL.E.G.O.,Vicenza Thisbook,includingallpartsthereof,islegallyprotectedbycopy-
right.Anyuse,exploitation,orcommercializationoutsidethenar-
rowlimitssetbycopyrightlegislation,withoutthepublisher’scon-
sent,isillegalandliabletoprosecution.Thisappliesinparticularto
ISBN978-3-13-139483-5 photostat reproduction, copying, mimeographing, preparation of
eISBN978-3-13-146813-0 microfilms,andelectronicdataprocessingandstorage.
V
Contents in Brief
 1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
 2 Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
 3 Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
 4 CompleteDecongestiveTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
 5 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
 6 Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
SampleFormsandTemplates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
 Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
VI
Foreword to the Third Edition
Asanurseresearcherfocusingonsecondarylymphede- specialized workshops for treating patients with less
mafollowingcancertreatment,itismyprivilegetowrite common kinds of lymphedema (e.g., truncal, head and
this foreword to the third edition of Lymphedema Man- neck,genital,neurologicimpairment,stage3limbs),and
agement–TheComprehensiveGuideforPractitioners. researchersinthefield.
Itisestimatedthatmorethan1millionmen,women, Practicing therapists require tangible and practical
andchildrenintheUnitedStatesarelivingwithlymph- tipsforadaptingthebasicsofCDTtoadvancedpatients
edema.Althoughitisalong-termcondition,withsupport with complicated diagnoses. The third edition of this
andadequatetreatment,thereismuchthatcanbedone bookisavaluableadditiontothelimitedresourcesthat
todecreaseswellingandmanageothersymptoms.Dur- areavailable.Theauthorsoffercurrentempiricalandev-
ingthelast20years,moreandmorehealthcareprofes- idence-based techniques for clinical success. As a com-
sionals, including physicians from various disciplines, panionbookfortheCDTcertificationcoursesofferedby
havemadelymphedemamanagementpartoftheirprac- bothoftheseleadingschools,thispublicationisdesigned
tice. toactasateachingmanualfornewlymintedlymphede-
Inadditiontoallofthefeaturespresentedinthefirst maspecialists.Thus,thethirdeditionincludesnewtopics
twoeditionsofJoachimE.Zuther’sLymphedemaManage- thatarelikelytobeofgreatinteresttopracticingthera-
ment, which have been updated (complete anatomy, pists,updatestopreviouslypublishedtopics,andpracti-
physiology, and pathology of the lymphatic system; a calguidelinesfortheapplicationandadaptationofCDT
comprehensiveguidetothemanagementoflymphedema forpatientswithlimbedemaaswellasotherlesscom-
anditsrelatedconditions(venousinsufficiencies,lipede- montypesofswellingandthoseinthepalliativecareset-
ma,axillarywebsyndrome,andwounds);descriptionsof ting.Theauthorsincorporate“howto”techniqueguide-
thecomponentsofcompletedecongestivetherapy(CDT); lines for several topic areas. I believe practicing lymph-
and detailed treatment sequences), the following topics edema specialists will gravitate to this book and find it
have been extensively revised, with contributions from accurate and evidence-based, yet less burdensome and
internationally recognized authors. Expanded features lessscientificallydensethanthealternatives.Itwillactas
include: filariasis; surgical and pharmaceutical options abridgefromtheclassroomtotheclinicandbecomea
forlymphedema;edemaversuslymphedema;obesityas continuingreferenceforpractice.
it relates to lymphedema; radiation-induced brachial Inadditiontoprovidingpracticalguidelinesforthead-
plexopathy; nutritional aspects of lymphedema; low- aptationofCDTforbasicandcomplexcases,thetextpro-
level laser therapy; intermittent compression therapy; vides a sound overview for researchers, physicians, and
careforcompressiongarments;exercises;truncallymph- otherhealthcareprofessionalsinunderstandingtheis-
edema;anddiagnosis.Newcontributorstothethirdedi- suesandcomplexitiesoflymphedemacare.Thenumer-
tionincludeco-editorSteveNorton,JohnBeckwith,Mi- ousfull-colordrawings,figures,andphotoshighlightsev-
chaelBernas,JoyC.Cohn,JaniceN.Cormier,KateD.Crom- eralkeypointstoenhancetheunderstandingforthera-
well,MargaF.Massey,MaureenMcBeth,LindaMcGrath pists, clinicians, educators, and researchers alike. The
Boyle, Judith Nudelman, Nicolle Samuels, Brad Smith, depthofknowledge,diversity,andrichexperienceofthe
SarahA.Stolker,andmyself. editorsisevidentthroughoutthebook.
Lymphedema Management is written and edited by Whatever the therapist’s background and circum-
Joachim E. Zuther and Steve Norton, both of whom are stance,themainaimoflymphedemamanagementisto
highlyrespectededucatorsoflymphedemaintheUnited better understand the condition of lymphedema and to
Statesandabroad.Each,asactingdirectorofhisrespec- helpthepatientattainhisorheroptimalhealthandfunc-
tiveschool(AcademyofLymphaticStudies,NortonSchool tionalstatus.Iamsuretheauthorssharethissamemain
ofLymphaticTherapy),hastrainednumerouspracticing objective. I applaud my respected colleagues Joachim E.
lymphedematherapistsintheUnitedStates,champion- ZutherandSteveNortonforthisfinecontributiontothe
ingCDTfromitsintroductionmorethan20yearsago.The medicalliterature.
additional contributors assembled include highly re-
spected practicing clinicians, many of whom conduct JaneM.Armer,PhD,RN,FAAN
VII
Foreword to the Second Edition
AsExecutiveDirectorandFounderoftheNationalLymph- written and superbly organized, with color-coded tabs
edemaNetwork(NLN),itiswithsincerepleasurethatI identifyingeachchapterforquickreference.Thechapters
writetheforewordtothesecondeditionof“Lymphedema areconstructedinalogicalmanner,beginningwithanat-
Management:TheComprehensiveGuideforPractitioners.” omy,followedbyphysiologyandpathophysiologyofthe
JoachimE.Zuther(Joe)andIfirstmetin1995duringa lymphaticsystem,co-morbiditiesandtreatment,aswell
bandagingworkshopinSanFrancisco.Intriguedwiththe as administrative and documentation issues. Illustra-
lymphaticsystem,butpuzzledbythelackofknowledge tions, photographs, and tables throughout the book au-
on the subject, we clearly had a coincidental vision: to thenticate and support the text. An excellent glossary
createawarenessandeducateprofessionalsinthisfasci- addseasetolocatingspecificterminology.
natingfieldofmedicine;tosupportandhelptheuntold Inthefouryearssincepublicationofthefirstedition,
numberofpatientswithswollenlimbsfromvariousun- therehasbeenahugemovementtowardmoresophisti-
derlyingcauses;and,mostimportantly,toofferadequate cation among therapists and researchers—studying the
treatmentforthisoftendebilitatingcondition. lymphaticsystemingreaterdepthandidentifyingaddi-
Sincethen,wehaveseenmuchofourvisionachieved: tionalco-morbiditieswhichaffectthelymphsystemand
specifically,severalthousandcertifiedlymphedemather- cause swelling; new and important information that
apists,noticeableinterestfromphysiciansinvariousdis- neededtobeincludedintheeducationofthelymphatic
ciplines,andtremendousprogressinbothbasicandclin- system.
ical research—performed in academic institutions and Acknowledging the need for updating and revising
nowpublishedinpeer-reviewedmedicaljournals. someofthefirsteditionchapters,aswellasaddingnew
Joehasplayedapivotalroleincreatinglymphedema topics and current information on various subjects, Joe
awarenessthroughthedisseminationofcurrentinforma- settothetaskofeditinginpreparationofthepublishing
tion,inadditiontotheeducationofprofessionalsthrough ofthesecondedition.
hisestablishmentoftheAcademyofLymphaticStudies, Thereisaninformativenewchaptercoveringaxillary
training thousands of physical and occupational thera- web syndrome that describes the anatomy, physiology,
pists,nurses,massagetherapists,andphysicians.Asare- evaluation,andtreatmentforthisobscurephenomenon.
sult,wenowhavehundredsofestablishedlymphedema Klippel-TrénaunayandParkesWebersyndromehavealso
clinics in universities, hospitals, and rehabilitation cen- beenincludedinthenewedition.Klippel-Trénaunaysyn-
tersthroughouttheUSA.Numerousphysicianshavecho- dromeisanoften-misunderstoodandunder-treatedvas-
sen to include the lymphatic system into their existing cular and lymphatic anomaly, seen more frequently in
practice.However,Joerecognizedthattheteachingonthe lymphedema clinics. The chapter on wounds has been
subjectofthelymphaticsysteminUSmedicalschoolsis revisedandcovers,indepth,commonskinchangesand
minimal,atmost.Heknewthatthepublishingofatext- woundtypesassociatedwithchroniclymphedema.
bookwasanabsoluteprerequisitetotheeducationofall I applaud and admire my friend and colleague, Joe
disciplines. Zuther,fortheyearsofhisdedication,unwaveringbelief
Joepublishedhisfirsteditionin2005,whichsoonbe- inhisvision,andforauthoringthesecondeditionofhis
cameatremendousassettothelymphedemacommuni- lifetimework.
ty, widely used in lymphedema clinics, training courses
andothermedicalpracticesworldwide.Thetextiswell SaskiaR.J.Thiadens
VIII
Preface to the Third Edition
Thisbookrepresentsanexcitingstepforwardforthefield evaluation, early detection/surveillance, risk reduction,
of lymphedema therapy and, in particular, as a much- exercise, and lymphedema diagnosis from a physician
needed aid to practicing lymphedema therapists and perspective have been extensively updated. Further up-
thoseaffectedbylymphedema.Thefirstandsecondedi- dates on lymphatic filariasis, axillary web syndrome,
tionshaveenjoyedwidedistribution,aidingthousandsof Klippel-Trénaunay and Parkes Weber syndromes, and
therapists and patients worldwide. Notably, there is no woundcarearealsopartofthisnewedition.
such resource available for the American therapist that Wefinditdifficulttoexpresshowheartwarmingand
containstangibleandhighlyspecificguidancefortreating rewardingitistoco-authorthisthirdeditionhavingbeen
avarietyofclinicalpresentationswithprovenandeffec- respectfulcolleaguesforthelast20years,trainingmany
tiveadaptationsofcompletedecongestivetherapy(CDT). ofthenation’stherapists.Withasharedvision,ourtwo
Variousexceptionalandhighlyexperiencedcontributors schoolswillaligninusingthistextbookasourrespective
havebeenassembledforthisedition,eachwithhundreds courseguides.Withthisstatementwehopetostrongly
ofpatientcasestodrawupon,asisreflectedintheirex- reflectourunityinreverencetothegoldstandardofCDT
tensive,sound,andgenerousadvice. and the collective evidence base it has amassed thus
New subject areas include: lymphedema taping, ge- provingitsunparalleledperformance.Wealsohopethat
netics and imaging, compression strategies for patients ouralliancestrengthensclinicianrelationshipsaswellas
with wounds, paralyzed limbs, and advanced-stage in- thecommitment,toadvancementwithincloselyrelated
volvement. Treatment of the head and neck, trunk-in- lymphedema-centeredestablishments,whichrelyheavi-
volved, morbidly obese and palliative patient types has lyonthecollaboration,commitmentandcooperationof
been added, with additional specific treatment adapta- educatorstocontinuecertifyinghighlyskilledlymphede-
tionsforamultitudeofnuancedprimaryandsecondary matherapists.Assuch,webothremainkeenlyawareof
lymphedemas.Thereisasectiondedicatedtolymphatic thefragilityoflymphedematherapyasaspecialtywithin
microsurgeryaswellasanoverviewofsurgicaltreatment thelargerrealmofrehabilitationmedicine.Tothatend,
outcomes for lymphedema. In addition considering the weremainfocusedonthechiefobjective,thatofensuring
ever-changinglandscapeofcancersurvivorship,asection thefutureofcompetentandsafetherapyforpatientsand
discussing oncology rehabilitation for the certified continuingtoproveCDT’seffectivenessatreducingthis
lymphedematherapist(CLT)willproveanessentialaddi- formofhumansuffering.
tion.Lastly,qualityoflife,metricsforedemadetection/
documentationalongwithcurrentresearchperspectives
areincludedandreflectourexcitementforfuturedevel-
opmentsandthewell-beingofthemultitudeofcurrent
andyetundiagnosedpatientbeneficiaries.
Topics that have been expanded upon include: ban-
daging with foam padding for the upper and lower ex-
tremities,clinicalconsiderationsandcareinstructionsfor
compressiongarmentsandbandages,step-by-stepgeni-
tal manual lymphatic drainage (MLD) and bandaging
techniques,aswellasinsightsforcompressiongarment
selection and application. CDT adaptations for various
universal complications associated with effective treat-
ment of lymphedema have been expanded and patient JoachimE.Zuther SteveNorton