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Edema:ComprehensiveManagement

LisaCabralPT,DPT,CLT,CWSWPTAFallConference2016

Disclosures

• ThespeakerhasnofinancialconflictofinterestforcontentofthispresentaIon.

• ThespeakerisnotendorsinganyparIcularproductortypeofequipment.

CourseObjecIves

•  TorecognizetheanatomyandfuncIonofthelymphaIcsystem

•  ToidenIfydifferenttypesofedema•  Todescribethebesttreatmentapproachesforlowproteinversushighproteinedema

•  Tounderstandthebasicsofgeneralwoundcaremanagement

Whyedemamanagement?

•  YoucanfinditinallseTngsofphysicaltherapypracIce

•  ComplicatededemacanlimitfuncIon,mobility,andoveralloutcomeofcare

•  ItiswithinourscopeofpracIceasphysicaltherapypracIIoners

THELYMPHATICSYSTEMWhatisit?Whatdoesitdo?

RoleoftheLymphaIcSystem

•  Conductimmunesystemsurveillance–  Immediateandlongtermresponsetopathogens

•  Assistthecardiovascularsystemtomaintainfluidhomeostasis

•  AidthedigesIvesysteminthebreakdownoflong-chainfaXyacids

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AnatomyoftheLymphaIcSystem

•  Lymphfluid:clearandtransparentsemifluidmedium

•  LymphaIcloads:protein,water,cellularcomponentsandparIcles,andfat

ComponentsoftheLymphaIcSystem

•  IniIallymphaIcs(capillaries)andpre-collectors–absorb

•  CollectorlymphaIcs–conduct•  Lymphnodes–filterandconduct•  Lymphtrunks–deeper,conduct•  Thoracicduct–deepest,largest,conducts

NormalLymphFlow

Lymphcapillaries➔ Pre-collectors➔Collectors➔Lymph

Nodes➔LymphaIcTrunks➔

Thoracic/RightLymphaIcDuct➔ Le^orRightSubclavianVein➔Heart

LymphCapillaries

•  AlsoknownastheiniIallymphaIcs•  “Mesh”likecomplexthroughoutthebody

•  ResponsibleforlymphformaIon•  AnchoringfilamentsfacilitateopeningandclosingofcapillaryjuncIons

•  MobilizaIonofso^IssuefromtheoutsidecanfacilitatechangeinpressureandsImulateanchoringfilaments

Pre-CollectorsandCollectors

•  Pre-collectors– ConnecIonbetweenlymphcapillariesandcollectors

•  Collectors– MovesfluidtolymphnodesandontolymphaIctrunks

– Similarstructuretoveins– Containsvalves(pair=lymphangion,every6-20mm)– Contracts10-12Imesperminute(smoothmuscle)

LymphNodes•  Regionalandcentral,600-700inthebody

•  ProtecIvefuncIon:filters,phagocytosisofpathogens,wasteproductsanddeadcells

•  ImmunefuncIon:makeanIbodies•  Thickeningofthelymphfluid:bloodcapillariesreabsorbwater

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• Lymphotomes:superficialanatomicalsegmentsthatdividethebodyintospecificareas/territoriesdrainedbythesamegroupofnodes

• Watersheds:divisionareasbetweentwolymphotomesthatallowlymphtomoveagainstthenormalflow

LymphaIcTrunksandDucts•  LymphaIcTrunks

–  Similartothecollectorsbuthavemoredevelopedmusclestructure

–  Aresultofwhensuperficialanddeepcollectorsmerge–  Sendsfluidtovenousangles

•  ThoracicDuct–  FromL2toT4–  LymphfrombilateralLE,le^arm,andle^quadrantofface–  EmpIesintothele^venousangle

•  RightlymphaIcDuct–  Lymphfromrightarm,upperrightquadrant,andface–  EmpIesintotherightvenousangle

Return of Lymph Fluid

• Venoussystem:le^andrightvenousanglesbetweenthesubclavianandjugularveinsattheleveloftheclavicles

• OnlydirectconnecIonwithlymphandvenoussystems

• Feedsbackintothecirculatorysystem(heart).

Physiology:StarlingEquilibriumEquaIon

Jv=Kf[Pc-Pif–σ(πp–πif)]

Capillaryfiltrate=Permeabilityofwaterandsmallsolutes[HydrostaIcpressuregradient–Permeabilityofplasmaprotein

(ColloidosmoIcpressuregradient)]

Physiology:StarlingEquilibriumEquaIon

– DescribeshowtheosmoIcandhydrostaIcpressuresinthecapillariesandintersIIalIssuedeterminethedirecIonoffluidmovement– Fluidisconstantlybeingfiltratedandreabsorbedatthecapillarybed– HydrostaIcpressure:pressureexertedbythebloodonthecapillarywalls– OsmoIcpressure:forcecreatedbylargemoleculessuchasplasmaproteins(opposeshydrostaIcpressure)

When the fluid flows from the interstitial space into the capillary, it is termed reabsorption When the fluid flows from the capillary into the interstitial space, it is termed filtration

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Physiology

•  Func1onalreserveofthelympha1csystem:ThetransportcapacityofthelymphaIcsystemis10xgreaterthan(>)thephysiologicamountoflymphloads(normalfuncIon)

•  Ifneeded,thelymphaIcsystemcanassistwhenthethereanoverloadofvenousfluidpresent.

•  Dynamicinsufficiency=Lymphload>Transportcapacity.Thus,edemaisnoted.

AbnormalPhysiology:Lymphedema

•  Lymphedema/Lymphosta1cedema=mechanicalinsufficiencyorlow-volumeinsufficiencyofthelymphaIcsystem– Highproteincontentisthehighlightoflymphedemacomparedtootheredemas.

LymphaIcFailureTransport Capacity Lymphatic Load

Dynamic (edema)

Normal Increased

Mechanical (lymphedema)

Decreased Normal

Combination (lymphedema)

Decreased Increased

Hemodynamic (cardiac edema)

Normal/Decreased Increased due to right ventricular failure

Evalua1onandAssessmentConsidera1ons

WhatdoIask?WhatdoIlookat?

SubjecIve

• Anyrecenthealthchanges?

• Didtheswellingoccurfastorslow?

• DoestheswellingimprovewithelevaIon?

• DoestheswellingimprovewithdiureIcs?

SubjecIve

• HaveyouhadanyrecentinfecIonorbloodclot?

• Wheredoyousleep?

• Isthereanypainassociatedwiththeswelling?

• DoestheswellinglimityourfuncIon?

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PastMedicalHistory

• Fullsystemsreview• Canceranditstreatments• InfecIons• Surgeriesortraumas• FuncIonalstatusandacIvitylevel• Historyofsmokingandalcoholuse• Socialhistory

ObjecIve

• GeneralPTassessment• Skinintegrity(palpaIon,texture,color,temperature,piTng,scars)

• Volumeorgirthmeasurementsoftheinvolvedareasofthebody

– IfpresentintheextremiIes,symmetricorasymmetric

• Pain

ClassifyingPiTngEdema

• 1+=2mmorless,disappearsrapidly• 2+=2-4mm,disappearsin10-15seconds• 3+=4-6mm,maylastmorethan1minute• 4+=6-8mm,lastsaslongas2-5minutes

ObjecIve

• Stemmersign:theonlyclinicaltestthatisareliableandvalidmethodtodiagnoselymphedema

– Thickeningoftheskinoftheproximalphalangesofthetoesorfingeroftheinvolvedlimb

– Can’t“tent”orpickuptheskinwhenpinched– PosiIve=definiteindicaIonoflymphedema– NegaIve=absenceofthediagnosisisnotcertain

DifferenIalDiagnosisforTypesofEdema

HowdoIputallthepiecestogether?

Lymphedema

• Lymphedemaisachronic,incurablecondiIonthatischaracterizedbyanabnormalcollecIonoffluidowingtoananatomicalalteraIonofthelymphaIcsystem(Macdonald,JM.2002)

• Highproteintypeedema• Canclassifiedasaprimaryorsecondarylymphedema

• StagedfromStage0toStage3

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EIologyofLymphedema:Primary

• Milroy’sdisease(congenIallymphedema)• Meige’sdiease(lymphedemapraecox)• LymphedemaTarda

EIologyofLymphedema:Secondary

•  Damagetolymphnodesand/orlymphvesselsthatresultsinmechanicalinsufficiency

•  Possiblecauses:Trauma,RadiaIontherapy,TumorobstrucIon,InfecIon,CVI,Surgery,InfecIon

StagesofLymphedema

• Stage0/Subclinical:PaIentfeels“heaviness”ininvolvedlimb.FibroIcchangesandfluidaccumulaIoncanoccurbeforevisibleswellingorpiTng

• Stage1:Reversiblelymphedema.AccumulaIonofprotein-richfluid,elevaIonreducesswelling.Tissuepitsonpressure.

StagesofLymphedema

• Stage2:Spontaneouslyirreversiblelymphedema.ProteinssImulatefibroblastformaIon(fibrosis).ConnecIveIssueandscarIssueproliferate.MinimalpiTng,evenwithmoderateswelling.

• Stage3:LymphostaIcelephanIasis.HardeningofdermalIssues,papillomasoftheskin,Issueappearanceiselephant-like(notallprogresstothisstage).

VenousHypertensionRelatedEdema

• Chronic“venousinsufficiency”

• PostthromboIcsyndromecanleadtothis

• IncreaseinbloodcapillarypressureresultsinanincreaseinnetfiltraIoncausinganincreaseinlymphaIcload

• Hemosiderinstainingisthekeyindicator

Phlebolymphedema

• EndstagevenousinsufficiencyrelatededemacancausesignificantoverloadtothelymphaIcsystemcausingpermanentchanges

• Thisiswhenonewouldseelipodermatosclerosis

• LimbsizemaybesmallrelaIvetotheendstagesoflymphedemabutdemonstratesulceraIons,varicosis,andpain

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Lipedema

• “LipedemaisachronicmetabolicdisorderoftheadiposeIssue,ofunknowneIology,andismarkedbyabilateralandsymmetricalswellingofthelowerextremiIes,causedbyextensivedepositsofsubcutaneousfaXyIssue.”AllenandHines,1940

Lipedema

• O^enmisdiagnosedasbilateralprimarylymphedema,extreme“celluliIs,”ormorbidobesity

• Sparesthefeet,bilateralandsymmetrical,negaIvestemmerssign

• Almostexclusivelywomen• Canleadtolymphedema(lipolymphedema)andvenousdisorders

• Doesnotimprovewithexercise

EdemaDuetoMalignancy

• GrowthofthetumorcanplacepressureonandlimitthelymphaIcsystem

• Symptomsincludepain,paresthesias,paralysis,rapiddevelopmentofswelling

• CanleadtoIssuebreakdownandwounds

TraumaIcEdema

•  PhysicaltraumacancauseatemporarydisrupIonofthetransportcapacity

•  Significantscarringwithtraumacanleadtoasecondarylymphedema

•  Surgery,blunttrauma,andburnscanresultininflammatoryreacIons

•  Typicallyreturnsbacktonormal

FluidRetenIonStates

• Endocrine,cardiac,renal,hepaIc,andothermedicalcondiIonscanresultinthebodyretainingfluids

• Typicallyfullbodyandbilateralinvolvementtothelimbsisnoted

• So^“marshmallow”like,lowproteinedema• CanbetreatedwithdiureIcs• Ifpoorlymanaged,canturnintoalymphedema

OtherInflammatoryProcesses

• InflammaIoncausesproteindumpingfromthecapillaries

• InflammatoryrheumaIsm/rheumatoidarthriIs:inflammaIonofthesynovialmembraneofjoints

• ReflexsympatheIcdystrophy:pain,edema,autonomicdysfuncIon,movementdisorderandtrophicchanges

• OsteoarthriIs

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DependentEdema

• O^enseeninthosethataresedentaryorhavelimitedmobility

• ImpairedlymphaIcflowduetoposiIoning,mostcommonlytheinguinalandpoplitealregion

• DecreasedmusclepumpacIvaIon• Typicallyresolves/improveswithelevaIonandposiIoning

CelluliIs

• A.K.A.Erysipelas• PainfulinflammaIonoftheso^IssueduetoacuteinfecIon

• Expandinglocalerythema,palpablelocallymphnodesinsomecases,feverandchills

• MostcommoncomplicaIonoflymphedema

LymphangiIs

• InflammaIonofoneormoreofthelymphaIcvessels,usuallyduetoaninfecIon

• StreptococcalinfecIonmostcommon• Fineredstreaksfrominfectedareathatspreadsproximallyonthelimb

• Canpresentwithfever,chills,headacheandmyalgia

• Treatedbypenicillinandhotsoaks

TreatmentOp1ons

NowthatIhaveanideaofwhattypeofedemaitis,whatdoIdonow?

TreatmentStrategies:LowProteinEdemas

• Lowproteinedema=alledemasexceptforlymphedema

• TreattheunderlyingmedicalcomplicaIon• ElevaIon/PosiIonalchanges• MusclepumpacIvaIon• Compressionmanagement• Kinesiotaping®• ElectricalSImulaIon

TreatmentStrategies:HighProteinEdemas

• FulldecongesIvetherapy• Lymphedema/vasopneumaIcpumps• ElectricalSImulaIon• Kinesiotaping®

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FullDecongesIveTherapy

• ManuallymphaIcdrainage• Compressionwraps• TherapeuIcexercise

GoalofDecreasingLymphaIcLoad

• RemovestagnantwasteproductsfromIssue• IncreaseoxygenIssuetopromotewoundhealing

• Decreasecycletofibrosis

ManualLymphaIcDrainage

• PosiIonpaIentwithheadslightlyelevated

• Workingphase(“onphase”):stretchingtheso^Issue/subcutaneousIssue• ResIngphase(“offphase”):elasIcityoftheskinmovesthetherapist’shandpassivelytoallowabsorpIonfromtheintersIIum

KeyConceptswithMLD

• Lightpressureapplied• Morefirmpressureoverareasoffibrosis• Each“workingphase”shouldlastabout1secondandrepeat5-7Imes• Clearproximallyfirstandthenflowdistaltoproximal

KeyConceptswithMLD

•  Clearandflowbetweengroupsoflymphnodes

•  Pumppoints:useoftwobundlesofnodestofacilitateimprovedlymphaIcmobilizaIon

-Ex.Medialkneeandlateralhip• HEPforselfmobilizaIontechniques

EffectsofMLD

• IncreaselymphproducIon• Increaselymphangiomotoricity• Reverseoflymphflow

– Deepcollectorsdon’tcrossbetweenwatershedsbutsuperficialcollectorsdo

• Increaseinvenousreturn• Soothing• Analgesic

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ContraindicaIonsforMLD

• AcuteCardiacedema• Renalfailure• AcuteinfecIons• AcutebronchiIs

• AcuteDVT• Malignancies• Bronchialasthma• Hypertension

PrecauIonsforMLD

• Pregnantwomen• Abdominalsurgeries• Hyperthyroidism(limitneckduetoincreasehormonerelease)

• AorIcaneurysm• InflammatorycondiIons• RadiaIonfibrosis

ExampleMLDPlanforLymphedema

• 1sttreatmentsession:MLDtotrunk• 2ndtreatment:MLDtotrunk,plusbilaterallimbs

• 3rdtreatment:MLDtotrunk,plusbilaterallimbs,instrucIononHEP

• Followingsessions:focusonareasofinduraIon,scarIssue,etc.

ExampleRouIneforEdemaPost-OpTotalKneeReplacement

1.  Tummyrubsx10anddeepbreathingx52.  Inguinalnodechopsx10followedbykneeto

chest3.  Poplitealnodeclearingx10followedby

sweepsfrominsideandoutsidekneetowardLATERALhip(alwaysdistaltoproximal)

4.  x10kicksandx20anklepumps5.  Tummyrubsx10anddeepbreathingx5

Compression Therapy

•  Elastic fibers of the cutaneous tissues are damaged in lymphedema

•  Goal = maintain the decongestive effect during the MLD session

EffectsofCompressionTherapy

• ImprovesvenousandlymphaIcreturn• ReducesnetfiltraIon• Improveseffectofthemusclepumps• Preventsre-accumulaIonofevacuatedfluidpostMLD

• Helpsbreakupandso^endepositsofconnecIveIssueandscarIssue

• ProvidessupportforthenowinelasIcfibers

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Bandaging

• Shortstretchisthebandageofchoice• MulIplelayersused• PaIentsshouldmaintaintheiracIvitylevels

• Criteriaforstabilizededema:reducIonincludesremodelingofthesubcutaneousfibrosis,pliableIssuewithnoinduraIon,andnofurtherdecreaseingirthfor7–10days.

BandageApplicaIon

• Dresswound(s)asappropriate• StockineXefirsttocollectsweat• CoXonorfoampadding• Typically3rollsofshortstretchbandageused:smallesttolargestwidth.SpiralapplicaIon,nevercircumferenIal

Bandaging

HammandPerdomo.

CompressionGarments

• Longtermcompressionmanagement

• UsedtopreservetreatmentsuccessduringdecongesIvetherapies

• CompressiongarmentsmeanttoMAINTAINcurrentedemanotreduceittobaseline

• IllfiXedandineffecIvecompressiongarmentsmaycauseharmtoapaIent

CompressionGarments

• Differentlevelsofcompressiondependentuponmanufacturers

• <20mmHgcompressionisnotsuitableinmanagementoflymphedema

• Usually20-40mmHgcompressiongarmentsareused

TherapeuIcExercise:Benefits

• Improvedstrength• DecreaseinresIngheartrate• Improvedstrengthinbone,tendonandligaments

• Decreaseinbodyfat• Physiologicaleffects:increasesbloodcapillarypermeability,filtraIon,andlymphaIcloadofwater

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ExerciseandEdema

• Mostbeneficialwhencompressionisused• Appropriatecompressionprovidesresistancetopromotethemusclepump

• NospecificexercisethatisbeXerorworseforedemamanagement

• DoNOToverstressthepaIentwithexcessiveexerciseasthiscancausemicroswelling

Lymphedema/VasopneumaIcPumps

• Improperuseofthepumpcancomplicatelymphedemamanagement

• Lymphedemapumpsclearproximallyfirst• TypicallybestuIlizedformaintenanceorinconjuncIonwithtreatment

• Goodforvenoushypertension

TapingObjecIves

• Neurosensory:assistinrestoringmotorpathwaysanddisruptpain

• Structural:assisttoimproveso^IssueorjointimpairmentsbyinhibiIngorfacilitaIng

• Microcirculatory:promotemovementofstagnantsuperficialfluid,removeirritantsandimproveoxygenaIon

KinesiotapingCorrecIveTechniques

• Mechanical:improvestabilityorbiomechanics• Fascial:directmovementoffasciaanddecreasefascialimitaIons

• SpaceCorrecIon:decreasepressureovertargetIssue

• Ligament/tendon:reducestressonaligamentortendon

• FuncIonal:providesensorysImulaIontoinhibitorfacilitateamoIon

• Circulatory/lymphaIc:toreduceedemaandpromotemovementoflymph

ApplicaIonandUse

• CanusevarioustypesoftapingtoaddressparIcularneeds

• ScarandfascialmobilizaIon• Edemaandbruisingmanagement• Forlymphedema,typicallyinconjuncIonwithfulldecongesIvetherapies

SpecificTechniques

• SpacecorrecIonli^ing– 10-35%tension– DecreasepressureontargetIssue

– Createrecoilandli^overtargetIssue

– I,donuthole,webcut

• CirculatoryandlymphaIccorrecIon

– 0-20%tension– Fancut– Anchorproximallytowardhealthylymphnode

– Fantailsovercongestedarea

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PrecauIonsforTaping

• Tapeallergies• GeriatricandcondiIonsthatcauseprematureaging

• CongesIveheartfailure• Diabetes• Kidneydisease

ContraindicaIonsforTaping

• Tapeallergies• FragileorhealingIssue• Openwounds• CelluliIsorinfecIon• Malignancysite• Coronaryarterydisease• Deepveinthrombosis• Pregnancy

ConsideraIonsbeforetheapplicaIon

• Skinshouldbecleaned,dry,andfreeofoilsormoisturebeforeapplicaIon.

• Removehairifneeded• Roundedges• AcIvateadhesivewithrubbing• EducatepaIentonwearImeandcareoftape

OtherTips

• Ifapplicable,documentthenumberof“blocks”used

• TheobjecIveofthetape• Targetedmuscleormusclegroup• CorrelatebacktofuncIon• Discussperformancewithandwithouttape

EvidenceforEdemaManagement

• Bialoszewskietal2009,RCT– 24parIcipantswithlowerextremityedema– Kinesiologytaping+PTvsPTonly– Decreasesnotedinthethighwithkinesiologytaping

• Han-JeTsai2009– 41parIcipantswithBCRL– Bandagingvskinesiologytaping– Nodifferenceinvolume– AcceptanceandadherencewasbeXerwithkinesiologytaping

ElectricalSImulaIonParameters

• Goal:TreaIngforedemareducIon– Muscle“milking”– Bipolarsetuponmuscleproximaltoedema– Lowfrequency(1-10pps)– Visible,comfortablemusclecontracIon– Elevatelimb– 15-30minuteswithorwithoutcoldapplicaIon

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Parameters

• Goal:producetetanicmusclecontracIons

– Frequency:arbitrary30-60pps– Mode:pulsed,on/off1-5or1-3– Amplitude:arbitrary1-500V– DuraIon/width:arbitrary5-30min

ElectrodePolarity

• NegaIve– Increases:Vascularity,SImulaIonoffibroblasIcgrowth,CollagenproducIon,EpidermalcellmigraIon

– InhibitsBacterialgrowth

• PosiIve– Increasesmacrophages

– Promotesepithelialgrowth

ApplicaIon

• Treatmentshouldbe30-60minutes• Electrodetype

– rubbercarbon,electro-meshglove/sock• Electrodearrangement

– Largedispersiveelectrodewith:• one,two,orfouracIveelectrodes(bifurcated)• Equalsize(ifmorethanoneacIveelectrode)

• Couplingmedia– gelorsalinesoakedsponge– ConducIvespray

PrecauIons

• Burn– Excessiveelectricaldensity

• IntensitytoohighforsizeoftheacIveelectrode• Directmetalcontact

GeneralRehabConsideraIons

• ImpairedmobilityandfuncIonduetosizeoflimbs

• GaitdeviaIons

• LimitedcardiovascularenduranceanddecondiIoning

ApproachesforPrevenIon

• EducaIon,educaIon,educaIon• ProtectskinandperforminspecIons• AppropriateprogressionofacIviIes• AvoiduseofbloodpressurecuffandneedlesIcksoninvolvedlimb

• Monitorandpreventrapidweightgain• Managephysicalchangeswithaging• Avoidsystemicorlocaleventscausinghyperemia• TakecauIonwithpressurechanges

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AROM/ joint

mobs

compression muscle strengthening

gait training

MLD breathing exercises

CP endurance

skin care patient education

CVI X X X X X X

secondary lymph

X X X X X X X X X

lipedema X X X X X X X

orthopedic conditions

with edema

X X X X X X X

CVI/lymphedema

X X X X X X X X X

AdaptedfromHammandPerdomo.

CommonEdemaDiagnosisandRecommendedInterven1ons

SkinandNailCare

• EdematousIssuebecomethickenedandscaly,increasingriskforskincracksandfissures

• PaIentswithlymphedemaaresuscepIbletoinfecIonofskinandnails• StreptococcusbacteriamostcommoncauseforinfecIonsinpaIentswithlymphedema

GeneralSkinCareRecommendaIons

• Soaps,moisturizers,andointments:Nofragrances,Hypoallergenic,NeutraloracidicpHscale

• Protectfromtrauma,keepskincleanandusebugsprayandsunscreen

• BasicmoistwoundhealingtechniquesinconjuncIonwithlymphedemamanagement

GeneralWoundCareManagementWhatifthereisawound?

Wounddepth

Par1althickness:skinlossinvolvingtheepidermisandupperlayerofthedermis.•  Healsthroughre-epithelializaIon•  TissueregeneratedtooriginalfuncIonFullthickness:skinlossextendingpastpapillarydermis.MayincludesubcutaneousIssue,tendon,muscle,andbone.•  HealsbygranulaIonIssueformaIon,contracIonand

eventualepithelializaIonfromwoundmargin.•  ResultsinscarformaIon(70-80%strengthoforiginal)•  Tissuedoesnotregenerate

Time to heal dependent on: VascularityTissueDepth

Full thickness: Distal Full thickness: Proximal

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Time to heal dependent on…

Geometric shape

Linear < Rectangular/Square < Circular

Implications for Mobility?

Full thickness Sacral Pressure Ulcer

Wound Healing Phases

SussmanC;Bates-JensenBM.

Hemostasis

Minutes Inflammation

Days Proliferation

Weeks Remodeling

Year(s)

“TreatthewholepaIent,nottheholeinthepaIent.”

Characteristics of Lower Extremity Ulcers Type Cause Pain Location Appearance

Arterial Arteriosclerosis Pain can be severe due to lack of blood flow.

Toes/fingers. Lower third of leg.

Defined borders. Dry/necrotic. Little to no granulation. Hairless, cooler skin.

Venous Venous Hypertension

Mild Proximal to the medial malleolus

Irreg. borders, red wound base, heavy drainage, hemosiderin staining

Pressure Prolonged pressure/Shear

Varies on structures involved.

Over bony prominences

Varies depending on location/depth. May note discoloration Non-blanching erythema

Neuropathic Diabetes (neuropathies)

None. Patients with an infection may experience pain.

Plantar Foot Pale, pink base, moderate drainage, callus tissue, atrophy, hammer toes.

Adapted from Hamm R. (2015)

Wound Bed Preparation (WBP)

WoundbedpreparaIonisthemanagementofawoundinordertoaccelerateendogenoushealingortofacilitatetheeffecIvenessofothertherapeuIcmeasures.Falanga,2003

PrincipalsofWBP:• IdenIfythecause• PaIentcenteredapproach• Assessthewound• Debridement• BacterialControl• MoistureBalance• Monitorrateofhealing

Sibbald, G. Et al., 2011

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TIME Principles of Wound Bed Preparation (International Advisory Panel on WBP)

Tissue non viable or deficient

Infection or inflammation

Moisture imbalance

Edge of wound non advancing or undermining

Defective matrix & cell

debris

High bacterial counts or prolonged

inflammation

Desiccation or excess

fluid

Non-migrating keratinocytes

Non-responsive wound cells

↓ Debridement

↓

↓ Antimicrobials

↓

↓ Dressings,

compression ↓

↓ Biological agents, adjunct therapies,

debridement

Restore wound base & ECM proteins

Low bacterial counts and controlled

inflammation

Restore cell migration,

avoid maceration

↓ Stimulate

keratinocyte migration K

loth

and

McC

ullo

ch, 2

010

4th

editi

on

Objec1ve:Necro1cTissueTypes

• NonviableTissue:necroIcIssue,cellulardebris,senescentnonfuncIonalcellsandbacterialbiofilms

• Eschar:composedofdeadskinorsubcutaneouscellsvariesincolorandtexture.Notsynonymouswitha“scab”

• Slough:non-viablesubcutaneousIssueandisaresultofthebody’sautolyIcprocesstophagocytosedeadcells

MoistWoundHealing

• Necessaryforwoundstoheal• Useofappropriatedressingshelpsfacilitatethisbalance

• Constantmonitoring/re-assessmentnecessarytomeetneedsofchangingwoundenvironment

Great Reference!

Ovington, L. Hanging Wet-to-Dry Dressings Out to Dry. Advances in Skin & Wound Care: The Journal for

Prevention and Healing. March/April 2002. 15:2; 79-84.

ConsideraIonsWhenSelecIngaDressing

• Drywound→Moistenit

• Excessivedrainage→Absorbit

• NecroIcwound→Debrideit

• GranulaIngwound→Protectit

DressingFunctions

• Absorbdrainage• Providemoisture(hydrate)

• ProtectIssue• Obliteratedeadspace

• Actasabarriertobacteria

• Minimize/controlodor

• Decreasepain• Offerbacterialcontrol

AbsorbencySpectrum

Gauze Foam Alginate Hydrofiber

Less Absorbent More Absorbent

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Let’sreview

• HowmuchdrainageistypicallyassociatedwitheIologylisted?

– DiabeIc/Neuropathic

– Venous– Arterial

• UsetheseopIons:– LiXle/Scant– Moderate– Heavy

“WhatDressingShouldIUse?”

• Variousstudieshavedonedressingcomparisons

• Weakevidence• NostandardtargetpopulaIonsused• Mostdomorethanbasicwettodry• Somestudiesdidshowthatthereweredifferencesinfrequencyofchanges,financialburdenandpainwithdressings

IsThereaRightAnswer?

• KnowthewoundpresentaIonandeIology• Whatisthegoalathand?• Whatisavailableatyourfacility?• Whowillbedoingthedressingchange• Frequency?• Pain?• Finances(insuranceandCMSlimitaIons)

WoundDressingsCategorizedbyFuncIonality

Adaptedfrom

Kloth,L.C.,McCulloch,J.M

.(2010)

Wound Dressing Function Dressing Category

Moisture maintenance Transparent Films Hydrocolloids

Moisture absorption Foams Alginates Hydrofibers

Moisture addition Hydrogels

Reduce bacterial levels (antimicrobial) Silver-containing dressings Iodine containing dressings

Reduce protease levels Collagen dressings Collagen-ORC dressings

Reduce odor Activated charcoal additive Cyclodextrin additive

Reduces pain Ibuprofen-containing dressing Soft silicone dressings

ImportanceofMonitoring

• Onedressing/combinaIonofdressingswillNOTbeappropriatefromstarttofinish

• DocumentaIonisEXTREMELYimportantsowecanrecognizechangesassoonastheyoccur

• Woundchangesnotedin2weekswillhelpyoudecide

DocumentaIonandBilling

• Policy:facility,NaIonalandlocalcoveragedeterminaIons,conservaIvetreatmentconsideraIons

• Billing:appropriateCPT,EnsurethepolicycoverstheparIcularwoundcarebeinguIlized

• DocumentaIon:outcomemeasures(funcIonalandself-report),photos,paIentorcaregivereducaIon

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CommonWoundCareCPTs

Sitetoaccessmostcommonlyusedcodesforwoundandedemacare:

www.apta.org/Payment/Coding/FAQs/AcIveWoundMgmt/

SitetoreferenceforuptodatechangesonCPTsingeneral:www.apta.org/Payment/Coding/CPTChanges/

CaseStudiesAllthatinfoisgreat!But,canIreallyapplyit?

References• BaranoskiS.,Ayello,E.A.(2015).WoundCareEssenIals3rdEdiIon

• BeXanyJA,FishDr,MendelFC.InfluenceofhighvoltagepulseddirectcurrentonedemaformaIonfollowingimpactinjury.PhysTher.1990.70;219-224.

• Casley-Smith, JR and Gaffney, R.M. (1981). Excess plasma proteins as a cause of chronic inflammation and lymphoedema: quantatative electron microscopy. Journal of Pathology, 133, 245-272.

• Chikyl, B. Lymphedema: An overview. Silent Waves: Theory and Practice of Lymph Drainage Therapy. Scottsdale, AZ, International Health & Healing, 2001

• Hamm and Perdomo. Lymphedema. Text and Atlas of Wound Diagnosis and Treatment. McGraw and Hill. 2015. 143-164.

• Kloth,L.C.,McCulloch,J.M.(2010).WoundHealing:EvidenceBasedManagement4thed

References• Lymphnotes.com. Last updated 2013. Accessed March 2014.

• Macdonald, JM. Wound healing and lymphedema: A new look at an old problem. Ostomy Wound Mange 2002; 47; 52-57.

• Zuther, Joachim. Lymphedema Management: The Comprehensive Guide for Practitioners. 2nd Edition. New York. 2009.

• Reed BV. Effect of high voltage pulsed electrical stimulation on microvascular permeability to plasma proteins. A possible mechanism in minimizing edema. Physical Therapy. 1988;68(4):491-5.

• Robinson, AJ, Mackler, LS. Clinical Electrophysiology, 2nd ed. Lippincott Williams & Wilkins, Philadelphia. 1995.

• Prentice WE. Therapeutic Modalities for Allied Health Professionals. McGraw-Hill. St. Louis. 2005.

References

• Taylor K, et al. Effects of electrically induced muscle contraction on posttraumatic edema formation in frog hind limbs. Phys Ther. 1992. 72; 127-132.

• Sibbald, G et al. Special Considerations in Wound Bed Preparation. Advances in skin and wound care. 2011;24;415-36.

• Snyder AR, Perotti AL, Lam KC, Bay RC. The influence of high-voltage electrical stimulation on edema formation after acute injury: a systematic review. J Sport Rehabil. 2010;19(4):436-51.

• SussmanC.,Bates-JensenB.(2012).WoundCare:ACollaboraIvePracIceManualforHealthProfessionals.4thediIon.