1. 衛生福利部國民健康署
2013年癌症復健相關人員培訓計畫
2013年癌症復健相關人員培訓計畫
Causes Lymphedema
Primary lymphedema: present at birth or
onset after puberty. Born without
enough lymph nodes, or lymphatic
collectors.
淋巴水腫之物理治療
彰化基督教醫療財團法人
鹿港基督教醫院
黃睦升 MS,PT
Secondary Lymphedema: developed due
to trauma, infection, surgery, tumors,
and/ or radiation to the lymph node
regions. Can be within days to several
years later.
1
2
：↑2~3 times (Mortimer et al., 1997)
3
4
1

2. The Causation of Edema
Lymphedema
BLOOD
Definition：An abnormal accumulation of tissue
proteins , causing edema and chronic inflammation
within an extremity.
Lymphatic
load
Tissue
Normal
HighHigh-flow
edema
LowLow-flow
edema
=lymphoedema
(high protein)
(Grabois M. Phys Med Rehab Rev 1994;8:267-77)
SafetySafety-valve
insufficiency
Lymphatic
Transport
Capacity
Functional overload of the lymphatic system
Lymph volume exceeds transport capacities
Also occurs in the face, trunk and external genitalia.
LYMPH
6
Stages of Lymphedema
CTCAE: lymphedema
International Society for Lymphology (Casley-Smith et al. 1985)
(Common Terminology Criteria for Adverse Events v3.0)
Stage 1 : pits on pressure
Stage 1
Includes both objective measures (interlimb discrepancy) and
subjective assessments.
reduced on elevation
no or mild fibrosis
Stage 2 : non-pitting on pressure
not reduced by elevation
moderate to severe fibrosis
brawny
Grade 1: 5%~10% interlimb discrepancy in volume or
circumference at point of greatest visible difference; swelling or
obscuration of anatomic architecture on close inspection; pitting
edema.
Grade 2: More than 10%~30% interlimb discrepancy in volume
or circumference at point of greatest visible difference; readily
apparent obscuration of anatomic architecture; obliteration of
skin folds; readily apparent deviation from normal anatomic
contour.
Grade 3: More than 30% interlimb discrepancy in volume;
lymphorrhea; gross deviation from normal anatomic contour;
interfering with activities of daily living.
Grade 4: Progression to malignancy (e.g., lymphangiosarcoma);
amputation indicated; disabling lymphedema.
Stage 2
Stage 3 : elephantiasis, warts
skin very thick and leathery
subcutaneous tissue hypertrophied
7
Stage 3
8
2

3. Surgical Therapy for Lymphedema
Drug Therapy for Lymphedema
Debulking or reduction
Surgery
Antibiotics: for acute or chronic infections
(ex: cellulitis and lymphangitis)
1. Microlymphatic-Venous
Anastomosis (LVA)
2. lymphatic-venouslymphatic-plasty
--Preventive antibiotics for recurrent ALD (acute lymphatic
--Preventive
dermatitis) (2005,20th International Congress of Lymphology)
Lymphology)
Diuretics: no effect or even aggravated swelling
Benzo-Pyrone (Coumarin):
Limitation：
1. few long term good results
2. failure after 2~3yrs
--Stimulate proteolysis by macrophages
--Increase the number of the macrophages over
edematous limb (N Engl J Med 329; 1158-63;1993)
－no effect and liver toxicity
Functional or physiological
surgery
Liposuction
--Destroy superficial & deep
lymphatic pathways
--Main complication：cellulitis
：
(N Engl J Med 340; 346-50;1999)
Circumferential
liposuction
Post-OP + compression
may sustained
garment
improvement in symptoms
9
Lymphatic Venous Anastomosis (LVA)
10
Circumferential Liposuction
0.5mm collecting
lymphatic
0.8mm subdermal venule
11
12
3

4. In later stage, filled with fibrosis and
adipose tissue
poor result
移植淋巴結 當抽水幫浦
林口長庚醫院副院長鄭明輝：
「嚴重水腫的患肢就像是正在淹
水一樣，已經淹到了好幾層樓
高，淋巴結就像是抽水機，經由
顯微手術將抽水機往最低的一樓
擺，開始抽水，就能逐漸解除淹
水慘狀。」
淋巴結移植手術：從淋巴結較多
的下頷處，將部分淋巴結移植到
右腳背上。
移植後的淋巴結發揮「抽水幫
浦」作用，將堆積的淋巴液慢慢
往上輸送，過了一年多，右腿總
算慢慢恢復原貌。
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14
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In later stage, filled with fibrosis and
adipose tissue
surgical intervention
4

5. 腹大網膜移植手術
早發型下肢淋巴水腫(
praecox)的男性患者 許文憲,2008)
的男性患者：
早發型下肢淋巴水腫(lymphedema praecox)的男性患者：(許文憲,2008)
術後7個月後之追蹤結果：其患肢體積、彈性、膝踝關節可彎曲程度及
術後7 個月後之追蹤結果： 其患肢體積、 彈性、
足踝變形程度均恢復正常，但是下肢色素沉著並無顯著改善。
足踝變形程度均恢復正常，但是下肢色素沉著並無顯著改善。
(Goldsmith HS, de los Santos R: Omental transposition for the treatment of chronic lymphedema.
Rev Surg 1966;23:303-304.)
術後仍需配合復健
治療，才能使患肢
有機會恢復至接近
正常之大小，時間
約需六至八個月，
甚至更久。
有腎臟病、缺血性
心臟病患者，通常
不建議施行此一移
植手術。
17
腹大網膜移植
18
先天性兩下肢淋巴水腫
(許文憲,2008)
許文憲,2008)
32歲秘魯籍的女子，罹患先天
性兩肢淋巴水腫20年，得長年
臥床。
因為重複感染，造成兩肢嚴重
「垂足」，趾骨併發骨髓炎。
19
動員18個科別、上百名醫護人
員為她進行10餘次手術。
切除她雙腿共15公斤的淋巴纖
維化組織，並且矯正垂足，全
程腿部皮瓣移植。
20
5

6. Surgical Therapy for Lymphedema
The most effective treatment?
(2005,20th International Congress of Lymphology)
Lymphology)
Currently not enough evidence to draw conclusions
about the best physical therapy to use in the treatment
of lymphoedema.
Supplement T’X for poor response to
T’
D.L.T.
Indication：conservative T’X failure.
Indication：
T’
(Physical therapies for reducing and controlling lymphoedema of the limbs (Review). 2007 The Cochrane Collaboration)
No evidence to suggest the most effective treatment for
secondary lymphedema.
Surgery+DLT
good long-term result
longLife long D.L.T. is necessary to keep
satisfactory result.
(Systematic review:conservative treatments for secondary lymphedema. Oremus et al. BMC Cancer 2012, 12:6)
(A Systematic Review of the Evidence for Complete Decongestive Therapy in the Treatment of Lymphedema From 2004 to 2011. Lasinski et al.
PM R 2012;4:580-601)
Insufficient evidence power:
Inconsistencies in defining and measuring lymphedema
lack of enough RCT.
Small sample sizes.
Ethical questions.
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History of Lymphedema
The medicine-based evidence is
undeniably strong that CDT is an effective
way to treat lymphedema.
Effective for various degrees of
lymphedema:
mild, moderate, or severe
early or late onset
recent or chronic
active cancer or palliative situations
(Lasinski et al. PM R 2012;4:580-601)
23
15,16th century:lymphedema has been known.
1936, Vodder:manual lymphatic drainage to treat lymphedema
1950-1970, Kinmonth:D/D lymphedema & venous edema
1981, Kubik:concept of lymphatic watersheds.
1975-1980s, M. Foldi (Germany):
put all techniques together
with his wife (E. Foldi) 1st modern clinic for T’x lymphedema
Complex Decongestive Physiotherapy (CDP)
1986, John Casley-Smith:Microcirculation
combine Kubik & Foldi methods
Complex Lymphatic Therapy (CLT)
or Complex Physical Therapy (CPT)
1998, Foldi, Leduc, Vodder school and Casley-Smith et al. agreed:
Decongestive Lymphatic Therapy (DLT)
24
6

7. Decongestive Lymphatic Therapy
(DLT)
Skin
Care
Manual
Lymphatic
Drainage
Compression
Therapy
Decongestive Lymphatic Therapy
(DLT)
Self
Drainage
Exercise
Intensive phase
(2~4 weeks)
Goal
Maintain phase
(6~9 months)
Max. reduction in 7~10 times
To mobilize the accumulated protein-rich fluid.
To initiate the reduction of fibrosclerotic tissues.
To maintain and even improve the results achieved in
intensive phase.
Loosen skin remodelling.
?
＊ Intensive phase: repeated after loose skin remodeling
(in maintain phase).
＊Each repeated DLT course:↓50% preserved
?
25
lymphedema
26
Obstruction of lymph vessels
LYMPHOEDEMA
Chronic
inflammation
Excess protein in tissues
REPEATED INFECTIONS
↓Lymphatic load
Damaged blood vessels
Spasms & Thrombosis
of Lymphatics
Cellular debris
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Increased Lymphatic Load
28
7

8. Skin complications of lymphedema
Skin Care Education
Hyperkeratosis: thickening of the epidermis.
1.Avoid
2.Avoid
3.Avoid
4.Avoid
Caused by overproliferation of the keratin layer and produces
scaly brown or grey patches.
infection and injury
pressure on the involved extremity
constrictive clothing
vigorous activity
重物不宜超過15磅 6.8公斤)
重物不宜超過15磅(約6.8公斤)
15
公斤
5.Avoid heat
6.Keep skin in good condition- moisture lotion
7.Avoid strong massage
29
30
Skin complications of lymphoedema
Skin complications of lymphoedema
Papillomatosis: multiple benign
epidermal tumors
Lymphangiectasia(lymphangiomata): excessive
dilatation of the lymphatics
Treatment: compression with multi-layer short stretch bandage.
31
due to dilatation of lymphatic vessels and
fibrosis, and may be accompanied by
hyperkeratosis.
may be reversible with adequate
compression.
32
8

9. Skin complications of lymphoedema
Lymphorrhoea: leakage of lymph
from the skin.
The surrounding skin should be
protected with emollient, and
nonadherent absorbent dressings
should be applied.
Bandages will reduce the underlying
lymphoedema, but needs to be changed
frequently to avoid maceration of the
skin.
In the palliative situation, light
bandaging may be more appropriate.
↑Lymphatic transport capacity
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Initial lymphatic
(2,3)
Collecting
lymphatic (5)
Vascular & Lymphatic System
1-epidermis
6-deep fascia
8,9-two
adjacent
drainage
regions
Lymphatic System
Lymphotome
&
Watershed
35
36
9

10. The Passage of Protein
in Normal Tissue
Blood capillary
Tissue channel
Lymphatic system
Effect of MLD
Vein
Mechanically move fluid
into initial lymphatic.
Make initial lymphatic &
collecting lymphatic pumping
& being emptied repeatedly.
Open valves of collecting
lymphatic that crossed
watershed.
Set up collateral pathway.
37
MLD techniques
Casley-Smith:
The Strokes
Nodal massage
Clearing across the
watersheds
Blocking flow
Clearance of deep trunk
areas
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Massage Technique
Vodder: four basic strokes
Stationary circle: for lymph
node
Pump technique: for
extremities
Rotary technique: for trunk
Scoop technique: for lower
parts of extremities
Massage area should be exposed！
Stroke pressure : <80 g/cm2 (60 mmHg).
gentle, not redness or pain.
20-40 m in diameter
壓力小於30mmHg即可使淋巴液通過微淋巴管，在動物實驗中，過大的力道(壓力大
於60mmHg)會使得微淋巴管塌陷。
Slowly with control：
with minimal friction by hands & fingers.
Speed: the greater the amount of fluid, the slower the movement.
40 min : 30 (trunk)/10(affected limb)
Higher pressure over watershed, lymph node and fibrosis area.
Watershed area：6cm (3cm from the midline and crossed over it 3cm)
＊Ulnar side of hand：vertical to watershed
＊Bil. thumbs encircle：for lateral trunk
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40
10

11. Massage for fibrosis area
Drainage pathway & Sequence
對於肢體或體表上很堅硬、纖維化的區域，可加重按摩力道，
創造新的組織通道(tissue channel)，即使這些通道已經沒有
瓣膜、也喪失推動淋巴液的功能，卻仍然能提供一個通向含有
正常淋巴管的區域。
另外，外在的壓迫(compression)是必須的，以保持淋巴液在這
些沒有瓣膜的組織通道能抵抗重力的往上回流。
然而在纖維化區域中，微淋巴管的內皮層可能會不正常的被打
開或撕裂，造成更多的淋巴液從微淋巴管滲漏出來，因而需要
馬上纏繞低壓力彈性繃帶。
若因為某種因素，而無法使用低壓力彈性繃帶，則必須省略纖
省略纖
維化區域的按摩，否則將造成淋巴液滲漏、組織間隙的蛋白質
維化區域的按摩
濃度升高、局部皮膚溫度上升、水腫加劇，甚至有感染的可
能。
Posterior Trunk
Anterior Trunk
41
42
Drainage pathway & Sequence
Face Lymph Pathways
1
43
2
44
11

12. Respiration
Lymphatic Drainage
Lymph flows into the sub-clavian veins most rapidly
at the peak of inspiration.
A one-way drainage：remove protein and
excessive fluid
Initial lymphatic pre-collector
collecting lymphatic lymph node
The rate of flow of lymph into venous circulation is
proportional to the depth of inspiration.
The mechanism of inspiration：
Superficial pathway
＊ Intra-thoracic pressure decreases decreased
pressure of the thoracic duct in the thoracic portion.
lymphatic trunk collecting duct
thoracic duct sub-clavian vein
vena cava R’t atrium
Deep pathway
45
教導患者做腹式呼吸(abdominal
breathing)，吸氣到最飽最深的程度、
接著吐氣時輔以治療師雙手給予往內
往上的壓力，產生較大的腹壓。
sub-costal
MLD practice: External genitalia
Pelvic Scoop:
M-breathing
sub-costal
The fingers placed superior
the pubic symphsis.
Toward the umbilicus.
A really deep pressure.
Umbilicus
Inside the pelvic rim
46
When working on the legs
observe the pubis and the genitalia
if became edematous, esp. scrotum.
當下肢與生殖器的淋巴水腫合併存
在時，需注意生殖器的皮膚照護、避
免黴菌感染，若只治療下肢淋巴水腫
(如淋巴引流或壓縮療法)，則可能會
加重生殖器淋巴水腫症狀，因此軀幹
淋巴區的清空則更加重要！
Inside the pelvic rim
•若合併有腹水
若合併有腹水(ascites)症狀，
症狀，
若合併有腹水
症狀
則不適合實施M-breathing。
則不適合實施
47
48
12

13. Past hx：R’t THR (+) 、R’t drop foot
：
Cervix Ca. S/P with R’t thigh and buttock lymphoedema
PT for Post TRAM Procedure
Evaluation：
– Inspect the flap for color, temperature, capillary refill
– Signs of swelling on the involved side
– Signs of infection, decreased tissue perfusion, or
edema
49
Rehabilitation Goals
To reduce stress on the sutures of the
abdominal wound closure
Prevent subdermal fibrosis and adhesions
1. Positioning the head of the bed at a 450
↓lymphostasis
2. Lie on the uninvolved side in a fetal position
Modulate abnormal sensation
3. May also hug a pillow closely to the chest when coughing and
avoid a Valsalva maneuver by exhaling during physical exertion.
Restore trunk alignment
4. Use "log-rolling" techniques without disrupting the abdominal
sutures.
↓stress on the lumbar spine
5. Maintain trunk flexion during transfers
Optimize proprioceptive acuity in residual
abdominal m.
Encourage normal muscle recruitment
patterns
– supine to sitting
– sitting to standing
– ambulation for short distances
6. Ambulation generally begins the postoperative day 1.
13

14. Post TRAM Exercise
One week after：
– active and active assistive exercises of upper extremities with
achieving full range of motion.
– General lower-extremity isometric exercises to prevent
deconditioning.
Several weeks after
– Abdominal strengthening exercises.
– Lifting and sit-ups are not permitted until 6 weeks.
Trunk strengthening
Exercises be for co-contraction of the oblique,
transversus abdominis, and multifidus muscles.
Examples of exercises：
– hook lying with pelvic rotation against resistance at the knee
– sitting with isometric trunk rotation against resistance
– bridging with isometric pelvic rotation against resistance
A home exercise program with self-resistance.
This time frame will depend on healing and on an
individual basis by the surgeon.
熱敷有助傷口復原及減少莢膜攣縮
低溫燙傷」
「低溫燙傷」
MLD practice: Breast reconstruction
14

15. Multiple channel pneumatic pump
optimal pressure parameters are not been
established
little or no lasting beneficial effects
fail to move lymph into different lymphtic
quadrant
may damage remaining health lymph vessels
need to combine self massage to the neck &
trunk
↑Lymphatic transport capacity
58
57
Compression Therapy
Effects of compression
Multi-layer bandage
Reduction in capillary filtration by enhanced
tissue pressure
Shift of fluid into non-compressed parts of the
body
Increase in lymphatic re-absorption and
stimulation of lymphatic transport
Improve rhythmic lymph pulsation
Breakdown of fibrosclerotic tissue
Suture line
& cuff effect
59
Compression garment
60
15

16. Short stretch bandages (in-elastic)
Bandaging Principles
low resting pressure & high working pressure
Maintain slight tension on bandages, except for
wrapping fingers or toes.
The bandage should never be stretched to its
maximum length.
The first bandage is always “light”, then increase
pressure slowly over a comfortable period of time.
Graded pressure：decreasing from distal to proximal.
：
Use only tape to fix a bandage.(clamps are dangerous;
they can injure the skin and cause serious infections).
Check pressure gradient after completing the bandage.
61
Multi-Layer Bandage
Cautions with Bandages
Padding:
Protect the skin and tissue preventing friction
and shearing.
Reshape the limb to a cylindrical shape
provides a smooth surface for an even distribution
of cross-sectional sub-bandage pressures, with a
decreasing pressure gradient from distal to
proximal points.
Even pressure by padding.
63
Different radius
62
Very high pressures may be achieved over
pressure points.
A joint bandage needs to provide
adequate pressure to enable reshaping
but reduce the potential for shearing and
friction.
Reducing slippage (may result in a
tourniquet effect)
Applied pressure should be with uniform
tension over the limb.
64
different pressure.
16

17. Addressing specific problems
When to Remove Bandages
□ Limb distal part: soreness, numbness,
more swelling, pain can’t relive by e’x
□Fingers nail: cyanosis, cold
※Bandages should always be adapted to the
individual: age, diagnosis, and other
condition-DM or peripheral neuropathy.
65
66
Bandaging the Head and Facial area
Lymphoedema bandaging for
head, breast and genitalia
A 12–16cm wide tubular bandage,
folded in half
Pressure:
Hook-and-loop fasteners for
easy apply.
applied gently and low to prevent paraesthesia or bruising in
irradiated regions.
No compression on neck.
67
The padding is placed within the tubular bandage.
To increase local pressure: by placing several layers of
foam.(fig2.)
68
17

18. Compression of the breast
Bandaging the male genitalia-1
A cup shape thick
foam(1.5-2.5cm): provide
a micro-massage
effect(Fig5)
Cohesive bandage to prevent
slippage.
Allow for urination.
Gently squeezes the
fibrosis.
(Fig6: L’t breast)
In severe lymphoedema, the penis
and scrotum are also padded with
3-4cm thick foam.
Foam padding: extended
to underneath the armpit
and overlap the edges of
the bra prevent
tourniquet effect.(Fig7)
69
Bandaging the male genitalia-2
70
Bandaging the male genitalia-3
Foam padding:
Primary genital lymphoedema with long-term
compression and elevated temperatures in the testicles
can result in fertility problems.
at least 2cm thick
anatomically contoured
foam.
Begin with a low level of compression and depending
on the severity and response.
Female genital
lymphoedema:
More complex
at least 1cm thick of
custom-made anatomically
contoured foam
Patients or their care-givers must learn self-bandaging
skills because excess fluid can rapidly accumulate in the
external genitalia if treatment is interrupted.
71
Attention to common cellulitis and fungal infection. 72
18

19. Compression Garment
Contraindications to high compression
Acute infection with local and/or systemic
symptoms
Untreated DVT
Untreated cardiac failure or HTN
Untreated genital oedema
Proven arterial insufficiency (ABPI <0.5–0.8)
Class I : 20-30 mmHg
hypertrophy scar, mild varicose vein
Class II : 30-40mmHg
mild arm lymphoedema
Class III : 40-50 mmHg
severe arm & mild leg lymphoedema
Class IV : >50 mmHg.
severe leg lymphoedema.
73
74
Self Drainage Exercise
Improve muscular contractions and joint mobility.
Reduce muscle atrophy.
Muscular contractions along with the low-stretch
bandages provide constant counter pressure to
keep the lymph fluid moving.
↑Lymphatic transport capacity
75
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19

20. 消腫運動的基本原則
要求自己每天做以達到最好的效果。
不要穿太緊的衣服，以免阻礙淋巴回流。
需先穿上彈性衣或綁著彈性繃帶時，做消腫運動
才有效果。
一定要按照每項運動的順序，就像按照淋巴引流
的順序一樣。
每項運動不要做太快，慢慢的數1.…2….3….。
運動不可以太累而讓肌肉酸痛，適量就好。
花費的時間：大約是30分鐘，但是一天若只做
10分鐘也總比都沒有做的好。
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78
FAQ
79
80
20

21. Avoid heavy lifting and resistance-training
exercise for arm lymphoedema？
？
徒手淋巴引流是否加速癌症轉移？
徒手淋巴引流是否加速癌症轉移？
一些學者認為徒手淋巴引流會將惡性癌細胞經由
淋巴結傳輸到血管系統，最後使癌細胞散佈全
身。然而當組織直接接觸到不同的癌細胞，必須
視癌細胞的生物特性及免疫系統的狀況，並不一
定會讓癌細胞散佈全身或形成轉移。
因此，不管患者的癌細胞仍存在或是復發，在先
經過必要的醫療處置後，如化學治療或放射線治
療等，都可接受去腫脹淋巴治療。
•Lawenda BD, Mondry TE, Johnstone PAS. Lymphedema: A primer on the
identification and management of a chronic condition in oncologic treatment. CA: A
Cancer Journal for Clinicians 2009;59(1):8-24.
•Pinell XA, Kirkpatrick SH, Hawkins K, Mondry TE, Johnstone PAS. Manipulative
therapy of secondary lymphedema in the presence of locoregional tumors. Cancer
2008;112(4):950-4.
即使文獻指出阻力式訓練或重量訓練可能使上肢淋巴水腫
的症狀惡化，使得臨床上對運動強度的設定仍趨於保留、
使得水腫肢體變的無力。(2006,Markes M)
但仍有學者以隨機控制實驗指出，6個月的重量訓練對上
肢淋巴水腫肢體的周徑及主觀症狀並無影響。(2006, Ahmed RL)
甚至以持續13週、每週兩次、共90分鐘的舉重運動可有效
緩解乳癌術後上肢淋巴水腫的症狀。(2009, Schmitz KH)
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Predictive factors for DLT effect in
lymphedema
•Markes M, Brockow T, Resch KL. Exercise for women receiving adjuvant therapy for
breast cancer. Cochrane database of systematic reviews (Online) 2006(4).
•Ahmed RL, Thomas W, Yee D, Schmitz KH. Randomized controlled trial of weight
training and lymphedema in breast cancer survivors. Journal of Clinical Oncology
2006;24(18):2765-72.
•Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L et al. Weight lifting
in women with breast-cancer-related lymphedema. The New England journal of medicine
2009;361(7):664-73.
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Predictive factors for DLT effect in
lymphedema
Baseline PEV was the only predictor of PREV in
our study. (including breast cancer related &
lower extremity lymphoedema)
a lower PEV would predict a better response to
DLT.
Duration of LE lymphedema was not
associated with PREV (DLT effect).
Studies on BCRL reported the opposite
conclusion
PEV=(baseline VL−VH)/VH×100%
PEV: percent of excess volume
PREV=100%×(post-treatment VL−baseline VL)/excess volume
PREV: percent reduction in excess volume (DLT effect)
Longer duration of UE lymphedema would
induce higher PEV and lead to worse DLT
efficacy.
early intervention in patients with mild
lymphedema would achieve better DLT efficacy.
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22. Treatment Goal
A cure is not yet available.
T’x is difficult, costly, and time consuming.
Aims
-to reduce and control the amount
of swelling in an affected limb
-to restore the function and cosmetics.
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Vicious Circles of Oedema
Take Home Message
DLT: skin care, MLD(<60mmHg),
compression therapy, self drainage
exercise.
To reduce lymphatic load: skin care.
To improve lymphatic transport capacity:
MLD
compression therapy
self drainage exercise.
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