6.3 - Lymphatic System

Question 1

Describe the function of the lymphatic system

Answer 1

Transportation of lymph (clear, extracellular fluid derived from blood plasma)
Collects waste
Assists immune response

Question 2

Describe the function of lymph nodes

Answer 2

Filter lymph & fight infection

Question 3

How much of the blood plasma and proteins return via lymph vessels?

Answer 3

10-20%

Question 4

Describe the anatomy of the lymph vessels

Answer 4

Have contractile tissue, valves, and smooth muscle

Pump lymph fluid back to the subclavian veins

Question 5

What promotes lymph flow?

Answer 5

Lymph vessel contraction
Accessory muscle contraction
Pressure changes during breathing
Dermal mechanical stimulation

Question 6

What is lymphedema?

Answer 6

Inability of lymphatic system to transport water & protein from tissues

Question 7

Lymph fluid has a high _____________ content.

What can this lead to?

Answer 7

Protein content

Hardening, infections, & increased volume of lymph

Question 8

Describe primary vs secondary lymphedema

Answer 8

Primary:
- Congenital / developmental
- ex: lymph node hypoplasia, Milroy’s disease

Secondary (most common)
- Caused by injury or disruption of the lymphatic system
- Ex: cancer treatment (surgery, chemo, radiation)

Question 9

Describe the clinical presentation of lymphedema

Answer 9

• Gradual onset of sx (months to years)
• “Heaviness” or “fullness” of limb
• Typically unilateral
• Gradually worsening edema
• Edema not relieve by elevation
• Early stages –> pitting edema; late stages –> non-pitting edema
• Skin changes
• Hx of lymph node disturbance

Question 10

What does an abnormal lymph node feel like?

Answer 10

FIRM
Mobile or non-mobile
Tender or non-tender

Question 11

Describe Stemmer’s sign

Answer 11

For lymphedema

(+) = cannot lift dorsal fold of foot / hand

Question 12

Describe the “2-cm rule”

Answer 12

Limb discrepancy is >2 cm –> should trigger referral and treatment for lymphedema

Question 13

What is lymphoscintigraphy?

Answer 13

Radiological imaging of lymphatic nodes / vessels

Helps determine extent and location of flow obstruction

Question 14

Describe the staging of lymphedema

Answer 14

“SPIT” - Subclinical, Pitting edema, Irreversible, Trunk-like (elephantiasis)

Preclinical (stage 0)
- “Heaviness” or “fullness” of limb
- Minimal to no observable edema

Stage 1 - REVERSIBLE lymphedema
- PITTING edema
- Edema decreases w/ elevation; reduced in the morning
- Edema increases with standing, activity

Stage 2 - IRreversible Lymphedema
- NON-pitting edema
- NON-reversible edema
- Skin changes begin - fibrotic changes
- (+) Stemmer sign

Stage 3 (Lymphostatic elephantiasis)
- Skin changes
- Hardening of dermal tissue
- Elephant-like skin

Question 15

Describe the grading of pitting edema

How much pressure should be used for grading?

Answer 15

1+ = indentation barely detectable
2+ = slight indentation, returns in 15s
3+ = deeper indentation, returns in 30s
4+ = deep indentation, lasts >30s

“Fingertip pressure” - enough to blanch the nail bed of the thumb

Question 16

Describe normal capillary refill

Answer 16

Nail bed refills w/in 3s

Question 17

Describe the grading for pulses

Answer 17

0 = absent
1 = diminished
2 = normal
3 = bounding

Question 18

What can cause decreased skin temperature in those w/ lymphedema? Increased skin temp?

Answer 18

Decreased = poor perfusion

Increased = infection, cellulitis

Question 19

Describe lipidemia vs lymphedema

Answer 19

Lymphedema - dysfunction of lymph system
- Typically unilateral
- Swelling of foot
- Not typically painful

Lipidema - pathological fatty deposirs
- BIL presentation
- NOT present in foot
- Often PAINful

Question 20

Is there a cure for lymphedema?

Answer 20

NO

Question 21

What is the goal of PT?

Answer 21

Decrease the effects of lymphedema & improve function

Question 22

What is axillary web syndrome?

Answer 22

Lymph node interruption in the axilla that creates lymphatic “cording”

Intervention: gentle stretch of “cords”

Question 23

What does complete decongestive therapy involve?

Answer 23

Manual lymphatic drainage
Compression therapy
Decongestive exercise
Skin care

Question 24

Compression therapy should be performed below ______ mmHg. Why?

Answer 24

45 mmHg

Greater than this causes lymphatic collapse

Question 25

What type of bandages should be used for compression therapy for lymphedema? Describe these bandages

Answer 25

Short stretch bandages

“don’t stretch much”

Low resting pressure (15-20 mmHg), high working pressure (increase muscle pump action)

Question 26

How should manual lymphatic drainage be performed?

Answer 26

Proximal segments first followed by distal segments

Strokes performed in the direction of flow

Gentle pressure <20 mmHg

Question 27

What exercise should be used for those w/ lymphedema?

Answer 27

Gentle, low impact exercise

Aquatic therapy, functional training, breathing exercises, aerobic exs

Question 28

Describe the contraindication to manual lymphatic drainage

Answer 28

Acute infection
Acute DVT
Malignancies
Renal failure
Cardiac edema

Renal & cardiac probs –> increased fluid return overloads these tissues

Infection & DVT –> don’t want to spread these

Question 29

Describe the contraindications to compression therapy

Answer 29

Peripheral arterial disease - ABI <0.8