Complication of Lymphedema Flashcards
Severed lymph collectors can reconnect the distal with the proximal lymph vessel stump, this is called……
Lympho-Lymphatic Anastomosis
How long does it take collectors to regenerate with blunt trauma?
2-3 weeks (faster than incisional trauma)
Scars will complicate treatment if …..
- Perpendicular to collectors
- Fascial adhered to the fascia (underlying tissue)
- wider than 3mm
- heavy scars or keloiding
The term for the thickening of the stratum corneum - is hypertrophy of the corneous layer.
Hyperkeratosis
The treatment plan for Hyperkeratosis
- do NOT cut to remove
- good skin hygiene (prevent infection)
- topical creams (salicylic acid, alpha-hydroxy acid, urea, tretinoin) to soften the keratin
Which topical ointment is used for Hyperkeratosis and how does it work?
Salicylic Acid - it is a keratolytic agent that breaks up the keratin and enhances the softening/shedding of the skin.
Term for epithelial tumours, that may need to be removed after decongestion and may recede with compression (scar tissue)
Papillomas and Warts
Signs of Fungal Infections
- Itching
- Crusting Skin
- Scaling Skin
- more common in lower extremities
- maceration between toes
- sweet odour often present.
Considerations for treatment when fungal infections are present.
- spores can spread
- medication needs to be started prior to initiating therapy
A syndrome characterized by marked thickening and yellow-to-yellow-green discoloration of the nails with no cure.
Yellow Nail Syndrome
Causes of Yellow Nail Syndrome
- poor lymph circulation
- poor venous circulation
- increased diffusion distance
- lymphedema, lung disease
What is a lymphatic fistula and how to treat it?
- Abnormal connection b/w lymph vessel and skin
- If popped - clean it with soap and water
- monitor for infection
- place sterile gauze over the area to protect and remind
- u-shaped padding
What are dilated veins on thorax and what causes them?
- Superficial expanded veins on the thorax.
- Caused when there is a blockage of superficial veins. (Radiation, Tumor, Hereditary, Liver problems)
- Safe to work over these areas
Network-like dilated superficial blood vessels as a result of radiation treatment.
Teleangiectasia
Describe Axillary Web Syndrome (AWS) - Cording Syndrome
Appears as a cord of tissue just underneath the skin located in the axilla and may run down the inside of the arm toward the elbow.
What causes AWS and frequency?
- Appears following cancer surgery with axillary lymph node removal.
- Appears within 2-4 weeks of occurrence in 6-72% of patients.
- Treated with manual techniques
What are the 3 types of Malignant Lymphedema?
1) Internal - cancer cells infiltrate lymph nodes and cause blockage
2) External - tumour in tissues block or obstruct vessels from the outside.
3) Stewart-Treves Syndrome - complications from long-standing lymphedema.
What are some signs and symptoms of Malignant Lymphedema
- Sudden onset and fast progression of pain/swelling especially in an extremity.
- paresthesia, pareses, paralysis
- enlarged lymph nodes
- ulcerations to the skin
- varicose veins on the thorax
- elevated shoulder to the side of extremity pain
What are the characteristics of pain in Malignant Lymphedema?
- sharp pain in extremity
- worse at night
- pain is not in the joint
- rapid swelling does not allow the surround tissue to adjust to increasing pressure
- pain from malignant cells infiltrating nervous tissue
What type of skin changes occur in Malignant Lymphedema (2)?
Reddish - malignant Lymphangiosis
Hematoma-Like - Angiosarcoma
What are the characteristics of swelling in Malignant Lymphedema?
Benign - bilateral, weeks to months
Malignant - Rapid - days to short weeks, Unilateral
Angiosarcoma treatment
First Choice - large resection or even amputation
Radiation and Chemotherapy - does not improve long-term outcomes significantly
Characteristics of Angiosarcoma.
- bluish skin
- hematoma-like lesions
- Stewart-Treves Syndrome
- non healing wounds
- proximal aspect of extremity is often larger than distal aspect
Characteristics of Radiation Fibrosis
- actually a burn
- pain with decreased ROM if near a joint
- paresthesia, pareses, paralysis years following treatment
- skin appears reddish-brown, dilated blood vessels
- compression of venous blood vessels
- tissue changes worsen (scar tissue may adhere to fascia)
Treatment consideration for Radiation Fibrosis.
- contraindication if adhesion to fascia or pain
- mild exercise program to stretch affected skin
- CDT may be applied with lighter pressure if skin discolouration (teleangiectasia) or dilated superficial veins are present but the skin is pliable.
Characteristics of Lymphostatic Fibrosis
- dark, reddish-brown skin
- shiny skin (shinier the skin the harder the fibrotic tissue
- hardening of the tissues in the involved limb
- caused when proteins attract fibroblasts which in turn create increased collagen fibers
- common in Stage II and Stage III lymphedema
Difference between Radiation vs Lymphostatic Fibrosis in regards to CDT.
Radiation - contraindication
Lymphostatic - NOT contraindicated
Treatment considerations for paralysis.
- modify exercises
- lots of padding with compression
- NEVER use compression garments higher than Class I
- immobility is detrimental to lymphatic system
Characteristics of Genital Lymphedema.
- often associated with lower extremity lymphedema (40-60% males)
- more common in males due to greater tissue elasticity.
Treatment Considerations for Genital Lymphedema
- apply initial bandages on penis and scrotum
- patient compliance is important
- treatment should precede the treatment sequence for leg lymphedema
What type of cellulitis is caused by streptococcus presents with papillary or upper layer dermis.
Erysipelas
Why are lymphedema patients more at risk for cellulitis?
- tissue hypoxia
- compromised immune system from chemo/radiation
- symptoms include fever and tenderness, skin is red with indistinct margins
- CDT is contraindicated until infection cleared
What are the two types of debulking procedures?
1) Excisional procedures - debulking and liposuction
2) Lymphatic Reconstruction
Why is liposuction not a preferable debulking procedure.
Fatty tissue is removed and destroying any remaining intact lymph collectors. Worsening existing lymphedema.
When should surgical debulking be considered?
Only after complete decongestive therapy should excision of redundant skin folds be considered.
Do debulking procedures prevent re-accumulation of lymph fluid and negate the need for compression garments?
NO
What is it called when lymph fluid vessels circumnavigate blocked areas and redirect lymph fluid into healthy drainage areas?
Collateral Circulation
Types of Collateral Circulation (5)
- Long upper arm type (allow lymph collectors to drain into supraclavicular lymph nodes)
- perforating pre-collectors (connect deep lymph system with superficial)
- anastomoses (inter-territorial draining quadrants)
- lymph vasa-vasorum (lymph vessels located in the adventitia of blood vessels)
- Initial lymph vessel plexus (cover entire superficial area)
What is the term for intact lymph collectors that increase their contraction frequency and intensity?
Lymphatic Safety Factor (within the same tributary area or territory.)
What is the terms for disconnect lymph collectors that can regenerate through soft scar tissue (<3mm)?
Lympho-Lymphatic Asnastomoses
What is the term for lymph collectors that re-grow into neighboring veins, not yet replicated by a surgical procedure.
Lympho-venous Anastomoses
Characteristics of Lymph Vasa-Vasorum
- normally dormant to surrounding lymph
- drains smaller amounts on lymph fluid
- can be manipulated (cephalic, femoral) veins with a special technique
- high intra-lymphatic pressure (dermal backflow) thus a pathway of lower pressure.
What is the term for lymph vessels that are in the adventitia of larger vessels?
Lymph Vasa-Vasorum (vessels of vessels)
Medication that binds to accumulated interstitial proteins, these fragments pass more readily into the venous capillaries and removed by the vascular system.
Flavonoids (not approved in the USA)
Topical Benzopryone that activates macrophages but no real proven effects.
Unguentum Lymphaticum
- all natural ointment
- smells bad
- only use 3x/week
Oral Benzopyrones that does not have FDA approval.
Coumarin
- flavonoid
- linked to liver toxicity
- questionable benefits
Explain what happens with macrophages if protein-rich fluid accumulates in the tissues?
Monocytes will leave the blood capillaries, once in the tissues they are macrophages (phagocytes) and digest the protein molecules. These protein molecules then become amino acids and removed by the blood circulatory system.
What happens to the net filtrate and lymphatic load when macrophages are able to decrease the protein concentration?
Net-filtrate will decrease and thus a reduction in the lymphatic load.
Important considerations when using compression pumps.
1) Never use pump to decongest
2) Pump will remove water but not proteins
3) NOT an alternative to MLD
4) Do not use in Phase I
Disadvantages of Compression Pumps.
- Most pumps disregard ipsilateral trunk quadrant - Lymph nodes and anastomoses not prepared
- May cause genital swelling
- Pressure may traumatize residual, functioning lymph vessels -Patients are immobile
- No effect on fibrotic tissue
- Time
- Cost
- Suggest minimum of 4 hours for effectiveness
- Parameters are unclear in regards to use, settings, etc.
What are the disadvantages of using diuretics to treatment lymphedema?
- worsen symptoms
- remove water content but the protein molecules remain
- the higher concentration of protein leads to increased swelling and tissue becomes more fibrotic.
- causes a “ballooning effect” of the limb
Diet considerations for treatment of Lymphadema.
-No special diet for lymphedema
- Protein is necessary
- Low salt
- Low fat
- Weight control
- Good hydration
Name 2 negative effects of traditional massage therapy in the treatment of lymphedema?
- Active hyperemia: histamines are released from mast cells in the tissues
- Superficial lymphatics may be
damaged - anchoring filaments and endothelial lining of lymph vessels
What are the effects of Ultrasound Therapy on the tissues?
1) Hyperemia
2) Fibronolytic effect - breaks down scar tissue
3) Pain relief
What are the guidelines published by the International Society of Lymphology for the use of ultrasound in the treatment of lymphedema?
- 50% pulsed -3 MHz
- .1-.3 w/cm2
- Dynamic head movement
- Do not use on radiation fibrosis
What is Iontophoresis (electrotherapy)
- Self-contained battery
- Time-released medications
- Delivers over 24 hr. period
- Single use
- Disposable
- Do not use on involved extremity or ipsilateral quadrant as it will cause hyperemia
Consideration for Thermal Therapy.
Any form should be avoided in the involved limb and associated quadrant as it will cause hyperemia.
What is the goal of Elastic Taping?
Redirect the flow of the lymph from a congested area to an area with sufficient lymphatic flow.
How does Elastic taping work and when is it used?
- creates a gentle list on the skin to allow the lymphatic vessels underneath to absorb and drain fluid to an area with sufficient lymphatic drainage.
- can be worn under compression therapy
- used in areas where bandaging is difficult (head/neck)
Contraindications for Elastic Taping.
- adverse reactions to the tape
- radiation fibrosis
- open wounds
- lymphatic cysts/fistulas
- fragile skin
How is Low-Level-Laser Therapy (LLLT) effective in treating lymphedema?
- stimulates the immune system
- affects macrophages
- treats fibrous scar tissue by affecting fibroblasts
- encourages lymphogenesis and lymphatic motoricity
What is Deep Oscillation Therapy
The tissue is electrostatically attracted and released again in a selected frequency, this will trigger deep resonance vibration. Minimal external pressure allowing for treatment over open wounds, trauma.
- this electrostatic field will break apart metabolic waste so the body can move it out.
