Exam 4 Flashcards
Lymphathic organs
Lymph nodes (600-700 in body) “Filtering stations,” produce WBC, regulate proteins in lymph Lymph vessels Intrinsic contractions, 6-10x/minute Thymus gland Spleen Tonsils Peyer’s patches
Lymphatic vessels
Capillaries
Pre-collectors
Collectors
Trunks
Mechanisms of Transportation
Intrinsic contraction Respiration Arterial/venous pulsation Skeletal movement New lymph (creates pressure)
Lymph fluid consists of
Proteins
75-100 g of proteins are transported by the lymph vessels per day
Water
Cells (RBC, WBC, Lymphocytes)
Waste products and other foreign substances
Fat (intestinal lymph, chyle)
Filtration=
Resorption + Lymph Flow
Lympathic load
How much – water, proteins, cells, etc
Lymph Time Volume (LTV)
Amplitude and frequency of intrinsic contractions
Transport Capacity
=Max LTV
= 10x LL in intact system
Functional Reserve
Difference between TC and LL
Normal
LL< TC
Dynamic insufficiency –
overload lymphatic system
Venous insufficiency, cardiac edema, DVT, etc
Mechanical insufficiency – lymphatic system damaged
Surgery, trauma, radiation, etc
Lymphedema always includes mechanical insufficiency
Combined insufficiency
damaged system and overload
Obesity, CVI, lipedema
Lymphedema
An abnormal collection of protein-rich fluid in the interstitium, which causes chronic inflammation and reactive fibrosis of the affected tissues
The lymph load exceeds the total capacity of the system
Risk Factors of Lymphedema
Axillary, inguinal, etc surgery Radiation therapy Partial or total mastectomy Node dissection Obese or overweight Lipedema History of infection in at-risk limb Constriction Tumor causing lymphatic obstruction Scarring lymphatic ducts by either surgery or radiation Intra-pelvic or intra-abdominal tumors Chronic venous insufficiency Drain complications
Primary Lymphedema
Mechanical insufficiency of the lymphatic system
Malformation of lymphatic vessels
Congenital or hereditary
Secondary Lymphedema
Known cause for lymphedema Surgery Radiation Trauma Filariasis Cancer/tumor Infection Obesity Self-induced
Early signs of Lymphedema
Limb feels heavy Skin feels tight Limb is achy (not painful) Clothing or jewelry is tight Can’t see wrinkles in skin
Stage: Latency
no visible/palpable edema, subjective complaints possible
Stage 1:
reversible (elevation), pitting edema often present, increased limb girth and heaviness, no fibrosis
Stage 2:
consistent swelling- does not change with elevation, spongy tissue feeling and often fibrotic changes, pitting becomes progressively more difficult
Stage 3:
lymphostatic elephantiasis, non-pitting, fibrosis and sclerosis, skin changes (hyperkeratosis)
Skin characteristics
Hyperkeratosis (Redding but it becomes hard)
Lichenification (leathery and hard)
Peau d’Orange Texture
Ulcers
May be more common with arterial, neutrotrophic, venous, or traumatic conditions
Vesicles (cysts)
Infection -lymphedema
Reflux
Weeping = lymphorea
Differential diagnosis
Deep vein thrombosis (DVT) Renal failure Postoperative complications Cysts Complex regional pain syndrome Cellulitis Cardiac edema Congestive heart failure Malignancy
Lipedema
Primarily women Bilateral, symmetrical swelling from ilium-> ankle Dorsum of feet not involved Little or no pitting Palpable nodules fat under skin Painful to palpation Bruise easily
Venous Edema
Mid/low calves, malleoli Skin discoloration Fibrosis of subcutaneous tissue Atrophic skin Wounds
Do medications help lymphedema?
no
Surgeries
lymph node transplant, debulking, liposuction
Tests and Measures for lymphedema
Lymphoscintigraphy: nuclear imaging method, tissue injection is transported by lymphatic system and allows assessment of superficial and deep lymphatics, no damage to lymph vessels
Venography and Doppler US: rule out venous problems
Stemmer’s Sign
thickening of skin on the dorsal hand/foot; inability to pinch skin in these areas
Complete decongestive therapy
Manual Lymphatic Drainage (MLD)
Compression Bandaging (multi-layer, short-stretch)
Exercise
Skin Care
Self Care & Risk Reduction / Education
Effects of Complete Decongestive Therapy
Decrease swelling (>50%)
Increase lymph drainage from the congested areas
Improve skin condition
Improve patient’s function, quality of life
Reduce risk of infection
Reductive Phase
Daily (5x/week) treatments until fluid reduction has plateaued
MLD followed by compression bandaging, exercise
60 minute appointments
Bandages stay on until return next appointment
Maintenance phase
Self-management program Self-MLD Compression bandaging or bandaging alternative at night Compression garments during day Skin care Exercise Pneumatic compression device, sometimes Periodic monitoring Replacements of compression garments every 4-6 months
CDT Precautions/Contraindications
Careful techniques, do not cause genital lymphedema
Do not use long-stretch bandages/ACE wraps (to stretchy so it will add too much pressure)
Skin irritation
Infection
Cognition/communication
Wounds
Manual Lymphatic drainage:
Increases the movement of lymph/interstitial fluid, including proteins
—Improves lymph transport capacity, lymph vessel contractility
Stretching of the skin affects the superficial lymph vessels
–Pressure phase promotes fluid movement in a desired direction
–Relaxation phase causes a vacuum due to the distention of the tissue and leads to refilling of the lymph vessels
Slow technique, 5-7 repetitions per area
Gentle technique
Do not rub or create redness
MLD Sequencing
Clear proximal regions and nodes
Move segmentally
Always stretch from distal to proximal
Compression Bandaging
- Improves efficiency muscle pump
- Prevents re-accumulation of evacuated fluid
- Facilitates softening of fibrotic tissue
Remedial Exercise
Part of treatment for lymphedema when limb reduction is goal
WITH COMPRESSION
Includes:
Diaphragmatic breathing
Active, repetitive, non-resistive motion; distal to proximal (ROM/flexibility)
Ball squeeze, elbow flex/ext, shoulder flex, cervical flex/ext, scap retraction
Ankle pump, knee flex/ext, hip flex, hip abd/add
Exercise
WITH COMPRESSION If arm, include hand compression Affects deep lymphatics Pay attention to feelings of heaviness, increased swelling Avoid extreme temperatures Allow adequate rest between sessions
Resistance training is beneficial
Be cautious
Start slow, with low weights, low repetitions
Gradual progression
Limit based on patient / patient’s symptoms
Aerobic Training is beneficial
increases circulation and immune response
Be cautious
Start slow
Gradual progression
Skin Care
Low ph moisturizer (Eucerin) Keep clean Clean cuts/tissue injuries and cover with an antibiotic ointment Careful nail cutting Use electric razor Avoid sunburns, burns, bug bites Wear gloves with outdoor work
Self-Care
Self-manual lymphatic drainage Self-bandaging Donning and doffing compression garments Exercises Skin/nail care
Risk Reduction
Maintain normal body weight
Protect skin integrity, maintain good skin hygiene
Avoid trauma to affected area (insect bites, acupuncture, burns, tattoos)
Exercise to prevent musculoskeletal injury
Avoid extreme heat or cold (hot tubs, saunas, extreme temperatures, cold)
Minimize limb constriction (jewelry, clothing, blood pressure)
Plan ahead with lymphedema therapist and physician for surgeries
Wear compression, move around during air travel
Watch for infection
Compression Garments
Designed to maintain limb size, not reduce it
Do not wear at night
If proximal compression is worn without distal pressure, swelling distally is likely
If sleeve is worn without glove, hand swelling is likely
Wash/dry per care instructions
Compression Grades
Class 1: 20-30 mmHg (beginning pressure arms)
Class 2: 30-40 mmHg (ideal pressure legs)
Class 3: 40-50 mmHg
Compression bandages are not covered by insurance
- about $60-80 for knee-high or arm
- about $80-$110 for thigh-high
Breast surgeries
Radical mastectomy Breast tissue, pec major/minor, nodes Modified radical mastectomy Breast tissue, spares pec major, nodes Lumpectomy Tumor and surrounding tissues
Post-Op
Full examination/evaluation
Pay close attention to skin, incisions, skin mobility, muscle guarding
Take limb measurements
Discuss activity modifications that may need to be made
Education on plan/ therapy progression
Lymphedema
Signs/symptoms infection
Lymphatic cording
- Thickened fascial cord(s) running just under the skin, visible or palpable when the upper extremity is in a flexed and abducted end range position
- Subjective report from the patient includes the experience of “pulling” through area of cording and beyond.
- Limited range of motion in area of cording
- Reports of discomfort or pain in area of cording
Cording treatment
Myofascial release techniques/ soft tissue mobilizations
Manual lymphatic drainage
Gentle stretching
Diaphragmatic breathing
Neural mobilization of the upper extremity
Radiation Fibrosis
Myofascial release techniques/ soft tissue mobilizations
Manual lymphatic drainage
Gentle stretching
Neural mobilization of the upper extremity
Cause of UE amputation
Trauma, Congenital, Disease
Cause of LE amputation
Disease
Reasons for No prosthesis
Limited perceived functional benefit
Reduced sensory input
Comfort
Hot &/or heavy
Benefits of oppositional prosthesis
Provides aesthetic appearance Light weight & simple Functions Opposition Holding objects Restore body image Proprioceptive feedback
Limitations of oppositional prosthesis
No active prehension
High cost for custom
Durability
Patient can have unreal expectations for cosmesis
Body-Powered Prosthesis
A.k.a. ‘cable driven’
Relies upon gross body movements captured through a harness
Benefits of Body-Powered Prosthesis
Moderate cost and weight
Durable
Environmentally resistant
Proprioception through harness system
Limitations of Body-Powered Prosthesis
Grip strength or pinch force
Restrictive & uncomfortable harness
Requires muscle power & excursion
Poor static & dynamic cosmesis
Externally Powered
A.k.a. ‘electrically’ powered or ‘myoelectric’
Powered by a battery
Myoelectric signals
Controlled by various input methods
Benefits of externally powered
Stronger grip force Moderate or no harnessing Minimal energy expenditure Least body movement to operate Moderate aesthetics
Limitations of externally powered
Heavier
More expensive
Limited sensory feedback
Extensive therapy training
Hybrid Prosthesis
A single prosthesis in which two or more technologies are combined
Less weight than fully powered system
More grip strength than a body powered system
Elbow and hand hybrid
Elbow: Body-Powered
Hand: Externally Powered
Hybrid benefits
Simultaneous control of the elbow and terminal device
Reduced weight compared to all electric
Traditional myoelectric control has limitations
Lack of control signals…usually just 2 electrodes
Rely on larger muscle groups for signal
Control muscles usually physiologically inappropriate
Pattern Recognition
Computer software translates muscle activity into prosthetic movements
Many electrodes
More complete muscle activity picture
Multi-articulating hands
Single motor
Single grip pattern
Pronation/supination done passively or with electric wrist rotator
Rigid, solid
Rehab therapy post delivery of prosthetic
- Donning of prosthesis
- control of components
- functional training
- occupational performance
