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Advanced Manual Therapy > Integumentary Unit > Flashcards

Integumentary Unit Flashcards

1
Q

Where does the lymphatic system empty into the venous system?

A

left subclavian vein; the area where the venous system pressure is the lowest

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2
Q

Role of the lymphatic system

A
  • immune surveillance
  • balance fluids and proteins in the circulatory system by transporting lymph fluid
  • assists in fat digestion
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3
Q

How is excess body fluid disposed of/excreted?

A

in the urine

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4
Q

Transport capacity

A

the body’s ability to transport fluid away from an area; 10-30% in the lymphatic system

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5
Q

Lymph fluid movement

A

peripheral to central

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6
Q

Mechanisms of lymph transport

A
  • contraction of the lymphangions
  • active and passive body movements
  • arterial pulsation
  • muscle pump
  • manual therapy techniques
  • respiration
  • “vis a tergo”
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7
Q

What is the rate of contraction of the lymphangions?

A

6-10 bpm

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8
Q

Primary lymphedema

A
  • congenital/hereditary
  • impaired vessel development
  • leg > arm
  • distal > proximal
  • female > male (9:1)
  • asymmetrical
  • 83% manifest before 35 YOA
  • onset usually at puberty
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9
Q

Secondary lymphedema

A

damage to the lymphatic system d/t:

  • trauma
  • surgery
  • radiation
  • inflammation
  • malignancy
  • CVI
  • filariasis
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10
Q

What are the main causes of LE in the western world?

A
  • breast CA
  • skin CA
  • reproductive system CA
  • prostate CA
  • trauma
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11
Q

What is the primary cause of LE in developing countries?

A

filariasis

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12
Q

Known predictors of LE onset

A
  • surgical dissection of nodes/organs
  • radiation therapy
  • age
  • obesity/increased body weight
  • injury/infection via dermal wounds
  • local hyperemia caused by exercise, heat, modalities
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13
Q

“Limb at risk”

A
  • refers only to the involved extremity
  • a lifelong condition
  • careful lifestyle choices
  • potentially a latency period between injury and clinical appearance of lymphedema
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14
Q

Changes in altered system

A
  • excess protein in tissues
  • excess fluid in the limb
  • decreased oxygenation
  • slow healing time
  • formation of fibrosis-proteins = “joiners”
  • lymphangions get clogged
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15
Q

Class I - Mild LE

A

less than 3 cm difference between limbs

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16
Q

Class II - Moderate LE

A

3-5 cm difference between limbs

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17
Q

Class III - Severe LE

A

5+ cm difference between limbs

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18
Q

Prevention and control of LE

A
  • skin care
  • exercise
  • maintain a healthy weight
  • precautions
  • seek early treatment (esp. if changes last longer than 1 wk)
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19
Q

Complete Decongestive Therapy - Phase 1

A
  • MLD
  • lymphedema bandaging
  • skin care
  • exercise
  • compression garment at the end of phase 1
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20
Q

Manual Lymph Drainage

A
  • increases frequency of vessel contractions
  • increases the volume of lymph that is transported
  • increases pressure in the vessels
  • can reverse the direction of lymph flow
  • enhances local arterial blood flow
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21
Q

Lymphedema Bandaging

A
  • encourages lymph vessels to empty through a mild increase in tissue pressure
  • prevents refilling of interstitium between treatments
  • provides essential support for tissues
  • improves the efficacy of the muscle pump during exercise/movement
  • softens fibrotic tissue through pressure
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22
Q

Exercise

A
  • increases lymph vessel contraction rate
  • improves lymph fluid circulation
  • improves the efficiency of thoracic duct via deep breathing
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23
Q

Compression Garments

A
  • prevent refilling of the interstitium
  • preserve limb reduction long-term
  • support tissues that have lost elasticity
  • must be worn to retain reduction of limb size
  • worn during the day (bandage at night)
  • most patients must wear for the remainder of life
24
Q

Skin Care

A
  • prevents accumulation of bacteria
  • helps prevent the onset of cellulitis
  • supplies moisture to dry skin
  • protects against sunburn, scrapes, cuts and other risks for infection
25
Q

Best practice during phase 1

A
  • treatment time: 60-120 min
  • 5 days/week
  • 2-6 weeks for moderate symptoms
  • 8-18 weeks for severe symptoms
  • self or family wrap by day 5
  • patient purchases bandages online
26
Q

CDT Phase 2

A
  • a compression garment
  • home exercise
  • bandaging
  • skin care
  • MLD if appropriate
27
Q

Contraindications to CDT

A
  • uncompensated cor pulmonale
  • acute infections: local or systemic, viral or bacterial
  • acute venous thrombosis
  • ongoing radiation treatments - wait 6 weeks after radiation is completed or until skin returns to normal color
  • conditions related to acute fluid management - cardiac, pulmonary, and renal insufficiency
28
Q

Relative Contraindications to CDT

A
  • cor pulmonale
  • implants such as pacemakers, venous ports
  • radiation damage to skin, other diseases
  • malignant melanoma, malignant lymphedema
  • conditions related to chronic fluid management - cardiac, pulmonary, and renal insufficiency
29
Q

Reasons LE treatment doesn’t work

A
  • lack of patient adherence
  • insufficient treatment: too late, not enough visits, not enough MLD, too few bandages, inexperienced therapist
  • comorbidities
  • unrealistic expectation of rapid outcome
  • malignant lymphedema
30
Q

Allyson

A
  • primary lymphedema
  • LE swelling at birth that worsened with age
  • had difficulty with self-esteem during middle school
  • felt more confident once she learned to manage her condition
  • studied abroad in Peru
  • Graduated from Colorado St.
31
Q

Tammy

A
  • survivor of stage III tongue CA
  • surgery to rebuild tongue
  • reoccurred in palate and tonsils
  • experienced chemo and radiation
  • caused swelling in face and neck
  • rebuilt tongue muscle with upper trapezius, which caused shoulder problems
  • was referred to an OT at the University of Michigan for secondary lymphedema
  • used a machine that had immediate effects on her d/t the reduction of fibrosis
  • pulls dermal and epidermal away from fascial tissues with vertical and horizontal forces
  • works in criminal justice
32
Q

Stephanie

A
  • Marengo, IL
  • experienced obesity for most of her life
  • worsened during high school
  • began noticing problems in 2008
  • was hospitalized with symptoms of Hashimoto’s disease
  • was treated with Lasix for three years, which made her legs much worse
  • a therapist tried short stretch compression bandaging, but not MLD, then gave her OTC compression garments
  • reached 520 lbs. in 2010
  • underwent gastric surgery in 2013
  • chose to have her left leg treated first
  • treatment gave her a purpose
  • BMI 67.8 down to 38.0
  • she got married in 2014
33
Q

T/F: Lymphedema is not painful

A

True

34
Q

Inspection

A
  • location of swelling
  • skin changes (i.e. color, texture)
  • scar tissue, radiation damage
  • lymphatic cysts, fistulas, other
35
Q

Palpation

A
  • temperature differences on the surface
  • pitting edema
  • fibrosis of underlying tissue
  • moist vs. dry with palpation
36
Q

Characteristics of DVT

A
  • sudden onset, usually unilateral
  • pain
  • cyanosis or rubor and heat
  • positive Homan’s sign
  • dx with Doppler US
37
Q

Characteristics of CHF and Cardiac edema

A
  • greatest distally
  • always bilateral
  • pitting edema
  • nearly complete resolution with elevation
  • no pain
  • hx consistent with CHF
  • may be SOB
  • meds for CHF
38
Q

Characteristics of Renal Failure

A
  • kidneys unable to remove waste
  • fatigue
  • flank pain between ribs and hips
  • swelling of ankle, foot, leg
  • changes in urination (increased/decreased/stopped)
39
Q

Characteristics of malignancy

A
  • pain, paresthesia, paralysis (rare)
  • proximal onset
  • rapid development, progressive
  • swelling in the supraclavicular fossa
  • could be purple discoloration
  • non-healing open wounds
  • hx of malignancy
  • pain that wakes them up at night
  • unusual fatigue and/or weight loss
40
Q

Characteristics of infection

A
  • acute: warm, red, burning, edema, pain, sweating, red streaks in the skin, systemic symptoms, fever
  • chronic: warm or cool, pale or red, edema, pain, little fever if any
  • eventual fibrosis, osteomyelitis, skin breakdown, rash
41
Q

Post-op complications

A
  • possible acute DVT
  • more than normal inflammation
  • infection
  • excess bleeding
  • symptoms from poor positioning
  • swelling as side effect of tourniquet
42
Q

Characteristics of CRPS

A
  • acute: warm, red, burning, edema, pain, sweating
  • chronic: cool, pale, edema, pain, dry

eventual fibrosis, osteoporosis, atrophy of skin and muscle

43
Q

Characteristics of lymphedema

A
  • slow onset, progressive
  • pitting in early stages
  • begins distally
  • cellulitis in hx is common
  • rarely painful but the swelling is uncomfortable
  • heavy, aching discomfort
  • skin changes
  • ulcerations unusual unless CVI is present
44
Q

Characteristics of Lipedema

A
  • a disorder of adipose tissue
  • the condition may be inherited
  • almost always female
  • women of all sizes, upper body can be normal size
  • excess deposit of fat cells
  • fatty tissue does not respond well to diet and exercise
  • can appear COMBINED with lymphedema
  • bilateral, symmetrical swelling: iliac crest to ankles
  • swelling spares the dorsum of feet
  • little/no pitting
  • no hx of cellulitis
  • painful upon palpation
  • can trigger 2˚ lymphedema
45
Q

Characteristics of CVI

A
  • non-pitting
  • hemosiderin staining
  • fibrosis of subcutaneous tissue
  • atrophic skin (poor quality)
  • usually ankle to the knee at most
  • wounds common
  • can trigger 2˚ lymphedema
46
Q

Characteristics of CVI

A
  • non-pitting
  • hemosiderin staining
  • fibrosis of subcutaneous tissue
  • atrophic skin (poor quality)
  • usually ankle to the knee at most
  • wounds common
  • can trigger 2˚ lymphedema
47
Q

Characteristics of Baker’s cyst

A
  • fluid filled cyst behind knee
  • causes a bulge that is often visible
  • may cause LE swelling
  • the feeling of tightness
  • pain with activity in flexion/extension
48
Q

Characteristics of myxedema

A
  • thyroid dysfunction
  • dry skin
  • brittle nails
  • thinning hair
  • decreased sweat
  • orange tint to the skin
  • deposition of mucinous substances in the skin (eyelids, face, elsewhere)
49
Q

Cyclical Idiopathic Edema

A
  • periodic swelling/bloating in the legs/abdomen
  • occurs in women while standing
  • disappears when laying down
  • happens most often before the menstrual period
  • rule out cardiac, kidney, liver disease
50
Q

Characteristics of edema

A
  • often rapid onset, may be progressive
  • pitting in early stages
  • begins at the injury, insult, or surgery site
  • cellulitis is NOT common in hx
  • usually painful until 2 weeks out
  • heavy, aching discomfort
  • rarely have skin changes due to acuteness
  • ulcerations unusual unless CVI
  • bruising common
51
Q

Diagnostic tests for LE

A
  • gold standard: physical exam and hx
  • lymphography
  • venous doppler
  • lymphoscintigraphy
  • CT scan
  • MRI
  • rule out heart, kidney, lung, liver, reproductive system
52
Q

Phlebolymphedema

A

a combination of CVI and lymphedema; must be compressed

53
Q

Watersheds

A

where lymph nodes runs toward

54
Q

Poor postures that obstruct lymph flow

A
  • crossing legs while seated
  • sleeping on stomach
  • sitting too long without break (flexed hips and knees)
  • keyboarding too long without breaks (flexed elbows)
  • driving without appropriate rest breaks
55
Q

MLD Pattern

A

neck - abdomen - ipsilateral adjacent nodes - contralateral nodes - affected nodes - affected limb

Advanced Manual Therapy (3 decks)

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