Lecture 13: Lymphedema: Physical Therapy Treatment and Management

Question 1

What are the 3 key functions of the lymphatic system?

Answer 1

1) Fluid balance and assistance w/ infection control

2) Removes waste from intersitium to venous system for exertion, and production of lymphocytes
* Closely related w/ a chronic venous insufficiency - if the venous system isnt working properly than the lymphatic system takes over
* Lypmhatic system essentially just picks up anything that is left behind by the venous system
* KNOW: the lymphatic system is part of your immune system, so it processes anything that is left behind and cleans it makes sure theres no pathogens etc.. makes sure it doesnt need to call WBCs/other immune responses

Question 2

What occurs when there is an imbalance of fluid uptake between the interstitium and lymphatic system?

Answer 2

Lymphedema

KNOW: It affects both men and women equally

Question 3

Where in the body is Lymphedema primarily seen?

Answer 3

LE/UE

However it can also be seen in the head,neck,genitals, and trunk/abdomen
* note these are more common when theres cancers involved and lymph nodes have been removed
* NOTE: trunk/abdomen lymphedema is typically a progression of LE lmyphedema (backs all the way up to abdomen)

Question 4

Chronic venous insufficency + Lymphedema =

Answer 4

Phlebolymphedema
* Its when the both occur at the same time

Question 5

KNOW: There is a close occurance w/ lymphedema and wounds

Question 6

KNOW: Lymphatic system is divided into superficial and deel lymphatics

Question 7

What are lymph organs?

Answer 7

1) Lymph nodes
2) Lymph vessels
3) Circulating lymph fluid

Question 8

What connects to lymph vessels to form drainage system

Answer 8

Lymphatic capillaries

Question 9

Lymphcapilaries
* Large or small
* Permable or inpermiable?

Answer 9

Large
Permeable

Question 10

What is fluid absorbed into the lymphatic system called?

Answer 10

Lymph

Question 11

Know these exist

Question 12

Clear and contains the lymphatic load

Answer 12

Lymph fluid

Question 13

Is the lymphatic system part of your immune system?
* why is it closely associated w/ cancer

Answer 13

Yes, it helps to activate the immune response for a pathogen

its associated w/ cancer because as the cancer starts to metastize these nodes pick it up and become swollen because its trying to process those cancer cells

KNOW: Lymphatic load consistns or protein, water, cellular, compents and particals of fat - I think this is just the shit the lymph node catches

Particals entering the body, such as dust, dirt, spores, etc, are absorbed by the lymphatic vessels and transported to the lymph nodes where immune response mechanisms are activated.

Question 14

Explain the Flow of lymph

Answer 14

Lymph capillaries –> Precollectors –> lymph collectors –> Lymph nodes –> thoracic duct or right lymphatic duct –> venous system

NOTE: each node has its own pumping system

Question 15

What does the Right thoracic duct collect?

What about the thoracic duct

Answer 15

R thoracic duct doesnt collect much, really just that R UE. Mostly collected by the thoracic duct

Question 16

What are Lymph angions
* How often do they occur?

Answer 16

Autonomic (automatic) contractions

Occur 10-12 times per minute

Question 17

What are lymphangiomotoricity

Answer 17

The rate at which lymph vessels contract and transport lymph fluid

Question 18

What drains regional lymph nodes?

Answer 18

Lymphatic territories

Question 19

What allows drainage from on territory to another (of lymph nodes)

Answer 19

Anastomses
* these are those connecting vessels
* Cross connection between adjacent

Question 20

What vertebral level is the thraocic duct located?
* Where does it drain lymph fluid to?

Answer 20

Located at T11-L2

Drains lymph fluid to left venous angle

Question 21

How much of the fluid from the body does the right lymphatic duct drain?
* What drains the other part?

Answer 21

only 1/4

Note: the thoracic duct drains the other part

Question 22

The two big vessels are venules/arterioles. They branch into capillaries and meet eachother as the oxygen is absorbed into the cells

The lymphatic system intertwines w/ these capillaries, and absorbes anything thats left over/around. It drains waste from those cells that isnt put into the venules/capillaries

Question 23

Primary lymphedema
* % of cases?
* What causes it?

Answer 23

10% of cases

Due to congenital malformation or imparired lymphatics (so often seen at birth)

Question 24

Secondary lymphedema
* % of cases
* What causes it?

Answer 24

90% of cases

typically caused due to cancer
* this is because it occurs when those lymphocytes are damaged/removed
* Happens secondary to something else

Question 25

Fluid stagnation and edema =

Answer 25

lymphedema

Question 26

Lymphadema occurs because of wwhat two things?

Answer 26

1) Dynamic insufficiency
2) Mechanical unsufficency

Question 27

Explain Dynamic insufficency

Answer 27

Lymphatic loads exceeds transport capcity, usually temporary but causes edema over time due to damage

EX: think about I75, when theres traffic because theres too many cars on road
* theres an increase in fluid into the lymphatic system for whatever reason

Question 28

Explain Mechanical insufficiency

Answer 28

Transport capcity decreases, such as when axillary lymph nodes are removed

EX: Traffic because they’re doing repairs. Theres litteraly less lanes to move on
* typically due to some kind of damage

Question 29

chronic venous insuffiency leads to what kind of lymphatic insuffieicny?

Answer 29

Dynamic insuffieincy

We have so much fluid that our veins arent carrying out on their own and needs the lymphatic system to take over = increased traffic
* The lymphatic load exceeds transport capcity (because the veins arent removing the waste they need to)

Question 30

Removing a lymph node to biopsy leads to what kind of lymphatic insufficiency?

Answer 30

Mechanical insufficiency.
* Transport capcity decreases because the lymph nodes were removed = have to go to other lymph nodes = cant remove as much waste now

Question 31

Can you have both dynamic and mechanical lymphatic insuffiency at the same time

Answer 31

Yes

Think having cancer and chronic venous insuffiency

Question 32

This is a normal lymph node draining waste from cells

Answer 32

This is abnormal. The lymph node is being damaged by X-ray and removed due to cancer treatment (it caught the cancer cells)
* NOTE: this would be an example of a mechanical insuffiency

Question 33

Lymphadenectomy/radiation:
* Can the lymph node absorb as much fluid after the radiation?

Answer 33

Cannot absorb as much fluid
* so even if they didnt get them removed the lymph nodes can still be damaged by radiation

This causes lymphatic pressure to increase which causes the lymph to ooze into the wall of the lymphatics and into the perilympahatic tissues
* when someone has a ton of that lymphatic in the extremity (think massive swollen extermity) it can look like little sweat beeds seeping out

Question 34

what is lymphangiosclerosis?

Answer 34

Hardening of lymph nodes
* makes them not work well
* Can happen secondary to radation

Question 35

Most common cause of secondary lymphedema:
* In the world
* In the usa

Answer 35

World = filiariasis
USA = cancer related lymphedema

Question 36

What is filiariasis spread by? What is it?

Answer 36

Most common cause of secondary lymphdema in the world

Infection that attacks the lymphatic system

Spread by misquitos

Question 37

Lipedema/Lipolymphedema
* Disorder of what kind of tissue
* Men or women more
* Affects LE or UE?

Answer 37

Disorder of adipose tissue

Affects women more

People will have smaller upper half of body and lower half
* will often be told to lose weight, but no matter how hard they try they cant lose weight in their LE’s
* Ankles might be skinny but not uptop

Question 38

Is lymphedema painful?

Answer 38

No

However, it can impact functional mobility
* You’re carrying around a heavy load

Question 39

Lymphedema leads to Atrophic skin changes. how do these changes persent?

Answer 39

Persent as fibrosis (hardening)
* this is due to a buildup of that collagen - that is ebcause it is not fully removed from the site

This doesnt appear until stage 2

Question 40

S/S of lymphedema

Answer 40

1) Atrophic skin changes - fibrosis (hardening)
2) Heaviness in affected limb
3) Delayed wound healing - arent getting the nutritents in our out as effiectly
4) Lymphohrrea - clear fluid that weeps from skin
5) increased risk of infection, most commonly cellulitits
6) Positive Stemmer sign

Question 41

KNOW: cellulitis is closely associated w/ lymphodema
* fast growing infection

Question 42

What is a stemmer sign

Answer 42

This is pinching between toes and getting skin

pos = so much edema that you can’t get the skin

Question 43

KNOW: You’ll need to do imaging techniques if you plan on having surgery for the lymphodema

Lymphoscintigraphy: Popular choice. Inject a dye in and take an x-ray and see where the lymph is going and if its absorbed (able to trace the fluid an find an abnormal node / if the fluid isnt draining properly)

Answer 43

Lymphoscintigraphy

Question 44

This is showing those skin fibrotic changes that can occur w/ lymphodema

Question 45

NOTE: simmer sign would be positive for this patient (wouldnt be able to grab those the skin between toes)

NOTE: They have cellulitis (common infection w/ lymodema)
* typically leave markers to see if cellulitis is increasing (can spread rapidly)

Question 46

Stemmer sign has a
* Sensitivity = 92%
* Specificity = 57%

What would it mean if its positive? What about negative?

Answer 46

High specificity rules in w/ a positive test. However, even if they got a positive test that specificitry is pretty low so they may still not actaully have lymphodema
* May just have excess adipose tissue

Sensitivity is fairly high so if they got a negative Stemmer sign we could rule out lymphodema

Question 47

Risk factors for lymphodema: - you look for these when a pt comes in and its a possible case of lymphodema
1) Surgical lymph removal - increased risk w/ more lymph nodes removed - can occur at any time - can go 10 years w/o lymphodema then suddenly develop it
2) Radiation therapy - node fibrosis, decreased immune response, makes skin more vulnerable
3) Surgical complications - seromas and infections
4) Time since surgery - more time since surgery = increased risk over time
5) Increased BMI
6) Air travel - because of the pressure changes (wear compression garmets to decrease chance of DVT)
7) Inflammation
8) Decreased lymphatic return
9) Scar tissue formation - any surgerical procedures where they go in may cause swelling which will affect the lymph system
* can apply manual drainage techniques to something as simple as a total knee

Question 48

Some damage to lymphatics; no vidible edema yet - what stage of lymphedema?

Answer 48

Stage 0 or Latent
* NOTE: if you’ve had any kind of lymphnode biopsy / removal you are already this stage

Question 49

Edema that is spontaneously reversible, acute phase
* Has pitting edema; reversible w/ elevation of the arm. Usually, upon walking in the moring, the limb(s) or affected area is normal or almost normal size

What stage is this?

Answer 49

Stage 1

The key is that it can just go away

Question 50

Spontaneously irreversible, chronic phase
* Spongy consistency and is “non-putting edema (will just instantly bounce back because there is so much fluid”. Fibrosis found in this marks the beginning of the hardening of the limbs and increasing size, more at risk for cellulitis because of that fluid staying stagnent in the limb

What stage is this?

Answer 50

Stage 2

Note that fibrosis is a trophic change that occurs in stage 2

Question 51

Elephantiasis; irreversible, end-stage

Irreversible and usually the limb(s) is/are very large. The tissue is hard (fibrotic) and unresponsive; consider debulking surgery at this stage

What stage is this?

Answer 51

Stage 3

NOTE: debulking surgery has a long recovery. Litteraly need to cut all along skin. Need skin grafts post surgery.

Question 52

DASH/LEFS = functional outcome measure - can do this

Circumferential measures can be done

Goni measures - can keep track of that lack of ROM due swelling / stength because of heaviness of limb

Functional assessment

Stemmer sign

Question 53

What is unilateral Edema?

Answer 53

Swelling in 1 LE or swelling in 1 UE’

Should take circumferential measures to both sides. CM = most common

Question 54

If the pt has unilateral lymphedema the average difference in CM will tell you the severity. Describe:
* Mild:
* Moderate:
* Severe:

Answer 54

Mild - <3 cm difference side to side

Moderate - 3-5 cm difference

Severe >5 cm difference

Question 55

KNOW: Volumetric measurements can also be taken for lymphedema
* Measure fluid displaced

Question 56

I think we need special liscense of compression bandaging and compression garmets

Compression pumps - did in MSK

Question 57

Healthy habits for pts at risk for lymphedema

Question 58

Manual lymphatic drainage:

Go down to muscle, then lighten up slightly
* then pull from distal to proximal

However start proximal in your hand placement and move distal
* You want to clear out the blockage at the top first then move down (going to have to push w/ much more pressure if you start distal)

Question 59

Benefits to manual therapy for pts w/ lymphedema

Stimulates dorment lymphnodes

rerouts fluid (moves fluid somewhere else)
* All im doing is making it rerout around the traffic jam

Question 60

manual lymphatic drainage done by a CLT (special 9 day course)

MLD can be used on any kind of edema - EX: sprained ankle, TKA, plastic surgery

Main points:
* Diaphragmatic breathing
* Proximal lymph node stimulation and clearing
* Prximal to distal clear (still pushing distal to prox, just start more proximal and move distal) - get that lane back open from the front so everything else will flow
* KNOW: You’re pushing slowly because everytime your pushing it allows everythign to be opened up (stretch and hold)

KNOW: Its very important that a patient is taught self MLD and be an active participant in their treatment plan

Question 61

Which lymph node is at the diaphgram level?

Answer 61

Cysterna kyle - main lymph node
* every time we do diaphramatic breathing (working on that diaphgram) you are working that cysterna kyle - and in turn working those contractions and working that absoprtion)

Question 62

Compression:

Multilayer short stretch compression bandages for reduction phase -
* Stockinette, cotton padding, short stretch bandages, toe or finger gauze for digit swelling
* used only in the first two weeks - which is where you can get most of that reduction of the limb
* can change everyday or so, tighten up this as the limb shrinks
* These are short stretch - they work when you work - we want them to be able to move in them, so they should be using extremity

Reduction kits for lymphedema
* Alternative Velcro reduction kit
* Easier for patent and carefiver to don and doff

Compression garmets for maintence
* Comes in variety of forms, depending on edema need
* Standard and alternative velcro garmet

All of these wraps can be worn over wound care dressings
* be mindful of the dressing that you place underneath as these wraps can stay non for up to a week

ABI should be checked prior to any compression recommendations

anyone can order these, esoeccailly off the shelf garmets

Question 63

Venous leg uclers: 2 layer, 3 layer, and 4 layer wraps - which one they wear depends on the ABI
* Sold in kits
* Don’t need to know the ABI # that corresponds to how many layers
* Know: the increased # of layers = more compression

Question 64

Surgical interventions for lymphodema are called

Answer 64

Microsurgery
* Called this because:
* Picture a dime, then a pin prick, thats how big the capillaries are (and these are basically the size of capllaries) = why its called microsurgery

Branch off of plastic surgery
* Lymphaticovenular anastomosis - venous to lymph node transfer - drains to venous system directly (good for cancer releated)
* Vascularized lymph node transfer - transfer a lymph node from a working site to non working site (not optimal because we dont know how lymphedema works)
* Ablative procedures (cutting part of lymph system out in hope that it reroutes)
* Liposuction - more for lipoedma (adipose tissue disoreder - do liposuction to this area and wear compression garmets)
* Suction assisted Protein lipectomy - associated w/ lipodema

bulking surgery can also be done in extremem cases (think elphantitis)