Lecture 13: Lymphedema: Physical Therapy Treatment and Management Flashcards
What are the 3 key functions of the lymphatic system?
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
What occurs when there is an imbalance of fluid uptake between the interstitium and lymphatic system?
Lymphedema
KNOW: It affects both men and women equally
Where in the body is Lymphedema primarily seen?
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)
Chronic venous insufficency + Lymphedema =
Phlebolymphedema
* Its when the both occur at the same time
KNOW: There is a close occurance w/ lymphedema and wounds
KNOW: Lymphatic system is divided into superficial and deel lymphatics
What are lymph organs?
1) Lymph nodes
2) Lymph vessels
3) Circulating lymph fluid
What connects to lymph vessels to form drainage system
Lymphatic capillaries
Lymphcapilaries
* Large or small
* Permable or inpermiable?
Large
Permeable
What is fluid absorbed into the lymphatic system called?
Lymph
Know these exist
Clear and contains the lymphatic load
Lymph fluid
Is the lymphatic system part of your immune system?
* why is it closely associated w/ cancer
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.
Explain the Flow of lymph
Lymph capillaries –> Precollectors –> lymph collectors –> Lymph nodes –> thoracic duct or right lymphatic duct –> venous system
NOTE: each node has its own pumping system
What does the Right thoracic duct collect?
What about the thoracic duct
R thoracic duct doesnt collect much, really just that R UE. Mostly collected by the thoracic duct
What are Lymph angions
* How often do they occur?
Autonomic (automatic) contractions
Occur 10-12 times per minute
What are lymphangiomotoricity
The rate at which lymph vessels contract and transport lymph fluid
What drains regional lymph nodes?
Lymphatic territories
What allows drainage from on territory to another (of lymph nodes)
Anastomses
* these are those connecting vessels
* Cross connection between adjacent
What vertebral level is the thraocic duct located?
* Where does it drain lymph fluid to?
Located at T11-L2
Drains lymph fluid to left venous angle
How much of the fluid from the body does the right lymphatic duct drain?
* What drains the other part?
only 1/4
Note: the thoracic duct drains the other part
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
Primary lymphedema
* % of cases?
* What causes it?
10% of cases
Due to congenital malformation or imparired lymphatics (so often seen at birth)
Secondary lymphedema
* % of cases
* What causes it?
90% of cases
typically caused due to cancer
* this is because it occurs when those lymphocytes are damaged/removed
* Happens secondary to something else
Fluid stagnation and edema =
lymphedema
Lymphadema occurs because of wwhat two things?
1) Dynamic insufficiency
2) Mechanical unsufficency
Explain Dynamic insufficency
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
Explain Mechanical insufficiency
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
chronic venous insuffiency leads to what kind of lymphatic insuffieicny?
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)
Removing a lymph node to biopsy leads to what kind of lymphatic insufficiency?
Mechanical insufficiency.
* Transport capcity decreases because the lymph nodes were removed = have to go to other lymph nodes = cant remove as much waste now
Can you have both dynamic and mechanical lymphatic insuffiency at the same time
Yes
Think having cancer and chronic venous insuffiency
This is a normal lymph node draining waste from cells
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
Lymphadenectomy/radiation:
* Can the lymph node absorb as much fluid after the radiation?
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
what is lymphangiosclerosis?
Hardening of lymph nodes
* makes them not work well
* Can happen secondary to radation
Most common cause of secondary lymphedema:
* In the world
* In the usa
World = filiariasis
USA = cancer related lymphedema
What is filiariasis spread by? What is it?
Most common cause of secondary lymphdema in the world
Infection that attacks the lymphatic system
Spread by misquitos
Lipedema/Lipolymphedema
* Disorder of what kind of tissue
* Men or women more
* Affects LE or UE?
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
Is lymphedema painful?
No
However, it can impact functional mobility
* You’re carrying around a heavy load
Lymphedema leads to Atrophic skin changes. how do these changes persent?
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
S/S of lymphedema
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
KNOW: cellulitis is closely associated w/ lymphodema
* fast growing infection
What is a stemmer sign
This is pinching between toes and getting skin
pos = so much edema that you can’t get the skin
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)
Lymphoscintigraphy
This is showing those skin fibrotic changes that can occur w/ lymphodema
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)
Stemmer sign has a
* Sensitivity = 92%
* Specificity = 57%
What would it mean if its positive? What about negative?
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
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
Some damage to lymphatics; no vidible edema yet - what stage of lymphedema?
Stage 0 or Latent
* NOTE: if you’ve had any kind of lymphnode biopsy / removal you are already this stage
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?
Stage 1
The key is that it can just go away
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?
Stage 2
Note that fibrosis is a trophic change that occurs in stage 2
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?
Stage 3
NOTE: debulking surgery has a long recovery. Litteraly need to cut all along skin. Need skin grafts post surgery.
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
What is unilateral Edema?
Swelling in 1 LE or swelling in 1 UE’
Should take circumferential measures to both sides. CM = most common
If the pt has unilateral lymphedema the average difference in CM will tell you the severity. Describe:
* Mild:
* Moderate:
* Severe:
Mild - <3 cm difference side to side
Moderate - 3-5 cm difference
Severe >5 cm difference
KNOW: Volumetric measurements can also be taken for lymphedema
* Measure fluid displaced
I think we need special liscense of compression bandaging and compression garmets
Compression pumps - did in MSK
Healthy habits for pts at risk for lymphedema
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)
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
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
Which lymph node is at the diaphgram level?
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)
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
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
Surgical interventions for lymphodema are called
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)
