Lymphedema Flashcards
What are the 4 stages of Lymphedema?
0) Pre-Stage (sub-clinical, latency stage)
1)Reversible Lymphedema
2)Spontaneously (Chronic) Irreversible
3) Lymphostatic Elephantiasis
Characteristic of Transport Capacity in Stage 0
Subnormal but still greater than lymphatic load and sufficient to manage normal loads. Functional reserve is reduced/limited.
Anyone who has had surgery or trauma involving the lymphatic system and does not develop visible lymphedema is considered to be in what stage?
Stage 0 (latency stage)
58% of post-mastectomy women
Malformation or Dysplasia of the lymphatic system is called _____.
Lymphagiopathy
What type of malformations are there in the lymphatic system? (4)
1) Hypoplasia (lack of cells)
2) Hyperplasia (increase in cells)
3) Aplasia (not developed)
4) Inguinal Lymph Node Fibrosis
Most common type of Dysplasia (85%)
Fewer and smaller diameter Collectors
Both Upper and Lower extremities (more common in lower)
Hypoplasia
Dysplasia that has collectors with larger diameters due to insufficient valvular system. Transport capacity is compromised leaving to retrograde flow of lymph.
Hyperplasia (megalymphatics)
Dysplasia with absence of lymphatic capillaries/nodes in certain areas of the body. Dorsum of the foot is the most common area.
Aplasia
Dysplasia that affects the lymph transport in the afferent lymph collectors, is fibrosis of the capsular and trabeculae are of lymph nodes.
Inguinal Node Fibrosis
AKA Kinmonth Syndrome
Characteristics of Stage 1 Lymphedema (5)
1) Possible to completely remove swelling.
2) No fibrotic tissue (pitting easily induced)
3) No secondary skin changes
4) No papillomas (benign skin tumors)
5) May recede overnight (early stage 1)
Stage 2 lymphedema is primarily defined by what?
Degree of Lymphostatic Fibrosis
Long-standing accumulation of protein-rich fluid causes …. (3)
1) Tissue proliferation and subsequent fibrosis
2) Limb volume and skin folds increase
3) Weakened immune defense and frequent infections
Stemmer Sign is positive if …..
the skin on the dorsum of the fingers and toes cannot be lifted.
Why does compression therapy assist with reducing fibrosis in stage 2?
Constant compression has a fibrinolytic effect.
Stage 2 - late stage charactersistic include ….. (4)
- proliferation of connective tissue
- production of collagen fibers
- increase in fatty deposits
- fibrotic changes
Stage III characteristics (3)
- Secondary skin changes (fungus, ulcers, cysts, fistulas, papillomas)
- frequent infections/cellulitis
- lymphorrhea (lymph fluid leaking on the skin)
Stage III can have an overgrowth of skin that appears like thick callus called ….
Hyperkeratosis
Stage III can have raised wart-like growths that often require surgical removal called…..
Papillomas
A Pediatric Lymphedema that occurs at (<2yr) , has a associated family history and typically involves lower extremities.
Milroy’s Disease
Primary lymphedema that occurs after birth but before the age of 35 (generally onset in adolescence).
Meige’s Disease
Pediatric Manual Lymph Drainage Considerations
- treat at least 1x/day (best when asleep)
- soft stationary circles and pump techniques best
- NO abdominal techniques
Pediatric Compression Therapy Considerations
- difficult with infants
- careful application (not able to provide feedback)
- must not interfere with growth
- should not restrict the ability to walk
Pediatric Compression-Specific Guidelines
- small bandages only
- need to be reapplied several times per day
- compression garments not for <1yr
- 20-30 mm/Hg should not be exceeded
Primary Lymphedema disease that includes a triad of port-wine stain, varicose veins and bony/soft tissue hypertrophy involving an extremity.
Klippel-Trenaunay-Weber Syndrome (KTWS)
Lymphatic filariasis is caused by ……
parasitic filarial worms which proliferate in the lymphatic system.
Develops from a mechanical insufficiency of the lymphatic system as a result of tissue lesions.
Post-Traumatic secondary lyphedema
Secondary lymphedema inflammation characteristics.
- sudden onset
- high-grade fever/chills
- general malaise
- streptococcal cellulitis
Secondary lymphedema inflammation in the lymph nodes
Lymphadenitis
Secondary lymphedema inflammation in the collectors.
Lymphangitis
What causes the damage in Lymphatic filariasis?
- worms feed on protein
- excrements damage lymphatics (lymphangitis)
- do not usually cross lymph nodes
Causes inflammation of lymph vessels primarily found in developing nations by entering cracks in the soles of feet.
Silica Dust
Why does trauma to the lower limbs especially ankle fracture cause secondary lymphedema?
Combination of the loss of the ankle and calf muscle pump and onset of chronic venous insufficiency.
Self Induced lymphedema causes fluid build-up because …..
- a tourniquet creates a fibrotic ring
- resistant to treatment often requires casting
Type of malignant lymphedema caused by an impaired lymph node due to tumour infiltration and/or blockage.
Lymphangiosis
Malignancy in which the blood capillary endothelial cells transform into a sarcoma cell.
Angiosarcoma or Stewart-Treves Syndrome
Characteristics of Steward-Treves Syndrome
- reddish/blackish lumps that increase in size
- ulcerate at an early stage
- often develop in untreated lymphedema
- highly malignant but rare
Cancer from lymphocytes that block lymph nodes and spread from one lymph node group to another.
Hodgkin’s lymphoma
Why is it important to obtain MD referrals for palliative patients for MLD/CDT with active cancer?
It was previously thought that these therapies could promote metastasis of the cancer. New research has shown otherwise.
Define benign lymphedema.
Lymphedema that develops following successful cancer treatment.
Term for secondary lymphedema due to valvular insufficiency of lymph collectors.
Lymphedema with Reflux
A pouch derived from a capillary or collector filled with lymph.
Cysts
Chylous cyst characteristics.
- contains fat (chyle)
- milky colour
- not possible about the horizontal watershed
- valvular failure at least to the cisterna chyli
Non-chylous Cysts characteristics.
- clear lymph fluid
- no fat
- found above and below the naval line (horizontal watershed)
Common place for cyst development.
Favour low-skin turgor
- web spaces
- antecubital /popliteal fossa
- axilla
- genital area
Why is Lymphedema and Chronic Venous Insufficiency (combination lymphedema) difficult to treat?
- ulcers
- thrombus
- fragile skin
- varicosities
Why is Lymphedema and Dibetes (combination lymphedema) difficult to treat?
- frequent wounds/infections
- impaired wound healing
- padding with bandaging
- compression of garments
Why is Lymphedema and CHF (combination lymphedema) difficult to treat?
- will move fluid into the circulatory system
- lower extremities - 70-80% of venous return
- compression may be contraindicated
The average length of treatment for uncomplicated upper and lower lymphedema.
Upper - 2 to 3 weeks (10 treatments)
Lower - 3 to 4 weeks (15 treatments)
What is the goal of complete decongestive therapy?
Reduce the size to normal or near normal bringing the lymphedema into the latency or 0 Stage.
Which diagnostic test uses a radioactive tracer injected intra/subdermally and considered the best method of functional evaluation of the lymphatic system?
Isotopic Lymphoscintigraphy
What type of diagnostic imaging may be used to monitor responses to therapy in lymphedema?
CT scans as they provide serial measurements of a cross-sectional area and tissue density.
Which type of diagnostic imaging is helpful in the identification of lymph nodes, enlarged trunks and differentiation of cause for lymphatic obstruction?
MRI
Why is direct lymphography not used frequently and if it is used, when?
Due to the risk of allergic and inflammatory reactions to the lymph system.
Used when patients are being considered for lymphatic surgery.
A diagnostic imaging technique that uses water-soluble iodinated contrast media infused intradermally to visualize local skin lymphatics and lymphatic trunks.
Indirect lymphangiography
A complementary tool for the non-invasive evaluation of swollen extremities. Thickening of cutaneous, epifascial and subfascial compartments can be observed.
Ultrasonography
Absolute contraindications for Complete Decongestive Therapy. (5)
1) Cellulitis/Acute infection
2) Renal Failure
3) Cardiac Edema
4) Acute DVT (pain with ambulation/coughing)
5) Acute bronchitis
Why is acute bronchitis an absolute contraindication for CDT?
Bronchi musculature are innervated by parasympathetic (ANS) and CRT can cause further bronchial spasms.
What are signs that cardiac edema is present a significant concern causing an absolute contraindication?
Severe congestive heart failure, no medication, unable to tolerate even short walks (SOB) and severe hypertension.
What are some examples of relative contraindications?
- Malignancies
- Bronchial Asthma (use inhalers, slow increase in time)
- history of hypertension (controlled)
Absolute Contraindications for Neck CDT. (5)
- Carotid Edoarterectomy
- hyperthyroidism
- carotid-sinus syndrome (can cause BP changes)
- history of CVA (cardiac arrhythmia)
- > 60yr old
Absolute contraindications for abdominal CDT. (13)
- Pregnacy
- CHF
- Dysmenorrhea
- Illeus (blockage of intestines, paralyzed intestine)
- Diverticulosis/litis (weakening or cysts of intestinal walls)
- <12yr old
- Aortic Aneurysm
- Inflammatory conditions (Crohn’s disease, colitis)
- Abdominal surgery (<1yr)
- Radiation fibrosis/cystitis
- Undiagnosed pain
- Post DVT
- Menstrual period
Absolute contraindications for compression therapy.
- Cardiac edema
- Arterial disease (PAD,Raynaud’s)
- Spasticity (Golgi Tendon Reflex)
- Acute Infections
Compression Relative Contraindications. (7)
- Hypertension
- cardiac arrhythmias
- paresis/paralysis/decreased sensation
- age
- malignant lymphedema
- CHF
- Reflex sympathetic dystrophy/complex regional pain syndrome.
When can compression therapy be considered with CHF?
- no acute pulmonary edema
- once cardio stimulatory medications/diuretics started