Lymphedema Flashcards
1
Q
What are the 2 main functions of the lymphatic system?
A
- Regulate fluid balance
- Assist with infection control
2
Q
How many liters of fluids are removed from the interstitial space per day?
A
18 L
3
Q
Of the 18 liters removed, __-__% via the veins and __-__% via the superficial and deep lymphatic vessels. How many liters via the lympathics?
A
80-90
10-20 (2-4L)
4
Q
What occurs when the lymphatics cannot remove the remaining interstitial fluid?
A
Lymphedema
5
Q
__-__% of women with breast cancer will develop lymphedema
A
23-45
6
Q
__% of women with ovarian cancer will develop lymphedema
A
21
7
Q
__% of patients with endometrial cancer will develop lymphedema
A
28
8
Q
Up to __% of men with prostate cancer will develop lymphedema
A
70
9
Q
What are the chief complaints of lymphedema?
A
- limb heaviness
- paresthesias
- achiness
- skin tightness
- poor-fitting clothes
- altered cosmesis
- decreased ADLs
- reduced ROM
10
Q
The lymphatic system is composed of 2 interconnecting drainage systems, what are they?
A
superficial and deep lymphatics
11
Q
Describe the function and arrangement of the superficial lymphatics
A
Drains the skin and subcutaneous tissue
Roughly parallels the veins
12
Q
Describe the function of the deep lymphatics
A
drains everything else (deep tissues and organs)
13
Q
What connects the deep and superficial lymphatic systems?
A
perforating lymphatics
14
Q
What is lymph made of?
A
water, protein, dead/dying cells/cellular components, fatty acids, foreign material and debris
15
Q
Describe the path lymph takes as it exits the interstitial spaces to
A
Lymph capillaries –> Lymph precollectors –> Lymph collectors –> Lymph nodes –> Lymph trunks
16
Q
What is the functional unit of a lymph vessel that lies between two semilunar (half moon-shaped) valves?
A
Lymphangion
17
Q
How many lymphangions are there in a typical arm collector? In a leg collector?
A
60-80
80-100
18
Q
The total number of lymph nodes ranges from ___-___ with the majority located where?
A
600-700
mesentaries
19
Q
Describe the path lymph takes from the LEs and the genitals
A
Passes through the inguinal nodes into the left and right lumbar trunks before emptying into the centrally located thoracic duct, which terminates into the left venous angle (the internal jugular vein and the subclavian vein)
20
Q
Describe the path lymph takes from the LEFT upper extremity
A
Filters through the axillary lymph nodes before emptying into the subclavian vein
21
Q
Describe the path lymph takes from the RIGHT upper extremity
A
Empties into the right subclavian vein aka the right venous angle
22
Q
Lymphatic territories are areas of skin made up of several adjacent lymph collectors that drain into the same regional lymph nodes. These territories are separated by natural boundaries called what?
A
watersheds
23
Q
What pressures govern fluid movement between capillaries, interstitium, and lymphatic system?
A
hydrostatic and osmotic pressure
24
Q
What are the 5 ways in which lymph moves centrally in a healthy lymphatic system?
A
- skeletal muscle contractions
- respiratory pump
- pulsations of the aorta
- lymphangiomotoricity
25
What is Lymphangiomotoricity?
the contraction of the smooth muscle within the lymphagnions
26
Lymphangiomotoricity is the key to decreasing edema when?
overnight while the patients are recumbent
27
What are the 2 types/causes of lymphedema?
primary and secondary
28
Describe primary lymphedema
Congenital malformation or impairment of lymphatics
29
Primary lymphedema accounts for only __% of all cases
10
30
Primary lymphedema cases are usually described by what 2 things?
type of lymphatic vessel abnormality or the age of onset
31
What are the 4 types of vessel abnormalities that occur with primary lymphedema?
- Aplasia
- Hypoplasia
- Hyperplasia
- Lymph node fibrosis
32
Describe aplasia
Lack of lymphatic vessels in a body region therefore no lymphatic drainage in this area
33
Describe hypoplasia
Lymphatic vessels are narrower than normal leading to significantly less lymphatic drainage
34
Hypoplasia is comparable tow what?
arterial stenosis
35
Describe hyperplasia
Lymphatic vessels are wider than normal
36
Hyperplasia is comparable tow what?
varicose veins
37
Hyperplasia accounts for __% of all cases of primary lymphedema
15
38
Lymph node fibrosis is most commonly seen in what lymph nodes?
inguinal
39
Classify the following:
Congenital Lymphedema: __-__
Lymphedema Praecox: __-__
Lymphedema Tarda: __
birth to 1 year
1-35 years old
after 35 years old
40
Describe secondary lymphedema
Results form a disruption in, or damage to, the lymphatic system
41
What are 3 causes of secondary lymphedema?
- Filariasis
- Cancer treatment
- Chronic venous insufficiency
42
What causes filariasis?
the bite of a mosquito that is infected with a parasitic worm
43
In the US, secondary lymphedema is most often seen following what?
medical or surgical procedures that disrupt lymph flow
44
What can be defined as a bilateral, symmetrical increase in adipose tissue deposition?
Lipedema
45
Lipedema affects the abdomen, buttocks, lower extremities but spares what?
the feet
46
Increased compliance of fat associated with lipedema allows interstitial fluid to accumulate, leading to what?
lipolymphedema
47
What are 3 characteristics of lipolymphedema?
- painful
- bruise easily
- diet-resistant weight gain
48
What are the 9 risk factors contributing to lymphedema?
- lymph node status
- radiation therapy
- surgical complications
- time since surgery
- increased BMI
- air travel without compression
- inflammation/increased lymphatic load
- decreased lymphatic return
- individuals prone to scar tissue formation
49
What is a sentinel lymph node biopsy?
A biopsy that removes only the first lymph node receiving lymph from the tumor
50
What 2 things does radiation therapy lead to?
Perilymphatic and lymph node fibrosis
51
What type of skin changes occur with radiation therapy?
- Sclerosis/fibrosis
- Dermal atrophy
- Decreased sweat glands
52
__% of breast cancer patients who had lumpectomy and axillary radiation developed lymphedema
26
53
The risk of lymphedema increases as the time since surgery _____.
increases
54
Why does the risk of lymphedema increase as time after surgery increases?
Possibly due to lymphatic fatigue
55
Why does the risk of lymphedema increase with air travel?
There is decreased atmospheric pressure on the body while flying which allows the body to swell
56
It is recommended that individuals at risk for lymphedema wear compression, greater than __ mm Hg for an UE and greater than __ mm Hg for a LE, while flying.
20
30
57
Why are patients instructed to avoid strenuous activity of at-risk limbs?
It may cause muscle microtrauma and inflammation, which leads to increased fluid that the patient’s lymph system may not be able to accommodate
58
What are some things that may cause decreased lymphatic return?
- clothing
- jewelry
- tourniquets
- BP cuffs
59
Why are patients prone to excessive scar tissue formation (keloids) at risk for lymphedema?
The trauma of surgical lymph node removal can be exacerbated by an abdominal increase in collagen deposition post-surgery
60
What are 4 tests and measures PTs must perform on a patient with suspected lymphedema?
- Circumferential Measurements
- Body Mass Index
- Circulation
- Sensory Integrity
61
What is the gold standard for measuring limb circumferentially?
volumetric displacement
62
True or False
You can measure a limb every 3, 4, 8, or 12 cm without it significantly effecting limb volume calculations
True
63
How is BMI calculated in the US?
BMI = weight in pounds x 703 / height in inches squared
64
Classify the following:
```
Underweight: less than __
Normal weight: __-__
Overweight: __-__
Obese Class I: __-__
Obese Class II: __-__
Obese Class III: greater than __
```
18. 5
18. 5-24.9
25-29.9
30-34.9
35-39.9
40
65
What are 3 circulation tests a clinician must perform in patients with LE lymphedema?
- Doppler US
- capillary refill
- ABI
66
True or False
Monofilament testing must be performed on all patients with lymphedema
True
67
Nerve entrapments (carpal/tarsal tunnel, etc.) associated with lymphedema can lead to what?
tissue distention, edema, and inflammation
68
What lymphedema patient population is at risk for neuropathy?
- Those with diabetes
| - Those who received chemotherapy
69
Lymphedema falls under what Cardiovascular/Pulmonary Practice Pattern?
6H
70
How many stages of lymphedema are there?
4 (0-3)
71
What is the descriptor for stage 0 lymphedema?
latent
72
What are the characteristics of stage 0 lymphedema?
- No edema present
- Reduced lymph system transport capacity
- Most commonly due to radiation or surgery
73
What is the descriptor for stage 1 lymphedema?
Reversible
74
What are the characteristics of stage 1 lymphedema?
- Pitting edema
- Greatly or completely reduces with elevation
- No secondary skin changes
75
What is the descriptor for stage 2 lymphedema?
Spontaneously irreversible
76
What are the characteristics of stage 2 lymphedema?
- Does not pit
- Does not substantially reduce with elevation
- Skin becomes brawny and fibrotic
- May have frequent skin infections
77
What is the descriptor for stage 3 lymphedema?
Lymphostatic elephantiasis
78
What are the characteristics of stage 3 lymphedema?
- Extreme increase in limb volume
- Deep skin folds
- Papillomas present
- Frequent skin infections
79
Mild Lymphedema = less than _ cm interlimb difference or less than __% limb volume increase
3
20
80
Moderate Lymphedema = between _-_ cm interlimb difference or between __-__% limb volume increase
3-5
20-40
81
Severe Lymphedema = greater than _ cm interlimb difference or greater than __% limb volume increase
5
40
82
Pain associated with lymphedema is typically described as what?
- deep ache or pressure sensation
- stretching type pain
- neuropathic pain
- discomfort or heaviness
83
Secondary lymphedema occurs ____ to the area of lymphatic obstruction or damage
distal
84
What is Lymphorrhea?
weeping
85
What type of drainage is most common in lymphedema?
serous
86
True or False
Copious wound drainage is the norm and wound beds are commonly covered with slough
True
87
What are 12 integumentary changes commonly seen in patients with lymphedema?
- xerosis
- hyperkeratosis
- fibrosis
- hair loss
- deep skin folds
- lichenification
- lipodermatosclerosis
- papillomas
- lymphorrhea
- vesicle of blister formation
- dermatitis
- ulceration
- infection
88
Thickening of the dorsal aspect of the digits may result in a positive ______ sign
Stemmer's
89
What is papillomatosis?
cobble-stone-like appearance of the epithelium
90
Are pulses typically normal or affected in patients with lymphedema?
normal
91
Is temperature generally affected in patients with lymphedema?
No, however it may be warm to the touch due to edema, inflammation, or infection
92
It has been determined that mild lymphedema will require _-__ visits. Whereas moderate lymphedema will require __-__ visits.
5-10
14-24
93
Generally one can expect a __-__% volume decrease within 6-36 visits
22-73
94
What are 5 things to instruct patients to do?
- protect from injury
- perform regular skin checks
- treat open areas
- weight management
- exercise
- utilize garments
95
What are 5 things to instruct patients not to do?
- get injections, piercings, or tattoos in affected area
- have BP taken in affected extremity
- avoid hot tubs/saunas
- do not walk barefoot
96
What are 3 things to be cautious of in patients with lymphedema?
- ensure cancer is not the cause of recurrent lymphedema
- refer spontaneous lymphedema to MD
- beware of patients with history of arterial insufficiency or DVT
97
Under what 3 circumstances should you request for further medical testing?
- signs and symptoms of infection
- to rule out recurrence
- if you cannot perform an ABI
98
What skin care suggestions should you advise a patient with lymphedema?
- keep the skin clean and dry
- avoid perfumes and high-alkaline soaps
- use low pH moisturizers
- keep open wounds clean and apply an antimicrobial over top
99
Who are the 4 leaders in the field of manual techniques for lymphatic drainage?
- Casley-Smith
- Foldi
- Leduc
- Vodder
100
What are 8 benefits of manual therapy?
- increase lymph formation
- propels lymph proximally
- increases lymph angiomotoricity
- reroutes stagnated lymph
- encourages development of collaterals
- reduces sympathetic and increases parasympathetic responses
- decreases pain/promotes relaxation
- decreases fibrosis
101
What are 7 precautions/contraindications of manual therapy?
- DVT
- active infection
- open wound
- metastatic disease
- CHF
- asthma
- abdominal inflammatory conditions (IBS, etc.) or currently pregnant
102
Describe the general process for manual therapy
Clear the proximal lymph system before moving distally. First at the venous angles of the neck then to the trunk, and then the affected extremity
103
What are 5 proposed benefits of compression therapy?
- Reduces ultrafiltration
- Enhances venous return
- Improves effectiveness of muscle pump
- Increases angiomotoricity
- May reduce fibrosis
104
What are 7 Precautions/Contraindications for Compression Bandaging?
- arterial insufficiency
- radiation damage with intact skin
- CHF
- DVT
- open wounds
- infection
- patients who are weak, immobile, insensate
105
What type of compression garment is used during high-risk activities?
Prophylactic
106
Use a __-__ mm Hg or light compression garment on patients with mild lymphedema or for a prophylactic UE
10-21
107
Use a __-__ mm Hg or medium compression garment on patients with moderate to severe UE lymphedema or for mild LE lymphedema
15-32
108
Use a __-__ mm Hg or strong compression garment on patients with moderate to severe LE lymphedema
30-40
109
Use a very strong compression garment with greater than __ mm Hg compression on patients with stage 3 LE lymphedema
40
110
Describe how compression pumps work and why they cannot be used on their own?
They remove the fluid from the area, but not protein. So once they are stopped the protein draws the fluid back into the area or the residual protein may lead to fibrosis
111
What are the 2 phases of intervention?
- intensive
| - self-management
112
Describe the difference of short and long term compression therapy
- Multilayer compression bandage short term
| - Compression garments long term
