Lymphedema Flashcards
What is lymphedema?
Swelling that occurs when PROTEIN-rich lymph fluid accumulates in the interstitial tissue
Stagnant lymph fluid causes swelling of the affected tissues
What is lymph responsible for?
Transporting essential immune chemicals and cells
Where is lymphedema typically found?
Usually in an extremity, but can also occur in the head, neck, genitals, and abdomen
What is PRIMARY lymphedema?
Abnormality of lymphatic system is present at birth
Swelling may be present at birth or develop later in life
What is SECONDARY lymphedema?
Occurs from damage to the lymphatic system
- Cancer treatments
- Burns
- Infections
- Progression of venous insufficiency
What is the prevalence of lymphedema?
Affects nearly 1% of the american population (2.5 million people)
Poorly understood in the medical community and often goes undiagnosed
Largest cause is Filariasis
- Parasitic infiltration into the lymphatics that is very common in third would countries
Secondary lymphedema affects 15-20% of women receiving axillary dissection and/or radiation
- 80% of patients experience onset within 3 years of surgery
Upper extremity lymphedema often occurs after what?
Breast cancer
Lower extremity lymphedema often occurs after what?
Uterine cancer
Prostate cancer
Lymphoma
Melanoma
Women after gynecological cancer (36% in vulvar cancers)
What are some characteristics of the lymphatic system?
Consists of the initial lymphatics, the lymphatic precollectors, the lymphatic ducts, and the lymph nodes
Lymphatic system filters and collects lymph and large molecules in the interstitial space that come from the intravascular space
The interstitial fluid contains proteins, lipids, water, and products from cellular breakdown
Lymphatic vessels are similar to veins, but with thinner walls to allow large proteins to permeate through
The lymph system carries the lymphocytes throughout the body to respond to antigens and communicate responses to other parts of the body
A healthy adult has how many lymph nodes?
600-700
What are some risk factors for lymphedema?
Obesity
Extent of surgery
Local radiation
Delayed wound healing
Tumor causing lymphatic obstruction
Scarring
How do you diagnose lymphedema?
History and physical examination
Soft tissue imaging
Lymphoscintigraphy
Measures of limb volume
Changes in biomechanical properties
Genetic testing
Vascular imaging
What are some aspects of the history taken which may point to lymphedema?
What is the reason for the swelling?
How long has the swelling been present?
How fast did the edema progress?
What are the underlying diseases?
Does the patient have pain?
Medications?
Surgical history?
What portions of the physical examination are important for lymphedema?
Observation of edema
Palpation of tissue
Skin changes
Scars, papilomas, hyperkeratosis
Temperature of skin
Pitting
Stemmer’s sign
- (+) when a thickened cutaneous fold of skin at dorsum of 2nd toe or finger cannot be lifted or is difficult to lift. A positive stemmer’s sign is indicative of lymphedema
What are the stages of lymphedema and each’s characteristics?
STAGE 0: Non-visible, latency
STAGE 1: Spontaneously reversible
- Puffy appearance of hand or foot
- Pitting edema present
- Elevation may temporarily relieve edema
STAGE 2: Spontaneously irreversible
- Spongy consistency of the skin
- Pitting is not as present during this stage
- Limb does not respond to elevation
STAGE 3: Lymphostatic Elephantiasis
- Dry, scaly skin; limb becomes very large
- Fluid leakage from skin may be present and skin infections are more common
What is the differential diagnosis for lymphedema?
Lipidema–bilateral, Stemmer’s sign negative, no pitting, and painful
Chronic venous insufficiency–Brawny and hemosiderin staining
Acute DVT–sudden onset, unilateral, and painful
Cardiac edema–bilateral, greatest edema is distal, pitting, and resolves with elevation
Congestive heart failure
Malignancy/active cancer–pain, paresthesia, and a rapid development
What are the components of treatment for COMPLETE DECONGESTIVE THERAPY (CDT) associated with lymphedema?
(Pneumatic compression pumps are also used to tx)
Manual lymph drainage (MLD)
Multi-layer, short stretch bandaging
Lymphatic exercise
Skin care
Education in lymphedema self-management and compression garments
What is Manual Lymph Drainage?
Specialized, hands-on technique that stimulates superficial lymphatic vessels to remove excess interstitial fluid
- Moves it through the subepidermal fluid channels that form when lymphatics are damaged
(Very light pressure with hands because these channels are so superficial)
Goal is to move fluid build-up from congested area where lymphatics are not working into the lymph vessels and lymph nodes that are functioning correctly
What are some other methods of encouraging lymph return?
Multilayer bandaging
Compression pumps
What are ways to prevent lymphedema?
No needle sticks or blood pressures in affected limb
Good skin care and cuticle care
Avoid cuts, scrapes, and bruises
Avoid extreme temperatures and sun burns
If flying, it is recommended to wear a compression sleeve
Activity modifications
For upper extremity, avoid repetitive motions
What is the clinical relevance of lymphedema?
Lymphedema education can be gained through continuing education courses
Training schools include Norton, Klose, ACOLS, etc.
Treatment is billed as manual therapy
Insurance typically covers treatment
Medicare does not cover cost of compression garments
Common ICD-10 codes used are 189.0 and 197.2
What is a basic review of lymphedema?
Lymphedema is a disease process
All other edemas are symptoms
There is no cure for lymphedema, only management options
Risk is life-long…it can present soon after surgery or radiation or many years down the road
