Lymphedema Flashcards
What compromises the lymphatic system?
Lymphatic organs:
- Lymph nodes (600-700 in the body): filtering stations that produce WBC and regulate proteins in the lymph
- Lymph vessels: provide intrinsic contractions 6-10x/minute
- Thymus gland
- Spleen
- Tonsils
- Peyer’s patches
Approximately how many lymph nodes are located in the axillary area?
30-40 lymph nodes
What comprises lymphatic vessels?
- Capillaries
- Pre-collectors
- Collectors
- Trunks
Vessels are all different sizes and carry the lymph differently
What are mechanisms of lymph transportation?
- Intrinsic contraction
- Respiration
- Arterial/venous pulsation
- Skeletal movement
- New lymph creates pressure
Where is 3/4 of the body’s lymph drained?
- Into the left side of the thoracic duct
Which direction to lymph valves go?
- Only one way
- Lymph nodes affect the front and back of the body
What makes up lymph fluid?
- Proteins: 75-100 g of proteins are transported by the lymph vessels per day
- Water
- Cells: RBC, WBC, lymphocytes
- Waste products and other foreign substances
- Fat (instestinal lymph, chyle)
How many liters of lymph does the body transport in one day?
- 2-2.5 L/day
How does fluid move from place to place?
- Through pressure gradients
- Diffusion: movement of fluid from high concentration to low concentration
- Osmosis: passage of fluid through semipermeable membrane
- Ultrafiltration: mechanical pressure separates water from protein and pushes water through membrane
Filtration = resorption and lymph flow
What are physiological factors to consider when treating someone with lymphedema?
- Lymphatic Load (LL): how much water, proteins, cells, etc. normally need to move
- Lymph Time Volume (LTV): amplitude and frequency of intrinsic contractions = lymph load
- Transport Capacity (TC) = Max LTV or 10x LL intact system
- Functional Reserve (FR): difference between TC and LL
What is considered normal in the lymphatic system?
- LL (lymphatic load) < TC (transport capacity)
What is dynamic insufficiency?
- The lymphatic system is overloaded: venous insufficiency, cardiac edema, DVT, etc.
- The lymphatic system is still able to move most proteins after swelling
- LL (lymphatic load) > TC (total capacity)
What is mechanical insufficiency?
- TC (total capacity) = LTV (lymph time volume) and LL (lymphatic load is greater than both)
- Lymphedema always includes mechanical insufficiency
- May be due to surgery, trauma, radiation, etc.
- Body is not capable of moving proteins out
What is combined insufficiency?
- Lymphatic load is high and system is damaged
- May be due to obesity, CVI, lipedema
What is the definition of lymphedema?
- An abnormal collection of protein-rich fluid in the interstitium, which causes chronic inflammation and reactive fibrosis of the affected tissues
- The lymph load (LL) exceeds the total capacity of the system
- Can occur anywhere in the body
What is the prognosis for lymphedema?
- There is no cure
- Early detection and management, and patient ability to self-manage yields a good prognosis
- If left untreated, or if poorly managed, then elaphantiasis will occur
What are risk factors for developing lymphedema?
- Axillary, inguinal, etc. surgery
- Radiation
- Partial or total mastectomy
- Node dissection
- Obesity/overweight: less space for lymphatic vessels and they collapse
- Lipedema
- History of infection in at-risk limb
- Constriction
- Tumor causing lymphatic obstruction
- Scarring lymphatic ducts by either surgery or radiation
- Intra-pelvic or intra-abdominal tumors
- Chronic venous insufficiency
- Draining complications
- Burns create compression from scarring so lymphedema is not typically seen in people with burns
- *Tourniquets can damage lymphatic vessels and create lymphedema distal to tourniquet
What are primary causes of lymphedema?
- Mechanical insufficiency of the lymphatic system
- Malformation of lymphatic vessels
- Congenital or hereditary
What are secondary causes of lymphedema?
- Surgery
- Radiation
- Trauma
- Filariasis (parasitic infection)
- Cancer/tumor
- Infection
- Obesity
- Self-induced
What are early signs and symptoms of lymphedema?
- Limb feels heavy
- Skin feels tight
- Limb is achy but not painful
- Clothing or jewelry becomes tight
- Wrinkles in skin are not present
- Fatigue
*There is typically a 30% increase in lymph volume before it is detectable by the human eye
What are the different stages of lymphedema?
- Latency: no visible/palpable edema, subjective complaints possible (heavy and feels tired)
- Stage 1: reversible (elevation), pitting edema often present, increased limb girth and heaviness, no fibrosis. Or edema goes away while sleeping. No skin changes but there may be some pitting
- Stage 2: consistent swelling, does not change with elevation, spongy tissue feeling and often fibrotic changes, pitting becomes progressively more difficult
- Stage 3: lymphostatic elephantiasis, non-pitting, fibrosis, and sclerosis, skin changes (hyperkeratosis)
What are characteristic skin changes that occur with lymphedema?
- Hyperkeratosis
- Lichenification (leathery and hard)
- Peau d’orange texture: can see hair follicles and looks like the peel of an orange. Can be a problem because it may indicate cancer reoccurrence or infection
- Ulcers: may be more common with arterial, neutrotrophic, venous, or traumatic conditions
- Vesicles (cysts or blisters)
- Lymphorea: “weeping”, fluid leaks out of skin and can become stuck to skin - looks yellow
What are complications of lymphedema?
- Infection: a medical emergency (cellulitis, dermatitis, lymphangitis, etc.)
- Reflux
- Lymphorea
*It is important to educate pts with lymphedema that they are at an increased risk of infection
What are lymphedema medical diagnostics and management?
- Medications: no evidence of medication aiding treatment
- Surgeries: currently, there are no surgeries to cure lymphedema. There are lymph node transplants and there used to be debulking (very dangerous and intense)
Tests and Measures:
- Lymphoscintoigraphy: nuclear imaging method, tissue injection is transported by lymphatic system and allows assessment of superficial and deep lymphatics, no damage to lymph vessels
- Venography and Doppler US: to rule out venous problems/DVT
- Lymphedema is normally determined by clinical diagnosis
*Diuretics can cause fibrosis
What questions are asked during an examination?
- What is the reason for the swelling? What medications do you take? Have you had any surgeries?
- How quickly did the swelling develop/progress?
- How long have you had the swelling?
- Does the swelling decrease at night?/
- What are you doing to help the swelling?
- Do you have any pain? (prob not due to lymphedema but may be sign of trauma, malignancy, infection, complex regional pain syndrome, etc.)
*Pts might need clearance from nephrologist or cardiologist
What tests are done during a lymphedema examination?
- Inspection: location, skin, signs of lymphorea, wounds, scars
- Palpation: temperature - is there an infection; what is the density; is there dryness?
- Stemmer’s Sign: thickening of skin on the dorsal hand/fotts; inability to pinch skin these areas
- Measurements: taken every 4 cm. Truncated cone formula to determine volume of limb which is not detected clinically until interstitial fluid reaches more than 30% above normal level. Bioimpedance if available
- MMT/ROM/Nerve mobility/Muscle length/Function/Etc.
- Home assistance/Financial resources
What is CDT?
Complete Decongestive Therapy:
- Manual Lymphatic Drainage (MLD)
- Compression bandaging (multi-layer, short-stretch)
- Exercise
- Skin care
- Skin care and risk reduction/education
*CDT takes advantage of the lymphatic system anatomy and its ability to contract, respirate, pulse, and move fluid
What are the effects of CDT?
- Decreases swelling > 50%
- Increases lymph drainage from the congested areas
- Improves skin condition
- Improves pt’s function and quality of life
- Reduces risk of infection
What are the two phases of CDT?
- Reductive phase
- Maintenance phase
What is the reductive phase of CDT?
- Daily (5x/week - 60 min treatments) treatments until fluid reduction has plateaued > MLD followed by compression bandaging and exercise
- Bandages stay on until return next appointment
*You never want to put a pt in a compression garment until you have decreased the swelling to its lowest level
What is the maintenance phase of CDT?
- Self-management program: self-MLD (ideally 60 min/day) > compression bandaging or bandaging alternative at night > compression garments during day > skin care > exercise > pneumatic compression device when needed
- Periodic monitoring
- Replacement of compression garments every 4-6 months
What are precautions and contraindications with CDT?
- Careful techniques that do not cause genital lymphedema
- Do not use long-stretch bandages/ACE wraps (can create a tourniquet)
- If there is skin irritation then pt might need to also work with dermatologist
- Infection
- Cognition/communication
- Lymphedema massage will help wounds heal faster and better but care must be taken
*Pts might need to wear tight shorts to help drain fluid into genital lymph nodes
Why is diaphragmatic breathing important?
- It is part of CDT treatment
- It encourages deep breathing to allow the diaphragm to move and stimulate lymph nodes in abdomen
- “at the top of every hour take 5 deep breaths”
How does manual lymphatic drainage affect the lymph system?
- Increases movement of lymph/interstitial fluid, including proteins
- Improves lymph transport capacity
- Improves lymph vessel contractility
- Stretching of the skin affects the superficial lymph vessels. Pressure phase promotes fluid movement in a desired direction. Relaxation phase causes a vacuum due to the distention of tissue and leads to refilling of the lymph vessels
- MLD is a slow technique and includes 5-7 repetitions per area
- MLD is a gentle technique that should not rub or create redness
- A side effect of MLD is increased urination
How should a therapist do MLD if a pt has nodes in the right axillary area that are not working?
- Start towards trunk (always open processing centers first) > stimulate abdomen by doing deep breathing > neck > nodes closest to region > then try to connect regions > then move to arm
- You want to think of a traffic jam when doing MLD. You do not want to start MLD distally. You want the stretch in the direction we want the fluid to move and then redo everything in reverse order
What are lymph node watersheds?
Watersheds represent linear territories where there a relatively few lymph collectors
What is the sequencing of MLD?
- Clear proximal regions and nodes
- Move segmentally
- Always stretch from distal to proximal
What is the purpose of compression bandaging?
- Improves efficiency of muscle pump
- Prevents re-accumulation of evacuated fluid
- Facilitates softening of fibrotic tissue
*Pt might need to have compression for groin, abdomen, and chest
What should you remember when bandaging?
- There should be more pressure distally and less pressure proximally
- There should be more layers distally and less layers proximally
- Must use short-stretch bandaging since it does not have a lot of stretch (50% stretch of initial length)
- Pts should exercise/move when wearing compression bandages
