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S5 PTA Special Topics > lymphedema > Flashcards

lymphedema Flashcards

1
Q

lymphatic system (6)

and function

A
  • tonsils - spleen - thymus gland - lymph nodes - lymphatic vessels - peyer’s patches (intestines)
  • prevents interstitial edema - assists in the digestion of fats - immunological functions - one way system
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2
Q

lymph nodes

A
  • 600-900
  • drain regions
  • make WBC
  • filter and concentrate fluid
  • drain all tissues except for CNS
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3
Q

superficial lymphatic system

A
  • like the roots of a plant
  • from the most distant parts of the body to the venous angles
  • anatomical variation is common
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4
Q

deep lymphatic system

A
  • thoracic duct drains approx 3/4 of the body

- right lymphatic duct drains approx 1/4 of the body

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5
Q

lymphatic system carrying

and what happens to it?

A

proteins - cells - water - fats

  • eventually lymph fluid returns to the venous system and becomes part of the plasma
  • must have healthy heart, lungs, and kidneys to process that fluid!
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6
Q

lymph capillaries

A
  • single cell layer
  • no basement membrane
  • anchoring filaments
  • swinging flaps to prevent backflow
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7
Q

lymphatic transporting vessels

A
  1. collectors: basement membranes - muscular walls - valves

2. trunks/ducts: largest vessels - thoracic duct - right lymphatic duct

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8
Q

lymphedema

A

abnormal accumulation of protein rich fluid in the interstitial spaces

  • results in chronic inflammation and reactive fibrosis of the tissues
  • progressive
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9
Q

lymphedema: clinical sign

A

pitting edema

- feels warm and soft - then soft playdough - the silly putty

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10
Q

lymphedema: typical locations

A
  • extremities (uni or bilateral)
  • trunk and breasts
  • genitals
  • intestinal
  • head and neck
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11
Q

primary lymphedema

A
  • lymphatic dysplasia
  • can be hereditary
  • often onset is at menstruation or pregnancy
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12
Q

secondary lymphedema

A
  • lymph node surgery
  • radiation therapy
  • traumatic injury to vessels or nodes
  • surgical scarring
  • malignant lymphedemas
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13
Q

stage 0

A
  • latency
  • patient is at risk for lymphedema, no visible and/or palpable swelling
  • check for subjective complaints
  • may use bioelectrical impedance analysis (BIA) to detect changes on affected side
  • treatment?
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14
Q

stage 1

A
  • reversible
  • visible swelling (may be fluctuating)
  • check for subjective complaints
  • mainly protein-rich fluid which responds to elevation
  • treatment?
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15
Q

stage 2

A
  • spontaneously irreversible
  • visible, chronic swelling
  • protein-rich fluid and fibrosis
  • elevation may provide some relief but will not be very effective
  • treatment?
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16
Q

stage 3

A
  • lymphostatic elephantiasis
  • visible, chronic swelling
  • protein-rich fluid, fibrosis, skin changes and cellulitis
  • infections common
  • treatment?
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17
Q

usual S&S lymphedema

A
  • onset may be slow or rapid
  • progressive
  • pitting
  • often starts distally (squaring of toes, stemmer’s sign positive, loss of anatomical, asymmetric if bilateral)
  • cellulitis is common
  • discomfort is common (heaviness, achiness, etc)
  • skin changes (later stages: hyperkeratosis, papillomas)
  • ulcerations are unusual
  • in contrast with venous disease the skin maintains hydration and elasticity for longer in the disease process
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18
Q

hyperkeratosis

A

over abundance of epidermal thickening with lymphedema

- changes start distally on the limb: hardened tissue, can be moss like, abrasive in advanced presentation

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19
Q

differential dx (9)

A
  1. venous insufficiency/obstruction
  2. congestive heart failure
  3. hepatic/renal disorders (biliary)
  4. nutritional disorders
  5. lipedema
  6. myxedema (thyroid disease)
  7. CRPS
  8. fluid retention symptoms
  9. immobility/dependency
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20
Q

CHF/cardiac edema

A
  • bilaterally symmetric LE edema
  • lacks skin coloring changes compared to CVI
  • soft pitting
  • reduces with elevation
  • shiny skin due to fluctuations in dependent edema
  • lower leg or entire leg
  • toes usually uninvolved
  • dyspnea
  • orthopnea
  • diuretics helpful
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21
Q

decompensated CHF

A
  • edema treatment is contraindicated!
  • orthopnea
  • wet cough
  • pleural effusion
  • dyspnea on exertion
  • swelling is moving into other areas of the body, not just the lungs
22
Q

kidney disease

A
  • initially soft edema similar to cardiac edema
  • becomes woody or indurated as kidneys fail
  • bilaterally symmetric
  • no breathing changes associated
  • typically lower legs only unless severe failure then progresses to thighs and trunk
23
Q

acute renal failure

A

sudden loss of kidney function caused by an illness, an injury, or a toxin that stresses the kidneys (may recover)

  • edema treatment is contraindicated!
  • tx mobilizes fluid back to systemic circulation
  • kidneys must filter after traveling to the heart and lungs
  • may be treated if on dialysis, but carefully
24
Q

chronic kidney disease

A

a long and usually slow process where the kidneys lose their ability to function

25
Q

end-stage renal disease

A

when the kidneys have completely and permanently shut down

26
Q

liver disease

A
  • bilateral and symmetric
  • commonly starts in lower legs, progresses rapidly into the thighs and the trunk
  • usually soft and pitting
  • reduces with elevation initially
  • may be associated with jaundice and right abdominal pain
27
Q

liver disease etiology

A
  • hepatitis
  • metastases to liver
  • malnourishment (hypoproteinemia)
  • severe alcoholism
28
Q

acute DVT

A
  • treatment is contraindicated!
  • check with MD regarding ambulation and exercise prescription
  • blood thinners must be in therapeutic range
  • no MLD over the DVT site until cleared by MD
29
Q

tests for DVT and risk factors (8)

A
  1. doppler ultrasound
  2. d-dimer test: helps determine if further testing is needed to diagnose diseases and conditions causing hypercoagulability
  3. wells prediction rule!
    * risk factors: cancer - recent surgery - immobility - trauma - meds (birth control, hormone therapy, antihormone therapy) - obesity - smoking - sitting
30
Q

indications for compression

A
  • persistent lymphedema
  • open wounds
  • venous insufficiency
31
Q

contraindications for compression

A
  • acute DVT
  • acute renal failure
  • arterial disease
  • CHF (decompensated)
  • relative contra: allergy to dressings
32
Q

late stage chronic venous insufficiency

A
  • upside down champagne bottle appearance
  • becomes less fluid
  • less fluctuation throughout the day
  • hemosiderin staining (brownish discoloration)
33
Q

cellulitis

A
  • treatment is contraindicated!
  • localized patchy redness
  • painful
  • warm
  • swollen
  • distal > proximal
  • fever
  • chills
34
Q

combined insufficiency and treatment

A
  • excessive fluid from non-healing humeral fracture
  • history of axillary node removal
  • like the bath and shower are running at the same time in a tub with a clog in the drain. water keeps on coming with no where to go
  • treatment: still has non healed fracture, most of excessive proteins have been removed-reducing the load on the lymphatic system, tissue is much softer
35
Q

5 components of complete decongestive therapy (CDT)

A
  1. manual lymph drainage
  2. compression bandaging
  3. exercise
  4. skin and nail care
  5. instruction in self-care
36
Q

compression in lymphedema

A
  • bandaging during CDT and night time
  • comp garments for daytime use
  • bandaging alternatives (short stretch bandages - long stretch bandages sports - unna boot - profore - coban2)
37
Q

short stretch bandage

A
  • main component of lymphedema bandage
  • comprilan and rosidal
  • all cotton! no rubber or latex
  • used as multi-layer bandage
  • therapist/patient controls amount of pressure/tension
  • suitable as long term application (hours/day)
  • washable and reusable

*resting pressure and working pressure (resistance against mm and joint movement). Provide low resting pressure and high working pressure (long stretch vice versa) to decrease lymphedema

38
Q

law of laplace

A

pressure = tension / radius

39
Q

principles of lymphedema bandaging

A
  • overlap bandages 50%
  • manage the tension while applying the bandage (pre-stretch bandage by about 50%)
  • maintain functional mobility to enhance the muscle/joint pump
  • prevents re-accumulation of fluid
  • breaks up lymphostatic fibrosis
40
Q

indications for lymphedema bandaging

A
  • lymphedema
  • chronic venous insufficiency (CVI)
  • combo venous and lymphatic edema
  • lipedema
  • post traumatic edema
  • post surgical edema
41
Q

contraindications for lymphedema bandaging (6)

A
  • acute infections (MD needs to clear pt)
  • arterial wounds
  • arterial disease (ABI 0.8 or below)
  • acute DVT
  • cardiac edema (untreated CHF)
  • acute trauma without diagnosis
42
Q

relative contraindications for lymphedema bandaging

A
  • sensory deficits
  • malignancy
  • diabetes (small vessel arteriole and sensory deficits, toe bandaging my be contra)
  • paralysis
  • poor cognition or altered mental status
  • sensitivity to the products used for bandaging
43
Q

manual lymph drainage (MLD)

A
  • increases lymph flow
  • increases reabsorption of protein-rich fluid
  • promotes relaxation
  • analgesic effect
44
Q

contraindications MLD (5)

A
  • acute DVT
  • acute infection
  • decompensated CHF
  • pleural effusion
  • untreated kidney failure
45
Q

relative contraindications MLD (5)

A
  • active cancer
  • malignant lymphedema
  • subacute DVT
  • dialysis
  • treatment in active radiation field
46
Q

foeldi

A

for optimal venous and lymphatic flow

  • full joint ROM
  • deep breathing
47
Q

exercise + bandaging

A
  • bandages counterbalance elastic insufficiency and increase tissue pressure as well
  • it has been shown that there is a positive correlation between tissue pressure and lymph flow (working pressure)
  • bandaging, in combo with movement, softens fibrosis and pitting edema
  • muscle contraction and elongation, and arterial pulsation, increase lymphangiomotoricity
48
Q

exercise

A

while compressed

  • increases muscle and joint pump
  • softens fibrosis
  • facilitates lymphatic drainage
49
Q

ideal exercise for active phase

A
  • includes active movements with bandages on
  • exercise not only the muscles of the edematous region, but also the neck and trunk to facilitate lymph flow centrally
  • uses gravity or light resistance throughout the range of motion to both shorten and elongate tissues
  • includes deep breathing
  • increases the heart rate
50
Q

aquatic exercise benefits

A
  • buoyancy
  • promotes relaxation
  • isokinetic exercise reduces inflammatory response
  • gradient compression with hydrostatic pressure of 22.4mmHg for every 12in of immersion
51
Q

aquatic exercise beware

A
  • too much too soon
  • risk of hypotension when exiting the water
  • erythema and increased lymph load
  • muscle soreness with floatation-type resistance and eccentric contractions
52
Q

self care

A
  • self compression
  • garments
  • self MLD
  • exercise
  • skin care

S5 PTA Special Topics (13 decks)

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