lymphedema Flashcards
lymphatic system (6)
and function
- 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
lymph nodes
- 600-900
- drain regions
- make WBC
- filter and concentrate fluid
- drain all tissues except for CNS
superficial lymphatic system
- like the roots of a plant
- from the most distant parts of the body to the venous angles
- anatomical variation is common
deep lymphatic system
- thoracic duct drains approx 3/4 of the body
- right lymphatic duct drains approx 1/4 of the body
lymphatic system carrying
and what happens to it?
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!
lymph capillaries
- single cell layer
- no basement membrane
- anchoring filaments
- swinging flaps to prevent backflow
lymphatic transporting vessels
- collectors: basement membranes - muscular walls - valves
2. trunks/ducts: largest vessels - thoracic duct - right lymphatic duct
lymphedema
abnormal accumulation of protein rich fluid in the interstitial spaces
- results in chronic inflammation and reactive fibrosis of the tissues
- progressive
lymphedema: clinical sign
pitting edema
- feels warm and soft - then soft playdough - the silly putty
lymphedema: typical locations
- extremities (uni or bilateral)
- trunk and breasts
- genitals
- intestinal
- head and neck
primary lymphedema
- lymphatic dysplasia
- can be hereditary
- often onset is at menstruation or pregnancy
secondary lymphedema
- lymph node surgery
- radiation therapy
- traumatic injury to vessels or nodes
- surgical scarring
- malignant lymphedemas
stage 0
- 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?
stage 1
- reversible
- visible swelling (may be fluctuating)
- check for subjective complaints
- mainly protein-rich fluid which responds to elevation
- treatment?
stage 2
- spontaneously irreversible
- visible, chronic swelling
- protein-rich fluid and fibrosis
- elevation may provide some relief but will not be very effective
- treatment?
stage 3
- lymphostatic elephantiasis
- visible, chronic swelling
- protein-rich fluid, fibrosis, skin changes and cellulitis
- infections common
- treatment?
usual S&S lymphedema
- 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
hyperkeratosis
over abundance of epidermal thickening with lymphedema
- changes start distally on the limb: hardened tissue, can be moss like, abrasive in advanced presentation
differential dx (9)
- venous insufficiency/obstruction
- congestive heart failure
- hepatic/renal disorders (biliary)
- nutritional disorders
- lipedema
- myxedema (thyroid disease)
- CRPS
- fluid retention symptoms
- immobility/dependency
CHF/cardiac edema
- 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
decompensated CHF
- 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
kidney disease
- 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
acute renal failure
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
chronic kidney disease
a long and usually slow process where the kidneys lose their ability to function
end-stage renal disease
when the kidneys have completely and permanently shut down
liver disease
- 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
liver disease etiology
- hepatitis
- metastases to liver
- malnourishment (hypoproteinemia)
- severe alcoholism
acute DVT
- 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
tests for DVT and risk factors (8)
- doppler ultrasound
- d-dimer test: helps determine if further testing is needed to diagnose diseases and conditions causing hypercoagulability
- wells prediction rule!
* risk factors: cancer - recent surgery - immobility - trauma - meds (birth control, hormone therapy, antihormone therapy) - obesity - smoking - sitting
indications for compression
- persistent lymphedema
- open wounds
- venous insufficiency
contraindications for compression
- acute DVT
- acute renal failure
- arterial disease
- CHF (decompensated)
- relative contra: allergy to dressings
late stage chronic venous insufficiency
- upside down champagne bottle appearance
- becomes less fluid
- less fluctuation throughout the day
- hemosiderin staining (brownish discoloration)
cellulitis
- treatment is contraindicated!
- localized patchy redness
- painful
- warm
- swollen
- distal > proximal
- fever
- chills
combined insufficiency and treatment
- 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
5 components of complete decongestive therapy (CDT)
- manual lymph drainage
- compression bandaging
- exercise
- skin and nail care
- instruction in self-care
compression in lymphedema
- bandaging during CDT and night time
- comp garments for daytime use
- bandaging alternatives (short stretch bandages - long stretch bandages sports - unna boot - profore - coban2)
short stretch bandage
- 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
law of laplace
pressure = tension / radius
principles of lymphedema bandaging
- 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
indications for lymphedema bandaging
- lymphedema
- chronic venous insufficiency (CVI)
- combo venous and lymphatic edema
- lipedema
- post traumatic edema
- post surgical edema
contraindications for lymphedema bandaging (6)
- 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
relative contraindications for lymphedema bandaging
- 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
manual lymph drainage (MLD)
- increases lymph flow
- increases reabsorption of protein-rich fluid
- promotes relaxation
- analgesic effect
contraindications MLD (5)
- acute DVT
- acute infection
- decompensated CHF
- pleural effusion
- untreated kidney failure
relative contraindications MLD (5)
- active cancer
- malignant lymphedema
- subacute DVT
- dialysis
- treatment in active radiation field
foeldi
for optimal venous and lymphatic flow
- full joint ROM
- deep breathing
exercise + bandaging
- 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
exercise
while compressed
- increases muscle and joint pump
- softens fibrosis
- facilitates lymphatic drainage
ideal exercise for active phase
- 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
aquatic exercise benefits
- buoyancy
- promotes relaxation
- isokinetic exercise reduces inflammatory response
- gradient compression with hydrostatic pressure of 22.4mmHg for every 12in of immersion
aquatic exercise beware
- 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
self care
- self compression
- garments
- self MLD
- exercise
- skin care
