Lymphedema

Question 1

Lymphatic system

Answer 1

• parallel to the venous system
• present in all parts of the body except the CNS and the cornea
• the body has 600-700 lymph nodes with the greatest groupings in the head and neck, axilla, groin, and intestines
• in a normal state the lymphatic system transports lymphatic fluid back to the venous circulation

Question 2

lymphatic pathway

Answer 2

• lymphatic system capillaries located close to blood capillaries and are responsible for pulling fluid into the lymphatic circulation
• once in lymphatic vessels, fluid transported from lymph nodes to lymphatic trunks to venous angles

Question 3

Lymphedema

Answer 3

• an excessive and persistent accumulation of extravascular and extracellular fluid and proteins in tissue spaces. It occurs when lymph volume exceeds the capacity of the lymph transport system

Question 4

Lymphatic fluid

Answer 4

water, waste, fat, and protein

Question 5

Lymphatic load

Answer 5

amount of fluid transported

Question 6

transport capacity

Answer 6

amount of fluid the lymphatic system can transport
•when balance is interrupted due to increased lymphatic load or a decreased transport capacity lymphedema may develop
•

Question 7

quadrants

Answer 7

When a quadrant’s lymph structures are affected the entire quadrant which empties into those structures can demonstrate lymphedema

Question 8

transport capacity in primary lymphedema

Answer 8

Transport capacity is affected when structures of the lymphatic system are impaired either by problems in the anatomical lymphatic structures= Primary Lymphedema

Question 9

transport capacity in secondary lymphedema

Answer 9

due to injury to lymphatic structures via surgery, radiation, trauma, or infection= Secondary Lymphedema.

Question 10

Primary lymphedema

Answer 10

• Less common, the result of insufficient development (dysplasia) and congenital malformation of the lymphatic system.
• Affects more females than males.
• Affects lower extremities greater than upper extremities

Question 11

types of primary lymphedema

Answer 11

Identified by age presentation:
•Congenital (Milroy’s disease) presents at birth
•Praecox (early) develops before 35 y/o
•Tarda: develops after 35 y/o

Question 12

Secondary Lymphedema

Answer 12

•Most common form of lymphedema caused by damage to lymphatic structures through:

• Surgical dissection of lymph nodes for cancer- i.e axillary for breast cancer, pelvic or inguinal nodes for pelvic (prostate) or abdominal cancers
• Systemic infection or Local trauma
• Obstruction, fibrosis-i.e from radiation
• Combined venous-lymphatic dysfunction
• Filariasis parasites

Question 13

Clinical manifestations of lymphedema

Answer 13

• As develops most often apparent in distal extremities especially over dorsum of hand or foot and may manifest more centrally in the axilla, groin , trunk and genitals.
• Described by severity of changes that occurs in skin and subcutaneous tissues and progresses from
• Pitting-> Non- pitting (i.e brawny) weeping

Question 14

types of edema

Answer 14

• Pitting
• brawny
• weeping

Question 15

Pitting edema

Answer 15

indentation of the skin that persists for several seconds after pressure is removed. No fibrotic changes.

Question 16

Brawny edema

Answer 16

edematous area feels hard with palpation. Progressive fibrotic changes.

Question 17

Weeping edema

Answer 17

most severe- fluid leaks from cuts and sores. Wound healing impaired

Question 18

Degrees of pitting edema

Answer 18

1+: indentation barely detectable
2+: slight indentation when skin is depressed- returns to normal in 15 seconds
3+: deeper indentation when pressed- returns to normal within 30 seconds
4+: indentation lasts for more than 30 seconds

Question 19

when skin is interrupted…

Answer 19

When skin is interrupted , it is common to see a seeping of clear, yellow tinged fluid that is slightly thicker than vascular fluid. The increased viscosity is due to protein in the fluid. Severe condition if leaking through pores of skin

Question 20

Sensory and ROM disturbances with lymphedema

Answer 20

Sensory disturbances- paresthesia, aching, heaviness may be felt. Finger coordination may be impaitred
ROM of fingers and wrist or toes and ankle may be decreased

Question 21

Lymphedema and infection

Answer 21

wound healing is delayed/ frequent infections and cellulitis (medical emergency) may occur

Question 22

Stage 0

Answer 22

Latency stage:
• essentially asymptomatic, occasional reports of heaviness
•has reduced transport capacity (i.e. loss of lymph nodes or fibrosis of lymph nodes- but body is still able to accomadate the lymphatic load so there is no swelling.
• this stage may present with the greatest possibility for reducing the onset of lymphedema K box 1024

Question 23

Stage I

Answer 23

Reversible pitting edema:
• elevation reduces swelling, may be normal in morning
• no tissue fibrosis
•swelling is soft or pitting

Question 24

Stage II

Answer 24

Spontaneously Irreversible:
•fibrosis of soft tissue, brawny, hard, swelling (non pitting)
• positive stemmer sign
•frequent infections (i.e. cellulitis) may occur

Question 25

Stage III

Answer 25

Lymphastatic Elephantiasis: • positive stemmer sign • significant increase in limb volume • typical changes noted- hyperkeratosis, papillomas, deep skin folds • bacterial and fungal infections of the skin and nails are more common

Question 26

Stemmer sign

Answer 26

*  (+) in stage I and II *  a positive Stemmer sign is an indication of Stage I or II lymphedema * considered positive if the skin on the dorsal surface of the fingers or toes cannot be pinched or is difficult to pinch compared to the uninvolved limb

Question 27

Other tests and measures for lymphedema

Answer 27

• History and systems review Exam of skin integrity- amount of edema, type of edema, papillomas, signs of infection- cellulitis, Stemmer sign, condition of nails, presence of fungus • Girth measurements-specific intervals/ landmarks, anatomical landmarks, specialized measuring boards • Volumetric measurements (more cumbersome, less practical- esp. for LE) • Bioimpedence measurements- the higher the resistance to flow the more extracellular fluid is present • ROM measurements- esp. hands, wrist, feet/ ankle, knee/ elbow, shld/ hip/ trunk- esp. as it relates to functional loss • Fine and gross coordination Balance/ Bed mobility/ Transfers/ Gait/ Hygiene function

Question 28

Lymphedema management phase I

Answer 28

* manual lymphatic drainage (MLD) by clinician *  multiple layer compression bandaging (worn until next session) *  skin and nail care * exercise

Question 29

Lymphedema management phase II

Answer 29

* self MLD by patient *  compression therapy- compression garment during day and multiple layer bandaging at night * skin and nail care * exercise

Question 30

Lymphedema management: pressure changes, diaphragmatic breathing, and muscle contractions

Answer 30

*  Dynamic pressure changes within the body can assist with lymphatic flow *  pressure changes can be in the form of diaphragmatic breathing producing intrathoracic pressure changes and causing an increased uptake of lymph fluid in the lymphatic trunks and ducts (especially important for patients with LE lymphedema * Active muscular contractions change pressure in a localized area which can be made even more effective combined with external forces from a bandage or compression garment

Question 31

Possible contraindications to MLD and compression

Answer 31

*  CHF *  some pulmonary disorders * renal failure/disease *  active infection * DVT

Question 32

Sequence of exercises

Answer 32

• Diaphragmatic breathing is performed prior to lymphatic drainage exercises • Exercise in particular sequence to enhance lymph flow: - central and proximal lymph vessels i.e. abdominal, inguinal, and cervical nodes are cleared first with trunk, pelvic, hip, and cervical exercises - then exercise proceeds distally from shoulders to fingers or hips to toes • compression garments or bandages should be worn throughout

Question 33

Lymphedema education

Answer 33

Patients should position the affected extremities to avoid constriction or the pooling of blood and fluids, Advise them to: - elevate the arm or leg above heart level - avoid rapid movements that could cause centrifugal pooling of fluid in hands or legs - avoid heat to limbs (heat can increase blood flow) avoid hot baths and saunas - avoid strain or constrictive pressure that may obstruct lymph flow (but do not avoid using the affected or at-risk limb altogether) - avoid tight fitting jewlery and clothing, elastic bandages, clothing with constrictive bands, and BP monitoring equipment on the lymphedemic arm - avoid carrying a purse or heavy objects on the affected arm - sit smart: do not cross legs while sitting or sit in one position for more than 30 minutes

Question 34

Venous circulation...

Answer 34

empties into the vena cava, which is why lymphedema massage is contraindicated in patients with CHF

Question 35

MLD

Answer 35

work proximal to distal as opposed to retrograde message for regular edema which would be distal to proximal