Lymphedema and Swelling Disorders: Manual Lymph Drainage, Bandaging, Garments, and Remedial Exercises

Question 1

lymphatic system =

Answer 1

cervical lymph nodes
thoracic duct
thymus
axillary lymph nodes
spleen
UE lymphatics
Inguinal lymph nodes
LE lymphatics
pelvic lymph nodes
lumbar lymph nodes
cisterna chyli

mammary gland lymphatics

Question 2

Lymph vessels absorb interstitial fluid from the skin and subcutaneous tissue➔

Answer 2

transport it to the circulatory system

Question 3

Nutritional fatty acids are absorbed via intestinal lymph called ___

Answer 3

chyle

Question 4

____ are manufactured and stored in lymphatic tissue

Answer 4

Lymphocytes (WBC)

Question 5

Thymus:

Answer 5

a lymphoid organ located in the anterior superior mediastinum➔ matures T cells for the immune system

Question 6

Spleen:

Answer 6

largest organ in the lymphatic system, acts primarily as a blood filter, RBCs are recycled in the spleen, WBC and platelets are stored in the spleen➔ located under the rib cage and above the stomach in the left upper quadrant of the abdomen

Question 7

Thoracic Duct:

Answer 7

the largest lymphatic vessel in the human body➔ 1-5 mm diameter, 40 cm long

Located left and anterior to the spine

Question 8

Thoracic Duct Drains into the ____

Answer 8

venous angle which is the Junction of the internal Jugular and subclavian
veins

Question 9

Cisterna Chyli:

Answer 9

a dilated sac at the lower end of the thoracic duct, functions as a temporary reservoir

Question 10

Lymph Vessels:

Answer 10

thin walled system for
Transporting lymph throughout the body
From distal to proximal

Question 11

Lymph nodes:

Answer 11

Part of the immune system

Generally located in the adipose tissue

Palpable sensitive nodes signify infection

Vary in size from 2-30 mm long, oval,
round, kidney shape
600-700 lymph nodes in the body, majority found in the abdomen

Question 12

Lymph Node Function:

Answer 12

Filtering station for noxious matter such as bacteria, toxins and dead cells

Regulate the concentration of protein in the lymph➔ hydrostatic and osmotic pressure controls the balance of water between the lymph nodes and blood vessels

Question 13

Lymph Nodes arrangement:

Answer 13

Arranged in chains

~600-700 -> 100-200 are mesenteric

Size ranges from .2 – 30 mm

Outside: fibrous capsule

Afferent Vessels: entering node

Efferent Vessels: exiting node

Question 14

Lymph Vessels

Answer 14

Capillaries
Pre-collectors
Collectors
Trunks
Ducts

Question 15

Lymph Vessels:
Different from veins and arteries➔

Localized pump action via movement and muscle contraction➔

Answer 15

NO central pump

moves fluid distal to proximal to the subclavian and into the circulatory system

Question 16

Lymph Capillaries
Do not contain one way valves➔

Answer 16

lymph can flow in any direction

One layer, overlapping endothelial cells

Question 17

exchange across capillary walls:

Answer 17

fluid & solutes flows out of capillaries to tissues due to blood pressure
*bulk flow

interstitial fluid flows back into capillaries due to osmosis
*plasma proteins increase osmotic pressure in capillary
*BP < OP

Question 18

Lymph Capillaries: Important Characteristics

Answer 18

Form a plexus throughout the body

Are larger in diameter than blood capillaries

Are able to absorb interstitial fluid as necessary

Have no valves inside the vessel➔ lymph can flow in any direction

Question 19

Lymph Capillaries: fluid leakage

Answer 19

fluid leaks through mini-valves into lymph capillaries

higher pressure on inside closes mini-valves

blood capillaries -> interstitial tissue -> lymph capillaries -> lymph collectors -> lymph trunks -> lymph ducts

Question 20

Pre-Collectors =

Answer 20

Channel the lymph fluid into the larger transporting vessels

Able to absorb fluid and molecules➔ similar to lymph capillaries

Situated vertically in the subcutaneous tissue

Connect lymph capillaries to collectors

Mostly function to move fluid in both directions with few valves

Some areas of smooth muscle and valves

Question 21

Collectors =

Answer 21

Three layer walls➔ similar to veins, however, thinner than veins

Inner layer: endothelial cells and basement membrane

Middle layer: smooth muscle

Outer layer: connective tissue

Contain valves➔ determine direction of lymph fluid flow➔ distal to proximal or toward the nearest regional node bed each valve segment called ‘lymphangion’

Question 22

Lymphangion Activity

Answer 22

sympathetic nervous system innervation of smooth muscle

Rhythmic contractions

Also utilizes skeletal muscle contraction, arterial pulsation, and respiration to move fluid

Question 23

Trunks

Answer 23

Larger than collectors

Primary trunks are formed by the joining of efferent collectors of regional lymph node beds

Question 24

Features of Lymph Trunks:

Answer 24

One way valves

Smooth muscle layer -> contraction

Question 25

Lymphatic vessel that empties lymph into one of the subclavian veins ->

Answer 25

superior vena cava -> right atrium

Question 26

Right lymphatic duct drains lymph from the ___

Answer 26

right upper limb, right side of thorax and right halves of head and neck

Question 27

Thoracic duct drains lymph into the ___

Answer 27

circulatory system at the left brachiocephalic vein between the left subclavian and left internal jugular vein

Question 28

Lymphatic Ducts Transport ___

Answer 28

1.5-2.5 L/24 hours

Question 29

Thoracic Duct

Answer 29

Largest lymph vessel
40 cm long
2-3 cm wide
20 valves

Moves lymph from lower body and left arm to left subclavian vein

Question 30

Right Lymphatic Duct

Answer 30

3 cm long

Moves lymph from right upper quadrant to right subclavian vein

Question 31

Definition of Lymphedema

Answer 31

Protein-rich edema that occurs when the lymph load or volume exceeds the lymph transport capacity in any body segment

Considered a disorder/disease

Question 32

Lymphatic vessels may be:

Answer 32

Absent or under-developed = Primary Lymphedema

Obstructed or damaged = Secondary Lymphedema

Question 33

Pedal edema➔

Answer 33

swelling in bilateral feet and LE due to long periods of sitting or standing➔ causes hypervolumenia

Question 34

Cerebral edema ➔

Answer 34

fluid accumulation on the brain due to abnormal metabolic conditions such as lupus, can also be due to high altitudes

Question 35

Pulmonary edema ➔

Answer 35

left sided heart failure leads to accumulation of fluid on the lungs

Question 36

Polymyositis ➔

Answer 36

inflammatory muscle condition that causes generalized weakness and swelling

Question 37

Musculoskeletal injury ➔

Answer 37

unresolved acute inflammation and edema leads to chronic inflammation and edema

Question 38

Definition of Edema

Answer 38

Visible and palpable excessive accumulation of interstitial fluid; usually detected when volume reaches 30% above normal.

Edema is a symptom and not a disease

Question 39

Definition of Lipedema

Answer 39

disorder characterized by massive, bilateral accumulation of fat below the waist and in the legs

Enlargement of the lower extremities is often accompanied by leg pain and accumulation of fluid

Little is known about the functional changes that lead to fat accumulation and pain in patients (women»>men) with lipedema.

Question 40

Definition of Cellulitis

Answer 40

potentially serious bacterial skin infection

The affected skin appears swollen and red and is typically painful and warm to the touch

Cellulitis usually affects the skin on the lower legs, but it can occur in the face, arms and other areas.

Question 41

tributary zone

Answer 41

each major lymph node grouping recerives lymph from a specific body region

Question 42

watersheds

Answer 42

direction of lymphatic flow of each tributary zone is defined by invisible boundaries

Question 43

anastamoses

Answer 43

areas between zones where vessels physically line up, critical in movement of lymph between adjacent zones during treatment

Question 44

Quadrants or ‘territories’ are only connected to each other through:

Answer 44

a few anastomotic branches – few vessels connecting the territories

Question 45

The only way lymph can move from one territory or zone to the next is through:

Answer 45

the initial lymph vessel network -> lymph capillaries

Question 46

These cross-over areas are called the ‘lymphatic water shed’ areas via ___

Answer 46

anastamoses

Question 47

Grade 0 lymphedema

Answer 47

Normal sensation

Normal appearance

Patient at risk to develop lymphedema

Question 48

Grade 1 Lymphedema

Answer 48

Abnormal sensation

Pitting

Reversible with elevation

Early intervention needed

Question 49

Grade II Lymphedema

Answer 49

Intermittent ‘heaviness’

Abnormal tissue texture

Irreversible with
elevation due to fibrosis

Question 50

Grade III Lymphedema

Answer 50

Elephantitis

Persistent ‘heaviness’

Grossly abnormal

Irreversibly damaged tissue

Treatment will help decrease severity of symptoms

Question 51

Edema 1+

Answer 51

Edema that is barely detectable, <2 mm depression, immediate rebound

Question 52

Edema 2+

Answer 52

A slight indentation visible when the skin is depressed, 3-4 mm depression, <15 second rebound

Question 53

Edema 3+

Answer 53

A deeper fingerprint when the skin is depressed, 5-6 mm depression, 10-30 second rebound

Question 54

Edema 4+

Answer 54

Large fingerprint when the skin is depressed,
>7 mm depression, >20 second rebound ➔ the limb may be 1.5-2 times normal size

Question 55

Lymph Fluid Movement

Answer 55

Water, protein and small molecules diffuse through the blood capillary walls into the interstitium -> process called filtration -> to nourish the tissues

Question 56

Ultrafiltration dependent on:

Answer 56

hydrostatic pressure in capillary and interstitial space

Colloid osmotic pressure gradient of plasma proteins

Question 57

In homeostasis, ‘reabsorption’ occurs when fluid moves:

Answer 57

from blood capillaries, to interstitial tissue, and back into the venule side of capillaries and into the lymph vessels due to higher concentration of plasma proteins

Question 58

Lymph Circulation

Answer 58

blood capillaries
lymph capillary
initial lymph vessels
pre-collectors
collectors (pumps)
lymph nodes
lymphatic ducts
subclavian venous system

Question 59

Filtration =

Answer 59

Reabsorption + Lymph Fluid

Question 60

Starling’s Equilibrium:

Answer 60

= 85% Venous Capillaries + 15% Lymph Capillaries

Question 61

Factors Affecting Tissue Fluid Exchange

Answer 61

Total tissue pressure

Gravity

Ultrafiltration: High BP??

Muscle contraction: what’s the impact

Diaphragmatic breathing

Intestinal contractions

Skin/tissue movement

Question 62

Functions of the Lymph System =

Answer 62

Transports proteins from the bloodstream back to the bloodstream after being filtered by lymph nodes

Immunological function
-> antigen presented to t cell stimulates B cell production of antibodies

Keeps connective tissue in a healthy state

Question 63

Lymphedema

Answer 63

High Protein edema➔ exudate

Congestion in the interstitium

Visible swelling

Chronic inflammation of the tissues ➔ proliferation of fibroblasts

Proliferation of fibroblasts = fibrosis

Question 64

Types of Lymphedema

Answer 64

Primary
Secondary

Question 65

Primary Lymphedema:

Answer 65

Rare inherited condition due to deficient lymph vessels

Question 66

Secondary Lymphedema:

Answer 66

Acquired lymphatic system deficits

Surgery

Radiation therapy

Trauma

Filariasis -> elephantiasis, parasite infection affects 90 million people world-wide -> primarily in tropical regions

Question 67

Lymphedema Prevalence:

Answer 67

250,000 million people worldwide, 5 million people in the United States, estimated 1 in 100,000 people have primary lymphedema

Question 68

Normal healthy lymphatic system = ___ is greater than the ___

Answer 68

transport capacity

lymphatic load

Question 69

Lymphatic system insufficiency = ____ is greater than the ___

Answer 69

lymphatic load

transport capacity

Question 70

Too much fluid in a normal system ➔

Answer 70

hypervolemia

Question 71

Normal fluid amount in an abnormal or damaged system ➔

Answer 71

primary and/or secondary lymphedema

Question 72

Recommended Treatment for Lymphedema

Answer 72

Complete Decongestive Therapy:
Manual Lymph Drainage
Bandaging
Garments
Remedial Exercise

Question 73

MLD: Increases the uptake and transport of lymph fluid➔

Answer 73

compression alone does not create a ‘stretch stimulus’ ➔ which causes peristalsis of lymph capillaries and pre-collectors

Question 74

MLD =

Answer 74

Gentle touch is necessary since the lymph vessels involved in fluid collection sit just beneath the skin – are < one mm in diameter

Working or pressure phase ➔ increase external pressure

Relaxation phase ➔ negative pressure

Stretch in the drainage direction during the working phase

Stronger touch is necessary for deeper structures and fibrotic areas

Question 75

Lymphangion contraction is:

Answer 75

~6 per minute at rest and ~20 per minute with activity

Question 76

MLD: Basic Sequence

Answer 76

Neck ➔ Right Duct ➔ Right Subclavian

Neck➔ Thoracic Duct ➔ Left Subclavian

Question 77

Contraindications for Manual Lymph Drainage

Absolute ➔ Red Flags

Answer 77

Congestive Heart Failure (CHF)

Renal failure
Acute infection
Thrombosis, DVT
AAA -> abdomen
Severe Arteriosclerosis
Surgery

Question 78

Contraindications for Manual Lymph Drainage

Relative ➔ Yellow Flags

Answer 78

Malignant or metastatic lymphedema

Hyperthyroidism

Pregnancy -> abdomen

Question 79

Compression Bandaging Contraindications

Answer 79

DVT➔ May mobilize blood clot

Infection➔ May spread infection from local to systemic

Cardiac Edema➔ CHF
Advanced Arterial

Disease➔ May further disturb arterial blood flow

Malignancy➔ Cancer related complications

Renal Disease➔ Renal related complications

Question 80

Compression Bandaging: Indications

Answer 80

Lymphedema
Edema
Chronic Venous Insufficiency
Post-traumatic edema
Post-surgical edema
Lipedema

Question 81

Compression Bandaging: Short Stretch bandage

Answer 81

Short stretch lymphedema bandages contain no elastic threads

Ace bandages contain elastic threads

Short stretch extends by 50%➔ Ace extends by 300%

Question 82

Lymphedema short stretch bandages➔

Answer 82

high working pressure and low resting pressure

Question 83

Working Pressure➔

Answer 83

multilayered bandage does not yield to the forces generated by fluid refilling or by bulging muscles when at work – these internal forces cannot overcome the thick, rigid bandage sheath

Question 84

Resting Pressure➔

Answer 84

the shortening force or constriction generated by an elastic bandage – increased risk of blood circulatory disturbances (tourniquet), soft tissue damage, and neuro problems

Question 85

Desirable fluid movement➔

Answer 85

distal areas to proximal areas

Question 86

This proximal movement of fluid relies on ____

Answer 86

compression gradient created around the involved limb

Question 87

Compression Bandaging: Principles

Answer 87

Low resting pressures
High working pressures

Question 88

Lymphedema patients graduate from ___ into ___garments as the limb reaches a decongested state

Answer 88

bandages

elastic compression