Lymphedema and Swelling Disorders: Manual Lymph Drainage, Bandaging, Garments, and Remedial Exercises Flashcards
lymphatic system =
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
Lymph vessels absorb interstitial fluid from the skin and subcutaneous tissue➔
transport it to the circulatory system
Nutritional fatty acids are absorbed via intestinal lymph called ___
chyle
____ are manufactured and stored in lymphatic tissue
Lymphocytes (WBC)
Thymus:
a lymphoid organ located in the anterior superior mediastinum➔ matures T cells for the immune system
Spleen:
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
Thoracic Duct:
the largest lymphatic vessel in the human body➔ 1-5 mm diameter, 40 cm long
Located left and anterior to the spine
Thoracic Duct Drains into the ____
venous angle which is the Junction of the internal Jugular and subclavian
veins
Cisterna Chyli:
a dilated sac at the lower end of the thoracic duct, functions as a temporary reservoir
Lymph Vessels:
thin walled system for
Transporting lymph throughout the body
From distal to proximal
Lymph nodes:
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
Lymph Node Function:
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
Lymph Nodes arrangement:
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
Lymph Vessels
Capillaries
Pre-collectors
Collectors
Trunks
Ducts
Lymph Vessels:
Different from veins and arteries➔
Localized pump action via movement and muscle contraction➔
NO central pump
moves fluid distal to proximal to the subclavian and into the circulatory system
Lymph Capillaries
Do not contain one way valves➔
lymph can flow in any direction
One layer, overlapping endothelial cells
exchange across capillary walls:
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
Lymph Capillaries: Important Characteristics
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
Lymph Capillaries: fluid leakage
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
Pre-Collectors =
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
Collectors =
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’
Lymphangion Activity
sympathetic nervous system innervation of smooth muscle
Rhythmic contractions
Also utilizes skeletal muscle contraction, arterial pulsation, and respiration to move fluid
Trunks
Larger than collectors
Primary trunks are formed by the joining of efferent collectors of regional lymph node beds
Features of Lymph Trunks:
One way valves
Smooth muscle layer -> contraction
Lymphatic vessel that empties lymph into one of the subclavian veins ->
superior vena cava -> right atrium
Right lymphatic duct drains lymph from the ___
right upper limb, right side of thorax and right halves of head and neck
Thoracic duct drains lymph into the ___
circulatory system at the left brachiocephalic vein between the left subclavian and left internal jugular vein
Lymphatic Ducts Transport ___
1.5-2.5 L/24 hours
Thoracic Duct
Largest lymph vessel
40 cm long
2-3 cm wide
20 valves
Moves lymph from lower body and left arm to left subclavian vein
Right Lymphatic Duct
3 cm long
Moves lymph from right upper quadrant to right subclavian vein
Definition of Lymphedema
Protein-rich edema that occurs when the lymph load or volume exceeds the lymph transport capacity in any body segment
Considered a disorder/disease
Lymphatic vessels may be:
Absent or under-developed = Primary Lymphedema
Obstructed or damaged = Secondary Lymphedema
Pedal edema➔
swelling in bilateral feet and LE due to long periods of sitting or standing➔ causes hypervolumenia
Cerebral edema ➔
fluid accumulation on the brain due to abnormal metabolic conditions such as lupus, can also be due to high altitudes
Pulmonary edema ➔
left sided heart failure leads to accumulation of fluid on the lungs
Polymyositis ➔
inflammatory muscle condition that causes generalized weakness and swelling
Musculoskeletal injury ➔
unresolved acute inflammation and edema leads to chronic inflammation and edema
Definition of Edema
Visible and palpable excessive accumulation of interstitial fluid; usually detected when volume reaches 30% above normal.
Edema is a symptom and not a disease
Definition of Lipedema
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.
Definition of Cellulitis
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.
tributary zone
each major lymph node grouping recerives lymph from a specific body region
watersheds
direction of lymphatic flow of each tributary zone is defined by invisible boundaries
anastamoses
areas between zones where vessels physically line up, critical in movement of lymph between adjacent zones during treatment
Quadrants or ‘territories’ are only connected to each other through:
a few anastomotic branches – few vessels connecting the territories
The only way lymph can move from one territory or zone to the next is through:
the initial lymph vessel network -> lymph capillaries
These cross-over areas are called the ‘lymphatic water shed’ areas via ___
anastamoses
Grade 0 lymphedema
Normal sensation
Normal appearance
Patient at risk to develop lymphedema
Grade 1 Lymphedema
Abnormal sensation
Pitting
Reversible with elevation
Early intervention needed
Grade II Lymphedema
Intermittent ‘heaviness’
Abnormal tissue texture
Irreversible with
elevation due to fibrosis
Grade III Lymphedema
Elephantitis
Persistent ‘heaviness’
Grossly abnormal
Irreversibly damaged tissue
Treatment will help decrease severity of symptoms
Edema 1+
Edema that is barely detectable, <2 mm depression, immediate rebound
Edema 2+
A slight indentation visible when the skin is depressed, 3-4 mm depression, <15 second rebound
Edema 3+
A deeper fingerprint when the skin is depressed, 5-6 mm depression, 10-30 second rebound
Edema 4+
Large fingerprint when the skin is depressed,
>7 mm depression, >20 second rebound ➔ the limb may be 1.5-2 times normal size
Lymph Fluid Movement
Water, protein and small molecules diffuse through the blood capillary walls into the interstitium -> process called filtration -> to nourish the tissues
Ultrafiltration dependent on:
hydrostatic pressure in capillary and interstitial space
Colloid osmotic pressure gradient of plasma proteins
In homeostasis, ‘reabsorption’ occurs when fluid moves:
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
Lymph Circulation
blood capillaries
lymph capillary
initial lymph vessels
pre-collectors
collectors (pumps)
lymph nodes
lymphatic ducts
subclavian venous system
Filtration =
Reabsorption + Lymph Fluid
Starling’s Equilibrium:
= 85% Venous Capillaries + 15% Lymph Capillaries
Factors Affecting Tissue Fluid Exchange
Total tissue pressure
Gravity
Ultrafiltration: High BP??
Muscle contraction: what’s the impact
Diaphragmatic breathing
Intestinal contractions
Skin/tissue movement
Functions of the Lymph System =
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
Lymphedema
High Protein edema➔ exudate
Congestion in the interstitium
Visible swelling
Chronic inflammation of the tissues ➔ proliferation of fibroblasts
Proliferation of fibroblasts = fibrosis
Types of Lymphedema
Primary
Secondary
Primary Lymphedema:
Rare inherited condition due to deficient lymph vessels
Secondary Lymphedema:
Acquired lymphatic system deficits
Surgery
Radiation therapy
Trauma
Filariasis -> elephantiasis, parasite infection affects 90 million people world-wide -> primarily in tropical regions
Lymphedema Prevalence:
250,000 million people worldwide, 5 million people in the United States, estimated 1 in 100,000 people have primary lymphedema
Normal healthy lymphatic system = ___ is greater than the ___
transport capacity
lymphatic load
Lymphatic system insufficiency = ____ is greater than the ___
lymphatic load
transport capacity
Too much fluid in a normal system ➔
hypervolemia
Normal fluid amount in an abnormal or damaged system ➔
primary and/or secondary lymphedema
Recommended Treatment for Lymphedema
Complete Decongestive Therapy:
Manual Lymph Drainage
Bandaging
Garments
Remedial Exercise
MLD: Increases the uptake and transport of lymph fluid➔
compression alone does not create a ‘stretch stimulus’ ➔ which causes peristalsis of lymph capillaries and pre-collectors
MLD =
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
Lymphangion contraction is:
~6 per minute at rest and ~20 per minute with activity
MLD: Basic Sequence
Neck ➔ Right Duct ➔ Right Subclavian
Neck➔ Thoracic Duct ➔ Left Subclavian
Contraindications for Manual Lymph Drainage
Absolute ➔ Red Flags
Congestive Heart Failure (CHF)
Renal failure
Acute infection
Thrombosis, DVT
AAA -> abdomen
Severe Arteriosclerosis
Surgery
Contraindications for Manual Lymph Drainage
Relative ➔ Yellow Flags
Malignant or metastatic lymphedema
Hyperthyroidism
Pregnancy -> abdomen
Compression Bandaging Contraindications
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
Compression Bandaging: Indications
Lymphedema
Edema
Chronic Venous Insufficiency
Post-traumatic edema
Post-surgical edema
Lipedema
Compression Bandaging: Short Stretch bandage
Short stretch lymphedema bandages contain no elastic threads
Ace bandages contain elastic threads
Short stretch extends by 50%➔ Ace extends by 300%
Lymphedema short stretch bandages➔
high working pressure and low resting pressure
Working Pressure➔
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
Resting Pressure➔
the shortening force or constriction generated by an elastic bandage – increased risk of blood circulatory disturbances (tourniquet), soft tissue damage, and neuro problems
Desirable fluid movement➔
distal areas to proximal areas
This proximal movement of fluid relies on ____
compression gradient created around the involved limb
Compression Bandaging: Principles
Low resting pressures
High working pressures
Lymphedema patients graduate from ___ into ___garments as the limb reaches a decongested state
bandages
elastic compression
