Lymphoedema Flashcards
What is lymphoedema?
A chronic swelling of a body part (usually limbs) caused by the accumulation of fluid and protein in the tissue spaces arising from congenital malformation of the lymphatic system, or damage to lymphatic vessels and/ or lymph nodes.
What occurs when lymphatics are not functioning adequately?
Extra cellular fluid accumulates in the tissues.
What are the roles of the lymphatic system?
- Preserves fluid balance
- Promotes fat absorption via intestinal lymphatics
- Host defence
What functions assist lymph drainage?
- Intrinstic pumping of lymph vessels
- Active muscle contraction
- Passive joint movement
- Pressure changes above and below the diaphragm with respiration
- Pulsation of adjacent blood vessels
What functions assist lymph drainage?
- Intrinstic pumping of lymph vessels
- Active muscle contraction
- Passive joint movement
- Pressure changes above and below the diaphragm with respiration
- Pulsation of adjacent blood vessels
When does primary lymphoedema occur?
Congential abnormality/malformation
When does secondary lymphoedema occur?
- Surgery
- Trauma
- Vascular conditions
- Obesity
- Inflammation
- Medication complication
What cancers are more commonly associated with lymphoedema?
- Breast
- Melanoma
- Gynaecological
- Head and neck
- Prostate
What are the possible risk factors for lymphoedema?
- Infection
- Excess body weight
- Too little exercise
- Heat
- Prolonged tight clothing
- Poor ungraduated bandaging
- Air travel
- High BMI
What effect does exercise have for lymphoedema?
Muscle contraction increases lymph flow and reduces the risk of excess fluid accumulating.
What benefit does strength training have on lymphoedema development?
- Decreased symptoms
- Increased quality of life
What is mastectomy?
Complete removal of all breast tissue
What procedures are included in breast conservation surgery?
- Wide local excision
- Lumpectomy
- Partial mastectomy
When is axillary lymph nodes removal indicated?
When cancer is determined to be invasive
What is involved at each level of axillary lymph node dissection?
Level 1: contents between lat dorsi, axillary vein, lateral border of pec minor
Level 2: + tissue beneath pec minor
Level 3: + resection of pec minor
What is a sentinel node biopsy?
Injection of dye or radioactive substance to locate first affected lymph node, then removed for examination
What are the possible complications of breast cancer surgery?
- Reduced shoulder ROM
- Pain
- Scarring
- Postural changes
- Arm lymphoedema
- Breast lymphoedema
What aspect of surgery most affects morbidity associated with the arm and shoulder?
Surgery involving the axilla
What aspect of surgery most affects morbidity associated with the arm and shoulder?
Surgery involving the axilla
When is axillary web syndrome most prevalent?
4-6 weeks post surgery
What factors affect the severity of lymphoedema?
- Extent of surgical intervention
- Other risk factors i.e. BMI
- Adjuvant treatment
What factors affect the severity of lymphoedema?
- Extent of surgical intervention
- Other risk factors i.e. BMI
- Adjuvant treatment
What factors affect the combination of treatment for breast cancer?
- Histological type of cancer (including oestrogen receptor status)
- Size of tumour
- Stage of cancer
- Grade of tumour
- Multifocality
Why is chemotherapy used and what is its prescription?
Used to eliminate micro metatstases; dose every three weeks for 4-6 cycles
When is radiotherapy most commonly used and what is its usual prescription?
Wide local excision (95%). Usual course is 9 days of treatment/fortnight over six weeks.
Why and when is hormone therapy used?
To block oestrogen in receptor positive individuals. Usually starts after chemotherapy and radiotherapy
For what period of time is hormone therapy commonly used for?
Five years
What additional procedures may be offered to pre-menopausal women to reduce oestrogen effects?
- Bilateral oophrectomy
- Ovarian oblation by radiation
What are the common side effects of chemotherapy?
- Nausea and vomiting
- Fatigue
- Hair loss
- Bone marrow suppression, leading to immunosuppression
- Peripheral oedema
- Weakening of skin and nails
- Peripheral neuropathy
What are the common side effects of radiotherapy?
- Fatigue
- Skin reactions
- Breast and upper limb oedema/lymphoedema
- Fibrosis of skin and chest wall muscles
What are the common side effects of hormonal therapy?
- Reduced bone density
- Hot flushes
- Incontinence
- Joint pain/inflammation
What are the roles of physiotherapy in the management post-mastectomy?
- Regain shoulder ROM and function
- Minimise secondary complications: scar, contraction, cording, sensory disturbance, weakness
- Education and management of lymphoedema
- Fatigue management
- Establish/re-establish regular exercise routine
What principles may physiotherapy treatment by based on?
Physiotherapy Management Care Plan (PCMP) developed in 1993
What are the subjective signs and symptoms of lymphoedema?
- Heaviness
- Aching
- Soreness
- Tightness
- Pins and needles
What are the objective signs of lymphoedema?
- Visual swelling
- Pitting
- Increased skin folds
- Stemmers sign
- Skin changes
What is stemmers signs?
Thickened skin at base of second finger, indicating presence of lymphoedema
What objective measure is used for lymphoedema diagnosis and how is it performed?
Circumferential measures: taken at 10cm intervals up both limbs for comparison
What limb circumference is considered clinical significant?
> 2cm difference from opposite side
What are the precautions of physiotherapy intervention for lymphoedema?
- Heat applications
- Constrictions i.e. tubigrip
- Vigorous massage/soft tissue work
- Dry needling
- Progression of strength exercise
What are the precautions of physiotherapy intervention for lymphoedema?
- Heat applications
- Constrictions i.e. tubigrip
- Vigorous massage/soft tissue work
- Dry needling
- Progression of strength exercise
What are the red flags associated with lymphoedema?
Any unusual pain or new symptoms in a patient with a history of cancer
What aspects are recognised in the best practice treatment guidelines for lymphoedema?
- Lymphatic drainage massage
- Exercise
- Skin care
- Compression
- ADL advice
What are the most important treatment components in early/mild lymphoedema?
- Self massage program
- Skin care
- Exercise
- Compression garment
What is the most important component of moderate-severe lymphoedema management?
Complex lymphoedema therapy
What is lymphorrhea?
Leaking lymph
What are the effects of compression therapy?
- Reduced capillary filtration
- Increased uptake of lymphatic collectors
- Increased movement of lymph through lymph vessels with skeletal muscle action and joint movement
What compression pressures should be used and when?
Low resting pressure
High working pressure
What are the classes of compression garments?
Graduated compression:
- Class 1: 15-20mmHg
- Class 2: 22-36mmHg
- Class 3: 35-46mmHg
- Class 4: 45-55mmHg
What compression pressure do TEDS stockings provide?
10-20mmHg
What can low level laser therapy be used for?
- Pain reduction
- Oedema management
