Lymphydema Flashcards
What are the causes of ACTIVE hyperemia
Anything that causes a greater demand for blood
Inflammation, infection, heat, friction, trauma, exercise
What are the causes of PASSIVE hyperemia
Anything that causes obstruction of the venous outflow
DVT, CHF, CVI (chronic venous insufficiency), Tumor
What is the mechanism for both passive and active hyperemia?
Vasodilation!
Name the major mechanism difference (and location of mechanism) between active and passive hyperemia
Active: due to increased blood flow on the pre-cap arterioles
Passive: due to obstruction on the venous side of the capillary bed
What is the result of both active and passive hyperemia?
Ultrafiltration: pressure in blood capillaries forces water to leave blood into the interstitium
What was starlings original equation?
Average BCP = COPp
In Starlings original equation (BCP =COPp) what did greater BCP cause?
Greater COPp cause?
BCP»_space;> COPp = ultrafiltration
COPp»_space;> BCP = reabsorption
What is the primary source of cellular nutrition?
Diffusion
How does diffusion proceed?
high to low concentration
How is diffusion measured?
L/min of flow
What is osmosis
Specialized diffusion through a semi-permeable membrane (capillaries)
Therefore generally water is moving from an area of low substrate concentration to an area of high to dilute it
Osmosis generally has a small contribution to normal nutrition of cells, diffusion mainly takes care of this. However, in what circumstances does osmosis become an important part of cell nutrition?
Disease states
How much flow volume is normal / day for osmosis?
2-4 L/day
Protein has a strong or high affinity for water
high
What is Albumin’s function
hold onto fluid volume in the blood
Its the primary protein in the blood
Why does COP develop?
Bc protein affinity to bind with water
What is the COP of plasma?
7g/% = 25 mmHg
What is ultrafiltration?
Hydraulic pressure of the blood capillaries forcing an additional amount of water to leave the blood and enter the interstitial space
When blood enters the capillary bed compare BCP to COPp and what this relationship creates.
BCP»_space; COPp
BCP wants to push water out and it wins out, therefore water moves into the interstitium
True or False: pre-capillary arterioles are passive structures?
False! they are highly muscularized and innervated by the ANS
Responsible for vasodilation and constriction which we know affects capillary pressure
What is the relationship between arterial BP and BCP
Decrease in arterial BP (due to vasodilation) = increase in BPC due to the greater influx of blood
What happens to central blood pressure when vasodilation occurs? BCP?
Central blood pressure: drops
BCP: increases
What is the result of both active and passive hyperemia
Ultrafiltration
Is BPC hydrostatic or osmotic?
Hydrostatic
What did Starling originally propose the extent of lymph function was?
What do we know now and what does that mean the role of the lymphatic system is?
takes 10% of the fluid not reabsorbed by the venous side of the capillary
We know now that there is almost no reabsorption of fluid in the capillary beds, therefore excess fluid is almost exclusively the responsibility of the lymphatic system.
How is the majority of capillary filtrate returned to blood circulation?
Thoracic duct
What is Glycocalyx?
What is it composed of?
What role does Glycocalyx play in reabsorption?
Carb rich layer coating the inner surface of the capillary vessel.
Composed of proteoglycans and glycoproteins therefore….
disrupts oncotic gradient (because its so high in proteins) AND prevents reabsorption of capillary beds due to creating a physical layer acting as a barrier
Compare and contrast the CV system and the lymphatic system
CV: closed, circular
Lymphatic: open, one way
This isn’t a question, just general things lymph system does specifically. She outlines four functions later that are less specific.
Recognizing, filtering and destroying bacteria, waste and other toxins
Launch immune system via T lymphocytes
Regulate lymph fluid volume
What are afferent lymph vessels?
bring unfiltered fluid to the lymph node for filtering
What are efferent lymph vessels?
Carry clean fluids away from the lymph nodes to the CV system to help form plasma in the blood
Is the lymphatic system a high or low pressure system?
low pressure
Where does lymphatic system pressure exceed CV system pressure?
What is the relevance of this?
The venous angle: therefore this is where the lymph gets dumped back into the CV system
Final common pathway of lymph
venous angle
At the level of the nodes what happens to excess water?
Excess water is given back to the venous side of the blood
3 major lymphatic functions
1) recycles proteins
2) immune surveillance: infection, cancer, removal of debris
3) Transportation of digested fat
Why is lymph responsible for filtering macromolecules?
They don’t fit through normally places, they generally require active transport, but not in lymph system
What is the significance of terminal ends to the lymphatic system?
Because they are tethered into the soft tissue, as tissue swells the anchoring opens and pores form allowing macromolecuels to fall i
Where do lymph capillaries sit?
just sub-epidermal;
Do lymph capillaries or lymph collectors have valves?
Lymph collectors
What part of the lymph system has anchoring filaments that create pores?
Lymph capillaries
Lymphangion is what
What is its pump?
“lymph heart”
No central pump! piggy backs on respiration, increased heart rate, MSK pump
Describe lymph collectors
Its a transport vessel: Valved
Highly muscular
Innervated by ANS
Resting rate of 6 beats/min
With ANS stimulation what happens to the rate of lymphangion?
increased rate
As more fluid is absorbed into the collector, the more the walls stretch and what is the result?
the more they end up contracted pulling more fluid towards CV system
What is the relevance of the lymphangion piggy backing on other systems
Exercising increases HR and MSK pump therefore increasing flow through the lymphatic system
Where are lymph collectors located?
superficial to fascial planes
What is in the lymph?
Protein, water, WBC, lymphocytes, CA cells, bacteria, viruses, fat, cellular debris, other debris (tattoo)
What two forces did Starling neglect?
COPi
Interstitial pressure
What do COPi and Pi do in terms of ultrafiltration
COPi: assists ultrafiltration
Pi: resists ultrafiltration
In a normal situation are COPi & Pi varrying much?
no
When does COPi typically come into play
when there is lymphatic dysfunction; when this happens proteins accumulate in the soft tissue, proteins attract water, and all this attracted water can’t go into lymphatic channels bc their bound into the soft tissue
When does Pi typically come into play
old age, planes. Pi is reduced therefore its ability to resist ultrafiltration (its normal function) is slim
What is something we do as PT’s to increase Pi?
Compression therapy
Is lymphydema normally bilateral or unilateal
both
Is acute DVT generally bilateral or unilateral?
Unilateral
Is a tumor causing swelling generally going to cause it unilaterally or bilaterally?
unilaterally
Is arthritis generally going to cause unilateral or bilaterally swelling?
unilateral
Is post thrombotic going to cause unilateral or bilateral swelling?
Unilateral
Chronic regional pain syndrome cause unilateral or bilateral swelling?
Unilateral
name the two diagnoses that can lead to both unilateral and bilateral swelling
Lymphydema
Venous insufficiency
Does trauma normally cause unilateral or bilateral swelling?
Unilateral
What is the key take home message for unilateral limb swelling
an UNEXPLAINED unilateral limb swelling is a tumor or clot until proven otherwise
Name some symptoms of an acute DVT
Sudden onset, painful, cyanosis, + homan’s, risk of PE, Wells Rule, dx by doppler US, venous obstruction/passive hyperemia
Explain Homan’s sign and what it is testing for
Testing for a DVT
PASSIVELY and abruptly dorsiflex the foot and squeeze the calf
Pain = +Homan’s
Explain what the Wells Rule is used for
placing patients into high, mod or low risk for DVT based on symptoms or characteristics
Explain the Wells scoring
> or = to 3 is high risk
1-2 is moderate risk
<1 is low risk
What is the Gaiter distribution and what is it a sign of?
Gaiter distribution: darkening flesh from ankle to the knee
Sign of venous insufficiency
What is hemosiderin staining a sign of?
CVI
Pt presents with decreased hair, and subjectively tells you their legs don’t sweat. You notice brawny skin, and pain above the medial malleolus. This is all consistent with what physiological occurrence?
CVI
How does arthritis affect hemodynamics?
arthritis = chronic inflammation
inflammation –> vasodilation –> increase in BCP –> active hyperemia –> increase in ultrafiltration
What medications are associated with edema/fluid retention?
Used for what chronic illness?
NSAIDS, steroids
Used for arthritis
CA is likely to cause passive or active hyperemia?
Passive, tumor causing obstruction
Are post-surgical or traumatic edema high or low protein?
Active or passive hyperemia?
High
Active leading to increased ultrafiltration
Name characteristics of edema stemming form systemic diseases
Always bilateral LE
Pitting
Ascites: abdominal swelling + LE’s
Anasarca: full body edema / “third spacing”
Explain the mechanism of “third spacing”
poor nutrition and falling albumin. Falling albumin = low protein = little ability to carry water. CV system is overloaded an cannot deal with the fluid
Low albumin =
High albumin =
Low = malnutrition, inflammation, liver disease
High = dehydration
When are pts albumin levels tested?
Liver disorder
Fatigue or weight loss
Nephrotic syndrome: swelling around eyes, belly or legs
To check nutritional status
Is CHF and cardiac edema active or passive hyperemia
passive
Name some characteristics of cardiac/CHF edema?
bilateral, pitting, resolves with elevation, no pain
Dyspnea, orthopena (SOB when lying flat) paroxysmal nocturnal orthopnea, jugular vein distention
Explain sufficiency edema
Normal lymph system
High protein edema
intermittent, easily solved: trauma or surgery
Explain dynamic edema
Normal lymph system
Passive hyperemia
Low protein edema
CHF, renal&liver disease, DVT, CVI, tumor
Explain mechanical edema
- primary
- secondary
both have high protein edema
LYMPHYDEMA
Primary: lymph system is abnormal
Secondary: lymph system is damaged
Explain combined edema
Lymphatics are failing
Mixture of high and low protein edema
- High: lymph nodes failing
- Low: veins failing/passive hyperemia
BCP net effect in soft tissue
Low protein edema
COPp net effect in soft tissue
Low protein edema
What is the most stable of the four hydrostatic pressures?
When does it change?
COPp
Changes in severe illness –> increase in ultrafiltration
When does Pi decrease?
Increase?
Decreases: Planes, aging, long term stretch of tissue
Increase: compression of tissues
Net effect of COPi?
High protein edema
What happens to COPi when the lymphatic system is damaged?
COPi increases
Irritating nature of this fluid leads to fibrosis and associated skin changes
name some treatments for edmea
- medical management of illness!
- PRICE for traumatic soft tissue injuries
- ESTIM: poor evidence
- Kinesiotaping
- Compression garments is key for chronic edema!
What does PRICE stand for
Protection Rest Ice Compression Elevate
Lymph system connects interstitial space to what?
venous return
Are lymphatics located endofascial or epifascial
Epifascial: outside of muscle compartments
Superficial lymphatics are absorptive in __________ tissue
subepidermal
Where are regional nodes concentrated
Neck, mesentery, and “roots” of limbs
Name the main areas these regional nodes drain
Cervical
Axillary
Inguinal
Cervical: head, neck above clavicular area
Axillary: arm, breast, trunk
Inguinal: leg, lower trunk, superficial genitals
What is the normal transport capacity of lymphatic system for water? for protein? and how much can it increase short fold
Water: 2-4 L/day
Protein: 75-100 g/day
Can increase 10 fold in short term
Match the primary lymphedema disease to their timing of presentation
Lymphedema Praecox
Milroy’s Disease
Lymphedema Tarda
After age 35
Birth
Adolsecence
Milroy’s Disease: birth
Lymphedema Praecox: adolescencemost common
Lymphedema Tarda: after age 35
Explain secondary lymphydema and give examples
Known trauma to lymphatics: surgery, trauma, radiation therapy, filariasis (#1 cause worldwide - parasite from mosquito), infection, metastisis, iatrogenic
General idea of lipedema
pathological deposition of fatty tissue below the waist resistant to diet
Normally women: strong hormonal linkage
Two co-morbidities that can be related the CVI
- morbid obesity
- post phlebitic syndrome: CVI after DVT
Comorbidities associated with lymphedema
CVI
Angiodysplasiasis
Lipedema
Signs and symptoms of lymphydema
Swelling,numbness, tingling, stiffness, pain, aching, heaviness, infection, redness/heat
What two conditions normally create pitting edema
CHF/cardiac edema and systemic disease
Explain the 4 stages of lymphedema
O: latency, reduced capacity - no apparent swelling but may have clinical symptoms
I: pits with pressure, spontaneously reversible with elevation
II: non-pitting, does not reverse w/elevation
III: elephantiasis - significant skin changes (severe fibrosis)
If edema is bilateral first and foremost are you guessing lymphydema or other medical condition?
Medical condition: CHF, systemic disease
What is Stemmer sign and what does it tell you?
+ if fold of skin lifted at base of toe is thickened or impossible to life
+ = lymphedema: tells you reactive fibrosis of soft tissue
Lymphedema Praecox presentation
- adolescent onset
- insidious onset
- pain free
- asymmetric
- (+) Stemmers sign
Is this presentation primary or secondary lymphydema?
Sever trauma from MVA at age 30, recurrent hx of open wounds, + stemmer sign
2ndary
What does, vascular hyperplasia, hemangiomas, tissue and bone hypertrophy signal
Primary lymphedema
Does lipedema have + or - stemmers sign
-
What is this clinical presentation consistent with?
Soft lumpy tissue, painful to palpation, easily bruises, - stemmers sign, symmetrical distribution, orthostasis with dependency
Lipedema
When is it common for lymphydemas to start after CA tx?
1.5 yrs
What are things you want to evaluate with lymphedema
Circumferential measurements, volumes, AROM, strength, skin condition, tissue texture, FUNCTION!
Describe the intensive phase of CDT
- Manual lymphatic drainage
- multilayer compression bandaging
- exercise to increase MSK pump
- meticulous skin care
Describe the maintenance phase of CDT
- Garment wear
- Compression at night
- Exercise
Manual lymphatic drainage effects
- increases absorption of fluid and protein by capillaries
- increases lymphangion activity
- diuresis
- relaxation
- analgesic
Contraindications to compression
Precautions?
Contraindications: Acute infection, arterial disease, acute CHF
Precautions: decreased sensation, limb paralysis
Compression increases or decreases interstitial pressure?
Ultrafiltration?
Increase Pi
Decreases ultrafiltration
Are high stretch or low stretch bandages safe to wear 24/7
low stretch bc they have low resting pressure
high stretch/ace bandages should be used short term
Effects of low stretch bandages
- Increase Pi
- Reduce ultrafiltration
- Increase MSK pump
- reshape irregular limb profile
- reduce fibrotic changes
true or false: the role of elastic garments is to reduce swelling?
FALSE: it is to maintain limb reduction or prevent limb from swelling
True or false: elastic bandages enhance the MSK pump?
False! low stretch bandages do
Where do you want the most pressure when wrapping
distally
Are flat knit or circular knit generally custom?
Flat knit
Does flat knit or circular knit have better containment?
Flat knit
What time of day do you wear elastic compression garments?
Daytime only!
Explain LaPlace law?
Pressure inversely proportional to radius
Small limb radius = more pressure
Large limb radius = less pressure
