Quiz 7 Flashcards
Below is Quiz 7 material on Lymphatic System
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1) Starling’s law / hypothesis / equilibrium / theory of fluid dynamics:
1A) Is this the Frank Starling model/Law?
2) Explain anatomy and physiology of blood (CV system) CAPILLARY EXCHANGE:
3)
- Fluid moving OUT of capillaries at arterial end is called: ____________
- Fluid moving IN to capillaries at venous end is called: _____________
4) Explain:
Plasma hydrostatic pressure
Tissue hydrostatic pressure
Plasma colloidal oncotic pressure
Tissue colloidal oncotic pressure
1) States that the fluid movement due to filtration across the wall of a capillary is dependent on the balance between the hydrostatic pressure gradient and the osmotic pressure gradient across the capillary.
1A) Frank Starling Law has to do with the heart. The more EDV increases, the more SV increase. Starling Law though has to do with capillary pressure gradients to move fluid in and out of capillaries.
2) Capillaries are obviously between arteries and veins (actually arterioles and venuoles), and throughout all tissues of the body. It is where blood circulates to deliver O2 to tissues and removes metabolic waste of CO2 to return it to lungs to exhale out.
3)
Fluid moving OUT of capillaries at arterial end is called: FILTRATION
Fluid moving IN to capillaries at venous end is called: REABSOPTION
4)
Blood from arterial end typically goes right to veins (90%), but some (10%) stays OUT of capillary into interstitial space (from a POSITIVE net filtration pressure) into lymphatic system (their capillaries are right there too and extra 10% goes into lymphatic system).
GOES FROM HIGH PRESSURE TO LOW PRESSURE (so a hydrostatic pressure in capillary of 33mmHg and pressure of 20mmHg outside in interstitial space causes a net filtration pressure of positive 13, so fluid flows from HIGH Pressure to LOW pressure, so it goes out of capillary.
So hydrostatic pressure in capillary at venous end is thus LOWER than interstitial / tissue space pressure, causing fluid/molecules to move from HIGH pressure (outside capillary in the tissues) to lower pressure inside capillaries.
You have 4 pressures: Plasma hydrostatic (blood in artery), plasma osmotic (blood at vein end), tissue/interstitial hydrostatic (outside in tissue at vein end), tissue/interstitial osmotic (outside in tissue at artery end)
Hydrostatic = push out
• Plasma hydrostatic pressure pushes fluid OUT of the
capillaries (and into the tissues) at artery end
• Tissue hydrostatic pressure pushes fluid OUT of the
tissue or interstitial space (and into the capillaries) at
vein end
Osmotic = pull in (trying to balance out the concentration with PROTEINS)
• Plasma osmotic pressure pulls fluid INto the
capillaries (and out of the tissues) at vein end
• Tissue osmotic pressure pulls fluid into the tissues
(and out of the capillaries) at artery end
While all 4 of these pressures are at work in varying degrees across the entire capillary bed, 2 play a
bigger role on the arterial side, and the other 2 on the venous side:
• Arterial side (pushing fluid/blood into the tissues)
a. Plasma hydrostatic
b. Tissue osmotic
• Venous side (pulling fluid/waste into the capillary)
a. Plasma osmotic
b. Tissue hydrostatic
1) What are Lymphatic capillaries
1A) Another name for lymphatic capillaries:
2) “Collecting lymphatics” are:
3) Lymph trunks:
4) Thoracic duct:
5) Right lymphatic duct:
6) Lymphangion:
6A) Do lymph vessels have valves to prevent lymph backflow?
7)
Afferent lymph vessels
Efferent lymph vessels
1) Lymph capillaries (or lymphatic capillaries): tiny capillaries located in and around blood vessel capillaries in interstitium which serve to drain and process extra-cellular fluid that leaked out of blood capillaries (which is that 10% that does not go back into capillary but stays in tissue/interstitial space).
1A) Precollectors
2) Lymph vessels
3) Lymph trunk is a collection of lymph vessels (or lymph vessels drain into trunks) that carry lymph, and is formed by convergence of many efferent lymph vessels. These trunks in turn drain into one of the two main lymph ducts (right lymph duct and the thoracic duct).
4) The MAIN lymph vessel of the lymphatic system, passing upward in front of the spine and draining into the LEFT subclavian vein near the base of the neck. All lymph vessels and trunks from both legs and entire LEFT side of body drain into thoracic duct (which drains into L subclavian vein).
5) Right lymphatic duct: It drains lymphatic fluid from the RIGHT thoracic cavity (this is the section of the trunk on the upper right side), the RIGHT arm, and from the right side of the neck and the head.
6) Section or a single unit of a lymph vessel
6A) YES
7)
- Lymph vessels that carry lymph TO a lymph node are called AFFERENT lymph vessels
- Lymph vessels that carry lymph AWAY from a lymph node are called EFFERENT lymph vessels (think of Efferent as Motor, so has to be AWAY).
1) Connatal vs. congenital
1A) How are the two from #1 typically differentiated?
2) Filariasis
(how to remember)
3) Axillary lymph node dissection
3A) What is a sentinel lymph node:
4) Sentinel lymph node dissection
4A) Why would someone do a sentinel vs. axillary lymph node dissection?
5) Lymphangiodysplasia
6) Anaplasia vs. hypoplasia vs. hyperplasia
7) Lymphangiectasia
(how to remember)
8) Debulking
1) Connatal means present from birth (had it your whole life), where congenital means genetic abnormality (abnormal development).
1A) Connatal means you had it since birth. Congenital is associated with an abnormality or disease.
2) Filariasis: parasitic infection from mosquitoes. Most common way world wide people get Lymphedema.
(remember: fil, fli = fly = mosquitos)
3) An axillary lymph node dissection (ALND) is surgery to remove lymph nodes from the armpit (underarm or axilla). The lymph nodes in the armpit are called axillary lymph nodes. An ALND is also called axillary dissection, axillary node dissection or axillary lymphadenectomy.
3A) The sentinel lymph node is the hypothetical FIRST lymph node or group of nodes draining a cancer.
4) Sentinel lymph node dissection is an alternative to traditional axillary lymph node dissection, and many women believe that it can spare them more invasive surgery and side effects. … Likewise, the sentinel lymph node is the first node “standing guard” for your breast. A Dr. will do an imaging technique using dye and first impacted lymph nodes will get dye first.
4A) Sentinel lymph nodes are closer to breast, so if you can remove those and cure problem, that is best. When it becomes bad you go to Axilla region to remove lymph nodes there. (Remember, the more lymph nodes you remove, the more prone you are to getting Lymphedema). Sentinel lymph nodes are the first lymph node(s) where breast cancer is likely to spread. The surgeon removes the sentinel node(s). … If cancer is present, more lymph nodes may be removed with a procedure called axillary dissection.
5) Has to do with enlarged lymph vessels … associated with PRIMARY lymphedema.
6) Cells changing (indication of Cancer), fewer number of cells, increased number of cells
7) Lymphangiectasia: This disease is characterized by LYMPHATIC VESSEL DILATION, chronic diarrhea and loss of proteins such as serum albumin and globulin. It has to do with SECONDARY or ACQUIRED lymphedema.
(angie always blew things out of proportion … dilated ….
in a fantasia way).
8) Debulking is the reduction of as much of the bulk of a tumour as possible. It is usually achieved by surgical removal. To remove fibrosclerotic connective tissue.
You are a physical therapist in an outpatient setting providing physical therapy care for a man who has Stage 1 lower extremity lymphedema secondary to an inguinal lymph node dissection. He asks you why his doctor keeps talking about avoiding abrasions or insect bites on his leg. Why is this so important?
This pt. has secondary lymphedema due to cancer treatment that removed nodes. As such, he needs to avoid reinjuring the effected area. Insect bites can cause a parasite to get into blood stream and thus potentially into lymphatic system, which could exacerbate the lymphedema.
During your interview with a patient, he reports that he had “blood poisoning” following a spider bite on his forearm. He says that he’s had bites before that didn’t poison his blood. What happened this time?
He probably got bitten by a mosquito
Lymphangitis is when lymph vessels swell / inflame as a result of a bite. It looks like red streak or blood poisoning.
You are a physical therapy student affiliating in an acute care setting. You and your clinical instructor are providing physical therapy care for a 52 year old woman who underwent a right radical mastectomy two days ago. During the treatment session today, your patient confides in you saying her worst fear is that her arm will swell up and she won’t be able to use it. Respond to her.
One of the common side effects of a mastectomy is removing lymph nodes which can cause lymphedema. It is critical for the patient to watch it and come in on any sign of swelling or lymphedema. Exercise helps. Compression bandages help. Elevation helps. But that just cause she had proceedure does not mean necessarily she will get lymphedema.
Compare and contrast the movement of bodily fluids by the cardiovascular system and the lymphatic system from the heart through the arteries and tissues back to the heart:
We know the heart pumps BLOOD out through arteries to arterioles, through capillaries to tissues. Cardiovascular system pumps blood out to tissues, and then blood back. It is a closed system. Then tissues send most fluid (blood, plasma, etc.) back through capillary through venuoles, through veins and back to heart.
The Lymphatic system only sends fluid BACK to the heart About 90% of blood/fluid goes through arteries-capillaries-vein route. 10% or so goes through lymphatic system.
1) Function of lymphatic system:
2) What is lymph?
2A) What is lymph composed of? And what is NOT in lymph?
3) What are lymph vessels
4) What are lymph nodes
5) Other important organs that are part of lymph system
6) Before lymph becomes lymph (by entering lymphatic system) it was called what:
7) Lymphatic vessels dump lymph into:
8) Where do lymph vessels start:
9) How does lymph move throughout the body:
10) What is route of lymph back up to heart:
11) Right lymphatic duct drains what part of the body
12) Main duct of lymphatic system is:
13) From #12 above, it drains what areas of body:
1)
- FILTERS lymph fluid to fight and protect against foreign invadors, infections, bacteria. FIGHTS INFECTION since lymphocyte cells are in lymph nodes to fight foreign invadors.
- Maintain fluid balance (to prevent edema)
- Assist in removal of cellular debris and waste (drain interstitial spaces near capillaries).
2) Lymph is fluid which has been absorbed into the lymphatic system from the interstitial spaces. Not blood, but fluid leaked from blood.
2A) Lymph contains a variety of substances, including proteins, salts, glucose, fats, water, and white blood cells. Unlike your blood, lymph does NOT normally contain any red blood cells.
3) Vessels that return this lymph fluid back to the heart. There are peripheral and deep vessels (peripheral runs to deep, which those run back up to heart paralleling the veins). MOST lymph vessels are superficial though.
4) Are throughout lymph system/vessels, and are little collecting spots to filter the lymph to fight foreign objects. In the lymph nodes, lymphocyte cells are created as part of body’s defense system. Lymph nodes are immune system checkpoints at which lymph being transported back to the blood vessels is inspected and filtered of foreign matter, including antigens.
5) Spleen, thryroid, thymus, tonsils, bone marrow
6) Interstitial fluid
7) Subclavian veins (well … lymph vessels dump lymph into lymphatic TRUNKS, which dump into lymphatic DUCTS, which drain into subclavian VEINS).
8) At capillaries, absorbing excess fluid not sent through CV system (interstitial fluid).
9) The lymph is moved through the body in its own vessels making a one-way journey from the interstitial spaces to the subclavian veins. Since the lymphatic system does not have a heart to pump it, its upward movement depends on the motions of the muscle and joint pumps.
AND, deeper vessels run parallel with veins … and like veins, these vessels have VALVES which prevent back flow.
10) Generally, lymph flows away from the tissues from superficial to deep vessels that run with veins. Most vessels are superficial though. They go to lymph trunks -> lymph ducts -> Subclavian veins. They pass through lymph nodes and eventually to either the right lymphatic duct or the largest lymph vessel in the body, the thoracic duct. These vessels drain into the right and left subclavian veins respectively.
11) Right arm, right neck and head, and right thorax area
12) Thoracic duct
13) Rest of the body (everything not included in Right Lymphatic duct)
1) What are the main functions of the lymphatic system:
1) One way vessel system that drains the excess 10% interstitial fluid and plasma proteins, filters it for foreign materials, and returns it to the CV blood circulation system.
- FILTERS lymph fluid to fight and protect against foreign invadors, infections, bacteria. FIGHTS INFECTION since lymphocyte cells are in lymph nodes to fight foreign invadors.
- Maintain fluid balance (to prevent edema)
- Assist in removal of cellular debris and waste (clear interstitial space)
1) Why would an individual develop lymphedema months or years after a surgery?
1) The Dr’s takes out nodes in a certain region and effects happen years later … not really sure why? Removing a node will cause scaring in that area, and then lymph builds/pools up over time and can’t get around scaring area. It slowly builds up.
1) What are Lymphotomes (or Lymphatic Territories)
2) What are watersheds
3) Lymph drainage territories =
4) How many lymphotomes is the trunk seperated into:
5) From 4 above, explain each
6) Explain route of lymph from lower limbs up
1) Distinct regions of the body for fluid drainage (like a dermatome) … where certain vessels drain into a similar node.
2) Division areas between lymphotomes where direction of lymph flow changes. Lymph drains in different directions on either side of a watershed. On the trunk, the direction of flow changes at the lymphatic watersheds. Lymph vessels on either side of the watershed transport lymph fluid to the left/right side of the trunk and to the upper (axillary)/lower (inguinal) lymph nodes, respectively.
3) Lymphotomes
4) 4
5)
- R and L Thoracic: drain into AXILLA nodes with the ipsilateral R or L UE lymph vessels.
- R and L Abdominal: drain into R or L INGUINAL lymph nodes
6) From superficial lymph vessels to deep (most are superficial). Starting from feet up to popliteal lymph nodes, then up to inguinal region lymph nodes. Then pelvic nodes, abdominal nodes, cistern chyli, thoracic duct, and finally into left subclavian vein. The right side goes from distal R UE up to axilla into right lymphatic vessel (through nodes all along the way) dumping into R subclavian vein.
1) What is the function of lymph nodes
2) Describe lymph node characteristics, and when should a PT be concerned:
1) These are FILTERS throughout the lymphatic system. They clean up waste products and cellular debris. They also produce LYMPHOCYTES and MACROPHAGES to kill foreign invaders.
2) If a PT can actually palpate a lymph node (small bean like projection under the skin), it may be enlarged, tender, red, etc. Usually you can’t see or palpate most of them. If they are seen by eye or palpable, the pt should have them checked out by their physician.
1) Lymphadenopathy:
2) Lymphadenitis:
(how to remember)
3) What is the difference between Lymphadenopathy and Lymphadenitis:
4) Lymphangitis:
4A) How to tell difference between Lymphadenitis and Lymphangitis:
5) Lymphedema:
6) Lipedema:
6A) Will the foot be swollen with Lymphedema or Lipedema?
7) Lymphoscintigraphy / Lymphoscintigram
8) Lymphangiectasia:
1) Lymphadenopathy: DISEASE OF LYMPH NODES, where they are abnormal in size or number. Swollen or enlarged from an infection or something.
2) Lymphadenitis: Swollen LYMPH NODES (inflammation/infection of the lymph nodes). Itis = inflammation.
(Remember: the D in denitis is for noDe)
3) Lymphadenopathy is the DISEASE or pathology of the enlargement of the lymph nodes, where Lymphadenitis is the actual swelling of the nodes (so MANIFESTATION of the disease).
4) Lymphangitis: Inflammation of lymph vessels
4A) Lymphadenitis has a D, and so it is for noDe (d in node … no D in lymph vessel).
5) Lymphedema: Also known as lymphoedema and lymphatic edema, is a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system. Swelling caused by blockage of lymphatic system. It is localized fluid retention and tissue swelling caused by compromised lymphatic system.
6) Lipedema: A disorder where there is enlargement of both legs due to deposits of FAT under the skin. Mainly in women … excess FAT DEPOSITS that can’t be lost through diet or exercise. From HIP TO ANKLE … Swelling of BOTH legs (bilateral) from hips to ankles from deposits of fat in legs. ** WITH LIPEDEMA the foot is NOT effected. Whereas with lymphedema, the foot could be swollen as well **
6A) Lymphedema
7) Lymphoscintigraphy: is an IMAGING technique used to IDENTIFY LYMPH DRAINAGE. A die is injected so it can disperse to the closest lymph node. Determine the number of sentinel nodes, differentiate SENTINEL NODES from subsequent nodes, locate the sentinel node in an unexpected location, and mark the sentinel node over the skin for biopsy.
It’s an arthogram for lymph vessels
8) This disease is characterized by lymphatic vessel DILATION, from secondary or acquired lymphedema. Chronic diarrhea and loss of proteins such as serum albumin and globulin are s/s.
1) What are the main 2 classifications of Lymphedema, and what causes them:
2) What are the stages of lymphedema
1) Primary or Secondary
- Primary: Idiopathic (don’t know how it starts … no known etiology), present from birth … INHERITED. Probably a developmental abnormality in the fetus (hypo or hyperplasia of cells).
- Secondary: ACQUIRED lymphedema, from injury or cancer treatment, surgery (mastectomy), damaged or removed lymph vessel / node, mosquitoes (Filariasis), worm larvae bite, etc.
2)
- Stage 0: Latent, early phase, lymph transport is impaired slightly, no evidence of swelling/edema, but fatigue and pain. NO edema present yet. No tightness.
- Stage I: It is reversible, Pitting edema, reverses with elevation, increases with activity or heat, Inflammatory response to eating protein, subcutaneous tissues begin to fibrosis.
- Stage II: Nonpitting, can’t reverse it, and doesn’t reduce with elevation, fibrosis present, and skin now changes. Start feeling tight.
- Can’t use manual lymph drainage.
- Stage III: This is ELEPHANTITIS, severe nonpitting, leathery keratotic skin, skin folds with tissue flaps, nonpitting fibrotic edema, atrophy, connective and scar tissue
What is fibrosis:
The thickening and SCARRING OF CONNECTIVE TISSUE, usually as a result of injury.
1) What are the structural impairments or failures that result from lymphedema:
2) What are some functional impairments or failures that result from lymphedema:
1)
- Damaged or narrowed vessels
- Torn anchoring filaments
- Valves being ruined
- Gaps or tears of lymph vessels
- Filariasis: parasitic infection from mosquitoes
2) Anything that causes a change or lack in tissue pressure (muscles pressure to help lymph flow):
- Bed rest
- Paralysis of lymph vessels
- Prolonged immobility
- Spasm of lymph vessels
- Impaired contraction of lymph vessels
1) How can lymphedema be prevented:
1)
- Primary:
- not anything you can do really (born with it)
- Secondary:
- if you had a treatment, protect limb from further injury
- Avoid heavy activity with involved limb
- Avoid heat on limb
- ELEVATE the leg
- Avoid tight clothing
- Avoid blood pressure cuffs on that area
- Keep limb clean and don’t let skin break
- Don’t gain extra weight
1) What is Stemmer’s sign
2) So how is Primary Lymphedema diagnosed?
3) How is Secondary Lymphedema diagnosed?
4) How do you treat lymphedema
1) Stemmer’s sign is a thickened fold of skin at the base of the second toe or second finger that can be gently pinched and lifted. The presence of this sign is most often an early diagnostic indication of PRIMARY LYMPHEDEMA; however, it can also develop later in secondary lymphedema.
2) Typically through the Stemmer’s sign
3) Medical test/exam, Unexplained swelling, lymphoscintigram (arthogram for lymph vessels), circumferential measuring.
4) If triggered by cancer, treat cancer first, then lymphedema. No real good medications. Could do surgery (limited success). But do Manual lymphatic drainage, compression garments, keep leg elevated, exercise.
1) What is the role of the PT to manage patients with Lymphedema
2) Why is knowing the anatomy of the lymph system so important to know as a PT
3) How does the role of the PT change depending on what stage the lymphedema patient is in:
1)
- MLD = manual lymph drainage … gentle manual therapy with basic strokes to improve activity of intact lymph vessels. Push fluid gently away from involved lymph nodes.
- Short stretch compression bandaging: Low pressure bandage to increase interstitial fluid pressure.
- Exercise while avoiding high risk activities
- Compression garments
- Education (anatomy, garment care, self-bandaging, self massage, infection management)
- Compression pumps
- Skin care
2)
- Which direction to apply pressure / treatment in (based on lymph node areas, watershed, lymphatomes).
- Know when and where to stop treatment … to push fluid excess away from involved lymph nodes to areas of uninvolved lymph nodes.
- Know how and where to apply bandaging
- PT’s will see pt’s in any setting with Lymphedema
- What exercises to prescribe, and what activities to avoid
- How to help with bandaging and compression devices
- Risk for infection
- Need to keep limb elevated
- AVOID heat
3)
- Stage 0: Warn patient, primary prevention, education
- Stage 1: Educate pt on elevating limbs, compression garments, exercise, some manual therapy (MLD), try to minimize condition.
- Stage 2: Caution with manual therapy (MLD), education, and remember elevation will NOT help.
- Stage 3: Elaphantitis … not much you can do, probably requires surgery (and these are typically only seen in 3rd world countries).
1) Describe differences of acute vs. chronic lymphadenitis:
1)
- Acute: local (like in cervical region) associated with an infection in that area. So cervical area could be from an infection in teeth or nose draining to cervical lymph nodes. Axilla area’s swollen lymph nodes could be from some infection in UE’s. You’ll see enlarged or swollen lymph nodes.
- Chronic: Long lasting, lymph nodes swell and then scar with fibrosis. Nodes are large and firm to palpate.
1) What again is Lymphangitis
2) How might you be able to spot or tell someone had this
3) How might you treat this:
1) Inflammation (swelling) of lymph vessels
2) RED STREAKS. Starting in the place of the infection up to the lymph nodes is a red streak. Red streak looks like “blood poisoning.”
3) Elevation, rest, immobilize, antibiotics and Dr’ help, manual lymph drainage, exercise
1) What again is Lipedema:
1)
- Swelling of BOTH legs from hips to ankles from deposits of fat in legs.
- Occurs more often in women
- FEET are NOT involved with lipedema
- Stemmer’s sign is NOT present with Lipedema
- Bilateral symmetry where in lymphedema typically it is not as symmetrical bilaterally.
1) T or F: Lymphatic system is just like CV system where it is a 2-way highway system of vessels to and from the heart?
2) What % of fluid/blood flows through capillaries, and what % goes into lymphatic system
3) How does fluid go in/out of capillaries, and into lymphatic system
4) Explain path of lymph fluid from entry point to heart
5) Main functions of Lymphatic system are:
6) Lymphotomes are seperated by what:
7) Review the lymph drainage through body:
8) Is lymphedema more common in men or women
9) Most common world-wide reason people get lymphedema:
10) What drugs are there for lymphedema:
1) False. It is a ONE way vessel system from interstitial spaces of tissue BACK to the heart.
2) 90% through capillaries, and 10% through lymphatic vessels
3) Diffusion based on pressures in and outside of these vessels (hydrostatic and oncotic/osmotic pressures). The 10% left over in interstitial spaces obviously is higher pressure than lymph capillaries, so lymph vessels pick it up since fluid goes from high to low pressure areas.
4) Extracellular fluid (10%) → precollectors / lymphatic capillaries → initial lymphatic vessels → larger collecting vessels → lymphatic trunks → lymphatic ducts → subclavian veins
5)
- Maintain fluid balance
- Fight infection
- Assist in removal of cellular debris and waste at capillary spaces
6) Watersheds
7)
- RIGHT SIDE OF BODY: R UE and R thoracic lymphotome → R lymphatic duct→ R subclavian vein
- THORACIC: L UE, L thoracic lymphotome, Bilateral LEs, external genital areas, abdominal lymphotomes → the L subclavian vein via the thoracic duct
8) Women
9) Filariasis (mosquito bite)
10) Not many … maybe a diuretic to decrease sodium retention (but I’d argue that could release more fluid in interstitial space).
1) What does lymph system pick up:
2) Lymph vessels follow/parallel veins, except in what area:
3) Can you palpate lymph vessels?
4) What MAIN areas are there lots of nodes
5) When would lymphedema happen?
1) Fat cells, cancer cells, macrophages, and proteins (larger molecules typically)
2) Gut
3) NO
4) R/L axilla, R/L inguinal region, popliteal, cervical, retroperitoneal node sites, elbow
5) When high protein edema / volume exceeds transport capacity of the lymph system, after a surgery with lymph nodes removed, trauma or injury to a vessel/capillary/node.
REVIEW:
1) What is primary lymphedema
2) What is secondary lymphedema
3) Biggest predictor of someone getting lymphedema?
4) Can someone develop lymphedema with only 1 node being removed?
1) Congenital, genetic
2) Acquired from cancer, surgery, injury, node removal, infection, toxins, parasites, etc.
3) How many lymph nodes are removed
4) Yes, absolutely.
1) What is the prostate gland
2) What is prostate cancer
3) How do they treat prostate cancer:
4) If prostate is removed, what should NOT be viewed / seen in tests? If it is detected, what do you do?
5) T or F: Typically secondary lymphedema is a result of a cancer treatment, surgery, injury?
6) Lymphedema is primarily measured how:
7) Why measure the circumference of lymphedema:
1) Stores and secretes fluid with semen and seminal vesicle fluid during ejaculation
2) Prostatic cancer cells can spread via the pelvic lymphatics to the nodes around the internal and common iliac arteries
3) DaVinci robotic prostatectomy removes the prostate gland, the internal urinary sphincter, and the prostatic urethra
4) PSA (prostate specific antigen) level is zero (if prostate removal worked properly). If you see something, then you need to do radiation.
5) True
6) Circumferential Measurements. Diagnosis of lymphedema requires at least a 2 cm difference in circumference between the uninvolved and involved extremity
7) Circumferential Measurements serve 3 purposes: to determine patient’s progress, record progress for insurance purposes, and a tool to assess your overall success of your program
Review Stages and Severity of Lymphedema progression
Stage:
I- Spontaneously REVERSIBLE
II- Spontaneously IRREVERSIBLE
III- Lymphostatic ELEPHANTITIS (very uncommon in
U.S., you see in 3rd world countries)
Severity
Minimal <20%
Moderate 20-50%
Severe >50%
(This % compares involved limb to uninvolved limb, and
this only works with unilateral lymphedema)
How do we treat Lymphedema:
- Manual lymph drainage
- Compression garments
- Exercise
- Pumps
- Medications (very limited)
- Surgery (may not cure, and can lead to more lymphedema)
Also:
- Look for red streaks, signs of infection, open wounds
- Avoid heavy lifting or dangerous sports/activities
1) What is manual lymph drainage:
2) Explain how you would do this:
3) What area do you NOT want to push fluid to?
1)
- Very light stretch to the skin to stimulate the lymphatics. You are essentially pushing lymph fluid away from involved node/limb/area - and you push lymph up/out/away from that area to an uninvolved node.
- It clears the involved nodes
- Opens the vessels for more lymph transport
- Pushes fluid from involved lymph nodes (areas) to uninvolved lymph nodes (areas).
2)
*** You start proximal and then move distal. So start at shoulder and clear it. Then move to elbow and clear it out. Then move to wrist and clear it out. With LE, start at hip and move it up to trunk. Then go to thigh. Then to knee. Then to ankle.
3) Genitals
For compression garments, you should increase pressure based on severity. So stage 1 is lighter compression, stage 2 is more/tighter compression garment.
You should wear this garment day and night, during exercise, etc.
ok
T or F: Lymphedema is curable
T or F: Temperature effects lymphedema
T or F: Altitude can effect lymphedema
T or F: Most lymphatic vessels are superficial above muscles. Why is this important to know?
FALSE. At this time, it is NOT curable, but rather manageable
True
True
True. You don’t have to press (manual therapy) too hard since the vessels are so superficial.
What things can make lymphedema be a life-long issue … and you should caution your patients about:
- Infections
- Circulatory compromises (like tight clothing, snug watches, tight socks, etc.)
- Stress to impaired lymphatic system (high elevation, heat, stress, injury, hot shower, etc.)
Phase 1 vs. Phase 2 of PT treatment
Phase 1: pt comes into clinic and PT does all the things listed above
Phase 2: pt does home treatment at home without coming in to pt.
Will exercise increase lymph flow?
Yes. As muscles exercise, they move to act as a pump to help lymph return back up to the heart.
BELOW ARE BINGO ?’s
1) This pressure drives fluid OUT of the capillary (filtration) and is highest at the arteriolar end of the capillary and lowest at the venular end
Notes from #1 above: Pressure inside capillary has to be PLASMA pressure. Pressure outside capillary has to be TISSUE (or interstitial) pressure.
2) This hydrostatic pressure is determined by the interstitial fluid volume and the compliance of the tissue interstitium, which is defined as the change in volume divided by the change in pressure.
3) This pressure within the capillary vessel that is principally determined by plasma proteins to pull fluid from tissues into capillary vessels.
*** NOTES: protiens are BIG part of lymphedema
4) Pressure generated by proteins in the tissue interstitial space to pull liquid from plasma/capillary out into tissue.
5) Tiny thin-walled vessels located in the spaces between cells which serve to capture fluid from the circulatory system and transport it to progressively larger lymphatic vessels
6) Vessels responsible for:
- Collecting lymph from capillaries
- Carrying lymph to and away from the lymph nodes
7) A collection of lymph vessels that carries lymph formed by the confluence of efferent lymph vessels. They drain into one of the two lymph ducts
8) The largest lymphatic vessel, sometimes called the left lymphatic duct
9) Responsible for draining lymphatic fluid from the right thoracic cavity, the right arm, and from the right side of neck
10) Functional unit of a lymph vessel that lies between two valves
11) A small bean-shaped structure that filters substances that travel through the lymphatic fluid; it contains lymphocytes that help the body fight infection and disease
12) Lymph nodes contain
13) Lymph vessels that carry lymph TO lymph nodes. What carry it FROM lymph vessel:
14) A lymph drainage area:
15) Division between lymphotomes; the area that separates 2 lymphotomes
16) Disease of the lymph nodes in which they are abnormal in size, number or consistency
17) What is term for inflammation of lymph nodes
18) What is term for inflammation of lymph vessels / walls of lymphatic channels. AND another term for it?
19) Localized swelling that occurs when lymph vessels are blocked or unable to carry lymph fluid away from the tissues
20) A leading cause of disability world-wide, this disease is caused by parasites that live in the human lymph system
(how is this transmitted, and what type of transmission
is this)
21) A surgical procedure that incises the axilla to identify, examine, or remove lymph nodes:
22) An alternative to axillary lymph node dissection that involved injecting a radioactive dye into area of tumor for tracking the first lymph nodes near area (breast). It is the first area that lights up on the imaging with the die.
23) Abnormal growth of lymphatic vessels often referred to as lymphatic malformation associated with PRIMARY lymphedema
24) Enlarged or dilated lymph vessels caused by a wide range of scarring processes. Also termed ACQUIRED lymphangiomas:
25) Surgical removal of excess tissue (like a tumor)
26) Irregular distribution of fat beneath the skin resulting in symmetric enlargement, usually of the legs and buttocks from fat from hip to ankles.
27) Thickened fold of skin at the base of the second toe that can be gently pinched and lifted seen in early diagnosis of primary lymphedema
1) Hydrostatic (plasma hydrostatic pressure)
2) Tissue hydrostatic pressure
3) Plasma colloidal osmotic pressure (within capillary = plasma. Oncotic/osmotic is proteins)
4) Tissue colloidal osmotic pressure (same as above)
5) Lymphatic capillaries (precollectors)
6) Collecting lymphatics (lymph vessels)
7) Lymph trunks
8) Thoracic duct
9) Right lymphatic duct
10) Lymphangion
11) Lymph nodes
12) Lymphocytes (B and T)
13) Afferent lymph vessels, Efferent lymph vessel
14) Lymphotomes
15) Watershed
16) Lymphadenopathy (aden = node, pathy = disease)
17) Lymphadenitis
18) Lymphangitis (“blood poisoning”)
19) Lymphedema
20) Filariasis
(mosquitos, vector borne)
21) Axillary lymph node dissection
22) Sentinel lymph node dissection
23) Lymphangiodysplasia
24) Lymphangiectasia
25) Debulking
26) Lipedema
27) Stemmers sign
Is heredity a primary or secondary cause of lymphedema?
What is the first stage of nonpitting edema where you do NOT get reduction with elevation is:
*** Lymphedema differs from lipedema how:
Are feet involved in lipedema:
Inflammation of lymph channels (red streak):
Enlargement of lymph nodes is (the overarching disease):
Most common cause of lymphedema world wise is:
*** Manifestations of stage 0 include:
What is Stemmers sign
******* Heat CAN be used in therapy of those with lymph issues IF they have an ________ lymphatic system. You can NOT use heat if there is _______ to lymphatic system.
Acanthosis nigricans =
Primary (primary is idiopathic genetics, secondary is acquired from cancer or surgery or injury)
Stage 2
Lymphedema is not as bilateral, the feet swell with lymphedema, and more of a RUBBERY feel.
NO
Lymphangitis (“blood poisening”)
Lymphadenopathy
Filariasis
Impaired lymph transport, no real edema or skin tightness yet
Thickened skin fold flap of skin on 2nd toe (indication of primary lymphedema)
INTACT, damage
Skin pigmentation disorder that causes darkening and thickening of the skin – feels like velvet
