The Lymphatic System And Lymphedema Flashcards
The lymphatic system is developmentally an offshoot of what system?
The venous system
What is the centrifugal or venous budding theory of lymphatic system development?
The lymphatic endothelium develops from the venous endothelium
What is the centripetal theory of lymphatic system development?
The venous and lymphatic systems develop from undifferentiated mesenchymal cells (stem cells)
The beginnings of lymphatic vessels are seen and main clusters of lymph nodes are seen with what week of embryonic development?
Week 5
What are the roles of the lymphatic system?
To collect and transport tissue fluid from the intercellular spaces in the tissues of the body to the venous system (fluid homeostasis)
Absorbs and transports fatty acids (as Chyle) from the digestive system
Absorbs and transports large molecules (including proteins and cellular debris) which are too large to be collected by the venous capillaries and veins
Plays a role in the immune responses as the lymph transported to the lymph nodes that act as filtering centers in the body
What color is normal lymph?
A clear/yellowish color
What color is Chyle?
Milky white
What are the commonalities bw the CV and lymphatic systems?
Superficial, deep, and organ systems
Similar vessel structure
Leukocytes (both systems contain monocytes and lymphocytes)
Blood plasma (lymphatic system returns filtered blood plasma to the bloodstream)
Serum proteins (lower concentration in the lymphatic system)
Common pathway to the heart
Protection of the body from infection and disease
What are some differences between the CV and lymphatics systems?
The lymphatic system is NOT a closed circulatory system, it’s more of a transport system
There’s no central pump in the lymphatic system
The lymph transport is interrupted by lymph nodes
What does the deep lymphatic system drain?
muscle tissue, tendon sheaths, nervous tissues, the periosteum, and joint structures
Do the deep or superficial lymphatic system transport vessels generally accompany blood vessels and are grouped together in the same membrane?
The deep lymphatic system
How is lymph moved through the lymphatic system?
Through the pumping action of blood through the arteries
What does the superficial lymphatic system drain?
The skin and subcutaneous tissue
T/f: lymphatic vessels are very thin and fragile
True
T/f: lymphatic drainage massage should be gentle to move the superficial tissues not like a deep tissue massage
True
The superficial lymphatic system absorbs and transports lymph via…
The interaction of oncologenic and hydrostatic pressure gradient
Muscle contractions (AROM and isometrics to get the jt and muscle pumps going
Arterial pulsations
Gentle movt of the skin
What are the primary lymphoid organs?
Areas where T and B cells mature
Red bone marrow
Thymus
T and B cells originate in bone marrow, but only ___ cells mature there, ____ cells mature in the thymus
B, T
Where do B cells mature?
In the red bone marrow
Where do T cells mature?
In the thymus
What are the secondary lymphoid organs?
Areas where mature lymphocytes first encounter their antigens and become activated
Nodes
Spleen
MALT (tonsils, Peyer’s patches, appendix)
Diffuse lymphoid tissues
What are the lymphatic organs that produce and store lymphocytes?
Lymph nodes
Lymph vessels
Spleen
Tonsils
Thymus
Peyer’s patches
What are Peyer’s patches?
Small lymph node like structures in the bowel
What is the glymphatic pathway?
Drainage pathways in the CNS
Fxnal lymphatic system surrounding the blood vessels in the brain’s meninges and SC
What is the glymphatic system?
The system that moves immune cells and fluid from the CSF and is connected to the deep lymph nodes in the neck
T/f: clearance of the glymphatic pathway increases during sleep
True
T/f: the glymphatic system may play an important role in neurological conditions like AD and MS
True
What are the lymphatic vessels from smallest to largest and order in which lymph enters the system?
Lymph capillaries
Pre collectors
Collectors
Lymph nodes
Trunks
Ducts
Where do the lymph capillaries originate?
In close proximity to blood capillaries in the interstitial space
What are the lymph capillary walls made of?
A single layer of overlapping endothelial cells (not one continuous tube like blood capillaries)
T/f: lymph capillaries are larger and more permeable than blood capillaries
True
T/f: lymph capillaries are able to absorb macromolecules like protein
True
What is the main fxn of the lymph capillaries?
To absorb fluid in lymph formation
What is the smallest of the lymphatic vessels?
Lymph capillaries
What is referred to as the initial lymphatics?
The lymph capillaries
What are anchoring filaments?
Filaments that attach to the lymph capillary and the surrounding fiber network to pull apart the overlapping layers of the wall for passage of fluids and particles
What do anchoring filaments do?
When the interstitial pressure rises and exceeds the pressure within the lymphatic vessels, the anchoring filaments open the intercellular channels by pulling adjacent endothelial cells apart, allowing the passsage of fluid and particles into the lymphatic vessels
When interstitial fluid is outside the lymphatic vessels, what is it called?
Interstitial fluid
When interstitial fluid enters the lymphatic vessel, what is it called?
Lymph
How much lymph gets TRANSPORTED throughout the body every 24 hours?
1.5-2L
What is contained in lymph fluid?
Proteins
Water
Cells (RBC, WBC, lymphocytes)
Waste products and other foreign substances
Fat (long chain triglycerides, cholesterol, and fat soluble vitamins A, D, E, and K)
What are the two types of lymphatic collecting vessels?
Pre collectors and collectors
What are the lymphatic collecting vessels?
The vessels that transport lymph to the venous system of the circulatory system
What are pre collectors?
The connection bw the lymph capillaries and collectors
What is the main function of the pre collectors?
To TRANSPORT lymph fluid from the capillaries to lymph collectors
What are the collectors?
The vessels that transport lymph fluid to lymph nodes and lymphatic trunks
T/f: the wall structure of lymph collectors is similar to veins
True
Why do the lymph collectors contain valves and muscular units?
To ensure that lymph flows in one direction, preventing blackflow
T/f: the interval bw the valves of lymph collectors is irregular and varies from 6mm up to 10 cm in larger trunks
True
Why may a patient have BLE edema that is asymmetrical?
Bc the lymphatic system is not symmetrical
What are the afferent lymph collectors?
The vessels that carry lymph to the lymphatic nodes
They are smaller and more numerous
What are the efferent lymph collectors?
The vessels that carry lymph away from the lymph nodes to the venous arches
They are larger and fewer in #
Which lymphatic collecting vessels are the main transporting vessels of the lymphatic system?
The efferent lymph collectors
The efferent lymph collectors
What is a lymphangion?
The segment of the collector located bw a proximal and distal pair of valves
What is lymphangiomotoricity?
The body’s natural contraction frequency of moving lymph
About 10-12 contractions per minute at rest
If we do MLD (manual lymphatic drainage) too quickly, what may occur?
We can disrupt the lymphangiomotoricity, so it must be slow and rhythmic
What factors influence lymphangiomotoricity?
Increased lymph production
External stretch on the lymphangion wall
Temperature
Activity of muscle/joint pumps
Diaphragmatic breathing
Pulsation of adjacent arteries
Stimulation of local sympathetic tone
Does increased lymph formation increase or decrease the lymphangiomotoricity?
Increases it
What can cause an external stret$h on the lymphangion wall that could disrupt the lymphangiomotoricity?
MLD
Does increased temperature increase or decrease lymphangiomotoricity?
Increases it
Why does diaphragmatic breathing influence lymphangiomotoricity?
Bc the thoracic duct pierces the diaphragm and can be stimulated by diaphragmatic breathing
Bc there are no valves in the lymph capillary network, what is an advantage to us?
We can move the fluid however we want here
What is the lymph capillary network?
The superficial large network of lymph capillaries all over the body
T/f: you have a set # of lymph nodes at birth
True
What is the shape of the lymph nodes?
Bean shape
Can lymph nodes increase and decrease in size throughout life?
Yes
Lymph nodes are generally embedded in what tissue?
Fatty tissues
Lymph nodes are encapsulated in what tissues?
Connective tissues
Where are a majority of lymph nodes located?
In the abdomen
A majority of lymph nodes are found in the _____, but the _____ and ______ contain a large # of nodes
Abdomen, head, neck
Where are lymph node groups found?
In the Scilla and inguinal regions
T/f: each lymph node and lymph node group receives lymph from a specific region of the body
True
T/f: enlarged lymph nodes are always suspicious bc of infection that can occur in the drainage area
True
When could it be normal to have swollen lymph nodes?
The lymph nodes in the neck area may be swollen after getting sick
Is a suspicious palpable node is felt or seen in the presence of a hx of CA, what should we do?
Refer to the physician
If we see or feel the presence of a painless enlarged lymph node, what do we do?
Refer to the physician
T/f: cancerous enlargements of the lymph nodes are always painful
False
Do afferent or efferent vessels go into the lymph nodes?
Afferent
Do afferent or efferent vessels come out of the lymph nodes?
Efferent
What are the 3 fxns of the lymph nodes?
Filter lymph (remove bacteria, toxins, and dead cells)
Produce lymphocytes
Regulate the concentration of the lymph
What are the deep lymph nodes?
Supraclavicular nodes
Deep abdominal/pelvic nodes
What are the superficial lymph nodes?
Axillary nodes
Inguinal nodes
Where are the supraclavicular nodes located?
Above the clavicle
Where do the supraclavicular nodes receive fluid from?
The head and lateral shoulders
T/f: if indicated to treat the UEs, clearance of what lymph nodes should precede all other treatment?
Supraclavicular nodes
T/f: the abdomen is richly invested with lymph nodes surrounding the organs and intestines
True
Where do the deep abdominal/pelvic nodes receive fluid from?
Superficial inguinal area
Congestion of the deep abdominal/pelvic nodes alone can cause swelling where?
In the LEs, abdomen, and genitalia
Where are the axillary nodes located?
Under the arms
Where do the axillary nodes receive fluid from?
The arm, chest, back, and breast tissue
Where are the inguinal nodes located?
In the groin area
Where do the inguinal nodes receive fluid from?
The legs, lower abdomen, gluteal region, and external genitalia
What forms the lymphatic trunks?
The jointing of efferent collectors of various regional lymph node groups
T/f: The wall structure of the lymphatic trunks is a more developed muscle structure
True
What are the lymphatic trunks innervated by?
The sympathetic nervous system
How are the lymphatic trunks names and identified?
According to their location and territories drained
Where do the lumbar trunks get lymph from?
LEs, lower body quadrants, external genitalia
Where do the bronchomediastinal trunks get lymph from?
Lungs, heart, trachea, and mammary glands
Where do the subclavian trunks get their lymph from?
The UEs, upper body quadrants, shoulder region, mammary glands
Where do the jugular trunks get lymph from?
The head and neck
Where do the intestinal trunks get lymph from?
The stomach and digestive system, liver, pancreas
What is the cisternq chyli?
The union of the lumbar trunks and intestinal trunk
About where is the cisterna chyli located?
~T11-T12
About how wide and long is the cisterna chyli?
~3-8cm long
~.5-1.5cm wide
Where does the cisterna chyli receive lymph from?
The lumbar trunks and intestinal trunk
Where is the origin of the thoracic duct?
The cisterna chyli
What is the largest lymphatic vessel in the body?
The thoracic duct
How long and wide is the thoracic duct?
36-45cm long
1-5cm wide
Where is the thoracic duct located?
To the left and anterior to the spine
What does the thoracic duct perforate?
The diaphragm
Diaphragmatic breathing stimulates what lymphatic duct?
The thoracic duct
What lymphatic duct transports 75% of the daily lymphatic load?
The thoracic duct
The thoracic duct transports lymphatic loads from where a.
The LLQ, RLQ, LUQ, left head and neck
How long is the R lymphatic duct?
1-2.5cm long
The R lymphatic duct is formed from the confluence of what trunks?
The R jugular, Supraclavicular, subclavian, and parasternal, trunks
Where is the R lymphatic duct located?
At the area of the R venous angle
Where does the R lymphatic duct connect with the venous system?
At the R venous angle
What lymphatic duct transports 25% of the daily lymphatic load?
The R lymphatic duct
The R lymphatic duct transports lymph from where?
The RUQ, right head and neck
What are the lymphatic watersheds?
The body’s natural pattern of draining lymph that represent a limitation in the flow of lymph in a particular direction and a change in the flow in the superficial collectors toward an opposite regional lymph group
Most research on lymphatic watersheds is in relation to what?
Cancer
T/f: there is a risk for lymphedema following a TKA bc there is a superficial lymph node located behind the knee
True
What are the lymphatic watersheds also called?
Boundaries
The lymph collectors on the trunk generally originate where?
At the watersheds and run straight towards the regional lymph nodes
What are the lymphatic watersheds on the trunks?
Median-Sagittal (vertical) watershed
Transverse (horizontal) watershed
Clavicle after shed
Spine of the scalp watershed
Chap (gluteal) watershed
What are interterritorial anastamoses?
When collectors have connection with adjacent territories and allows interterritiorial lymph flow
What are the anastomoses of the trunk?
Interaxillary
Interinguinal
Axilloinguinal
What is the anterior axillo axillary (AAA) anatamosis?
The connection bw the RUQ and LUQ
connection bw CL axillary lymph node groups on the anterior side of the upper trunk
What is the posterior axillo axillary (PAA) anastomosis?
The connection bw the CL axillary lymph node groups on the posterior aspect of the upper trunk
What is the axillo inguinal (AI) anastomosis?
The connection of ipsilateral collectors of upper and lower quandrants
Connection bw the axillary and inguinal lymph node groups on the same side
What is the anterior interinguinal (AII) anastomosis?
Connection bw CL inguinal lymph node groups on the anterior lower body quadrants
Where is the anterior interinguinal (AII) anatasamosis located?
Over the pubic area
Where is the posterior interinguinal anastomosis (PII) located?
Over the sacrum
What is the posterior interinguinal anastomosis?
Connection bw CL inguinal lymph node groups on the posterior lower body
What is the Starling principle of fluid exchange?
Answer fluid movt bw blood and tissues are determined by the differences in hydrostatic and colloid osmotic (oncotic) pressures bw plasma inside the micro vessels and fluid outside them
What is the main fxn of the lymphatic system?
To facilitate fluid movt from the tissues back to the blood circulation
What is the primary site of exchange?
The blood capillaries in the blood capillary beds
What are the mechanisms involved in the capillary change?
Diffusion
Osmosis
Ultra filtration
Re-absorption
What is diffusion?
The movt of particles in a solution from an area of high concentration to an area of lower concentration
Is diffusion and active or passive process?
Passive
What factors influence diffusion?
Temp
Concentration gradient
Size of the molecules
Surface area
Diffusion distance
If temperature increases, what happens to diffusion?
It increases too
Do larger or smaller molecules move faster in diffusion?
Smaller
What is simple diffusion?
The movt of molecules from high to low concentration without separation on the concentration gradient
Where is an area that simple diffusion occurs?
In the interstitial spaces
What is the process for exchange of oxygen and carbon dioxide in the tissues in the body?
Diffusion
What is slow diffusion?
The movt of molecules is slowed/hindered by a barrier (membrane)
Where does slow diffusion occur?
In the blood vessels
To ensure sufficient gas exchange a _____ ______ ______ is necessary
Short diffusion distance
When there is edema in the tissue, the distance bw blood capillaries and the tissues is increased and can result in what?
Decreased oxygen supply and increased waste products
Why is there an increased risk for infection and skin breakdown with edema?
Bc it increases the diffusion distance leading to decreased oxygen supply and increased waste products
What is osmosis?
The movt of water molecules from an area of higher water concentration to an area of lower water concentration across a membrane that is permeable to water and impermeable to other molecules
The direction of water in osmosis is from the _____ solute concentrated area to the ____ solute concentrated area
Less, more
What is the osmotic pressure?
The pull of the less concentrated water generating a force
The osmotic pressure is directly proportional to what?
The number of dissolved molecules (ie. the concentration)
The more concentrated the solution, the ____ water will be needed to saturate itself and the ____ pressure will develop bw the two substances
More, more
What causes the colloid osmotic pressure?
The presence of proteins in the fluid
T/f: proteins in the interstitial fluid is lymphedema pulls water towards it
True
Why don’t diuretic work for pts with lymphedema?
Bc these drugs get rid of fluid, but not proteins which as the problem in lymphedema
Are there pharmaceutical that can decrease proteins for lymphedema treatment?
Nope
Why don’t drainage devices or pumps work for lymphedema?
Bc it doesn’t address the excess proteins in the fluid, only gets rid of excess water
Why does MDL work for lymphedema?
Bc it is trying to get rid of excess proteins by stimulating the lymphatic system to do its job of picking up extra proteins from the fluid
What is the transport capacity?
The amount of lymph fluid the lymphatic system can transport when working at its max intensity
At rest, the lymphatic system works at ____% of its TC
10
In a normally functioning system, the TC is equal to what?
The max lymph time volume (LTVmax)
What is the functional reserve?
The difference bw the TC and lymph load (LL)
What are the three insufficiencies that lead to edema?
Dynamic insufficiency
Mechanical insufficiency
Combined insufficiency
What is dynamic insufficiency?
When the LL>TC but the TC hasn’t decreased
Does dynamic insufficiency cause lymphedema?
NO, it is normal edema that results like in an ankle sprain
Which type of insufficiency involves a functioning system that has extra stress added onto it?
Dynamic insufficiency
Is dynamic or mechanical insufficiency a high volume insufficiency?
Dynamic insufficiency
Is dynamic or mechanical insufficiency a low volume insufficiency?
Mechanical insufficiency
Does dynamic or mechanical insufficiency result in low protein edema?
Dynamic insufficiency
Does dynamic or mechanical insufficiency result in high protein edema (lymphedema)?
Mechanical insufficiency
How is dynamic insufficiency treated?
With elevation, compression, and exercise
Is MLD indicated in dynamic insufficiency? Why or why not?
It is not indicated bc it is not lymphedema and the lymphatic system is in tact
What are examples of causes of dynamic insufficiency?
Cardiac insufficiency
Immobility
Chronic venous insufficiency in the early stages of
Pregnancy
What is mechanical insufficiency?
When the LL>TC and the TC has been reduced due to damage to the lymphatic system
Is the lymphatic system damaged in mechanical insufficiency?
YES
T/f: the mechanism for protein removal is impaired or reduced in mechanical insufficiency
True
T/f: Any lymphedema is a mechanical insufficiency
True
How is mechanical insufficiency treated?
Complete decongestive therapy (CDT)
Is there a gold standard way to diagnose lymphedema?
Nope, so your ass better take a good history
Which type of insufficiency results from some kind of insult to the lymphatic system like a surgery, radiation, or trauma?
Mechanical insufficiency
What is combined insufficiency?
Decreased TC and elevated LL resulting from a wearing down of the system
T/f: combined insufficiency may start with normal TC but then when the LL is always above the TC, it wears down the system
True
What is edema?
Excessive accumulation of interstitial fluid that causes swelling
T/f: edema is a symptoms of other conditions
True
Edema may be a symptom of what other conditions?
CHF
Chronic venous insufficiency Immobility
Immobility
Pregnancy
Renal failure
Why is edema pitting, but lymphedema usually isn’t?
Bc edema is an accumulation of fluid, but lymphedema is protein rich fluid which can lead to fibrosis
T/f: edema can be transient or permanent
True
What condition may cause permanent edema?
Cardiac edema
What is the treatment for edema?
Elevation, compression garments, diuretics, and dietary changes (lower salt intake)
What is lymphedema?
An abnormal accumulation of protein rich fluid due to insufficient lymphatic transportation causing limb swelling, reactive fibrosis, chronic inflammation, and increased risk for infection
Is lymphedema a disease or a symptom of a disease?
Lymphedema is a disease rather than a symptom
Does lymphedema go away?
No, it is a lifelong disease that will progress without treatment
What is the gold standard treatment for lymphedema?
Complete decongestive therapy (CDT)
What are the components of CDT?
MLD (manual lymphatic drainage)
Compression therapy
Education
Exercises
Skin care
What occurs if there is an abnormal accumulation of water and protein in the subcutaneous tissues?
Lymphedema
What is the swelling of soft tissues that results from the accumulation of protein rich fluid in the extracellular spaces?
Lymphedema
Where is lymphedema commonly seen?
In the extremities, but can’t occur in the head, neck, abdomen, and genitals
Is there a cure for lymphedema?
Nope
What are the 3 common causes of lymphedema?
Parasites
Breast cancer surgery/radiation
Primary lymphedema
What is a common parasitic cause of lymphedema?
Filariasis
What is filariasis?
Mosquito borne invasion of lymphatics indigenous to tropical regions
If someone has lymphedema with no known lymphatic trauma, but recently traveled, what may be the cause?
Filariasis
What are the classifications of lymphedema?
Primary (idiopathic) edema
Secondary (acquired) lymphedema
What is primary (idiopathic) lymphedema?
A developmental abnormality (dysplasia) of the lymphatic system that results in a mechanical insufficiency that usually affects the LEs
Are more males or females more affected by primary (idiopathic) lymphedema?
Females
What is secondary (acquired) lymphedema?
A mechanical insufficiency of the lymphatic system caused by a known insult to the lymphatic system
What are the 3 types of dysplasia of primary lymphedema?
Hypoplasia
Hyperplasia
Aplasia
What is hypoplasia primary lymphedema?
Incomplete development of the lymph vessels
What is the most common form of dysplasia in primary lymphedema?
Hypoplasia
What is hyperplasia primary lymphedema?
When the diameter of the lymph collectors is larger than normal and results in malfxn of the valve system with the collectors and may lead to lymphatic reflux
What is aplasia primary lymphedema?
When the lymphatic collectors are so few that they are considered absent bc if they were completely truly absent the tissues would be unable to support life
What are the 3 classifications of primary lymphedema?
Congential (connatal) lymphedema
Lymphedema praecox
Lymphedema tarda
How are primary lymphedemas classified?
By the age of onset of swelling
What is congenital (connatal) lymphedema?
Lymphedema clinically evident at birth or within the first 2 years of life
What classification of primary lymphedema is Milroy’s disease?
Congenital (connatal) lymphedema
What is lymphedema praecox?
Primary lymphedema present b4 35yo
What is the most common form of primary lymphedema?
Lymphedema praecox
Lymphedema most often arises when?
During puberty or pregnancy
What is lymphedema tarda?
Primary lymphedema after 35 yo
T/f: lymphedema tarda is relatively rare
True
What is Milroy’s disease?
Congenital lymphedema usually involving the LEs
Hypoplasia primarily of lymph capillaries and possible intestinal dysplasia
Does Milroy’s disease occur more commonly in males or females?
Males
If a child has a bloated stomach and oily stool, what may be the cause?
Milroys disease
What is meige’s disease?
Non congenital familia lymphedema that occurs near puberty more in females usually involving the BLEs
Hypoplasia of lymphatic tissues
What is the most common form of primary lymphedema?
Meiges disease
What is distichiasis syndrome?
Congenital anomaly where there is a double row of eyelashes along the posterior border of the eyelid
Hyperplasia of the superficial lymphatic vessels
Fairly rare
What are the most common causes of secondary lymphedema?
Filariasis
Surgery/radiation
Trauma
Infection
Malignant tumors
Immobility
Chronic venous insufficiency
Self induced
What is the leading cause of lymphedema worldwide?
Filariasis
How is filariasis transmitted to humans?
Via mosquito bites in tropical regions
What is the most common cause of secondary lymphedema in the US?
Surgical procedures in treatment of cancer
T/f: radiation can cause fibrosis in the tissues leading to impaired lymph transport
True
T/f: trauma to the lymphatic system may cause reduction in lymph flow and scar tissue can interfere with lymph flow
True
How do infections cause secondary lymphedema?
Recurrent acute or chronic inflammatory processes affecting the lymphatic vessels may lead to fibrotic changes in the vessels and decrease lymph flow
What is the most common cause for inflammation of the lymphatic system and lymphedema worldwide?
Filariasis
How can malignant tumors cause secondary lymphedema?
By causing an obstruction of the lymphatic system
What is malignant lymphangiosis?
When malignant tumors infiltrate the lymphatic system
What is phlebolymphedema?
Secondary lymphedema that develops as a result of insufficient venous return
May have started as chronic venous insufficiency
How can secondary lymphedema be self induced?
By use of a tourniquet to produce a venous and lymphatic obstruction
What are the stages of lymphedema?
Stage 0 latency stage
Stage 1 reversible lymphedema
Stage 2 spontaneously irreversible
Stage 3 lymphatic elephantiasis
Is there a definitive time period for a person to remain in a stage of lymphedema?
Nope
What differentiates bw stages of lymphedema?
The consistency of tissues and the progression of fibrosis
T/f: the limb size defines the stage of lymphedema
False, fibrosis of the tissues does
What is the goal of treatment of the stage of lymphedema?
To return persons to the latency stage (stage 0)
What is the subclinical stage of lymphedema with no visible or palpable signs of edema where the TC is subnormal yet remains sufficient to manage a normal LL?
Stage 0: latency stage
What stage of lymphedema may have no clinical signs of edema, but the patient may complain of a sensation of heaviness, after logged sensation, tightness of clothes, achiness, or limb numbness?
Stage 0: latency stage
Is there usually pain in stage 0 lymphedema
Nope
T/f: those is stage 0 lymphedema are an at risk group
True
What stage of lymphedema has clinically apparent swelling that may be transient with subnormal TC that is eventually able to catch up with LL, has low protein content in the lymph fluid, and is not yet fibrosis?
Stage 1: reversible lymphedema
What stage of lymphedema is primarily identified by puffy appearance distally, putting edema, and swelling that reduces with elevation?
Stage 1: reversible lymphedema
What stage of lymphedema is primarily identified by tissue proliferation and fibrosis, difficulty pitting the edema, and a (+) Stemmers sign?
Stage 2 spontaneously irreversible
In what stage of lymphedema do pts usually stabilize?
Stage 2
What stage of lymphedema is primarily identified by increased volume of edema, lymphatic fibrosis that increases in firmness so that pitting may or may not be present, and skin alterations are present?
Stage 3: lymphatic elephantiasis
What skin alterations may be present in stage 3 lymphedema?
Papillomas
Cysts and fistulas
Hyperkeratosis
Mycotic infections of nails and skin
Ulceration
What are papillomas?
Wart like projections
What is hyperkeratosis?
Thickening of skin
Which stage of lymphedema is characterized by a deepening of the natural skin folds?
Stage 3: lymphatic elephantiasis
What are the complications of lymphedema?
Cellulitis/lymphangitis/infections
Fungal infections
Papillomas
Lymphcysts
Stewart-Treves syndrome
Axillary web syndrome
What are the s/s of cellulitis, lymphangitis, and Fungal infections as a result of lymphedema?
Sudden redness, warmth, worsening edema, inflammation, pain, fever, chills, malaise
What are the s/s of fungal infection as a complication of lymphedema?
Itching, whitish and moist bw the toes and under skin folds
What causes papillomas in lymphedema?
Congestion of lymph vessels
What are lymphcysts?
Fluid filled blisters
What is lymphangitis?
Inflammation of the subcutaneous lymphatic channels leaving a red streak radiating from the infection site in the direction of the regional lymph nodes
What is Stewart-Treve’s syndrome?
A rare lymphangiosarcoma
What is axillary web syndrome?
A post op complication characterized by an abnormal scarring of the subcutaneous tissue from the axillary down to the medial arm
What are things we can do or use to get a diagnosis of lymphedema?
(+) Stemmers sign
Palpating/visualization
Interview/eval
Lymphography
Lymphoscintigraphy
Indocyanine green (ICG) lymphography
Magnetic resonance lymphangiography
US
What is the gold standard test for diagnosing lymphedema?
Lymphoscintigraphy
What is Lymphoscintigraphy?
Inject a radioactive tracer in the skin of the dorsal of the hand or foot to provide repeat whole body scans for images of the pathway of the lymphatic flow
What is lymphograpy?
Using an oily contrast with iodine injected into a lymphatic vessel in the hand or foot to provide precise anatomical depiction of the lymphatic vessels and nodes
How long must a patient be immobile for when doing lymphography?
60-90 minutes
What is the og method to image the lymphatic system?
Lymphography
What is ICG Lymphography?
Injection of fluorescent marker into the skin of the hand or foot that is then absorbed into the lymphatics and moves up the limb with the lymphatic fluid to provide detailed imaging of superficial peripheral lymphatic vessels in real time
Why do we use US in the diagnosis of lymphedema?
To rule out a DVT or other obstruction
What is the difference between lymphedema and lipedema?
Lymphedema is usually not painful, has a (+) Stemmers sign, is pitting early on, asymmetric if BL, has a buffalo hump on hands and feet, with loss of foot and hand contours, and squaring of toes
Lipedema is BL symmetrical swelling from the iliac crests to the ankles with hands and feet spared, little to no edema, painful, (-) Stemmers sign, and easily bruised
When does lipedema usually start?
Around the time of puberty
What is it called when lipedema develops into lymphedema?
Lipo lymphedema
Is lipedema an obesity issue?
Not necessarily, it is just an abnormal laying of adipose tissues in the limbs, buttocks, and hips
What are the characteristics of lipedema?
Onset during puberty
Mainly in women
BL symmetrical swelling from iliac crests to ankles
Affects the subcutaneous tissue of the hips, buttocks, legs, and arms
Hands and feet are spared so Stemmers sign is neg
Painful to palpation
Bruise easily
What are the characteristics of chronic venous insufficiency edema?
Gaiter distribution (ankles to midcalf)
Brawny (hard)
Hemosiderin staining
Fibrosis of subcutaneous tissues
Vicerations
What are the characteristics of a DVT?
Sudden onset usually unilateral pain, cyanosis
T/f: a DVT is potentially lethal so we should contact their PCP if we suspect it
True
What are the characteristics of cardiac edema?
Greatest distally
Always BL
No pain
Pitting
Complete resolution with elevation
What are the characteristics of congestive heart failure?
Swelling greatest distally
Swelling always BL
pitting
Swelling resolves with elevation
No pain
Dyspnea on exertion and orthopnea
JVD
What are the characteristics of malignant lymphedema?
PAIN
paresthesia
Paralysis
Rapid development
Shiny tight skin
Swelling proximal to the tumor
Y/f: malignant lymphedema may represent a new malignancy or be the first sign of a recurrent malignancy
True
What is edema due to thyroid dysfunction (hypothyroidism) that tends to occur in women and the elderly with a hx of radiation
Myxedema
What are collateral connections between vessels that allows drainage to be shared
along the most efficient pathway or pathways based on the demands
placed on the territory or presence or absence of congestion within
the neighboring skin region?
Interterritorial anastamoses
What is a key difference bw primary and secondary lymphedema?
Secondary lymphedema will have a known insult
What are the treatment options for lymphedema?
Surgery
Low level laser therapy
Acupuncture
Elastic taping
CDT
What is the gold standard treatment of lymphedema?
CDT
What are the surgical options for lymphedema?
Excisional/debulking
Micro surgery
Suction assisted protein lipectomy
Who should surgery for lymphedema be reserved for?
Pts in which more conservative treatments like CDT haven’t worked
Is surgery a cure for lymphedema?
Nope
T/f: surgical treatments for lymphedema should only be performed by a lymphedema surgeon
True
Do pts still have to wear compression after surgical treatment of lymphedema?
Yup
Is excisional/debulking seen often as a treatment for lymphedema in the US?
No
What is excisional/debulking surgery for lymphedema?
An extreme measure involving radical removal of skin and soft tissues in the lymphedematous area which is then covered in skin grafts typically for pts with stage 3 lymphedema
What are the complications of excisional/debulking surgery for treatment of lymphedema?
Bleeding, infection, necrosis, chronic wounds/delayed healing, blood clots, scarring/poor appearance, destruction of remaining lymph vessels, lymphedema recurrence
What is the goal of micro surgery for treatment of lymphedema?
To create microscopic connection bw lymphatic vessels and adjacent veins to bypass the lymphatic obstruction
Micro surgeries tend to have better results when performed in what individuals?
Those with early stage lymphedema
What are complications of microsurgery?
Infection, bruising, scarring, may not be effective at reducing lymphedema
What are the 2 types of micro surgeries?
Lymphatic-venous anastamosis (LVA)
Vascularized lymph node transfer (VLNT)
What is lymphatic-venous anastamosis micro surgery?
Direct connection of lymphatic vessels in the lymphedema affected area to nearby veins thus allowing lymph fluid to drain directly into the venous system
Who is the best candidate for LVA?
Those with early lymphedema
T/f: there are good results with LVA by using conservative therapy and compression first to reduce excess fluid
True
What is vascularized lymph node transfers micro surgery (VLNT)?
Involves the transfer of lymph nodes and surrounding tissue and fat from an unaffected part of the body to the lymphedema area
1-3 healthy nodes are harvested from a healthy area and transplanting them to an area where lymph nodes were removed and or damaged
What are the complications of VLNT?
Bleeding, infection, clots, scars, lymphedema in the harvested areas
What is suction assisted protein lipectomy?
Permanent removal of lymphatic solids and fatty deposits that are typically found in later stages of lymphedema and are unresponsive to conservative therapy
Who are the best candidates for suction assisted protein lipectomy (SAPL)?
Individuals with continued chronic non pitting lymphedema even after completing a thorough course of CDT
Does SAPL address the causes of swelling and fluid accumulation?
Nope
What is low level laser therapy?
A light modality that causes non thermal effects by impacting cellular level changes
What is the theory on how LLLT helps treat lymphedema?
LLLT impacts the lymphatic system by increasing lymph flow though lymph angiogenesis, stimulation of the lymphatic vessel contraction, and inhibiting the formation of tissue fibrosis
What is acupuncture?
Insertion of needles into specific points along the meridians of the body to rebalance energy flow
What is the goal elastic taping for lymphedema?
To direct lymphatic fluid towards areas of less congested lymphatic pathways or to lymph nodes
How it is believed that elastic taping works for lymphedema treatment?
It influences fluid dynamics and lymphatic transport bc when the individual moves, the tape facilitates a slight tug on the superficial integument which replicates the effect of MLD and pulls on anchoring filaments, opening the lymphatic vessels and allowing the uptake of lymphatic loads
Elastic taping is most effective in ____ stages of lymphedema
Early
T/f: elastic taping can be considered an option for edema management when compression garments aren’t well tolerated
True
What is a noninvasive multi-component approach to treat lymphedema?
Complete decongestive therapy (CDT)
What are the goals of CDT?
To return lymphedema to stage 0/latency stage by utilizing the reminding lymph vessels and other lymphatic pathways
To maintain the normal/near normal size of the limb and prevent the accumulation of lymph fluid
Prevention and elimination of infections
Reduce and remove fibrotic tissues
What are the contraindications for CDT?
Acute malignancy
Acute cellulitis
Currently receiving chemo or radiation
Untreated CHF
DVT
Infection
Hemorrhage
What are the components of CDT?
MLD
Compression exercises
Skin and nail care
Education
What are the phases of CDT?
Intensive phase (phase1) and maintenance phase (phase 2)
What is involved in phase 1 intensive phase CDT?
Daily consecutive treatments for 2-4 weeks
Skincare, MLD, compression bandages, exercise, education, and self care
How long is phase 1 CDT done.?
Once a day (Monday through Friday) for 2-4 weeks
When is phase 1 of CDT completed?
When limb measurements plateau
What is involved in the maintenance phase (phase 2) of CDT?
Self management, skincare, self MLD, self bandaging, exercise
When should compression garments be worn in phase 2 CDT?
During the day
When should compression banadages or bandage alternative be worn in phase 2 CDT?
During the night
Describe the compression bandages used
Short stretch bandages with cross weaving to create a soft cast effect
When does phase 2 CDT begin?
Immediately following phase 1
What is manual lymph drainage?
Gentle manual techniques with specific hand movts used to follow lap pathways to facilitate the movt of lymph through the lymph vessels
T/f: MLD is designed to have an effect on the fluid components and lymphatic structures located in the superficial tissues
True
How do MLD work?
It creates alternative pathways for lymph drainage with manipulation of healthy lymph nodes and vessels that are generally located adjacent to the area of congestion
What is the goal of MLD?
To re-route the lymph flow around blocked areas into healthy lymph vessels which drain into the venous system , thus allowing the limb to return to near normal size
What are the most common effects of MLD?
Increase lymph production
Increase lymphangiomotoricity
Reverse the lymph flow
Increase venous return
Soothing
Analgesic
How does MLD increase lymph production?
By stretching the anchoring filaments of the lymph capillaries to stimulate intake of fluid into the lymphatic system
How does MLD increase lymphangiomotoricity?
Stimuli of the smooth musculature stimulates the lymph collectors and results in increased contraction frequency of the lymphangions
MLD moves the lymph fluid and re-routes the lymph via ______ _______ and ______
Collateral collectors, anastamoses
______ _______ of the MLD strokes increases the venous return in the superficial venous system
Directional pressure
T/f: the light pressure of MLD promotes a parasympathetic response for soothing
True
How does MLD create an analgesic effect?
By draining toxic substances from the tissues and promoting pain relief
What are the 4 basic strokes used in MLD?
Stationary circles, pump, scoop, rotary
What is the working phase and what is the resting phase of MLD?
The working phase is when light pressure is applied
The resting phase is when pressure is released
What are the principles of MLD?
Proximal to distal
Slow rhythmic movt/strokes
Light pressure
Treatment usually 60 min
No reddening of skin
Move lymph toward nodes responsible for draining
Hands flat on the skin with soft pads of fingers and hands
What are common mistakes during MLD?
Too much pressure
Moving too fast
Not using flat soft hands
Not enough stretching of the skin
Being too abrupt
What are the contraindications to MLD?
Cardiac edema
Renal failure
Acute infections
Acute bronchitis
Acute DVT
What are the goals of compression therapy for lymphedema?
To maintain the decongestive effect achieved with MLD
To prevent re-accumulation of fluid
What are the effects of compression therapy?
Improves venous and lymphatic return
Improve effectiveness of the musc/jt pumps during activity
Prevents re-accumulation of lymph fluid
Maintains results achieved during MLD
Facilitates breakdown of lymphatic fibrosis
The type of compression used is dependent upon what?
The phase of CDT treatment
What are the options for compression?
Short stretch bandages
Compression garments
Combo of short stretch bandages and compression garments
Bandage alternative
When in phase 1 CDT, what compression is used?
Bandages are worn 24/7
When in phase 2 CDT, what compression is used?
Compression garments during the day
Compression bandages or bandage alternatives at night
What is La Place’s law?
If consistent compression is applied to a cone shaped extremity from distal to proximal, a natural compression gradient will occur
How can we create a compression gradient?
By using padding and compression bandages to create a cone
Should bandages be applied proximal to distal or distal to proximal?
Distal to proximal
Is padding necessary in compression garments? Why or why not?
It’s not necessary bc compression garments have a pressure gradient built into the garment
Are short or long stretch bandages used for compression therapy in lymphedema?
Short stretch bandages
Short stretch bandages have a _____ working pressure and a _____ resting pressure
High, low
Long stretch bandages have a _____ working pressure and a _____ resting pressure
Low, high
Short stretch bandages have about ___% extensibility while long stretch bandages have about ____% extensibility
60, 140
What are the contraindications to compression bandages?
Acute DVT
Acute infections
Cardiac edema
Advanced arterial disease
Advanced renal disease
T/f: compression bandages can pose a hinderage to some bc of their bulkiness
True
T/f: compression garments must be worn for life
True
How often should compression garments be replaced?
Every 6 months
What are some signs that someone’s compression garments should be replaced?
If the garment doesn’t return to the og shape after washing it
If the garment has runs or holes in it
If the individual no longer feels the compression
If the garment is easy to put on
What are some factors that should be considered when chooses a compression garment?
The individuals lifestyle
Skin integrity
Home support
Ability to don/doff garments
Work environment
What act was designed to improve insurance coverage for the medically necessary, doctor prescribed compression supplies that are needed in lymphedema treatment?
The lymphedema treatment act
What is a pneumatic compression device?
Multi chamber inflatable sleeves that move compressed air into the sleeves sequentially distal to proximal
T/f: advanced pneumatic compression devices have the option to do proximal clearing first
True
What are the parts of good skin care in CDT?
Daily bathing with a non drying soap
Careful and thorough drying bw skin folds, fingers, and toes
Moisture with a low pH lotion
No tight fitting clothes or jewelry in the affected extremity
Avoid nicks, cuts, and burns
Inspect skin and nails daily
Cleanse wounds immediately
Contact physician at first sign of infection
What are the general benefits of exercise for lymphedema?
Weight management
Decreased stress
Decreased depression
Improve immune fxn
Provide socialization
Improve CV health
Utilize muscle and joint pumping mechanisms
Increase fxnal mobility
What are the exercise guidelines for lymphedema?
Wear compression bandages/garments when exercising
Wear comfortable loose clothing
Initiate exercise gradually and progress as indicated
Continue to monitor the limb for any volume changes
Incorporate breathing exercises at the start of end of every session
Stop if you feel tired or out of breath
Perform exercises in a slow and controlled manner
Avoid movts that cause pain
Maintain good posture
After exercise, rest and elevate the limb for 15-20 minutes
What are some beneficial exercises for lymphedema?
Walking
Swimming/water exercises
Easy biking
Yoga
