What are LOL fats?
- small monoglycerides and free fatty acids
- long chain fatty acids and reformed triglycerides
What are LOL cells?
- circulating B and T lymphocytes
- macrophages
- dendritic cells (veiled cells)
- other WBC’s
- dead and dying cells
- mutated cells
- cell fragments (including RBC’s)
What is LOL water?
- 95% lymph
- slightly alkaline 7.4
- clear and colourless
- milky is lipids present
What are the three fluid dynamics?
- filtration - blood pressure - into tissues - one way
- diffusion - needs concentration gradient
- osmosis
What is the starling hypothesis?
BP + C/OTP C/OBP + TP
At what end is colloid osmotic tissue pressure?
Arterial end
Increased blood pressure so increased filtration
At what end is colloid osmotic blood pressure?
- venous end
- decreased blood pressure so decreased filtration and possible reabsorption
What is active hyperaemia?
Sphincter open increases blood flow and results in increased filtrate
Eg - massage, exercise, blushing, heat, cellulitis
What is passive hyperaemia?
Blood accumulation in capillaries due to reflux or stasis. Does not affect sphincter
Eg - CVI, thrombosis, chronic venous insufficency
What is ultra filtrate?
At blood capillary fluid is forced out into the pericapillary tissue through a fine filter by blood pressure, which exceeds the colloid-osmotic pressure of plasma proteins
What are the two classifications of lymphedema?
Functional and organic
What is functional lymphedema?
Problem with lymph vessel function
Skeletal muscle paralysis
- stroke, para/quadriplegic, post polio
Can be valve incompetence - long term venous stasis
Spasm of smooth muscle in collector - inflammation
What is organic lymphedema?
Damaged pathways or nodes - irreversible
Lymph node dissection
Radiotherapy
Trauma
Filariasis
What is primary lymphodema?
Deficiencies in formation of vessels or nodes
Congenital
High protein edema
Forms - hypoplasia, aplasia, hyperplasia
What is secondary edema,
Event of disease process resulting in damage or impairment of LVS
High protein edema
What do primary and secondary edema have in common?
Both high protein
What is lymphedema?
Mechanical insufficiency
- lowered transport capacity
- problem in the LVS - damaged, absent
- accumulation of protein rich fluid in the CT
What are the four characteristics of primary lymphedema?
- Begins distal and progresses proximally
- Commonly in one or both legs
- Usually pain free
- Progress can be slow
What is secondary lymphedema?
Disease process - not ore existing
Can be organic or functional
Organic - irreversible, damage to structure
Functional - reversible, changes in function
What is characteristic of secondary lymphedema?
Begins proximal and progresses distally
What is stemmer sign?
Determines if swelling in distal extremities
Ability to lift skin on the proximal phalange of the digits
Informative not diagnostic (cause)
A positive is if cannot lift skin
What is the kibik - stemmer sign?
Also determines swelling in distal extremity
Ability to lift skin over MCP’s or MTP’s
Positive - cannot lift skin
Gives information not diagnosis
Stages
What is the latent stage?
Sub clinical (stage 0)
No visible edema - safety factors still working
Slow accumulation of fluid and proteins
What is stage 1?
Reversible (disappears with bed rest)
Soft, pitting, protein rich fluid
What is stage 2?
Irreversible
Hard, strong pressure required to cause pitting or no pitting, fibrosis, increased volume and adiopse tissue
What is stage 3?
Called elephatiasis
Fibrosis, pachydermia, hyprkeratosis, papillomatosis,
Pain may be present
Lymph, blood vessels and nerve sheaths can become fibrotic and sclerotic
What are the three possibly complications from stage 3?
Lymphocele - mass containing lymph with no endothelial lining
Lymph cysts - extension of cutaneous lymph vessels / cyst is cavity with endothelial lining
Lymph fistula - caused by increased pressure in cutaneous lymph vessels - opens surface of skin
Erysipelas/cellulitis - aggressive infection - due to reduced immune defense - development of secondary tumours or relapses due to chronic lymph stasis
What are the two other classifications of lymphedema and their characteristics
Acute - less than 3 months, may spontaneously resolve, cancer patients after surgery or radiology
Chronic - more than 3 months, does not spontaneously resolve - influx of inflammatory cells - dendritic, mast, plasma cells and lymphocytes - increase in microcirculation - growth of new CT - fibre and fat
What is lipedema?
Disorder of subcutaneous fat metabolism and distribution
Women only 10-15% of pop
Most common is lower limbs
Chronic and progressive
Familial
Soft pliable skin, tender and cool to touch, always bilateral and symmetrical, whole limb and bruises easily
What are treatment options for lipodema,
Early - compression garment with physical activity
Mid - massage and sometimes compression
Late - CDT
Others - liposuction, infared therapy, laser
What is dynamic edema?
Lymph system working normally or at max capacity. Too much fluid in spaces
Low protein edema - may lead to lymphedema
High volume of LOL - high BP, thrombus, chf
Define post ischaemic edeme…
Surgery performed in blood free manner - edema develops when area is re supplied with blood.
Cause is usually tissue damage.
Define exudate
Appearance of protein rich fluid from vessels during inflammation
Define transudate?
Low protein, usually clear, serous fluid not appearing during inflammation but with local or general congestion, increased capillary permeability
Define induration…
Definite or diffuse hardening or thickening of a tissue or organ due to reactive hyperplasia of ct - after inflammation
What are the 4 properties of loose connective tissue?
Recoil ability (elastin and collagen)
Thixotrophy
Inertia mass - fixed state until acted upon, at least 15 mins in area to affect
Transit stretch - distance and time it takes for nutrition to tissue and waste to capillary
What are the effects on smooth muscle?
Blood vessels - elderly, raynauds, diabetes, (vasomotion)
Lymph vessels - increase transport capacity
Digestive tract - constipation
Effects on the nervous system?
Analgesic effects
- stimulation of mechanoreceptors inhibits pain pathways (gate theory) trauma, migraines, headaches, neuralgia, OA, CRPS, phantom pain
Sympathicolytic effects
- calming - palliative care, recuperation, stress, sleep disorders, fibromyalgia
Effects on immune system
Immunological
- increased lymph flow MAY affect immunological processes - chronic inflammation, wound healing - ulcers, arthritic conditions
How does it effect drainage?
Affects circumferential and longitudinal muscles of lymphangion
Affects a chain on angions
Increased pumping and filling of angions
Collectors stimulated, fluid displaced, easier for pre collectors to empty into collectors
At blood vessels - removal of tissue proteins, MLD acts like tissue pressure
Into initial lymphatics
Emptying of proximal vessels, movement of skin - post surgical edema, chromic inflammation, hematoma, skin conditions
