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Flashcards in Integumentary Unit Deck (55):

Where does the lymphatic system empty into the venous system?

left subclavian vein; the area where the venous system pressure is the lowest


Role of the lymphatic system

- immune surveillance
- balance fluids and proteins in the circulatory system by transporting lymph fluid
- assists in fat digestion


How is excess body fluid disposed of/excreted?

in the urine


Transport capacity

the body's ability to transport fluid away from an area; 10-30% in the lymphatic system


Lymph fluid movement

peripheral to central


Mechanisms of lymph transport

- contraction of the lymphangions
- active and passive body movements
- arterial pulsation
- muscle pump
- manual therapy techniques
- respiration
- "vis a tergo"


What is the rate of contraction of the lymphangions?

6-10 bpm


Primary lymphedema

- congenital/hereditary
- impaired vessel development
- leg > arm
- distal > proximal
- female > male (9:1)
- asymmetrical
- 83% manifest before 35 YOA
- onset usually at puberty


Secondary lymphedema

damage to the lymphatic system d/t:
- trauma
- surgery
- radiation
- inflammation
- malignancy
- filariasis


What are the main causes of LE in the western world?

- breast CA
- skin CA
- reproductive system CA
- prostate CA
- trauma


What is the primary cause of LE in developing countries?



Known predictors of LE onset

- surgical dissection of nodes/organs
- radiation therapy
- age
- obesity/increased body weight
- injury/infection via dermal wounds
- local hyperemia caused by exercise, heat, modalities


"Limb at risk"

- refers only to the involved extremity
- a lifelong condition
- careful lifestyle choices
- potentially a latency period between injury and clinical appearance of lymphedema


Changes in altered system

- excess protein in tissues
- excess fluid in the limb
- decreased oxygenation
- slow healing time
- formation of fibrosis-proteins = "joiners"
- lymphangions get clogged


Class I - Mild LE

less than 3 cm difference between limbs


Class II - Moderate LE

3-5 cm difference between limbs


Class III - Severe LE

5+ cm difference between limbs


Prevention and control of LE

- skin care
- exercise
- maintain a healthy weight
- precautions
- seek early treatment (esp. if changes last longer than 1 wk)


Complete Decongestive Therapy - Phase 1

- lymphedema bandaging
- skin care
- exercise
- compression garment at the end of phase 1


Manual Lymph Drainage

- increases frequency of vessel contractions
- increases the volume of lymph that is transported
- increases pressure in the vessels
- can reverse the direction of lymph flow
- enhances local arterial blood flow


Lymphedema Bandaging

- encourages lymph vessels to empty through a mild increase in tissue pressure
- prevents refilling of interstitium between treatments
- provides essential support for tissues
- improves the efficacy of the muscle pump during exercise/movement
- softens fibrotic tissue through pressure



- increases lymph vessel contraction rate
- improves lymph fluid circulation
- improves the efficiency of thoracic duct via deep breathing


Compression Garments

- prevent refilling of the interstitium
- preserve limb reduction long-term
- support tissues that have lost elasticity
- must be worn to retain reduction of limb size
- worn during the day (bandage at night)
- most patients must wear for the remainder of life


Skin Care

- prevents accumulation of bacteria
- helps prevent the onset of cellulitis
- supplies moisture to dry skin
- protects against sunburn, scrapes, cuts and other risks for infection


Best practice during phase 1

- treatment time: 60-120 min
- 5 days/week
- 2-6 weeks for moderate symptoms
- 8-18 weeks for severe symptoms
- self or family wrap by day 5
- patient purchases bandages online


CDT Phase 2

- a compression garment
- home exercise
- bandaging
- skin care
- MLD if appropriate


Contraindications to CDT

- uncompensated cor pulmonale
- acute infections: local or systemic, viral or bacterial
- acute venous thrombosis
- ongoing radiation treatments - wait 6 weeks after radiation is completed or until skin returns to normal color
- conditions related to acute fluid management - cardiac, pulmonary, and renal insufficiency


Relative Contraindications to CDT

- cor pulmonale
- implants such as pacemakers, venous ports
- radiation damage to skin, other diseases
- malignant melanoma, malignant lymphedema
- conditions related to chronic fluid management - cardiac, pulmonary, and renal insufficiency


Reasons LE treatment doesn't work

- lack of patient adherence
- insufficient treatment: too late, not enough visits, not enough MLD, too few bandages, inexperienced therapist
- comorbidities
- unrealistic expectation of rapid outcome
- malignant lymphedema



- primary lymphedema
- LE swelling at birth that worsened with age
- had difficulty with self-esteem during middle school
- felt more confident once she learned to manage her condition
- studied abroad in Peru
- Graduated from Colorado St.



- survivor of stage III tongue CA
- surgery to rebuild tongue
- reoccurred in palate and tonsils
- experienced chemo and radiation
- caused swelling in face and neck
- rebuilt tongue muscle with upper trapezius, which caused shoulder problems
- was referred to an OT at the University of Michigan for secondary lymphedema
- used a machine that had immediate effects on her d/t the reduction of fibrosis
- pulls dermal and epidermal away from fascial tissues with vertical and horizontal forces
- works in criminal justice



- Marengo, IL
- experienced obesity for most of her life
- worsened during high school
- began noticing problems in 2008
- was hospitalized with symptoms of Hashimoto's disease
- was treated with Lasix for three years, which made her legs much worse
- a therapist tried short stretch compression bandaging, but not MLD, then gave her OTC compression garments
- reached 520 lbs. in 2010
- underwent gastric surgery in 2013
- chose to have her left leg treated first
- treatment gave her a purpose
- BMI 67.8 down to 38.0
- she got married in 2014


T/F: Lymphedema is not painful




- location of swelling
- skin changes (i.e. color, texture)
- scar tissue, radiation damage
- lymphatic cysts, fistulas, other



- temperature differences on the surface
- pitting edema
- fibrosis of underlying tissue
- moist vs. dry with palpation


Characteristics of DVT

- sudden onset, usually unilateral
- pain
- cyanosis or rubor and heat
- positive Homan's sign
- dx with Doppler US


Characteristics of CHF and Cardiac edema

- greatest distally
- always bilateral
- pitting edema
- nearly complete resolution with elevation
- no pain
- hx consistent with CHF
- may be SOB
- meds for CHF


Characteristics of Renal Failure

- kidneys unable to remove waste
- fatigue
- flank pain between ribs and hips
- swelling of ankle, foot, leg
- changes in urination (increased/decreased/stopped)


Characteristics of malignancy

- pain, paresthesia, paralysis (rare)
- proximal onset
- rapid development, progressive
- swelling in the supraclavicular fossa
- could be purple discoloration
- non-healing open wounds
- hx of malignancy
- pain that wakes them up at night
- unusual fatigue and/or weight loss


Characteristics of infection

- acute: warm, red, burning, edema, pain, sweating, red streaks in the skin, systemic symptoms, fever

- chronic: warm or cool, pale or red, edema, pain, little fever if any

- eventual fibrosis, osteomyelitis, skin breakdown, rash


Post-op complications

- possible acute DVT
- more than normal inflammation
- infection
- excess bleeding
- symptoms from poor positioning
- swelling as side effect of tourniquet


Characteristics of CRPS

- acute: warm, red, burning, edema, pain, sweating

- chronic: cool, pale, edema, pain, dry

eventual fibrosis, osteoporosis, atrophy of skin and muscle


Characteristics of lymphedema

- slow onset, progressive
- pitting in early stages
- begins distally
- cellulitis in hx is common
- rarely painful but the swelling is uncomfortable
- heavy, aching discomfort
- skin changes
- ulcerations unusual unless CVI is present


Characteristics of Lipedema

- a disorder of adipose tissue
- the condition may be inherited
- almost always female
- women of all sizes, upper body can be normal size
- excess deposit of fat cells
- fatty tissue does not respond well to diet and exercise
- can appear COMBINED with lymphedema
- bilateral, symmetrical swelling: iliac crest to ankles
- swelling spares the dorsum of feet
- little/no pitting
- no hx of cellulitis
- painful upon palpation
- can trigger 2˚ lymphedema


Characteristics of CVI

- non-pitting
- hemosiderin staining
- fibrosis of subcutaneous tissue
- atrophic skin (poor quality)
- usually ankle to the knee at most
- wounds common
- can trigger 2˚ lymphedema


Characteristics of CVI

- non-pitting
- hemosiderin staining
- fibrosis of subcutaneous tissue
- atrophic skin (poor quality)
- usually ankle to the knee at most
- wounds common
- can trigger 2˚ lymphedema


Characteristics of Baker's cyst

- fluid filled cyst behind knee
- causes a bulge that is often visible
- may cause LE swelling
- the feeling of tightness
- pain with activity in flexion/extension


Characteristics of myxedema

- thyroid dysfunction
- dry skin
- brittle nails
- thinning hair
- decreased sweat
- orange tint to the skin
- deposition of mucinous substances in the skin (eyelids, face, elsewhere)


Cyclical Idiopathic Edema

- periodic swelling/bloating in the legs/abdomen
- occurs in women while standing
- disappears when laying down
- happens most often before the menstrual period
- rule out cardiac, kidney, liver disease


Characteristics of edema

- often rapid onset, may be progressive
- pitting in early stages
- begins at the injury, insult, or surgery site
- cellulitis is NOT common in hx
- usually painful until 2 weeks out
- heavy, aching discomfort
- rarely have skin changes due to acuteness
- ulcerations unusual unless CVI
- bruising common


Diagnostic tests for LE

- gold standard: physical exam and hx
- lymphography
- venous doppler
- lymphoscintigraphy
- CT scan

- rule out heart, kidney, lung, liver, reproductive system



a combination of CVI and lymphedema; must be compressed



where lymph nodes runs toward


Poor postures that obstruct lymph flow

- crossing legs while seated
- sleeping on stomach
- sitting too long without break (flexed hips and knees)
- keyboarding too long without breaks (flexed elbows)
- driving without appropriate rest breaks


MLD Pattern

neck - abdomen - ipsilateral adjacent nodes - contralateral nodes - affected nodes - affected limb