Components of Lymphatic System
Lymphatic Vessels > Lymphatic Collectors > Lymphatic trunks
How many main lymphatic trunks are there?
2 main lymphatic trunks.
What is the function of the Right lymphatic trunk?
Right lymphatic trunk is responsible for draining lump from R arm and R side of head
What is the function of the thoracic trunk?
responsible for draining lymph from the remainder of the body
Where do they lymphatic trunks empty?
Empty lymph directly into the venous system via the subclavian veins
Describe Primary lymphedema?
Congenital—abnormal development of lymphatic system
Describe Secondary lymphedema.
Occurs as a result of disease or injury to the system.
May included trauma, surgery, radiation, tumor growth, multiparity, chronic venous insufficiency or infection
List the three types of insufficienceis in the lymphatic system that may lead to lymphedema
- Dynamic insufficiency
- Mechanical insufficiency
- Combined insufficiency
Which insufficiency is the most common?
Dynamic insufficiency
Explain dynamic insufficiency
Excessive lymph circulating in the system which exceeds transport capacity of lymph system
What does dynamic insufficiency result in?
pitting edema
List some examples of dynamic insufficency
- CHF
- Pregnancy
- Chronic venous insufficiency
Explain mechanical insufficency
Transport capacity of the system is decreased d/t damage to the lymph system
Will mechanical insufficiency also result in pitting edema?
No. Mechanical insufficiency results in increased protein-rich lymphedema which is NON-PITTING
Describe combined insufficiency.
There is both an increase in lymph fluid + decrease in transport capacity
What is the primary sign of lymphedema?
Swelling in the extremities.
True or false: A therapist should take blood pressure on a limb with lymphedema
False
When performing circumference measurements, how may circumference points should be taken on the limb?
At least seven circumferences
How would a therapist differentiate lymphedema from lipedema?
Lipedema: Normal Lymphatic function + Symmetrical Swelling of extremities + (-) Stemmer’s sign
Mostly seen in women
When comparing extremities while measuring the circumference of affected extremity, what would classify the affected extremity as having lymphedema?
2-3 cm difference b/t four comparative circumferences on bilateral UE
What is a tell-tale sign of lymphangitis?
Red Stripes proximal to the infection site (typically caused by streptococcus)
What are preventative measures for ppl who are at risk for lymphedema?
- Meticulous skin care/nail care—moisturizer important
- Loose fitting clothing/jewelry
- Extreme temperatures—no hot tub/saunas above 102 degrees
- Lifestyle management—exercise, no heavy lifting
What is Complete Decongestive Therapy for lymphedema?
Treatment model that consists of :
- Phase I: Intensive acute treatment phase (4-6wks)
- Phase II: self-management phase (long-term management)
True or False: patients may need to return to phase I whenever new symptoms appear?
True
What are 4 things that CDT consists of?
- Manual Lymphatic drainage (MLD)
- Compression therapy
- Exercise
- Skin care
The purpose of MLD is?
To move lymph around blockages
What should be cleared prior to working on affected areas?
Decongest proximal areas and uninvolved areas to prepare area for new lymph
What is the purpose of compression therapy?
Maintains reduction in edema that is achieved by MLD.
What kind of compression bandages are typically used?
Short-Stretch bandages
True or false: Compression should be apart of every treatment for individuals with lymphedema, edema, and CVI (unless red flags present)
True
True or false: A patient with mixed arterial and venous disease, and ABI test is indicated to provided information about the safety of using compression on the LE
True
T or F: Edema affects healing of wounds therefore compression therapy should be initiated asap in the presence of a wound
True
True or False: Mechanical “Milking” or deep pressure techniques should be used with lymphedema
False: these techniques damage superficial capillaries
Short bandages have ____ resting pressure and _____ working pressure.
Low resting pressure and high resting pressure
This means they are less stretch and more rigid, that increase efficiency of muscle pump during activities
Low resting pressure makes more tolerable to wear
High resting bandages (i.e. ace) will ______ superficial lymph capillaries and restrict fluid absorption
Occluded
How many hours a Day should short-stretch compression bandages be worn?
24 hours
During Phase I of lymphedema treatment what compression bandages are used?
Short-Stretch bandages
During Phase II what compression therapy is used?
Combination of compression garments (During the day) and compression bandages (during the night)
When should compression garments be fitted?
Once edema levels have plateaued
For lymphedema: short-stretch compression wrap until limb reduction goal reached then ________ to _______ compression garments at ______ to ____ mmHg to 30 to 40 mmHg depending on location and severity of swelling + ability of the patient to don and doff garments
high to moderate compression
20 to 30 mmHg
Describe the basic exercise guidelines for lymphedema.
- Start with trunk exercises
- Extremity exercises working from proximal joints to distal joints
- End with trunk exercises and deep breathing
When performing low impact aerobic activities therapist must monitor for what?
Lymph overload
List signs and symptoms of lymph overload.
Discomfort, aching, pain in proximal lymph areas
Change in skin
If any are present , DISCONTINUE exercise
What bacterial infections are common with lympedema?
Streptococcus and cellulitis
True or false: Lymphedema impairs immune system function allow for bacterial and fungal growth
True
List the contraindications for CDT.
- Acute infection
- Cardiac edema
- Diabetes
- HTN
- Malignancy
- Renal insufficiency
- DVT
What modalities are contraindicated with lymphedema
A. Modalities that cause vasodilation (heat, hydrotherapy, saunas, contrast bath, paraffin)
B. Electrotherapeutic modalities greater than 30Hz
T or F: If a patient is exercising (Phase II), compression garments should be worn.
True
If a therapist is using an Intermittent Pneumatic compression the must use caution. What should the therapist perform prior and post IPC?
Therapist should perform MLD prior and post IPC.
In what stage should you use ICP, if a therapist decides to use it?
Stage I lymphedema only: DO NOT use if there is any chagne in skin or subcutaneous tissue, exacerbation of inflammation and fibrosis can occur in Stage II and Stage III
What Pneumatic Pressures are contraindicated?
> 45 mmHg
True or False: IPC pressure should be kept very low to reduce risk of collapse of superficial capillaries
True
True or false: With IPC each patient should be carefully examined and BP readings should be taken before each treatment
True
True or false: Increasing oral peripheral resistance with IPC will increase the work of the heart, increasing BP.
True
Filariasis
- Disease caused by parasitic infection
- seen in tropical climates
- one of most common causes of secondary lymphedema
Hyperkeratosis
Thickening of the outermost layer of the skin (usually occurs stage III)
Lymphadenitis
Infection and inflammation of a lymph node (may be acute or chronic)
Lymphadenopathy
Disease that affects the size, number or consistency of them lymph nodes
Lymphangitis
Infection and inflammation of lymphatic system pathways
Name this disease: An inherited type of primary lymphedema that typically presents in infancy. BLE edema is most common symptom of this disease.
Milroy’s disease
Non-pitting edema
harder and not compressible when pressure applied
Observed with stage III
Papilloma
Benign wart-like skin growth that is typically observed in stage III
A test used to aid in teh dx of lymphedema. It is (+) if skin at the dorsal base of 2nd finger/toe can’t be easily lifted away from the bone, which indicates thickening of the skin due to fibrotic changes. What test is being described?
Stemmer’s Sign
Lipodermatosclerosis
Thickening and hardening of the subcutaneous tissue and brown skin discoloration
Lymphangiectasia
Dilation of lymph vessels, may appear as blister like protuberances
Lymphorrhea
Leakage of lymph from the skin surface
Contraindications for IPC?
- HTN (>140/90)
- Acute inflammation or trauma
- Local infection
- DVT
- Cardiac or kidney dysfunction
- Obstructed lymphatic channels
- Impaired cognitive function
