Flashcards in Lymphedema Deck (112):
What are the 2 main functions of the lymphatic system?
- Regulate fluid balance
- Assist with infection control
How many liters of fluids are removed from the interstitial space per day?
Of the 18 liters removed, __-__% via the veins and __-__% via the superficial and deep lymphatic vessels. How many liters via the lympathics?
What occurs when the lymphatics cannot remove the remaining interstitial fluid?
__-__% of women with breast cancer will develop lymphedema
__% of women with ovarian cancer will develop lymphedema
__% of patients with endometrial cancer will develop lymphedema
Up to __% of men with prostate cancer will develop lymphedema
What are the chief complaints of lymphedema?
- limb heaviness
- skin tightness
- poor-fitting clothes
- altered cosmesis
- decreased ADLs
- reduced ROM
The lymphatic system is composed of 2 interconnecting drainage systems, what are they?
superficial and deep lymphatics
Describe the function and arrangement of the superficial lymphatics
Drains the skin and subcutaneous tissue
Roughly parallels the veins
Describe the function of the deep lymphatics
drains everything else (deep tissues and organs)
What connects the deep and superficial lymphatic systems?
What is lymph made of?
water, protein, dead/dying cells/cellular components, fatty acids, foreign material and debris
Describe the path lymph takes as it exits the interstitial spaces to
Lymph capillaries --> Lymph precollectors --> Lymph collectors --> Lymph nodes --> Lymph trunks
What is the functional unit of a lymph vessel that lies between two semilunar (half moon-shaped) valves?
How many lymphangions are there in a typical arm collector? In a leg collector?
The total number of lymph nodes ranges from ___-___ with the majority located where?
Describe the path lymph takes from the LEs and the genitals
Passes through the inguinal nodes into the left and right lumbar trunks before emptying into the centrally located thoracic duct, which terminates into the left venous angle (the internal jugular vein and the subclavian vein)
Describe the path lymph takes from the LEFT upper extremity
Filters through the axillary lymph nodes before emptying into the subclavian vein
Describe the path lymph takes from the RIGHT upper extremity
Empties into the right subclavian vein aka the right venous angle
Lymphatic territories are areas of skin made up of several adjacent lymph collectors that drain into the same regional lymph nodes. These territories are separated by natural boundaries called what?
What pressures govern fluid movement between capillaries, interstitium, and lymphatic system?
hydrostatic and osmotic pressure
What are the 5 ways in which lymph moves centrally in a healthy lymphatic system?
- skeletal muscle contractions
- respiratory pump
- pulsations of the aorta
What is Lymphangiomotoricity?
the contraction of the smooth muscle within the lymphagnions
Lymphangiomotoricity is the key to decreasing edema when?
overnight while the patients are recumbent
What are the 2 types/causes of lymphedema?
primary and secondary
Describe primary lymphedema
Congenital malformation or impairment of lymphatics
Primary lymphedema accounts for only __% of all cases
Primary lymphedema cases are usually described by what 2 things?
type of lymphatic vessel abnormality or the age of onset
What are the 4 types of vessel abnormalities that occur with primary lymphedema?
- Lymph node fibrosis
Lack of lymphatic vessels in a body region therefore no lymphatic drainage in this area
Lymphatic vessels are narrower than normal leading to significantly less lymphatic drainage
Hypoplasia is comparable tow what?
Lymphatic vessels are wider than normal
Hyperplasia is comparable tow what?
Hyperplasia accounts for __% of all cases of primary lymphedema
Lymph node fibrosis is most commonly seen in what lymph nodes?
Classify the following:
Congenital Lymphedema: __-__
Lymphedema Praecox: __-__
Lymphedema Tarda: __
birth to 1 year
1-35 years old
after 35 years old
Describe secondary lymphedema
Results form a disruption in, or damage to, the lymphatic system
What are 3 causes of secondary lymphedema?
- Cancer treatment
- Chronic venous insufficiency
What causes filariasis?
the bite of a mosquito that is infected with a parasitic worm
In the US, secondary lymphedema is most often seen following what?
medical or surgical procedures that disrupt lymph flow
What can be defined as a bilateral, symmetrical increase in adipose tissue deposition?
Lipedema affects the abdomen, buttocks, lower extremities but spares what?
Increased compliance of fat associated with lipedema allows interstitial fluid to accumulate, leading to what?
What are 3 characteristics of lipolymphedema?
- bruise easily
- diet-resistant weight gain
What are the 9 risk factors contributing to lymphedema?
- lymph node status
- radiation therapy
- surgical complications
- time since surgery
- increased BMI
- air travel without compression
- inflammation/increased lymphatic load
- decreased lymphatic return
- individuals prone to scar tissue formation
What is a sentinel lymph node biopsy?
A biopsy that removes only the first lymph node receiving lymph from the tumor
What 2 things does radiation therapy lead to?
Perilymphatic and lymph node fibrosis
What type of skin changes occur with radiation therapy?
- Dermal atrophy
- Decreased sweat glands
__% of breast cancer patients who had lumpectomy and axillary radiation developed lymphedema
The risk of lymphedema increases as the time since surgery _____.
Why does the risk of lymphedema increase as time after surgery increases?
Possibly due to lymphatic fatigue
Why does the risk of lymphedema increase with air travel?
There is decreased atmospheric pressure on the body while flying which allows the body to swell
It is recommended that individuals at risk for lymphedema wear compression, greater than __ mm Hg for an UE and greater than __ mm Hg for a LE, while flying.
Why are patients instructed to avoid strenuous activity of at-risk limbs?
It may cause muscle microtrauma and inflammation, which leads to increased fluid that the patient’s lymph system may not be able to accommodate
What are some things that may cause decreased lymphatic return?
- BP cuffs
Why are patients prone to excessive scar tissue formation (keloids) at risk for lymphedema?
The trauma of surgical lymph node removal can be exacerbated by an abdominal increase in collagen deposition post-surgery
What are 4 tests and measures PTs must perform on a patient with suspected lymphedema?
- Circumferential Measurements
- Body Mass Index
- Sensory Integrity
What is the gold standard for measuring limb circumferentially?
True or False
You can measure a limb every 3, 4, 8, or 12 cm without it significantly effecting limb volume calculations
How is BMI calculated in the US?
BMI = weight in pounds x 703 / height in inches squared
Classify the following:
Underweight: less than __
Normal weight: __-__
Obese Class I: __-__
Obese Class II: __-__
Obese Class III: greater than __
What are 3 circulation tests a clinician must perform in patients with LE lymphedema?
- Doppler US
- capillary refill
True or False
Monofilament testing must be performed on all patients with lymphedema
Nerve entrapments (carpal/tarsal tunnel, etc.) associated with lymphedema can lead to what?
tissue distention, edema, and inflammation
What lymphedema patient population is at risk for neuropathy?
- Those with diabetes
- Those who received chemotherapy
Lymphedema falls under what Cardiovascular/Pulmonary Practice Pattern?
How many stages of lymphedema are there?
What is the descriptor for stage 0 lymphedema?
What are the characteristics of stage 0 lymphedema?
- No edema present
- Reduced lymph system transport capacity
- Most commonly due to radiation or surgery
What is the descriptor for stage 1 lymphedema?
What are the characteristics of stage 1 lymphedema?
- Pitting edema
- Greatly or completely reduces with elevation
- No secondary skin changes
What is the descriptor for stage 2 lymphedema?
What are the characteristics of stage 2 lymphedema?
- Does not pit
- Does not substantially reduce with elevation
- Skin becomes brawny and fibrotic
- May have frequent skin infections
What is the descriptor for stage 3 lymphedema?
What are the characteristics of stage 3 lymphedema?
- Extreme increase in limb volume
- Deep skin folds
- Papillomas present
- Frequent skin infections
Mild Lymphedema = less than _ cm interlimb difference or less than __% limb volume increase
Moderate Lymphedema = between _-_ cm interlimb difference or between __-__% limb volume increase
Severe Lymphedema = greater than _ cm interlimb difference or greater than __% limb volume increase
Pain associated with lymphedema is typically described as what?
- deep ache or pressure sensation
- stretching type pain
- neuropathic pain
- discomfort or heaviness
Secondary lymphedema occurs ____ to the area of lymphatic obstruction or damage
What is Lymphorrhea?
What type of drainage is most common in lymphedema?
True or False
Copious wound drainage is the norm and wound beds are commonly covered with slough
What are 12 integumentary changes commonly seen in patients with lymphedema?
- hair loss
- deep skin folds
- vesicle of blister formation
Thickening of the dorsal aspect of the digits may result in a positive ______ sign
What is papillomatosis?
cobble-stone-like appearance of the epithelium
Are pulses typically normal or affected in patients with lymphedema?
Is temperature generally affected in patients with lymphedema?
No, however it may be warm to the touch due to edema, inflammation, or infection
It has been determined that mild lymphedema will require _-__ visits. Whereas moderate lymphedema will require __-__ visits.
Generally one can expect a __-__% volume decrease within 6-36 visits
What are 5 things to instruct patients to do?
- protect from injury
- perform regular skin checks
- treat open areas
- weight management
- utilize garments
What are 5 things to instruct patients not to do?
- get injections, piercings, or tattoos in affected area
- have BP taken in affected extremity
- avoid hot tubs/saunas
- do not walk barefoot
What are 3 things to be cautious of in patients with lymphedema?
- ensure cancer is not the cause of recurrent lymphedema
- refer spontaneous lymphedema to MD
- beware of patients with history of arterial insufficiency or DVT
Under what 3 circumstances should you request for further medical testing?
- signs and symptoms of infection
- to rule out recurrence
- if you cannot perform an ABI
What skin care suggestions should you advise a patient with lymphedema?
- keep the skin clean and dry
- avoid perfumes and high-alkaline soaps
- use low pH moisturizers
- keep open wounds clean and apply an antimicrobial over top
Who are the 4 leaders in the field of manual techniques for lymphatic drainage?
What are 8 benefits of manual therapy?
- increase lymph formation
- propels lymph proximally
- increases lymph angiomotoricity
- reroutes stagnated lymph
- encourages development of collaterals
- reduces sympathetic and increases parasympathetic responses
- decreases pain/promotes relaxation
- decreases fibrosis
What are 7 precautions/contraindications of manual therapy?
- active infection
- open wound
- metastatic disease
- abdominal inflammatory conditions (IBS, etc.) or currently pregnant
Describe the general process for manual therapy
Clear the proximal lymph system before moving distally. First at the venous angles of the neck then to the trunk, and then the affected extremity
What are 5 proposed benefits of compression therapy?
- Reduces ultrafiltration
- Enhances venous return
- Improves effectiveness of muscle pump
- Increases angiomotoricity
- May reduce fibrosis
What are 7 Precautions/Contraindications for Compression Bandaging?
- arterial insufficiency
- radiation damage with intact skin
- open wounds
- patients who are weak, immobile, insensate
What type of compression garment is used during high-risk activities?
Use a __-__ mm Hg or light compression garment on patients with mild lymphedema or for a prophylactic UE
Use a __-__ mm Hg or medium compression garment on patients with moderate to severe UE lymphedema or for mild LE lymphedema
Use a __-__ mm Hg or strong compression garment on patients with moderate to severe LE lymphedema
Use a very strong compression garment with greater than __ mm Hg compression on patients with stage 3 LE lymphedema
Describe how compression pumps work and why they cannot be used on their own?
They remove the fluid from the area, but not protein. So once they are stopped the protein draws the fluid back into the area or the residual protein may lead to fibrosis
What are the 2 phases of intervention?