Lymphedema is an excessive accumulation of fluid in tissues caused by a failure of the lymphatic system. Physical therapy uses complete decongestive therapy including manual lymphatic drainage, compression bandaging, exercise, and skin care/patient education to manage lymphedema. Manual lymphatic drainage uses light pressure strokes to increase lymph flow and break down fibrotic tissues. Compression bandaging provides graduated compression to assist lymph transport. A team approach including self-management training helps patients control this chronic condition.
5. The big picture Works with venous system for fluid return Removes plasma proteins Filters antigens, bacteria, waste products Produces white blood cells
18. Anatomical landmarks Lymphotomes Distinct regions of the body for fluid drainage Watersheds Division areas between lymphotomes where direction of flow changes Anastomoses Collateral vessels offering alternate routes of drainage
19. Lymph Fluid Transparent, yellowish fluid 96% water – more dilute than plasma Also consists of proteins, lipids, minerals, hormones, cells, bacteria, cell waste, etc. Body produces 2.4L of lymph fluid daily, 25L of lymph fluid cycles through the heart
20. Pathology Lymphedema An excessive accumulation of protein-rich fluid in the tissues caused by a transport failure of the lymphatic system.
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22. Pathophysiology Mechanical Insufficiency - lymphostatic Low-flow edema, low-volume insufficiency A breakdown in the transport capacity of the lymphatic system Dynamic Insufficiency - lymphodynamic High-flow edema, high-volume insufficiency A high load placed on the lymph system exceeds its capacity Combination – Safety Valve Insufficiency
23. Causes of Lymphedema Primary Secondary Congenital deficit in number or size of lymph nodes and/or pathways Milroy’s Disease – present at birth Meige’s Disease or Lymphedema praecox – appears at puberty Lymphedema tarda – adult onset Caused by removal or or damage to lymph nodes and/or pathways Cancer/cancer treatments Trauma Chronic Venous Insufficiency Paralysis Filariasis
27. Stages of Lymphedema Stage 0 Latent, sub-clinical condition Swelling not evident despite impaired lymph transport Stage 1 Completely & spontaneously reversible Soft, pitting edema Little to no fibrosis Skin easily pinched & moved
28. Stages – cont. Stage 2 Spontaneously Irreversible Tissues usually fibrotic Pitting requires strong pressure, or no pitting Can usually be reversed with treatment Stage 3 - Elephantiasis Irreversible No pitting, significant fibrosis Huge size, papillomas, hardening of the skin
31. Goals While the immediate goal of lymphedema therapy is to relieve swelling, the ultimate goal is to enable the patient to self-manage and control this chronic condition.
43. Red Flags! Contraindications Precautions Any bacterial infection Acute congestive heart failure Acute deep vein thrombosis Acute renal disease Acute pulmonary edema Malignancy Arterial disease Sensation deficits Low blood counts Areas of inflammation Wounds
44. Skin and Wound Care Prior to treatment, skin should be clean and moisturized Wounds must be addressed
45. Manual Lymphatic Drainage Goals of technique: Increase peristalsis of lymphangion Break down fibrotic tissues Increase lymph volume in lymph vessels Decrease congestion in interstitium
46. Basic Principles Treatment begins proximal, to “clear” proximal lymphotomes before moving to affected lymphotomes Massage is directed towards the cleared lymphotome Pressure is very light Strokes are rhythmic
47. Strokes “Scoops” – massaging lymph nodes Firmer pressure, circular motion “Clearing” Begin furthest from the affected area Clears the way for fluid drainage Moves proximal to distal “Flowing” Begin closest to the affected area Always done after clearing Moves distal to proximal
50. Medical Compression Bandaging Low stretch bandages Provides low stretch when no contraction Higher compression when muscles contract Prevent re-fill of lymphatics Work with muscle pumping Follow “Law of Laplace” – the smaller the radius the greater the pressure Help break up fibrotic areas
51. Bandaging Guidelines Worn 23 hrs/ day (off only for bathing) Should re-wrap daily to prevent loosening Should have more compression (more layers) distally Bandages should be washed frequently
53. Compression Garments Maintains reduction gained during therapy Transition to garments when reduction plateaus Garments for daytime wear, options for nighttime Insurance coverage varies greatly
54. Therapeutic Exercise Exercises facilitate muscle pumping Should be done with compression Progress proximally to distally Very low resistance, few repetitions, rests as needed
56. Conclusion Do all the good you can,By all the means you can,In all the ways you can,In all the places you can,At all the times you can,To all the people you can,As long as ever you can -John Wesley
57. Thank You! Presented by Jennifer K. Root, PT, DPT, CLT Clinical Specialist MidMichigan Medical Center Rehabilitation Services
Editor's Notes
90% of fluid that is in the interstitial spaces is resorbed by venous capillaries, 10% absorbed by lymphaticsLymph system can take up to 10% overload
Cell junctions open/close in response to changes in interstitial pressure.Pressure changes occur from movements of anchoring fibers, light compression, muscle contraction, respiration, pulsation of nearby arteries
Collectors – 3 cells thick – inner layer muscularValves separating lymphangion are 6 to 20 mm apart.Lymph enters the lympangion, causing a stretch reflex of the smooth muscle layer, which then contracts to move the lymph into the next lymphagionRate is appx. 10x per minute, increases 10 to 30 x per minute w/exercise
Efferent pathways can connect w/ venous system, other lymph vessels, or can continue along same lymph vessel
Right Lymphatic DuctTerminates at junction of R. internal jugular & subclavian veinDrains right side of thorax, right arm, and right side of face & neckThoracic DuctBegins at cysternachyliTerminates at junction of L. internal jugular & subclavianDrains left side of thorax, left arm, left side of face & neck, entire abdomen and lower extremities
Lymphotomes – 4 of trunk, multiple lymphotomes in each extremityWatersheds – no valves, can act as detours from congested areas
Affects 140-150 million people worldwide.In our clinic lymphedema quickly became 25% of our total caseload.
Primary – estimated 1 in 6000 individuals (your text, 1985), typically females, unilateral LE involvementOf primary – 75% are praecoxSecondary – Cancer/Rx is most common cause in developed countriesWorldwide – filariasis is most common. Caused by a parasitic infection carried by mosquitoes. Affects 120 million people in over 80 countries.