Lymphedema
Anatomy and physiology
Lymphatic physiology
- Works simultaneously with the venous system for fluid return
- Removes plasma proteins
- Filters antigens, bacteria, and waste products
- Produces white blood cells
Lymph nodes
- Series of sinuses that filter antigens, bacteria, and produce plasma
- Key in immunological response
- Total in body = 600, with 300 in the head/neck
Two primary lymphatic ducts of the body
- Right lymphatic duct
- Thoracic duct
Lymph fluid composition
- Transparent, yellowish fluid containing water, proteins, lipids, minerals, and hormones
- Human body produces 2.4L of lymph fluid daily.
- 25L cycles through the heart
Pathology
Lymphedema
- Excessive accumulation of lymph fluid due to dysfunction in the lymphatic system, leading to increased edema
- Causes: Surgery, physical trauma, radiation, infection, etc
Effects of lymphedema
- Chronic swelling
- Excessive tissue proteins
- Fibrotic changes
- Chronic inflammation
- Infections – cellulitis
- Skin changes – “peau d’orange”
Related impairments
- Functional deficits
- Loss of mobility
- Difficulty wearing normal clothing
- Psychological issues
Stages of lymphedema
Stage 1
- Latent, sub-clinical condition
- Swelling not evident despite impaired lymph system
Stage 2
- Completely & spontaneously reversible
- Soft, pitting edema
- Little to no fibrosis
- Skin easily pinched & moved
- Stemmer sign present
Stage 3
- Spontaneously irreversible
- Tissues are usually fibrotic
- Pitting requires strong pressure or no pitting
- Can usually be reversed with treatment
- Stemmer sign present
Stage 4 - Elephantiasis
- Irreversible
- No pitting, significant fibrosis
- Hardening of the skin
Image #106
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Goals of manual lymph drainage
- Peristalsis of lymph fluid
- Breakdown of fibrotic tissues
- Increase lymph volume in lymph vessels
- Decrease congestion in the interstitium
Basic principles
- Treatment begins proximally to clear proximal lymphotomes before moving to affected lymphotomes
- Massage is directed towards the cleared lymphotome
- Pressure is very light
- Strokes are rhythmic
Contraindications
- 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
- Open wounds
- Strokes are rhythmic
Bandaging techniques
Compression garments
- Maintains reduction gained during therapy
- Transition to garments when reduction plateaus
- Garments for daytime wear, options for nighttime
- Insurance coverage varies greatly
- Pressure should not exceed diastolic blood pressure
Therapeutic exercise
- Exercises facilitate muscle pumping
- Should be done with compression
- Progress from proximally to distally
- Very low resistance
Patient education
- Home exercise
- Self-massage
- Skin care
- Precautions
- Compression garments