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, specifically lymphocytes
  • All white blood cells originate in the bone marrow; organs within the lymphatic system, like the thymus, spleen, and lymph nodes, are crucial for their development and function.

Lymph nodes

A series of sinuses that filter antigens and bacteria. The plasma that seeps out of blood capillaries into the surrounding tissues forms lymph fluid. * Key to immunological response

• Total in the 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
• The human body produces 2.4 L of lymph fluid daily.
• 25 L 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’- a medical term describing a characteristic appearance of the skin (skin of an orange)

Related impairments

• Functional deficits
• Loss of mobility
• Difficulty wearing normal clothing
• Psychological issues

Stages of lymphedema

Stage 1

• Latent, subclinical condition
• Swelling not evident despite impaired lymph system

Stage 2

• Completely and spontaneously reversible
• Soft, pitting edema
• Little to no fibrosis
• Skin easily pinched and 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

Definitions

Stemmer sign

Inability to lift a fold of skin on the dorsal surface of the second toe or finger is typically associated with stage 2 and stage 3 lymphedema.

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 always begins proximally to clear proximal lymph nodes before moving to affected lymphotomes (a specific region of the skin that drains lymph to a particular group of lymph nodes).
• Massage is directed towards the cleared lymph node
• Pressure is very light

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

Bandaging techniques

Compression garments

• Maintains the reduction gained during therapy
• Transition to garments when reduction plateaus
• Garments for daytime wear, options for nighttime
• Insurance coverage varies greatly

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