Lymphatic disorders Dr.Rehab Gwada

lymphatic system is a vascular network of tubules and ducts that collect, filter, and return lymph to blood circulation. Lymph is a clear fluid that circulates throughout the body to remove wastes, bacteria, and other substances from tissues . This fluid becomes the interstitial fluid that surrounds cells . Lymph contains water, proteins , salts, lipids , white blood cells , and other substances that must be returned to the blood.

functions of the lymphatic system to drain & return interstitial fluid (lymph)to the blood. That helps to maintain normal blood volume and pressure. (fluid balance) to absorb and return fats and fat-soluble vitamins from digestive system to the blood. to filter fluid of pathogens, damaged cells, cellular debris, and cancerous cells .(immunological defense)

Major Structures of lymphatic system Lymph fluid Lymph vessels Lymph nodes lymphoid organs :- Tonsils & Adenoids Veriform appendix & peyer’s patches Spleen Thymus http://www.youtube.com/watch?v=BX8fBlme9vQ

Diseases and Disorders Lymphoma – a general term for malignancies that develop in the lymphatic system. The cancer affects immune cells called lymphocytes, which are white blood cells.

Continued- Disorders & Diseases Lymphadenitis – inflammation of the lymph nodes that can be caused by a variety of sources lymph nodes become enlarged, hard, smooth or irregular, red, and may feel hot to the touch. Lymphadenopathy – enlargement of the lymph nodes Tonsillitis – infection of the tonsils, usually caused by strep. severe sore throat, fever, malaise, difficulty swallowing, earache, and enlarged, tender lymph nodes in the neck.

Cont. Lymphedema is an accumulation of protein rich fluid in extracellular & extravascular space, principally in subcutaneous fat due to defect in lymphatic system. Increased concentration of proteins draws greater amount of water into interstitial spaces Exceeds transport capacity of the lymphatic system, leading to lymphedema  

Edema & Lymphedema, what's different? In edema the lymphatic system is normal and functioning at one hundred percent of its working capacity, however fails to remove fluid.   The edema is low in protein and soft in texture and treatment would be directed to the cause.

Etiology {Classification} of Lymphedema: Primary Secondary Congenita Age<1y Praecox Age 1-35years Trada Age >35years Lymphatic Obstruction Lymphatic interruption Cancer related lymphedema Infection Inflammatory Traumatic

Loss of muscular strength , flexibility and ROM Usually unilateral Sign &Symptoms Pain less swelling Heaviness and tension in the limb especially at the end of day in hot weather. ; sense of fullness Positive Stemmar sign. Loss of muscular strength , flexibility and ROM Usually unilateral Worse after prolonged dependency Aching and bursting pain. Deformity (elephantiasis).

Sign &Symptoms Skin conditions: Skin changes are common and ranging from dry skin, depression of the natural skin folds. thicker skin Rougher skin Ulcerations and skin break down with lymph exuding, Fibrotic, overgrowths, lympangiosarcoma Skin infection, lymphangitis, and cellulites

Lymphedema Location

Stage of Lymphedema:- Stage I It is spontaneously reversible and pitting ,with associated increase in limb girth &heaviness Stage II It is marked by a spongy consistency of the tissue without signs of pitting, & mild tissue fibrosis Stage III Lymphostatic elephantiasis

Severity of Lymphedema Mild lymphedema: One to two cm increase in girth measurements between the involved and non-involved limb Moderate lymphedema: Two to five cm increase in girth measurement Severe lymphedema: Greater than five cm increase

Differentiated diagnosis 1-The main reason for investigation is not to confirm the diagnosis but to exclude potentially conditions such as DVT. 2-General examination is necessary to exclude medical conditions such as heart failure. 3-Simple serum analysis is done to exclude hepatic or renal impairment. 4-Urine analysis is done to exclude any protein –losing nephropathy.

Examination and Evaluation of Lymphatic Function Special Considerations Full Medical History & Clinical Feature of Limb Swelling Daily activities and position of limb Functional assessment Skin integrity Girth measurements Volume measurements

Examination and Evaluation of Lymphatic Function Tonometer:- It is device used to measure the amount of the pressure necessary to depress skin a specified amount (tissue tonicity). Multi-Frequency Bioelectrical Impedance (MF-BIA):- It has the ability to measure the extent of the extra-cellular fluid levels and to learn whether they are within or outside of normal range by using bio-impedance. (Invasive Technique):- measure the peripheral lymphatic function, lymph movement, lymph draining. It involves injections of a radiotracer.

(Bioimpedance Spectroscopy (BIS): It is a more recently developed method for measuring the water content of the body. BIS has been shown to provide reliable data to be used in the diagnosis of breast cancer-related lymphedema

Treatment of Lymphedema The treatment available for lymphedema reduction may be divided into three general categories : A complex decongestive therapy (CDT)), Drug therapies, Surgery. Relative contraindications of (CDT)include:- 1-Significant congestive heart failure. 2-Acute deep vein thrombosis, 3-Acute or untreated infection, 4-Inflammation of the affected limb 5-Local irradiated soft tissue and active malignancy.

Goals of Treatment:- To stimulate the lymphatic system to promote reduction of edema. To prevent further accumulation of edema. To retain or restore function and cosmoses to the affected limb. To help patients cope with psychological sequel of lymphedema . To educate patients about lymphedema and home care program.

Manual lymph draining(MLD Complex Decongestive Therapy(CDT) Manual lymph draining(MLD Elevation Compression therapy Skin care Remedial exercises

Elevation Elevate the involved limb when using a sequential compression pump Elevate limb when sleeping, resting, and during sedentary activities Compressive bandages or garment should be worn during periods of elevation

Direction of massage is towards specific lymph nodes Manual lymph draining(MLD), gentle, rhythmic massaging of the skin Proximal congestion in the trunk, groin, buttock, or axilla is cleared first. Direction of massage is towards specific lymph nodes Usually involves distal to proximal stroking Goals: To mobilize and prevent re-accumulation of edema fluid. To initiate the regression of fibrosclerotic tissue. To continue the breakdown of the scar tissue.

2- No-stretch (non-elastic) bandage. 3-Compression garment Compression Therapy:- 1-Low elastic (low-stretch) bandage. 2- No-stretch (non-elastic) bandage. 3-Compression garment 4-Intermittent Pneumatic Compression (IPC).

Bandages

Compression Garments

Exercise Active range of motion, stretching, and low-intensity resistance exercise is incorporated with manual drainage techniques Exercises should be performed with compressive bandages or garment. Exercises are performed in a specific sequence, often with the limb elevated(assist lymph flow).

Exercise Low-intensity cardiovascular/pulmonary endurance activities included Deep breathing and relaxation also incorporated http://www.youtube.com/watch?v=DYG7ccjfzDg http://www.youtube.com/watch?v=ZIDnuYtX_LM

Skin Care: - -Low level laser therapy:- Skin care is an important aspect of the treatment program related to the increased risk of local infection. 1-Patients are instructed to avoid cuts or breaks in the skin 2-Any cuts that do occur should be cleaned treated with a topical antibiotic and covered. 3-In addition it is recommended that patients protect their skin by applying a moisturizing cream on a regular basis, to keep the skin supple ,moist, and in good general conditions. 4-Medical procedures on the affected extremity including blood pressure reading, blood draws and injections should be avoided. -Low level laser therapy:-

Treatment Works Thank you