By Christina Hankins PT, CLT, CWS Lymphedema By Christina Hankins PT, CLT, CWS

Objective Identify form and function of circulatory and lymph systems Describe various factors that affect the movement of fluid Describe difference between edema and lymphedema Describe stages of lymphedema Describe types of lymphedema Describe lymphedema treatment Describe Referral process

Anatomy of circulatory system 3 structural elements Heart Blood cells- RBC, WBC, platelets Plasma – water, salts, proteins, vitamins, minerals, hormones, dissolved gases, toxins, medications, and fats Blood vessels Arteries, veins, and blood capillaries

Anatomy of Lymphatic system 3 structural components Lymph vessels Trunks, collectors, precollectors, and lymph capillaries Lymphatic tissues Lymph nodes (600-700), spleen, and thymus Lymph fluid Proteins, WBC, Medications, toxins, fats, water, bacteria

Lymph capillaries > Collectors> Nodes>Lymph Vessels>Venous angle Originate close to BC Closed tubes in the interstitial spaces of sub endothelial layers of the skin Larger than BC More permeable Anchoring filaments that connect to skin Flat endothelial cells, arranged in a single layer, overlap

Lymph Collectors Are larger vessels than LC Valves that contract Propel lymph into lymph nodes

What does the Lymph system Do? Basically a scavenger system that removes proteins, excess fluid, debris, and other matter from the interstitial spaces….

Factors affect fluid movement Diffusion Osmosis/osmotic pressure Colloid osmosis/ colloid osmotic pressure Filtration and reabsorption Diffusion- Molecules moving in a solution so as to equalize there are several factors that can speed up or slow down this process temperature, concentration gradient (larger the difference the faster the diffusion rate, size of molecules, surface area, diffusion distance the shorter the distance the more effecitve diffusion. Clinically 1 cm of swelling increaases the diffusion distance by 100xs. Osmosis- diffusion of water mol across a selective permeable membrane from a place of higher water concentration to a place of lower. Cell membranes in the body are generally permeable to water and water in and out of cells will be the same. Some times a concentration difference for water may develop across a membrane. In the case of lymphedema yOu have have a high protein concentration within the interstital tissue ( why because the main function of the lymph system is to remove protein, if I doesn’t work because of sx or cancer, scar tissue… then the protein doesn’t get removed). If protein doesn’t get removed Protein attracts water which brings more fluid volume to already congested area which goes back to increasing the diffusion distance…. The only way to overcome this Pressure ( focethe water back into the cells or BC is to apply compression Filtration and absorption –Filtration depends on a pressure gradient between both sides of the membrane and always moves from high area to low. In the blood capillary the colloid osmotic pressure is 29mmhg, in the interstitium it is 25, this causes filtration. At the venous capillary, the blood cap is 14 mmHG which is lower the the Colloid osmotic pressure of the intersititum which facilitates reabsorbption.

Physiology of lymphatic system Passive edema protection Pressures ^ in BC> pressure ^ in interstitial fluid> ^ reabsorption rate Active edema protection Safety factor: Increase permeability of Lymph Capillaries Increase contraction frequency of Lymph collectors Lymph systems way of kicking into high speed to deal with additional fluid what ever the cause is.

Edema or Lymphedema? Dynamic insufficiency Lymphatic load > Transport capacity of an intact functioning lymph system CHF, CVI (stage I or II), immobility, hypoproteineima, pregnancy Edema is a swelling caused by the accumulation of abnormally large amounts of fluid in the intercellular spaces of the body Treat with Elevation Compression Exercise If dynamic insufficienty is present over long periods of time beasue of the tissue damage (cells not getting the nutrition they need) you can have 2ndary damage to lytmph collectors which will lead to a Mechanical insufficiency

Lymphedema Mechanical insufficency Reduction of transport capacity due to damage of insufficient lymph system Surgery, radiation, chronic inflammation, paralysis, Primary lymphedema Lymphedema is high protein edema To treat CDT- Complex decongestive therapy Because the lymph system can’t remove protein as it is compromised the result is a high protein intersititum. Chronic inflammation- The stagnation of watrer, protein, and other wast products in the intersititum causes tissue damage (decreased circulation, lack of 02 and nutrients). The protein rich swelling increases the diffusion distance and thus reduces the ability of the bodys defense mechanisms prone to infections

Lymphedema or Edema? Combined insufficiency Lymph transport is compromised Compounded with a sx or trauma

Stages of Lymphedema Stage 0 Stage I Stage II Stage III Transport capacity is subnormal yet sufficient Stage I Pitting edema that recedes over night, 0 skin changes Stage II Fibrosis, cellulitis, pitting difficult to induce, wounds Stage III Fibrosis, papillomas, cysts, fistuals, hyperkeratosis, recurrent cellulitis, wounds

Types of Lymphedema Primary Secondary Born with insufficient or compromised lymph system Secondary Due to know insult Cancer, surgery, venolymphedema, obesity induced lymphedema, CHF induced

CDT in Home Health 4-6 weeks, although treatment set up upon individual need Ensure pt is a good candidate Education Disease process Bandage Ther Ex MLD Garments Pumps Lymphedema will not go away unless you manage.

CDT Benefits Individual comprehensive treatment with focus on education to work towards independence with maintenence program Incorporate function Can fit into shoes Ambulates much easier with smaller legs Decreased risk of infection Heal wounds

Home Health Benefits Great support staff In home assessment SN, PT, OT, MSW, Aides In home assessment Readily available to caregivers

Refer to Home Health Physical therapy to Eval and treat (Bilateral LE) lymphedema Send prescription to Home Health Phone Fax Demographics