1. Lymphatic disorders
Dr.Rehab Gwada

2. 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.

3. 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)

4. Major Structures of lymphatic system
Lymph fluid
Lymph vessels
Lymph nodes
lymphoid organs :-
Tonsils & Adenoids
Veriform appendix & peyer’s patches
Spleen
Thymus

5. 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.

6. 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.

7. 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

8. 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.

9. 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

10. 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).

11. 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

12. Lymphedema Location

13. 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

14. 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

15. 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.

16. 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

17. 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.

18. (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

19. 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.

20. 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.

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

22. 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

23. 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.

24. 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).

25. Bandages

26. Compression Garments

27. 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).

28. Exercise
Low-intensity cardiovascular/pulmonary endurance activities included
Deep breathing and relaxation also incorporated

29. 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:-

30. Treatment Works
Thank you