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

2. 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

3. 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

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

5. 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

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

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

8. 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.

9. 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.

10. 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

11. 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

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

13. 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

14. 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

15. 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.

16. 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

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

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