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Lymphedema program for MMCC PTA program

Lymphedema program for MMCC PTA program

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  • 90% of fluid that is in the interstitial spaces is resorbed by venous capillaries, 10% absorbed by lymphaticsLymph system can take up to 10% overload
  • Cell junctions open/close in response to changes in interstitial pressure.Pressure changes occur from movements of anchoring fibers, light compression, muscle contraction, respiration, pulsation of nearby arteries
  • Collectors – 3 cells thick – inner layer muscularValves separating lymphangion are 6 to 20 mm apart.Lymph enters the lympangion, causing a stretch reflex of the smooth muscle layer, which then contracts to move the lymph into the next lymphagionRate is appx. 10x per minute, increases 10 to 30 x per minute w/exercise
  • Efferent pathways can connect w/ venous system, other lymph vessels, or can continue along same lymph vessel
  • Right Lymphatic DuctTerminates at junction of R. internal jugular & subclavian veinDrains right side of thorax, right arm, and right side of face & neckThoracic DuctBegins at cysternachyliTerminates at junction of L. internal jugular & subclavianDrains left side of thorax, left arm, left side of face & neck, entire abdomen and lower extremities
  • Lymphotomes – 4 of trunk, multiple lymphotomes in each extremityWatersheds – no valves, can act as detours from congested areas
  • Affects 140-150 million people worldwide.In our clinic lymphedema quickly became 25% of our total caseload.
  • Primary – estimated 1 in 6000 individuals (your text, 1985), typically females, unilateral LE involvementOf primary – 75% are praecoxSecondary – Cancer/Rx is most common cause in developed countriesWorldwide – filariasis is most common. Caused by a parasitic infection carried by mosquitoes. Affects 120 million people in over 80 countries.
  • Mention Stemmer’s Sign!Measurement technique – volume calculationsDiagnostic tests – lymphoscintigraphy (radiological isotope evaluation), lymphography (blue dye test),Ultrasound (for filriasis worm) MRI (lymph in


  • 1. Lymphedema
    Physical Therapy
    Treatment & Management
  • 2. “I wouldn’t want to be a physical therapist – you have to touch people’s feet!”
  • 3. Overview
    Anatomy & Physiology
    Principles of Management
    Manual Lymphatic Drainage Massage
    Compression Bandaging/Garments
    Patient Education
  • 4. The Lymphatic System
    Anatomy & Physiology
  • 5. The big picture
    Works with venous system for fluid return
    Removes plasma proteins
    Filters antigens, bacteria, waste products
    Produces white blood cells
  • 6. Initial Lymphatics – “Pickles”
    • Initial Lymphatics
    • 7. Lymph capillaries
    • 8. Superficial
    • 9. Overlapping endothelial cells
    • 10. Anchoring fibers
    • 11. Valves prevent fluid backflow
  • Plumbing – collector sequence
    • Lymphatic Capillaries > Precollectors
    • 12. Afferent Collectors
    • 13. Muscular cell walls with valves
    • 14. Lymphangions – section between the valves
    • 15. Lymph Nodes
  • Lymph Nodes
    600 in body, 300 head/neck
    Series of sinuses
    Important immunological functions
    Offers 100x more resistance to flow than ducts
  • 16. Collector Sequence – cont.
    Efferent collectors
    Lymphatic Trunks
    Lymphatic Ducts (2)
  • 17.
  • 18. Anatomical landmarks
    Distinct regions of the body for fluid drainage
    Division areas between lymphotomes where direction of flow changes
    Collateral vessels offering alternate routes of drainage
  • 19. Lymph Fluid
    Transparent, yellowish fluid
    96% water – more dilute than plasma
    Also consists of proteins, lipids, minerals, hormones, cells, bacteria, cell waste, etc.
    Body produces 2.4L of lymph fluid daily, 25L of lymph fluid cycles through the heart
  • 20. Pathology
    An excessive accumulation of protein-rich fluid in the tissues caused by a transport failure of the lymphatic system.
  • 21.
  • 22. Pathophysiology
    Mechanical Insufficiency - lymphostatic
    Low-flow edema, low-volume insufficiency
    A breakdown in the transport capacity of the lymphatic system
    Dynamic Insufficiency - lymphodynamic
    High-flow edema, high-volume insufficiency
    A high load placed on the lymph system exceeds its capacity
    Combination – Safety Valve Insufficiency
  • 23. Causes of Lymphedema
    Congenital deficit in number or size of lymph nodes and/or pathways
    Milroy’s Disease – present at birth
    Meige’s Disease or Lymphedema praecox – appears at puberty
    Lymphedema tarda – adult onset
    Caused by removal or or damage to lymph nodes and/or pathways
    Cancer/cancer treatments
    Chronic Venous Insufficiency
  • 24. Sequellae
    Chronic swelling
    Excessive tissue proteins
    Fibrotic changes
    Chronic inflammation
    Infections – cellulitis
    Skin changes – “peau d’ orange”
  • 25. Signs of Lymphedema
    Puffiness, heaviness, fullness of limb
    Stiffness, decreased ROM
    Weakness, fatigue
    Skin tension – feeling of “bursting”
    Numbness, paresthesias
  • 26. Consequences
    Functional deficits
    Loss of mobility
    Difficulty wearing normal clothing
    Psychological issues
  • 27. Stages of Lymphedema
    Stage 0
    Latent, sub-clinical condition
    Swelling not evident despite impaired lymph transport
    Stage 1
    Completely & spontaneously reversible
    Soft, pitting edema
    Little to no fibrosis
    Skin easily pinched & moved
  • 28. Stages – cont.
    Stage 2
    Spontaneously Irreversible
    Tissues usually fibrotic
    Pitting requires strong pressure, or no pitting
    Can usually be reversed with treatment
    Stage 3 - Elephantiasis
    No pitting, significant fibrosis
    Huge size, papillomas, hardening of the skin
  • 29. Other Types of Edema
  • 30. Principles of Management
    “If you can help me, I’ll add you to my Christmas card list!”
  • 31. Goals
    While the immediate goal of lymphedema therapy is to relieve swelling, the ultimate goal is to enable the patient to self-manage and control this chronic condition.
  • 32. Complete Decongestive Therapy
    Manual Lymphatic Drainage (MLD)
    Compression Bandaging
    Skin care – patient education
    Compression Garments
  • 33. Adjunct Treatments
    Myofascial Release
    Aquatic therapy
    Wound Care
    Pneumatic pumps
  • 34. Team Approach
    • Physician/nurses
    • 35. Other therapists
    • 36. Certified garment fitter
    • 37. Nutritionist
    • 38. Psychologist
  • Phases of Treatment
    Phase 1 – Active Intervention
    Attending therapy 2-5x/week
    Compression bandaging 23 hrs/day
    Daily home exercise/self massage
    Phase 2 – Self-Management
    Transition to compression garments
    Maintaining home program
    Occasional follow-up appointments
  • 39.
  • 40. Treatment Techniques
    “You’re just making that up to make me look stupid!”
  • 41. Patient Examination
    Functional mobility
    Skin Integrity
    Edema measurement
  • 42. Diagnostic Testing
    Radiological isotope evaluation
    Direct oil contrast – “blue-dye”
    Assess presence of filarial worm
  • 43. Red Flags!
    Any bacterial infection
    Acute congestive heart failure
    Acute deep vein thrombosis
    Acute renal disease
    Acute pulmonary edema
    Arterial disease
    Sensation deficits
    Low blood counts
    Areas of inflammation
  • 44. Skin and Wound Care
    Prior to treatment, skin should be clean and moisturized
    Wounds must be addressed
  • 45. Manual Lymphatic Drainage
    Goals of technique:
    Increase peristalsis of lymphangion
    Break down fibrotic tissues
    Increase lymph volume in lymph vessels
    Decrease congestion in interstitium
  • 46. Basic Principles
    Treatment begins proximal, to “clear” proximal lymphotomes before moving to affected lymphotomes
    Massage is directed towards the cleared lymphotome
    Pressure is very light
    Strokes are rhythmic
  • 47. Strokes
    “Scoops” – massaging lymph nodes
    Firmer pressure, circular motion
    Begin furthest from the affected area
    Clears the way for fluid drainage
    Moves proximal to distal
    Begin closest to the affected area
    Always done after clearing
    Moves distal to proximal
  • 48.
  • 49. MLD Pathways
  • 50. Medical Compression Bandaging
    Low stretch bandages
    Provides low stretch when no contraction
    Higher compression when muscles contract
    Prevent re-fill of lymphatics
    Work with muscle pumping
    Follow “Law of Laplace” – the smaller the radius the greater the pressure
    Help break up fibrotic areas
  • 51. Bandaging Guidelines
    Worn 23 hrs/ day (off only for bathing)
    Should re-wrap daily to prevent loosening
    Should have more compression (more layers) distally
    Bandages should be washed frequently
  • 52. Bandaging Techniques
  • 53. Compression Garments
    Maintains reduction gained during therapy
    Transition to garments when reduction plateaus
    Garments for daytime wear, options for nighttime
    Insurance coverage varies greatly
  • 54. Therapeutic Exercise
    Exercises facilitate muscle pumping
    Should be done with compression
    Progress proximally to distally
    Very low resistance, few repetitions, rests as needed
  • 55. Patient Education
    Home exercise
    Skin care
    Compression garments
  • 56. Conclusion
    Do all the good you can,By all the means you can,In all the ways you can,In all the places you can,At all the times you can,To all the people you can,As long as ever you can
    -John Wesley
  • 57. Thank You!
    Presented by
    Jennifer K. Root, PT, DPT, CLT
    Clinical Specialist
    MidMichigan Medical Center
    Rehabilitation Services