Lymphatic system and physical therapy management

1. LYMPHATIC SYSTEM
Under supervision of / dr. Amr Zaki.

2. ‫االسم‬ ‫الجلوس‬ ‫رقم‬
‫حسين‬
‫دمحم‬ ‫حسين‬ ‫عصام‬ 4251
‫احوذ‬ ‫حسين‬
‫شحاتة‬ ‫علي‬ 4250
‫بختيار‬ ‫انور‬ ‫دمحم‬ ‫حكين‬ 4253
‫دمحم‬ ‫يحي‬ ‫حسن‬
‫هحوود‬ 4248

3. ANATOMY OF LYMPHATIC SYSTEM:-
The lymphatic system consists of many parts.
These include:-
 Lymph: Lymph, also called lymphatic fluid, is a
collection of the extra fluid that drains from cells
and tissues(that is not reabsorbed into the
capillaries) plus other substances. The other
substances include proteins,minerals, fats,
nutrients, damaged cells, cancer cells and foreign
invaders (bacteria, viruses, etc). Lymph
alsotransports infection-fighting white blood cells
(lymphocytes).

5. Lymph nodes: Lymph nodes are bean-shaped glands that monitor and
cleanse the lymph as it filters through them. The nodes filter out the
damaged cells and cancer cells. These lymph nodes also store lymphocytes
and other immune system cells that attack and destroy bacteria and other
harmful substances in the fluid. You have about 600 lymph nodes scattered
throughout your body. Some exist as a single node; others are closely
connected groups called chains. A few of the more familiar locations of
lymph nodes are in your armpit, groin
·.and neck. Lymph nodes are connected to others by the lymphatic vessel.
Lymphatic vessels: Lymphatic vessels are the network of capillaries
(microvessels) and a large network of tubes located throughout your body
that transport lymph away from tissues. Lymphatic vessels collect and
filter lymph (at the nodes) as it continues to move toward larger vessels
called collecting ducts. These vessels operate very much like your veins do:
They work under very low pressure, have a series of valves in them to
.keep the fluid moving in one direction

6. Collecting ducts: Lymphatic vessels empty the lymph into the right
lymphatic duct and left lymphatic duct (also called the thoracic duct).
These ducts connect to the subclavian vein, which returns lymph to your
bloodstream. The subclavian vein runs below your collarbone. Returning
lymph to the bloodstream helps to maintain normal blood volume and
pressure. It also prevents the excess buildup of fluid around the tissues
(called edema)
Spleen: This largest lymphatic organ is located on your left side under
your ribs and above your stomach. The spleen filters and stores blood and
produces white blood cells that fight infection or disease
Thymus: This organ is located in the upper chest beneath the breast
bone. It matures a specific type of white blood cell that fights off foreign
organisms
Tonsils and adenoid: These lymphoid organs trap pathogens from the
food you eat and the air you breathe.
.They are your body’s first line of defense against foreign invaders

7. Bone marrow: This is the soft, spongy tissue in the center of certain
bones, such as the hip bone and breastbone. White blood cells, red blood
cells, and platelets are made in the bone marrow
Peyer’s patches: These are small masses of lymphatic tissue in the
mucous membrane that lines your small intestine. These lymphoid cells
monitor and destroy bacteria in the intestines
Appendix: Your appendix contains lymphoid tissue that can destroy
bacteria before it breaches the intestine wall during absorption.
Scientists also believe the appendix plays a role in housing ―good
bacteria‖ and repopulating our gut with good bacteria after an infection
has cleared

8. Types of Lymphedema:-
Primary lymphedema may appear at any time, though it stems from a
genetic mutation present at birth. Damage to the lymph nodes or
lymphatic system from to cancer treatment is the typical cause of
secondary lymphedema, the most common type.
This type of lymphedema, also called hereditary lymphedema, develops
from genetic mutations present at birth.
Types of primary lymphedema include:
Milroy’s disease: A familial type of lymphedema that is present at birth,
this disorder has been linked to the FLT4 gene. This gene is responsible
for one of the early steps in lymphatic development.
Lymphedema praecox: This is the most common type of primary
lymphedema, accounting for 80% of people who have lymphedema. It
generally develops in females between ages 9 and 25.
Lymphedema tarda: This hereditary lymphedema occurs in adulthood,
typically after age 35.

9. Lymphedema-distichiasis syndrome: This condition typically appears at
or after the onset of puberty and affects the lower legs. People with
lymphedema-distichiasis syndrome have an extra row of eyelashes that
grows from the lining of the eyelids. This syndrome is often linked to
mutations in the FOXC2 gene.
Hypotrichosis-lymphedema-telangiectasia syndrome: This type of
congenital lymphedema is linked to mutations in the SOX18 gene and
causes other symptoms such as sparse hair, eyebrows, and eyelashes.
Hennekam syndrome: This rare form of lymphedema causes symptoms
including lymphangiectasia (abnormally wide lymph vessels), intellectual
disability, and unusual facial features.

10. Secondary Lymphedema:-
Secondary lymphedema can develop at any age after damage or trauma to
the lymphatic system. The condition can occur shortly after the trauma or
even many years later. It usually appears in the arms or legs, but it may
spread to other areas of the body, such as the neck, underarm, or groin.

11. Investigation :-
Although lymphedema usually can be identified by history and physical
examination, patients often undergo ultrasound, MRI, and/or CT prior to
their referral to our center. These tests are not sensitive or specific for
lymphedema and only may show skin thickening or subcutaneous edema.
Lymphedema cannot be diagnosed by histopathology; biopsy specimens
may show non-specific skin and adipose inflammation.
The definitive diagnostic test for lymphedema is lymphoscintigraphy.
Although newer imaging modalities can give information that may be
useful for surgical planning, they are not as accurate for diagnosing
lymphedema. Magnetic resonance lymphangiography outlines lymphatic
vasculature of the limb, but has a sensitivity of 68% for lymphedema.
Indocyanine green lymphangiography details subdermal lymphatics, but
the specificity for lymphedema is 55%.

12. Types of lymphoscintigram results. ( A ) Normal study showing tracer
uptake into the bilateral inguinal nodes 45 minutes following injection
into the feet. ( B ) Abnormal test illustrating absent uptake of
radiolabeled colloid into the right inguinal nodes. ( C ) Abnormal test
showing dermal backflow of tracer into the left leg.

13. Complete decongestive therapy (CDT),
also called complex or multimodal decongestive physiotherapy, is the term
proposed by Michael Földi in the 1980s to define lymphedema treatment. His
approach is divided into two separate phases .
The first, intended to obtain the most important reduction of lymphedema
volume, is comprised of several components: low-stretch bandage, manual
lymph drainage (MLD), skin/nail care, and exercises, each having its own
specific objective and role in limiting the impact of this disorder. The intensive
strategy of this stage aims to achieve a 30–40 % lymphedema-volume
reduction , eliminating only the fluid component of lymphedema. The second
phase of CDT helps stabilize lymphedema volume over the long-term and is
based on wearing an elastic garment, exercises, skin care, and, sometimes,
MLD .

14. Low-Stretch Bandage:-
Low-stretch bandage is the major element of CDT. It is able to achieve
important and significant lymphedema-volume reduction. A low-stretch
bandage is wrapped in multiple—2 to 4 (even 5 when lymphedema volume is
huge)—layers after covering the affected limb with padding composed of
foam and/or cotton batting . A low-stretch bandage is defined as having an
elongation below 100 %, as previously described by Partsch et al. The
bandage should be wrapped around the affected limb by a trained
physiotherapist or nurse (depending on the various practices in different
countries), applying pressure with the hand without pulling the band and
squeezing the limb, which causes pain and makes it impossible for the
patient to keep the bandage in place, especially during the night. Bandages
are applied progressively, starting from the distal extremity (hand, foot,
sometimes toe or finger) and gradually placed more proximally until reaching
the axilla or groin (knee if lymphedema only concerns the lower leg). The low-
stretch bandage exerts a low but not non-existent pressure that increases
with muscular activity (exercise) that is recommended while wearing it. It
may be kept in place for 24 h and reapplied every day or 48–72 h for the
weekend. Bandaging may include finger/hand or toes/feet if they are affected
by lymphedema .

16. Manual Lymph Drainage:-
MLD is a specific technique practiced by physiotherapists specialized in
lymphatic-drainage techniques. The theoretical goal of MLD is to increase the
lymphokinetic activity of normal lymphatics or stimulate the functional units
of lymph vessels (lymphangion) to contract more frequently to channel lymph
towards adjacent lymphatics. Several MLD technical variants (Casley-Smith,
Vodder, Földi, Leduc) have been described, with or without node pumping,
using more or less cutaneous pressure, and beginning on the proximal or
distal side . MLD usually lasts 30–45 min, or even longer for some authors.
Classically, it begins by manual stimulation of the lymph nodes in adjacent
drainage regions (neck, subclavicular, contralateral axilla, back, ipsilateral
groin) and is followed by manual decongestion of the involved trunk, shoulder,
arm, forearm and, if necessary, hand and fingers for the upper limb or back,
abdomen, thigh, calf, and foot and, if necessary, toes. Several physiotherapists
proposed not doing the first step of manual stimulation and retaining only
manual decongestion; others suggest exerting greater pressure on the skin,
especially when it is firm or hard.

17. Exercises:-
Exercises are considered another major component of CDT. Most of the
proposed exercises concern upper-limb lymphedema occurring after
breast-cancer treatment; much fewer deal with primary or secondary
lower-limb lymphedema. Different types of exercises have been devised:
against/without resistance, isometric, aerobic, including the
lymphedematous limb, with repetitive, progressive, and therapist-guided
movements. Various types of soft and remedial exercises are used, always
associated with posture correction, abdominal breathing, including neck
(stretches), shoulder (shrugs, rotations, stretches), arm (isometric biceps
curl), elbow (circles), forearm, wrist (rotations), and fingers
(opening/closing) . During the CDT intensive phase, ideally with the
short-stretch bandage or elastic garment in place, these exercises are
intended to facilitate lymph resorption into remaining functional lymph
channels. However, muscular activity may more difficult while wearing
an elastic garment (recommended) that nonetheless appears essential in
this situation . During the maintenance phase, patients are encouraged
to continue regular daily exercises at home.

18. Skin and Nail Care:-
Meticulous skin and nail care is mandatory for patients with lymphedema.
Patients with limb lymphedema are confronted with various cutaneous
complications, most of which can represent a site of entry for infections,
particularly cellulitis (erysipelas). Notably, lower-limb lymphedema increases
the risk of cellulitis 70-fold, in comparison to a non-lymphedematous limb .
Elastic Garment:-
Practitioners should encourage long-term and consistent wearing of an elastic
garment. Their own motivation is a major driving force to stoke the patient’s
motivation. Wearing an elastic garment is the foundation of the CDT
maintenance phase to stabilize lymphedema volume after the intensive phase.
An elastic garment may be also the first-line treatment for patients with
recent-onset moderate lymphedema after breast-cancer treatment. Indeed,
the results of a recent randomized study demonstrated that CDT was unable
to achieve significantly better lymphedema-volume reduction than elastic
compression for patients after breast-cancer treatment .

20. Other Components Not Included in CDT:-
Although CDT is composed of low-stretch bandage, MLD, skin care,
exercises and wearing an elastic garment, some other major factors
contribute importantly to managing lymphedema. Obesity is a predictor of
upper-limb lymphedema after breast-cancer treatment . High body mass
index (BMI) is also associated with the severity of lymphedema, i.e., its
volume . Overweight and obese patients should be oriented towards specific
consultation with a dietician or nutritionist to incite them to lose weight
because weight control is a major component of lymphedema management .
Pneumatic compression is not included in CDT but is sometimes associated
with bandaging during the first intensive phase .
Alternative techniques (electrostimulation, acupuncture, elastic taping,
laser, endermology (mechanical cellulite massage therapy), extracorporeal
shock wave, deep oscillation, hyperbaric oxygen, ultrasound) are sometimes
used but weakness of their evaluations does not allow us to recommend
these techniques before further well-defined studies are conducted [24].
Other medical therapies, including diuretics, benzopyrones, selenium, or
tocopherol, are not recommended .

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