Lymphatic System Jeopardy Jenna Heffernan, Bill Nixon, Adriana Zalar

Precautions and Contraindications Signs and Symptoms Treatments Wraps and Drainage Precautions and Contraindications Etiology Catch All 200 400 600 800 1000

Signs and Symptoms-200 A chronic disorder with excessive accumulation of fluid due to obstruction of lymphatics or removal of lymph nodes.

Answer Lymphedema

Signs and Symptoms-400 The most common, and perhaps obvious, sign/symptom that an individual with lymphedema will exhibit.

Swelling of the extremities Answer Swelling of the extremities Swelling in the extremities results from mechanical insufficiency of the lymphatic system. Can be unilateral or bilateral

Signs and Symptoms-600 As a result of lymphedema, an individual might experience this in their joints.

Decreased flexibility/ROM Answer Decreased flexibility/ROM Fluid accumulation and swelling can lead to restricted ROM and decreased flexibility

Signs and Symptoms-800 Hi, I’m a man with lymphedema. You might describe my skin as looking/feeling like this…...

Hard, thick, and tight skin. Answer Hard, thick, and tight skin. Because the lymph can not drain properly, fibrosis occurs due to the excessive amount of protein molecules accumulating in the underlying tissue.

Signs and Symptoms-1000 My name is Charlie and I have lymphedema. During the initial interview what did I describe about my clothing to you?

Answer I find it difficult to fit into my clothes in certain places. My clothes feel tight. Individuals with lymphedema often describe tight fitting clothes or accessories such as watches, bracelets, rings, socks, and shoes.

Treatment-200 I am an individual with lymphedema. You, as an astute physical therapy student, will recommend that I wear these 24 hours per day (assuming there are no contraindications).

Short stretch compression stockings. Answer Short stretch compression stockings. Short stretch compression bandages are the dressings of choice for lymphedema because they provide the active resistance necessary for drainage. i.e low resting pressure and high working pressure.

Treatment-400 I am an individual with lymphedema. As we approach the end of a treatment session you proceed to tell me about skin care. You remind me of these important tips…..

Answer Keep the skin clean and dry. Apply fragrance-free lotion daily to maintain the skins moisture.

Treatment-600 I am a patient with lymphedema. During one of our sessions I notice you are rubbing my legs. I ask what you are doing and you report you are using a technique known as this.

Manual Lymph Drainage (MLD) Answer Manual Lymph Drainage (MLD) MLD is a gentle form of skin stretching to increase uptake of lymph fluid in the lymph system.

Treatment-800 When performing drainage techniques, the physical therapist will emphasize flow in this direction.

Example begin at the toes/foot and work towards the hip. Answer Distal → Proximal Example begin at the toes/foot and work towards the hip.

Treatment-1000 Skin Care, Decongestive Exercises, Compression Therapy, and MLD are four aspects to a treatment plan known as this.

Complete Decongestive Therapy (CDT) Answer Complete Decongestive Therapy (CDT)

Wraps and Drainage-200 What are the two main types of compression wrappings used for lymphedema treatment and management?

Short Stretch and Long Stretch Bandages Answer Short Stretch and Long Stretch Bandages Short Stretch = high working pressure, low resting pressure; wear up to 23-24 hours/day; stretches to 60% of length Long Stretch = low working pressure, high resting pressure; wearing only during activity NEVER during rest or sleep; stretches to 170% of length

Wraps and Drainage-400 Which type of compression wrapping would be used to treat a patient who presents with acute lymphedema characteristics?

Answer Short Stretch Short stretch wraps are initially used to help decrease lymphedema until it is managed or plateaued, and then compression garments or long stretch wraps will be implemented

Wraps and Drainage-600 Sleeves or stockings connected to a pump that provides sequential compression from the end of the extremity toward the body

Pneumatic compression devices Answer Pneumatic compression devices

Wraps and Drainage-800 Name at least one additional type of material required, when implementing compression wrapping, that would be placed on the affected limb.

Stockinette, padding, high density foam, toe/finger wraps Answer Stockinette, padding, high density foam, toe/finger wraps These materials are used to prevent breakdown and/or irritaiton of the skin that could lead to discomfort or infection. At the least, a stockinette should be used to cover the limb prior to using compression wraps.

Wraps and Drainage-1000 When performing compression wrapping, using a spiral technique from distal → proximal, what is the percentage of overlap coverage that is standard practice?

Answer 50%

Precautions/Contraindications-200 Leg pain or swelling, typically in the calf or the foot, would be considered a “red flag” when treating patients with lymphedema due to what possible condition?

Deep Vein Thrombosis (DVT) Answer Deep Vein Thrombosis (DVT) Treatment of lymphedema typically involves moving protein fluid out of the distal extremities and towards the trunk. This could potentially lead to a break off the blood clot in the lower extremity.

Precautions/Contraindications-400 Diagnosis when the heart is unable to maintain adequate circulation of blood in the tissues of the body or to pump out the venous blood returned to it by the venous circulation. Problematic when unmanaged in patients with lymphedema.

Congestive Heart Failure (CHF) Answer Congestive Heart Failure (CHF) If unmanaged, CHF can be problematic in lymphedema patients due to increased fluid being pumped to the heart during lymph drainage techniques, which leads to increased stress on the heart Need to monitor BP during treatment, always using blood pressure cuff on contralateral side of mastectomy Blood Urea & Nitrogen (BUN) Range: >20 mg/dL can indicate CHF or MI

Precautions/Contraindications-600 A common, potentially serious bacterial skin infection. Usually presents in the lower extremities as swollen, red area of skin that feels hot and tender. Contraindication to lymphedema management.

Answer Cellulitis Compression and manual lymph drainage are typically contraindicated until patient has been started on antibiotics Importance of compliance with treatment between episodes to reduce recurrence, as lymphedema exacerbations increase the risk of skin breakage, which increases the risk of infection

Precautions/Contraindications-800 Diseases in which abnormal cells divide without control and can invade nearby tissues. Lymphedema more common in female patients suffering from a form of this disease. More of a precaution to lymphedema management.

Answer Cancer Need to be cautious and conscious of patients with a history of CA. Secondary lymphedema is a common complication following surgery for breast cancer, and radiation treatment can affect the flow of fluid by damaging the lymph nodes and vessels.

Precautions/Contraindications-1000 A condition in which the kidneys lose the ability to remove waste and balance fluids, which when deemed as chronic is termed...

Answer Renal Failure Manual lymph drainage would increase the amount of fluid being moved back onto the kidneys, increasing the amount of stress placed on the already damaged organs to remove waste from the blood. Creatinine Range: >1.3 mg/dL may be a result of renal dysfunction or CHF

What causes edema vs. lymphedema? Etiology-200 What causes edema vs. lymphedema?

Protein rich fluid vs. non-protein fluid Answer Protein rich fluid vs. non-protein fluid Lymphedema is an increase in protein-rich fluid in the interstitial space due to insufficiency of lymphatic system, while edema is an increase in non-protein fluid which typically occurs after a trauma and can resolve in a few days Chronic edema can progress to lymphedema

Differentiate between causes of primary and secondary lymphedema Etiology-400 Differentiate between causes of primary and secondary lymphedema

Answer Primary Lymphedema: developmental abnormality (dysplasia) of the lymphatic system o LE>UE o Unilateral>bilateral o Females>males Secondary Lymphedema: mechanical insufficiency due to an insult to the lymphatic system o Surgery, radiation, trauma o More common than primary lymphedema

Etiology-600 Aplasia, Hypoplasia, Hyperplasia, Fibrosis, and Agenesis are all causes of?

Answer Primary lymphedema Aplasia – absence of single lymph collectors, capillaries, or LN Hypoplasia – incomplete development of lymph vessels, number of collectors are reduced and diameter is smaller Hyperplasia – AKA lymphangiectasia – diameter is larger than normal, malfunction of vascular system Fibrosis of LN – affects node and lymph transport

Etiology-800 Patient A presents to your clinic following a surgical procedure with the diagnosis of lymphedema. Patient B presents with the same diagnosis but with no prior surgical or traumatic history, what is the difference between these two patients?

Answer Patient A most likely has secondary lymphedema and patient B has primary lymphedema Primary lymphedema – developmental abnormality of the lymphatic system o Unilateral>bilateral o Females > males Secondary lymphedema – mechanical insufficiency due to an insult to the lymphatic system o Surgery, radiation, trauma o More common than primary lymphedema

Etiology-1000 What causes lymphedema when the variables of lymphatic load and transport capacity are taken into consideration?

Answer LL > TC = lymphedema Transport capacity TC – maximum amount of lymph transport if the lymphatic system works as hard as it can Lymphatic load (LL) – substances from the interstitium which cannot be absorbed by the venous end of blood capillaries consisting of water, protein, cells, and fat Functional reserve (FR) – amount of compensation available above normal lymphatic load o FR = TC-LL

What are the 3 main lymph nodes in the body? Catch All-200 What are the 3 main lymph nodes in the body?

Cervical, axillary, and inguinal Answer Cervical, axillary, and inguinal Drainage patterns and patterns of swelling: Cervical – superior to clavicle Axillary – UEs and ipsilateral trunk Inguinal – LEs/ipsilateral trunk

What are watersheds in regards to the lymphatic system? Catch All-400 What are watersheds in regards to the lymphatic system?

The body is divided into 4 watersheds Answer Linear areas on skin that separate territories from each other and contain relatively few lymph collectors The body is divided into 4 watersheds Sagittal Horizontal Clavicular Gluteal

Catch All-600 As a physical therapist who is treating lymphedema, what factors would you examine when determining the severity of lymphedema? (At least 5)

Answer Volume changes Circumferential measurements Palpation Skin Integrity Strength assessment ROM assessment Observation Volume Changes: Minimal: less than 20% volume increase Moderate: 20-40% volume increase Severe: greater than 40% volume increase Limb Differences with Circumferential Measurements: Minimal: 1.5-3.0 cm Moderate: 3.0-5.0 cm Severe: > 5.0 cm

Catch All-800 A patient came to you for direct access for L foot pain. During your initial evaluation you note edema in B LEs, B LEs hemosiderin staining, a positive Stemmer’s sign on the dorsum of the feet, and significantly impaired skin mobility throughout B LEs. Your patient tells you that this is normal for her legs and that she has not seen her PCP for it. During differential diagnosis you determine that your patient is most likely suffering from:

Chronic venous insufficiency Answer Chronic venous insufficiency Differential diagnoses to consider: o CVI o Lipedema o Fluid retention (renal or cardiac, endocrine) o DVT o Hyponatremia o Symmetrical swelling usually is sign of other underlying problem

Catch All-1000 How many stages of lymphedema are there, and what are the names of each:

Answer 4 Stages Stage 0 – Latency Stage 1 – Reversible Stage 2 – Spontaneously Irreversible Stage 3 – Lymphostatic Elephantitis