1. Lymphatic System Jeopardy
Jenna Heffernan, Bill Nixon, Adriana Zalar

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

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

4. Answer
Lymphedema

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

6. 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

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

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

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

10. 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.

11. 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?

12. 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.

13. 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).

14. 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.

15. 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…..

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

17. 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.

18. 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.

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

20. 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.

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

22. Complete Decongestive Therapy (CDT)
Answer
Complete Decongestive Therapy (CDT)

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

24. Short Stretch and Long Stretch Bandages
Answer
Short Stretch and Long Stretch Bandages
Short Stretch = high working pressure, low resting pressure; wear up to 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

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

26. 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

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

28. Pneumatic compression devices
Answer
Pneumatic compression devices

29. 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.

30. 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.

31. 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?

32. Answer
50%

33. 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?

34. 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.

35. 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.

36. 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

37. 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.

38. 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

39. 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.

40. 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.

41. 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...

42. 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

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

44. 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

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

46. 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

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

48. 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

49. 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?

50. 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

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

52. 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

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

54. 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

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

56. 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

57. 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)

58. 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: cm
Moderate: cm
Severe: > 5.0 cm

59. 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:

60. 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

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

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