1. Lymphatic Disorders

2. References Therapeutic Exercise: Foundations and Techniques by Kisner and Colby. 5 th Edition, Pages 834 - 847. Goodman and Snyder, page 315. Reference: Therapeutic Modalities in Rehabilitation, 3 rd Edition, by William Prentice, pages 490 – 496. Reference: Modalities for Therapeutic Intervention, 4 th Edition, by Susan Michlovitz and Thomas Nolan, pages 174 – 179.

5. Lymphedema Excessive and persistent accumulation of extravascular and extracellular fluid and proteins in tissue spaces Excessive and persistent accumulation of extravascular and extracellular fluid and proteins in tissue spaces Caused by a disturbance of the water and protein balance across the capillary membrane Caused by a disturbance of the water and protein balance across the capillary membrane Increased concentration of proteins draws greater amount of water into interstitial spaces Increased concentration of proteins draws greater amount of water into interstitial spaces Exceeds transport capacity of the lymphatic system, leading to lymphedema Exceeds transport capacity of the lymphatic system, leading to lymphedema

6. Lymphedema Also develops when lymph vessels or lymph nodes are missing, impaired, damaged or removed

7. Primary lymphedema –rare,caused by absent lymph vessels at birth, or caused by abnormal lymphatic vessels. Secondary lymphedema –due to blockage or interruption that alters the lymphatic system.

8. Secondary lymphedema can develop from infection, malignancy, surgery, scar tissue formation, trauma, deep vein thrombosis (DVT), radiation or other cancer treatment.

9. Disorders of the Lymphatic System Leading to Lymphatic Insufficiency Congenital Malformation Congenital Malformation Infection and Inflammation Infection and Inflammation Obstruction or Fibrosis Obstruction or Fibrosis Trauma, Surgery, Neoplasms Radiation Therapy Surgical Dissection of Lymph Nodes Surgical Dissection of Lymph Nodes Chronic Venous Insufficiency Chronic Venous Insufficiency

10. Clinical Signs and Symptoms of Lymphedema Edema of the dorsum of the foot or hand Edema of the dorsum of the foot or hand Decreased range of motion, flexibility and function Decreased range of motion, flexibility and function Usually unilateral Usually unilateral Worse after prolonged dependency Worse after prolonged dependency No discomfort or a dull, heavy sensation; sense of fullness No discomfort or a dull, heavy sensation; sense of fullness Reference: Goodman and Snyder, page 315.

11. Clinical Manifestations of Lymphatic Disorders Lymphedema Lymphedema Increased girth and weight of the limb Increased girth and weight of the limb Sensory disturbances Sensory disturbances Stiffness and limited range of motion Stiffness and limited range of motion Decreased resistance to infection Decreased resistance to infection

12. Lymphedema Location

13. Severity of Lymphedema Mild lymphedema: One to two cm increase in girth measurements between the involved and non-involved limb Mild lymphedema: One to two cm increase in girth measurements between the involved and non-involved limb Moderate lymphedema: Two to five cm increase in girth measurement Moderate lymphedema: Two to five cm increase in girth measurement Severe lymphedema: Greater than five cm increase Severe lymphedema: Greater than five cm increase

14. Types of Lymphedema Pitting edema Pitting edema Short duration edema Finger indentation of the skin Brawny edema Brawny edema Tissue feels hard upon palpation Indicates fibrotic changes Weeping Weeping Fluid leaks, wound healing is impaired Occurs mostly in the lower extremities

16. Examination and Evaluation of Lymphatic Function Special Considerations History, systems review History, systems review Daily activities and position of limb Daily activities and position of limb Functional assessment Functional assessment Skin integrity Skin integrity Girth measurements Girth measurements Volume measurements Volume measurements

17. Components of a Decongestive Lymphatic Therapy Program Elevation Elevation Manual lymphatic drainage Manual lymphatic drainage Compression Compression Exercise Exercise Skin care Skin care Daily living precautions Daily living precautions

18. Elevation Elevate the involved limb when using a sequential compression pump Elevate the involved limb when using a sequential compression pump Elevate limb when sleeping, resting, and during sedentary activities Elevate limb when sleeping, resting, and during sedentary activities Compressive bandages or garment should be worn during periods of elevation Compressive bandages or garment should be worn during periods of elevation

19. Manual Lymphatic Drainage Slow, very light, repetitive stroking and circular massage movements performed in a specific sequence, limb elevated whenever possible Slow, very light, repetitive stroking and circular massage movements performed in a specific sequence, limb elevated whenever possible Proximal congestion in the trunk, groin, buttock, or axilla is cleared first Proximal congestion in the trunk, groin, buttock, or axilla is cleared first Direction of massage is towards specific lymph nodes Direction of massage is towards specific lymph nodes Usually involves distal to proximal stroking Usually involves distal to proximal stroking

20. Manual Lymphatic Drainage

21. Labor and time intensive Labor and time intensive Specialized training needed Specialized training needed Continuing education Certification

22. Manual Lymphatic Drainage

24. Exercise Active range of motion, stretching, and low-intensity resistance exercise is incorporated with manual drainage techniques Active range of motion, stretching, and low-intensity resistance exercise is incorporated with manual drainage techniques Exercises should be performed with compressive bandages or garment Exercises should be performed with compressive bandages or garment

25. Exercise Exercises are performed in a specific sequence, often with the limb elevated Exercises are performed in a specific sequence, often with the limb elevated Low-intensity cardiovascular/pulmonary endurance activities included Low-intensity cardiovascular/pulmonary endurance activities included Deep breathing and relaxation also incorporated Deep breathing and relaxation also incorporated

26. Exercise Exercises performed in a specific sequence can assist lymph flow Exercises performed in a specific sequence can assist lymph flow Awareness of other medical conditions Awareness of other medical conditions Patient education Patient education

27. Exercise

28. Compression No-stretch, non-elastic or low-stretch elastic bandages are used No-stretch, non-elastic or low-stretch elastic bandages are used Sports bandages, such as ACE wraps, are NOT recommended in the treatment of lymphedema Sports bandages, such as ACE wraps, are NOT recommended in the treatment of lymphedema Compressive garments are available Compressive garments are available Use of a sequential, pneumatic compression pump on a daily basis may be recommended Use of a sequential, pneumatic compression pump on a daily basis may be recommended

29. Bandages

30. Compressive Bandages

34. Compression Garments

36. Sequential, Pneumatic Pumps

37. Intermittent Compression Devices Contraindications Deep vein thrombosis Deep vein thrombosis Local superficial infection Local superficial infection Congestive heart failure Congestive heart failure Acute pulmonary edema Acute pulmonary edema Displaced or acute fractures Displaced or acute fractures

38. Intermittent Compression Devices Reference: Therapeutic Modalities in Rehabilitation, 3 rd Edition, by William Prentice, pages 490 – 496. Reference: Modalities for Therapeutic Intervention, 4 th Edition, by Susan Michlovitz and Thomas Nolan, pages 174 – 179.

39. Skin Care and Hygiene Lymphedema increases risk of skin breakdown, infection, and delayed wound healing Lymphedema increases risk of skin breakdown, infection, and delayed wound healing Proper skin care Proper skin care Inspection Inspection Protection Protection

40. Treatment Works

44. THE END