Lymphedema
What is Lymphedema? Lymphedema is a chronic health condition which causes localized swelling. There are 2 types: Primary lymphedema: a person is born with the condition where the lymphatic vessels are not formed completely or malformed Secondary lymphedema: the swelling is acquired after an injury or damage to the lymphatic vessels: Post surgery, crushing injury, cancer related treatment, removal of lymph nodes. This causes a blockage in the drainage pathways and fluid builds up behind the blockage
THE LYMPHATIC SYSTEM PATHWAY FROM BEGINNING TO END Lymphatic capillaries are located in the tissue space -- -entrance into the lymphatic system Capillaries o Stabilized by filaments o 70 % of the lymphatic vessels are in the capillaries under the skin Pre collectors (next level of system) Collectors (like veins) go towards the neck Lymphangions: small contractile section Smooth muscle One way valve Contract 4-6 times/min but can be increased to 30times/min Larger collectors pathways follow veins Nodes clean the lymph fluid Anastomoses Terminus at the neck (connection for fluid from lymphatic system back into veins and blood) ( Dr Vodders Manual Lymph Drainage pg 11-13) http://www.lymphnotes.com/pic.php/id/86/
Lymphatic System
Circulatory System
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VEINS, ARTERIES AND LYMPH VESSELS http//www.oralcancerfoundation.org/tre atment/images/lymph6.gif
LYMPH NODE http://www.drkrider.com/assets/page%20items/head-&-neck.gif
LYMPHATIC TRUNK DRAINAGE Lymph from the whole body drains into the left and right venous arch. RIGHT LYMPHATIC DUCT o Drains: Right thoracic quadrant Right arm Right side of the head Anterior and posterior thorax skin Right side skin upper abdomen LEFT THORACIC DUCT o Drains: ¾ of the trunk Left arm Left side of head The 2 abdominal quadrants skin Left thoracic quadrant skin and internal organs Lower extremities
WHAT IS LYMPH.Water.Lymphocytes.Protein.Fats.Metabolites.10 % of total body fluid transport.http://www.lymphnet.org/lymphedemafaqs /overview.htm.http://www.lymphnotes.com/pic.php/id/86/
F u n c t i o n s o f t h e l y m p h N u t r i t i v e D r a i n a g e T r a n s p o r t p r o t e i n A b s o r b F a t s D e f e n c e
MOVEMENT OF LYMPH Smooth muscle Skeletal muscle Arterial pulsation Thoracic and abdominal pressure variations Peristalsis Suction pressure through vessels Abdominal breathing External manipulation D r V odders Manual L ymph D rainge pg 14
LYMPHEDEMA PATHOLOGY (Secondary Lymphedema) Destruction or removal of vessels/nodes (surgery, scars, cancer, radiation) Excess protein and fluid in tissue Stagnant fluid gels and becomes fibrotic Inhibits oxygen flow Culture for bacteria Progressive Limits range Best Practices for M anagem ent of Lym phedem a pg 3 http://www.lymphnet.org/lymphedemafa Qs/overview.htm
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SIGNS AND SYMPTOMS OF LYMPHEDEMA Heaviness Bursting Feeling Increased Size of Limb Tightness Pins and Needles Sensation WORSENING SYMPTOMS Infections-Red, Hot and Pain Increased Numbness Skin Thickening Lymph Leaking Through the Skin
American Society of Lymphology (ASL) Clinical Lymphedema Staging Stage I Mild or reversible edema No skin changes, infections No functional limitations Stage II Moderate edema None to minimal skin changes None to occasional infections Mild to moderate functional limitations Occasional limits on activities. Stage III Moderate to severe edema Moderate skin changes with significant fibrosis Less than FOUR infections per year Moderate to significant functional limitations Frequent and significant limits on activities Stage IV Severe edema Severe skin changes with advanced fibrosis MORE THAN FOUR infections per year Moderate to severe functional limitations Constant and severe limits on activities Lymphedema: Diagnosis and Treatment by B.B. Lee et al. Springer, 2008
Treatments Manual Lymph drainage Compression therapy Skin care Education Exercise
MANUAL LYMPH DRAINAGE Goal: softening, pain relief, reduce swelling and increased range. Performed within tolerance and not over tumors or malignant edema. Gentle soothing massage Movement in direction of flow of lymphatic pathways and away from blockage or cancer area 2 directional stretch of skin Increases movement of lymph up to 5 times faster Softens fibrotic tissue resulting Moves fluid away from a blockage and across watersheds. Process o Open drainage at neck o Node basins o Move fluid in limb towards neck. Clear proximally first and then move distally http://www.lymphnotes.com/pic.php/id/86/
LYMPHATIC MASSAGE http://www.massage-career-guides.com/images/description-of-manual-lymphaticdrainage-ariana-institute-21300772.jpg
Contraindications to MLD and SLD General Acute cellulitis/erysipelas Renal failure Unstable hypertension Severe cardiac insufficiency Hepatic cirrhosis with abdominal fluid ( ascites) Superior vena cava obstruction Untreated tuberculosis or malaria Local contraindication* Untreated thyroid dysfunction Primary tumours Metastases Caution required: cardiac insufficiency. *MLD and SLD should not be performed at these sites.
COMPRESSION THERAPY Goal: reduce swelling, softening of the skin and provide comfort Note: compression therapy may not be tolerated for many in palliative care MLLB ( Multi-Layered Lymphedema Bandaging) Short stretch bandaging--- higher pressure distally 2-4 weeks typically but varies on tolerance and needs Compression garment Pumps Best Practices for Management of Lymphedema pg 17,32-34
EDUCATION Education of the lymphatic system Lymphatic drainage pathways Self massage Precautions and safety Indications of worsening condition or infection Avoidances o Needles in affected area o Extreme heat
Skin Care Check skin daily for cuts, scrapes, burns, trauma If skin injury, clean and use antibiotic cream Keep clean and dry Moisturize with low Ph, no fragrance lotion CAUTION Signs of tissue infection (CELLULITIS OR ERYSIPELAS) Start antibiotic immediately as infection can be very virulent Stop massage and bandaging until acute infection is resolved. o Redness o Pain o Itching o Increased temperature o Rash or red line moving up limb o Flu like symptoms Best Practices for Management of Lymphedema pg 5
EXERCISES Deep Breathing Stretching Strengthening: Aerobic
EXERCISE Principal: gradual build up of all programs with self massage Stretching o Yoga o Tai chi o Range of motion exercises Weight lifting (with garment) Cardio exercises o Water exercise o Bike o Walk/jog Programs o CanWell (YMCA, Juravinski and HHS) membership required o ENCORE (YWCA) free o Dragon Boat Racing o Knot-A-Breast (KAB) Curves circuit training
Exercise Post Cancer Treatment Decreases Pain Improves Function Reduces/Delay Recurrence Improves Fatigue Improves Balance Increases Survival Rate Improves Cardio-Resp Improves Bone Density Improves Range Improves Strength
EXERCISE PERSCRIPTION FOR CANCER PATIENTS (Under guidance of a health care professional) 0-4 weeks post-op----- gentle range of motion 4-8 weeks post-op-------walking and moving about 8 weeks post-op--------- Do a combination of: Strength training and aerobic exercises 3 times a week 50-75% Max Heart Rate 30 minutes work up to 1 hour
OTHER THERAPIES Scar management Myofacial Release Kinesio-taping Neural techniques Mobilization Friction http://www.lymphnotes.com/pic.php/id/86/
References http://www.lymphnet.org/ http://www.lymphnotes.com Related site http://www.lymphontario.ca/