Lymphatic disorders
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lymphatic system
• is a vascular network of tubules and ducts that
collect, filter, and return lymph to blood circulation.
• Lymph is a clear fluid that circulates throughout the
body to remove wastes, bacteria, and other
substances from tissues .
• This fluid becomes the interstitial fluid that
surrounds cells .
• Lymph contains water, proteins , salts, lipids ,
white blood cells , and other substances that must be
returned to the blood.
functions of the lymphatic system
• to drain & return interstitial fluid (lymph)to the
blood. That helps to maintain normal blood volume
and pressure. (fluid balance)
• to absorb and return fats and fat-soluble vitamins
from digestive system to the blood.
• to filter fluid of pathogens, damaged cells, cellular
debris, and cancerous cells .(immunological defense)
Major Structures of lymphatic system
• Lymph fluid
• Lymph vessels
• Lymph nodes
• lymphoid organs :-
– Tonsils & Adenoids
– Veriform appendix & peyer’s patches
– Spleen
– Thymus
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Diseases and Disorders
• Lymphoma – a general term for malignancies
that develop in the lymphatic system. The
cancer affects immune cells called
lymphocytes, which are white blood cells.
Continued- Disorders & Diseases
Lymphadenitis – inflammation of the lymph nodes that
can be caused by a variety of sources
◦ lymph nodes become enlarged, hard, smooth or irregular, red,
and may feel hot to the touch.
◦ Lymphadenopathy – enlargement of the lymph nodes
Tonsillitis – infection of the tonsils, usually caused by
strep.
◦ severe sore throat, fever, malaise, difficulty swallowing,
earache, and enlarged, tender lymph nodes in the neck.
.Cont
• Lymphedema
is an accumulation of protein rich fluid in extracellular & extravascular
space, principally in subcutaneous fat due to defect in lymphatic system.
Increased concentration of proteins draws greater amount of water into
interstitial spaces
Exceeds transport capacity of the lymphatic system, leading to
lymphedema
?Edema & Lymphedema, what's different
• In edema the lymphatic system is normal and
functioning at one hundred percent of its
working capacity, however fails to remove
fluid.
• The edema is low in protein and soft in texture
and treatment would be directed to the cause.
:Etiology {Classification} of Lymphedema
Lymphedema
Primary Secondary
Congenita Praecox Trada Lymphatic Lymphatic
Age<1y Age 1-35years Age >35years Obstruction interruption
Cancer related
Inflammatory
lymphedema
Infection Traumatic
Sign &Symptoms
Pain less swelling
Heaviness and tension in the limb especially at the
end of day in hot weather. ; sense of fullness
Positive Stemmar sign.
Loss of muscular strength , flexibility and ROM
Usually unilateral
Worse after prolonged dependency
Aching and bursting pain.
Deformity (elephantiasis).
Sign &Symptoms
• Skin conditions:
• Skin changes are common and ranging from dry
skin, depression of the natural skin folds.
• thicker skin
• Rougher skin
• Ulcerations and skin break down with lymph
exuding,
• Fibrotic, overgrowths, lympangiosarcoma
• Skin infection, lymphangitis, and cellulites
Lymphedema Location
Stage of Lymphedema:-
Stage I
It is spontaneously reversible and pitting ,with associated increase
in limb girth &heaviness
Stage II
It is marked by a spongy consistency of the tissue without signs of
pitting, & mild tissue fibrosis
Stage III
Lymphostatic elephantiasis
Severity of Lymphedema
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
Severe lymphedema: Greater than five cm increase
Differentiated diagnosis
The main reason for investigation is not to confirm the -1
diagnosis but to exclude potentially conditions such as
.DVT
2-General examination is necessary to exclude medical
conditions such as heart failure.
3-Simple serum analysis is done to exclude hepatic or
renal impairment.
4-Urine analysis is done to exclude any protein –losing
nephropathy.
Examination and Evaluation of Lymphatic
Function
Special Considerations
• Full Medical History & Clinical Feature of Limb
Swelling
• Daily activities and position of limb
• Functional assessment
• Skin integrity
• Girth measurements
• Volume measurements
Examination and Evaluation of Lymphatic
Function
Tonometer:-
It is device used to measure the amount of the pressure necessary to
depress skin a specified amount (tissue tonicity).
Multi-Frequency Bioelectrical Impedance (MF-BIA):-
It has the ability to measure the extent of the extra-cellular fluid levels and to
learn whether they are within or outside of normal range by using bio-
impedance.
(Invasive Technique):-
measure the peripheral lymphatic function, lymph movement, lymph
draining.
It involves injections of a radiotracer.
:Bioimpedance Spectroscopy (BIS)(
It is a more recently developed method for measuring the water content of
the body. BIS has been shown to provide reliable data to be used in the
diagnosis of breast cancer-related lymphedema
Treatment of Lymphedema
The treatment available for lymphedema reduction may be divided into three
general categories :
A complex decongestive therapy (CDT)),
Drug therapies,
Surgery.
Relative contraindications of (CDT)include:-
1-Significant congestive heart failure.
2-Acute deep vein thrombosis,
3-Acute or untreated infection,
4-Inflammation of the affected limb
5-Local irradiated soft tissue and active malignancy.
-:Goals of Treatment
•To stimulate the lymphatic system to promote reduction of
edema.
•To prevent further accumulation of edema.
•To retain or restore function and cosmoses to the affected limb.
•To help patients cope with psychological sequel of lymphedema .
•To educate patients about lymphedema and home care program.
Complex Decongestive Therapy(CDT)
Manual lymph
draining(MLD
Remedial
Elevation
exercises
Compression
Skin care
therapy
Elevation
Elevate the involved limb when using a
sequential compression pump
Elevate limb when sleeping, resting, and
during sedentary activities
Compressive bandages or garment should be
worn during periods of elevation
Manual lymph draining(MLD),
gentle, rhythmic massaging of the skin
Proximal congestion in the trunk, groin, buttock, or axilla is
cleared first.
Direction of massage is towards specific lymph nodes
Usually involves distal to proximal stroking
Goals:
To mobilize and prevent re-accumulation of edema
fluid.
To initiate the regression of fibrosclerotic tissue.
To continue the breakdown of the scar tissue.
Compression Therapy:-
1-Low elastic (low-stretch) bandage.
2- No-stretch (non-elastic) bandage.
3-Compression garment
4-Intermittent Pneumatic Compression (IPC).
Bandages
Compression Garments
Exercise
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 are performed in a specific
sequence, often with the limb elevated(assist
lymph flow).
Exercise
• Low-intensity cardiovascular/pulmonary
endurance activities included
• Deep breathing and relaxation also incorporated
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- :Skin Care
Skin care is an important aspect of the treatment program related to the
increased risk of local infection.
1-Patients are instructed to avoid cuts or breaks in the skin
2-Any cuts that do occur should be cleaned treated with a topical antibiotic
and covered.
3-In addition it is recommended that patients protect their skin by applying
a moisturizing cream on a regular basis, to keep the skin supple ,moist, and in
good general conditions.
4-Medical procedures on the affected extremity including blood pressure
reading, blood draws and injections should be avoided.
-Low level laser therapy:-
Treatment Works
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