NPTE Lymphatic System Review

Lymphedema definition

Abnormal accumulation of lymph fluid in tissues due to lymphatic dysfunction.

what is the flow of lymph

Fluid is transported from lymphatic capillaries

Lymphatic collecting vessels

Along the length of these vessels, lymph

nodes occur to filter the lymph

Lymphatic trunks

Lymphatic collecting ducts

subclavian veins

what is lymphatic load

amount of lymphatic fluid transported

what is transport capacity

maximum amount of fluid that lymphatic system can transport

Lymphatic Load > Transport Capacity=

Lymphedema

for venous insufficiency what is happening to the lymphatic load

it inc since pooling of blood is happening. so lymphedema happens

if there is lymph node removal what happens to transport capacity

fluid overload transport capacity is reduced so causes lymphedema

Primary vs. secondary lymphedema

Primary is congenital/hereditary; secondary results from injury, surgery, or infection.

Examples of primary lymphedema

Milroy's disease (congenital) 0-2 yrs, bilateral not common, Lymphedema Praecox (Meige disease)teens 9-25, and Lymphedema Tarda. over 35+ yrs, rare

Causes of secondary lymphedema

Lymph node removal, tumor, trauma, infection, chronic venous insufficiency, or filariasis.

Pitting edema description

Fingertip pressure causes persistent indentation; reflects short-duration edema with minimal fibrosis.This reflects significant but short duration edema with little or no fibrotic changes in skin or subcutaneous tissue.

Brawny edema description

Tissue feels hard on palpation; indicates progressive fibrotic subcutaneous changes.

Weeping edema description

Fluid leaks from cuts/sores with impaired healing; usually in lower extremities. MOST SEVERE OF LYMPHEDEMA

Positive Stemmer's sign definition

Inability to pinch/lift dorsal skin of fingers or toes; indicates Stage II/III lymphedema.

Lymphedema Stage 0 (Latency)

No visible edema, reports of heaviness, Stemmer's sign negative, tissue normal.

Lymphedema Stage I (Reversible)

Soft pitting edema, reduces with elevation, Stemmer's sign negative.

Lymphedema Stage II (Spontaneously Irreversible)

Brawny non-pitting edema, positive Stemmer's sign, fibrosclerotic changes, adipose proliferation.

Lymphedema Stage III (Lymphostatic Elephantiasis)

Severe brawny edema, positive Stemmer's sign, papillomas, hyperkeratosis, frequent infections.

Pitting Edema 1+ grade

Mild, barely perceptible indentation; less than 1/4 inch pitting.

Pitting Edema 2+ grade

Moderate depression, returns to normal within 15 seconds; 1/4 to 1/2 inch.

Pitting Edema 3+ grade

Severe depression, takes 15-30 seconds to rebound; 1/2 to 1 inch.

Pitting Edema 4+ grade

Very severe, depression lasts >30 seconds; greater than 1 inch.

Lipedema clinical features

Bilateral and affects only proximal areas, symmetrical lower extremity swelling sparing the feet; tender/painful to touch.

no known cause

Lymphedema vs. Lipedema distribution

Lymphedema is asymmetric/unilateral with foot edema, cellulitis common, no pain on pressure, distal edema and + stemmers sign

Lipedema is symmetric bilateral without foot edema, pain on pressure, easy bruising

Measurement choice for Proximal limb edema

Girth (circumferential) measurements at 10 cm intervals.

Measurement choice for Distal limb edema (hand/foot)

Volumetric measurement via water displacement.

Immerse the limb in a tank of water to a

predetermined anatomical landmark and measure the volume of water displaced and see how much water spills out

Measurement choice for Pre- and post-surgery

Bioelectric impedance analysis.

if the question ask Lymphatic Insufficiency than what do you use:

Lymphoscintigraphy (lymphangioscintigraphy): Measured during rest and exercise, identifies lymphatic insufficiency

when do you use doppler US?

to differentiate between venous insufficiency

Palpation: Normal lymph node

Soft, non-tender, mobile, and non-palpable.

Palpation: abnormal lymph node

Tender

Hard

Immobile

Palpation: Malignant lymph node

Firm/hard and fixed (immobile).

Palpation: Inflammatory/Infectious lymph node

Enlarged, tender, and mobile.

Lymphangitis definition

Inflammation of lymphatic vessels presenting with red streaks, pain, and fever.

common caused by bacterial infection (e.g., Streptococcus).

Lymphadenitis definition

Inflammation and painful enlargement of lymph NODES due to infection.

Lymphadenopathy definition

Abnormal enlargement of lymph nodes.

Non-tender/ fixed nodes → think malignancy; tender nodes are often due to infection.

management of lymphedema: what is the main goal

Main goal of treatment is to minimize the lymphedema as much as possible or return the lymphedema to a latency stage

• Interstitial pressure is increased by external forces: manual lymphatic drainage or compression therapy

• Dynamic pressure changes within the body: diaphragmatic breathing or muscle contractions

• A muscle contraction combined with external forces from a bandage or compression garment can be even more effective in the movement of fluid

Complete Decongestive Therapy (CDT) components

Manual lymphatic drainage, compression, exercises, and skin/nail care.

What is the correct order for Manual Lymphatic Drainage (MLD)?

Clear proximal areas first (trunk, groin, buttocks, axilla)

Then treat distal areas

Why? You must create space for lymph to drain before moving fluid from the extremities.

🧠 Memory Trick: "Clear the Traffic Jam First!" 🚗🚗🚗

Think of a traffic jam:

If the highway (proximal) is blocked, cars (lymph) can't move.

Open the highway first, then let traffic flow.

MLD clearing sequence

Proximal central areas cleared first, then distal areas processed.

MLD stroking direction

Distal-to-proximal toward specific functional lymph nodes.

What are the contraindications to Manual Lymphatic Drainage?

Acute infection

❌ Cardiac failure

❌ Renal failure

❌ Acute DVT

❌ Active malignancy

❌ Uncontrolled hypertension

❌ Severe asthma

CARDS AH

C = Cardiac failure

A = Active malignancy

R = Renal failure

D = DVT (acute)

S = Severe asthma

A = Acute infection

H = Hypertension (uncontrolled)

What are the components of Phase I (Intensive Phase) of Complete Decongestive Therapy?

Manual Lymphatic Drainage (MLD)

Multiple-layer compression bandaging

Skin & nail care

Exercise

What are the components of Phase II (Maintenance Phase)?

Self-MLD by the patient

• Compression therapy

○ Compression garment during

the day

○ Multiple layer bandaging in the

evening/night

• Skin and nail care

• Exercise

CDT Phase I compression type

Low-stretch short-stretch bandages (low resting pressure, high working pressure).

from distal to proximal direction

using during day and night

which bandage you dont use with lymphedema?

ACE wraps NOT recommended (long stretch bandages)

what exercises can you give for lymphedema:

first train in breathing!

Active ROM, stretching, low intensity

resistance exercises - performed

wearing compression garment or

bandages

• Examples of exercises: treadmill, stair climbing, biking, swimming

• Proximal-to-Distal direction

why is it important to take care of skin and nail care for lymphedema

Prevention of skin breakdown,

infection and delayed wound healing

• BP: NEVER TAKE ON AFFECTED LIMB

• Temperature: SAUNA, HOT TUB should be avoided

Sequence for Lymphedema Remedial Exercises

Proximal-to-distal progression (e.g., cervical, shoulder, elbow, wrist/fingers).