Week 4: Wound Etiology - Lymphedema

lymphatic system

fluid balance and assists with infection control

When does lymphedema occur?

when the lymphatics can't remove lymph. Imbalance of fluid uptake between the interstitium and lymphatic system.

What is a common indicator of lymphedema

cellulitis

Lymphedema is often seen with what other condition?

Chronic venous insufficiency

When venous system can't remove fluid, what picks up the load?

lymphatics

Phlebo Lymphedema

lymphatic failure due to chronic venous congestion (VI)

Lymphatic drainage targets the _____ lymphatics

superficial

superficial lymphatics

drains skin, and subcutaneous tissue.

deep lymphatics

drains muscles, tendons, and joints

Cisterna Chyli

Largest lymph node, helps stimulate the whole and system and remove fluid.

Lymphatic capillaries

connects to vessels to form drainage system

Lymph fluid

fluid absorbed through the lymphatic system

Flow of lymph

Lymph capillaries -> pre-collectors -> lymph collectors -> lymph nodes -> thoracic duct or right lymphatic duct -> venous system

Lymph node main function

protection and immune function. Filter for harmful materials in lymph. Protection of antigen stimulated lymphocytes.

Where in the lymphatic system is the immune system response activated?

Lymph nodes.

Lymph angions

Valves which are irregular lymph collectors. Provide contraction for the lymphatic system.

lymphangionmotoricity

autonomic contractions of the lymph angions

What allows manual lymphatic drainage to work

anastomoses that allow drainage from one territory to another.

Lymphedema etiology

lymphedema occurs when the lymphatics are unable to the protein rich fluid

Dynamic Insufficiency of the lymphatic system

excess lymph that the lymphatic system can't handle

Mechanical insufficiency of the lymphatic system

the capacity to transport lymph decreases.

Primary lymphedema

rare, usually congenital, due to lymphatics giving up

Secondary lymphedema

caused by damage to lymphatic vessels that is most frequently due to cancer treatment, surgery, infection, trauma, or burns

Most common lymphedema in the US is ____ related

cancer

Lipedema

a chronic abnormal condition that is characterized by the accumulation of fat and fluid in the tissues just under the skin. Painful, and no swelling to hands and feet, usually in legs.

Lipolymphedema

Form of lymphedema caused by lipedema, which usually has very limited improvement with interventions

Lipedema/Lipolymphedema reduced with what?

liposuction and manual lymphatic drainage before and after.

Is lymphedema painful?

usually not, but can negatively impact function

Fibrosis

Caused by buildup of collagen formation in the later stages of lymphedema. Fibrogen is not absorbed because it is too big.

treatment for fibrosis

manual techniques to break up the fibrosis.

One of the first signs of fibrosis

heaviness in the affected limb.

Lymphorrea

leakage of lymph from the skin surface

what is the cause of cellulitis with lymphedema?

From stagnation and poor flow, accumulating bacteria.

Risk factors for lymphedema

-Lymph node removal

-Radiation therapy.

-Surgical complications.

-Increased BMI

-Air travel

-Inflammation

-Decreased lymphatic return

-Scar tissue formation

Lymphedema stage 0

subclinical, no edema, impaired lymph.

Lymphedema stage 1

early onset, fluid built up may subside with elevation; pitting edema present. usually progresses throughout the day.

Lymphedema stage 2

elevation no longer helps, fibrosis present, frequent skin infection (cellulitis)

Lymphedema stage 3

skin thickening, hyperpigmentation, papilloma

PT tests and measures for lymphedema

-Outcome measures (LEFS, DASH)

-Circumferential measures of affected and unaffected limb

-Goni measurements.

-MMT, strength

-Functional assessment

Mild severity unilateral edema

<3 cm difference in limbs

Moderate severity unilateral edema

3-5 cm difference in limbs

Severe unilateral edema

>5 cm difference in limbs

PT interventions for lymphedema

-Pt. ed (proper skin care)

-Therapeutic exercise

-Manual lymphatic drainage

-Compression bandaging and garments

-Compression pumps

Therapeutic exercise for lymphedema

AROM, elevation, strength, perform with compression, cardio, diaphragmatic breathing

Compression bandaging

multi layer short stretch compression for first 2-3 weeks.

The amount of layers on compression bandage depends on what?

Depends on ABI results. Higher ABI, more layers

Compression garments

permanent, for use after first 2-3 weeks

indication for compression pumps

lymphedema and chronic VI to help clear fluid

Manual lymphatic drainage main points

-diaphragmatic breathing

-Proximal lymph node stimulation

-Perform PROXIMAL to DISTAL

Surgical intervention for lymphedema

Microsurgery by plastic surgeons.

Can lymphatic drainage be used for JUST edema without lymphedema?

YES

Who can also benefit from lymphatic drainage?

Joint replacements, sprained ankle, ligament tears, plastic surgery.

Lymphedema

Fluid stagnation and edema due to dynamic or mechanical insufficiency.

Superficial Lymphatics Target

MLD (Manual Lymphatic Drainage)

Lymph Organs Example: biggest lymph node

Cisterna Chyli

Lymphatic Capillaries Function

Connect to vessels to form drainage system, large and highly permeable

Lymph Fluid Composition

Clear and contains lymphatic load, part of immune system.

Lymph Flow Sequence

Lymph capillaries → precollectors → lymph collectors → lymph nodes → thoracic duct or right lymphatic duct → venous system.

Lymph Angions

Valves in lymph collectors with autonomic contraction.

Lymph Node Functions

Protection (filter), immune, thickening of lymph.

Anastomoses

Allow drainage from one lymphatic territory to another.

Etiology of Lymphedema

Fluid stagnation and edema.

Mechanical Insufficiency

Transport capacity decreases, often due to lymph node removal.

Dynamic Insufficiency

Lymphatic load exceeds transport capacity.

Primary Lymphedema

10% of cases, result of congenital malformation or impaired lymphatics.

Secondary Lymphedema

Most common caused by filiariasis (worldwide) or cancer-related (US).

Phlebolymphedema

Chronic venous insufficiency with lymphedema.

Lipedema

Disorder of adipose tissue.

Symptoms of Lymphedema

Heaviness, delayed wound healing, lymphorrhea, increased risk of infection, negatively impacts functional mobility.

Fibrosis

Buildup of collagen formation in later stages of lymphedema.

Lymphorrhea

Clear fluid that weeps from skin.

Risk Factors for Lymphedema

Surgical lymph node removal, radiation therapy, surgical complications, time since surgery, increased BMI, air travel, inflammation, decreased lymphatic return, scar tissue formation.

ISL Lymphedema Stage 0

Subclinical, no edema present, but impaired lymph transport.

ISL Lymphedema Stage 1

Early onset, fluid buildup may subside with elevation; pitting edema present.

ISL Lymphedema Stage 2

Elevation no longer helps, fibrosis present, frequent skin infections (cellulitis).

ISL Lymphedema Stage 3

Skin thickening, hyperpigmentation, papillomas.

PT Tests and Measures for Lymphedema

DASH, Lymphedema Life Impact Scale, LEFS, circumferential measures, ROM, strength, functional assessment.

Unilateral Edema Severity: Mild

<3 cm difference in circumferential measures

Unilateral Edema Severity: Moderate

3-5 cm difference in circumferential measures

Unilateral Edema Severity: Severe

5 cm difference in circumferential measures

Lymphedema PT Interventions

Patient education, therapeutic exercise, manual lymphatic drainage, compression garments/short stretch bandages, vasopneumatic compression pump.

Manual Lymphatic Drainage (MLD)

Should be performed by trained/certified individual.

MLD Main Points

Diaphragmatic breathing, proximal lymph node stimulation and clearing, proximal to distal clear and flow.

Importance of Self-MLD

Patient should be taught self-MLD and be an active participant in their treatment plan.

Compression Bandages

Multilayer short stretch compression bandages used during the reduction phase

Wound Etiologies

Abrasions, skin tears, de-gloving.

Abrasions

Caused by friction to the skin’s surface. Superficial or partial thickness

Skin Tears

Traumatic wounds resulting from shear or friction forces that separate the epidermis from dermis. Partial thickness wound. Example: Elderly at risk.

De-Gloving

When the skin is avulsed from underlying tissue.

Surgical Wound

Closed with stables, sutures, or tissue adhesives

Radiation-Induced Skin Damage

Directly/indirectly destroys tissue, inhibits inflammatory response & proliferative phase of healing.

Vasculitis

General term in reference to inflammation of blood vessels.

Pyoderma Granulosum

Non-infectious progressive necrotizing skin condition.

Cancer Causing Wounds

Skin cancers (squamous cell, basal cell, melanoma) as well as other cancers can cause wounds (colorectal, sarcomas, ovarian, lung, etc.)

Arterial Disease Process

Narrowing, distal extremities (think of frost bite=black gangrene)

Venous Disease Process

Leaky veins with hemosiderin staining.

Pressure Injury Process

Caused by tissue ischemia from pressure. DTI - don’t know depth of injury, just like pressure injury covered in black eschar.

Neuropathic Wound Process

Typically dying back neuropathy (stocking/glove); arteries hardened and potentially narrow.

Burns Pathophysiology

Thermal, Electrical, Chemical size: % TBSA or Lund and Browder Chart (more for pediatrics)

Skin Screening

Moles during exam, hemosiderin staining, lack of hair on legs, cold distal extremities