NPTE Lymphatics

Most commonly used amount of compression for stage II UE lymphedema ?

30-40 mmHg

Typical amount of compression used in stage II LE lymphedema?

40-50 mmHg

Lymph flow

1. Excess fluid goes into lymphatic capillaries

2. Lymphatic collecting vessels

3. Along length of vessels, lymph nodes occur to filter lymph

4. Lymphatic trunks

5. Lymphatic collecting ducts

6. Subclavian vein

Lymphatic load

Amount of lymphatic fluid transported

Transport capacity

maximum amount of fluid that lymphatic system can transport

Lymphedema

A decrease in transport capacity with either same amount of lymphatic load or increased load

Primary vs Secondary lymphedema

Primary: Congenital or heredity cause (Milroy's disease- malformation of lymphatic system)

Secondary: injury to one or more components of lymphatic system (cancer, radiation, node removal)

What are the three severities of lymphedema?

Pitting edema: found in Stage 1 and early Stage 2, makes a pit but indentation resolves

Brawny edema: (like brawny paper towel =strong) tissue is hard and severe with fibrotic changes to subcutaneous tissue

Weeping edema: most severe and long duration form, fluid leaks from cuts or sores, almost exclusively in LE and in Stage 3

Stemmer sign

What: used to indicate worsening of lymphedema

Tests for: severity of lymphedema

How to preform: pinch skin on the dorsum of fingers or toes

(+)= cannot pinch/lift skin compared to uninvolved limb

Lymph03dema =

How to remember lymphedema stages start at 0 and go to 3

(4 levels but starts at 0-3)

Stage 0: Latency

-No clinical edema

-Stemmer sign = (-)

-Tissue and skin appears normal

-Reports heaviness

Stage 1: Reversible Stage

-Reversible

-soft and pitting edema

-Increases with standing but reduces with elevation

-Stemmer sign = (-)

Stage 2: Spontaneously Irreversible

-Irreversible

-May have pitting edema that progresses to hard/brawny edema

-Stemmer sign = (+) --> but may be (-) in early stage 2

-Tissue appears fibrosclerotic and proliferation of adipose tissue

Stage 3: Lymphostatic Elephantiasis

- Skin changes - papillomas, deep skin fold, warty protrusions, hyperkeratosis, mycotic infection

-Brawny edema

-Stemmer sign = (+)

-bacterial and viral infections are common

Pitting Edema Scale

1+ = mild, 0.25 in, 0 sec pit

2+ = moderate, 0.25-0.50 in, < 15 sec pit

3+ = severe, 0.50-1.0 in, 15-30 sec pit

4+ = very severe, 1.0 in, > 30 sec pit

Lipedema

-bilateral condition affecting LE with excess fat deposit in proximal areas such as buttocks and thighs but NOT DISTAL such as feet

-affects skin's elasticity - skin is sensitive to pressure and touch, which makes it easier to bruise and is painful to palpation

Lipedema vs. Lymphedema

Lymphedema: UL, can have cellulitis, not painful to touch, has distal edema, (+) stemmer sign

Lipedema: BL, no cellulitis, painful to touch, no distal edema, stemmer sign (-)

Bioimpedance measurements:

What: use of a low level alternating electrical current to measure resistance to flow through extracellular fluid in UE

When: pre and post surgical intervention

lymphoscintigraphy

Measured during rest and exercise - identifies lymphatic insufficiency

If the stem of the question asks about Proximal measurements -

Use girth measurement (every 10 cm landmarks)

If the stem of the question asks about distal UE/LE measurements -

Use volumetric

If the stem of the question asks about pre-post surgery -

Use bioelectric impedance

If the stem of the question asks about lymphatic insufficiency -

use lymphoscintigraphy

Lymph node palpation

Normal: soft, non tender, non palpable, < 1 in diameter

Abnormal:

-Tender

-Hard and immobile and rubbery