Lymphedema

Dr Ankit shahi
Lymphadenopathy

• Def :- Accumulation of lymphatic fluid in tissue spaces.

• First thing to examine is ABI (Not rubor dependency test)>>>>>>>>>>>>>>>>> To make
sure that there is no arterial insufficiency >>>>> because in lymphedema >>> if we give
wraps or bandages it may further deteriorate the problem
• (1 Question)
Causes

• Cause :- Inheritance, or injury to lymphatic vessels

• lymphadenectomy)
• Surgical dissection of lymph nodes – Eg -Breast cancer, Pelvic or abdominal cancer
• lymphangitis - Inflammation of lymph vessels
• lymphadenitis – lymph nodes inflammation
• lymphadenopathy - enlargement of lymph nodes
• Combined Venous-Lymphatic Dysfunction
• Lymph is the fluid that circulates throughout the lymphatic system. It is
formed when the interstitial fluid (the fluid which lies in the interstices of all
body tissues)[1] is collected through lymph capillaries. It is then transported
through larger lymphatic vessels to lymph nodes, where it is cleaned by
lymphocytes, before emptying ultimately into the right or the left
subclavian vein, where it mixes back with the blood.
• Since the lymph is derived from the interstitial fluid, its composition
continually changes as the blood and the surrounding cells continually
exchange substances with the interstitial fluid. It is generally similar to
blood plasma, which is the fluid component of blood. Lymph returns proteins
and excess interstitial fluid to the bloodstream. Lymph may pick up bacteria
and bring them to lymph nodes, where they are destroyed. Metastatic cancer
cells can also be transported via lymph. Lymph also transports fats from the
digestive system (beginning in the lacteals) to the blood via chylomicrons.
 The lymphatic capillaries are situated close to the blood capillaries and
are responsible for pulling the fluid into the lymphatic circulation
(Fig. 25.2).30,47,57,105,107 Once inside the lymphatic vessels,the fluid
is transported from lymph nodes to lymphatic trunks. The end result is
the collection of the lymphatic fluid at the venous angles.

This increased viscosity comes from the high level of protein contained
in the fluid transported by the lymphatic system.
Rough for prep
Lymphedema is an excessive and persistent accumulation of extravascular and
extracellular fluid and proteins in tissuespaces.
It occurs when lymph volume exceeds
the capacity of the lymph transport system, and it is associated
with a disturbance of the water and protein balance
across the capillary membrane.

An increased concentration of proteins draws larger amounts of water into interstitial

spaces, leading to lymphedema. Furthermore, many disorders of the cardiopulmonary
system can cause the load on lymphatic vessels to exceed their transport capacity and
subsequently cause lymphedema.
KISNER – CHAPTER 25
Types and causes

• 1* lymphedema
• Congenital condition with abnormal Lymph node or vessel
• 2* Lymphedema
• Surgery
• Tumor
• Radiation th.– causing fibrosis of tissue
• Venous insufficiency
 Distinguishing feature

• Feeling of heaviness, fullness, edema,

• aching pain in affected area,
• discoloration,
• ↓ROM and flexibility,
• Stage 1 :---
• Pitting edema
• Elevation reduces swelling
• No tissue fibrosis
• Stage 2 :--
• Non Pitting edema.
• Pitting is difficult to induce due to Presence of fibrotic tissue
• Stemmers Sign + (Not as severe as stage 3--- Starts to appear)
• Stage 3-
• Late stages of lymphedema >>>> Thickening of skin folds at toes which are difficult to pinch n lift.>>>>>Stemmers
sign
• (hyperkeratosis, papillomas, deep skin folds)
• Bacterial and fungal infections of the skin and nails common
• Patient presents swelling in bilateral lower extremity which does not
change with elevation of feet. Stemmer sign is negative.
Stages Characteristics
Stage 0 (Latency) No clinical edema Stemmer sign negative
Tissue and skin appear “normal”
Lymph transport capacity already reduced
Stage 1 (Reversible Edema present (soft and pitting) Edema reversible with elevation
Stage) Edema increases with standing and activity Stemmer sign negative
Tissue appears “normal”
Stage 2 (Spontaneously Edema present; initially may still be soft and pitting in early stage 2 but then
Irreversible Stage) progresses to nonpitting “brawny” edema
Edema does not reverse with elevation
Stemmer sign positive (although still may be negative at early stage 2) Tissue
appears fibrosclerotic; proliferation of adipose tissue
Frequent infections
Skin changes
Stage 3 (Lymphostatic Edema present; severe “brawny” nonpitting edema Edema does not reverse with
Elephantiasis) elevation
Stemmer sign positive
Tissue appears fibrosclerotic; proliferation of adipose tissue Frequent infections
Skin changes (papillomas, deep skinfolds, warty protrusions, hyperkeratosis,
mycotic infections, etc.)
Other symptoms

• Sensory disturbances
• Due to blockage of blood supply to the tissues
• Prone to infection
• Poor healing
Stemmer sign

• A positive Stemmer sign, an

indication of Stage II or III
lymphedema, may be identified
during palpation (Fig. It is
considered positive if the skin on
the dorsal surface of the fingers
or toes cannot be pinched or is
difficult to pinch compared with
the uninvolved limb. A positive
Stemmer sign can be indicative
of a worsening condition.
• Therapist wants to apply compression bandage in patient’s lower leg
to treat Lymphedema. In which of the following scenarios, Bandaging
will be contraindicated ?

• Aortic aneurysm
• Renal failure
• Venous insufficiency
• Ankle brachial index < 0.8
• Answer- D
• ABI <0.8
Examination

• Girth measurement
• Volumetric analysis
• Bioimpedance Measurements
 Intervention

• Complete Decongestive Therapy

• A combination of all tech in
• Phase 1 –Intensive
• education, skin care, and exercise
• manual lymphatic drainage,
• Lymphedema bandaging //
• Lastly compression garments,

• Phase 2 – Self care

• Skin care
• Compression garment during day
• Lymphatic bandaging at night
• MLD as desired
Manual Lymph Drainage (MLD)

Def :- Massage used to decrease edema from an extremity by draining it into lymph nodes

How to perform :- ?
• UE prior to LE
• Go from Distal to Proximal But Work on proximal segments first, then Distal extremities
• Drain the proximal part first, Direction of drainage will be distal to proximal
• If too much pressure is applied, it will flatten the lymph nodes and lymph will not be able
to drain -----While Massage
Wrapping Technique

• Compression bandage wrapped

to reduce edema
Physiology :- Use a short stretch
compression bandage;
• Distal end should be tighter to
skin to promote flow of lymph
back up to circulatory system
Bandaging

• Bandages are the key component of compression during phase I,

• while a combination of compression garments (day) and bandages (night) are the typical means of achieving
compression during phase II.
Bandage types
Short stretch

• Purpose:- Lymph edema

• More compression during Activity while less compression during rest
• ADV :- Good for lymphedema.
Bandage types
High Stretch

• More compression during rest and Less compression while activity

• They can become like tourniquet at rest , not allowing fluid to flow up
• High-stretch sports bandages, such as Ace™ wraps, are not recommended for treating
lymphedema
Short stretch vs High Stretch

• High Stretch compress more at rest and ends up blocking the lymphatic vessels.
• Short stretch more compression during activity which does not block the Lymphatics due
to the muscle contraction and relaxation during activity.
Complete Decongestive Therapy

Exercise :--
• Always start with Low Intensty Exc:-- Always with Compression Garment
• Walking
• Easy biking
• Swimmng
• Water aerobics
• Tai CHI
Avoid Initially :--Mod risk activities
• Runnning
• Jogging
• Stair climbing
• Soccer Tennis goolf , Volleyball
•
Intermittent Pneumatic Compression

• Def :- An inflatable sleeve attached to a mechanical pump used to promote fluid return to
circulatory system
• How to use :-
• should not be used alone, use in conjunction with other therapies;
• Pt should be sitting if in arm (To allow lymph to go to Heart thru IVC)
• laying down if in trunk or LE – should not be in an dependent position
Lymph INTV
• Compression >50mmHg may injure the lymphatic vessels;
•
• 16-18 mmhg :-- Used in pressure stocking to prevent DVT
•
• 20-30 :-- to control scar tissue formation
• 30-40 mmhg :- Control edema in ambulatory patients.
•
Garment Selection for Lymphedema
Proper garment selection is key not only for effective long-term treatment of lymphedema but to improve patient
compliance by making the garment as comfortable to wear as possible.
Factors that should be considered during garment selection include compression level, type of knit, use of custom-
made or off-the-shelf garment, and style (including body areas to cover).

Compression Levels
• Often range from 20 to 60+ mm Hg, with lower extremities typically receiving higher compression levels (e.g., level
III: 40 to 50 mm Hg) garments than upper extremities (e.g., level II: 30 to 40 mm Hg).
• The highest listed level of compression for a given garment is found at the most distal segment of the garment as the
compression gradient is built into the garment.
• Other factors to consider include the ability of the patient to don and doff the garment, the patient’s activity level, and
the presence of comorbidities
 Management Post breast Cancer surgery
• Education :-
• Minimize postoperative swelling.-
• Positioning,
• Rom exc,
• Hand and finger contraction movements
• Breathing Exercises
• Postural Correction
• Leans anteriorly while supporting the Operated Extremity
• Prone to develop Fwd head posture and Rounded shoulder
• Early signs of Lymphedema :-
• MLD
• Compression Therapy
• Focus on Operated UE mobility
• Endurance Exercises
• Strengthening Exercises
• Exc for lymphedema post breast cancer
surgery
Conditioning exercises
• are done at low-intensity (at 40% to 50% of the
target
• heart rate) when lymphedema is present and
at higher intensities
• (as high as an 80% level) when the
lymphedema has
• been reduced and exercise is otherwise safe
Lymphedema Exercise

• Lymphedema- Exec always with Short stretch bandage, compression garment., Low risk
activites (cycling, swimming, water aerobics)
• Move to mod risk activities in case of no Exacerbation. (jogging, running, jumping)
• High Risk- (Football sports)
Lymphoma

• Lymphoma (Hodgkin’s or non-Hodgkin’s)

• Def :- Cancer anywhere in lymphatic system
• Physiology :- Enlarged lymph nodes,
fevers, sweats, itchiness, weight loss, fatigue
Typical 5 year survival rate; depends on tumor progression
Lymphocytosis

• Def:- Increased WBC;

• indicative of blood cancer or chronic infection
• Diagnosed:- Only detected with blood count
• Depends on reason; if infection, treat the illness
Lipedema
• Gradual and progressive symmetrical accumulation of fat in the subcutaneous tissue, typically seen in the
buttocks and lower extremities
 Major Characteristics Distinguishing Lipedema from
Lymphedema

Clinical Feature Lipedema Lymphedema

Gender Almost exclusively in women Women > men

Family history Common Rare

Distribution Bilateral lower extremities (rarely UE) Unilateral, or bilateral with one leg affected
symmetric involvement more severely (asymmetric)

Cellulitis Rare Common

Pain on pressure Present Absent

Easy bruising of affected area (hematoma) Present Absent

Distal edema in the foot Absent Present

Stemmer sign Absent Present (positive)

(negative)
Question

• Que – a 62 yr old lady who had developed lymphedema in her RT UE after a breast surgery done 3 weeks
back, has been referred for Physical therapy. Therapist on evaluation finds grade 3 Lymphedema
throughout the UE from shoulder girdle to fingers. Which of the following exercise sequence should be
followed in order to address this problem?

• A)Shoulder rotations first, followed by elbow flexion extension and Lastly wrist circumduction
movements.
• B)Wrist flexion & extension exercises followed by Pronation and supination movements and lastly
Shoulder horizontal Abduction and Adduction movements
• C)Shoulder Shrugs and rotations followed by wrist rotations and Lastly Pronation and supination
movements
• D)Fingers flexion extension and rotation movements first followed by wrist rotations/flexion/extension
then elbow movements and lastly Shoulder shrugs, rotations, flexion and extension movements
Question

• Que :- A 72 yr old patient who is in late stage 1 of lymphedema post venous insufficiency,
demonstrates signs of significant lymph accumulation in trunk, neck, pelvis and bilateral
upper and Lower extremities. Therapist decides to use the manual lymphatic drainage
technique in order to clear out the secretion to prevent chances of infection
development. Which of the following body parts needs to be drained first?

• A) Neck, abdominal and Inguinal areas

• B) Neck and Bilateral Upper extremity
• C) Inguinal and bilateral Lower extremities
• D) Abdominal and Bilateral Upper extremity
Question

• Que :- A 72 yr old patient who is in late stage 1 of lymphedema post venous insufficiency,
demonstrates signs of significant lymph accumulation in trunk, neck, pelvis and bilateral upper
and Lower extremities. Therapist decides to use the manual lymphatic drainage technique in
order to clear out the secretion to prevent chances of infection development. Which of the
following exercises should be focus of treatment at the start of Lymphedema rehabilitation.

• A) Knee to chest , heel slides and ankle pumps in supine

• B) Shoulder shrugs/rolls, Elbow bending excercises and Circling the wrists
• C) Pelvic tilt, Neck rotations and sidebending and Abdominal breathing Exercises
• D) Hip abduction exc, Neck rotations and ankle toe pumps
• Que – One question on – Clearing the central cpathways
first and then going to the perioheral lymphatic channels
• Eg– Clear – Cervica, trunk and pelvic – then go to Shoulder
and UE and then go to Hip and LE
• Good article
• https://unclineberger.org/patientcare/support/ccsp/
images-documents/lymphedema-workbook
 • Que :- Patient with a history of cor pulmonale and a recent
Practice episode of Ascitis has been admitted to the hospital for the
Increased secretion in the lateral basal segments of lower
Question lobe of Left lung. Since you are an experienced therapist at
the facility , what will be your recommendation to the newly
licensed PT?

• A) Give Post Drainage with 20” elevation of Foot end of bed in

right Side lying.
• B) Give postural drainage with 20 elevation of foot end of bed
in Left sidelying
• C) Give postural drainage 16” elevation of foot of bed in right
side lying
• D) Do not give postural drainage.
 • Que :- Therapist decides to give percussion to a patient with a
Practice H/O of Aortic Aneurysm in order to clear the secretions of the
left lung Lower lobe ant segments. What will be the best
Question treatment here in this patient?

• A) Clapping at the left lower lobe in the Rt side lying position

• B) Postural drainage for the left lower lobe in left side lying
position
• C) Clapping at the Left lower lobe in the Left side lying
position
• D) Postural drainage For the Lt lower lobe I the Rt side lying
position
Practice Question

• Que :- A patient with Excesssive secretions and a History of Cystic fibrosis is referred to a
physical therapy clinic in order to clear her secretion from the left lower lobe and increase
the airway to her lungs. What will be the appropriate treatment here for this patient?

• A) PD & Clapping & Shaking

• B) Postural drainage
• C) Clapping and vibration
• D) Percussion & Shaking
Practice Question

• Que :- Patient with Increased secretion in right lung apical lobes, is taking treatment in the
therapy gym, therapist decides to give vibrations by positioning the patient appropriately .
Therapist gives 10 vibrations and each vibration is given during each expiration of 3-4 seconds.
But the patient is not able to expell out any secretions. What will be the next step by the
therapist?

• A) Continue vibration and add other drainage techniques such as Percussion

• B) Stop vibration and use percussion after a small break in order for patient to catch breath
• C) Change the position and perform percussion with Shaking
• D) Use suction machine for 20 secs
• What area are you targeting ?