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The Lymphatic System of the Human Body

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The Lymphatic System of the Human Body THE LYMPHATIC SYSTEM OF THE HUMAN BODY We love your lymphatics We want you to love them too! THERAPIST QUALIFICATIONS VODDER ACADEMY IN AUSTRIAN TYROL Recuperating cancer patients attend the clinic for two weeks, soon after their medical treatment, for post-operative treatments, early preventative treatment for Oedema and to learn how to self-treat themselves at home. OUR SERVICES HOW MUCH DOES IT COST? TREATMENTS REBATES • Physiotherapy $115/hr • Private Health rebates on Physio/OT/RMT • Occupational Therapy $115/hr • CHP (Chronic Health Plan) up to 5/pa Medicare subsidised treatments for Physio/OT • Remedial/Pregnancy Massage $85/hr for $52.95 (including Sozo) • Sozo Testing $55/30 mins • DVA – fully subsidised up to 20/pa • Garment Fitting $55/30 mins • ACAT – fully subsidised up to level of cover • ICWA (Insurance Commission WA) ROLE OF THE LYMPHATIC SYSTEM • Sewerage System of the body • Fluids - uptake and clearance that can’t get back into th blood vessels • Absorption of fats (long chain fatty acids) • Maintains blood volume • Immune response WASTE MAINTENANCE • Collects & drains: 2-4L Lymph per day. • 100mls lymph drain from each arm daily = about a ½ cup of tea. • 200-300mls drain from each leg daily = about 1½ cups of tea. • Works at about 20% of capacity. LYMPH SYSTEM • Superficial and deep • 80% above the muscle 20% deep • 60% cervical • Lymph from the legs, groin, abdomen and left chest, arm and neck drain to left terminus • Lymph form right chest, arm and side of head to the right terminus IT ALL STARTS IN THE SKIN! ILV & ANCHORING FILAMENTS THE FACTORIES – LYMPH NODES • Holds invaders (pathogens) to identify! • Immune response factory • Waste recycling plant • Returns H2O back to blood • Stores insolubles – Ink! • We can’t make new nodes THORACIC DUCT • Thoracic duct 38-45cms long & 5mm in diameter, largest lymphatic vessel = Super Highway! • Cisterna chyli is a dilated lymphatic sac that represents origin of thoracic duct = Vacuum Cleaner! • Clears the whole of the lower part of the body and upper left quadrant. LYMPHANGIOGRAPHY BIO-IMPEDANCE SPECROSCOPY BIO-IMPEDANCE SPECTROSCOPY (BIS) Not to be confused with Bio-impedance ANALYSIS (BIA) - often found in gyms etc. TERMINOLOGY! • OEDEMA = Fluid Retention • ACUTE oedema = Short term (< 3 months) Post op, seromas, fracture, strains, wounds etc. • CHRONIC oedema = LYMPHOEDEMA (> 3 months?) a problem with lymphatic system = OR could be other causes BEWARE THE CAUSE OF SWELLING! • Lymphoedema: Primary and Secondary • Filariasis • Venous insufficiency, (e.g. varicose veins) • Recurrence of Cancer • DVT • Post operative swelling • Cardiac Disease (CHF) • Thrombophlebitis • Renal Disease / Liver Disease • Lymphangioma (Pseudotumor) • Hypoalbuminemia • Lipoedema / Lipedema • Metabolic disorders • Obesity • Infection – cellulitis, Erysipelas RED FLAGS • Sudden acute onset • Pain as the principle complaint • Skin colour changes • Collateral veins • Lumps, sores or ulcers • Paraesthesia or neurological signs • History of cancer not recently monitored Further assessment & investigation needed CT scan, Doppler, biopsy etc. for cause CELLULITIS • Consensus document: lymphoedema.org.au • Occurs very quickly (24 hours) • Needs immediate intravenous antibiotics LYMPHOEDEMA • The National Breast and Ovarian Cancer Centre “conservative estimates suggest that 20% of breast, genitourinary, gynaecological, or melanoma survivors will experience Secondary Lymphoedema. • Lymphoedema generally occurs in the first 2-3 yrs after surg or radiotherapy • Risk drops over time - provided no other trauma occurs • At birth, about one person in every 6000 will develop Primary Lymphoedema (Folidi M,E. (2006) • Significant negative impacts: frustration, distress, depression, anxiety, and body image disturbance, financial, productivity….. INCIDENCE OF LYMPHOEDEMA FOLLOWING CANCERS • Breast Cancer (axillary clearance) 21 - 28% (sentinel node biopsy) 5% • Cervical Cancer 24% • Melanoma 9 - 29% • Prostate Cancer 10 - 60% • Vulvar Cancer 36 - 47% (Beesley et al (2007) After gynaecological treatment 10% reported diagnosed LO, 15% reported undiagnosed “symptomatic”lower limb swelling. PRIMARY LYMPHOEDEMA • A congenital condition where there is an abnormality of the development of the lymphatics. BIS FOR PRIMARY LYMPHOEDEMA LIPEDEMA FAT deposits under the skin not recognised by Lysosomes (not a lymphatic issue) Affects 11% of women (probably underestimated due to lack of diagnosis Congenital, but cause uncertain BIS FOR LIPEDEMA SECONDARY LYMPHOEDEMA • Trauma and tissue damage • Venous disease • Immobility and dependency • Factious – self harm • Infection such as cellulitis • Obesity • Filariasis BIS FOR SECONDARY LYMPHOEDEMA SYMPTOMS OF LYMPHOEDEMA STAGES • Stage 0: Latent, patient at risk, may have subjective complaint (heaviness), no visible oedema. Now detectable by BIS - provided there is a baseline, reversible. • Stage I: Soft pitting oedema present, subsides on elevation, reversible, negative Stemmer’s sign. • Stage II: Firm, non pitting oedema present, rarely reduces on elevation, positive Stemmer’s sign. Late stage II: There may or may not be pitting as tissue fibrosis evident. Treatment – reduction & management. • Stage III: Tissue fibrotic (hard) and pitting is absent, management, significant skin changes: (hyperkeratosis elephantiasis, lymphangiectasia, papillomatosis, lymphorrhoea) Treatment – reduction & management. STAGES OF SECONDARY LYMPHOEDEMA HOW DO WE FIX IT? COMPLEX DECONGESTIVE THERAPY • Manual Lymph Drainage (therapist / pumps) • Compression (Bandaging / Wraps / Sleeves) • Exercise (Walking / Hydrotherapy) • Skin Care (Moisturise / protect / treat wounds) EARLY INTERVENTION!!! EARLY INTERVENTION – LYMPHATIC REDIRECTION TRAIN THE LYMPHATIC SYSTEM TO FLOW IN A DIFFERENT DIRECTION! • The body can grow new vessels but it can’t replace nodes! • Uses the body’s anastomoses • Uses highly hypoallergenic lymphatic tape - Curetape (form of Kinesiotape) • NO scientific evidence BUT now we can track with BIS • Plenty of anecdotal evidence and Sporting injury observations SPORTING INJURIES WITH TAPING SPORTING INJURIES WITH TAPING EARLY INTERVENTION – LYMPHATIC REDIRECTION • What does it entail? • Baseline BIS • 6 treatments – Manual lymph drainage & taping Fill up the anastomoses Tape body to encourage lymph to flow to other nodes • BIS in 3 – 6 months • Self-care education • Compression sleeve for flying EARLY INTERVENTION – LYMPHATIC REDIRECTION BIS FOR SECONDARY LYMPHOEDEMA BIS FOR SECONDARY LYMPHOEDEMA – FOLLOW UP 5 MONTHS WHY ARE SCARS IMPORTANT? • They can • We can • Restrict movement • Perform MLD/MSTR • Adhere to organs/deeper tissue • Use Low Level Laser (LLL) • Cause seromas • Use Physiokey (neurostimulator) • Block superficial lymph flow • Use taping • Look unsightly • 28 Feb 12 Mar 18 Apr 20 May WHAT IS CORDING? Axillary web syndrome Lymphatic cording • Incidence varies among the few reports • Associated with pain and limitation in in the literature ROM shoulder • Definite clinical entity following axillary • Most authors show resolution in 3 surgery for breast cancer months (Tilley et al 2009) • Treatment - Scar work - Laser - Taping - Exercise SCARS & CORDING FAILURE LYMPH SYSTEM • Load is greater than ability of LVS to manage • Progressive accumulation of fluid + inc. concentration- leads to more inflammation • Reduced oxygen levels • Inc. distance between blood and lymph vessels • Normal cells in tissues not dong what they should • Excessive fat deposition where slow/poor flow INCREASED RISK • Prior damage-e.g. hip joint, frozen shoulder, soft tissue injury • Blood vessel disease • Thyroid disease-makes large sticky molecules- which attract fluid-myxoedema • Inflammatory events • Lipoedema RISKS TRANSPORT CAPACITY REDUCTION • Surgery, radiotherapy • Fibrous tissue • Body mass- excess fat • Immobility or lack of activity • Too much pressure on a small area - e.g. bra, underwear too tight RISKS INCREASE LOAD • High capillary BP • Injured blood vessels • Weak capillaries and blood vessels • Infection • Sunburn • Heating of skin • Poor quality skin care • Not warming down after strenuous exercise RISK ASSESSMENT - ARMS RISK ASSESSMENT - LEGS LYMPHOEDEMA - TREATMENT GOALS - CDT • Reduce load • Increase lymph transport • Reduce Blood Pressure * • Movement * • Diligent skin care (gloves/moisturise/ect.) * • Manual Lymph Drainage * • Treat wounds/infection * • Massage * • Reduce BMI & RAD Nutrition * • Bandaging * (Rare Adipose Disorders) • Vibration * • Compression (garments) * • Taping * • Change oedema causing medications * SKIN CARE CHECKLIST • Keep your skin clean and dry – cleanse daily using a soap substitute, such as aqueous cream, Oilatum or Neutrogena soap bars or an E45 wash. • Moisturise your skin at least once a day. Use a glycerine based moisturiser (QV/Sorbolene) • Clean cuts or grazes straight away with clean water, then put an antiseptic cream on and cover the area. • Protect your skin from the sun by wearing a high factor sun cream or cover up with clothes. • Use an insect repellent containing at least 50% DEET– if you're bitten or stung, try not to scratch and use antihistamine cream. • Avoid hot baths, saunas and steam rooms because this can increase swelling. • Avoid extremes of temperature that can dry your skin – including hot, cold or windy weather. • Don’t wear tight clothing or jewellery. • Avoid sitting or standing for long periods of time if you have leg swelling. • Don't have injections, blood taken, or your blood pressure checked on the affected arm.
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