Sheri B.Feldscher OT, CHT 3/9/2015

EDEMA MANAGEMENT Anatomy and Physiology

Sheri B. Feldscher OT, CHT

Lymphatic System Functions of Lymphatic System

. Scavenger system . Immune function  Removes excess fluid, debris,  By protecting the body from and other materials from the disease and infection tissue spaces  Via production, maintenance, and . Alternate pathway to the distribution of lymphocytes heart . Responsible for returning proteins that have  For substances too large to be accumulated in the interstitial disposed of through the venous system spaces back into the venous system https://www.studyblue.co www.dynamicwellnesssolution . Restoring balance m/notes/note/n/lymphatic‐ s.org/lymphsystem.html system/deck/5249093

Fluid Transport Through Blood Capillaries Definitions . Net capillary filtration pressure is the balance of pressure between: . Lymph  Fluid collected from  Capillary (hydrostatic) pressure tissues  Moves fluid from capillary outward through the membrane  Flows via lymphatic  Pressure is greater at arterial than venous end vessels through lymph  Results in fluid filtering out at arterial end and being reabsorbed at nodes and drains into the venous end of blood capillaries venous system  Interstitial fluid pressure  Forces fluid inward through the capillary membrane when (+) and . Interstitium outward when (‐)  Interstitial fluid colloid osmotic pressure  The spaces between cells  Pressure created by dissolved proteins causing osmosis of fluid  Interstitial fluid is the fluid http://thessgiatro.gr/index.php/topics/scie  If high will cause osmosis of fluid outward through the membrane between cells derived by ntific‐article/item/1885‐ filtration from the  Plasma colloid osmotic pressure capillaries  Pressure created by dissolved proteins causing osmosis of fluid  Draws fluid inward through the membrane

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Fluid Transport Through Blood Capillaries Mechanism of Edema

 After injury the inflammatory response changes the permeability of the microvessels . When net filtration pressure  Allowing plasma proteins to leak into interstitial spaces rises excessively  They are too large to permeate the venous system  Too much fluid is moved  The role of the lymphatic system is to dispose of matter outward into the interstitial too large for venous system spaces for the lymphatics to  If damaged or overloaded (dynamic insuffiency) manage  Ability to dispose of these larger plasma proteins is hindered  If lymphatic load exceeds the  If these proteins remain in the interstitium transport capacity  Colloid osmotic pressure increases and draws more fluid into extracellular edema will result http://lymph.weebly.com/lymphati c‐system.html the interstitial space

Edema Lymphatic Tissue Drainage System

. Can only occur if the . 3 levels of structures lymphatic system has failed  Lymphatic capillaries  Collector lymphatics . By DfiitiDefinition  NdNodes . Accumulation of excess fluid in the intercellular spaces in the body

Lymphatic capillaries Lymphatic capillaries

. Beginning of the lymphatic . Consists of single layer of system overlapping endothelial cells that have connector filaments . Found in the dermis at the anchoring them to surrounding CT dermal‐epidermal junction  Forms flap like junctions that open forming a flat 2 dimensional when local interstitial pressure continuous network over changes  When open, fluid flows in changing the entire body internal pressure from low to high, Quizlet.com  Except the CNS and cornea causing junctions to close  Enables vessels to stay open even http://www.nature.com/nri/journal/v4/ under high tissue pressure n1/fig_tab/nri1258_F2.html  Fluid is unable to flow out

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Lymph Precollectors and Collectors Lymph Precollectors and Collectors

. Lymphatic loads are . Segments between 2 valves in a collector are called lymph reabsorbed by the lymph angions capillaries and flow into  The contraction of smooth larger lymph vessels muscle in each angion generates propulsive force of called precollectors which lymph flow along the lymph drain into collectors vessel  Collectors have valves  At rest lymph angions pump http://royalsocietypublishing.org/conte spaced every 6‐20 mm 6‐10x/min  With muscle contraction from nt/9/69/601  Prevent the backflow of lymph http://fau.pearlashes.com/a exercise they can pump 10x natomy/Chapter%2035/Cha that amount pter%2035.htm

Lymph Nodes Trunk Lymphotomes

. Divided into 4 lymphatic quadrants . Propulsion directs the (drainage territories) lymph fluid into regional  L and R Upper Quadrant‐Thoracic Lymphotomes  Extend from anterior midline to vertebral and central lymph nodes column on L and R sides of upper trunk to be filtered  Lyypmph drains from superficial to deeper vessels that connect to nodes  Nodes consist of a  Between lymphotomes are watershed areas complex of sinuses that where normal drainage is away from the perform immunologic watershed toward the nodes  There are superficial collateral vessels across functions watershed areas http://www.cyberound http://howshealth.com/lymph‐node‐cancer/  Ultimately empties into  * With lymph congestion they provide s.com/cmecontent/art alternative pathway to uncongested lymph 137.html?pf=yes the venous system vessels  L and R Lower Quadrant‐ Abdominal Lymphotomes

Drainage Areas for Lymphatic Duct Drainage Areas for Thoracic Duct

. UE drain mainly into . Both LE, both abdominal axillary nodes lymphotomes, L thoracic . Lymph from R thoracic lymphotome and L side of lyypmphotome , RUE and head drain into the R side of head drain Thoracic Duct into trunks that empty  Largest lymphatic vessel in into R Lymphatic Duct the body extending from L2  Duct empties into R toT4 http://www.lymphedemablog.com/wp Subclavian Vein and into http://www.tabers.co http://quizlet.com/5502405/  Thoracic Duct empties into ‐content/uploads/2011/09/venous‐ m/tabersonline/repvi anatomy‐ch‐23‐lymphatic‐ angle.jpg the Superior Vena Cava ew?type=539‐ flash‐cards the venous system at the of the heart 22&name=D31 juncture of the Subclavian and Jugular Veins

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Lymphatic Therapies

. Types  Complete Decongestive Therapy  Manual Lymph Drainage Lyypmphatic therapies  Manual Edema Mobilization . Overall Theory  To remove plasma proteins from edematous areas by stimulating the lymphatic system  Enables these proteins to leave the interstitial spaces and enter lymphatic structures  By ridding the interstitial spaces of these hydrophilic proteins, subacute and chronic edema decreases

Complete Decongestive Therapy Manual Lymphatic Drainage

. 2 phase non‐invasive intervention for lymphedema . Specialized manual technique based on physiologic  Benefits principles of lymph flow and lymph vessel emptying  Open collateral lymphatic drainage pathways . Affects lymph system by moving lymph fluid around  Increased pumping by deep lymphatic pathways blocked areas toward collateral vessels,  Reduction and breakdown of fibrotic tissue anastomoses, and unildinvolved llhymph node regions  Phases . Benefits  Phase I (intensive)  Increases lymph angiomotoricity (pulse)  Increases volume of transported lymph fluid  Involves MLD, bandaging, use of compression garments  Increasing pressure in lymph collector vessels  Phase II (self mgt)  Improving lymph transport capacity  Pt wears compression garment during day; bandaging at night, exercise, and self MLD  Potentially increasing arterial blood flow

Manual Edema Mobilization Differences

. A lymphatic stimulation technique used for Manual Edema Mobilization Manual Lymphatic Drainage recalcitrant sub acute or chronic limb/ hand edema in the orthopedic population . Designed for orthopedic . Originally intended for patients with subacute and . Basic Premise individuals w lymphedema chronic edema . Insufficient Lymphatic  Diaphragmatic breathing, light skin‐traction massage, . Lymphatic system is intact System and exercise help stimulate the lymphatic system  High plasma protein  By changing interstitial pressure which enables the  Temporarily overloaded edema associated with proteins to leave the interstitial spaces and enter  Treatments are shorter and mechanical obstruction lymphatic structures typically involve moving  Treatments are longer  By ridding the interstitial spaces of these proteins the less fluid and more involved edema decreases  Large amounts of fluid may need to be rerouted . Key point: throughout the body  Lymphatic system is intact but temporarily overloaded

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Critical Points Lymphedema

. High plasma protein edema associated with a mechanical obstruction or insufficiency of All edema is not the same the lymphatic system . Lymphatic system is unable to clear the interstitial tissues . Most distinguishing feature is resultant high content plasma proteins in the interstitial fluid . Over time can lead to fibrosis http://www.agoracosmopolitan.com

Stroke Edema Edema from Kidney or Liver Disease

 Caused by decreased  Simple pitting edema plasma proteins in  Perpetuated by the loss the interstitium of motor function  Pitting edema (muscle pump)  Eventually can become gel‐like and then fibrotic  Contraindication

Edema from Cardiac Conditions Inflammatory Edema

 Acute (0‐72 hours) . Increased venous and  Inflammatory phase of wound healing capillary pressures  Initial flooding of damaged tissue area  Bilateral pitting edema with electrolytes and water around ankles/feet  Edema is liquid, soft, and easy to mobilize  Contraindication  These low‐protein substances readily http://en.wikipedia.org/wiki/Acute diffuse by osmosis back into the _decompensated_heart_failure venous system

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Inflammatory Edema Subacute Edema Treatment . Characterized by excess plasma proteins . Rest  Lymphatic transport is compromised by  Immobilization, when possible, should occur in the damaged lymphatics intrinsic–plus position . Fibroblastic phase of wound healing  Early active motion when appropriate  Edema is more viscous from the eldlevated protein content . Ice  Fibroblasts are activated by the proteins trapped in the  Avoid heat modalities that may increase bleeding interstitium and produce collagenous tissue . Compression  Exudate causes fibrosis/ thickening of tissues with subsequent shortening of ligamentous & tendinous structures . Elevation  If untreated will progress to a gel‐like state  Decreases hydrostatic pressure, . Persistent edema, immobilization, and poor positioning reducing the flow of fluid into will lead to a stiff hand the interstitium

Subacute Edema‐Treatment Subacute Edema‐Treatment

. Consider   Heat in elevation to precondition structures, increase Lymphatics must be specifically stimulated CT extensibility and circulation in preparation for . AROM/Tendon Gliding exercise  Splinting  Active muscle pumping is single most important stimul us for increasing  Dynamic to increase ROM lymphatic flow  Gentle prolonged force to influence collagen fibers  Exercise stimulates the superficial lymphatics by altering tissue . Compression pressure (allowing fluid to flow into the lymphatic system) and  Isotoner gloves, Coban wraps, Elastomull wraps stimulates the deeper lymphatics which aids in propelling the . Lymphatic Therapies lymph through the deeper vessels  Massage  Lymphangions have a higher rate of contraction or “pumping” during  Creates a locally negative pressure gradient, draining the exercise lymphatic system distally . Other  Kinesiotape, Chip bags

Chronic Edema Chronic Edema Treatment

. Maturation phase of  Lymphatics must be specifically wound healing stimulated . Techniques to increase tissue . Persistent edema leads hydrostatic pressure to fibrosis with  Compression garments  Isotoner gloves, coban, tubigrip, elevated protein count elastomull wraps, chip bags, . kinesiotape Edema becomes hard,  Lymphatic Therapies thick, and brawny as . Splinting the result of connective  To influence tissue remodeling tissue infiltration and  Low load long duration stress . High‐volt pulsed direct current may fibrosis decrease edema by reducing microvascular permeability to plasma proteins

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Chip Bags Kinesiotape

. Made from small pieces of varied‐ density foam . When applied to the skin over an . Provide light stimulating inflamed area, the stretch in the compression tape gently lifts the skin . Retain body heat  Creates an area of negatg ive . Provide further tissue softening pressure, allowing both blood . Provide significant local pressure vessels and lymphatic vessels to and are especially helpful for dilate, draining the area brawny areas  Improved blood flow enhances  Extremity should be wrapped delivery of oxygen and nutrients from distal to proximal to assist to the injured tissues, with lymphatic and venous drainage accelerating the healing process

Evidence (Bandaging) Critical Points

. Leduc et al (1998, 1990) found that the . Stimulation of the lymphatic system is combination of multilayered bandages on the forearm combined with exercise increased necessary to decrease sub acute and protein absorption by lymphatic capillaries chronic edema (high‐ protein edema) . External pressure and temperature also facilitate  Enables the proteins to leave the interstitial spaces lymph movement and and enter lymphatic structures  Kurz (1997) demonstrated that the flow of lymph within the vessel is best between 22‐41° C  By ridding the interstitial spaces of these proteins  Sharply slows down or stops below and above those the edema decreases temps  Bandaging can influence protein absorption by providing light compression and perhaps by providing a buildup of body heat that is within the mid range of ideal temp to mobilize lymph

Critical Points Critical Points

The initial lymphatic system is superficial, fine, and fragile Diaphragmatic breathing, light massage, and exercise help stimulate the lymphatic system  Firm compression may collapse the lymph vessels o By changing interstitial pressure and causing increased lymphatic protein absorption

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Diaphragmatic Breathing Scars

. Edema cannot go through scars . Thoracic duct is the largest lymphatic structure (L2‐T4) and one of the deepest  Will need to be rerouted around scars and incisions . Diaphragmatic breathing changes pressure in . Goal is to reroute congested lymph duct around areas of tissue damage into . The pressure change creates a adjacent functioning lymph capillaries vacuum pulling lymph from peripheral structures centrally toward the subclavian veins

Case Example Pre

. 43 yo RHD Director Instructional Tech at ACC . 6 weeks s/p R CTR . Volumeter testing R 35ml > L Thank You . 15ml decrease in 1 session using MEM . Home program Post  Diaphragmatic Breathing  AROM exercises  Light skin‐traction massage

References References

. Howard SB and Krishnagiri S. The use of manual edema . Priganc VW and Ito MA. Changes in edema, pain, or ROM following mobilization for the reduction of persistent edema in the upper MEM: a single‐case design study. J Hand Ther. 2008 (4):326. limb. J Hand Ther. 2001, 14(4)291. . Villeco J. Edema: Therapist’s Management. . In Skirven TM, . Knygsand‐Roenhoej K. A Randomized Clinical Controlled Study Osterman AL, Fedorczyk JM, and Amadio PC. (Eds) Rehabilitation of Comparing the Effect of Modified Manual Edema Mobilization the Hand and UE (Sixth Ed), Philadelphia: Mosby Inc, 2011, 845‐57. Treatment with Traditional Edema Technique in Patients with a . Hettrick H. Management of Upper Extremity Lypymphedema. . In Fracture of the Distal Radius. J Hand Ther, 2011, 24:184‐94. Skirven TM, Osterman AL, Fedorczyk JM, and Amadio PC. (Eds) Rehabilitation of the Hand and UE (Sixth Ed), Philadelphia: Mosby . Artzberger SM and Priganc VW. Manual Edema Mobilization: An Inc, 2011, 858‐67. Edema Reduction Technique for the Orthopedic Patient. In Skirven TM, Osterman AL, Fedorczyk JM, and Amadio PC. (Eds) . Leduc O, Peeters A, Bourgeois P: Bandages: scintigraphic Rehabilitation of the Hand and UE (Sixth Ed), Philadelphia: demonstration of its efficacy on colloidal protein reabsorption during muscle activity. Progress in Lymphology XII, Excerpta Med, Mosby Inc, 2011, 868‐81. Int Cong Ser. 887:421‐423 1990. . Leduc O, Leduc A, Bourgeois P, et al.: The physical treatment of . Kurz I 4th ed Textbook of Dr. Vodder’s Manual Lymph Drainage. upper limb edema. Cancer. 15 (83):2835‐2839 1998 vol 2 1997 Haug Heidelberg

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