THE LYMPHATIC SYSTEM OF THE HUMAN BODY We love your lymphatics We - - PowerPoint PPT Presentation

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

• Physiotherapy

$115/hr

• Occupational Therapy

$115/hr

• Remedial/Pregnancy Massage $85/hr
• SozoT

esting $55/30 mins

• Garment Fitting $55/30 mins

REBATES

• Private Health rebates on Physio/OT/RMT
• CHP (Chronic Health Plan) up to 5/pa

Medicare subsidised treatments for Physio/OT for $52.95 (including Sozo)

• DVA – fully subsidised up to 20/pa
• 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

• rigin 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
• Venous insufficiency, (e.g. varicose veins)
• DVT
• Cardiac Disease (CHF)
• Renal Disease / Liver Disease
• Hypoalbuminemia
• Metabolic disorders
• Infection – cellulitis, Erysipelas
• Filariasis
• Recurrence of Cancer
• Post operative swelling
• Thrombophlebitis
• Lymphangioma (Pseudotumor)
• Lipoedema / Lipedema
• Obesity

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
• Restrict movement
• Adhere to organs/deeper tissue
• Cause seromas
• Block superficial lymph flow
• Look unsightly
• We can
• Perform MLD/MSTR
• Use Low Level Laser (LLL)
• Use Physiokey (neurostimulator)
• Use taping
• 28 Feb 12 Mar 18 Apr 20 May

WHAT IS CORDING?

• Incidence varies among the few reports

in the literature

• Definite clinical entity following axillary

surgery for breast cancer

• Treatment - Scar work
• Laser
• Taping
• Exercise
• Associated with pain and limitation in

ROM shoulder

• Most authors show resolution in 3

months (Tilley et al 2009) Axillary web syndrome Lymphatic cording

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
• T
• o 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
• Reduce Blood Pressure *
• Diligent skin care (gloves/moisturise/ect.) *
• Treat wounds/infection *
• Reduce BMI & RAD Nutrition *

(Rare Adipose Disorders)

• Compression (garments) *
• Change oedema causing medications *
• Increase lymph transport
• Movement *
• Manual Lymph Drainage *
• Massage *
• Bandaging *
• Vibration *
• Taping *

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.

https://www.cancerresearchuk.org/about-cancer/coping/physically/lymphoedema-and-cancer/treating/caring-for- your-skin

RAD DIET – DR KAREN HERBST & PROF NEIL PILLER

MANUAL LYMPH DRAINAGE - MLD

WHAT DOES IT DO?

• Assists take up of lymph
• Moves lymph inside the lymph vessels
• Relieves pain
• Reduces stress
• Very gentle movements!

WHAT DOES IT HELP?

• Fluid retention
• Fibrosis
• Sinusitis
• Wounds & Ulcers
• Post surgery recovery
• Fibromyalgia

NEAR-INFRARED FLUORESCENCE IMAGING

BANDAGING

• For short term quick

reductions

• Needs to be done during

the winter

• Best method for large

limb reductions

COMPRESSION GARMENT PRESCRIPTION

HOW TO CHOOSE THE RIGHT GARMENT?

• Round Knit or Flat knit or Cut and Sew?
• Off the Shelf or Custom made?
• How much compression?
• Cotton /Lycra/Wool?
• Night garment / Day garment?
• Wraps?
• Which brand?
• How many to purchase?
• Are they independent?
• Are they flying?
• Prophylaxis?
• Do they sit all day?
• Have other co-morbidities (THR /

arthritis/vascular compromised/wounds/oozy/over dressings)?

NOT THE RIGHT GARMENT!

WRAPS

• Easier to apply
• Palliative
• Paediatric
• Fluctuations in oedema/rebound oedema
• Donning and Doffing problems
• Limited access to bandaging
• What is the patient willing to do?
• Very difficult shape
• Over dressings

EXERCISE PRINCIPLES

• Skeletal muscle contraction
• Warm up and down
• Start low level work up
• Exercise with your garment on
• Do it in the water!
• T’ai Chi & Qi Gong- link with respiration

WHAT SORT OF EXERCISE?

• Studies have shown that a variety of exercise regimes have positive benefits:
• Aqua – therapy: optimal temp 28 degrees. (Johansson et al, 2004)
• Machine based therapy.
• Progressive weight training. (Ahmed, 2006), (Schmitz, 2010).
• Tai Chi. (Taylor-Piliae et al, 2006)
• Deep Breathing and arm exercises. (Moseley at al, 2005)
• Yoga.
• Strenuous Exercise?

AND THERE’S MORE

• Progressive weight training may increase the functional capacity of the effected arm

without exacerbating symptoms. (Ahmed et al, 2006)

• Improved bone health and limb function, fracture risk. (Winters-Stone et al, 2011)
• Decrease risk of developing site specific cancer in particular colon and breast

cancer (Lee, 2003) and rate of reoccurrence.

REFERENCES

• “The Big Picture: Everything you wanted to know about lymphoedema. Professor Neil

Piller: Director, Lymhpoedema Assesment Clinic, Flinders Medical Centre. 2011.

• http://www.lymphoedema.org.au/
• https://www.movinglymph.com.au/
• https://www.bcna.org.au/health-wellbeing/physical-wellbeing/lymphoedema/

REFERENCES

• 1. Karkkainen, M.J., Saaristo, A., Jussila, J., Karila, K.A., Lawrence, E.C., Pajusola, K., Bueler, H., Eichmann, A., Kauppinen, R., Kettunen, M.I., Yla-Herttuala, S., Finegold,

D.N., Ferrell, R.E. and Alitalo, K. (2001). A model for gene therapy of human hereditary lymphedema. PNSA; 98 (22): 12677-12682.

• 2. Földi M, E. (2006). Földi’s Textbook of Lymphology 2nd edition, Elsevier.
• 3. Brice, G., Mansour, S., Bell, R., Collin, J.R.O., Child, A.H., Brady, A.F., Sararazi, M., Burnand, K.G., Jerrery, P., Murday, V.A. (2002). Analysis of the phenotypic

abnormalities in lymphoedema-distichiasis syndrome in 74 patients with FOXC2 mutations or linkage to 16q24. J Med Genet; (39): 478-483.

• 4. Beesley, V., Janda, M., Obermair, A., Battistutta, D. (2007). Lymphedema after gynecological cancer treatment: prevalence, correlates, and supportive care needs.

Cancer; 109 (12): 2607-14.

• 5. He, K., Cui, B., and Teng, L. (2012). The effect of anti-VEGF drugs (bevacizumab and aflibercept) on the survival of patients with metastatic colorectal cancer

(mCRC). Onco Targets Ther; (5): 59-65.

• 6. Kume, T. (2012). Review Article The Role of FoxC2 Transcription Factor in Tumor Angiogenesis. Journal of Oncology;( 2012): Article ID 204593 7 pages.
• 7. Pinto, P.S., Sirlin, C.B., Andrade-Barretto O.A., Brown, M.A., Mindelzun, R.E., Mattrey, R.F., (2004). Cisterna chyli at routine abdominal MR imaging: a normal

anatomic structure in the retrocrural space. Radiographics; 24 (3): 809-17.

• 8. emedicine.medscape.com/article/1087313 – differential
• 9. C.J. Moffatt, P.J. Franks, D.C. Doherty, A.F. Williams, C. Badger, E. Jeffs, N. Bosanquet and P.S. Mortimer. (2003) Lymphoedema: an underestimated health problem.

QJM: An International Journal of Medicine; 96 (10): 731-738.

• 10. lymphoedema.org.au/ALA/Documents/ALA_Position_Statement-on_Cellulitis
• 11. Lymphoedema Framework: Best Practice for the Management of Lymphoedema. International Consensus. London: MEP Ltd, 2006.
• 12. Salven, P., HeikkilA, P., and Joensuu, H. (1997). Enhanced expression of vascular endothelial metastatic melanoma. Br J Cancer; 76(&): 930-934.
• 13. Shin, B.W., Sim, Y., Ho, J.J., and Kim, G.C. (2011) Lipedema, a Rare Disease. Annals of Rehabilitation Medicine; 35(6): 922-927.
• 14. ghr.nlm.nih.gov
• 15. cancer.org.au
• 16. Moshiri, M., Katz, D.S., Boris, M. and Yung, E. (2002). Using Lymphoscintigraphy to Evaluate Suspected Lymphedema of the Extremities. American Journal of

Roentgenology;178(2).

EXERCISE REFERENCES

1. Pinto, P.S., Sirlin, C.B., Andrade-Barretto O.A., Brown, M.A., Mindelzun, R.E., Mattrey, R.F., (2004). Cisterna chyli at routine abdominal MR imaging: a normal anatomic structure in the retrocrural space. Radiographics; 24 (3): 809-17. 2. Moseley, A. & Piller, N.B. (2008). Exercise for a limb lymphoedema: Evidence that it is beneficial. Journal of Lymphoedema: 3(1):51-56. 3. Havas, E., Parviainen, T., Vuorela, J., Toivanen, J., Nikila, T. & Vihko, V. (1997). Lymph flow dynamics in exercising human skeletal muscle as detected by

• scintography. J. Physiol; 504(1): 233-9.

4. Shields, J. (1980). Central Lymph Propulsion. Lymphology ; 13: 9-17. 5. Sumner , D.S. (1995). Hemodynamics and pathophysiology of venous disease. In: Rutherford RB,ed. Vascular Surgery. 4th edn. WB Saunders, Philadelphia: 1673-98. 6. Mazzoni, M.V., Skalak, T.C., Shmid Shonbein, B.W. (1990). Effects of skeletal muscle fibre deformation on lymphatic volumes. AMJ Physiol; 259 (part 2): H1860-8. 7. Tilley, A., Thomas-MacLean, R., Kwan, W. (2009). Lymphatic cording or axillary web syndrome after breast cancer surgery. Canadian Journal of Surgery: 52(4): E105-E106.

THANK YOU FOR LISTENING! ANY QUESTIONS?