Lymphedema Lecture Notes

Course Resources

• Lymphedema PowerPoint
• Videos on Manual Lymphatic Drainage, Lymphedema Strokes, and Bandaging
• Questionnaires & Scales for Lymphedema Patients

Lymphedema Overview

• Affects at least 3 million Americans
• Worldwide cases: 140-250 million
  • Most common cause: Filariasis, a parasitic infection
• Types:
  • Secondary Lymphedema: 2-3 million in the US
    • Common post-breast cancer surgery with radiation
  • Primary Lymphedema: 1-2 million in the US
    • Congenital or hereditary
    • Generally affects lower extremities

Complete Decongestive Therapy (CDT)

• Non-invasive, multi-component treatment
• Effective in Europe since the 1970s and US since the 1990s

The Lymphatic System

• One-way system: returns lymphatic fluid to bloodstream
• Components:
  • Initial lymph vessels (lymph capillaries)
  • Lymph nodes (filter impurities)
  • Lymphatic trunks (larger collectors)
• Key Terms:
  • Lymphatic Load: Protein, water, cells, fat
  • Lymph Angion: Section between a pair of valves in lymph collectors
  • Lymph Formation: Process of lymph entering initial lymphatic system

Anatomy & Historical Context

• Key Historical Figures:
  • Hippocrates, Aristotle, Thomas Bartholin
• Lymph Capillaries:
  • Single-layered endothelial cells
  • Anchoring filaments keep them open under tissue pressure
• Lymph Collectors:
  • Inner wall, smooth muscle layer, and outer layer
  • Valves ensure one-way flow

Lymph Node Functions

• Primary Functions:
  • Protective: Filter harmful materials
  • Immune: Produce lymphocytes
  • Thicken lymphatic fluid

Lymphatic Pathways

• Thoracic Duct:
  • Largest lymphatic trunk
  • Drains into the left venous angle
• Drainage Points:
  • Axillary, inguinal, and cervical lymph nodes
  • Specific pathways for breast cancer-related lymphedema

Pathophysiology

• Transport Capacity (TC): Max lymph fluid transportable
• Functional Reserve: System’s ability to increase capacity
• Types of Insufficiency:
  • Dynamic Insufficiency: Normal TC, high load
  • Mechanical Insufficiency: Reduced TC

Stages of Lymphedema

1. Stage 0: Latency/Subclinical
   • Subnormal TC but sufficient for normal loads
   • ~58% of postmastectomy women
2. Stage 1: Reversible
   • Soft tissues, no fibrosis, pitting present
   • Swelling can recede overnight with management
3. Stage 2: Spontaneously Irreversible
   • Tissue proliferation and fibrosis, pitting difficult
   • Increased risk for cellulitis
4. Stage 3: Lymphostatic Elephantiasis
   • Increased volume, severe tissue changes
   • Frequent infections, deeper skin folds

Complete Decongestive Therapy (CDT) Components

• Manual Lymphatic Drainage (MLD):
  • Gentle manual technique
  • Increases lymph production, flow rerouting
• Compression Therapy:
  • Bandages, garments
  • Increases tissue pressure, supports muscular function
• Decongestive Exercises:
  • Exercise with compression
  • Enhances lymphatic and venous return
• Skin and Nail Care:
  • Prevent/control infections, essential for CDT

CDT Phases

1. Intensive Phase:
   • Daily treatments until decongestion
   • Involves MLD, bandaging, exercises, skin care
2. Self-Management Phase:
   • Lifelong process
   • Daily self-care, garment use, periodic checkups

Surgical & Pharmaceutical Interventions

• Surgical:
  • Debulking, Liposuction, Micro-surgery
  • Generally not effective for CDT patients
• Pharmaceutical:
  • Diuretics, Benzopyrones, Antibiotics
  • Limited by side effects or specificity

Additional Notes

• Compression Pump Therapy:
  • Moves water, not proteins
  • Not a substitute for CDT
• Diet & Obesity Management:
  • Low-salt, low-fat diet
  • Importance of hydration and controlled weight

Conclusion

• Accurate diagnosis and effective, especially CDT, are critical for managing lymphedema.
• CDT is endorsed by major health organizations and is cost-effective.
• Lifelong management and patient compliance are key.