The Connection between the Immune & Lymphatic Systems

Written by Joel Robert Thompson

            Hello everyone.  I am a third year Doctor of Physical Therapy student who has had the privilege of training here at North Carolina Physical Therapy since the beginning of August.  My main research interest is around autoimmunity, namely a disease called Ankylosing Spondylitis, as well as how exercise and physical therapy can positively influence the immune system as a whole.  For this reason, I have told many of our patients here at NCPT that I am interested in lymphedema and NCPT because the lymphatics are part of the immune system and so I want to take a little time to explain what exactly I mean by that.  How do the lymphatics play a role in immune function after all? 

It is pretty straightforward to say that a large chunk of your immune cells live in the lymph vessels and lymph nodes – which they do – but that does not really answer how the lymphatic system acts as part of the immune system and why that even matters or helps the body.  I will steal from Philipp Dettmer and give the most succinct description of the lymphatic system as “The Immune System Superhighway.”  We talk a lot about how the vessels in the body are roads to bring nutrients, oxygen, and all the good stuff to the cells.  It all comes from your heart via the arteries, which you may all recognize as the red vessels on a body map.  From there, the veins (blue vessels) and lymph system (green/yellow vessels) return all that stuff – the blood that needs an oxygen refill, extra nutrients, byproducts of energy creation, etc – to the heart, liver, kidneys to either be returned to circulation and removed from the body. 

When explaining the lymphatic system, we give the common estimate that about 80% of the fluid originally pumped by the heart is returned with the veins, about 10% sticks around in the space between the cells, and the remaining 10% is drained and returned to circulation via the lymphatic system.  Although this is absolutely true – give or take a few percentage points – it does leave out the distribution of what is in that 10% that is described as Lymph fluid.  Lymph is described as white or clear because most of the blood (not to mention the excess nutrients and all the other good stuff) goes into the veins.  Rather, the lymph system is a bit more gross: it drains the stuff that is otherwise ‘stuck’ in the space in between cells.  This certainly includes some nutrients unabsorbed by the cells and plasma and platelets that went unused.  However, the larger chunk of this includes cellular debris, waste products (from converting the raw nutrients into energy), dead cells, and – most relevant here – any signs of bacteria or viruses that may be plaguing the system. 

And when I say “signs” of infection, it is regrettably a bit darker than that.  When a cell is about to die, it will send out a warning sign that simultaneously warns other cells to be careful and attracts immune cells (for context, Rabies is so insidious because the infection deactivates this warning signal in affected cells).  One of the immune cells in particular, called dendritic cells, act almost like intelligence officers.  These cells will swallow the infected cells whole and study what specifically is infecting your body.  It does this by isolating the surface protein chains on the invading cells.  In a microscopic world where things do not have eyes, all cells have little protein chains on their surface that acts to identify the cell.  This is very helpful to identify what is self and what is foe (and is a major part of the problem with autoimmune diseases).

The dendritic cell then uses the protein chains it gathered from eating the invading cells and uses them to recruit more help.  In short, your body already has an immune cell that is specifically designed to fit almost any infection and your body maintains cells that ‘remember’ each infection that has attacked your body.  This is why many people argue it is important to expose yourself to stuff as a kid via eating dirt and bathing in mud (this is not entirely true, of course, but the spirit is common).  We call these cells Helper T-cells and they mostly hang out in the lymph nodes.  (You have probably heard of T-cells because these are the cells specifically that the HIV virus primarily targets.)  So the dendritic cell enters the lymphatic system and goes node by node until it finds a T-cell that matches the infection that it has identified.  Once identified, the T-cells can direct the immune system and create more of the specific cells, antigens, and antibodies needed to combat the specific infection.

The question, of course, is why do the T-cells and ‘dormant’ immune cells hang out in the lymphatic system rather than circling the blood stream, constantly guarding against infection.  To be fair, many of them do, especially in the immediate periods after infection.  However, the storage of immune cells in the lymphatic system is, in short, to keep the system from being too active.  Many immune cells cause widespread damage and have no system for differentiating good cells and bad cells.  Thus, these cells need to be kept in reserve until they are truly necessary.  Much of your crummy feeling from when you are sick is actually just your immune system trying to fight the infection rather than the infection itself.  Fever, inflammation, achiness; that is all your body’s immune response to infection, not necessarily the infection itself.

And while hanging out in the lymph vessels, these immune cells gather in lymph nodes.  Thus, any substance that is moving along the lymph system back to the heart to reenter circulation must push through these collections of immune cells.  Although not a proper detoxifying and filtration system such as the kidney, the lymph nodes do identify harmful cells and gobble them up or neutralize them so they cannot return to circulation.  A colleague of mine refers to this process as the lymph nodes acting like a sort of TSA checkpoint that inspects, analyzes, and scans what is coming out of the space between cells. 

            So naturally if the lymphatic system is not operating properly – or, to continue the TSA metaphor, acting short-staffed because some lymph nodes are not acting properly – the immune system has fewer opportunities to catch foreign invaders before they begin to set up shop in the body, in our skin, and in the space between the cells.  I am excited, then, for the opportunity to work with patients to help promote better movement of lymph fluid and ultimately help the immune system function better in order to help the patients at North Carolina Physical Therapy.

Kismet Connections

As a student, I distinctly remember walking into the workroom one morning to see my clinical instructor hunched over her computer, bawling her eyes out. I come to find out one of her patients, whom she had been working with, on and off, for the past five years had passed away. I don’t remember what I said to her, or if I said anything at all.

She told me to get started on our next patient’s treatment session as she remained in the workroom. It wasn’t until lunch time when we went over the morning’s notes, ate and went for a quick walk, that she started telling these wonderful stories about her patient. They had formed a true friendship over the years. She told me the only way she stayed at work that morning was because she received an email from the patient’s husband relaying the message that the patient had passed away under the exact conditions that she dreamt about: with her husband in a wonderful villa in Italy, no longer focusing on her cancer.

In my hospital rotation as a student, I knew that a percentage of patients would pass away there. I saw the trends in the chart and I witnessed the decline in their function. I prepared myself, but I wasn’t a part of their active care once it was their final decline. I never had the opportunity to get close with the patients in the hospital; my treatment time with them was limited.

I was at my last clinical rotation for 6 months. Split between Outpatient Oncology and Pelvic Health. During that time one of my patients passed away, however I only got to work with him for 2-3 weeks before he died. Again, I never built that connection. Nothing even close to the relationship my clinical instructor and her patient had. So, although I sympathized with her, I could not emphasize.

Over the last three years of my own clinical practice, I have had the pleasure of working with numerous wonderful patients. A few of which I was able to develop a deep connection. My friend calls it kismet.

With oncology rehabilitation, a good number of the patients are done with their cancer interventions and are working on improving their function to return to their life before cancer. Yet another percentage of patients are in the throes of fighting cancer, or nearing the end of their battle. Similar to the hospital setting, towards the end, you can see the functional decline, you understand that their time is limited. I’ve had a few of my kismet connections have their last physical therapy session. A goodbye without saying goodbye, and it wasn’t a ‘see you later’ either.

I have developed that bond with the patient, their spouse, their family. I understand, and now emphasize, with my clinical instructor. I know that sometimes, the inevitable happens. I feel those feelings too. I feel the sadness and the loss. The heartache.

And even though the foreseeable will happen, having a clinical background doesn’t make it any easier. Sometimes I think if I don’t confirm their passing, then there’s a small chance that they are still on this earth. But that’s not fair to them. I don’t wish any more suffering than what they already had to endure.

Today, I discovered two of my (favorite) patients had passed away. I worked with both of them on and off for the past 3 years. Today, I came to term with the fact that the inevitable happened. I am sad for their families.  I am sad. I know by working with this population, things won’t get easier. Death will happen. But because of these bonds, it motivates me to continue giving my all to my next patient. Fighting for them. Pushing them. Helping them reach their goals.

It also solidifies the thought that everyone in this community feels: FUCK CANCER. Fuck colon cancer, and fuck multiple myeloma. Fuck acute lymphocytic leukemia, fuck glioblastomas, fuck breast cancer, fuck cervical cancer, and fuck neuroendocrine cancer. FUCK ALL CANCERS.

I write this for all of my angels. My kismet connections. My college bestie. My coworker. My family member. And all of my past, current and future patients. Thank you for spending your time with me. I appreciate your commitment and desire. Thank you for teaching me, and making me a better physical therapist – a better person. I will never forget our time together. I will always cherish you in my heart. And to my last clinical instructor, Val, thank you for allowing me to see the vulnerable side of you. Thank you for saying it’s okay to love your patients and to grieve for them. That gift is invaluable.

March Mobility Mondays

Every Monday in March, I will be providing a few Mobility exercises for a specific part of the body. Today we will be focusing on Thoracic Spine Mobility.

The Thoracic Spine is your mid-back, made up of 12 vertebral segments. The T-Spine allows you to bend sideways, rotate, and go into flexion and extension. The ribs also articulate with the thoracic vertebrae. The ribs are important with breathing. If there are any limitations in your thoracic spine, these movements can become altered, and in turn could lead to pain, restricted range of motion of your mid back and shoulders, and decreased breathing capacity.

I have provided 3 simple exercises to help promote Thoracic Mobility. You can perform these exercises whether you have restrictions or not. But if you do feel that you are limited, please contact me or your local physical therapist for a formal evaluation.

The first exercise is called The Archer

The second exercise is called Quadruped Thoracic Rotation

The last exercise is called Foam Roller

This can be helpful for people with:

  • Upper back pain or mid back pain
  • Poor posture
  • Difficulty reaching overhead to wash hair or reach a high cabinet
  • After breast cancer surgery
  • Chest radiation
  • Stiffness/soreness after a workout
  • Among Others

Contact Dr. Jillian Meyer if you would like to discuss further.

Vascular Edema

Why does Granny have swollen legs? How can I get my skinny legs back? I haven’t seen my ankles in years.

Vascular Edema is typically a result of Chronic Venous Insufficiency. CVI is caused by deficient valves inside the veins, which fail to prevent retrograde flow of venous blood during muscle pump activities (ie walking). Because of these “bad valves” there is a pooling of venous blood in your legs with standing and walking. This is why elevation is so important! But you can’t stay elevated for the rest of your life… so that is where compression garments come into play. Compression garments provide external structure to the vein’s walls, preventing the pooling, allowing you to move and groove you like you’ve been known to do.

Have you ever said, “But compression garments are hard to put on and they cause pain”?

That is true for a lot of people. And that is why we have to get the edema out of your legs before you get fitted for compression garments.

“How do I get the edema out?” you might ask…

This is where a Certified Lymphedema Therapist comes into the picture. Complete Decongestive Therapy is necessary to address your swelling. CDT is quite a sacrifice, but well worth it. In as little as 4 weeks, we can decrease the edema in your legs – to where you can see your ankles again!. Along with a specific lymphatic massage (known as Manual Lymphatic Drainage), we use several layers of short-stretch bandages, these remain on your legs continuously until we get the results you want, and then we measure you for well-fitting compression garments.

Let’s Get Started!

If you have chronic leg swelling and have had enough, schedule an evaluation with Dr. Meyer, a LANA-Certified Lymphedema Therapist. She guarantees you will see results in as little as 4 weeks.

What is Cardiotoxicity?

“Many oncology patients are at risk for emergent medical conditions brought on either by their disease itself, or its treatment. Such conditions typically arise from structural/mechanical defects, metabolic derangements, and/or hematological deficits. Although rehabilitation staff members do not treat these emergent conditions, they are uniquely positioned to recognize changes in patient status that may signal an emergent condition…”

Conditions seen in the Oncologic Population:

  • Superior Vena Cava Syndrome (SVCS)
  • Venous Thromboembolism (VTE)
  • Acute Heart Failure
  • Infection/Cellulitis
  • Metastases
  • Cardiotoxicity


  • Cardiotoxicity is a condition where there is damage to your heart, commonly seen in patients undergoing chemotherapy. This damage does not allow the heart to pump blood effectively to the rest of the body, resulting in deficits.
  • Oncologic patients with cardiac risk factors or (i.e. diabetes, dyslipidemia, high blood pressure, smoking history, and obesity [BMI >30], etc.), and with history of chronic venous disease, are more vulnerable to cardiovascular injuries/death
  • Other risk factors that could contribute to cardiotoxicity include: renal disease, left ventricular hypertrophy, resting glucose >100mg/d

Type II Cardiotoxicity causes cell dysfunction, especially in the muscles, and is reversible.

People undergoing chemotherapy using taxanes are 2-3x greater risk of falls.

There is an increase in chemotherapy-related cardiac dysfunction because oncology patients are surviving longer and these effects can be seen even 20-30 years after receiving treatments.

What Does This Mean for Me?

Your oncology team will keep an eye on your symptoms and be able to medically manage, but because of the dysfunction seen in muscles, you may experience residual weakness. This looks like: having difficulty moving around in bed, getting up from a low chair, walking more than a few blocks, completing your chose, feeling off balance or reliance on an assistive device or furniture to walk around.

The good news, with rehabilitation under the supervision of a Doctor of Physical Therapy, you will gain strength, improve your cardiovascular endurance, and improve your balance over time. You will be better able to return to your previous level of function.