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Fluid Congestions- Lymphatics. Year 3-4 Intern/Resident CORE (OUCOM) OMM Curriculum. Conditions Associated with Lymphedema. Hypertension Heart Conditions Arterial Conditions Venous Insufficiency, Thrombosis, Phlebitis or Obstruction Diabetes Thyroid Conditions Inflammation

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fluid congestions lymphatics

Fluid Congestions-Lymphatics

Year 3-4

Intern/Resident

CORE (OUCOM) OMM Curriculum

conditions associated with lymphedema
Conditions Associated with Lymphedema
  • Hypertension
  • Heart Conditions
  • Arterial Conditions
  • Venous Insufficiency, Thrombosis, Phlebitis or Obstruction
  • Diabetes
  • Thyroid Conditions
  • Inflammation
  • Auto-immune Disease
  • Hormonal Conditions
  • Malignancy

Chilky p.197

1 st signs of lymphedema
1st Signs of Lymphedema:
  • Puffiness
  • Stiffness
  • Fatigue, malaise, discomfort
  • Tightness
  • Skin Tension
  • Tension, pressure, heaviness
  • Heat
  • Pain affecting the skin or articulation – bursting, shooting
  • Numbness, paresthesia
  • Difficulty putting on a watch or ring or shoe
  • Slight increase in weight for an unknown reason

Chilky p.196

other signs of lymphedema
Other Signs of Lymphedema:
  • Fibrosis – ‘Leathering’
  • Decreased Range of Motion
  • Stemmer’s Sign: skin fold of the proximal phalanx of the second toe cannot be raised.
    • Positive in 82-92% of Primary Lymphedema
    • Positive in 56% of Secondary Lymphedema

Chilky p.196; Pissas A. et al, 1999

severity of lymphedema extremities
Severity of Lymphedema (extremities)
  • Mild: unilateral edema of an extremity ≤ 3cm larger
  • Moderate: 3-5cm larger
  • Severe: >5cm larger

Chilky p.196

primary lymphedema
Primary Lymphedema:
  • Idiopathic
  • Lymphatic vessels or nodes are either undeveloped (aplastic), underdeveloped (hypoplastic), or too large and incompetent (hyperplastic)
  • 70-90% Female
    • 90% lower extremities
    • 80% distal lymphatics

Chilky p.171

secondary lymphedema
Secondary Lymphedema
  • ‘Malignant Lymphedema’
    • Cancer, metastatic cancer, post-surgical, radiation therapy
  • ‘Benign Lymphedema’:
    • Trauma/burn
    • Infection/Inflammation/Allergy
    • Paralysis (wheelchair edema)
    • Chronic venous insufficiency

Chilky p.177

secondary lymphedema1
Secondary Lymphedema

‘Benign Lymphedema’:

  • Trauma or Somatic Dysfunction:
    • We can look for local and regional fluid stasis effects of these two problems.

Chilky p.177

diagnosis of lymphedema
Diagnosis of Lymphedema
  • Classic ‘Lymphedema stays in the most external compartment, over the muscle.’ (Chilky p.195)
    • The lower extremity is a classic example.
  • We are looking for indications of local tissue edema that inhibits the body’s capacity to heal and self-regulate.
  • Local tissue edema can manifest almost anywhere in the body –
    • Musculoskeletal
    • Other Body Systems

BodyWorlds, p.200

diagnosis of lymphedema1
Diagnosis of Lymphedema
  • Although Classic Lymphedema stays in the most external compartment, over the muscle, the question must be asked?
    • How do the deep lymphatic fluids get from within the muscle (or other tissues encased in a fascial envelope) to the most external compartments?
    • They have to penetrate the fascial envelope with the arteries and nerves.
      • What if that envelope is strained/distorted, diminishing flow and increasing backpressure within the compartment (not to the degree that a compartment syndrome is created)? => decreased oxygenation, nutrition & waste removal]
  • Implications for DX & Tx

BodyWorlds, p.200

slide11
Visualize the veins & lymphatics that accompany the arterial system.

You then get a visual sense of the extent of the lymphatic system.

Latex casts can be made of the high pressure arterial system, but not effectively for the low pressure systems.

0

BodyWorlds, p.201

slide12
If lymphatics could be preserved independently, this rendition might be close.

0

BodyWorlds, p.201

slide13
‘Early in vasculogenesis, endothelial cells that express VEGFR-3 respond to VEGF stimulation by differentiating into the precursors of the lymphatic vessels.’

Carlson, Human Embryology, 3rd Ed., p. 434

lymphatic development coalesces around the developing venous system
Cardinal vein development;

Azygos vein development

0

Lymphatic development coalesces around the developing venous system.

Common

Cardinal vein

Azygos vein

6 weeks

8 weeks

Human Embryology, 3rd Ed., p. 441, 445

slide15

0

Jugulo-axillary Lymph Sac

  • Lymph sacs develop in the 5th & 6th weeks of fetal development

Retroperitoneal Lymph Sac

Cisterna Chyli

Posterior Lymph Sac

Human Embryology, 3rd Ed., p. 445

slide16

0

  • Lymph sacs can be thought of as focus points for the developing lymphatic system.
  • Lymph vessels will ultimately join these lymph sacs in an organized fashion.

Human Embryology, 3rd Ed., p. 445

slide17
Lymphatic development:

‘Two large channels (right and left thoracic ducts) connect the jugular lymph sacs with the cistern.

Soon a large anastomosis forms between these channels.’ (Developing Human, 7th Ed., p. 375)

0

9 weeks

Human Embryology, 3rd Ed., p. 441, 445

slide18
Lymphatic development:
  • At 9-10 weeks the right thoracic duct crosses the midline at about T4-T6
  • For patients: This has relevance to optimizing lymphatic drainage for any problem below this level.

Human Embryology, 3rd Ed., p. 445

slide19
‘Except for the superior part of the chyle cistern, the lymph sacs are transformed into groups of lymph nodes during the early fetal period.
    • Mesenchymal cells invade each lymph sac and break up its cavity into a network of lymph channels – the primordial of the lymph sinuses.
    • Other mesenchymal cells give rise to the capsule and connective tissue framework of the lymph node.’ (Developing Human, 7th Ed., p. 375)
slide20
This embryonic organization can assist you in your thinking about the path of lymphatic drainage for any given problem.
slide21

0

Jugulo-axillary Lymph Sac

  • Lymphatic vessels soon join the jugulo-axillary lymph sacs
  • They pass along main veins to the head, neck, and upper limbs

Human Embryology, 3rd Ed., p. 445

slide22

0

  • Lymphatic vessels soon join the lumbar and iliac plexuses which are derived from posterior lymph sacs
  • They pass along main veins to the lower trunk and lower limbs

Posterior Lymph Sac

Human Embryology, 3rd Ed., p. 445

slide23

0

  • Lymphatic vessels soon join the retroperitoneal lymph sac and the chyle cistern (cisterna chyli).
  • They pass to the primordial gut

Cisterna Chyli

Human Embryology, 3rd Ed., p. 445

slide24
Thus we see the aggregation of lymph nodes in certain areas (related to the embryologic precursors – the lymph sacs):

Jugulo-axillary lymph sacs

Retroperitoneal lymph sac and the cisterna chyli

Posterior lymph sacs

Clinically Oriented Anatomy, 5th Ed., p.45

slide25
These thus have fairly direct relationships to:

Junctional Areas:

C-T Junction

L-T Junction

L-S Junction

Diaphragms:

Superior Thoracic Aperture (Thoracic Outlet)

Thoraco-abdominal Diaphragm

Pelvic Diaphragm

Clinically Oriented Anatomy, 5th Ed., p.45

slide26
These are ‘High Yield Areas’ for Somatic Dysfunction:

T4-T6

Junctional Areas:

C-T Junction

L-T Junction

L-S Junction

Diaphragms:

Superior Thoracic Aperture (Thoracic Outlet)

Thoraco-abdominal Diaphragm

Pelvic Diaphragm

Clinically Oriented Anatomy, 5th Ed., p.45

slide27
We want to treat from proximal to distal.

So the fluid has somewhere to go.

Junctional Areas:

C-T Junction

L-T Junction

L-S Junction

Diaphragms:

Superior Thoracic Aperture (Thoracic Outlet)

Thoraco-abdominal Diaphragm

Pelvic Diaphragm

Clinically Oriented Anatomy, 5th Ed., p.45

internal organs lymphatic drainage
Think of the Lymphatics that accompany each organ’s arterial system.

What are the somatic dysfunctions (that could affect lymphatic flow) proximal to each of these organs?

0

Internal Organs & Lymphatic Drainage

BodyWorlds, p.203a

fascial restriction somatic dysfunction lymphatic drainage
Fascial Restriction/Somatic Dysfunction & Lymphatic Drainage
  • How much pressure does it take to impede lymphatic drainage?
types of somatic dysfunction

Quality of ROM

Quantity of ROM

End Field of ROM “End Feel”

Tissue Textrue Changes

Appropriate Techniques

MYOTONIC

Like bungee cord or rubber band

Reduced

RUBBERY - Like hitting the end of a bungee cord

Usually tight, hypertonic

ME, MFR, FPR, FM,Gentle ROM

ARTICU-LAR

Crepitant to good

Reduced

ABRUPT - Like hitting a wall

Crepitant to normal

Impulse, ME, ROM, MFR, FPR, FM

NEURO-MUSCULAR

Variable

Usually reduced

Variable

Tender Point*

SCS, I-MFR, FPR, FM

MYO-FASCIAL

Asymmetric tug

Variable

Variable

Asymmetric tug

MFR D or I, FPR, FM

VASCULAR

Variable

Reduced d/t Edema

Variable

Edematous

TX Proximal

SD of other types

Types of Somatic Dysfunction

Source: Herb Yates, DO, FAAO

types of somatic dysfunction1
Types of Somatic Dysfunction
  • Summary for Vascular Type :
    • When Fluid Congestion is a primary concern treatment of proximal somatic dysfunction of myotonic, articular, neuromuscular, or myofascial origin is indicated.
    • Treat from the Superior Thoracic Aperture progressive closer to the area of concern for fluid congestion.
slide33
Flow Chart: Treat from proximal to distal.
  • Lymphatic trunks return fluids to central circulation – Superior Thoracic aperture:
    • Rib 2, Chondrals & manubrium
    • Rib 1, Chondrals & manubrium
    • C6-T2
    • Anterior Cervical Fascia
    • Treatment priority – most intense TART/STAR findings first
      • if tolerable for the patient;
      • in hospital, you don’t want to tax an already stressed, low vitality patient – small amounts of treatment in greater frequency, even 2-3 times per day
lymphatic treatment continued
Lymphatic Treatment (continued)
  • Thoraco-abdominal Diaphragm Function:
    • Flattened? One Hemi-diaphragm? Redome
    • T7-12 & associated ribs
    • Which of these elements are present in my patient?
    • Treatment priority – most intense TART/STAR findings first
      • if tolerable for the patient;
      • in hospital don’t want to tax an already stressed, low vitality patient
lymphatic treatment continued1
Lymphatic Treatment (continued)
  • Rib Raising
    • In some instances this may be the first thing done for the patient.
lymphatic treatment continued2
Lymphatic Treatment (continued)
  • Next Focus Dependent Upon Most Symptomatic Region Related to Chief Complaint:
    • HEENT – Neck, Head
    • Thorax – Other thoracic, rib, fascial elements
    • Upper Extremity – Axilla/Trunk
    • Abdomen – Visceral lymphatic techniques, L1-5
    • Sacro-pelvis – Abdominal concerns, sacrum, innominate, pelvic diaphragm, pelvic diaphragm
    • Lower Extremity – Adominal, Sacro-pelvic, hip, knee, interosseous membrane, ankle, foot
lymphatic treatment continued3
Lymphatic Treatment (continued)
  • Lymphatic Pump
    • Sutherland Lymphatic Pump Sequence
    • Miller Lymphatic Pump
    • Pedal Pump
  • Home Treatment
    • Two person pedal pump
    • Two person Miller lymphatic pump with minimal chest compression
resources
Resources:
  • Chilky B, Silent Waves Theory & Practice of Lymph Drainage Therapy, I.H.H. Publishing, Scotsdale Arizona, 1st edition, revised 2002
  • Carlson, BM, Human Embryology and Developmental Biology, 3rd edition, Mosby, Philadephia, PA, 2004.
  • Von Hagen’s G, Bodyworlds - The Anatomical Exhibition of Real Human Bodies, Institut fur Plastination, Heidelberg, Germany, 2004
resources1
Resources:
  • Moore KL, Dalley AF, Clinically Oriented Anatomy, 5th Edition, Lippincott Williams & Wilkins, Philadelphia, PA, 2006.
slide41
Information beyond this point is for student / intern / resident reference & need not be included in the powerpoint presentation.
evidence based medicine
Evidence Based Medicine:
  • 1) Sleszynski SL, Kelso AF, “Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis” JAOA, Vol 93, No 8, August 1993, p.834-845.
  • (2) Jackson KM, et al, “Effect of Lymphatic and Splenic Pump Techniques on the Antibody Response to Hepatitis B vaccine”, JAOA, Vol 98, No 3, March 1998, p. 155-160.
  • (3) Knott EM, et al “Increased Lymphatic Flow in the Thoracic Duct during Manipulative Intervention”, JAOA, Vol 105, No 10, October 2005, p.447-456.
prevalence incidence of lymphedema
Prevalence & Incidence of Lymphedema
  • United States:
  • Primary Lymphedema: approx. 2 million
  • Secondary Lymphedema: 2.5-3 million
prevalence incidence of lymphedema1
Prevalence & Incidence of Lymphedema
  • World
  • 1 out of every 40 people in the world may be affected.
  • Influence of ‘Somatic Dysfunction’ – Evidence Base Unknown

Chilky p.170

slide45

Sutherland’s Vibratory lymphatic

  • treatment of:
  • -Thoracic duct
  • -Cysterna chyli
  • -Greater Omentum:
  • Fingerpad contact with the index, middle & ring fingers is made over the area.
  • The second hand rests over the top of the this hand to introduce vibration at 1-2 cycles per second – minimal compression is used to get to the structure of interest.

Teachings In the Science of Osteopathy

slide46

Rib Raising:

  • Contact is made with the rib angles or near the costotransverse junction.
  • Lateral anterior traction is maintained gently until softening occurs.
  • Eight ribs on each side can be addressed simultaneously.

Foundations for Osteopathic Medicine. P.1065

slide47

Rib Raising:

  • In the seated position, it is easy to add side bending or rotation to help localize resistance. Gentle articulatory motion can also be utilized with the patient in the seated position.

Foundations for Osteopathic Medicine, p. 1065

miller thoracic pump

Foundations for Osteopathic Medicine, p. 1069

Miller Thoracic Pump
  • Palmar contact below the clavicles
  • As pt. exhales, gently compress and vibrate at 1-2 cycles per second
  • Several variations:
  • Gently resist each inhalation through about 5 cycles and slowly release
  • Vibrate with exhalation, then just after the start of inhalation let the pressure off of the chest suddenly – creates significant negative pressure in the chest.
pectoral traction
Pectoral Traction
  • Grasp the anterior axillary folds with finger pads
  • Gently lift superior anterior
  • Feel for chest wall resistance via the pectoral attachment.
  • Hold for 15-30 seconds; repeat as tolerated.
  • Helps expand the chest

Foundations for Osteopathic Medicine, p. 1068

dome the pelvic diaphragm

Foundations for Osteopathic Medicine, p. 1067

Dome the Pelvic Diaphragm
  • Index and middle fingers follow the inside of the ischium slowly up to perceived resistance – this is the pelvic diaphragm
  • Several pt. coughs against your finger resistance will help release the hemi-diaphragm

If a cough is not desired, follow the breathing and resist the descent of the diaphragm during inhalation.

thoraco abdominal diaphragm

Foundations for Osteopathic Medicine, p. 1066

Thoraco-abdominal Diaphragm
  • Thumbs gently carry the costal margin slightly lateral and superior
  • Thumbs can simultaneously resist the drop of the diaphragm during the inhalation phase of respiration.
thoracic inlet outlet
Thoracic Inlet/Outlet:
  • Finger pads drape over the clavicle onto the soft tissues of the supraclavicular fossa and apply caudal/anterior pressure gently
  • The opposite hand carries the abducted arm slightly inferior at the same time (to help localize forces in the supraclavicular fossa).
  • Release pressure gently with both hands.
  • Repeat 2-3 times.

Foundations for Osteopathic Medicine, p. 1064

pedal pump
Pedal Pump:
  • Patient supine, feet at edge of table
  • Physician has thighs against the balls of the patient’s feet
  • Physician gently rhythmically rocks thighs against the feet to create enough rocking motion so the patient’s chin is seen to move a little bit.
  • Keep it comfortable for the patient
  • Alternatively, physician can gently pull the dorsum of each foot (simultaneously) into plantar flexion creating the rocking all the way to the chin.