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Theory

› Anatomy & Physiology


› Pathology
› Principles of Management
Treatment
› Manual Lymphatic Drainage Massage
› Compression Bandaging/Garments
› Exercise
› Patient Education
Anatomy & Physiology
Works with venous
system for fluid return
Removes plasma
proteins
Filters
antigens, bacteria, w
aste products
Produces white
blood cells
Initial Lymphatics
› Lymph capillaries
Superficial
Overlapping
endothelial cells
Anchoring fibers
Valves prevent fluid
backflow
 Lymphatic Capillaries >Precollectors
 Afferent Collectors
• Muscular cell walls withvalves
• Lymphangions –section between thevalves
 Lymph Nodes
600 in body, 300
head/neck
Series of sinuses
Important
immunological
functions
Offers 100x more
resistance to flow
than ducts
Efferent collectors
Lymphatic Trunks
Lymphatic Ducts (2)
Right
Lymphatic
Duct

Thoracic
Duct
Lymphotomes
Distinct regions of
the body forfluid
drainage

Watersheds
Division areas
between
lymphotomes where
direction of flow
changes

Anastomoses
Collateral vessels
offering alternate
routes of drainage
Transparent, yellowish fluid
96% water –more dilute than plasma
Also consists of
proteins, lipids, minerals, hormones, cells,
bacteria, cell waste,etc.
Body produces 2.4L of lymph fluid
daily, 25L of lymph fluid cycles through
the heart
Lymphedema
An excessive accumulation
of protein-rich fluid in the
tissues caused by a transport
failure of the lymphatic
system.
Mechanical Insufficiency -
lymphostatic
› Low-flow edema, low-volume insufficiency
› A breakdown in the transport capacity of
the lymphatic system
Dynamic Insufficiency -lymphodynamic
› High-flow edema, high-volume insufficiency
› A high load placed on the lymph system
exceeds itscapacity
Combination –Safety Valve Insufficiency
Congenital deficit in number or size of
lymph nodes and/or pathways
› Milroy’s Disease –present at birth
Primary › Meige’s Disease or Lymphedema praecox –
appears at puberty
› Lymphedema tarda –adultonset

Caused by removal or or damage to


lymph nodes and/or pathways
› Cancer/cancer treatments
Secondar

› Trauma
› Chronic Venous Insufficiency
y

› Paralysis
› Filariasis
Chronic swelling
Excessive tissue proteins
Fibrotic changes
Chronic inflammation
Infections –cellulitis
Skin changes –“peau d’ orange”
Puffiness, heaviness, fullness of limb
Stiffness, decreased ROM
Weakness, fatigue
Skin tension –feeling of “bursting”
Pain
Numbness, paresthesias
Functional deficits
Loss of mobility
Difficulty wearing normal clothing
Psychological issues
Stage 0
› Latent, sub-clinical condition
› Swelling not evident despite impairedlymph
transport
Stage 1
› Completely & spontaneously reversible
› Soft, pitting edema
› Little to no fibrosis
› Skin easily pinched & moved
Stage 2
› Spontaneously Irreversible
› Tissues usually fibrotic
› Pitting requires strong pressure, or no pitting
› Can usually be reversed with treatment
Stage 3 -
Elephantiasis
› Irreversible
› No pitting, significant fibrosis
› Huge size, papillomas, hardening of the skin
Acute Venous Lipedema
“If you can help me, I’ll add you
to my Christmas card list!”
While the immediate goal of lymphedema therapy is to
relieve swelling, the ultimate goal is to enable the patient
to self-manage and control this chronic condition.
1. Manual Lymphatic Drainage(MLD)
2. Compression Bandaging
3. Exercise
4. Skin care –patient education
5. Compression Garments
Myofascial Release
Kinesiotaping
Aquatic therapy
Wound Care
Pneumatic pumps
 Physician/nurses
 Other therapists
 Certified garment fitter
 Nutritionist
 Psychologist
Phase 1 –Active
Intervention
› Attending therapy 2-5x/week
› Compression bandaging 23 hrs/day
› Daily home exercise/self massage

Phase 2 –Self-Management
› Transition to compression garments
› Maintaining home program
› Occasional follow-up appointments
“You’re just making that up to
make me lookstupid!”
History
Functional mobility
Musculoskeletal
Neurological
Skin Integrity
Edema measurement
Cardiovascular
Lymphoscinitigraphy
› Radiological isotope evaluation
Lymphography
› Direct oil contrast –“blue-dye”
Ultrasound
› Assess presence of filarial worm
MRI
CT
Any bacterial infection
Acute congestive heart failure

Contraindications
Acute deep vein thrombosis
Acute renal disease
Acute pulmonary edema

Malignancy
Arterial disease
Sensation deficits
Precaution

Low blood counts


Areas of inflammation
s

Wounds
Prior to treatment, skin should be clean
and moisturized
Wounds must be addressed
Goals oftechnique:
1. Increase peristalsis of lymphangion
2. Break down fibrotic tissues
3. Increase lymph volumein lymph vessels
4. Decrease congestion ininterstitium
Treatment begins proximal, to “clear”
proximal lymphotomes beforemoving to
affected lymphotomes
Massage is directed towards the cleared
lymphotome
Pressure is very light
Strokes are rhythmic
“Scoops” –massaging lymph nodes
› Firmer pressure, circular motion
“Clearing”
› Begin furthest from the affected area
› Clears the way for fluid drainage
› Moves proximal to distal
“Flowing”
› Begin closest to the affected area
› Always done afterclearing
› Moves distal to proximal
Low stretch
bandages
› Provides low stretch when no contraction
› Higher compression when muscles contract
Prevent re-fill of lymphatics
Work with muscle pumping
Follow “Law of Laplace” – the smaller the
radius the greater thepressure
Help break up fibrotic areas
Worn 23 hrs/ day (off only for bathing)
Should re-wrap daily to prevent
loosening
Should have more compression (more
layers) distally
Bandages should be washed frequently
Maintains reduction gained during
therapy
Transition to garments when reduction
plateaus
Garments for daytime wear, options for
nighttime
Insurance coverage variesgreatly
Exercises facilitate muscle pumping
Should be done with compression
Progress proximally to distally
Very low resistance, few repetitions, rests
as needed
Home exercise
Self-massage
Skin care
Precautions
Compression garments
Do all the good you can,
By all the means you can,
Inall the ways you can,
Inall the places you can,
At all the times you can,
Toall the people you can,
As long as ever you can
-John Wesley
Presented by
Jennifer K. Root, PT, DPT,CLT
Clinical Specialist
MidMichigan Medical Center
Rehabilitation Services

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