Lymphatic OMT for the General Practitioner

Abel Biesman, DO

John Dinh, DO

FOMA 2020

No actual or potential personal, financial or legal conflict of interest in relation to this program or presentation

All illustrations used in this presentation belong to the public domain. Source material cited either on slide or in notes.

Review of lymph composition

Review of lymphatic system function and purpose

Review of basic anatomy

Indications and contraindications for Osteopathic Manipulative Treatment (OMT) with lymphatic emphasis

Adjunctive OMT treatments for office complaints utilizing the lymphatic system

Research support

Composition

Functions

Anatomy

Composition

Fluid from capillaries

Debris and bacteria from wounds

Circulating Lymphocytes

Macrocytes

Metabolic waste, CO2, O2

Proteins * (low amount but critical)

Fluid Balance

Helps return excess fluid and proteins to circulatory system which cannot be processed by venous system

Immune Support

Production of immune cells

Transport of bacteria to lymph nodes

Fat Transport

Absorption of chylomicrons which are too large for venous system

A number of proteins and debris in the interstitial tissues have no other recourse to return to circulation other than the lymphatic system

“Now we see this great system of lymphatics is the source of construction and purity. If this be true, we must keep the lymphatics normal all the time or see confused Nature in the form of disease. We strike at the source of life and death when we go to the lymphatics.” - A. T. Still

National Cancer Institute

About 3 L per day of Interstitial fluid not reabsorbed by venous system

50% of proteins that exit artery/venous system

Increased 5-15x by exercise or lymphatic techniques

Thieme Atlas of Anatomy Interstitial Tissues

90%

Lymphatics Capillary

10%

Adapted image Original from National Cancer Institute

Fluid

Intrinsic

One way valves

Rhythmic vessel wall contraction

Extrinsic

Muscle contraction squeezing lymphatic vessels

Diaphragm motion and pressure differentials

Circulatory System • Closed system • Artery -> Vein fluid transition

same vessel • Limitations in ability to absorb

based on particle size Lymphatic system • Connected with circulatory

system • Open system • Blind opening in capillaries • Able to transport larger particles

The Lymphatics by Delamere, et al.

SEER Program: National Cancer Institute

Prenodal Postnodal

Lymphatic Capillary Plexuses

Collecting Vessels

Regional Lymph Node

Lymphatic Trunk

Lymphatic Duct

Anatomy of Lymphatic Vessels

Terminal Drainage

Right Thoracic Duct

Right Jugular

Right Upper Extremity

Heart

Right Upper Lung Lobe

Left Thoracic Duct

Everything else…

Left Jugular

Left Upper Extremity

Remaining Lung Lobes

Lower body

Lymphatic Drainage

Right duct drainage

Left duct drainage

Adapted image: Original from National Cancer Institute

Somatic Dysfunction here impairs ALL Venous and Lymphatic Circulation as the inlet is the terminal site for drainage.

Thoracic Inlet Clavicle 1st ribs T1 (sometimes T2) Sibsion’s fascia/

suprapleural membrane The thoracic duct, subclavian

& jugular veins course through this region for return to central circulation


The Lymphatics By Delamere, et al.

Openings for the :

Vena cava, azygous, hemiazygous v. (T8)

Esophagus (T10)

Aorta (T12)

Thoracic Duct (T12)

Adapted image: Original from Anatomy of the Human Body By H. Gray and C. Goss

Anatomy of the Human Body By H. Gray and C. Goss

Assists transport of low pressure venous / lymphatic fluids from the lower extremities and maintenance of intra-abdominal pressures.

Muscles of the pelvic floor require proper tone for proper function

Venous and lymphatic drainage from the lower extremities must pass under the inguinal ligament

Applied Anatomy of the Lymphatics Millard, F. P., and A. G. Walmsley.


• Supraclavicular Space

• Posterior Axillary Fold

• Thoracoabdominal diaphragm

• Pelvic Diaphragm

• Popliteal Fossa

• Achilles Tendon

INDICATIONS CONTRAINDICATIONS

Edema from any cause

Infection

Atelectasis prevention

Recent Fractures

Open bleeding wounds

DVT

Coagulopathy

Anuresis

Cancer*

Still debated by specialists both among oncologists and neuromusculoskeletal specialists

No research supporting cancer spread from lymphatic techniques in immunocompetent subjects

Research does show that lymphatic techniques and exercise have similar effects on lymphatic flow

79 participants

All received decongestive lymphatic techniques for 8 days

Taught self management techniques

Long term follow up at 38 days

Results

Upper extremity size: 44% reduction

Lower extremity size: 42% reduction

Extremity size reductions maintained at long term follow up (-38% and -41% for upper and lower limbs)

Thoracic duct flow in 4 dogs via a

transonic flow transducer placed just above heart in thoracic duct

Dogs received: Thoracic, Abdominal & Pedal pumps

Exercise defined at 3 mph at 0o incline.

Results displayed similar rise in lymphatic flow from pump techniques and exercise.

• Comparison between lymphatic pump and incentive spirometry in post cholecystectomy patients from 1989-1990

• 21 people in each group

• Results

• In first 4 days, lymphatic pump had higher FVC

• By day 5, incentive spirometry and lymphatic pumps had similar FVC

Conclusion: lymphatic pump helps prevent atelectasis in post surgical patients

Influenza patients treated osteopathically during 1917-1918 had a 0.25% mortality rate, as compared to the national average of 6% (10% for pneumonia patients, compared with 33% to 75% for the national average).

Total mortality 110,120 patients with influenza treated by 2445 Osteopathic physicians was 0.25%.

Mortality in patients receiving traditional medical care was 5% to 6%.

Among patients with influenza pneumonia treated medicinally, mortality was estimated at 33%, and even as high as between 68% and 78% in some large centers.

The death rate due to pneumonia among 6258 patients cared for by osteopathic physicians was 10%.

21-30 million world wide, 23% of U.S. population died!

JAOA • Vol 104 • No 9 • September 2004 • 370–371

Chokepoints:

Thoracic inlet (always)

Thoracoabdominal diaphragm (lungs or below)

Pelvic Diaphragm (pelvis or below)

Popliteal fossa (knees or below)

Condition Specific:

Galbreath, spine, ribs, etc

Lymphatic pump

Chokepoints (start)

Thoracic inlet

Thoracoabdominal diaphragm

Pelvic diaphragm

Popliteal fossa

Pumps (end)

Thoracic pump a.k.a. Miller pump

Abdominal pump

Pedal pump

Placement: Thumb: Posterior 1st rib

Pointer: Sternoclavicular junction just above clavicle

Middle: Sternoclavicular junction just below clavicle

Test motion in all planes

Hold until release (20-60 sec) in either ease or restriction for indirect/direct technique

Recheck motion in 3 planes

Placement: Thumb: Posterior 1st rib

Pointer: Sternoclavicular junction just above clavicle

Middle: Sternoclavicular junction just below clavicle

Test motion in 3 planes



Position Contact with

supraclavicular fascia Contact with first rib at

manubrium Other hand controlling

arm

Abduct ipsilateral arm about 90o

Fine tune motion at arm to build tension at thoracic inlet

Hold until release (20-60 sec)

Position:

Use thumbs or hypothenar eminences

Broad contact along diaphragm just under coastal margin and xiphoid process

Have patient take slow deep breaths

Follow exhalation with additional pressure and resist inhalation

Repeat for 3-5 breaths

Repeat last step if necessary

Position:

Fingers contacting ribs broadly medial to rib angles

Wrists flat against table

Lift fingers and pull laterally best done while pushing elbows down for leverage

Can pull and hold for 3-5 seconds and repeat 3-5 times

or

Create rhythmic pattern of motion ventrally and laterally with return to baseline for 5-10s

Position:

Thumbs just medial to ischial tuberosity

Follow femur to ischial tuberosity then slide just medial

Have patient cough if you need confirmation. You will feel muscle press against thumbs.

Apply direct pressure cephalad and laterally until release (20-60 sec)

Position:

Thumb just medial to ischial tuberosity

Follow femur to ischial tuberosity then slide just medial

Have patient cough if you need confirmation. You will feel muscle press against thumbs.

Apply direct pressure cephalad and laterally until release (20-60 sec)

Then repeat on other side

Placement:

Fingers with broad contact with popliteal fossa using both hands

Test motion in 3 planes



Placement: Hands placed on chest

bilaterally with thenar eminence just below clavicle

For women, can either place their hands underneath

Or

Place hands centrally one hand over the other

Apply rhythmic pressure at about 120 cycles per minute in diagonal direction with just enough force to move feet

Continue for about 1-2 minutes

Placement: Same as for Thoracic Pump

Have patient take full breath.

Follow exhale. Have patient take ½ breath

while resisting inhale. Again follow exhale.

Have patient take ¼ breath while resisting inhale. Again follow exhale

Have patient take another full breath with release of all pressure just before inhale.

Repeat if needed

Placement:

Same as for Thoracic Pump

Apply pressure with exhalation only to exaggerate exhale

Remove pressure with inhalation

Repeat 3-5 breath cycles

Repeat again if needed

Placement:

Palm of hand in contact with ball of patient’s foot

Apply cephalad force in rhythmic fashion

Just enough force for motion at patient’s head

Aim for 120 cycles per minute

Continue for 1-2 minutes

Employ following techniques as needed after clearing chokepoints yet before performing a lymphatic pump.

These are designed to help lymphatic flow in a more local region.

Gentle stroking maneuver from distal to proximal to “milk” lymphatic back towards thoracic inlet.

Placement: Place patient’s ear

between 3rd and 4th digits with broad contact with palm

Other hand stabilizing head

Rotate clockwise and counterclockwise Drag skin and fascia with

hand Should not be sliding

over skin

Continue about ½ - 2 minutes

Placement: 3rd, 4th, and 5th fingers

curling behind posterior ramus of the mandible

Hypothenar eminence along body of mandible

Patient mouth slightly open


In rhythmic motion draw mandible slightly forward for 3-5 seconds before returning to baseline

Continue 30 sec – 2 min

Placement: Fingers contact at jaw

angle and following sternoclidomastoid (SCM) muscle


Move caudally while dragging skin and fascia toward the thoracic inlet

Lift fingers and reset at jaw angle

Repeat above steps in rhythmic fashion

Continue 30 sec – 2 min

Focusing on Lymphatic Techniques

Thoracic inlet release

Cervical chain drainage

Galbreath

Auricular drainage

Check for sinus pain and consider effleurage

Thoracic pump

Thoracic inlet release

Cervical chain drainage

Galbreath drainage

Sinus effleurage

Thoracic pump

Thoracic inlet

Abdominal diaphragm

Fix spinal somatic dysfunction

Fix rib somatic dysfunction

Rib raising

Thoracic pump with exaggerated breathing

Thoracic inlet

Abdominal diaphragm

Fix spinal somatic dysfunction (focus T1-4)

Fix rib somatic dysfunction

Liver release

Kidney release

Pelvic diaphragm

Bladder lift

Popliteal fossa

Pedal pump

Thoracic inlet

Abdominal diaphragm

Pelvic diaphragm

Popliteal fossa

Pedal pump

Thoracic inlet

Open appropriate chokepoints

Pump of choice

Cornell, B. (2016). Lymphatic System. BioNinja. Retrieved from Cornell, B. (2016). Lymphatic System. Retrieved from https://ib.bioninja.com.au/higher-level/topic-11-animal-physiology/111-antibody-production-and/lymphatic-system.html

D'Alanzo, G. (2004). Influenza Epidemic or Pandemic? Time to Roll Up Sleeves, Vaccinate Patients, and Hone Osteopathic Manipulative Skills. Journal of the American Osteopathic Association, 104, 9, 370–371. Retrieved from https://jaoa.org/article.aspx?articleid=2093004

Delamere, G., et al. The Lymphatics. Constable, 1903.

Drake, R., Vogl, W., & Mitchell, A. (2005). Grays Anatomy for Students. University of Michigan: Elsevier Churchill Lvgst.

Gray, Henry, and Goss, Charles. Anatomy of the Human Body. Philadelphia and New York : Lea & Febiger, 1858.

Hansen, J. T., & Netter, F. H. (2010). Netters clinical anatomy. Philadelphia, PA: Saunders/Elsevier.

Knott, Marty, B.A., Tune, Johnathan D., Ph.D., Stoll, Scott, D.O., Ph.D., Downey, H. Fred, Ph.D., “Lymphatic Pump Treatments Increase Thoracic Duct Flow,” Osteopathic Research Center News, Vol. 1, issue 2, June 2003.

McCauley, Lyndsey. “The Effect of Lymphatic Pump Treatment on Anti-Tumor Immune Responses.” Theses and Dissertations, University of North Texas Health Science Center, 1 May 2011, unthsc-ir.tdl.org/handle/20.500.12503/26535.

Millard, F. P., and A. G. Walmsley. Applied Anatomy of the Lymphatics. Kirksville, Mo., The Journal Printing Company, 1922.

Nicholas, Alexander S., and Evan A. Nicholas. Atlas of Osteopathic Techniques. 3rd ed., Wolters Kluwer, 2016.

SEER Training Modules, Components of the Lymphatic System. U. S. National Institutes of Health, National Cancer Institute. <https://training.seer.cancer.gov/>.

Schünke, Michael, et al. General Anatomy and Musculoskeletal System. 1st ed., Thieme Medical Publishers, 2014.

Sleszynski SL, Kelso AF, “Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis,” J Am Osteopath Assoc 1993 Aug; 93(8):834-8, 843-5

Szuba, A, et. al., “Decongestive lymphatic therapy for patients with cancer-related or primary lymphedema,” Am J Med, 2000 Sep; 109(4), pp. 296-300.

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Lymphatic OMT for the General Practitioner