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Edema management
Exploring Hand Therapy
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Definition
Excessive fluid that is accumulated in the intracellular spaces
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Inflammatory response
Series of nonspecific events for protectionRedness, swelling, heat, pain & loss of function
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Edema
Affected by vascular and nonvascular process
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Anatomy
extracellular fluidFluid is subdivided into two main areas:
Interstitial fluidOutside the closed vascular system
Blood plasmaNon-cellular portion of the blood
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Arterial system and venous system
Arterial system Brings oxygen Venous system gets rid of waste and carbon dioxide
Oxygen and carbon dioxide are lipid-soluble substances (allowing diffusion through membrane)
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Diffusion and filtration
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Capillary – everywhere and close to every cell
Capillary wall is a single layer of high permeable Surrounded by a basement membraneDiameter is large enough for red blood cells and other blood cells to pass Blood enters the capillaries through the arteriolesBlood exists through the venules
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Transport
oxygen and glucose are in higher concentration in the blood stream vs the interstitial fluid interstitial fluidCarbon dioxide will diffuse in opposite directionProteins too large to diffuse easily through the capillary membrane --flow linear along the capillary
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Transport
small amounts of proteins leak out of the blood capillaries into the interstitium….balance … so the lymphatic system’s job is to return the proteins back into the venous system.
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Anatomy
Interstitium space between cells and the fluid between the cells)Constant exchange of fluid between the intercellular tissue and blood plasma across the capillary membrane.Fluid in the interstitium is trapped by proteoglycan filaments
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Tissue GEL
Similar to blood plasma Poor viscosity in the tissue gel
Water molecules, electrolytes, nutrients and cellular waste
Normally <1% of “free” fluid in gel
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When edema occurs 30% - 50% accommodates
Cannot accommodate additional fluidAmount of free fluid increases and may even expand to more than ½ of the interstitial fluidInterstitial fluid can increase to several hundered % above normal (severely edematous)
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Types of edema
Pitting (interstitial)Fluid that is “free” moving and can be displaced with pressure
Brawny (interstitium)Fluid becomes clotted with fibrinogenDifficult to move and firm to touch
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Lymph (extracellular) (Failure of lymphatics)
Protein rich fluid in the extracellularspace and subcutaneous tissue and a blockage of lymphatics and a failure to drain
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Edema
Pitting edema
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Pitting edema
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Edema
Brawny edema --interstitium becomes clotted with fibrinogenThe fibrinogen inhibits the fluid from moving easilyTissue cells will swell
Normally the interstitium will swell
Brawny edema is firm to the touch
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Healthy Capillary Filtration --
Net filtration across the capillary membrane is a balance b/w the forces that push fluid out into the interstitial spaces (filtration)And the force that moves fluid inward (resorption).
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Healthy Capillary Filtration (cont)
Filtration pressure is higher than the reabsorption pressureLymphatics balance
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Fluid Filtration and resorption depends on the capillary walls
Pressure acting on the capillary membraneCapillary permeability is selective
Affected by pressuresConcentrations Integrity of membraneCapillary pressure is increased
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4 pressures that effect capillary filtration
Capillary pressure (hydrostatic)Blood pressure in capillary –Pressure increased at arterial end vsvenous end of capillary
Interstitial fluid pressure (hydrostatic)
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4 Pressures continued
Plasma colloid osmotic pressureDissolved proteins causing osmosis of fluid
Interstitial fluid colloid osmotic pressure
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Edema in the Hand
Afferent blood flows on the volar surfaceControlled by arterial blood pressure
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Any constriction across the dorsum of the hand can damage vessels resulting in edema or lymphedema
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Circulatory system
ArteriesArteries are blood vessels that carry oxygen rich blood AWAY from the heart. Remember, A A Arteries Away, A A Arteries Away, A A Arteries Away.
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CapillariesCapillaries are tiny blood vessels as thin or thinner than the hairs on your head. Capillaries connect arteries to veins. Food substances (nutrients), oxygen and wastes pass in and out of your blood through the capillary walls.
VeinsVeins carry blood back toward your heart.
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Hand Position
15mmHg with elevated hand35mmHg dependent position
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EdemaActive motion -- “retrograde” venous and lymphatic flow.
augment the return flow by moving the elbow and shoulder (proximal)AROM and compression
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Edema treatment depends on the stage of wound healing
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Inflammatory response -3 to 5 daysGoal is for body to protect
Vasoconstriction followed by Vasodilation(dilation of blood vessels)Stimulated by histamine & bradykinin(other chemicals as well) (increases capillary permeability)Increase blood supply to damaged areaCausing the redness, increased temperature increasing white blood cells, increasing vascular permeability
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Inflammatory response
The body protects itself and the blood, clotting factors, fluids move into the injured area And EDEMA or swelling occurstransudate
Water and dissolved electrolytes
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Treating Edema (tranudate)
ElevationCold – pain control and to help balance system
To decrease vasodialtion and membrane permeability, control capillary infiltration, and arterial blood flow
Active motion (Gentle)Minimal –
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Pain controlrestGoal minimize the pooling of blood in injured areaExcessive edema can slow wound healing by decreasing arterial, venous and lymphatic flow
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Edema
Pain is caused by:Swelling on never endingsNerve endings exposed to bacteria
Aspirin decreases pain by inhibiting the production of prostaglandins).
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Lymphatic system
Draining fluid, proteins, lipids, microorganisms and debris from tissueReturn proteins to bloodvolume of interstitial fluidbalance of protein and fluid pressure
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Edema
increased volume of lymph, and it may accumulate in the tissues and distend them. This condition is known as edema. The lymphatics are intact therefore most edema is temporary
As tissue heals the blood vessels do not excessively leak controlling edema
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Edema
Although edema is temporary the overload may produce fibrosis causing the edemaprevent the lingering edemaMacrophages help to eliminate protein as well
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Edema: Proliferative stage (2 -6 weeks)
Viscous due to increased protein contentExcessive fluid is referred to as EXUDATEFibrosis and thickening of tissueShortening of structuresVicious cycle resulting in Dense Fibrous Tissue
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Fibroplasia phase (concern for us)
ongoing problemFluid is more viscous (increased protein)Edema is now referred to as exudatewhich protein rich excessive fluidfibrosis & thickening of tissues
Reduced nutrition and inelasticity
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Treatment in proliferation phase
Decrease fluid accumulationCompression accompanied with elevation, AROM
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Brawny edema
Occurs in this phase of wound healing especially if the colloid osmotic pressure is increased (due to increase in proteins) resulting in higher capillary pressureClotting occurs preventing expulsion of fluid
Resulting in brawny edema
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Edema: Maturation Phase ( up to 2 years)begins when fibroplasia subsides
Remodeling is accomplished by STRESS being placed on collagen fibersFibrosis may occur (persistent – stagnant edema)Elevated protein contentStretching of tissue spacesMay become hard, thick and brawnyLasting longer than 3 months is chronic
Fibrotic 48
Maturation phase
Persistent edema requires continued use of compression garments as Worst case scenario arterial flow is impaired as well as metabolic circulation and cellular nutrition… necrosis of tissue can occur
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Prevention
Begin as soon as you see your patientYou cannot see the beginning of edema30% of interstitial fluid volume is not visible50 ml of fluid in hand may accumulate before seen
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Preventing EDEMADressing
Post surgery: BulkyCold
Inflammatory stage: Vasoconstriction, reducing metabolic rate, arteriolar blood flow, capillary infiltrationGood control for painCAUTION: do not use if arterial compromise
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PreventingElevation
Inflammatory phase or immediately after injury or surgeryEasy, cheap, controls painHelps prevent dependent edemaCombines w/gentle AROM increases pumping and decreases fluid accumulation assisting lyphatics and venous systemsReplant limb must NOT be elevated above heart
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Goal of Elevation
Facilitating venous and lymphatic drainageDecreases hydrostatic pressure in blood vDecreases capillary pressure
Peripheral venous and arterial pressure affected by gravity (pressure decreased if above the heart)Dependent edema:
Increases intravascular pressure and capillary pressure
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Edema/ elevate with finger ext
Plumbing
Photo from Interactive Hand: Primal 2001 54
Active Motion
Pumping, soft tissue movement, compression of veins and lymphatic vStrong muscle action assist in drainage of venous and lymphatic vCaution
Excessive exercise and no isometric
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AROM entire limb
Prevent adhesionInclude proximal muscles to increase distal drainageTENDON gliding
Heat
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Compression
Proliferation & Maturation stageMaintain gains made in edema reduction by reducing capillary filtrationReinforce tissue hydrostatic pressure and increases venous and lymphatic flowContraindicated with arterial compromise, new skin grafts or unhealed burn woundsMust teach patient to monitor for capillary flow (color, cool, numb)
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Compressive bandages – important in fibroplastic phase
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DEMO
JunoJobstCoban/CowrapOff the shelfWrap
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Compression therapyLight support – Fashion hosiery, Jobst, Sigvarus
8-14mmHg Antiembolism compression
16-18 mmHgLow compression – venous insufficiency
18-24 mmHg – dependent edema – not very active
Low to moderate – venous insufficinecy25-35 mmHg able to participate in rehabilitation
Moderate compression30-40 mmHg
High compression – pumps, jobst (vairox jobst)40-50 mmHg (edema from 60
Compression therapy
Decrease fibroblast synthesis of collagen
Decreasing blood flow and causing local hypoxiaGoal is for the compression to apply pressure to mechanically FORCE fluid out of the tissue
Fibroplastic PhaseIn the maturation phase goal is to help maintain the gains achieved in clinic with edema reduction by reducing capillary filtration.
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Isotoner gloves
Therapeutic glovesControl edema
Arthritis, injury, CRPS, raynoids,
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Isotoner®Really nice– lightweight spandex and nylon allows for an even gentle compression in the moderate compression range : 23-32mmHgWhat is really nice is the soft, seamless construction and this is nice because it minimizes or eliminates the pressure marksThis glove is designed without a seam at the base of the thumb.A regular glove always has that seam circle around the bottom ofthe thumb which can cause pressure marks. You can see the Isotoner glove extends the seam down to avoid this area. I have never seen any other gloves that are designed this way -Edema -- wear all day & night and the Isotoner are comfortable and effective
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Isotoner® ORDERING information
Therapist ordering Info:Sammons Preston- 800-228-3693
www.sammonspreston.com
North Coast Medical- 877-231-9300www.ncmedical.com
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Isotoner®Patient/consumer Ordering info
Patient’s may order direct from Isotoner513-682-8240
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Compression for edema
Using bandagesDown side is bulky and limits the NORMAL use of the hand
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Retrograde Massage
Goal: Remove edema from the limbMay help with removal of lymphatic fluidContinuous pressure of massage can decrease interstitial fluidHelp decrease adhesionMobilize tissue fluid
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Vibration
To soften scars and the formation of scarsMinimize adhesions
Soften tissue
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CPM
Post op patientsStiff hand
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Electrical Modalities
HVPC
Maturation phaseStralka et el Avoid or be very careful in inflammatory phase as the muscle contraction can increase vasodialation and clotting time
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NMS
Research has shown to decrease edema even in flaccid hands
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LASER
The effects of LLLT are photochemicalRed and near infrared light can affect cell membrane permeability and aid the production of ATP thereby providing the cell with more energy Cell will be at a better or an optimum condition to begin the natural healing process.
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LASER
When using LLLT for edema we usually treat it locally… meaning Laser light irradiates the local affected areaThe treatment technique depends on the depth of the tissue.
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LASER
Improved microcirculationDilation of lymphatic vesselsReduction in the permeability of blood vesselsTreat proximal to the edema first to open the blood flow –
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LASER
If edema present 2-4 J to the effected area and proximal to area and somethimes up to 10-15 J with a GaAlAs laser
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Intermittent compression
Help remove by products
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Instrument Assisted Mobilization
Graston Technique(VIDEO)
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Trigger points
Soft tissue restrictions that prevent muscles from working normally
Can treat with LLLT and massageOpen the venous and lymphatic system
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SCAR
Mobilize around the scarBegin to stimulate or clear and flow proximal to scar or blocking area
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Manual Edema – Myofascial approach
Used in conjunction with other treatmentsMassage, passive stretchElongate and release the tightness or restrictionsGoal is to gain symmetrical balance of the restricted asymmetrical stress
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Edema Mobilization
Case by case Rationale to choosing technique/modalityWhat exercises will compliment edema mobilization and continue to rehabWhat should you avoid or put on holdWhat will be a good adjunct to treating edema
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Manual edema mob and Manual Lymph drainage
The term of manual lymph drainage was produced by Dr. Vodder in 1932MEM is taught by Sandra Artzberger and founded from Australian backgroundsThe Vodder technique is using the lymphatic pathways to reroute blocked fluid while the MEM is used to stimulate lymphatic flow but recommends certification for lymph drainage to treat patients with lymph node removal
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Manual Edema Mobilizationor Mobilizing EDEMAStimulate the venous and lymphatic system to absorb excessive fluidPrinciples of Manual lymphedema treatmentCompression bandagesExercise
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Artzberger
Sandy Artzberger developed specific MEM methods in the mid 1990sSandy offers continuing education courses to help prefect your methods
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Contraindications of MEM or Edema Mobilization
Cardiac or pulmonary status
CHF, if in doubt consult physicianInfectionAreas of inflammation
MEM proximal to area of inflammationActive cancerRenal failurePrimary Lymphedema or post mastectomy lymphedema
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Principles of MEM
Light pressure (14-25 mmHg)Pre-exercise & post exercise (PRN)Segments (proximal to distal: distal to proximal)
Lymphatic pathwaysSelf massageLow stretch compression bandaging Compression techniques
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Rationale
Stimulate collectors to open/close Initial lymphatics have no pumping mechanism needs stimulatedProximal muscle stimulation increases transportExercise to help stimulate the lymphatic system and increase transport by 10X
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Rationale
Massage nodes (elbow, neck) to help with uptake
Nodes can get “kinked” or are like a “bottle neck”Stimulate to increase effectiveness of nodes
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Method
Start proximalStimulate the neck and upper armElbowHand
First dorsal interosseous spaceDorsum of handPalm: lateral/distal Digits (lateral flow and clear to dorsum of hand)
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Method
Perpendicular stretch
StrokeLight stroke
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Home Massage
Important component to treatmentHave the patient demonstrateThis is self massage they can do independentlyNO CREAM
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Persistent edema
retrograde massage try the MEM or myofascial therapy. This should helpYou will want to stop heat modalities and modify
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Compression Therapy
Works with exercise to facilitate movement of excess fluid from extremity40mmHg is recommended for persistent edema if the patient is able to exercise or if L.E. walkWrapping (vicki darlington)
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Thank you and now we are going to end our talk with Vicki Darlington.
Vicki Darlington, OTR/L,CHT,CLT. has been an occupational therapist for 25 years, & has worked in St. Petersburg,Flher entire career. She graduated the SUNY at Buffalo, NY. She is the Director of The OT/Hand Therapy department @ The Rehabilitation Institute of Edward White Hospital, St. Pete Fl for the past 8 years.
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An Introduction to the Assessment and Managementby Vicki Darlington
of Lymphedema in the Upper Extremity
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Introduction
The lymphatic system is mentioned while studying human anatomy but I don’t recall ever discussing it in OT school.
This course will be a very brief overview. It is presented with the hope that you will be interested enough to pursue certification.
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Treatment of Lymphedema
Certification as a lymphedema therapist is a 2 ½ week course. These techniques can guide you to facilitate lymph flow in a swollen upper extremity.However, I highly recommend becoming certified before working with lymphedemapatients on a regular basis.
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Definition of Lymphedema
The swelling of a body part ,usually an extremity that is caused by an abnormal accumulation of protein rich fluid and water due to a low volume mechanical insufficiency of the lymphatic system, (The transport capacity (TC) of the LS falls below the lymphatic Load (LL). (fig. 1)
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Lymphatic System
Clears interstitial spaces of excess fluids,cellular debris,protein molecules and (long chain fatty acids –only in the intestines).
These are substances that are not reabsorbed by the venous end of the blood capillaries from the tissues.
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Anatomy of Lymphatic System
The lymphatic system is a one ended system, starting as dead-end vessels in the connective tissues and ends in the venous system. It is an accessory route by which lymph fluid can flow from the tissue spaces into the bloodstream.
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Anatomy of Lymphatic System
Before reaching the venous circulation,lymph fluid travels through successive lymph nodes,thereby filtering impurities from the lymph fluid.The cardiovascular system is closely associated with the lymphatic system.
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Anatomy of Lymphatic System
How do both systems compare?Both have superficial and deep organ systems.Similar vessel structureCommon pathways to the heartProtect the body from infection and disease.
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The main differences between the two systems:
The LS is not a closed circulatory system. When speaking of the movement of lymph fluid it is called lymph transport , not circulation.There is no central pump to the lymphatic system.The lymph transport is interrupted by lymph nodes.
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Anatomy of the LS
The LS is divided into superficial and deep layers and is separated by fascia.The superficial (suprafascial) layer is responsible for drainage of the skinand subcutaneous tissue.The deep LS drains the lymph from muscle tissue,tendon sheaths,nervous tissues,periosteum and joint structures.
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Anatomy of the LS
The transport vessels of the superficial system are embedded in the subcutaneous fatty tissue.Deep transport vessels generally accompany blood vessels and are grouped together with them in the same membrane. Perforating vessels connect the deep with the superficial,
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Components of the LS
The LS consists of lymph vessels,which absorb and transport lymph fluid, and lymphatic tissue.Once the interstitial fluid enters the LS, it is called lymph.Lymph fluid is composed of protein water,cell debris, lymphocytes,a few erythrocytes (absorbed fatty acids –only in intestinal lymph called chylus).
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Components of the LS
Lymphatic vessels are found in all areas with a blood supply with the exception of the CNS,nail tissue, cornea or hair.Lymphatic vessels are categorized as lymph capillaries, precollectors, lymph collectors and lymphatic trunks.
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Components of the LS
The main purpose of lymph capillaries is lymph formation or the absorption of the lymph fluid into the LS.The main purpose of the pre-collectors are to transport lymph fluid from the capillaries to the lymph collectors.
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Components of the LS
Lymph collectors are responsible for draining lymphatic fluid from certain body areas, called tributary or drainage areas. Each lymph collector has a section between a distal and proximal valve, which is made up of smooth muscle and is called the lymph angion.
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Components of the LS
The valves allow the fluid to travel in the proximal direction only . The lymph angions allow the lymph fluid to travel by contracting. The frequency of contraction is determined by autonomous regulation of the SNS.
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Components of the LS
This leads to Lymphangiomotoricity the safety factor of the LS.This is the ability to react to an increase in lymph formation by an increase in contraction frequency.This ability is used to our advantage in manual lymph drainage,diaphramaticbreathing and mm pumping (exercises).
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Components of the LS
Most drainage areas of the superficial LS are subdivided into lymphatic territories.Lymphatic territories consist of several collectors which transport fluid into the same group of regional lymph nodes.
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Components of the LS
Lymphatic territories are separated by lymphatic watersheds.Collectors on the extremities parallel the watersheds.Collectors on the trunk tend to originate at the watersheds.
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Figure 2
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Components of the LS
Lymph collectors transport the lymph fluid from superficial, deep and organ systems to the lymphatic trunks, which then forward the lymph to the venous angles.(see figure 117)
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Components of the LS
Lymph tissues are a framework of dense nodules within connective tissue or as aggregations of lymphoid cells enclosed in a capsule which are lymph nodes,spleen and thymus.
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Components of the LS
Lymph nodes have 3 main functions.Protective function- filtering harmful material(cancer cells,pathogens,dust and dirt).Immune function-produce antibodies(lymphocytes which are white blood cells that attack foreign invaders).
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Components of the LS
Thickening of lymph fluid-thereby reducing the amount of lymph returning via the thoracic duct into the venous system.A set number of lymph nodes is present at birth. They do not regenerate or vanish.
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Lymphatic Watersheds
Represent linear areas on the skin that separate territories from each other and contain relatively few lymph collectors. (see fig. 4)1. Sagittal Watershed- divides the lymphatic drainage of the head, neck, trunk and external genitalia into equal halves.
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Lymphatic Watersheds
Upper Horizontal Watershed- separates the neck and shoulder territory from the territories of the arm and thorax. It runs from the jugular notch (manbrium) running laterally to the acromion, and continues posterior to the vertebral levels between C7 and T2.
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Lymphatic Watersheds
Transverse Watershed-starts at the umbilicus and follows the caudal limitation of the rib cage to the vertebral column. This watershed separates the upper from the lower territories on the trunk.
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Lymphatic Watersheds
Congested lymph fluid causes the lymphatics in the affected area to dialate. The greater resistance in these dialatedcollectors and precollectors forces the lymph back into the lymph capillaries and across the watershed.
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Inter-territorial Anastamoses
This abnormal dialation may eventually result in valvular insufficiency which leads to a retrograde flow of lymph from the congested territory to an adjacent territory free of edema.These pathways are known as Interterritorial Anastamoses.(see Lymphetic pathways)
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Inter-territorial Anastamoses
AAA(Anterior Axillo-Axillary)-Thisconnection is found between the right and left upper quadrants.collectors here create a connection between the contrlateralaxillary lymph node groups on the anterior side of the trunk.(see Lymphatic pathways)
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Inter-territorial Anastamoses
AI(Axillo-Inguinal)- the collectors of the ipsilateral upper and lower quadrants connect the axillary and inguinal lymph node groups on the same side.PAA(Posterior Axillo-Axillary)-Theconnection between the contrlateralaxillary lymph nodes on the posterior side of the upper quadrants.
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Inter-territorial Anastamoses
AII ( Anterior Inter-inguinal )-is located over the mon pubis area and connects the contralateral inguinal lymph nodes on the anterior lower body quadrants.PII ( Inter-inguinal) – collectors forming this anastamosis are found on the sacramand connect the contralateral inguinal lymph nodes groups on the lower body quadrants. (Lympathetic pathways)
)130
Lymphatic Drainage of the UE
Lymph vessels of the UE are divided into deep and superficial layer. Connections are found between the two layers in both directions. The regional lymph nodes for both layers are the axillary lymph nodes.
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Lymphatic Drainage of the UE
Collectors of the hand-A pair of collectors run on the sides of each digit and incline backwards to the dorsum of the hand.(Fig. 5&6)From the palm, collectors transverse in different directions. Collectors belonging to the mesothenar territory drain the central palmar plexus.
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Lymphatic Drainage of the UE
It runs on the volar side between the thenar and hypo-thenar eminence upward to form the medial forearm territory.The radial hand territory drains the radial border of the palm,the web space between the index and thumb, and the thenar eminence.
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Lymphatic Drainage of the UE
Ulnar hand territory-drains the ulnar border of the palm,the hand and the hypothenar eminence.All of these collectors pass around to join the collectors on the dorsum of the hand and go to the dorsum of the wrist.The lymph vessels then join the collectors of the forearm.
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Lymphatic Drainage of the UE
Collectors of the forearm- the collectors in this area are separated into the radial, ulnar and and median territories.They converge accompanying the cephalic and basilic veins and converge together in the antecubitalarea.
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Lymphatic Drainage of the UE
There are antecubital lymph nodes.Collectors from the forearm continue to travel to the axillary lymph node group along the medial upper arm territory.- it is located between the biceps and the triceps on the medial upper arm muscles.
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Lymphatic Drainage of the UE
Lateral upper arm territory- is responsible for drainage of the skin on the dorsolateralupper arm and shoulder. Its collectors drain partly into the axillary and supraclavicular lymph nodes.
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Manual Lymph Drainage
In order to drain an edematous upper extremity, the watersheds and anastamoses become important areas to work. The movements are very light, only to skin stretch.Due to our time contraints ,every massage technique can not be covered.
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Manual Lymph Drainage
Manual techniques that are designed to increase the flow of lymph and the interstitial fluid.The basic hand positions of MLD are adapted to the anatomy and physiology of the LS.Trunk work precedes arm lymph drainage in order to facilitate lymphangiomotoricity that was discussed previously.
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Manual Lymph Drainage
There are many different strokes. The strokes used only apply light pressure.
The sequence of strokes consist of a working and resting phase.
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Manual Lymph Drainage
Due to the high viscosity of the lymph fluid, the working phase lasts at least 1 second. To adequately stimulate the lymph collectors to contract, the strokes should be repeated 5-7 times in one area.
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Manual Lymph Drainage
Direction of strokes depends on the direction of lymph flow. If an area is congested due to surgery ,trauma or radiation , it will be necessary to redirect the flow of lymph towards areas of sufficient lymphatic pathways.
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Manual Lymph Drainage
Principals of treatment: the areas that are closest to the venous angle are stimulated first, which allows the drainage of more peripheral areas.In the UE , treatment begins proximally and continues to the distal region. Regional lymph nodes are treated first.
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Basic Strokes
1. Stationary Circles- are used mainly at lymph node groups, therefore the axillary and antecubital lymph nodes.
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Basic Strokes
Pump- Circle shaped stretching of the skin with the entire palm. Used in the extremities. Can be stationary or dynamic.
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Basic Strokes
For our limited time here today we will only cover stationary circles and pumps on the UE and associated watersheds, and anastamoses. There are several strokes yet, will not be covered today.Before starting lab, there are contraindications to MLD and compression bandaging that must be mentioned.
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Contraindications to MLD
Acute infections (Cellulitus)Cardiac or pulmonary edemaAcute BronchitisAcute DVTAnticoagulantsHemopheliaDeep variscosities
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Contraindications to MLD
Consider patients present cardio-pulmonary status. If the limb is 80-mlgreater in volume from the other extremity: Could moving this much fluid into the heart and lungs compromise the patient’s cardiac status?
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Contraindications to Compression Bandaging
Acute infectionsCardiac edemaArterial diseasesRSD/CRPSRaynaud’s DiseaseSpasticity
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Basic Strokes
Stationary Circles-Applied mainly at the lymph node groups.Circle shaped stretching of the skin with the palmar surface of the fingers or the entire hand.Working phase-the pressure increases for about a ¼ of a circle using radial or ulnar deviation of the wrist. (stationary circles)
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MLD Techniques for LUE1. Massage open pathway from L armpit to R armpit across top of chest- 5 times.2.Massage lymph nodes in R armpit using circular upward motion-5 times.
3.Massage down L side of body from L armpit to L crease of thigh-5 times. 4. Massage lymph nodes in L groin area,along crease of thigh ( upward circular motions)-5 times
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MLD technique continued
5.Massage outer upper L arm from elbow to top of shoulder,stretchingupward-5 times.6.Massage inner upper L arm going across to outer arm in sets of 2-3,working
from elbow up to inside of armpit,pushing to outside of arm (each set 5 times.
Repeat #5 (2 times)7. Massage L forearm both top/bottom pushing upward,thenmassage top of hand & fingers-5 times
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MLD techniques for RUE
1. Massage open pathway from R armpit to L armpit across top of chest- 5 times.2.Massage lymph nodes in L armpit using circular upward motion-5 times.
3.Massage down R side of body from R armpit to R crease of thigh-5 times.4. Massage lymph nodes in R groin area,along crease of thigh ( upward circular motions)-5 times
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5.Massage outer upper R arm from elbow to top of shoulder,stretchingupward-5 times.6.Massage inner upper R arm going across to outer arm in sets of 2-3,working from elbow up to inside of armpit,pushing to
7. Massage R forearm both top/bottom pushing upward,then massage top of hand & fingers-5 times
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Basic Strokes-stationary circle
Resting phase-the hand is relaxed and maintains contact with the skin.Can use both hands or one. Can be done at the same time or with alternating hands.Think of a clock ,directing pressure towards 12 and perpendicular/directional stretch towards 3 o’clock.
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Basic strokes
PUMPApplied mainly at extremities. A circle shaped stretching using the entire palm.Working Phase- the hand is put in palmar flexion and ulnar deviation, the thumb is in opposition of the fingers.
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Basic strokes-Pump
During the transition into radial deviationand wrist extension, the pressure increases smoothly.Resting Phase- The hand relaxes and goes back into palmar flexion and ulnar deviation.(Fig.8)Can be done with one or both hands alternating.
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Direct Lymph Flow
Pumps across AAA to unaffected side.(5-7 times)SC’s to healthy lymph nodes(5-7 times)Dynamic SCs down affected side of body from arm pit to inguinal lymph nodes.Dynamic SCs to affected inguinal lymph nodes(5-7)
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Direct Lymph Flow
Pumps on outer upper arm (affected) from above elbow to top of shoulder in upward motion (5-7).Dynamic SCs inner upper arm starting at
elbow, going across towards outer arm in 2-3 sets ,going up to arm pit region (5-7)
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Direct Lymph Flow
Bilateral SCs using thumbs at antecubitalLNs.Pumps bottom then top of forearm (5-7)Bilateral thumb SCs to volar aspect of hand,mini scs with thumb & index to each digit,then to dorsal aspect of hand (5-7)
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Direct Lymph Flow
Repeat (5-7) times to axillary lymph nodes on affected side.
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Compression Bandaging
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Relevance in Hand Therapy
Techniques appropriate forInflammatory edema which results from
trauma,injury and/or surgical procedures in which edema lasts more than 2 weeks. This decreases the lymphatic transport out of the affected area due to casting,surgical incisions,scars or tissue loss.
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Relevance in Hand Therapy
Protein is trapped in the tissue which activates fibroblastic activity. This activates production of collagenoustissues. This changes the spongy-like edema to turn to a thicker gellikeconsistency resulting in chronic fibrotictissues.
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Relevance in Hand Therapy
PATIENTS AT RISK:• Nerve laceration/compression
causing muscle paralysis •Crush injury/Compartment Syndrome•Skin/Graft Tissue loss• CVA/Stroke patients with lack of
muscle pumping due to paralysis
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TIPS & TRICKS
Mark arm/ hand in 4 cm. increments with a dry erase marker to measure swelling at initial evaluation and at 3 treatment intervals.Use tendon glides, joint blocking , isometrics, while in compression bandaging for HEP.
172
TIPS & TRICKS
If scarring and fibrosis (from radiation/removal of lymph nodes) blocks lymph flow, use watersheds (pathways) to re-rout lymph to functioning lymph nodes.Use handy inexpensive bandage winder to quickly rewind bandages.
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References
Lymphedema Management-”The Comprehensive Guide for Practitioners.”Joachim E. Zuther.C.I.,M.L.D./C.D.T.Thieme Medical Publishers, copyright 2005.
174
References
Academy of Lymphatic StudiesCourse manual.
Phone: 1-800-863-5935WWW.ACOLS.COM
30
175
References
Textbook of Dr. Vodder’s manual lymph drainage,Kasseroller,R: Heidelberg,1998,Haug.
176
References
Special thanks to Crystal Hollingsworth,OTR/L,CLT for providing MLD handouts for patientsAnd detailed UE bandaging handout.