manualtreatmentof lymphedema - .Vodder Manual Lymphdrainage accordingto slowly harmonious correctly

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  • 04.09.2012

    1

    The different aspects in the

    manual treatmentof lymphedema

    patients

    Elvira Albrecht & Marietta SlePhysiotherapists - Fldiklinik

    Instructors for ML/CDT - FldischuleFldiklinik

    manual treatment oflymphedema

    Manual

    Lymphdrainage

    manual treatment oflymphedema

    =

    ?

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    2

    typical indications

    characteristics of MLD techniques

    What is Manual Lymphdrainage?

    effects

    definition

    According toLehrbuch der Lymphologie (Fldi + Fldi), Lehrbuch der Entstauungstherapie (Bringezuund Schreiner), MLD nach Vodder (Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly),deme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at

    MLD is a special kind of massage

    MLD is a decongesting massage

    MLD is a massage technique which does not fall into the

    categories of any already defined techniques

    definition

    Vodder, stationary circles, pump strokes, scoop and

    rotary technique

    According toLehrbuch der Lymphologie (Fldi + Fldi), Lehrbuch der Entstauungstherapie (Bringezu und Schreiner), MLD nach Vodder(Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly), deme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at

    characteristics of MLD techniques

    covering a large area

    circle shaped

    working/pressure phase and relaxation phase

    slowly and gently

    rhytmically and repetitively

    adapted pressure

    According toLehrbuch der Lymphologie (Fldi + Fldi), Lehrbuch der Entstauungstherapie (Bringezu und Schreiner), MLD nach Vodder(Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly), deme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at

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    effects

    increase of lymphangiomotoricity

    increase of lymph time volume

    helps to move interstitial fluid

    increase velocity of lymph flow through the lymph nodes

    analgesic effect

    vagotonic effect, sympathicolytic effect

    helps to influence fibrotic tissue

    Immune system ??

    stimulates new channels (anastomoses)

    positive side effect: influences increasedmuscel tension & intestinal activity

    According toLehrbuch der Lymphologie (Fldi + Fldi), Lehrbuch der Entstauungstherapie (Bringezu und Schreiner), MLD nach Vodder(Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly), deme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at

    typical indications

    lymphedema

    phlebolymphostatic edema

    lipedema syndrome

    postoperative/posttraumatic edema

    edema caused by rheumatic disease

    scleroderma

    complex regional pain syndrome

    lymphatic children

    lymphostatic encephalopathia

    cosmetic : for acne, rosacea, scars, stretch marks

    Burns

    application in gynaecology: mastodyni, newmothers with lactation problems, edema

    associated with pregnancy

    neurology: edema associated with apoplexy, MSpatients

    altering the vegetative nervous system in burn-outsyndrom, stress, and for older patients after majorsurgery, during fasting

    tinnitus patients

    Headache patients

    According toLehrbuch der Lymphologie (Fldi + Fldi), Lehrbuch der Entstauungstherapie (Bringezu und Schreiner), MLD nach Vodder(Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly), deme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at

    New therapeutic method in the service of beauty

    pumping and emptying circle-shaped movements

    gentle stationary circles

    Estrid & EmilVodder

    Manual Lymphdrainage according to

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    4

    water content of the body =

    basic fluid, in which all

    parts of the body are

    intrinsically linked

    lymphatic system =

    environment

    lymphatic system =

    cleansing systemlymph =

    omnipresent

    lymph =

    stream of lifeinterstitial fluid =

    transit route and

    transport system

    Estrid & EmilVodder

    Manual Lymphdrainage according to

    slowly

    harmonious

    correctly

    pressure not more than 30 mmHg

    Estrid & EmilVodder

    Manual Lymphdrainage according to

    lymphatic syndrome

    cosmetics

    hematoma

    eczema

    skin diseases

    leg wounds

    prevention

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    5

    Estrid & EmilVodder

    Manual Lymphdrainage according to

    lymph renewal

    circulation activation

    reduction swelling of the mucosa

    regeneration of cell activity

    propelling lymph and removing edema

    stimulation of cell activity und speeding up regeneration

    1. The Vodders developed the

    Manual Lymphdrainage

    at that time for a

    different set of symptoms.

    2. As a consequence you need to think about

    modifications of methods to fit the patients

    symptoms today.

    anatomy of the skin

    Cutis: epidermis

    dermis/corium

    Subcutis=hypo-dermis

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    epidermis

    Keratinocytes

    Melanocytes Langerhans cells Regulate bodytemperature

    0.8 1.4 mm

    dermis

    Mechanoreceptors

    Nerve endings Hair follicels Sweat glands Lymph- andbloodvessels

    subcutis/hypocutis

    No part of the skin Connective tissue Elastin Fibroblasts Macrophages Adipocytes Padding andinsulation

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    7

    skin anatomy

    lymphatics cells,fibers

    epidermis no lymphaticskeratinocytes,melanocytes,Langerhans cells

    dermisinitiallymphatics,precollectors

    fibroblastscollagen fibers

    subcutispraefascialcollectors

    fibroblasts,macrophages,adipocytes

    edematous skin / normal skin

    edematous skin / normal skin

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    epidermis in lymphedema

    Epidermal hyperplasia

    Hyperkeratosis Papillomatosis Hyperpigmentation Verrucousprotuberances

    Elephant skin

    papillomatosis cutis

    hyperpigmentation, papillomatosis, elephantiasis

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    9

    cutis and subcutis in lymphedema

    Stage 1 proteinrichfree fluid reversible stage

    Stage 2 Alteration ofconnective tissue -irreversible stage

    Stage 3 lymphostatic fibrosis- elephantiasis

    elements of the connective tissue

    Cellular compartment Fibroblasts Blood- andlymphvessels

    Nerves Small number ofinflammatory cells

    Leucocytes

    Macrophages Mast cells granulocytes

    Non-cellularcompartment Extracellular matrixECM

    Free fluid proteins

    extracellular matrix ECM

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    glycoproteins (fibronektin)adhesionmolecules

    elements of ECM

    Collagens ( 5 types) Type I (90%) connectivetissue,tendons,ligaments

    Type III: dermis,blood vessels

    Glycoproteins Fibronectin (adhesion molecule) Elastin,fibrillin (elastic fibers)

    Proteoglycans Hyaluron and others

    encyme activity regulatesconstant remodeling of ECM

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    proteinrich edema damages tissue

    proteinrich fluid

    activated fibroblasts

    chronic inflammation

    proliferation of

    adipose tissue proliferation of

    connective tissue -

    fibrosis

    sclerosisproliferation of blood

    vessels

    proliferation of

    epidermis cells:

    pachydermia

    hyperkeratosis

    papillomatosis

    lymphedema & connectivetissue

    Alteration ECM andcellularcompartment

    High density of cellsand fibres

    Less elastic fibres More collagen fibres Widened dermis and

    subcutis

    lymphedema & lymphatics

    Lymphatics enbeded in alterated ECM

    Changes in basementmembrane

    Anchoring filamentsdegenerated

    Loss of elastic fibres Fibrotic valves Enlarge lymphvessels Disability to contract /

    insufficiency

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    In lymphedema, morphological changes ofconnective tissue, especially in the lymphatics,

    lead to the necessity of modifying MLD

    See you in 15 minutes??

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    Do you recognize treatment techniquesthat also you use for treating yourlymphedema patients?

    What would you call these techniques?

    Pressure dosage

    Performingsurface

    Intensity levels

    staying on one place

    Combination of MLD withother approved techniques

    1 sec x sec

    MLD & soft tissue technicqes

    Number of repetition 1 x , 2x , 3x , x

    Intensity levels

  • 04.09.2012

    14

    Connective Tissue - assessment

    Objective: Ultrasound MRI

    Subjective:

    palpation

    palpation

    mind

    expe-rience

    sense

    additional medical history

    Limiting factor

  • 04.09.2012

    15

    Age

    Limiting factor

    skin condition

    Limiting factor

    pain

    Limiting factor

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    16

    What do you feel when your therapist is appliyingintensive tissue techniques in the area of the

    alterated tissue?

    There is a bit of punctual pain during application and right after that I feel kind of relief. Light and free

    everyday I have a pressure inside, so this counterpressurefrom outside feels like a comfortable pain. Afterward it works in the tissue

    What do you feel when your therapist is appliyingintensive tissue techniq