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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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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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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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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
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Connective Tissue - assessment
Objective: Ultrasound MRI
Subjective:
palpation
palpation
mind
expe-rience
sense
additional medical history
Limiting factor
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Age
Limiting factor
skin condition
Limiting factor
pain
Limiting factor
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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
