Fluid Congestions- Lymphatics

1. Fluid Congestions-Lymphatics Year 3-4 Intern/Resident CORE (OUCOM) OMM Curriculum

2. Conditions Associated with Lymphedema • Hypertension • Heart Conditions • Arterial Conditions • Venous Insufficiency, Thrombosis, Phlebitis or Obstruction • Diabetes • Thyroid Conditions • Inflammation • Auto-immune Disease • Hormonal Conditions • Malignancy Chilky p.197

3. 1st Signs of Lymphedema: • Puffiness • Stiffness • Fatigue, malaise, discomfort • Tightness • Skin Tension • Tension, pressure, heaviness • Heat • Pain affecting the skin or articulation – bursting, shooting • Numbness, paresthesia • Difficulty putting on a watch or ring or shoe • Slight increase in weight for an unknown reason Chilky p.196

4. Other Signs of Lymphedema: • Fibrosis – ‘Leathering’ • Decreased Range of Motion • Stemmer’s Sign: skin fold of the proximal phalanx of the second toe cannot be raised. • Positive in 82-92% of Primary Lymphedema • Positive in 56% of Secondary Lymphedema Chilky p.196; Pissas A. et al, 1999

5. Severity of Lymphedema (extremities) • Mild: unilateral edema of an extremity ≤ 3cm larger • Moderate: 3-5cm larger • Severe: >5cm larger Chilky p.196

6. Primary Lymphedema: • Idiopathic • Lymphatic vessels or nodes are either undeveloped (aplastic), underdeveloped (hypoplastic), or too large and incompetent (hyperplastic) • 70-90% Female • 90% lower extremities • 80% distal lymphatics Chilky p.171

7. Secondary Lymphedema • ‘Malignant Lymphedema’ • Cancer, metastatic cancer, post-surgical, radiation therapy • ‘Benign Lymphedema’: • Trauma/burn • Infection/Inflammation/Allergy • Paralysis (wheelchair edema) • Chronic venous insufficiency Chilky p.177

8. Secondary Lymphedema ‘Benign Lymphedema’: • Trauma or Somatic Dysfunction: • We can look for local and regional fluid stasis effects of these two problems. Chilky p.177

9. Diagnosis of Lymphedema • Classic ‘Lymphedema stays in the most external compartment, over the muscle.’ (Chilky p.195) • The lower extremity is a classic example. • We are looking for indications of local tissue edema that inhibits the body’s capacity to heal and self-regulate. • Local tissue edema can manifest almost anywhere in the body – • Musculoskeletal • Other Body Systems BodyWorlds, p.200

10. Diagnosis of Lymphedema • Although Classic Lymphedema stays in the most external compartment, over the muscle, the question must be asked? • How do the deep lymphatic fluids get from within the muscle (or other tissues encased in a fascial envelope) to the most external compartments? • They have to penetrate the fascial envelope with the arteries and nerves. • What if that envelope is strained/distorted, diminishing flow and increasing backpressure within the compartment (not to the degree that a compartment syndrome is created)? => decreased oxygenation, nutrition & waste removal] • Implications for DX & Tx BodyWorlds, p.200

11. Visualize the veins & lymphatics that accompany the arterial system. You then get a visual sense of the extent of the lymphatic system. Latex casts can be made of the high pressure arterial system, but not effectively for the low pressure systems. 0 BodyWorlds, p.201

12. If lymphatics could be preserved independently, this rendition might be close. 0 BodyWorlds, p.201

13. ‘Early in vasculogenesis, endothelial cells that express VEGFR-3 respond to VEGF stimulation by differentiating into the precursors of the lymphatic vessels.’ Carlson, Human Embryology, 3rd Ed., p. 434

14. Cardinal vein development; Azygos vein development 0 Lymphatic development coalesces around the developing venous system. Common Cardinal vein Azygos vein 6 weeks 8 weeks Human Embryology, 3rd Ed., p. 441, 445

15. 0 Jugulo-axillary Lymph Sac • Lymph sacs develop in the 5th & 6th weeks of fetal development Retroperitoneal Lymph Sac Cisterna Chyli Posterior Lymph Sac Human Embryology, 3rd Ed., p. 445

16. 0 • Lymph sacs can be thought of as focus points for the developing lymphatic system. • Lymph vessels will ultimately join these lymph sacs in an organized fashion. Human Embryology, 3rd Ed., p. 445

17. Lymphatic development: ‘Two large channels (right and left thoracic ducts) connect the jugular lymph sacs with the cistern. Soon a large anastomosis forms between these channels.’ (Developing Human, 7th Ed., p. 375) 0 9 weeks Human Embryology, 3rd Ed., p. 441, 445

18. Lymphatic development: • At 9-10 weeks the right thoracic duct crosses the midline at about T4-T6 • For patients: This has relevance to optimizing lymphatic drainage for any problem below this level. Human Embryology, 3rd Ed., p. 445

19. ‘Except for the superior part of the chyle cistern, the lymph sacs are transformed into groups of lymph nodes during the early fetal period. • Mesenchymal cells invade each lymph sac and break up its cavity into a network of lymph channels – the primordial of the lymph sinuses. • Other mesenchymal cells give rise to the capsule and connective tissue framework of the lymph node.’ (Developing Human, 7th Ed., p. 375)

20. This embryonic organization can assist you in your thinking about the path of lymphatic drainage for any given problem.

21. 0 Jugulo-axillary Lymph Sac • Lymphatic vessels soon join the jugulo-axillary lymph sacs • They pass along main veins to the head, neck, and upper limbs Human Embryology, 3rd Ed., p. 445

22. 0 • Lymphatic vessels soon join the lumbar and iliac plexuses which are derived from posterior lymph sacs • They pass along main veins to the lower trunk and lower limbs Posterior Lymph Sac Human Embryology, 3rd Ed., p. 445

23. 0 • Lymphatic vessels soon join the retroperitoneal lymph sac and the chyle cistern (cisterna chyli). • They pass to the primordial gut Cisterna Chyli Human Embryology, 3rd Ed., p. 445

24. Thus we see the aggregation of lymph nodes in certain areas (related to the embryologic precursors – the lymph sacs): Jugulo-axillary lymph sacs Retroperitoneal lymph sac and the cisterna chyli Posterior lymph sacs Clinically Oriented Anatomy, 5th Ed., p.45

25. These thus have fairly direct relationships to: Junctional Areas: C-T Junction L-T Junction L-S Junction Diaphragms: Superior Thoracic Aperture (Thoracic Outlet) Thoraco-abdominal Diaphragm Pelvic Diaphragm Clinically Oriented Anatomy, 5th Ed., p.45

26. These are ‘High Yield Areas’ for Somatic Dysfunction: T4-T6 Junctional Areas: C-T Junction L-T Junction L-S Junction Diaphragms: Superior Thoracic Aperture (Thoracic Outlet) Thoraco-abdominal Diaphragm Pelvic Diaphragm Clinically Oriented Anatomy, 5th Ed., p.45

27. We want to treat from proximal to distal. So the fluid has somewhere to go. Junctional Areas: C-T Junction L-T Junction L-S Junction Diaphragms: Superior Thoracic Aperture (Thoracic Outlet) Thoraco-abdominal Diaphragm Pelvic Diaphragm Clinically Oriented Anatomy, 5th Ed., p.45

28. Think of the Lymphatics that accompany each organ’s arterial system. What are the somatic dysfunctions (that could affect lymphatic flow) proximal to each of these organs? 0 Internal Organs & Lymphatic Drainage BodyWorlds, p.203a

29. Fascial Restriction/Somatic Dysfunction & Lymphatic Drainage • How much pressure does it take to impede lymphatic drainage?

30. Treatment of Lymphatics:

31. Quality of ROM Quantity of ROM End Field of ROM “End Feel” Tissue Textrue Changes Appropriate Techniques MYOTONIC Like bungee cord or rubber band Reduced RUBBERY - Like hitting the end of a bungee cord Usually tight, hypertonic ME, MFR, FPR, FM,Gentle ROM ARTICU-LAR Crepitant to good Reduced ABRUPT - Like hitting a wall Crepitant to normal Impulse, ME, ROM, MFR, FPR, FM NEURO-MUSCULAR Variable Usually reduced Variable Tender Point* SCS, I-MFR, FPR, FM MYO-FASCIAL Asymmetric tug Variable Variable Asymmetric tug MFR D or I, FPR, FM VASCULAR Variable Reduced d/t Edema Variable Edematous TX Proximal SD of other types Types of Somatic Dysfunction Source: Herb Yates, DO, FAAO

32. Types of Somatic Dysfunction • Summary for Vascular Type : • When Fluid Congestion is a primary concern treatment of proximal somatic dysfunction of myotonic, articular, neuromuscular, or myofascial origin is indicated. • Treat from the Superior Thoracic Aperture progressive closer to the area of concern for fluid congestion.

33. Flow Chart: Treat from proximal to distal. • Lymphatic trunks return fluids to central circulation – Superior Thoracic aperture: • Rib 2, Chondrals & manubrium • Rib 1, Chondrals & manubrium • C6-T2 • Anterior Cervical Fascia • Treatment priority – most intense TART/STAR findings first • if tolerable for the patient; • in hospital, you don’t want to tax an already stressed, low vitality patient – small amounts of treatment in greater frequency, even 2-3 times per day

34. Lymphatic Treatment (continued) • Thoraco-abdominal Diaphragm Function: • Flattened? One Hemi-diaphragm? Redome • T7-12 & associated ribs • Which of these elements are present in my patient? • Treatment priority – most intense TART/STAR findings first • if tolerable for the patient; • in hospital don’t want to tax an already stressed, low vitality patient

35. Lymphatic Treatment (continued) • Rib Raising • In some instances this may be the first thing done for the patient.

36. Lymphatic Treatment (continued) • Next Focus Dependent Upon Most Symptomatic Region Related to Chief Complaint: • HEENT – Neck, Head • Thorax – Other thoracic, rib, fascial elements • Upper Extremity – Axilla/Trunk • Abdomen – Visceral lymphatic techniques, L1-5 • Sacro-pelvis – Abdominal concerns, sacrum, innominate, pelvic diaphragm, pelvic diaphragm • Lower Extremity – Adominal, Sacro-pelvic, hip, knee, interosseous membrane, ankle, foot

37. Lymphatic Treatment (continued) • Lymphatic Pump • Sutherland Lymphatic Pump Sequence • Miller Lymphatic Pump • Pedal Pump • Home Treatment • Two person pedal pump • Two person Miller lymphatic pump with minimal chest compression

38. SUMMARY

39. Resources: • Chilky B, Silent Waves Theory & Practice of Lymph Drainage Therapy, I.H.H. Publishing, Scotsdale Arizona, 1st edition, revised 2002 • Carlson, BM, Human Embryology and Developmental Biology, 3rd edition, Mosby, Philadephia, PA, 2004. • Von Hagen’s G, Bodyworlds - The Anatomical Exhibition of Real Human Bodies, Institut fur Plastination, Heidelberg, Germany, 2004

40. Resources: • Moore KL, Dalley AF, Clinically Oriented Anatomy, 5th Edition, Lippincott Williams & Wilkins, Philadelphia, PA, 2006.

41. Information beyond this point is for student / intern / resident reference & need not be included in the powerpoint presentation.

42. Evidence Based Medicine: • 1) Sleszynski SL, Kelso AF, “Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis” JAOA, Vol 93, No 8, August 1993, p.834-845. • (2) Jackson KM, et al, “Effect of Lymphatic and Splenic Pump Techniques on the Antibody Response to Hepatitis B vaccine”, JAOA, Vol 98, No 3, March 1998, p. 155-160. • (3) Knott EM, et al “Increased Lymphatic Flow in the Thoracic Duct during Manipulative Intervention”, JAOA, Vol 105, No 10, October 2005, p.447-456.

43. Prevalence & Incidence of Lymphedema • United States: • Primary Lymphedema: approx. 2 million • Secondary Lymphedema: 2.5-3 million

44. Prevalence & Incidence of Lymphedema • World • 1 out of every 40 people in the world may be affected. • Influence of ‘Somatic Dysfunction’ – Evidence Base Unknown Chilky p.170

45. Sutherland’s Vibratory lymphatic • treatment of: • -Thoracic duct • -Cysterna chyli • -Greater Omentum: • Fingerpad contact with the index, middle & ring fingers is made over the area. • The second hand rests over the top of the this hand to introduce vibration at 1-2 cycles per second – minimal compression is used to get to the structure of interest. Teachings In the Science of Osteopathy

46. Rib Raising: • Contact is made with the rib angles or near the costotransverse junction. • Lateral anterior traction is maintained gently until softening occurs. • Eight ribs on each side can be addressed simultaneously. Foundations for Osteopathic Medicine. P.1065

47. Rib Raising: • In the seated position, it is easy to add side bending or rotation to help localize resistance. Gentle articulatory motion can also be utilized with the patient in the seated position. Foundations for Osteopathic Medicine, p. 1065

48. Foundations for Osteopathic Medicine, p. 1069 Miller Thoracic Pump • Palmar contact below the clavicles • As pt. exhales, gently compress and vibrate at 1-2 cycles per second • Several variations: • Gently resist each inhalation through about 5 cycles and slowly release • Vibrate with exhalation, then just after the start of inhalation let the pressure off of the chest suddenly – creates significant negative pressure in the chest.

49. Pectoral Traction • Grasp the anterior axillary folds with finger pads • Gently lift superior anterior • Feel for chest wall resistance via the pectoral attachment. • Hold for 15-30 seconds; repeat as tolerated. • Helps expand the chest Foundations for Osteopathic Medicine, p. 1068

50. Foundations for Osteopathic Medicine, p. 1067 Dome the Pelvic Diaphragm • Index and middle fingers follow the inside of the ischium slowly up to perceived resistance – this is the pelvic diaphragm • Several pt. coughs against your finger resistance will help release the hemi-diaphragm If a cough is not desired, follow the breathing and resist the descent of the diaphragm during inhalation.