淋巴水腫之物理治療

楊靜蘭

臺大醫院復健部物理治療技術科

台大物理治療學系兼任講師

Lymphedema

Abnormal accumulation of tissue proteins, edema, and chronic inflammation within an extremity

Primary lymphedema

Malformation or malfunction of the

lymphatic system

- hypoplasia

- hyperplasia: too large collector,

valve not working properly

- aplasia

Secondary lymphedema

Surgery- lymph node removed

Radiotherapy- scar tissue

Trauma

Infection

Filariasis

Paralysis or immobility

Chronic venous insufficiency

Stages of lymphedema

Stage I: edema is pitting and reversible

Stage II: spontaneous irreversible

proliferation of connective

tissues, hardening of the extremity

Stage III: elephantiasis, papilloma

cartilage-like hardening

完整之減腫脹物理治療法

Complete decongestive physiotherapy

Complex physical therapy

Complex lymphedema therapy

Decongestive lymphatic therapy

Complex physical therapy

Intensive phase: 4 wks

Maintaining phase: 6-9 months

- enlarging collateral lymphatics

linking obstructed lymphotomes to

normal ones

- connective tissue, loose skin

remodel

完整之減腫脹物理治療法

Manual lymph drainage

Bandaging

Exercise

Skin care

(International society of lymphology, 1997)

Manual lymph drainage (1)

Purpose: mechanically move fluid into initial lymphatic; cause collateral lymphatics that cross the watershed become larger

Superficial lymphatic system

Deep lymphatic system

16: perforating lymphatics

initial lymphatic

precollector collecting vessel

Watersheds

Sagittal, horizontal- four quadrant (lymphotome), each section consisting of a limb and the adjacent quadrant of the trunk (Fig)

Boundaries between the areas of lymph drainage, the direction in which lymph drains

Linear area on the skin and contain few lymph collectors

Some lymph fluid may cross the watershed via lymph capillaries (initial lymphatic plexus)

Horizontal Watersheds

Upper horizontal watershed: a line from the jugular notch (manubrium) to the aromion, and continues posterior to the vertebral levels between C7 and T2;separates the neck and shoulder territory from the territories of the arm and thorax

Lower horizontal watershed: start at the umbilicus and follows the caudal limitation of the rib cage to the vertebral column

Anastomoses

small lymphatic vessel

anterior axillo-axillary, P-A-A

anterior inter-inguinal, P-I-I

axillo-inguinal (Fig)

Manual lymph drainage (2)

Skin movement：outer 0.3mm of the skin

Rich bed of lymph capillaries in the

superficial tissues

Stretches the microfilaments just below the

skin which control opening to the initial

lymphatic, thus allowing interstitial fluid to

enter the lymphatic system while also

stimulating lymph vessels to contract

Lymph collectors

Lymph angion: 6-20 mm, up to 10cm

Lymph transportation

Manual lymph drainage (3)

Pressure: very light, gentle; the softer

the tissue, the lighter the pressure, as

trying to move one Kleenex over the

surface of another Kleenex

30~40mmHg

1.5~8 ounces/square inch (pressure

found in the collecting lymphatics)

Manual lymph drainage (4)

40-90 mins on consecutive days

Direction: toward the lymph node

Speed: the greater the amount of fluid, the slower the movement

Rhythm: maintain connection with the same area for at least a minute, repeating the stroke with the same pressure, direction, and speed

Manual lymph drainage (5)

Direction: stretching the lymphatics

longitudinally, horizontally, and

diagonally; toward the lymph node

(neck, axilla, and groin)

Does not include long strokes, heavy

pressure, rapid movements (ex:

percussion)

Direction Upper body: between the

waist and clavicle;

between the waist and spine of the scapula on the dorsum of the trunk

R’t axillary nodes: right arm and right side of the trunk

L’t axillary nodes: left arm and left side of the trunk

Neck: medial side of each breast, along the sternum

Direction

Lower body:

Inguinal nodes in front: superficial lymphatics in the buttocks drain laterally around the body to the inguinal nodes in front

Lateral area of the posterior thigh draining laterally around the leg

Medial area of the posterior thigh draining medially around the leg

Lymph node

Function: produce lymphocyte/filter

lymph

Do not regenerate

Sensitive to radiotherapy

Lymph circulation slows down at the

lymph nodes, prone to congestion

Factors influence lymph move

Do not have a central pump like the heart of the blood circulatory system

Lymph angion

-Random spontaneous contraction of the smooth

muscle wall of the lymph vessel

-Stretch reflex of the angions, start and stop depending on whether the pressure inside the lymphatics exceeds or falls

Pumping of the arterial system

Pumping of the skeletal muscles during activity(Fig)

Pressure changes in the thorax during breathing

Factors influence lymph move

Low amplitude body movement, ex:

walking 40 paces/min, tend to empty

lymphatics in the chest and abdomen

External mechanical factor: manual

lymphatic massage

Basic movements

• Stationary circle

• Thumb walk, thumb circle

• Pump, pump-chase

• Scoop

• “J” strokes, “Jay walk”

• Flat hand push: only stretches the

lymphatics in one direction

• Figure 8

Stationary circle

• Working phase: Straight stretch- oval-shaped stretching of the skin; slight compression at the beginning of the movement, stretch of the tissues at the end of the movement

• Zero phase

Thumb walk, thumb circle

• Applied with the palmer surface of the thumb

• Primarily on the hand and foot, face, bony protuberance

Pump

• on the extremities, gently compress the tissues and scoop or stretch the skin toward the appropriate lymph node

• Working phase: the hand is placed on the skin with ulnar deviation and wrist flexion, finger extended, thumb in opposition to the fingers, transit to radial deviation and wrist extension

Scoop

• Applied on distal extremities, spiral shaped movement

• Working phase: hand in ulnar deviation and pronation (perpendicular to the pathway of lymph collectors), web space between the index finger and thumb is in contact with the skin, gliding over the skin in a spiral like movement

Rotary, “J” strokes, “Jay walk”

• on the back of the torso, thigh • Hand in an elevated position and

parallel to the pathway of lymph collectors, wrist in flexion, all finger tips in contact with the skin

• Palm placed on the skin in an elliptical movement (over the ulnar side)

Fibrosis technique

• Kneading: the fibrotic tissue is lifted softly from the underlying tissue in an S-shape

• Fibrotic tissue fold is lifted and the other hand pressing down on it

• Contraindicated in the area of radiation fibrosis

Sequence

• Begin on the well side first: massage lymph node and trunk quadrant opposite to the edematous side

• Clearing across the watersheds • Clearance of deep truncal areas • Massage the lymph nodes and trunk

quadrant closest to the edematous limb

• Massage the proximal area of the edematous limb

• Massage the distal area of the edematous limb

• Lymph node

Truncal decongestion for unilateral secondary U/E lymphedema

• Terminus • Lateral neck lymph node (20 circles, 6-10 cirs/s) • Anterior thorax on the contralateral side

– Axillary lymph node – Thoracic breathing

• Activation and utilization of the AAA/PAA/AI anastomosis

• Inguinal lymph nodes on the ipsilateral, affected side

• Intercostal and parasternal techniques on the affected trunk quadrant to utilize deep drainage pathway

Extremity for unilateral secondary U/E lymphedema

• Upper extremity

• Lymph nodes

superficial- supratrochlear (cubital) nodes

deltoideopectoral nodes (Fig)

deep- axillary nodes (Fig)

Lymphatic vessels

superficial- dense plexus of the palm

radial(cephalic vein), medial(median),

ulnar(basilic) forearm bundle (Fig)

Extremity for unilateral secondary U/E lymphedema

• Mesothenar territory/Medial forearm territory/Medial upper arm territory

• radial hand territory/radial forearm territory/axillary, supraclavicular lymph node

• ulnar hand territory/ulnar forearm territory/antecubital lymph

node

deltoideopectoral nodes

Subclavian trunk

Mesothenar territory

ulnar hand territory

Medial upper arm

Lateral upper arm

AAA

AI

•Sternum -> parasternal nodes

Pectoralis major muscle along the clavicle (7 7s stationary circle

•Rib cage (near the axilla, below the breast)

PAA

IA (thoracic portion)

•Lateral edge of scapula & underarm region of the trunk

Thoracic spine

The intercostal lymph nodes occupy the posterior parts of the intercostal spaces, in relation to the intercostal

vessels. They receive the deep lymphatics from the postero-lateral aspect of the chest

The efferents of the glands in the lower four or five spaces unite to form a trunk, which descends and opens either into the cisterna chyli or into the commencement

of the thoracic duct. The efferents of the glands in the upper spaces of the left side end in the thoracic

duct; those of the corresponding right spaces, in the right lymphatic duct

Intercostal technique

Stationary circle with 3

or 4 finger pads, with pressure working deep (perforation precollector)

Truncal decongestion for bilateral secondary U/E lymphedema

Supine • Lateral neck lymph node • Abdominal treatment/diaphragmatic breathing • Inguinal lymph nodes on both sides • Activation and utilization of the AI

anastomosis on both sides (rotary technique and stationary circle)

• Intercostal and parasternal techniques on the both affected trunk quadrants to utilize deep drainage pathway

Abdominal treatment

• Superficial abdominal treatment: Increase lymph transport within the thoracic duct and larger lymphatic trunks

• Deep abdominal treatment:Caudal part of the thoracic duct, the cisterna chyli, the pelvic and lumbar lymph node are stimulated

Truncal decongestion for unilateral secondary L/E lymphedema

• Lateral neck lymph node • Axillary lymph nodes on the ipsilateral,

affected side • Activation and utilization of the IA

anastomosis on the affected side (rotary technique and stationary circle)

• Inguinal lymph nodes on the contralateral side

• Activation and utilization of the AII/PII anastomosis

• Abdominal treatment/diaphragmatic breathing

• Paravertebral technique

Lumbar area

• Area outlined by the lower horizontal watershed, horizontal gluteal fold, and the sagittal watershed

• Effleurage, starting at the posterior sagittal watershed toward the inguinal LN

• PII

• Paravertebral lymph node

Stationary circle paravertebrally with the finger pads (working deep)

Paravertebral lympn node

Truncal decongestion for bilateral secondary L/E lymphedema

Supine • Lateral neck lymph node • Abdominal treatment/diaphragmatic

breathing • axillary lymph nodes on both sides • Activation and utilization of the IA

anastomosis on both sides (rotary technique and stationary circle)

Practice • Lower extremity

Lymph nodes- anterior tibial node,

popliteal node, inguinal node (Fig),(Fig)

lymphatic vessels

superficial- medial (great saphenous vein),

lateral (small saphenous vein)

deep- anterior/posterior tibial, peroneal (Fig)

Collectors on the L/E

• inguinal node/ pelvic lymph node/ lumbar lymph node/ lumbar trunk / cisterna chyli/ thoracic duct

• Collectors from the dorsum of the foot/ ventromedial territory/ skin of the lower leg, except an area in the middle of the calf/ follow the great saphenous vein/ pass behind the medial condyle of the femur/ superficial inguinal LN

• Dorsolateral territory/ drain skin in the middle of the calf/ follow the small saphenous vein/ superficial popliteal LN/ deep popliteal LN/ deep inguinal LN

Lower quadrant • Terminus • Deep abdomen- lumbar node chain • Inguinal nodes • IT band (upper/middle/lower) • Rectus femoris (upper/middle/lower) • Gracilis (lower half of the medial thigh) • Flush knee: thumb scroop • Lower leg

Lower quadrant • Ankle, metatarsal, lateral malleolus: thumb

scroop； • center of sacrum, off each side stretch laterally over waist • Popliteal lymph nodes • Gluteal region to knee • Knee to ankle • stationary circle between the malleoli and

Achilles tendon tendon • Dorsum and sole of the feet • Inguinal node

Genital lymphedema

Usually irreversible without treatment, tends to become more fibrotic and increases in size

Malignant/primary/secondary

Combined penile and scrotal swelling

Genital swelling should precede the sequence for leg lymphedema

Complications including lymphatic cysts, fistula, lymphorrhea, bacteria and mycotic infection

Genital lymphedema treatment

If fistula is present, wearing sterile gloves for treatment

Lateral neck lymph node axillary lymph nodes on both sides Activation and utilization of the IA

anastomosis on both sides Inguinal lymph nodes on both sides Abdominal treatment/diaphragmatic

breathing Treatment of the scrotum

Face and neck • Indication: • Local injury (bruising and swelling), dental

surgery or cosmetic surgery • Low energy resulted of stress, overwork,

or depression can depress the immune system

• Tense facial muscles- MLD not only move lymph, it is deeply relaxing

• Unhealthy skin-MLD remove toxins

Face and neck • Contraindication:

• open wounds, incisions, scratches and abrasions should allow to heal

• Local swelling due to allergies, hormones, steroids, fatigue, infection, excess salt in the diet

neck

• Performed on both sides of the neck and face

• Supraclavicular nodes: 20 stationary circles over the sternal and clavicular attachments of the SCM muscle, 7s /circle, 3 mins

• 20 stationary circles on the area between the ear and the mastoid process, posterior and inferior to the ear (parotid and retroauricular lymph node)

neck • Drain the nodes along the region of

the SCM muscle, stationary circles 7 times,7s/circle, total 3-4 mins (lateral cervical lymph node)

• 8-10 mins to drain the cervical lymph nodes

Direction • Face and neck • Lymph nodes in the neck: lymph from

the superficial lymphatics of the head

• Occipital nodes: lymph from the top of the head, back of the head, then drain toward the cervical nodes (along the SCM)

• Pre-auricular and mandibular nodes: lymph from the fascial lymphatics, then drain into the cervical nodes

neck

• Place the flat fingers of both hands under the neck, 7 7s stationary circles over the cervical vertebrae, on the sides of the neck, 7 7s stationary circles

• Two flat fingers inside the triangle formed by the SCM, the clavicle, and the scalene muscle, 7 7s stationary circles

• Under the chin, under the jaw line (midway between the chin and the angle of the jaw), under the ear (submandibular LN)

neck • Thyroid cartilage

• Depression between the cartilage and the SCM muscle

Posterior neck and occipital area

• Deep lateral cervical lymph node • Occipital and parietal region,

retroauricular lymph node and parotid LN

• Upper trapezius m (in the direction of the supraclavicular fossa)

• Paravertebral lymph node

face

• Pretreatment: lateral neck • In the direction of the angle of the jaw • On the chin (below the bottom lip), 7 7s

stationary circle (submental, submendibular LN)

• Deep lateral cervical LN • Above the jaw line, over the molar • Lower and upper jaw • Bridge of the nose and cheek • Upper lip/ Corners of mouth

face • 2nd and 3rd fingers: tip/bridge/root of the nose,

lower eyelids, toward the cheeks, to supraclavicular fossa

• Medial corner of the eyes, upper eyelid and eyebrow, to preauricular LN

• Corner of the mouth • Chin (below the bottom lip) • Over the region of the molar teeth • Masseter • On the region of the TMJ • Eye sockets (below the eyebrows) • Forehead toward preauricular LN

face

• Temple (temporalis) • Two fingers in front, two fingers behind

the ear • Scalp • TMJ • Masseter • Between the ear and mastoid process • sternal and clavicular attachment of the

SCM

Contraindications

cancer (malignancy): metastasis

open wounds, rashes, inflamed skin

fever

Infection

heart or kidney disease (CHF, kidney

dialysis)：edema may occur, MLD increasing

blood volume by returning fluid to the blood circulation

low blood pressure

Contraindications

Asthma

Hyperthyroidism, Hypothyroidism

blood clots and phlebitis:

-avoid massage for two weeks after surgery

-consult physician for patients taking coumadin

-Homan’s test

-warmer, reddened, swollen varicose vein

organ transplant: immune suppressing medication

chemotherapy

Compression therapy

Max reduction in 7-10 days

Tissue looses elasticity, does not return to original position and shape even when fluid ↓

Improve muscle pumping action,

increase total tissue pressure

Padding

Compression therapy

Bandages

Special garments

Bandage (1)

first 7-10 days, consecutive day

short-stretch bandage:low resting p, high working p

Graded compression: greater compression distally and lesser proximally, amount of pressure determined by layer of bandages

Bandage (2)

Should not bandage when

- infection

- circulatory, nerve, or arterial

insufficiency problem

- pain or numbness

- recurrence of cancer

Special garments

used when arm size is fairly stable

Prevent swelling and maintain size of the limb

20-40mmHg; 40-50mmHg in severe case

During physical activity and exercise

Vasopneumatic pump (1)

Little or no lasting beneficial effects

Fail to move lymph into different lymphatic quadrant

May cause fibrotic ring on the arm

May damage remaining healthy lymph vessels

Vasopneumatic pump (2)

Keep the pressure low-never >35mmHg

Used with comprehensive tx:self- massage to the neck and trunk

Segmental gradient compression starting at fingers and moving up toward the shoulder

Vasopneumatic pump (3)

Contraindication

- infection of the limb

- local or proximal malignancy

- anti-coagulant p’t

- DVT

Palliative pumping – adjunct to pain control in patient with advanced carcinoma

Exercise

Wear bandage or compression garment during ex

Abdominal breathing exercise

- clearance of deep trunk area

Lymph drainage exercise

Stretching and flexibility exercise

Strengthening exercise

Aerobic exercise

Lymph drainage exercise • Pelvic tilt • Partial sit-up with breathing • Neck rotation • Head tilt • Shoulder shrug • Shoulder rolls • Shoulder blade squeeze • Isometric hand press

Lymph drainage exercise • Shoulder rotation

• Elbow bend

• Wrist circle

• Fist clench

• Finger exercise

• breathing

Stretching and flexibility ex

Breast ca: tightness in the pectoral area or ↓shoulder mobility

For shoulder joint

cane exercise

door or corner stretch, towel

stretch

Strengthening exercise

Allow to do more activity without triggering the lymphatic response

Watch if swelling persist 24 hours after ex

Mastectomy: Shoulder blade and shoulder girdle muscle group of the arm may weaken; abdominal muscle

(Schmitz, 2009)

Aerobic exercise

Increase lymph flow (coupled with deep breathing), lose weight (obesity:higher risk for developing lymphedema and breast ca)

Walking or bicycling, swimming when it’s cool

UBE

Education

Avoid infection and injury

Avoid pressure on the involved

extremity

Avoid constrictive clothing

Avoid vigorous activity

Avoid heat

Keep skin in good condition

Education

Maintain ideal body weight

Avoid extended use of Diuretics

Eat healthful foods