Lymphatic techniques Flashcards
2 key areas of the body that affect the flow of lymphatic fluid
Respiratory diaphragm and thoracic inlet
How does the diaphragm work as a lymphatic pump?
Major pump of the body.
- Diaphragm contracts and its dome descends toward the abdomen.
- This increases the volume of the thorax –> decreasing intra-thoracic pressure and increasing intra-abdominal pressure.
These pressure differentials help venous and lymphatic return to the heart.
Thoracic inlet as a pump
The thoracic inlet is important due to the location of the thoracic and right lymphatic ducts.
- The majority of the lymphatic fluid in the body passes through the thoracic duct as it is returned into the blood venous system.
- The rest of the lymph enters the right lymphatic duct.
Both ducts must pass through the thoracic inlet area.
Junctional areas of the body that have increased biomechanical stress that often have SD
Cervicothoracic
Thoracolumbar
Lumbosacral
Location of thoracic inlet
Cervicothoracic junction area
Diaphragm junction location
The diaphragm is anatomically linked to the thoracolumbar junction via its attachments to L1 and rib 12 (which is anatomically related to T12)
Definition of lymphatic techniques
Those designed to remove impediments to lymphatic circulation and promote and augment the flow of lymph.
The purpose of treatments is to improve the functional capacity of the lymphatic system, includes maintenance of fluid balance in the body, purification, and cleaning of tissues, and enhancement of immune response.
As the lymphatic system is also involved in tissue nutrition and the absorption of macronutrients from the GI tract and interstitial fluids, treating the lymphatics can theoretically improve tissue nutrition.
Lymph stasis
Can result in edema and accumulation of particulate matter, exudates, toxins, and bacteria, leading to inflammation, impaired immune cell mobilization, tissue hypoxia, tissue fibrosis, and a variety of diseases
Treatment involving fascial layers
Any treatment that reduces fascial restrictions can theoretically improve lymphatic flow by optimizing the capacity of the intrinsic lymphatic pumps
Lymphatic pump techniques
Employ direct forces such as external pressure, changes in pressure gradients, and oscillatory movements to act as extrinsic pumps to mobilize lymphatic fluid.
Indications
- Edema, tissue congestion, lymphatic stasis
- Infection
- Inflammation
Absolute Contraindications
- Aneuresis if not on dialysis
- Necrotizing fascitis
- Lack of patient consent and/or cooperation
Thoracic inlet MFR/ “Steering Wheel” Technique
- Place hands on either side of the base of the pt’s neck with your fingers overlying the thoracic inlet and clavicle, palms over the upper trap, and thumbs contacting the transverse process of T1
- Apply a slight compression to engage the thoracic inlet fascia and move your hands independently to find the area of greatest restriction or ease on each side.
- Use superior/inferior, clockwise, counterclockwise, and tranlatory motions to assess fascia
- Hold the fascia in the position of greatest restriction or ease until a release is palpated
Rib raising
- Instruct pt to cross their arms in front of them, with their forearms overlapping. Instruct pt to lean forward resting their forearms on your chest or shoulder
- Contact the rib tubercles b/l with your fingerpads starting at the upper ribs
- Place one of your feet slightly in front of the other for stability and lean backward, applying a gentle anterolateral pressure b/l at the tubercles
- Continue treating the ribs, rhythmically moving your hands from superior to inferior.
Pelvic diaphragm release (Ischiorectial fossa release)
Diagnosis: restricted L pelvic diaphragm
Pt: supine with knees flexed
- Find pt’s L ischial tuberosity with your left thumb and slide just medial to it
- Apply a gentle superior pressure, engaging the ischiorectal fossa until a restriction is found, then apply a lateral pressure to stretch the pelvic diaphram
- Gradually increase your superior and lateral pressure until no further change is palpated
Techniques to remove central impediments to lymphatic flow
- Thoracic inlet/outlet release
- Rib raising
- Pelvic diaphragm
Techniques to remove distal impediments and move lymph from distal to central
- Anterior axillary fold technique
- Popliteal fossa release
Anterior axillary fold release
- Place your 2nd and 3rd digits on the anterior aspect of the right anterior axillary fold and your thumb on the posterior aspect of the anterior axillary fold opposite your 2 fingers
- Slowly and gently squeeze an area of congestion bw your thumb and fingers. Then apply a gently traction away from midline.
- Hold this pressure for 30-60 sec or until a release is palpated.
- Repeat for other areas of congestion along the axillary fold
Popliteal fossa MFR
- Place your hands on the medial and lateral aspect of the popliteal fossa
- Apply a slight anterior compression to engage the popliteal fossa fascia and move your hands to find the area of greatest restriction or ease. Use superior/inferior, clockwise/counterclockwise, and translatory motions to assess the fascia.
- Hold the fascia in the position of greatest restriction or ease until a release is palpated.
Oscillatory treatments to extrinsically augment lymph flow
Thoracic pump Pedal pump Abdominal pump Liver pump Spleen pump
Thoracic pump
Do not attempt this on COPD pts as it may create air trapping in the lungs. The exaggerated respiration modification may hyperventilate the pt; therefore light headedness and dizziness are common side effects
- Place your palms inferior to the pt’s clavicles with your fingers overlying the anterior chest wall (for females, you may place your hands more medially over the sternum)
- Instruct pt to inhale and exhale deeply
- During exhalation, increase your pressure on the rib cage by following the ribs’ inferior motion.
- Toward the end of exhalation, while maintaining downward pressure on the ribs, introduce a vibratory motion to the rib cage at the rate of 2 compressions/sec
- Repeated for several min or as tolerated by the pt.
Exaggerated Respiration Modification
- Rather than inducing vibratory motion during exhalation, you may follow respiration completely through exhalation
- During the beginning of the next inhalation phase suddenly release your pressure
Pedal pump
- Place palms over the plantar aspect of pt’s toes, wrapping your fingers anteriorly over the dorsum of the toes
- Carefully dorsiflex the feet to their comfortable limit
- While maintaining the feet in dorsiflexion, introduce a rhythmic motion toward the pt’s head at a rate of roughly 2 compressions/sec for 30 sec to 2 mins. This rhythm may be increased or decreased depending on the pt. The goal is to create a comfortable fluid wave of motion from head to toe emanating form your hands.
Modification: you can also do this in plantar flexion
Abdominal pump
- Place palm on pt’s epigastrium with your fingers pointing superiorly
- Pump gently in a rhythmic fashion at a rate of 20-30/min
- Continue pumping for 30 sec-2 min, or as tolerated by pt
- Release your pressure
Liver pump/Liver quiver
- Place cephalad hand underneath the lower ribs and your caudal hand on the anterior abdominal wall just inferior to the costal margin
- As the pt inhales deeply, palpate the inferior border of the liver with your caudal hand
- As the pt exhales deeply, slide your caudal hand superiorly underneath the costal margin.
- Instruct pt to inhale and exhale again. Then during exhalation, use a fast vibratory motion over the liver with your caudal hand. increase your pressure with each subsequent breath
- Repeat for 30 sec-2 min or as tolerated by pt
Spleen pump/Splenic stimulation
- Use your cephalad hand to abduct the pt’s left arm to 90 degrees and apply a gentle lateral traction
- Place your caudal hand over the lower ribs, which overly the spleen, so your fingers run parallel to the intercostal spaces
- While maintaining traction of the left arm, apply a gentle medial vibratory motion at a rate of 2 compressions/sec with your caudal hand
- Continue the vibratory motion for 30 sec-2 min, or as tolerated by pt.
Modification 1:
- Place one hand on the anterior rib cage and the other hand on the posterior rib cage overlying the spleen
- Slowly compress the rib cage b/ your hands for several seconds. Then release your pressure suddenly
Modification 2:
- Place one hand on the posterior rib cage underneath the spleen
- Percuss the back of your hand with a fist at a rate of 2/sex for 30 sec-2 min, or as tolerated by pt
