Lymphatic techniques

Question 1

2 key areas of the body that affect the flow of lymphatic fluid

Answer 1

Respiratory diaphragm and thoracic inlet

Question 2

How does the diaphragm work as a lymphatic pump?

Answer 2

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.

Question 3

Thoracic inlet as a pump

Answer 3

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.

Question 4

Junctional areas of the body that have increased biomechanical stress that often have SD

Answer 4

Cervicothoracic
Thoracolumbar
Lumbosacral

Question 5

Location of thoracic inlet

Answer 5

Cervicothoracic junction area

Question 6

Diaphragm junction location

Answer 6

The diaphragm is anatomically linked to the thoracolumbar junction via its attachments to L1 and rib 12 (which is anatomically related to T12)

Question 7

Definition of lymphatic techniques

Answer 7

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.

Question 8

Lymph stasis

Answer 8

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

Question 9

Treatment involving fascial layers

Answer 9

Any treatment that reduces fascial restrictions can theoretically improve lymphatic flow by optimizing the capacity of the intrinsic lymphatic pumps

Question 10

Lymphatic pump techniques

Answer 10

Employ direct forces such as external pressure, changes in pressure gradients, and oscillatory movements to act as extrinsic pumps to mobilize lymphatic fluid.

Question 11

Indications

Answer 11

• Edema, tissue congestion, lymphatic stasis
• Infection
• Inflammation

Question 12

Absolute Contraindications

Answer 12

• Aneuresis if not on dialysis
• Necrotizing fascitis
• Lack of patient consent and/or cooperation

Question 13

Thoracic inlet MFR/ “Steering Wheel” Technique

Answer 13

• 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

Question 14

Rib raising

Answer 14

• 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.

Question 15

Pelvic diaphragm release (Ischiorectial fossa release)

Answer 15

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

Question 16

Techniques to remove central impediments to lymphatic flow

Answer 16

• Thoracic inlet/outlet release
• Rib raising
• Pelvic diaphragm

Question 17

Techniques to remove distal impediments and move lymph from distal to central

Answer 17

• Anterior axillary fold technique

- Popliteal fossa release

Question 18

Anterior axillary fold release

Answer 18

• 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

Question 19

Popliteal fossa MFR

Answer 19

• 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.

Question 20

Oscillatory treatments to extrinsically augment lymph flow

Answer 20

Thoracic pump
Pedal pump
Abdominal pump
Liver pump
Spleen pump

Question 21

Thoracic pump

Answer 21

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

Question 22

Pedal pump

Answer 22

• 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

Question 23

Abdominal pump

Answer 23

• 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

Question 24

Liver pump/Liver quiver

Answer 24

• 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

Question 25

Spleen pump/Splenic stimulation

Answer 25

• 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