認識淋巴系統、淋巴水腫
與照護方法
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
n Abnormal accumulation of tissue
proteins, edema, and chronic
inflammation within an extremity
Primary lymphedema
n Malformation or malfunction of the
lymphatic system
- hypoplasia
- hyperplasia: too large collector,...
Secondary lymphedema
n Surgery- lymph node removed
n Radiotherapy- scar tissue
n Trauma
n Infection
n Filariasis
n P...
Stages of lymphedema
n Stage I: edema is pitting and reversible
n Stage II: spontaneous irreversible
proliferation of co...
完整之減腫脹物理治療法	
 
n Complete decongestive physiotherapy
n Complex physical therapy
n Complex lymphedema therapy
n Deconge...
完整之減腫脹物理治療法
n Intensive phase: 4 wks
n Maintaining phase: 6-9 months
- enlarging collateral lymphatics
linking obstructe...
完整之減腫脹物理治療法	
 
n Manual lymph drainage
n Bandaging
n Exercise
n Skin care
(International society of lymphology, 1997)
Factors influence lymph move
n  Do not have a central pump like the heart of the
blood circulatory system
n  Lymph angio...
Factors influence lymph move
n Low amplitude body movement, ex:
walking 40 paces/min, tend to empty
lymphatics in the che...
Manual lymph drainage (1)
n Purpose: mechanically move fluid into
initial lymphatic; cause collateral
lymphatics that cro...
Superficial
lymphatic
system
Deep
lymphatic
system
16: perforating lymphatics
initial
lymphatic
precollector
collecting ve...
Watersheds
n Sagittal, horizontal- four quadrant
(lymphotome), each section consisting of a
limb and the adjacent quadran...
Horizontal Watersheds
n Upper horizontal watershed: a line from the
jugular notch (manubrium) to the aromion,
and continu...
Anastomoses
n small lymphatic vessel
n anterior axillo-axillary, P-A-A
n anterior inter-inguinal, P-I-I
n axillo-ingui...
Manual lymph drainage (2)
n Skin movement:outer 0.3mm of the skin
n Rich bed of lymph capillaries in the
superficial tis...
Manual lymph drainage (3)
n  Pressure: very light, gentle; the softer
the tissue, the lighter the pressure, as
trying to ...
Manual lymph drainage (4)
n 40-90 mins on consecutive days
n Direction: toward the lymph node
n Speed: the greater the ...
Manual lymph drainage (5)
n Direction: stretching the lymphatics
longitudinally, horizontally, and
diagonally; toward the...
Direction
n Upper body: between the
waist and clavicle;
between the waist and spine
of the scapula on the
dorsum of the t...
Direction
n  Lower body:
n  Inguinal nodes in front:
superficial lymphatics in the
buttocks drain laterally
around the b...
Lymph node
n Function: produce lymphocyte/filter
lymph
n Do not regenerate
n Sensitive to radiotherapy
n Lymph circula...
Contraindications
n  cancer (malignancy): metastasis
n  open wounds, rashes, inflamed skin
n  fever
n  Infection
n  h...
Contraindications
n  Asthma
n  Hyperthyroidism, Hypothyroidism
n  blood clots and phlebitis:
-avoid massage for two wee...
Compression therapy
n Max reduction in 7-10 days
n Tissue looses elasticity, does not
return to original position and sh...
Compression therapy
n Bandages
n Special garments
Bandage (1)
n first 7-10 days, consecutive day
n short-stretch bandage:low resting p,
high working p
n Graded compressi...
Bandage (2)
n  Should not bandage when
- infection
- circulatory, nerve, or arterial
insufficiency problem
- pain or numb...
Special garments
Special garments
n  used when arm size is fairly stable
n Prevent swelling and maintain size of
the limb
n 20-40mmHg; 4...
Vasopneumatic pump (1)
n  Little or no lasting
beneficial effects
n  Fail to move lymph into
different lymphatic
quadran...
Vasopneumatic pump (2)
n Keep the pressure low-never
>35mmHg
n Used with comprehensive tx:self-
massage to the neck and ...
Vasopneumatic pump (3)
n Contraindication
- infection of the limb
- local or proximal malignancy
- anti-coagulant p’t
- D...
Exercise
n Wear bandage or compression
garment during ex
n Abdominal breathing exercise
- clearance of deep trunk area
n...
Lymph drainage exercise
n  Pelvic tilt
n  Partial sit-up with breathing
n  Neck rotation
n  Head tilt
n  Shoulder shr...
Lymph drainage exercise
n  Shoulder rotation
n  Elbow bend
n  Wrist circle
n  Fist clench
n  Finger exercise
n  brea...
Stretching and flexibility ex
n Breast ca: tightness in the pectoral
area or ↓shoulder mobility
n For shoulder joint
can...
Strengthening exercise
n Allow to do more activity without
triggering the lymphatic response
n Watch if swelling persist...
Aerobic exercise
n Increase lymph flow (coupled with
deep breathing), lose weight
(obesity:higher risk for developing
lym...
Education
n Avoid infection and injury
n Avoid pressure on the involved
extremity
n Avoid constrictive clothing
n Avoi...
Education
n Maintain ideal body weight
n  Avoid extended use of Diuretics
n  Eat healthful foods
Lymph collectors
n  Lymph angion: 6-20 mm, up to 10cm
n  Lymph transportation
Lymphatic circulation inside the muscle increases up
to 15 times the resting rate
Watersheds between
the trunk and the extremities
n  Inguinal watershed:
separating the lower
extremity from the trunk;
st...
楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602
楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602
楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602
楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602
楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602
楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602
楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602
楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602
楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602
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楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602

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楊靜蘭 物理治療師
國立臺灣大學醫學院附設醫院復健部物理治療技術科總治療長
國立臺灣大學物理治療學系兼任講師

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Transcript of "楊靜蘭物理治療師-認識淋巴系統水腫與照顧方法20130602"

  1. 1. 認識淋巴系統、淋巴水腫 與照護方法 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
  2. 2. Lymphedema n Abnormal accumulation of tissue proteins, edema, and chronic inflammation within an extremity
  3. 3. Primary lymphedema n Malformation or malfunction of the lymphatic system - hypoplasia - hyperplasia: too large collector, valve not working properly - aplasia
  4. 4. Secondary lymphedema n Surgery- lymph node removed n Radiotherapy- scar tissue n Trauma n Infection n Filariasis n Paralysis or immobility n Chronic venous insufficiency
  5. 5. Stages of lymphedema n Stage I: edema is pitting and reversible n Stage II: spontaneous irreversible proliferation of connective tissues, hardening of the extremity n Stage III: elephantiasis, papilloma cartilage-like hardening
  6. 6. 完整之減腫脹物理治療法 n Complete decongestive physiotherapy n Complex physical therapy n Complex lymphedema therapy n Decongestive lymphatic therapy
  7. 7. 完整之減腫脹物理治療法 n Intensive phase: 4 wks n Maintaining phase: 6-9 months - enlarging collateral lymphatics linking obstructed lymphotomes to normal ones - connective tissue, loose skin remodel
  8. 8. 完整之減腫脹物理治療法 n Manual lymph drainage n Bandaging n Exercise n Skin care (International society of lymphology, 1997)
  9. 9. Factors influence lymph move n  Do not have a central pump like the heart of the blood circulatory system n  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 n  Pumping of the arterial system n  Pumping of the skeletal muscles during activity(Fig) n  Pressure changes in the thorax during breathing
  10. 10. Factors influence lymph move n Low amplitude body movement, ex: walking 40 paces/min, tend to empty lymphatics in the chest and abdomen n External mechanical factor: manual lymphatic massage
  11. 11. Manual lymph drainage (1) n Purpose: mechanically move fluid into initial lymphatic; cause collateral lymphatics that cross the watershed become larger
  12. 12. Superficial lymphatic system Deep lymphatic system 16: perforating lymphatics initial lymphatic precollector collecting vessel
  13. 13. Watersheds n Sagittal, horizontal- four quadrant (lymphotome), each section consisting of a limb and the adjacent quadrant of the trunk (Fig) n Boundaries between the areas of lymph drainage, the direction in which lymph drains n Linear area on the skin and contain few lymph collectors n Some lymph fluid may cross the watershed via lymph capillaries (initial lymphatic plexus)
  14. 14. Horizontal Watersheds n 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 n Lower horizontal watershed: start at the umbilicus and follows the caudal limitation of the rib cage to the vertebral column
  15. 15. Anastomoses n small lymphatic vessel n anterior axillo-axillary, P-A-A n anterior inter-inguinal, P-I-I n axillo-inguinal (Fig)
  16. 16. Manual lymph drainage (2) n Skin movement:outer 0.3mm of the skin n Rich bed of lymph capillaries in the superficial tissues n 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
  17. 17. Manual lymph drainage (3) n  Pressure: very light, gentle; the softer the tissue, the lighter the pressure, as trying to move one Kleenex over the surface of another Kleenex n 30~40mmHg n 1.5~8 ounces/square inch (pressure found in the collecting lymphatics)
  18. 18. Manual lymph drainage (4) n 40-90 mins on consecutive days n Direction: toward the lymph node n Speed: the greater the amount of fluid, the slower the movement n Rhythm: maintain connection with the same area for at least a minute, repeating the stroke with the same pressure, direction, and speed
  19. 19. Manual lymph drainage (5) n Direction: stretching the lymphatics longitudinally, horizontally, and diagonally; toward the lymph node (neck, axilla, and groin) n Does not include long strokes, heavy pressure, rapid movements (ex: percussion)
  20. 20. Direction n Upper body: between the waist and clavicle; between the waist and spine of the scapula on the dorsum of the trunk n R’t axillary nodes: right arm and right side of the trunk n L’t axillary nodes: left arm and left side of the trunk n Neck: medial side of each breast, along the sternum
  21. 21. Direction n  Lower body: n  Inguinal nodes in front: superficial lymphatics in the buttocks drain laterally around the body to the inguinal nodes in front n  Lateral area of the posterior thigh draining laterally around the leg n  Medial area of the posterior thigh draining medially around the leg
  22. 22. Lymph node n Function: produce lymphocyte/filter lymph n Do not regenerate n Sensitive to radiotherapy n Lymph circulation slows down at the lymph nodes, prone to congestion
  23. 23. Contraindications n  cancer (malignancy): metastasis n  open wounds, rashes, inflamed skin n  fever n  Infection n  heart or kidney disease (CHF, kidney dialysis):edema may occur, MLD increasing blood volume by returning fluid to the blood circulation n  low blood pressure
  24. 24. Contraindications n  Asthma n  Hyperthyroidism, Hypothyroidism n  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 n  organ transplant: immune suppressing medication n  chemotherapy
  25. 25. Compression therapy n Max reduction in 7-10 days n Tissue looses elasticity, does not return to original position and shape even when fluid ↓ n Improve muscle pumping action, increase total tissue pressure n Padding
  26. 26. Compression therapy n Bandages n Special garments
  27. 27. Bandage (1) n first 7-10 days, consecutive day n short-stretch bandage:low resting p, high working p n Graded compression: greater compression distally and lesser proximally, amount of pressure determined by layer of bandages
  28. 28. Bandage (2) n  Should not bandage when - infection - circulatory, nerve, or arterial insufficiency problem - pain or numbness - recurrence of cancer
  29. 29. Special garments
  30. 30. Special garments n  used when arm size is fairly stable n Prevent swelling and maintain size of the limb n 20-40mmHg; 40-50mmHg in severe case n During physical activity and exercise
  31. 31. Vasopneumatic pump (1) n  Little or no lasting beneficial effects n  Fail to move lymph into different lymphatic quadrant n  May cause fibrotic ring on the arm n  May damage remaining healthy lymph vessels
  32. 32. Vasopneumatic pump (2) n Keep the pressure low-never >35mmHg n Used with comprehensive tx:self- massage to the neck and trunk n Segmental gradient compression starting at fingers and moving up toward the shoulder
  33. 33. Vasopneumatic pump (3) n Contraindication - infection of the limb - local or proximal malignancy - anti-coagulant p’t - DVT n Palliative pumping – adjunct to pain control in patient with advanced carcinoma
  34. 34. Exercise n Wear bandage or compression garment during ex n Abdominal breathing exercise - clearance of deep trunk area n Lymph drainage exercise n Stretching and flexibility exercise n Strengthening exercise n Aerobic exercise
  35. 35. Lymph drainage exercise n  Pelvic tilt n  Partial sit-up with breathing n  Neck rotation n  Head tilt n  Shoulder shrug n  Shoulder rolls n  Shoulder blade squeeze n  Isometric hand press
  36. 36. Lymph drainage exercise n  Shoulder rotation n  Elbow bend n  Wrist circle n  Fist clench n  Finger exercise n  breathing
  37. 37. Stretching and flexibility ex n Breast ca: tightness in the pectoral area or ↓shoulder mobility n For shoulder joint cane exercise door or corner stretch, towel stretch
  38. 38. Strengthening exercise n Allow to do more activity without triggering the lymphatic response n Watch if swelling persist 24 hours after ex n Mastectomy: Shoulder blade and shoulder girdle muscle group of the arm may weaken; abdominal muscle (Schmitz, 2009)
  39. 39. Aerobic exercise n Increase lymph flow (coupled with deep breathing), lose weight (obesity:higher risk for developing lymphedema and breast ca) n Walking or bicycling, swimming when it’s cool n UBE
  40. 40. Education n Avoid infection and injury n Avoid pressure on the involved extremity n Avoid constrictive clothing n Avoid vigorous activity n Avoid heat n Keep skin in good condition
  41. 41. Education n Maintain ideal body weight n  Avoid extended use of Diuretics n  Eat healthful foods
  42. 42. Lymph collectors n  Lymph angion: 6-20 mm, up to 10cm n  Lymph transportation
  43. 43. Lymphatic circulation inside the muscle increases up to 15 times the resting rate
  44. 44. Watersheds between the trunk and the extremities n  Inguinal watershed: separating the lower extremity from the trunk; starts at the pubic symphysis and follows the iliac crest to the apex of the sacrum n  Axillary watershed: separating the arm from the trunk; starts at the coracoid process traveling along the axillary fold, continuing posterior to the midpoint of the spine of the scapula

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