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楊靜蘭 物理治療師

楊靜蘭 物理治療師



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

    • 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, valve not working properly - aplasia
    • 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
    • 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
    • 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
    • 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
    • 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 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
    • 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
    • Manual lymph drainage (1) n 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 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)
    • 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
    • Anastomoses n small lymphatic vessel n anterior axillo-axillary, P-A-A n anterior inter-inguinal, P-I-I n axillo-inguinal (Fig)
    • 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
    • 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)
    • 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
    • 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)
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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 compression: greater compression distally and lesser proximally, amount of pressure determined by layer of bandages
    • Bandage (2) n  Should not bandage when - infection - circulatory, nerve, or arterial insufficiency problem - pain or numbness - recurrence of cancer
    • Special garments
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • Lymph drainage exercise n  Shoulder rotation n  Elbow bend n  Wrist circle n  Fist clench n  Finger exercise n  breathing
    • 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
    • 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)
    • 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
    • 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
    • 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; 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