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楊靜蘭物理治療師-癌症病人淋巴水腫實務操作20130602
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楊靜蘭物理治療師-癌症病人淋巴水腫實務操作20130602

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楊靜蘭 物理治療師

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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楊靜蘭物理治療師-癌症病人淋巴水腫實務操作20130602 楊靜蘭物理治療師-癌症病人淋巴水腫實務操作20130602 Presentation Transcript

  • 癌症病人淋巴水腫治療   實務操作練習 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 助教:李詩瑋、陳佳琳、賴芝錦治療師 台大醫院復健部物理治療技術科
  • 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
  • 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 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
  • 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   O Usually irreversible without treatment, tends to become more fibrotic and increases in size O Malignant/primary/secondary O Combined penile and scrotal swelling O Genital swelling should precede the sequence for leg lymphedema O 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
  • 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
  • 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