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淋巴水腫之物理治療 楊靜蘭


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淋巴水腫之物理治療 楊靜蘭

  1. 1. 淋巴水腫之物理治療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 Abnormal accumulation of tissue proteins, edema, and chronic inflammation within an extremity
  3. 3. Primary lymphedema Malformation or malfunction of the lymphatic system - hypoplasia - hyperplasia: too large collector, valve not working properly - aplasia
  4. 4. Secondary lymphedema Surgery- lymph node removed Radiotherapy- scar tissue Trauma Infection Filariasis Paralysis or immobility Chronic venous insufficiency
  5. 5. Stages of lymphedema Stage I: edema is pitting and reversible Stage II: spontaneous irreversible proliferation of connective tissues, hardening of the extremity Stage III: elephantiasis, papilloma cartilage-like hardening
  6. 6. 完整之減腫脹物理治療法 Complete decongestive physiotherapy Complex physical therapy Complex lymphedema therapy Decongestive lymphatic therapy
  7. 7. Complex physical therapy Intensive phase: 4 wks 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 Manual lymph drainage Bandaging Exercise Skin care (International society of lymphology, 1997)
  9. 9. Manual lymph drainage (1) Purpose: mechanically move fluid into initial lymphatic; cause collateral lymphatics that cross the watershed become larger
  10. 10. initial lymphaticprecollector collecting vesselSuperficiallymphaticsystem Deep lymphatic system 16: perforating lymphatics
  11. 11. Watersheds Sagittal,horizontal- four quadrant (lymphotome), each section consisting of a limb and the adjacent quadrant of the trunk (Fig) Boundaries between the areas of lymph drainage, the direction in which lymph drains Linear area on the skin and contain few lymph collectors Some lymph fluid may cross the watershed via lymph capillaries (initial lymphatic plexus)
  12. 12. Horizontal Watersheds 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 Lower horizontal watershed: start at the umbilicus and follows the caudal limitation of the rib cage to the vertebral column
  13. 13. Anastomoses small lymphatic vessel anterior axillo-axillary, P-A-A anterior inter-inguinal, P-I-I axillo-inguinal (Fig)
  14. 14. Manual lymph drainage (2) Skin movement:outer 0.3mm of the skin Rich bed of lymph capillaries in the superficial tissues 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
  15. 15. Lymph collectors Lymph angion: 6-20 mm, up to 10cm Lymph transportation
  16. 16. Manual lymph drainage (3) Pressure: very light, gentle; the softer the tissue, the lighter the pressure, as trying to move one Kleenex over the surface of another Kleenex 30~40mmHg 1.5~8 ounces/square inch (pressure found in the collecting lymphatics)
  17. 17. Manual lymph drainage (4) 40-90 mins on consecutive days Direction: toward the lymph node Speed: the greater the amount of fluid, the slower the movement Rhythm: maintain connection with the same area for at least a minute, repeating the stroke with the same pressure, direction, and speed
  18. 18. Manual lymph drainage (5) Direction: stretching the lymphatics longitudinally, horizontally, and diagonally; toward the lymph node (neck, axilla, and groin) Does not include long strokes, heavy pressure, rapid movements (ex: percussion)
  19. 19. Direction Upper body: between the waist and clavicle; between the waist and spine of the scapula on the dorsum of the trunk R’t axillary nodes: right arm and right side of the trunk L’t axillary nodes: left arm and left side of the trunk Neck: medial side of each breast, along the sternum
  20. 20. Direction Lower body: Inguinal nodes in front: superficial lymphatics in the buttocks drain laterally around the body to the inguinal nodes in front Lateral area of the posterior thigh draining laterally around the leg Medial area of the posterior thigh draining medially around the leg
  21. 21. Lymph node Function: produce lymphocyte/filter lymph Do not regenerate Sensitive to radiotherapy Lymph circulation slows down at the lymph nodes, prone to congestion
  22. 22. Factors influence lymph move Do not have a central pump like the heart of the blood circulatory system 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 Pumping of the arterial system Pumping of the skeletal muscles during activity(Fig) Pressure changes in the thorax during breathing
  23. 23. Factors influence lymph move Low amplitude body movement, ex: walking 40 paces/min, tend to empty lymphatics in the chest and abdomen External mechanical factor: manual lymphatic massage
  24. 24. 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
  25. 25. 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
  26. 26. Thumb walk, thumb circle• Applied with the palmer surface of the thumb• Primarily on the hand and foot, face, bony protuberance
  27. 27. 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
  28. 28. 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
  29. 29. 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)
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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)
  34. 34. Extremityfor unilateral secondaryU/E lymphedema Subclavian trunk Lateral upper arm deltoideopectoral nodes• Mesothenar territory/Medial forearm territory/Medial upper arm territory Medial upper arm• radial hand territory/radial forearm territory/axillary, supraclavicular lymph node• ulnar hand territory/ulnar forearm Mesothenar territory territory/antecubital lymph ulnar hand territory node
  35. 35. Pectoralis major muscle along the clavicle (7 7s stationary circle AAAAI •Sternum -> parasternal •Rib cage (near nodes the axilla, below the breast)
  36. 36. •Lateral edge of scapula &PAA underarm region of the trunk IA (thoracic portion) Thoracic spine
  37. 37. Intercostal technique 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 lowerfour or five spaces unite to form a trunk,which descends and opens either into thecisterna chyli or into the commencement of the thoracic duct. The efferents of the glands in the upperspaces of the left side end in the thoracic duct; those of the corresponding right Stationary circle with 3 spaces, in the right lymphatic duct or 4 finger pads, with pressure working deep (perforation precollector)
  38. 38. Truncal decongestion for bilateral secondary U/E lymphedemaSupine• 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
  39. 39. 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
  40. 40. Truncal decongestionfor 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
  41. 41. Lumbar area• Area outlined by the lower horizontal watershed, horizontal gluteal fold, and the sagittal watershed Paravertebral• Effleurage, starting at the lympn node posterior sagittal watershed toward the inguinal LN• PII• Paravertebral lymph node Stationary circle paravertebrally with the finger pads (working deep)
  42. 42. Truncal decongestion for bilateral secondary L/E lymphedemaSupine• 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)
  43. 43. 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)
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. Genital lymphedema Usually irreversible without treatment, tends to become more fibrotic and increases in size Malignant/primary/secondary Combined penile and scrotal swelling Genital swelling should precede the sequence for leg lymphedema Complications including lymphatic cysts, fistula, lymphorrhea, bacteria and mycotic infection
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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)
  52. 52. 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
  53. 53. 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
  54. 54. 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)
  55. 55. neck• Thyroid cartilage• Depression between the cartilage and the SCM muscle
  56. 56. 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
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. Contraindications cancer (malignancy): metastasis open wounds, rashes, inflamed skin fever Infection heart or kidney disease (CHF, kidney dialysis):edema may occur, MLD increasing blood volume by returning fluid to the blood circulation low blood pressure
  61. 61. Contraindications Asthma Hyperthyroidism, Hypothyroidism 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 organ transplant: immune suppressing medication chemotherapy
  62. 62. Compression therapy Max reduction in 7-10 days Tissue looses elasticity, does not return to original position and shape even when fluid ↓ Improve muscle pumping action, increase total tissue pressure Padding
  63. 63. Compression therapy Bandages Special garments
  64. 64. Bandage (1) first 7-10 days, consecutive day short-stretch bandage:low resting p, high working p Graded compression: greater compression distally and lesser proximally, amount of pressure determined by layer of bandages
  65. 65. Bandage (2) Should not bandage when - infection - circulatory, nerve, or arterial insufficiency problem - pain or numbness - recurrence of cancer
  66. 66. Special garments used when arm size is fairly stable Prevent swelling and maintain size of the limb 20-40mmHg; 40-50mmHg in severe case During physical activity and exercise
  67. 67. Vasopneumatic pump (1) Little or no lasting beneficial effects Fail to move lymph into different lymphatic quadrant May cause fibrotic ring on the arm May damage remaining healthy lymph vessels
  68. 68. Vasopneumatic pump (2) Keep the pressure low-never >35mmHg Used with comprehensive tx:self- massage to the neck and trunk Segmental gradient compression starting at fingers and moving up toward the shoulder
  69. 69. Vasopneumatic pump (3) Contraindication - infection of the limb - local or proximal malignancy - anti-coagulant p’t - DVT Palliative pumping – adjunct to pain control in patient with advanced carcinoma
  70. 70. Exercise Wear bandage or compression garment during ex Abdominal breathing exercise - clearance of deep trunk area Lymph drainage exercise Stretching and flexibility exercise Strengthening exercise Aerobic exercise
  71. 71. Lymph drainage exercise• Pelvic tilt• Partial sit-up with breathing• Neck rotation• Head tilt• Shoulder shrug• Shoulder rolls• Shoulder blade squeeze• Isometric hand press
  72. 72. Lymph drainage exercise• Shoulder rotation• Elbow bend• Wrist circle• Fist clench• Finger exercise• breathing
  73. 73. Stretching and flexibility ex Breast ca: tightness in the pectoral area or ↓shoulder mobility For shoulder joint cane exercise door or corner stretch, towel stretch
  74. 74. Strengthening exercise Allow to do more activity without triggering the lymphatic response Watch if swelling persist 24 hours after ex Mastectomy: Shoulder blade and shoulder girdle muscle group of the arm may weaken; abdominal muscle (Schmitz, 2009)
  75. 75. Aerobic exercise Increase lymph flow (coupled with deep breathing), lose weight (obesity:higher risk for developing lymphedema and breast ca) Walking or bicycling, swimming when it’s cool UBE
  76. 76. Education Avoid infection and injury Avoid pressure on the involved extremity Avoid constrictive clothing Avoid vigorous activity Avoid heat Keep skin in good condition
  77. 77. Education Maintain ideal body weight Avoid extended use of Diuretics Eat healthful foods