The most common application of MLT techniques is for secondary lymphedema that can occur after breast or prostate cancer treatment i. In the mids, the use of MLT drainage techniques for secondary and primary lymphedema started to become known and gain popularity in the United States through reported outcomes.
If excess plasma proteins remain in tissue for a prolonged period, they cause chronic inflammation, with the eventual fibrosis of tissue. For high-plasma protein edemas, a program of MEM or MLT is necessary to move excess proteins out of the interstitium to break the scenario of chronic inflammation leading to fibrosis. Only lymphatic drainage along with macrophage phagocytic activity removes the excess proteins. Table describes common types of high-protein edemas, complex edemas, and low-protein edemas commonly seen by therapists.
From reading the table, it becomes evident that as soon as there is some type of compromise of the lymphatic system and excess proteins remain in the interstitium, the gellike edema begins, which can lead to fibrosis. Foldi et al. Classified by grades. Grade I: pitting that reduces with elevation; no fibrosis. Grade II: does not reduce with elevation, fibrosis; ranges from moderate to severe with elephantiasis as the extreme of this grade. Magnetic resonance imaging and isotopic lymphoscintigraphy show that lymphedema occupies the epifascial compartments.
Thus fibrosis of joints rarely occurs. A knowledge of the anatomy of the lymphatic system and its function is essential to develop effective edema reduction treatment programs.
This understanding begins at the arterial, venous, and lymphatic capillary level. Arteriole hydrostatic pressure of 35 mm Hg is sufficient to cause the escape into the interstitium of electrolytes, nutrients, a few plasma proteins, and other elements needed for continued tissue cell metabolism. When fluid and large molecules enter the lymphatic system, it is called lymph.
Lymph contains large molecules not permeable to the venous system, such as fat cells, hormones, tissue waste products, bacteria, and excess plasma proteins. The lymphatic tissue drainage system consists of three levels of structures. Lymph capillaries, called the initial lymphatics and precollectors, make up the first level. These are finger-shaped, closed at one end, netlike vessels located in the interstitium that directly or indirectly drain every part of the body.
The vessels consist of a single layer of overlapping endothelial cells that have connector filaments anchoring them to surrounding connective tissue Fig. The flaplike junctions formed by the overlapping endothelial cells open when the local interstitial pressure changes. The junctions open; fluid flows in, changing the internal pressure of the lymphatic from low to high, thus closing the flaplike junctions. Lymph then enters into the deeper collector lymphatics that have walls consisting of three layers.
The inner layer is called the intima or endothelium. The media or middle layer consists of smooth muscle and thin strands of collagen fibers that respond to the stretch reflex. The outer layer, called the adventitia, is formed by connective tissue. Every 6 to 20 mm within the collectors are valves that prevent the backflow of lymph.
These collector segments with a distal and a proximal valve and a space between the valves are called lymphangions. As fluid enters a lymphangion, it fills the segment, stimulating a stretch reflex of the medial smooth muscle layer. The ensuing contraction causes the proximal valve to open and propel the lymph to the next proximal lymphangion Fig.
At rest, lymphangions pump 6 to 10 times per minute. However, with muscle contraction from exercise, lymphangions can pump 10 times that amount. Collector lymphatics propel lymph to the nodes. The nodes consist of a complex of sinuses that perform immunologic functions. After leaving nodes, lymph either enters the venous system through lymph-venous anastomoses or continues to move into deeper lymphatic trunks and eventually returns to the heart. Anatomically, the trunk is divided into four lymphatic quadrants, or lymphotomes drainage territories Fig.
These consist of left and right upper quadrants, called thoracic lymphotomes, and left and right lower quadrants, called abdominal lymphotomes. The thoracic lymphotomes extend from the anterior midline to the vertebral column on both the left and right sides of the upper trunk. Lymph drains within the lymphotomes from superficial to deeper vessels that connect to nodes see Fig.
Between the lymphotomes are watershed areas i. There are only a few superficial and deep connecting lymph vessels across watershed areas, but there are superficial collateral vessels.
These collateral connections across watersheds are very important because when there is lymph congestion, they provide alternative pathways to uncongested lymph vessels. The extremities also have lymphotomes. The upper extremity lymphotomes drain mainly into the axillary nodes. Detail of this information and more extensive drawings can be found in the work of Foldi and Kubik. Lymph from the right thoracic lymphotome, right upper extremity, and right side of the head drains into trunks that eventually empty into the right lymphatic duct.
This duct empties into the right subclavian vein and into the superior vena cava of the heart. Both lower extremities, both abdominal lymphotomes, the left thoracic lymphotome, and the left side of the head drain into the thoracic duct, which is the largest lymphatic vessel in the body and extends from L2 to T4.
The thoracic duct empties into the venous system at the juncture of the left subclavian and jugular veins. Success of edema reduction programs and related problem solving depends on clinically applying lymphatic anatomic information. For instance, movement of the large molecules not permeable to the venous system out of the interstitium depends on stimulating the flaplike endothelial cell junctions of the initial lymphatics to open and close.
Heavy massage or compression will not stimulate, but instead collapse, the initial lymphatics and prevent absorption of lymph. Eliska and Eliskova found that a minute friction massage to the dorsum of feet done with 70 to mm Hg of force caused temporary damage to the endothelial lining of the initial and collector lymphatics.
For patients with edema, this damage occurred within 3 to 5 minutes. Miller and Seale found that external pressure facilitates lymph clearance. They also found that a pressure of 60 mm Hg initiated lymphatic closure, with complete closure at 75 mm Hg. With complete closure of the initial lymphatics, there is no uptake of lymph from the interstitium.
Thus the clinical treatment approach should be light-compression massage to stimulate, not hinder, absorption at the dermis level. Heavy compression or squeezing collapses the lymphatics, causing the fluid component of lymph to be pushed into the venous system. However, plasma proteins, tissue waste products, fat cells, and so forth, remain in the interstitium. The digit or limb temporarily looks smaller, but the swelling returns. Plasma proteins that remain in the interstitium increase colloid osmotic pressure, attracting more fluid out of the capillaries and into the interstitium, thus refilling occurs.
Light compression of initial lymphatics for absorption of protein can also be accomplished through a multilayered low-stretch bandaging system. Leduc et al. It has also been shown that temperature affects movement of lymph. Lymph moves from the collector lymphatics through the lymph nodes.
The Casley-Smiths state that congestion of lymph is often present around lymph nodes. They further state that lymph nodes give times the resistance to the flow of fluid as the thoracic duct. In clinical treatment, it is seen that massaging the nodes proximal to the edematous site increases the rate of lymph movement out of the area and prevents lymph congestion in the node area.
Thus, if the nodes proximal to the edematous area are first massaged e. Enlarged nodes e. All lymph fluid eventually returns to the venous system and enters the heart as part of the venous system. As a result, therapists have to be careful not to quickly return a large volume of fluid back into the heart if there are any preexisting or uncontrolled cardiac or pulmonary problems.
MEM classes teach how to safeguard against potential problems. The division of the trunk into four lymphatic quadrants, or lymphotomes, is significant clinically. MEM was first described in the late s as a method of decreasing subacute and chronic edema in orthopedic patients through stimulation of the lymphatic system. However, although the concept of MEM is relatively new, the history of MEM from a physiologic perspective is closely linked with historical revelations regarding the lymphatic system.
Throughout the 17th and 18th centuries, scientists, anatomists, and physicians described the role of the lymphatic system as part of the circulation system within the body, with lymph flowing from tissues, through the lymphatics, and into the bloodstream.
Additionally, during this time frame, the connection between the lymphatic system and edema was also appearing in the literature. Treatment techniques designed to capitalize on this link between the lymphatic system and edema started appearing in the literature during the 19th and 20th centuries, as several massage therapists and physicians designed different manual techniques to stimulate the lymphatic system for edema reduction purposes.
Since then, variations of the MLD technique have been reported in the literature under terms such as decongestive lymphatic therapy, complex decongestive physiotherapy, and lymph drainage therapy. Recently, the term manual lymphatic treatment MLT has been increasingly used in scientific publications to describe principles common to all schools of lymphatic drainage, and, therefore, despite the numerous acronyms, all these aforementioned techniques are designed to stimulate the lymphatic system through the application of light compression bandages, light massage, exercises, and skin care.
Currently, there is one published quasiexperimental study on MEM. This study demonstrated statistically significant reductions in edema in four of the five subjects by using a single-subject design study when MEM was entered into the standard treatment protocol. Additionally, there is one published case study on MEM demonstrating how MEM can be incorporated into a treatment program for a patient with multiple traumas to the upper limb.
Although MEM is starting to appear in the literature as an effective treatment option for specific patient populations, , there is still a need for continued research on the use of lymphatic therapies for orthopedic patients because such research may alter how therapists initially treat orthopedic edema. MEM is built on the same theoretical foundation as manual lymphatic therapies.
The anatomical and physiological support for manual lymphatic therapies is that stimulation of the lymphatic system is necessary to decrease high-protein edema.
Typically, the concentration of these larger proteins in the interstitial spaces remains low because these proteins do not diffuse easily through the microvessels. These plasma proteins that leak into the interstitium are too large to permeate the venous system , and need to be disposed of through the lymphatic system , because a primary role of the lymphatic system is to dispose of matter that is too large for the venous system.
However, after an injury, the lymphatic system may be damaged or overloaded, which can hinder its ability to dispose of these larger plasma proteins. This increase in the interstitial colloid osmotic pressure subsequently draws more fluid into the interstitial spaces. Therefore, if these proteins remain in the interstitium, the edema will persist because of the pull of fluid into the interstitium. Prolonged stagnation of plasma proteins in the interstitium leads to chronic inflammation. The lymphatic tissue drainage system consists of three levels of structures.
The lymph capillaries, called the initial lymphatics and precollectors, make up the first level. The vessels consist of a single layer of overlapping endothelial cells that have connector filaments anchoring them to surrounding connective tissue , Fig. The flaplike junctions formed by the overlapping endothelial cells open when the local interstitial pressure changes.
When the junctions open, fluid flows in, changing the internal pressure of the lymphatic from low to high, thus closing the flaplike junctions. Lymph then enters the deeper tube-shaped collector lymphatics. The collector lymphatics have walls consisting of three layers. The inner layer is called the intima or endothelium.
The media or middle layer consists of smooth muscle and thin strands of collagen fibers that respond to the stretch reflex. The outer layer, called the adventitia, is formed by connective tissue. Every 6 to 20 mm within the tube-shaped collectors are valves that prevent the backflow of lymph. The space, or chamber, between the valves is called a lymphangion.
As fluid enters a lymphangion, it fills the segment, stimulating a stretch reflex of the medial smooth muscle layer. The ensuing contraction causes the proximal valve to open and propel the lymph to the next proximal lymphangion , Fig. At rest, lymphangions pump 6 to 10 times per minute. However, with muscle contraction from exercise, lymphangions can pump 10 times that amount. The collector lymphatics propel lymph to the nodes.
The nodes consist of a complex of sinuses that perform immunologic functions. After leaving the nodes, lymph either enters the venous system through lymph-venous anastomoses or continues to move into deeper lymphatic trunks and eventually returns to the blood circulatory system via the left and right subclavian veins.
Anatomically, the trunk is divided into four lymphatic quadrants, or lymphotomes drainage territories. These consist of left and right upper quadrants, called thoracic lymphotomes, and left and right lower quadrants, called abdominal lymphotomes. The thoracic lymphotomes extend from the anterior midline to the vertebral column on both the left and right sides of the upper trunk. Lymph drains within the lymphotomes from superficial to deeper vessels that connect to nodes.
Between the lymphotomes are watershed areas i. These collateral connections across watersheds are very important because when there is lymph congestion, they provide alternative pathways to uncongested lymph vessels.
The extremities also have lymphotomes. The upper extremity lymphotomes drain mainly into the axillary nodes. Detail of this information and more extensive drawings can be found in the work of Kubik. Lymph from the right thoracic lymphotome, right upper extremity, and right side of the head drains into trunks that eventually empty into the right lymphatic duct. This duct empties into the right subclavian vein and into the superior vena cava of the heart.
Both lower extremities, both abdominal lymphotomes, the left thoracic lymphotome, and the left side of the head drain into the thoracic duct, which is the largest lymphatic vessel in the body and extends from L2 to T4.
As defined by Medline Plus, in a publication of the National Institutes of Health, edema is a type of swelling caused by trapped fluid within the body's tissues.
It is essential to identify the underlying cause of edema to develop a proper treatment plan. According to the Mayo Clinic, doctors may recommend taking diuretics and using home remedies to remove excess fluid from body tissues and effectively treat edema.
Normally, the body removes excess fluid before it builds up, but several factors may lead to edema. Some are temporary such as edema caused by pregnancy. Other forms of edema may be caused by a serious underlying health concern such as heart, liver, or kidney disease. Temporary conditions of edema may occur to most people at some point in their lifetime and may be easily treated by massage therapy.
However, if the edema is caused by a more serious condition, then your priority should be to see a physician for a complete diagnosis of the cause. Massage therapy works by directing pressure to the skin and muscle areas affected by edema.
The lymphatic system is activated during the process and the fluid drains away naturally. The activation of the lymph nodes is the key to getting the body to naturally drain away from the excess fluid accumulation that causes edema. The lymphedema massage , also known as Manual Lymphatic Drainage MLD or Lymph Drainage Therapy LDT , is a gentle form of massage that helps the body's lymphatic system start moving again while reinforcing the immune function.
You may probably have to schedule more than one session and discuss your symptoms clearly with the massage therapist. Your massage therapist can also show you some self-massage techniques that you can use between appointments. Anyone wanting to address issues of musculature, as well as lymph, must try minutes of deep tissue massage, followed by minutes of lymph massage.
This is a special type of massage introduced by Emil Vodder, a Danish massage practitioner. It involves employing the lymphatic system to drain fluids from the area affected by edema. Generally, the massage is gentle and done in the direction of the heart. The technique used has since been improved upon by Bruno Chikly, a French doctor. In the new system, lymph flow is classified by rhythm, depth, and pressure. A lymphatic map now makes it possible for massage practitioners to better relieve edema.
The basic principle of manual lymphatic drainage as practiced now involves massaging the body parts nearer proximal to the heart before the parts farther away distal. This technique was introduced following a clearer understanding of the lymphatic system.
It is important to massage proximal areas first to clear the path for the flow of fluids when the distal parts are massaged. If the distal parts were massaged first, the drainage will only move the edema from one part of the body to another since the path to the lymph nodes will be obstructed. After a manual lymphatic massage, the area affected by the edema should be wrapped in low-stretch bandages. This is necessary to support the connective tissue and maintain a constant pressure that inhibits the further accumulation of fluids.
Massage or manual lymphatic drainage is not recommended for all types of edema. It is especially useful for lymphedema and pedal edema.
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