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

• 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.
  Lymphedema n Abnormal accumulation oftissue proteins, edema, and chronic inflammation within an extremity
• 3.
  Primary lymphedema n Malformation ormalfunction of the lymphatic system - hypoplasia - hyperplasia: too large collector, valve not working properly - aplasia
• 4.
  Secondary lymphedema n Surgery- lymphnode removed n Radiotherapy- scar tissue n Trauma n Infection n Filariasis n Paralysis or immobility n Chronic venous insufficiency
• 5.
  Stages of lymphedema n StageI: 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.
  完整之減腫脹物理治療法 n Complete decongestivephysiotherapy n Complex physical therapy n Complex lymphedema therapy n Decongestive lymphatic therapy
• 7.
  完整之減腫脹物理治療法 n Intensive phase: 4wks n Maintaining phase: 6-9 months - enlarging collateral lymphatics linking obstructed lymphotomes to normal ones - connective tissue, loose skin remodel
• 8.
  完整之減腫脹物理治療法 n Manual lymphdrainage n Bandaging n Exercise n Skin care (International society of lymphology, 1997)
• 9.
  Factors influence lymphmove 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.
  Factors influence lymphmove 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.
  Manual lymph drainage(1) n Purpose: mechanically move fluid into initial lymphatic; cause collateral lymphatics that cross the watershed become larger
• 12.
  Superficial lymphatic system Deep lymphatic system 16: perforating lymphatics initial lymphatic precollector collectingvessel
• 14.
  Watersheds n Sagittal, horizontal- fourquadrant (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)
• 16.
  Horizontal Watersheds n Upper horizontalwatershed: 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
• 17.
  Anastomoses n small lymphatic vessel n anterioraxillo-axillary, P-A-A n anterior inter-inguinal, P-I-I n axillo-inguinal (Fig)
• 19.
  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
• 20.
  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)
• 21.
  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
• 22.
  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)
• 23.
  Direction n Upper body: betweenthe 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
• 24.
  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
• 25.
  Lymph node n Function: producelymphocyte/filter lymph n Do not regenerate n Sensitive to radiotherapy n Lymph circulation slows down at the lymph nodes, prone to congestion
• 26.
  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
• 27.
  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
• 28.
  Compression therapy n Max reductionin 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
• 29.
  Compression therapy n Bandages n Special garments
• 30.
  Bandage (1) n first 7-10days, 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
• 32.
  Bandage (2) n  Shouldnot bandage when - infection - circulatory, nerve, or arterial insufficiency problem - pain or numbness - recurrence of cancer
• 33.
  Special garments
• 34.
  Special garments n  usedwhen 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
• 35.
  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
• 36.
  Vasopneumatic pump (2) n Keepthe 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
• 37.
  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
• 38.
  Exercise n Wear bandage orcompression 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
• 39.
  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
• 40.
  Lymph drainage exercise n Shoulder rotation n  Elbow bend n  Wrist circle n  Fist clench n  Finger exercise n  breathing
• 41.
  Stretching and flexibilityex n Breast ca: tightness in the pectoral area or ↓shoulder mobility n For shoulder joint cane exercise door or corner stretch, towel stretch
• 42.
  Strengthening exercise n Allow todo 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)
• 43.
  Aerobic exercise n Increase lymphflow (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
• 44.
  Education n Avoid infection andinjury n Avoid pressure on the involved extremity n Avoid constrictive clothing n Avoid vigorous activity n Avoid heat n Keep skin in good condition
• 45.
  Education n Maintain ideal bodyweight n  Avoid extended use of Diuretics n  Eat healthful foods
• 46.
  Lymph collectors n  Lymphangion: 6-20 mm, up to 10cm n  Lymph transportation
• 48.
  Lymphatic circulation insidethe muscle increases up to 15 times the resting rate
• 53.
  Watersheds between the trunkand 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