E2 LAB - Lymphatics

What do you do after you've treated the carpal tunnel baffle?

Move from segment to segment (proximal to distal) and start fluid movement from distal to proximal in that segment to move fluid toward the Thoracic Inlet/Cysterna Chyli

Upper Extremity Lymphatic Sequence Procedure?

1. For the following locations, use gentle, increasing pressure to the congested underlying lymphatics and fascia. Hold the pressure until a release is palpated. -There may be multiple points of congestion within a given area -Each congested area should be treated. -After treatment is complete, including both addressing the baffles as well as augmenting flow, reassess for changes in lymphatic congestion a. Anterior and Posterior Axillary Fold Release - use either a pincer grasp on the axillary fold and apply traction, or apply a compressive force as described above. Reassess. b. Antecubital Fossa Release-apply a compressive force as described above with the thumbs engaging the fascia of the antecubital fossa and spreading laterally. Hold until a release is felt. Reassess. c. Carpal Tunnel Release- apply a compressive force as described above with the thumbs engaging the fascia of the carpal tunnel and spreading laterally. Hold until a release is felt. Reassess.

Lower Extremity Lymphatic Sequence Procedure?

1. For the following locations, use gentle, increasing pressure to the congested underlying lymphatics and fascia. Hold the pressure until a release is palpated. -There may be multiple points of congestion within a given area. -Each congested area should be treated. -After treatment is complete, including both addressing the baffles as well as augmenting flow, reassess for changes in lymphatic congestion. a. Inguinal ligament- apply a compressive force as described above with the palpating (under) hand engaging the inguinal ligament perpendicularly. The top hand provides the compressive force into the ligament. Hold until a release is felt. Reassess. b. Popliteal fossa- apply a compressive force as described above with fingers of both hands engaging deeply into fascia of the popliteal fossa and providing a gentle spreading force. Hold until a release is felt. Reassess. c. Achilles tendon- apply a compressive force as described above with fingers and thumb of the right hand engaging the fascia of the space just anterior to the Achilles tendon at the level of the malleoli. Hold until a release is felt. Reassess.

What is the order of baffles for LE? (6)

For LE Open ALL the baffles from Thoracic Inlet to Ankle except those specific to Upper Extremity Thoracic Inlet -> thoracoabdominal diaphragm -> pelvic diaphragm -> inguinal ligament -> popliteal fossa -> Achilles Tendon

Thoracic Pump/ Miller Pump Mechanism? What patient is contraindicated? Example diagnosis? Physician Position? Patient Position?

Mechanism: This technique increases the negative pressure within the thoracic cavity to create an exaggerated inhalation. -This increase in negative pressure creates a stronger suction force pulling lymph up from the abdominal cavity into the thoracic cavity and emptying from the thoracic duct into the superior vena cava. -The modifications of this technique are relatively contraindicated in COPD patients, as they may increase air trapping. -This technique can hyperventilate the patient and cause transient light-headedness or dizziness. Example Diagnosis: Lymphatic congestion anywhere Physician Position: Standing at patient's head Patient Position: Supine

Thoracic Pump/ Miller Pump Modification 1?

Modification 1: 1.Follow steps 1-3 above. -Place palms inferior to patient's clavicles with fingers overlying the anterior chest wall. For female patients, rotate the fingers laterally and minimize pressure over breast tissue by placing more of the pressure on the hypothenar eminence. -Instruct patient to inhale and exhale deeply. -Introduce a rhythmic posterior/inferior motion at a rate of roughly 2 compressions per second. This rhythm is specific to each patient and should be comfortable for both the physician and patient. 2. During exhalation, increase pressure on rib cage by following the ribs' posterior/inferior motion—augmenting exhalation. During inhalation resist anterior/superior motion of the rib cage. 3. Follow steps 4-6 above. -Continue/Induce rhythmic motion for 30 seconds to 2 minutes until a release is palpated. -Return patient to neutral. -Reassess.

Thoracic Pump/ Miller Pump Modification 2?

Modification 2: 1.Follow steps for modification 1. 2. As patient begins last breathing cycle abruptly release pressure just as they begin to inhale. 3. Patients will often reflexively gasp air expanding the chest cavity. -(They also have a tendency to start coughing, so turn your head away from them and their head away from you before you start the pump.) 4. Reassess.

Pedal Pump/Dalrymple Pump Modified procedure? (6)

Modification: 1. Place palms over the dorsal aspect of the patient's feet 2. Carefully plantar flex the feet. 3. While maintaining plantar flexion, introduce a rhythmic motion (augmenting dorsiflexion) toward the patient's head at a rate of roughly 2 compressions per second. This rhythm is specific to each patient and should be comfortable for both •the physician and patient. You should see motion from the top of the head to the bottom of the feet. 4. Continue inducing rhythmic motion for 30 seconds to 2 minutes until the motion feels freely connected from the patient's head to toe and free of restriction. 5. Return patient to neutral. 6. Reassess.

What do you do after you've treated the achilles tendon baffle?

Move from segment to segment (proximal to distal) and start fluid movement from distal to proximal in that segment to move fluid toward the Thoracic Inlet/Cysterna Chyli

Treatment: Thoracic Inlet MFR ("steering wheel technique") Procedure? (5)

Procedure: 1. Anterior contact is made across sternoclavicular junction and ribs 1 and 2. Posterior contact is made with T1-2 and costovertebral junction. Therefore, the physician places hands on either side of the base of the patient's neck with fingers overlying the thoracic inlet and clavicle, palms over the upper trapezius, and thumbs contacting the transverse process of T1. 2. Apply slight compression to engage the thoracic inlet fascia, including Sibson's fascia. 3. Induce motion in anterior-posterior, medial-lateral, and rotational planes until the desired position is achieved.* 4. Hold 20-60 seconds until tissue creep indicates a release of tissue tension. 5. Reassess. With direct MFR, place the tissues in the position that creates more tension and follow the barrier as it moves until the release. With indirect MFR, place the tissues in the direction(s) of ease and follow until palpating a release.

Diaphragm Doming (Respiratory-assist ME) Procedure?

Procedure: 1. Contact just posterior and inferior to the anterior and lateral costal margin using the thumb. The rest of the hand drapes over the inferior-lateral costal margin. 2. Gently slip the thumbs under the costal margin and apply a slight superiorly and medially directed compression force to engage the costal margin and the diaphragmatic fascia. 3. Instruct the patient to take several slow and full breaths. 4. As the patient exhales, a gentle but firm compression is induced with a superomedial force vector in the direction of the uppermost dome of the diaphragm. 5. As the patient inhales, the operator holds this compression, effectively restricting full inhalation. 6. This procedure is repeated for 2-3 breaths. 7. Reassess.

Thoracic Pump/ Miller Pump Procedure? (6)

Procedure: 1. Place palms inferior to patient's clavicles with fingers overlying the anterior chest wall. -For female patients, rotate the fingers laterally and minimize pressure over breast tissue by placing more of the pressure on the hypothenar eminence. 2. Instruct patient to inhale and exhale deeply. 3. Introduce a rhythmic posterior/inferior motion at a rate of roughly 2 compressions per second. -This rhythm is specific to each patient and should be comfortable for both the physician and patient. 4. Continue rhythmic motion for 30 seconds to 2 minutes until a release is palpated. 5. Return patient to neutral. 6. Reassess.

Pedal Pump/Dalrymple Pump Procedure? (6)

Procedure: 1. Place palms over the plantar aspect of the patient's toes, wrapping your fingers anteriorly over the dorsum of the toes. 2. Carefully dorsiflex the feet. 3. While maintaining dorsiflexion, introduce a rhythmic motion (augmenting dorsiflexion) toward the patient's head at a rate of roughly 2 compressions per second. This rhythm is specific to each patient and should be comfortable for both the physician and patient. You should see motion from the top of the head to the bottom of the feet. 4. Continue inducing rhythmic motion for 30 seconds to 2 minutes until the motion feels freely connected from the patient's head to toe and free of restriction. 5. Return patient to neutral. 6. Reassess.

What is the order of baffles for UE? (4)

Thoracic Inlet -> Axilla -> Antecubital Fossa -> Carpal Tunnel

What are the steps to diagnose the lymphatic system? (3)

To refresh your memories, diagnose each of the baffle areas, starting with the Thoracic Inlet in the same way you would diagnose any area that is to be treated with MFR. 1) Get a firm (not hard, or pokey) grip on the area to be tested, using as much surface area of your hands as possible. -A good idea is to think about using the palmar surface of all of the interphalangeal joints as well as the entire palm of the hand (or as much of that area as will fit). 2)Move the tissue in 3 planes, looking for restrictions in each one 3)Remember, the diagnosis is where the tissues like to go

T/F? Treat lymphatics proximal to distal. What do you ALWAYS start with?

True. Always start with opening Thoracic Inlet

Most of the techniques listed in this lab include instructions on hand placement for diagnosis (and treatment), starting with the first one, "Steering Wheel Technique".

just fyi

What are two conditions that must be fully evaluated and controlled before or concurrently with OMT before lymphatic treatment?

•A poorly controlled patient with CHF could easily be volume over-loaded by over-treating the lymphatics •Although it was originally NOT recommended to work on lymphatics for patients with cancer, that has changed. IT IS STILL IMPORTANT TO LIST RISKS AND BENEFITS BEFORE TREATING.

What are indications for lymphatic treatment? (5)

•Congestive heart failure (CHF) •Pregnancy •Pre-op and Post-op patients •Sedentary/Bedridden patients •Lymphoma and other malignancies

LOBS

•Discuss the potential goals for myofascial release (MFR) techniques. •Identify the indications, limitations and contraindications for Muscle Energy Technique, Myofascial Release and Pump techniques in this body region Describe and demonstrate techniques discussed in lab: •Re-doming of the Diaphragm (MFR) •Thoracic Inlet (MFR) •Upper Extremity Lymph sequence •Lower Extremity Lymph sequence •Pedal Pump •Thoracic Pump •Sutherland's Lymphatic technique

Lower Extremity Lymphatic Sequence Example diagnosis? Physician Position? Patient Position?

•Example Diagnosis: Lymphatic congestion in left lower extremity •Physician Position: Seated or standing at patient's side •Patient Position: Supine

Upper Extremity Lymphatic Sequence Example diagnosis? Physician Position? Patient Position?

•Example Diagnosis: Lymphatic congestion in right upper extremity •Physician Position: Seated or standing at patient's side •Patient Position: Supine

Diaphragm Doming (Respiratory-assist ME) Example diagnosis? Physician Position? Patient Position?

•Example Diagnosis: Restriction in diaphragm excursion, inhalation or exhalation •Physician Position: Standing to the patient's side facing cephalad •Patient Position: Supine

Sutherland's Lymphatic Technique Example diagnosis? Physician Position? Patient Position?

•Example diagnosis: Lymphatic stasis •Physician position: Standing at the head and side of the patient •Patient position: Supine

Exception: What is the order of baffles in people with sinus congestion or other HEENT problems? (3)

•Exception: If treating sinus congestion or other HEENT problems, treat Thoracic Inlet, then OA, then the thoracoabdominal diaphragm because those are all the baffles that might affect drainage from the head.

Pedal Pump/Dalrymple Pump Mechanism? What should be done before this technique? Example diagnosis? Physician Position? Patient Position?

•Mechanism: This technique increases pressure on the lymphatic fluid system, augmenting flow toward the thoracic duct. -Before using this technique, the thoracic inlet, thoracic diaphragm, and lower extremity baffles should be treated. •Example Diagnosis: Lower extremity lymphatic congestion •Physician Position: Standing at the foot of the table •Patient Position: Supine

Treatment: Thoracic Inlet MFR ("steering wheel technique") Mechanism? Diagnosis? Physician position? Patient position?

•Mechanism: Utilizing the boundaries of the thoracic inlet, it is easy to treat the entire complex with MFR to release lymphatic obstruction and promote lymphatic flow throughout the body. •Diagnosis: Flexed, rotated and sidebent right •Physician Position: Standing behind patient or seated at patient's head •Patient Position: Seated or supine

Sutherland's Lymphatic Technique Procedure? (10)

•Procedure: 1. Place a sensing hand over the left* subclavicular area near the midclavicular line. 2. Place the treating hand over the sensing hand and induce rhythmic oscillations in a superior to inferior manner for 30-60 seconds. 3. Next, move to the epigastric area; stand to the patient's side and face cephalad. 4. Place a sensing hand so that the finger pads are just inferior to the xiphoid process pointed superiorly (over cisterna chyli). 5. Place a treating hand over the sensing hand and induce rhythmic oscillations in an inferior to superior manner for 30-60 seconds. 6. Next, move to the hypogastric area; stand to the patient's side facing cephalad. 7. Place a sensing hand with finger pads approximately 2 inches inferior to the naval pointed superiorly. 8. Place a treating hand over the sensing hand and induce rhythmic oscillations in an inferior to superior manner for 30-60 seconds. 9. Release the pressure. 10. Reassess. •*Note - If the desired area to be drained corresponds to the right thoracic inlet (head and right upper extremity), do this technique on the right side

What are the goals of MFR in lymphatic treatment? (3)

•Restore Healthy motion of fluids (like lymph and blood) (optimize Flow) •Relieve Congestion in tissues (remove obstructions) •Restore "normal" Common Compensatory Pattern