manualtreatmentof lymphedema - lymfologi · vodder manual lymphdrainage accordingto slowly...
TRANSCRIPT
04.09.2012
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The different aspects in the
manual treatmentof lymphedema
patients
Elvira Albrecht & Marietta SüßlePhysiotherapists - Földiklinik
Instructors for ML/CDT - FöldischuleFöldiklinik
manual treatment oflymphedema
Manual
Lymphdrainage
manual treatment oflymphedema
=
?
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typical indications
characteristics of MLD techniques
What is Manual Lymphdrainage?
effects
definition
According toLehrbuch der Lymphologie (Földi + Földi), Lehrbuch der Entstauungstherapie (Bringezuund Schreiner), MLD nach Vodder (Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly),Ödeme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at
� MLD is a special kind of massage…
� MLD is a decongesting massage…
� MLD is a massage technique which does not fall into the
categories of any already defined techniques
� …
definition
� Vodder, stationary circles, pump strokes, scoop and
rotary technique
According toLehrbuch der Lymphologie (Földi + Földi), Lehrbuch der Entstauungstherapie (Bringezu und Schreiner), MLD nach Vodder(Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly), Ödeme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at
characteristics of MLD techniques
� covering a large area
� circle shaped
� working/pressure phase and relaxation phase
� slowly and gently
� rhytmically and repetitively
� adapted pressure
According toLehrbuch der Lymphologie (Földi + Földi), Lehrbuch der Entstauungstherapie (Bringezu und Schreiner), MLD nach Vodder(Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly), Ödeme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at
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effects
� increase of lymphangiomotoricity
� increase of lymph time volume
� helps to move interstitial fluid
� increase velocity of lymph flow through the lymph nodes
� analgesic effect
� vagotonic effect, sympathicolytic effect
� helps to influence fibrotic tissue
� Immune system ??
� stimulates new channels (anastomoses)
� positive side effect: influences increasedmuscel tension & intestinal activity
According toLehrbuch der Lymphologie (Földi + Földi), Lehrbuch der Entstauungstherapie (Bringezu und Schreiner), MLD nach Vodder(Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly), Ödeme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at
typical indications
� lymphedema
� phlebolymphostatic edema
� lipedema syndrome
� postoperative/posttraumatic edema
� edema caused by rheumatic disease
� scleroderma
� complex regional pain syndrome
� „lymphatic children“
� lymphostatic encephalopathia
� cosmetic : for acne, rosacea, scars, stretch marks
� Burns
� application in gynaecology: mastodyni, newmothers with lactation problems, edema
associated with pregnancy
� neurology: edema associated with apoplexy, MSpatients
� altering the vegetative nervous system in burn-outsyndrom, stress, and for older patients after majorsurgery, during fasting
� tinnitus patients
� Headache patients
According toLehrbuch der Lymphologie (Földi + Földi), Lehrbuch der Entstauungstherapie (Bringezu und Schreiner), MLD nach Vodder(Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly), Ödeme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at
New therapeutic method in the service of beauty
�pumping and emptying circle-shaped movements
�gentle stationary circles
Estrid & EmilVodder
Manual Lymphdrainage according to
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water content of the body =
„basic fluid“, in which all
parts of the body are
intrinsically linked
lymphatic system =
environment
lymphatic system =
cleansing systemlymph =
omnipresent
lymph =
stream of lifeinterstitial fluid =
transit route and
transport system
Estrid & EmilVodder
Manual Lymphdrainage according to
� slowly
� harmonious
� correctly
� pressure not more than 30 mmHg
Estrid & EmilVodder
Manual Lymphdrainage according to
�„ lymphatic syndrome“
�cosmetics
�hematoma
�eczema
�skin diseases
�leg wounds
�prevention
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Estrid & EmilVodder
Manual Lymphdrainage according to
� lymph renewal
� circulation activation
� reduction swelling of the mucosa
� regeneration of cell activity
� propelling lymph and removing edema
� stimulation of cell activity und speeding up regeneration
1. The Vodders developed the
Manual Lymphdrainage
at that time for a
different set of symptoms.
2. As a consequence you need to think about
modifications of methods to fit the patients
symptoms today.
anatomy of the skin
• Cutis:– epidermis
– dermis/corium
• Subcutis=hypo-dermis
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epidermis
• Keratinocytes
• Melanocytes
• Langerhans cells
• Regulate bodytemperature
• 0.8 – 1.4 mm
dermis
• Mechanoreceptors
• Nerve endings
• Hair follicels
• Sweat glands
• Lymph- andbloodvessels
subcutis/hypocutis
• No part of the skin• Connective tissue• Elastin• Fibroblasts• Macrophages• Adipocytes• Padding andinsulation
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skin anatomy
lymphatics cells,fibers
epidermis no lymphaticskeratinocytes,melanocytes,Langerhans cells
dermisinitiallymphatics,precollectors
fibroblastscollagen fibers
subcutispraefascialcollectors
fibroblasts,macrophages,adipocytes
edematous skin / normal skin
edematous skin / normal skin
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epidermis in lymphedema
• Epidermal hyperplasia
• Hyperkeratosis• Papillomatosis• Hyperpigmentation• Verrucousprotuberances
• Elephant skin
papillomatosis cutis
hyperpigmentation, papillomatosis, elephantiasis
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cutis and subcutis in lymphedema
• Stage 1 proteinrichfree fluid – reversible stage
• Stage 2 Alteration ofconnective tissue -irreversible stage
• Stage 3 –lymphostatic fibrosis- elephantiasis
elements of the connective tissue
• Cellular compartment– Fibroblasts
– Blood- andlymphvessels
– Nerves
– Small number ofinflammatory cells
• Leucocytes
• Macrophages
• Mast cells
• granulocytes
• Non-cellularcompartment– Extracellular matrixECM
– Free fluid
– proteins
extracellular matrix ECM
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glycoproteins (fibronektin)adhesionmolecules
elements of ECM
• Collagens ( 5 types)– Type I (90%) connectivetissue,tendons,ligaments
– Type III: dermis,blood vessels
• Glycoproteins– Fibronectin (adhesion molecule)– Elastin,fibrillin (elastic fibers)
• Proteoglycans– Hyaluron and others
encyme activity regulatesconstant remodeling of ECM
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proteinrich edema – damages tissue
proteinrich fluid
activated fibroblasts
chronic inflammation
proliferation of
adipose tissue proliferation of
connective tissue -
fibrosis
sclerosisproliferation of blood
vessels
proliferation of
epidermis cells:
pachydermia
hyperkeratosis
papillomatosis
lymphedema & connectivetissue
• Alteration ECM andcellularcompartment
• High density of cellsand fibres
• Less elastic fibres
• More collagen fibres
• Widened dermis andsubcutis
lymphedema & lymphatics
• Lymphatics enbeded in alterated ECM
• Changes in basementmembrane
• Anchoring filamentsdegenerated
• Loss of elastic fibres• Fibrotic valves• Enlarge lymphvessels• Disability to contract /
insufficiency
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In lymphedema, morphological changes ofconnective tissue, especially in the lymphatics,
lead to the necessity of modifying MLD
See you in 15 minutes??
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• Do you recognize treatment techniquesthat also you use for treating yourlymphedema patients?
• What would you call these techniques?
Pressure dosage
Performingsurface
…
Intensity levels
staying on one place
Combination of MLD withother approved techniques
1 sec x… sec
MLD & soft tissue technicqes
Number of repetition 1 x , 2x , 3x , ………x
Intensity levels
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Connective Tissue - assessment
• Objective:
– Ultrasound
– MRI
• Subjective:
palpation
palpation
mind
expe-rience
sense
additional medical history
Limiting factor
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What do you feel when your therapist is appliyingintensive tissue techniques in the area of the
alterated tissue?
„ There is a bit of punctual pain during application and right after that I feel kind of relief. Light and free“
„ everyday I have a pressure inside, so this counterpressurefrom outside feels like a comfortable pain. Afterward it works in the tissue“
What do you feel when your therapist is appliyingintensive tissue techniques in the area of the
alterated tissue?
„ It pinches me a bit and there issome kind ofdiscomfort“
• There is no general rule how to dose the
intensity of fibrotic tissue treatment in
lymphedema patients. It is more a specific
decision the therapist has to make for each
patient.
• An experienced therapist will take both into
consideration, findings in palpation as well as
limiting factors.
Conclusion