Osteopathic Lymphatic Treatment Considerations

00:00 So, going back to our case, our 24-year-old female with idiopathic lymphedema, and we decided to utilize OMT after any other organic cause before the edema was ruled out. So when utilized, osteopathic manipulative medicine for treating lymphatics, there are certain things we have to take into account. First and foremost, we want to address any sort of restrictions of the musculoskeletal system which may contribute to decrease lymphatic flow. So,we want to treat the muscular pumps. So looking at muscle spasms that we could treat, we want to treat the diaphragm to allow for improved motion to allow for those pressure changes in the thorax, the pumping of the cisterna chyli. We also want to look at rib cage motion. So if we have rib cage restrictions that would decrease lymphatic flow because we cannot get as much excursion of the rib cage when we are breathing and also looking at how peripheral edema could overload the interstitial tissue and then impede lymph drainage. So try to decrease that edema by promoting the pump could help to overcome that pressure. So, our goals of treatment include enhancing fluid flow, improving respiratory exchange, improving the removal of waste products and improving the supply of nutrients to the region. Certain indications for lymphatic drainage techniques include treating pulmonary diseases, COPD, any sort of lymphedema, acute musculoskeletal injuries due to the inflammation, and also treating liver diseases. So, we are going to take a closer look at the different types of lymphatic treatments that we could utilize. It is important to understand that there is a specific sequence that we have to follow when utilizing osteopathic treatment and so first we should start off by utilizing osteopathic techniques aimed at removing any sort of restrictions to lymphatic flow. This will include looking at the diaphragms throughout the body, anywhere where these restrictions might prevent proper flow. The second step is to aim at treating any sort of restrictions that normally would help promote lymph flow. So here addressing restrictions of the thoracic cage or the musculoskeletal system. Finally, we want to utilize techniques to augment lymph flow. So, different techniques that include pumping techniques to get flow moving a little bit better. So, it is again important to follow that sequence because you really want to open up the drains first before you start pumping. So, it is most efficient to treat the central components and then we are going to work outward towards the periphery.

02:59 So, we always want to work from proximal to distal. So, one of the key areas to look at structurally is our thoracic inlet. The thoracic inlet is the area of terminal drainage. So, our left thoracic duct passes through that thoracic inlet before it drains into the subclavian and so if we have restrictions of the thoracic inlet that is going to prevent proper lymphatic flow. The cisterna chyli lies just posterior to the abdominal diaphragm and so any restriction of the abdominal diaphragm will also potentially compress on the cisterna chyli and also any sort of restriction of the abdominal diaphragm is going to decrease this excursion thus decreasing them out of changes in pressure in the thoracic cavity. So, here is a closer look at the thoracic inlet. Again, the thoracic inlet is that area of terminal drainage should be the area that we address first. So, any sort of restrictions of the first rib C7-T1, the sternum, the clavicles, all these could play a part in how the thoracic duct and the right lymphatic duct drain in the region. So, we want to remove any sort of possible obstructions to the lymphatics first and so if you think about it, lymphatic runs along a longitudinal plane and any horizontal structures could potentially impede its flow. So, the horizontal structures throughout our body are our diaphragms and so there are seven main diaphragms in the body that we need to consider when treating lymphatics. So in the head, we have the diaphragma sellae where the pituitary hangs from, you have the tentorium cerebelli. So these two when you are working with the cranial and patients that may present with issues with headaches or anything that may require more lymphatic drainage, you want to think about treating the structures that attach to these diaphragms. We mentioned the thoracic inlet as a potential diaphragm that needs to be treated, the abdominal diaphragm is a key diaphragm again that needs to be treated for lymphatics, pelvic diaphragm has many different muscles in the region that could also influence proper drainage in the abdominal cavity and also the lower extremities. The popliteal fossa is not a true diaphragm but it is where the gastroc and the hamstrings kind of meet and so if we have any sort of muscle spasm in the gastrocs or the hamstrings that could potentially restrict that lymphatic flow along the posterior aspect of the leg. Finally, the plantar fascia is also a diaphragm and here restrictions swelling in the feet could be potentially affected by that fascia. We are taking a closer look at the respiratory diaphragm and so the abdominal diaphragm attaches anteriorly to the xiphoid and the sternum, the anterior costal margin which is the ribs 7 through pretty much 10 anteriorly, posteriorly at the 11th and the 12th rib and also along the lumbar vertebrae. So, if we have restrictions of the abdominal diaphragm it is crucial that you look at these structures to check for any somatic dysfunctions and make sure you treat it with osteopathic manipulation. So, here we are emphasizing again how the diaphragm moves with inhalation and exhalation, so the diaphragm will descend when you inhale again creating a negative pressure in the thoracic cage and then the diaphragm will dome when you exhale and relax. So, there are changes to the thorax also which help to increase venous and lymphatic return. So when I inhale, the thoracic cage expands and when I exhale they recoils and so if there are restrictions of the thoracic cage and spine that is also going to contribute to decreased lymphatic flow. So, when we want to augment to shape change we want to treat the diaphragm to improve its natural motion and then also try to improve thoracic cage excursion and then try to improve fluid flow throughout the thorax with different pumps. So, with the lymphatic treatment again, always try to address the respiratory and circulatory systems, respiration is the primary force behind lymph motion and by treating the respiratory diaphragm we help to get more excursion and improve that pressure change in the chest to allow for proper lymph flow. So, here you could see the application of osteopathic manipulation with using balanced ligamentous tension in the thoracic inlet or you could use a myofascial release and also we could utilize diaphragm doming where utilizing gentle pressure on the diaphragm to improve diaphragmatic motion. So, our thoracic cage here is consistent of about 146 different joints. These are the articulations between the spines itself and the spine and the rib and the ribs with the sternum. So, any sort of somatic dysfunction along the rib cage, the thoracic spine, the sternum contribute to its excursion. So, like we have said before breathing is the main force creating lymphatic flow and if we have restrictions to breathing or along the thoracic cage that could restrict the amount of lymphatic flow. So, the other thing that treating the ribs and the rib heads could do is could potentially balance our autonomic system so remember that larger lymph vessels do have smooth muscle around it that contract and so if we have hypersympathetic tone that could potentially constrict the larger lymph vessels. So utilizing gentle rib raising could help decrease some facilitation and balance autonomic tone. Rib raising could also potentially improve thoracic cage excursion. To address parasympathetic innervation, we want to address any potential somatic dysfunctions at the cranial base below the occiput. So utilizing suboccipital release treating the OA, any sort of dysfunctions along the upper cervical region could also contribute to compression of the vagus nerve leading to problems with parasympathetic innervation of our lungs and you could also utilize balanced ligamentous tension to treat the cervical spine. It is also important to remember the sacrum also provides parasympathetic innervation to the body so making sure to check the SI joints and the sacrum when addressing parasympathetics. There are different techniques that we could utilize to improve thoracic compliance. We could utilize myofascial release; muscle energy to the clavicles, ribs and spine; utilizing inhibitory pressures to the accessory muscles of respiration. So, our diaphragm is the main muscle for respiration but we have accessory muscles for respiration that help to move the thoracic cage and usually those muscles are not engaged unless you have difficulty breathing or you need to increase your thoracic motion and movement such as when you are exercising. So, these muscles in patients that have infection or chronic disease sometimes will become more hypertrophied. So if you ever treat somebody who has emphysema or COPD you could see how their neck muscles, their sternocleidomastoid, their scalene muscles, those accessory muscles of respiration that become really hypertonic and hypertrophied because of its overuse and so osteopathic manipulation could help relax some of those accessory muscles of respiration that are being shortened and spasmed and allow it to function better. We could also utilize articulatory techniques to get the spine and ribs moving better and again rib raising either seated or supine could help to articulate and move the rib cage so that they move better and allow for better excursion of the thoracic cage.