楊靜蘭　物理治療師 國立臺灣大學醫學院附設醫院復健部物理治療技術科總治療長 國立臺灣大學物理治療學系兼任講師

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 of tissue
proteins, edema, and chronic
inflammation within an extremity

3. Primary lymphedema
n Malformation or malfunction of the
lymphatic system
- hypoplasia
- hyperplasia: too large collector,
valve not working properly
- aplasia

4. Secondary lymphedema
n Surgery- lymph node removed
n Radiotherapy- scar tissue
n Trauma
n Infection
n Filariasis
n Paralysis or immobility
n Chronic venous insufficiency

5. Stages of lymphedema
n Stage I: 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 decongestive physiotherapy
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: 4 wks
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 lymph drainage
n Bandaging
n Exercise
n Skin care
(International society of lymphology, 1997)

9. Factors influence lymph move
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 lymph move
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
collecting vessel

14. Watersheds
n Sagittal, horizontal- four quadrant
(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 horizontal watershed: 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 anterior axillo-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: between the
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: produce lymphocyte/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 reduction in 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 7-10 days, 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 Should not bandage when
- infection
- circulatory, nerve, or arterial
insufficiency problem
- pain or numbness
- recurrence of cancer

33. Special garments

34. Special garments
n used when 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 Keep the 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 or compression
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 flexibility ex
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 to do 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 lymph flow (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 and injury
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 body weight
n Avoid extended use of Diuretics
n Eat healthful foods

46. Lymph collectors
n Lymph angion: 6-20 mm, up to 10cm
n Lymph transportation

48. Lymphatic circulation inside the muscle increases up
to 15 times the resting rate

53. Watersheds between
the trunk and 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