Manual Lymphatic TherapyManual Lymphatic Therapy

Increasing outcomes and decreasing Increasing outcomes and decreasing lengths of stay in orthopedic lengths of stay in orthopedic

populations with MLTpopulations with MLT

Purpose for the coursePurpose for the course

•• To become familiar with the indications and To become familiar with the indications and contraindications for Manual Lymphatic Therapy in contraindications for Manual Lymphatic Therapy in orthopedic populations. orthopedic populations.

•• To benefit patient outcomes and add to the marketable To benefit patient outcomes and add to the marketable skills of the therapists and the toolbox from which to skills of the therapists and the toolbox from which to draw the most beneficial treatmentsdraw the most beneficial treatments

•• To increase patient outcomes and decrease lengths of To increase patient outcomes and decrease lengths of stay using MLTstay using MLT

What does the lymphatic system What does the lymphatic system do?do?

•• An open loop system that absorbs excess fluid from extraAn open loop system that absorbs excess fluid from extra--cellular cellular tissue spaces. This fluid is designed to cleanse and filter thetissue spaces. This fluid is designed to cleanse and filter the tissues tissues as it goes. The fluid is eventually moved to the circulatory syas it goes. The fluid is eventually moved to the circulatory system stem and joins it in the function of absorbing fats from the intestinand joins it in the function of absorbing fats from the intestines. This es. This fluid is rich in white blood cells. Any excess fluid is then mofluid is rich in white blood cells. Any excess fluid is then moved from ved from the circulatory to the renal system to be excreted. the circulatory to the renal system to be excreted.

•• The lymph system functions to filter harmful bacteria, make whitThe lymph system functions to filter harmful bacteria, make white e blood cells, increasing immunity, maintain a fluid balance in thblood cells, increasing immunity, maintain a fluid balance in the e body, and assist in the digestion of fats in the intestines.body, and assist in the digestion of fats in the intestines.

•• A MAJOR component of the immune system.A MAJOR component of the immune system.

Lymphatic System Anatomy and Lymphatic System Anatomy and Physiology OverviewPhysiology Overview

•• Lying parallel to the circulatory system, it differs in that it Lying parallel to the circulatory system, it differs in that it is a open is a open loop system, there is no central pump as with the cardiovascularloop system, there is no central pump as with the cardiovascularsystem, and pumps at a much slower rate.system, and pumps at a much slower rate.

•• Magically, we are created with all of our major areas of Magically, we are created with all of our major areas of lymphnodeslymphnodeson the ventral side of our body. This is important, because we on the ventral side of our body. This is important, because we can can protect all of them by curling up in a fetal position if we are protect all of them by curling up in a fetal position if we are to come to come under attack!under attack!

Lymph System AnatomyLymph System Anatomy•• Superficial Superficial LymphaticsLymphatics. Strings of pearls. Capillary. Strings of pearls. Capillary--like vessels like vessels

includes preincludes pre--collectors, collectorscollectors, collectors•• Deep Deep LymphaticsLymphatics. Lymph does not leave a body part or organ . Lymph does not leave a body part or organ

without being filtered by the without being filtered by the lymphaticslymphatics. . •• DeepDeep--trunks, ducts, then empties into the venous system around the trunks, ducts, then empties into the venous system around the

clavicles. clavicles. CysternaCysterna ChyliChyli

•• Plane Barriers, (known as watersheds) Plane Barriers, (known as watersheds)

•• Microcirculation and Lymph Transport SystemMicrocirculation and Lymph Transport System

•• Lays parallel to the circulatory systemLays parallel to the circulatory system

•• Proteins, cell fragments, bacteria, viruses, waste, toxins, fatsProteins, cell fragments, bacteria, viruses, waste, toxins, fats, and I, and I

•• Organic substances are moved through the body via the lymph Organic substances are moved through the body via the lymph system. (1, p.48)system. (1, p.48)

Anatomy, contAnatomy, cont’’dd

•• There are 600There are 600--700 lymph nodes in the body.700 lymph nodes in the body.

•• The areas most concentrated with lymph nodes are the The areas most concentrated with lymph nodes are the neck, each neck, each axillaaxilla, each groin area, and the abdomen., each groin area, and the abdomen.

•• The nodes serve to filter the lymph fluid, thicken the The nodes serve to filter the lymph fluid, thicken the lymph fluid, to make more lymphocyteslymph fluid, to make more lymphocytes--which increases which increases the bodythe body’’s immunity, and to store matter that cans immunity, and to store matter that can’’t be t be removed such as coal dust, dyes, silica, minerals, glass, removed such as coal dust, dyes, silica, minerals, glass, etc. etc.

StarlingStarling’’s Laws Law

•• Ideally the body maintains the homeostasis/equilibrium Ideally the body maintains the homeostasis/equilibrium of fluid exchangeof fluid exchange

•• The capillary pressure/colloidThe capillary pressure/colloid--osmotic pressure of the osmotic pressure of the tissues to filter will stay equal to the bloodtissues to filter will stay equal to the blood’’s s oncoticoncoticsuction power to reabsorb fluid into the bloodstream. suction power to reabsorb fluid into the bloodstream.

•• This results in balance of the bodyThis results in balance of the body’’s fluid system. If s fluid system. If there is not balance, the result is congestion, and edema there is not balance, the result is congestion, and edema (swelling), and other body systems respond(swelling), and other body systems respond

Lymphatic FluidLymphatic Fluid

•• Lymph fluid is rich in protein making the edematous area Lymph fluid is rich in protein making the edematous area very thick and heavy feeling.very thick and heavy feeling.

•• Treatment is necessary to not only move the fluid out of Treatment is necessary to not only move the fluid out of the area, but also the protein. If it is not treated, over the area, but also the protein. If it is not treated, over time, the lymphatic vessels will stretch out permanently time, the lymphatic vessels will stretch out permanently and external compression and treatment will be and external compression and treatment will be necessary for a lifetime to maintain proper pressure in necessary for a lifetime to maintain proper pressure in the valves to move fluid more normally.the valves to move fluid more normally.

How does it work? How does it work?

•• IMLT stimulates the immune system by increasing lymph IMLT stimulates the immune system by increasing lymph function directly and blood circulation indirectly. Venous function directly and blood circulation indirectly. Venous circulation is aided by the motion, and edemas can be circulation is aided by the motion, and edemas can be reduced.reduced.

•• Pain can be reduced by the inhibitory effect of the Pain can be reduced by the inhibitory effect of the mechanomechano--receptorsreceptors--stimulating parasympathetic stimulating parasympathetic responses.responses.

What can the techniques be used What can the techniques be used for?for?

•• To move lymph fluid including protein, fat and toxins To move lymph fluid including protein, fat and toxins from one part of the body to anotherfrom one part of the body to another

•• Decrease painDecrease pain

•• Stimulating immunityStimulating immunity

•• Clearing areas where toxins are held, i.e. celluliteClearing areas where toxins are held, i.e. cellulite

•• Decreasing sympathetic responses, thus helping with Decreasing sympathetic responses, thus helping with depression, anxiety, stress, insomnia and muscle depression, anxiety, stress, insomnia and muscle tensiontension

Indications for therapyIndications for therapy•• Orthopedic traumas, surgeries (see what other sources Orthopedic traumas, surgeries (see what other sources

can be cited for complete list)can be cited for complete list)•• WoundsWounds•• Edema (if properly identified)Edema (if properly identified)•• ArthritisArthritis•• AntiAnti--spasticityspasticity•• PainPain•• DermatologicalDermatological--acne, scars, cellulite, stretch marks,acne, scars, cellulite, stretch marks,•• Orthopedic ConditionsOrthopedic Conditions•• Sports Medicine, Fractures, Carpal TunnelSports Medicine, Fractures, Carpal Tunnel•• Tinnitus/VertigoTinnitus/Vertigo•• Dry Eyes, fibromyalgia, CFS/rheumatic conditionsDry Eyes, fibromyalgia, CFS/rheumatic conditions•• (verbally go over complete list in number 1 book)(verbally go over complete list in number 1 book)

Contraindications for Therapy (All Contraindications for Therapy (All Lymphatic Therapies)Lymphatic Therapies)

•• CHFCHF•• Renal Failure (must be able to urinate)Renal Failure (must be able to urinate)•• DVT or any major obstructions or serious cardiac DVT or any major obstructions or serious cardiac

conditions (groceries)conditions (groceries)•• Infection (Infection (CellulitisCellulitis) Infection and inflammation are not ) Infection and inflammation are not

the same. Infection always has inflammation, but the same. Infection always has inflammation, but inflammation is not always infection. Signs and inflammation is not always infection. Signs and Symptoms of Symptoms of cellulitiscellulitis: red streaking, fever, chills. Ask if : red streaking, fever, chills. Ask if the patient has had any recent cuts or abrasions. Pet the patient has had any recent cuts or abrasions. Pet scratches, etc. scratches, etc.

•• Active bleeding/internal or externalActive bleeding/internal or external•• Untreated cancersUntreated cancers

PrecautionsPrecautions

•• Thyroid disorders (avoid anterior neck)Thyroid disorders (avoid anterior neck)•• Asthmatics where attacks are triggered by the Asthmatics where attacks are triggered by the vagusvagus

nerve (avoid work over the sternum)nerve (avoid work over the sternum)•• PrePre--cancerous areascancerous areas•• History of TBHistory of TB•• The abdomen during menstruationThe abdomen during menstruation•• Hypotension, treated cancers, (certified therapists only) Hypotension, treated cancers, (certified therapists only) •• New sudden onset edemaNew sudden onset edema•• Edemas/Edemas/lymphedemaslymphedemas for certified therapists only (find for certified therapists only (find

alternative source for alternative source for addladdl prec. On p59)prec. On p59)

What is Standard MLD/CDP What is Standard MLD/CDP Therapy?Therapy?

•• A complete program including skin care, hygiene, A complete program including skin care, hygiene, exercises, self massage instruction, MLD, compression exercises, self massage instruction, MLD, compression therapytherapy

•• MLD affects the autonomic nervous system (1 p.29)MLD affects the autonomic nervous system (1 p.29)

•• Other names for MLD/CDPOther names for MLD/CDP

•• It is a systematic, rhythmic method of purposefully It is a systematic, rhythmic method of purposefully stretching the skin to produce an increase in the volume stretching the skin to produce an increase in the volume of flow of the lymph fluid through the filtering system of of flow of the lymph fluid through the filtering system of the body, resulting in detoxification of the body. the body, resulting in detoxification of the body.

Special Applications in Long Term Special Applications in Long Term CareCare

•• CVICVI--Allows the patient to be up, and functional, Allows the patient to be up, and functional, participating in activities, etc. instead of in their room with participating in activities, etc. instead of in their room with legs elevatedlegs elevated

•• Post surgeryPost surgery--great for hip and knee replacements. great for hip and knee replacements. Assists in the evacuation of edema to allow greater ROM Assists in the evacuation of edema to allow greater ROM increases and hasten recoveryincreases and hasten recovery

•• Consider living situation when deciding about Consider living situation when deciding about compressioncompression

•• PostPost--mastectomy, Secondary diagnoses: previous mastectomy, Secondary diagnoses: previous cancers, prostate, ovarian.cancers, prostate, ovarian.

The keys to performing proper The keys to performing proper Integrated Manual Lymph TherapyIntegrated Manual Lymph Therapy

•• PressurePressure! Crucial to engage the ! Crucial to engage the lymphaticslymphatics, not the musculoskeletal , not the musculoskeletal system. This therapy should NEVER be painful or cause system. This therapy should NEVER be painful or cause erythemaerythema. . We use the least amount of pressure necessary to engage the We use the least amount of pressure necessary to engage the lymphaticslymphatics. This feels like moving the skin to the point of a . This feels like moving the skin to the point of a myofascialmyofascial barrier.barrier.

•• RhythmRhythm--On two three, off two three is a good beginners rhythm. As On two three, off two three is a good beginners rhythm. As you become more experienced, you will be more tuned in to the you become more experienced, you will be more tuned in to the rhythms of your clients (include items in p61 book 1)rhythms of your clients (include items in p61 book 1)

•• SequenceSequence! ! --proximal to distal, opening the nodes and pathways that proximal to distal, opening the nodes and pathways that you are draining to first!you are draining to first!

•• DirectionDirection--stretching motion in the direction of the vesselstretching motion in the direction of the vessel’’s origins origin•• These four facets must be applied correctly to increase the pumpThese four facets must be applied correctly to increase the pumping ing

action in the systemaction in the system•• Flat HandsFlat Hands, using as much surface area as possible even the palm. , using as much surface area as possible even the palm.

This differs from typical Swedish (get access to lymph charts) This differs from typical Swedish (get access to lymph charts) Develop treatment sequences. Develop treatment sequences.

Additional Integrated Manual Additional Integrated Manual Lymphatic Therapy TechniquesLymphatic Therapy Techniques

•• Pay attention to any scar tissue that may affect lymphatic fluidPay attention to any scar tissue that may affect lymphatic fluid flow, flow, including the direction and rate of flow. Loosen up scar tissueincluding the direction and rate of flow. Loosen up scar tissue within within your scopes of practice, i.e. US and soft tissue techniques, scayour scopes of practice, i.e. US and soft tissue techniques, scar r massage, cross friction massage, etc. If the scar is deep, the massage, cross friction massage, etc. If the scar is deep, the lymphaticslymphatics in that area are already damaged, so you do not have to in that area are already damaged, so you do not have to be as wary of pressure in that area. be as wary of pressure in that area.

•• Overall increase in lymphatic circulation is important. Water aOverall increase in lymphatic circulation is important. Water activity ctivity is important due to the natural compressive force of the water ois important due to the natural compressive force of the water on the n the limbs. Also, impressive is the fact that the pressure is greatelimbs. Also, impressive is the fact that the pressure is greater at the r at the bottom of the pool than at the top, so just with water walking, bottom of the pool than at the top, so just with water walking, clients clients will get an increase in the natural flow from distal limbs to prwill get an increase in the natural flow from distal limbs to proximal oximal body.body.

•• MiniMini--trampoline jogging/bouncingtrampoline jogging/bouncing•• Swiss Ball bouncing, rockingSwiss Ball bouncing, rocking•• JumpJump--roperope

Billing CodesBilling Codes

•• 97001 PT evaluation (OT, ST, MT) 97001 PT evaluation (OT, ST, MT)

•• 97530 Therapeutic Activities 97530 Therapeutic Activities ––Skin care instruction, Skin care instruction, teaching proper donning and doffing of compression teaching proper donning and doffing of compression stockingsstockings

•• 97110 Therapeutic Exercises97110 Therapeutic Exercises--LymphedemaLymphedema exercises exercises and instructionand instruction

•• 97140 Manual Therapy97140 Manual Therapy--Lymphatic drainage massageLymphatic drainage massage

CodesCodes

•• Diagnosis codes: 457.1 Diagnosis codes: 457.1 lymphedemalymphedema, , lipidemalipidema•• PhlebolymphedemaPhlebolymphedema, 457.0 post, 457.0 post--mastectomy mastectomy

lymphedemalymphedema syndromesyndrome•• Treatment ICDTreatment ICD--9 Codes9 Codes•• 729.5 Pain in limb729.5 Pain in limb•• 729.81 Swelling in limb729.81 Swelling in limb•• 781.2 Abnormality of Gait781.2 Abnormality of Gait•• 719.7 Difficulty in walking719.7 Difficulty in walking•• 457.0 457.0 PostmastectomyPostmastectomy lymphedemalymphedema•• 457.1 457.1 LymphedemaLymphedema otherother•• 709.2 Scar conditions/fibrosis of skin709.2 Scar conditions/fibrosis of skin

Medicare Specific Billing Medicare Specific Billing GuidelinesGuidelines

•• Treatment must be reasonable and necessary to restore Treatment must be reasonable and necessary to restore patientpatient’’s PLOFs PLOF

•• Must document change in function! Again, not Must document change in function! Again, not documentation of specific number of feet walked, or that documentation of specific number of feet walked, or that they are now able to lift 5 pound weights 30 repetitions, they are now able to lift 5 pound weights 30 repetitions, but: Patient can now walk around her home without pain but: Patient can now walk around her home without pain allowing her to care for her children.allowing her to care for her children.

•• Client can now lift arms overhead without pain to Client can now lift arms overhead without pain to complete household chores.complete household chores.

•• Girth measurements, ROM, strength measurements are Girth measurements, ROM, strength measurements are objective, but do not demonstrate change in functionobjective, but do not demonstrate change in function

Alternate forms of treatment for Alternate forms of treatment for edemaedema

•• LymphedemaLymphedema pumppump--often considered a method of last resort often considered a method of last resort (outdated). Can create a dependency on the pump for treatment (outdated). Can create a dependency on the pump for treatment as if moves the fluid, but not the protein component of the lympas if moves the fluid, but not the protein component of the lymph. h. Also increases the risk of genital edemaAlso increases the risk of genital edema

•• ElevationElevation•• SurgerySurgery•• DiureticsDiuretics•• BandagingBandaging•• Low compression support hose. Low compression support hose. ““TEDS are for BEDSTEDS are for BEDS””•• Doubling up on lower compression hose to increase the pressure Doubling up on lower compression hose to increase the pressure

tolerated, but aid in the ability to tolerated, but aid in the ability to donndonn themthem•• Compression GarmentsCompression Garments•• Exercises, standard physical therapy, ROMExercises, standard physical therapy, ROM•• Self massageSelf massage•• Reid sleeves, Circ aids, Reid sleeves, Circ aids,

Why do we need to treat edemas?Why do we need to treat edemas?

•• ShortShort--term: We treat any decrease in ROM, pain, infection risk, term: We treat any decrease in ROM, pain, infection risk, venous and arterial obstruction, and decrease in functional activenous and arterial obstruction, and decrease in functional activities vities such as gait, reaching, etc.such as gait, reaching, etc.

•• Secondly, when the vessels are full of this proteinSecondly, when the vessels are full of this protein--rich fluid, there is rich fluid, there is less oxygen in the vessels, decreasing the rate at which wounds,less oxygen in the vessels, decreasing the rate at which wounds,surgery sites and skin ulcerations heal. This also puts the patsurgery sites and skin ulcerations heal. This also puts the patient at ient at risk of risk of cellulitiscellulitis, or infection of the bloodstream., or infection of the bloodstream.

•• LongLong--term: We prevent any longterm: We prevent any long--term change in function, skin term change in function, skin ulcerations, ulcerations, hemosiderinhemosiderin pigmentation, fibrosis that can become pigmentation, fibrosis that can become irreversible.irreversible.

Alternate Forms of Edema Alternate Forms of Edema ContinuedContinued

CVICVI--Chronic Venous InsufficiencyChronic Venous Insufficiency

Vascular insufficiency: Signs and symptoms: achy feeling Vascular insufficiency: Signs and symptoms: achy feeling at the end of the day, better with elevation, darker in color at the end of the day, better with elevation, darker in color when on the ground/floor. Staining of the when on the ground/floor. Staining of the LELE’’ss, most , most common in common in LELE’’ss Skin ulcers and Skin ulcers and cellulitiscellulitis are a common are a common risk that is decreased with compression therapy.risk that is decreased with compression therapy.Arterial insufficiencyArterial insufficiency--pain with compression pain with compression (contraindicated for MLD)(contraindicated for MLD)MyxedemaMyxedemaPMS, medication abusePMS, medication abuseCombined formsCombined forms

Review QuestionsReview Questions

ResourcesResources

•• Organizations for more information:Organizations for more information:•• www.lymphedemahope.comwww.lymphedemahope.com•• www.lymphnet.orgwww.lymphnet.org•• www.lighthouselymphedema.orgwww.lighthouselymphedema.org•• www.elymphnotes.orgwww.elymphnotes.org•• www.breastcancer.orgwww.breastcancer.org

•• www.discountsurgical.comwww.discountsurgical.com•• www.bandagesplus.comwww.bandagesplus.com•• Pass around sheet for address info email, etc. for future marketPass around sheet for address info email, etc. for future marketinging•• Contact for 135 hour course infoContact for 135 hour course info•• Have book of manuals and forms for marketing to sell. Have book of manuals and forms for marketing to sell. •• Give students 10% discount on complete CDP courseGive students 10% discount on complete CDP course

Decreasing Length of Stay and Increasing Outcomes in Orthopedic Populations with Manual Lymph Drainage

Carmen Thompson, BS, LPTA, CMT, CLT

Cross Country EducationLeading the Way in Professional Development.

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