Lymphatic techniques

Lymphatic techniques use the respiratory-circulatory model to enhance lymphatic and venous flow. Lymphatic flow is mainly affected by extrinsic and intrinsic forces. Congestion and edema may accumulate in response to infection, tissue injury, or somatic dysfunction. Treatment aiming to restore lymphatic drainage has shown to augment the healing process.

General

• The lymphatic system is part of the adaptive immune system as well as the circulatory system and comprises the thymus and bone marrow (primary lymph organs); mucosa-associated lymphatic tissue (MALT), the spleen, and the lymph nodes (secondary lymphatic organs); the lymphatic vessels and capillaries; and the lymph fluid.
• The lymphatic system's primary function is to return excess interstitial fluid and waste products, such as proteins and cellular debris, to the bloodstream.
• Lymphatic capillaries absorb the interstitial fluid throughout the body via diffusion.

Lymphatic drainage

• Thoracic duct
  • Drains lymph fluid from all body sections except for the right arm, the right side of the thorax, and the right head and neck region (including the left side of the thorax and upper limb)
  • The thoracic duct continues from the cisterna chyli, ascends the posterior mediastinum (thoracic aorta to its left), and empties into the left venous arch (junction of the left subclavian vein and left internal jugular vein).
• Right lymphatic duct
  • Drains lymph fluid from the right arm, the right side of the thorax, and the right head and neck region.
  • Empties into the right venous arch (junction of the right subclavian vein and right internal jugular vein)
• For more information, see “Lymphatic system.”

Lymphatic flow

Lymphatic fluid movement is affected by intrinsic and extrinsic forces.

• Extrinsic forces
  • Skeletal muscle contraction
  • Artery pulsation
  • Respiration (negative intrathoracic pressure)
  • Exercise
  • Musculoskeletal manipulative medicine
• Intrinsic forces
  • Smooth muscle contraction
  • Interstitial fluid pressure changes

Treatment

Lymphatic techniques use the respiratory-circulatory model to enhance lymphatic and venous flow.

• Sequence
  • Techniques that remove fascial restriction are followed by techniques that improve lymphatic flow
  • Treatment should start at the site of terminal lymphatic drainage of the affected tissue, and then move peripherally to sites proximal to the affected tissue.
    1. Thoracic inlet myofascial release (or release of the other three major myofascial junctions, depending on the affected tissue)
    2. Thoracoabdominal diaphragm redoming
    3. Lymphatic pump techniques
    4. Mobilization of targeted tissues (e.g., pectoral traction, Galbreath technique)
• Indications
  • Edema, tissue congestion, lymphatic and/or venous stasis
  • Pregnancy
  • Infections
  • Significant lymphatic or venous congestion (e.g., post-mastectomy lymphedema)
  • Acute somatic dysfunctions
  • Sprains
• Absolute contraindications
  • Necrotizing fasciitis
  • Anuria

Frontal lift

• Position: supine
• Procedure
  1. Grasp the frontal bone by placing hands anterior to the coronal suture and lateral to the eyebrows.
  2. Interlock fingers and apply a gentle anterior-superior lift.
  3. Hold until a release is felt.

Nasion spread (frontonasal lift)

• Function: increase mobility between the frontal and nasal bones; increase lymphatic flow of the paranasal sinuses
• Position: supine
• Procedure
  1. Contact the frontal bone with one hand.
  2. Grasp the nasal bone with the index finger and thumb with the other hand.
  3. Apply a gentle separating force by applying traction inferiorly on the nasal bone.
  4. Hold until a release is felt.

Zygomatic lift

• Position: supine
• Procedure
  1. Contact the zygomatic arch with the thenar eminences and interlock fingers.
  2. Apply gentle anterior traction.
  3. Hold until a release is felt.

Direct pressure & effleurage of frontal sinuses

• Position: supine
• Procedure
  1. Place the thumbs on the frontal sinuses just lateral to the midline.
  2. Apply 7–10 gentle compressions.
  3. With gentle pressure on the sinuses, add 7–10 strokes laterally to the pterion.

Direct pressure & effleurage of maxillary sinuses

• Position: supine
• Procedure
  1. Place the thumbs on the maxillary sinuses.
  2. Apply 7–10 gentle compressions.
  3. With gentle pressure on the sinuses, add 7–10 strokes laterally.

Drainage of the nasal passage

• Position: supine
• Procedure
  1. Contact the nasal bone by crossing the thumbs on each side.
  2. Apply intermittent medial pressure while traveling down the nasal bone 7–10 times.
     • Pressure should be applied on the bone and not cartilage.

Galbreath technique

• Function: facilitate lymph movement toward the jugulodigastric node
• Indications: otitis media, sinus congestion, dysfunction of the submandibular region
• Position: supine with the examiner seated on the opposite side of the restriction
• Procedure
  1. Stabilize the forehead with one hand.
  2. Contact the mandible with the other hand.
     • Contact the ascending ramus with the 2^nd and 3^rd fingers.
     • Contact the angle and body of the mandible with the 4^th and 5^th fingers.
  3. Apply anterior medial traction in a slow rhythmic manner.
  4. Repeat until the patient feels a release.

Post-auricular sternocleidomastoid muscle lymphatic drainage

• Position: supine
• Procedure
  1. Turn the patient's neck away from the affected side.
  2. Place the thumb on the mastoid process and follow the sternocleidomastoid muscle down the cervical spine with gentle pressure.
  3. Repeat 7–10 times.

Cervical lymphatic drainage

• Position: supine
• Procedure
  1. Turn the patient's neck away from the affected side and stabilize the head.
  2. Stroke the cervical lymphatic chain by stroking in a downward direction from anterior to posterior of the sternocleidomastoid muscle.
  3. Repeat 7–10 times.

Thoracic inlet release (necklace technique)

• Function: releases restriction in terminal lymphatic drainage into the subclavian veins; always the first step in lymphatic treatments
• Indication: lymphatic congestion
• Position: supine
• Procedure
  1. Contact the thoracic inlet by placing palms over the trapezius muscle and fingers over the medial clavicle and proximal sternum.
  2. Determine restricted barriers.
     • Flexion and extension: Gently place thoracic inlet into flexion and extension.
     • Rotation: Gently twist the thoracic inlet into right and left rotation.
     • Side bending: Gently place thoracic inlet into right and left side bending.
  3. Place thoracic inlet into the restrictive barriers and apply lateral traction until a release is felt.

Thoracic lymphatic pump

• Function: increases rib cage motion
• Indications
  • Lymphatic congestion
  • Atelectasis
• Position: supine
• Procedure
  1. Place hands just inferior to the clavicles on the anterior aspect of the upper ribs
  2. Optional: ask female patients to place hands onto the superior aspect of the breasts for comfort
  3. Ask patient to inhale.
  4. Upon exhalation, augment a downward movement of the ribs by applying posterior-inferior pressure.
  5. Apply a vibratory compression at the end of exhalation.
  6. Allow patient to inhale without resistance.
  7. Repeat until palpatory sense of increased soft tissue compliance and decreased tissue congestion is attained.

Pectoral traction

• Function: increases rib cage motion
• Indications
  • Lymphatic congestion of the upper limbs
  • Respiratory conditions (wheezing, asthma)
• Position: supine with examiner at the head of the table
• Procedure
  1. Grasp the inferior border of the pectoralis muscles.
  2. Apply superior traction.
  3. Continue until a release of tension is felt.

Upper extremity lymphatic pump

• Position: supine
• Procedure
  1. Flex the patient's arms 180°.
  2. While grasping proximal to the wrists, apply vibratory traction, creating an oscillatory pump.
  3. Continue for 15–30 seconds.

Thoracoabdominal diaphragm redoming

• Function: improve thoracoabdominal diaphragm excursion, respiration, and lymphatic return
• Indications
  • Lymphatic congestion
  • Decreased diaphragm excursion

Doming of the diaphragm (anterolateral attachments)

• Position: seated
• Procedure
  1. Contact soft tissues just along the inferior costal margin with finger pads.
  2. Monitor respiratory excursion of the diaphragm.
  3. Gently resist downward motion of the diaphragm during inhalation and follow superiorly through exhalation.
  4. Repeat with slow, deep breathing of the patient until a release is felt.

Doming of the diaphragm (supine)

• Position: supine
• Procedure
  1. Place finger pads on the outer aspect of the inferior border of the ribs.
  2. Thumbs should point medially, directly under the xiphoid process.
  3. Ask patient to inhale and then exhale.
  4. Upon exhalation, apply a posterior-superior motion (augmenting motion of the diaphragm).
  5. Resist inferior motion of the diaphragm upon inhalation.
  6. Repeat for several respiratory cycles.

Abdominal pump

• Function: improve lymphatic return
• Indications
  • Upper and lower gastrointestinal dysfunctions
  • Chronic heart failure
  • Upper respiratory tract dysfunctions
  • Hiatal hernia
  • Decreased mobility of the spine and rib cage
• Position: supine with knees bent at 90°
• Procedure
  1. Contact lower quadrant of the abdomen (just superior to the inguinal ligament).
  2. Gently lift in an upward and opposite direction: Special attention should be focused on the internal organs.

Mesenteric release (supine)

• Position: supine
• Procedure
  1. Place both hands on the anterior abdominal wall.
  2. Apply clockwise and counterclockwise rotations with a downward compression.
  3. Repeat until a release is felt from the small and large intestines.

Mesenteric release (prone; known as Marian Clark drainage)

• Position: prone in knee-chest position
• Procedure
  1. From just above the pubic bones, lift the internal abdominal contents superiorly in an oscillatory motion.
  2. Shift hand placement to localize treatment.
     • Cecum: right lower quadrant
     • Sigmoid colon: left lower quadrant
     • Pelvic organs: suprapubic region
  3. Repeat until a release is felt.

Ganglion release (celiac ganglion release, superior mesenteric ganglion release, inferior mesenteric ganglion release)

• Functions
  • Celiac ganglion release: reduce T5–T9 sympathetic tone
  • Superior mesenteric ganglion release: reduce T10–T11 sympathetic tone
  • Inferior mesenteric ganglion release: reduce T12–L2 sympathetic tone
• Indications
  • Celiac ganglion: upper GI dysfunctions (i.e., distal esophagus, stomach, proximal duodenum, portions of the pancreas, liver, gallbladder, spleen)
  • Superior mesenteric ganglion release: middle GI dysfunctions (i.e., portions of the pancreas and duodenum, the jejunum, the ileum, the ascending colon, and the proximal two-thirds of the transverse colon)
  • Inferior mesenteric ganglion release
    • Lower GI dysfunctions (.e., (distal two-thirds of the transverse colon, descending colon, sigmoid colon, rectum)
    • Genitourinary dysfunctions
    • Pelvic dysfunctions
• Position: supine
• Procedure
  1. Contact the skin overlying the ganglion with five finger pads.
     • Celiac ganglion: 1/3^rd between xiphoid and umbilicus
     • Superior mesenteric ganglion: 2/3^rd between xiphoid and umbilicus
     • Inferior mesenteric ganglion: just above the umbilicus
  2. Gently meet resistance of tissues.
  3. Hold resistance during inhalation.
  4. Add posterior pressure on exhalation.
  5. Repeat until a release is felt.

Liver and gallbladder pump

• Position: lateral recumbent with the right side up
• Procedure
  1. Contact the rib cage with both hands on the posterior lower ribs and the anterior costal arch.
  2. Ask patient to take deep breaths.
  3. Apply a gentle downward compression during exhalation.
  4. Allow the rib cage to expand during inhalation.
  5. Repeat alternating compression-relaxation as necessary.

Splenic drainage

• Position: lateral recumbent with the left side up
• Procedure
  1. Contact the rib cage with both hands on the posterior lower ribs and the anterior costal arch.
  2. Ask patient to take deep breaths.
  3. Apply a gentle downward compression during exhalation.
  4. Allow the rib cage to expand during inhalation.
  5. Repeat alternating compression-relaxation as necessary.

Rib raising

• Function
  • Decrease sympathetic activity
  • Improve lymphatic return
  • Increase chest wall motion
• Indications
  • Pneumonia
  • Lymphatic congestion
  • Congestive heart failure
• Contraindications
  • Spinal or rib fracture
  • Spinal cord injury
  • Malignancy
• Position: supine
• Procedure
  1. Place your hands under the patient's thorax, touching the rib angles.
  2. Apply traction.
  3. Raise the patient's ribs by pushing your fingertips anteriorly and lowering your forearms.

Paraspinal inhibition (rib-less rib raising)

• Function: downregulation of sympathetic tone
• Indication: postoperative ileus
• Position: supine
• Procedure
  1. Contact 12^th rib or just inferior to the thoracolumbar junction.
  2. Place finger pads lateral to the transverse processes along the paraspinal muscles.
  3. Apply anterior force.
  4. Hold until a release is felt.

Pelvic diaphragm release

• Function: improve pelvic diaphragm excursion and lymphatic return
• Indications: lymphatic congestion, decreased diaphragm excursion

Pelvic diaphragm release (prone)

• Position: prone
• Procedure
  1. Contact ischial tuberosities bilaterally.
  2. Place fingertips just medial to the tuberosities to reach pelvic diaphragm.
  3. Monitor respiratory excursion.
  4. Resist downward movement of pelvic diaphragm during inhalation and follow superiorly through exhalation.
  5. Repeat through slow, deep breathing of the patient until a release is felt.

Pelvic diaphragm release (lateral recumbent)

• Position: lateral recumbent
• Procedure
  1. Contact superior ischial tuberosity.
  2. Place fingertips just medial to the superior tuberosity to reach pelvic diaphragm.
  3. Monitor respiratory excursion.
  4. Resist downward movement of pelvic diaphragm during inhalation and follow superiorly through exhalation.
  5. Repeat through slow, deep breathing of the patient until a release is felt.

Lower extremity lymphatic pump

• Position: supine
• Procedure
  1. Apply a superior force that dorsiflexes the feet in a vibratory pattern, creating an oscillatory pump.
  2. Continue for 15–30 seconds.

Popliteal fossa release

• Position: supine
• Procedure
  1. Grasp the medial and lateral aspect of the popliteal fossa .
  2. Determine fascial restriction in each cardinal direction.
  3. Apply an anterior force with the fingertips and engage fascial restriction until the resistance is met.
  4. Continue until a release is felt.