Lymphatic Drainage

Lymphe

 
What do we call lymphatic fluid?

Lymphatic fluid is a mostly clear, light yellow protein-rich fluid, that transports all waste products from the body into the blood circulation system  in a semi-circulation system . In the area of the small intestine the lymphatic fluid becomes milky and cloudy when fat is digested  (chylus).

What does the Lymphatic System consist of?
The Lymphatic System consists of
-  lymphatic vessels with the transport system
-  lymphatic tissue = conglomeration (accumulation) of lymphocytes     
-  lymph nodes

Transport of lymphatic fluid

Lymphatic fluid generates in the periferral tissue, mouthes into the venous system and has no pump. That is the reason why we are referring to  „Lymphatic Transport“ and not to „lymphatic circulation“ .
In this transport system we distinguish

-        Superficial System
         draining actively lymphatic fluid from the skin and the mucosa
-        Deep system
         draining lymphatic fluid passively from muscles, joints and  

         lymph nodes

-        Organ system
         specifically adapted lymph vessels like villi

What is Lymphatic Drainage?

Lymphatic Drainage is a manual method that supports the transport of the lymphatic fluid

Where does the lymphatic fluid come from?

The lymphatic fluid origins in the plasma.

Plasma is part of the blood.

What is a Lymph edema?

We distinguish primary and secondary lymph edema. Primary lymph edema develop when lymph vessels are impaired or missing, Secondary lymph edema come from excess formation of lymphatic fluid.
 

Blood

 
Life is  metabolism

Our metabolism works, because everything vital gets transported in the blood stream. The closed circuit of blood vessels has the heart as a pump. The deep  lymphatic system runs parallel to the blood circulation system.
 
Blood circulation is vital for
         transport of matter
         exchange of matter
         breathing
         excretion
         distribution of hormones
         defense of diseases
         regulation of heat
 
Blood consists of
45 % solid matter and 55 % of liquid matter
 
These 45 % of solid matter consist of
         90 % erytrocytes - the are the transport vehicles
         10 % leucocytes - defense and thrombocytes  - repair
 
These 55 % liquid matter consist of
         90 % water
         7  % protein (so called macro molecules)
         3 % other materials (trace minerals, vitamins, etc)
 
The 7 % proteins consist of
Albumin - transport
Globuline - defense
Fibrinogene - repair

Circulation

 
we distinguish the large (Body) circulation

and the small (Lung) circulation
 
Body circulation

oxygen rich blood from the lung circulation goes to
 
the heart    left atrium, left ventricle
through the body, aorta, arteries, arterioles, pre-capillar arterioles
gas  exchange in the capillaries
now the blood is oxygen-poor that goes through
the body    post capillar venoles - venoles - veins -vena cava inferior -
vena cava superior
the heart    right atrium - right ventricle -
 
Lung circulation

oxygen poor blood from the body  goes to
the body    pulmonary artery - lung - pulmonary vein
the heart    left atrium - left ventricle
 
gas exchange
now it is oxygen rich blood again that goes into the body circulation
 
Arteries always lead away from the heart,

veins always lead towards the heart.
 
The deep lymph vessels always go parallel to the veins. Lymphatic vessels of the deep lymphatic system are always found in the peri-vascular sheath together with arteries and veins. The pulse wave of the artery transports the lymphatic fluid (passive transport mechanism)
 

Blood Pressure

 
Normal Blood Pressure rates 120/80 (120 over 80) in a healthy person.
120 stands for the systolic pressure, that is the pressure that is created through the contraction of the heart muscle within the blood vessel.
80 mg HG is the pressure, that is measured during the relaxation phase of the heart.
Within the body we find different pressure values.
The Initial Blood Presssure of 120 mgHg at the heart diminishes down at the pre-capillaries to 30 mgHg and to almost 0 mg Hg at the Vena cava.
Within the capillaries we find completely different pressures. It‘s called

Micro Circulation

Pressure in the aorta is 100 mgHg or 100 Torr
Pressure in the pre-capillary arteriols is 55 Torr
These pre-capillary arterioles have sphincters that control the narrowing or  distending of the arterioles. That is why the pre-capillary arteriole is also called the
place of the peripheral resistance.

The pre-capillary arteriole has its own pulsation, called Vasomotion . Pulse rate is 10 per minute. According to the body‘s demand one sphincter activity controls the supply of 10 to 100 capillaries. Pulsation is regulated and controlled by hormones and oxygen partial pressure (pO2). Distending the arterioles comes with heat and muscle work - that‘s when the blood flow is stimulated. Constriction comes with cold temperature,  secretion of adrenalin (being pale of anger) or high blood pressure.

There is a fine tuning between the Blood Pressure (RR) the position of the sphincter within the arteriole and the  Blood Capillary Pressure (BCP)

For instance:
RR high = narrow capillary sphincter = low BCP
RR low = wide capillary sphincter  = high BCP means high Ultrafiltration means more extra cellular liquid. That is the reason, why patients with lymph edema should not go into a sauna and why they should move intensively only under compression.
 

Blood Chemistry

and the formation of lymphatic fluid

Exchange of gas at lung and body capillaries comes with diffusion and ultra-filtration.

What is Diffusion?

Diffusion is the mixture of liquids by means of the autonomous movement of molecules.The mixing coefficient depends on the Size of the particles - the smaller the parts the faster the mixture;  and the temperature - the higher the temperature the faster the mixture; cocentration of particles - the higher the concentration, the faster the mixture; the contact surface - the larger  the contact surface, the faster the mixture

We distinguish
easy diffusion - p.e. by carrier molecules
hindered diffusion - p.e. through semi-permeable membrane
example: protein molecules attract water molecules (peas in a pot absorb water) Protein molecules in a blood vessel attract water from the surrounding tissue.
Most bodily functions are regulated by diffusion.

What is osmosis?

Osmosis is an unilateral diffusion, fluids  are mixed via a semi-permeable membranes. For example a membrane does not give way to certain protein molecules. The colloid osmotic pressure (COD) indicates how much water is attracted by protein molecules. All blood capillaries are semi-permeable for protein which means, they let the protein get out of the blood vessel, but inhibit the re-entry.

What is ultrafiltration?

Ultrafiltration is exchange of molecules under different pressures. The blood capillary pressure expells the water from the arterial branch of the capillary into the interstitium (surrounding tissue)

What is re-absorption?

Re-absorption takes place in the venous branch of the capillary. 90 % of the ultra-filtrated liquid and small molecules get re-absorbed.  Large molecules are not absorbed and get hauled off in the lymph system.

What happens to the left over 10 %?

They are absorbed by lymph vessels.

Forming of protein poor edema

In case of a chemical imballance of Ultra filtration and re-absorption water remains sitting in the interstitium, thus forming a protein poor edema (see also venous thrombosis or heart failure) A protein poor edema is no lymph edema and is not treated with manual Lymphatic Drainage (see under contra indications)
 

What is the Starling Equiblibrium?

In the end organ of the circulation, where arterial capillaries become venous capillaries, water is always expelled from the arterial branch of the capillary and reabsorbed from the venous branch of the capillary. The 10 % of liquid that is not absorbed is called lymph -obigatory  load (LL) and is hauled off by the lymph vessels.
Transport of the lymph works according to the principle of the Starling equilibrium, stating that the exchange of material between blood vessel and interstitium is balanced - in an equilibrium.
 
Formation of a protein-rich edema (lymph edema)

Every imbalance of the Starling Equilibrium results in a lymphatic edema.
 

There are two reasons for the formation of a lymph edema:

1. The transport capacity of the lymph nodes and vessels is insufficient (genetic or traumatic) then less lymphatic fluid is transported and remains in the interstitium or, caused by disease, more lymph fluid is produced and a normal transport capacity can‘t manage the quantity. The effect is the same. Lymph edema:
 

Construction and Function of the Lymphatic System

We distinguish 

Initial vessels ,

collectors,

lymph nodes and

lymph truncs

The smallest unit of of the lymphatic system is called  Lymphangion

Anchor fibers keep the lymph vessel as long open until the inner pressure of the lymphatic vessel closes the valve. Besides that the lymphatic vessels have pressure receptors that get controlled by the autonomous nervous system. Thats why lymphatic vessels respond to pressure from within and from the outside. As lymphatic vessels have to tolerate a movement of liquids to all sides, their walls are extremely permeable.

Lymph fluid gets transported via the so called Lymph Angio Motoric and is transported to the Pre-Collector

From there the lymphatic fluids gets to the Collector

The collector consists of a three-layer wall (intima, media adventitia) It has valves and is surrounded by a muscle layer
All collectors are connected via anastomoses and most collectors have besides that collaterals, so to circumvent  lymphostasis.

Every lymph node  is draining  a certain region (drain area). Lymphatic fluid always goes in one-way directions. For instance the lymph vesssels of the head drain to  the subclavicular lymph nodes via ears, tonsills, chin, throat. As shown on the chart lymph fluid goes in certain directions that can be compared to water-sheath in rivers. We know for instance the „head-set“ water-sheath.  Everything that comes from a given  line behind the ears is drained  back of he head and neck. All the other fluid is drained frontal via face and throat to the subclavicular lymph nodes.

The collectors lead to the lymph nodes and further to the lymph truncs which mouth into the ductus thoracicus (80%) and from there into the venous angle. The other 20 % mouth into the truncus iugularis, truncus subclavicularis and truncus broncho-mediastinalis  and with these also into the venous angle.

The lymphatic fluid transports lymph-obligatory large molecules.

A capable healthy lymphatic system transports the lymph-obligatory protein load back into the blood vessels.
Lymph nodes are filters and the place for the formation of lymphocytes. Lymphocytes are vital for the function of the immune system.

Lymph nodes consist of

         capsuled lymphatic tissue, afferent vessels
         marrow, follicles and efferent vessels

On its way from the peripherie to the circulatory system the lymphatic fluid has to pass several lymph nodes. The body has about 650 lymph nodes of different size. 200 are already in the digestive tract.

The effect of manual lymphatic drainage

1.      Lymphangions are stretched, thus enabling the anchor-fibers

        to open the lymph capillaries

        More lymphatic fluid gets absorbed
2     The pressure receptors are stimulated and the lymph-angio-

        -motoric is stimulated    •   
         This results in better transport of lymphatic fluids.
3.     Manual lymphatic Drainage effects for 4 hours a faster 

        pulsation of the lymph transportation vessels

Lymphatic drainage supports, by soft stretching of the connective tissue, the absorption of lymphatic fluid into the lymph vessels. By targeted manipulation this liquid is guided to the next available lymph node and from there to the next lymph nodes group. Manual lymphatic drainage always works towards the next available lymph node.

Transport of the Lymphatic Fluid
We distinguish an active and passive transport mechanism

Active transport mechanism means,
that the protein molecules, that got out of the arterial branc of the capillay into the interstitium, cannnot get back into the venous capillary branch and are absorbed by the lymphatic system
 

Passive transport mechanism means,
that the lymphatic fluid is moved by
         contraction of lymphangions
         artery pulsation (in the deep system)
         active and passive movement of muscles
         muscle pum (e.g. calf)
         breathing
         massage
 

What are Lymph obligatory Loads (LL)?
LL are water, cells, other substances (tatoo colours) that have been ultra filtrated in the capillary system, but not reabsorbed. They are absorbed by the lymphatic system. In case of disease the LL can be higher (for instance a bad tooth makes a swelling) The LL is also called the Lymph-Time-Volume in relaxation
 

What is the Lymph-Time-Volume (LTV)?
The LTV is the amount of lymphatic fluid transported in a certain time. In relaxation this LTV is 1-1.5 ml/minute. The body transports about 2 quarts of lymphatic fluid a day, but in cases of stress this amount can be ten times that much.
 

What is Transport Capacity?
Transport capacity is the maximum transport of lymphatic fluid, that can be managed in a healthy body with a certain time span. Transport capacity can be dramatically diminished by genetic defects or by trauma (injuries or surgery)
 

Manual Lymphatic Drainage improves the Transport capacity

and thus the transport management of lymph obligatory loads
 

The Body‘s Answer to Lymphstasis

There is a fine regulation that we do not get a lymphostasis all the time when we hurt ourselves. There are some safety mechanisms that help immediately, when the system gets overloaded.
1.      Safety valve function starts immediately

2.      Anastomoses are used
         Anastomoses have valves, so that the lymph fluid is transported

         in one direction only          

      We distinguish:
               lympho-lymphatic (means from one collector to the next)
               lympho-venous (from the lymph collector directly into the

               vein)

Anastomoses are genetically implied and get activated in the healing process .The more one remains imobile after an  injury the better the formation of anastomosisses and the better the healing of wounds after surgery or injury.

3.      Collaterals are used (Collaterals are circumvention vessels for the same lymphatic vessel. Collaterals are genetically  formed.

4.      Genesis of macrophages . Macrophages „eat“ the lymph-obligatory substances. Macrophages have a life span of only             20-25 days. Then they become Lymph Load (waste)   themselves.
Only when these 4 mechanisms fail, we get a lymph edema.

Therapy of choice is the

Manual Lymphatic Drainage.

Alteration of the tissue due to lymph edema
Lymph edema are protein rich edema. Cells are dissipated by the high load of proteins,
that results in      longer diffusion way
that results in      worse supply and nourishment of cells
that results in   fibroblasts are attracted  via epistaxis to the protein molecules and   form a fibrosis (hardening of tissue)
then  the lymph edema is no more pitting when pressed lightly
that results in      a hard lymph edema
By that augmentation of connective tissue the pressure increases on the capillaries and results in a worse supply of oxygen in theis area. A bad supply of oxygen results in formation of fatty tissue. This leads to a higher risk of infections and  the formation of ulcers.

There are two stages of lymph edema

1.      reversible stage
         that is the stage where ML is highly effective and healing
         -        soft pitting  edema
         -        elevation brings relieve and reflux
         -        no alteration in the tissue

2.      non reversible stage
         occurs when stage 1 reamains untreated
         -        hard edema
         -        no reflux on elevation
         -        secundary tissue alteration

Lymph vessels and lymph nodes

On Head and neck we find
Lnn occipitales                      on the base of the scull
Lnn parotides                        on the parotis
Lnn faciales                           along the N facialis
Lnn cervicales superior        along the  M. steroncleidomastoid
Lnn cervicales inferiorat the insertion of the M.sternocleidomastoid
Lnn prae-auriculares            in front of the ear
Lnn retro-auriculares           behind the ear
Lnn submandibulares            lateral under the chin
Lnn submentalis                   under the tip of the chin
Iugularis interna string       alongside the  Vena iugularis
Accessorius string              alongside the Nervus accessorius
Transversale string             alongside the  M. steroncleidomastoid

on the chest we find superficial
Lnn subclavicularis               in the clavicula
Lnn infraclaviculares            deeper in the clavicula
Lnn axillares                         in the armpit
Lnn parasternales                 alongside the sternum

in the abdomen area we find
Lnn inguinales                      in the groin
Lnn iliacales                         in the lower abdomen
Lnn lumbales                        in the middle of the abdomen

                                            infront of the lumbar spine  

             
in the arms there are the
Deltoid-bundles                                 on the M. delta
dorso-mediale upper arm bundles      on the back side ofthe uper arm
medialupper arm bundle                    on the front side of the uper arm
Lnn cubitales                                    alongside the cubital vein
radial bundle                          alongside the radial side of the lower
ulnar bundle                           alongside the ulnar side of the lower

                                              arm

in the legs there are the
dorso-lateral  bundles                    on the thigh
Pes anserinum                                under the knee medial
Lnn popliteae                                  in the bend of the knee
ventro-medial bundle                     in the  lower leg
 

Lymphtruncs

 
Lymph fluid that has been filtered in the lymphnodes, gets transported in the lymphatic vessls into the lymph truncs
 
of the head  ........into......... Truncus iugularis sinister et dexter  ......left and right side of the neck

From neck and arms ..............Truncus subclavicularis ...............Fossa clavicularis  right and left

From the right chest ..........Truncus broncho-mediastinalis ..........right side of the chest

From the left trunc .............Ductus thoracicus  ..............left middle above navel

From abdomen.................Cysterna Chyli  ...........Start of Duct.thoracicus
...............Truncus gastro intestinalis.................right upper  abdomen.

from the legs ............Truncus lumbalis .............right + left lower abdomen
 
All lymphatic trunci mouth into the vein angle below the fossa clavicularis into the blood circulation
 

Contra (counter) Indications

When should Manual Lymphatic Drainage not be used?

1)      Inflammation and infection with pathogenous germs
By Manual Lymphatic Drainage the germs or bacteria can be spread. In case thre are no bacteria involved, for instance after burning or trauma, Manual Lymphatic Drainage  may be used beneficiary.

2)      Cardial edema
         On right heart failure, the right heart is unable to pump sufficient amounts of blood into the lung circulation. The right side of the heart enlarges and causes a back  flow into the venous system (passive hyperemia) This increases also the pressure   in the vein angle. That is why the Ducturs thoracicus cannot deliver any lymph   fluid which backlashes into the lymph vessels. Because higher pressure occurs in the venous branch of the capillary less water gets resorbed and remains in the   tissue. Trying to move that fluid back to the vein angle by ML would overwhelm  the whole system and could  as a last consequence kill a person with that condition.

How do I know a right heart failure?
If a person  has a soft, pitted symmetrical edema, grey skin, blue lips and is short in breath he/she should be positioned correctly (elevated chest , lower  legs) and a doctor should be called immediately.. If the signs are not that clear, whether you have to deal with a right heart failure,

there is another simple test:
Let the person stand in front of you and ask him/her to let the hand hang at the side for about a minute. The veins on the hands should become visible and filled. Then ask the him/her to lift both hands above the head. Within 10 seconds the veins should be emptied. If not, send the this person to a doctor and don‘t do the Manual Lymphatic Drainage

3)      Edema with thrombosis
With a thrombosis a blood clot is blocking a vein. The affected vein inflames and  causes a swelling of the surrounding tissue. By the backflow, the blood capillary pressure of the venous  branch of the capillary increasses. Result is less re-absorbtion. Water reamains in  the tissue. This is the so called passive hyperemia.
         Due to the risk of causing an embolism, ML is absolutely contra-indicated

4) Other contra indications for ML are:

Hyperthyreosis (too active thyroid gland)
Hypersensitivity of the Sinus carotis (ML causes then palpatiation)
Dysrhythmyia (DAH = disordered action of the heart)
Inflammation after cobalt radiation

When is Manual Lymphatic Drainage useless?

It is not contraindicated, but useless to use ML when there is no lymphatic edema.
Such a protein poor edema is the renal edema.
 
Renal edema:

Due to some renal diseases too much protein is expelled, the colloid-osmotic pressure in the plasma sinks. This means there are less protein molecules within the blood vessel. Result : Only a small quantity of water can be absorbed. (10 peas in a pot with 100 ml water, or 100 peas in a pot with 100 ml water) It results in a generalized protein poor edema. ML is useless, because there is no mechanic but chemical reason for this extra cellular water. Same is valid for Colitis ulcerosa and M. Crohn. and final stage of hunger edema.
 

Manual Lymphatic Drainage and Cancer
Due to the findings of scientists, ML does not spread cancer cells in the body. But it is highly recommanded to contact the primary doctor of the patient.
 

Indications for Manual Lymphatic Drainage

 
Sclerodermia:

Sclerodermia is an autonomous collagen disease.Skin, the fat layer under the dermis and even organs start to harden. Regular ML on a lifelong basis is able to alleviate symptoms and slow the process of the hardening
Lymphostasis in the head area (Aprosexia nasalis)
Lymphostasis that comes mainly with breathing through the mouth only. ML is very successful, especially on children.
Whiplash Syndrome: Lymphostasis  with problems on the cervical spine: Classic case is the whiplash syndrome. ML - done on a regular basis over months, is able to improve the healing process .
Edema after injury: Caused by the reactive inflammation the blood capillary pressure is increased in ther arterial branch of the capillary. There is more Ultra filtration than re-absorption. Result is excess water in the tissue. ML can help very effectively.
Leg edema...and Cellulite..
 
Lymphostasis in the legs (CVI = chronic venous insufficiency)
To understand the mechanism that leads to the formation of CVI we should look at the vein apparatus in particular:
Veins consist of longitudinal, elastic fibers (partly  non-striped muscle) and have in contrary to arteries very thin walls.

We distinguish:

Superficial veins and deep veins

The superficial veins are connected with each other by Venae communicantes and with the deep veins by the Venae perforantes. Deep veins are less flexible than superficial veins and are situated underneath the connective tissue. Only on the inner malleolus there are no V, communicantes. There is no mechanism for compensation, thats why this area is prone to leg ulcers.

The following diseases are cause for CVI

(ChronicVein Insufficiency)

1.  Thrombphlebitis - an inflammation of a superficial vein
2.  Phlebo-Thrombosis - pathologic alteration in the deep vein system

Both conditions lead to destruction of the vein wall and thus to CVI

Stage I of CVI =

latence stage

Symptom   Pateint  has no edema. Safety valve function still works
Therapy     compression recommanded
                   Manual Lymphatic Drainage brings good relieve

Stage II of CVI =

phlebo-lympho-dynamic insufficiency

Symptoms:  edema are protein poor, soft and pitted
                   leg edema after stress
                   heavy legs
                   burning feet
                   varicous veins
                   punctual bleeding into the tissue
                   brown discoloration of the skin
Therapy:    obligatory compression plus

Stage III of CVI=

Phlebo-lympho-Static Insufficiency

Symptoms:  Permanent edema
                   Inflammation of lymph vessels
                   protein rich, hard not pitted edema
                   Stemmer sign positiv
                   Onset of Ulcus cruris venosum
Therapy:    obligatory compression plus regular ML
 

Other indications for Manual Lymphatic Drainage

Cellulitis

If I had not experienced it on myself. I would not have dared to believe, that there is a cure against the so-called "Cellulitis"

Cellulitis translates correctly as “Inflammation of the Cells”
But Cellulitis is no inflammation at all. Cellulitis or Cellulite is big fat-cells  bulging through the loose mesh of connective tissue. Mainly in women, because women have looser connective tissue. To get rid of Cellulite you have to find a procedure to diminish these cells. One proven way is Lymphatic Drainage. With Lymphatic Drainage the excess water and part of the fat is guided into deeper layers and transported via the lymphatic fluid into the Circulation System. From there it is transported via the kidneys to the bladder. Which explains, that there is always a good  water elimination after a well done Lymphatic Drainage.
 

Aging

Lymphatic drainage can slow the aging process by improving the micro-circulation. Face Lymphatic drainage applied on a regular basis makes  a radiant complexion.